Two Docs Talk Informatics: Conquering Misconceptions

Narrator: 0:01

Welcome to MedEvidence, where we help you navigate the truth behind medical research with unbiased, evidence-proven facts, powered by ENCORE Research Group and hosted by cardiologist and top medical researcher, Dr. Michael Koren.

Dr. Michael Koren: 0:16

Hello, I'm Dr. Michael Koren and our host today for this MedEvidence presentation called Two Docs Talk About How to Look Up Things. I'm very pleased to have Dr. John Rowda, an ophthalmologist and a long-standing colleague of mine, who I've worked with on many clinical trials in the past, to talk about this issue. In our first session, we talked about the fact that there's so many biases, there's so much information that people can become overloaded, and we have this tendency in our society, given all this information, to look up things and to find things and to read things that confirm what we already believe, rather than becoming objective about evaluating an issue. And what I'm going to do in this session is bring up one of the most controversial things that we've talked about as clinicians and as people who live in our community and as Americans. T he concept of whether or not to wear a mask and in what circumstances to wear a mask through the COVID-19 crisis. And I know John's very passionate about this and he and I have actually done a fair amount of our own research and have some views that we'd like to share with people. So, John, once you get everybody up to speed in terms of the controversy and, where it's been irrational and rational ways of understanding things.

Dr. John Rowda: 1:31

Well, I'll try to be inflammatory right away. We'll talk about Dr. Fauci, and I follow this stuff and try to research it, and in the early days, when COVID was just coming out, there would be people who discredit Dr. Fauci, saying, well, look at this video and he's saying that we don't need a mask. At that time that was about January, maybe 2020, when the vaccine was just coming out and there weren't. Well, it was not out, and he was talking to the press that we didn't need a mask because all the numbers and information coming from China was that is not a big problem. That's the only information he had. And that's what he was relying to the public. Well, just a month or two or three later, it was a huge problem. And he still did not recommend that the public wear a mask. Well, the problem was they realized how bad COVID was. There were not enough masks for the ICU workers and the emergency room workers, let alone the rest of the hospital, to wear 24-7, and so he wanted these masks saved for those at highest risk. And later, when the mass production came up, then he started reporting that the public would be safest if they wore a mask. So if you play those three videos with not knowing the background, you think, well, this guy changes his mind all the time. This is awful. Not only that he had a reason for it, but that's, that's a good scientist. When he gets new information, they change their mind. You get new information, good research level one research. You change your opinion, that's a normal scientist.

Dr. Michael Koren: 3:06

Yeah, and great point. And Tony Fauci has certainly been villainized. I've met him on a couple of occasions. He's actually a very nice person. And I think, a sincere person, and unfortunately, he's been at the center of a media storm. But quite frankly, I think he really spent his entire career looking after the public health of US citizens. And I hate it when he's villainized. It's unnecessary because he has no evil intentions. But you know, having said that, maybe he could have done a better job of articulating uncertainty at times and perhaps done a better job of explaining the pros and cons of masks, in particular in some of the other controversial issues with regards to COVID-19.

Dr. John Rowda: 3:51

I looked up more on Fauci and what I saw that during COVID there's 16 national and international medical societies and research societies named him their man of the year. In America he's vilified. Italy and Israel named him their man of the year, for his work on COVID in their country. And here he's a villain. I think it's grossly unfair.

Dr. Michael Koren: 4:17

Yeah, yeah, well, any event, so, we'll go to more, less controversial. Well, I am a fan, actually, of Tony Fauci. And he actually did some of his training at Cornell, where I did my training. In fact, I was a chief resident at Cornell and had the same job that he did 20 years after him, so I have that connection with him. But, having said that, I do think he probably could have done a better job in certain circumstances, of explaining the pros and cons, and he was in a tough situation because, you know, he spanned different presidents and different political agendas and you know different media cycles. I t's a very challenging job to do all that. But let's dig in a little bit more. So, even to this day, we don't know if we should be wearing a mask or what the pros and cons are. I want to dig into that a little bit with you, John. I'm going to start with an anecdote of my own. So, sort of during the teeth of the crisis it was probably maybe June or July of 2020, the gyms had just gotten permission to reopen, as your call? It's probably a little bit later, actually, now that I'm thinking about, it was actually September 2020. So let me be precise It was September 2020. The gyms had recently been given permission to reopen but there was social distancing. And I went to the gym that I usually go to that was closed literally for three or four months. And I was doing my work on the bicycle, the stationary bicycle, and I was, you know, probably 20 feet away from everybody else. But I was told gently by one of the folks who was a monitor at the gym that this was a mask mandatory session. And I had typically gone to sessions that didn't require masks, even though we were socially distant. So I said, oh, okay, I didn't know that. So I went to my car I actually, you know, obviously I work in a hospital and I had a bunch of different masks. So I brought my paper mask and I brought my N95 mask. And I was interested to see how it would affect my ability to use the bike. So I get there and I put the paper mask on and I'm doing my exercise and I'm saying, okay, that's not too bad. I said, let me take that off and put the N95 mask on and see how I do with that. So I'm taking the mask off and as I'm fiddling with it, the monitor comes by and says please, you need to wear your mask at all times during this mask mandatory session. And I said, yeah, I have no problem with that, I'm just doing a little experiment here. So I put the N95 mask on. I have to say it was more difficult to exercise with the N95 mask that has the smaller pores than it was with the paper mask, and probably easier to exercise without a mask at all for a number of reasons. So I'm doing this back and forth and it so happens that I was also very, very involved in the COVID-19 vaccine studies at that exact time. So I was starting to explain to people that these are different masks. And the paper mask has bigger pores. It's really designed to protect people against bacteria and I know you have some interesting historical insights about that. Whereas an N95 mask has a much smaller pore size and maybe works better for viruses, and I was just trying to understand that from a personal standpoint. So it was really interesting. A woman came by about five minutes later and she says to me well, I'm glad you brought up a fuss about the mask. She says all this is going to go away after the election is over. She came to me and I said well, no, this is a serious question. We don't know all the answers, but masks have some efficacy. Quite frankly, we're 20 feet away from each other so I'm not that worried. But whatever, I'll wear the mask for now. But I can sort of calm her down and also identify myself as a scientist that's working in this area. And then, literally five minutes later, somebody came up to me and he looks at me with derision and he says the problem with this world and this epidemic is because of people like you that won't wear their masks. And I said you know this is what I do for a living. And I started giving him a lecture about masks and pointing these things out. And he turns away and says it's best that you and I just don't talk and he goes off. So it just sort of highlighted the fact that people had their set opinions about masks and really didn't care that much about the data. And you know we're all about the data, so let's get into the data. So give us a little bit of a historical perspective. First of all about the fact that masks in general are a very effective means of preventing the spread of infectious disease.

Dr. John Rowda: 8:47

I read a book about pandemics written before the current pandemic. And the history goes back to about the 1870s. A German surgeon started wearing a mask for all his surgeries and his infection rate went down considerably. And that was starting to spread, which back then spread very, very slowly around the world. Something like 15 years later, the Mayo brothers in Rochester, Minnesota, saw that information and they did that, then they tried to take it up a step and they made everybody in the operating room wear a mask.

Dr. Michael Koren: 9:24

So the Mayo brothers first started by doing their surgeries wearing a mask, which wasn't routine at that time. Notice the dip in their infection levels and then sort of spread the word in the US.

Dr. John Rowda: 9:33

Yeah, and they had the lowest reported infection rates in the nation. People started coming from around the world to have surgery before the age of antibiotics And they had the reputation that people didn't die after having general surgery.

Dr. Michael Koren: 9:47

Yeah, and this was probably the late 1800s, during the time that Louis Pasteur was helping people understand about germ theory, and probably at the same time hand washing became a bigger deal and other measures to reduce infection rates. Just to be fair, there may have been other factors involved, but certainly masking and spreading bacteria through your respiratory cycle was one of them.

Dr. John Rowda: 10:10

And the author of this book compares, t he only pandemic that compares is actually worse than our current one was the pandemic of 1917 in San Francisco. And San Francisco was interesting in the author' s statistics is San Francisco did the best of any city in the United States, partly because it started mostly in Philadelphia, traveled slowly no planes back then across the country, and interestingly to me was that he felt it was the earthquake in San Francisco 10 years before that set the stage. He said the infrastructure was destroyed water, sewer, everything, everything for public health had been destroyed and the public health officials and the politicians created a plan and the citizens followed that plan to recover. So when the pandemic came you had the trifecta the public officials worked with the public health people, the politicians and the citizens believed them. A nd the three of them worked together and they had the best statistics of any city in the nation in 1917 pandemic.

Dr. Michael Koren: 11:18

Interesting. Yeah, it's a lot of interesting things about that. And just for the audience, you're talking about the Spanish flu epidemic that lasted for about a year and a half between probably 1917 and 1919. And you know they call the Spanish flu, but it probably started in the US, Kansas. Although there's still a little bit of debate about that. But it became more known and widespread due to World War I. W here literally, you know, thousands of soldiers were getting sick from the flu, and a particular characteristic of that virus is that it affected young people much more than older people, which is really interesting. So probably older people had some immunity from a previous viral infection that the younger people didn't have. And you know, amongst healthy troops in the US Army there was like a 5% mortality rate or 7% mortality rate.

Dr. John Rowda: 12:10

So they're packed together in barracks. That's exactly true. They think that, yeah, like 30 or 50 years before, there had been a pandemic that wasn't very virulent but, it was the same type of virus, and so old people had protection and the young did not.

Dr. Michael Koren: 12:24

Yeah, and obviously in the COVID crisis it was completely the opposite young people tended to do well and older people can be devastated by it. So every pandemic is a little bit different. And you have to look at the science of numbers and data to your initial point, you have to make adjustments as you learn more. So we're going to end this particular session with that, but I want to bring it back in our next session and then talk about more of the details and different ways of understanding masks and mask mandates in terms of actual data.

Narrator: 0:01

Welcome to MedEvidence, where we help you navigate the truth behind medical research with unbiased evidence, proven facts powered by ENCORE Research Group and hosted by cardiologist and top medical researcher, Dr. M ichael Koren.

Dr. Michael Koren: 0:16

Hello, I'm Dr. Michael Koren and I'm your host for this session of MedEvidence. In particular, we have a wonderful guest here, Dr. John Rowda, and he's joining me for this program called Two Docs Talk about how to look up things. The conversation is always organic when we have these sessions and we really got into a neat discussion about the use of masks, particularly masking during the COVID-19 crisis. I'd like to pick up from where we left off in our last session and talk about actual data. People have these very strong opinions one way or another about wearing masks or not wearing a mask. We both told anecdotes about it, but how to get to the truth? What do we do to actually learn how to advise our patients and how to advise the public? So what are your thoughts on that, John?

Dr. John Rowda: 1:04

Well, we have great problems with people understanding research and looking for quality research, reliable information. One of the simplest things we were talking about is that there are videos of people wearing a mask, not wearing a mask or wearing an N95 and coughing in front of a black screen and seeing the difference of your cough you're transmitting through the air and that picture, the video is worth a thousand research studies. It works. It works. It stops stuff from blowing out of your mouth. But in the COVID specifically, the virus mostly comes and goes, comes out of you and comes into you to get infected. It's through your nose and there is a huge problem of getting people to wear it over their nose. I don't know if they didn't know, or is there a way of protesting having to wear a mask that I'm not sure.

Dr. Michael Koren: 2:02

It may not be that comfortable for people not used to it, but you bring up some good points. So that video evidence that you describe is something that is fascinating to me because it brings up the point that masks for viruses in particular probably work better for sick people to prevent them from spreading it, rather than healthy people who may be exposed to a sick person. So to be clear, if somebody is sick in a room and has COVID and is sneezing and coughing and filling up the room with virus and you're wearing a mask, it may not be that protective because you're going to get it on your skin, you get it on your hands and at some point you're going to touch your nose and mouth, et cetera, and so you're still not terribly well protected. But that same person, if that we were wearing a mask, particularly an N95 mask, it would prevent that person from transmitting the virus into the room. So this concept of healthy people protecting themselves versus sick people protecting others is one of the elements of mask wearing that I think sometimes gets lost. So that's one element of it. Then the other element that we alluded to this, but I think it's important you can weigh in, is that some people are using cloth masks and some people are using paper masks and some people are using surgical N95 masks. So explain to people a little bit more about those concepts so people can have a better understanding of what that means.

Dr. John Rowda: 3:22

Well, the N95 is the best because it has the smallest pores. The cloth masks, the surgical masks, those are three layers and we've heard people say that each layer they'll say that the openings are too big to stop the virus. Well, the virus doesn't know where the holes are. So some of the viruses are going to hit the mask and most of the virus comes out on some sort of a mucus droplet. So you don't even have to stop the virus, you stop the nucleus droplet and you stop the virus. So they are effective, but different degrees of effectiveness. And then to add onto what Mike said, is people oftentimes are contagious, say a day or two before they have symptoms. So that's another reason to wear a mask during a pandemic. Is that not just when you're sick? If you want to try to stop a highly contagious and virulent organism, you have to go with the program.

Dr. Michael Koren: 4:25

Yeah, yeah, sure. And the other thing that I like to remind my patients of is that we're in a COVID time, so everybody's thinking about COVID, but there are other illnesses out there and one of the very interesting parts of the epidemiology of COVID is we found that during the stages of COVID where people were more compliant with social distancing and wearing masks, that flu rates went down, that other viral rates went down, other illnesses went down. So again, masks aren't specific just for COVID-19 virus coronaviruses, but for others. The other thing, the other point I would make, is that masks should be used properly and there were some studies that show that maybe masks didn't work as well as it anticipated and that could be related to using them improperly. So when we use surgical mask paper masks they're meant to be thrown away. You know where they're meant to be worn for a day or for a few hours and then thrown away. And I had this issue with a few patients. They'd be wearing cloth masks and I just asked them when was the last time you washed that mask? And inevitability they would tell me three weeks ago. And you know that's obviously defeating the purpose of it to a large degree, in that they have these bacteria laid in pieces of cloth over their face. That can't be a good thing over a long period of time. So not only is it about wearing a mask or not wearing a mask, but actually following a protocol where you understand what the mask is trying to accomplish and then use it properly. Use it properly, and then that makes a huge difference. So we'd like to make those points.

Dr. John Rowda: 6:00

Well, as you're talking, I was thinking about, when you compare, that we see people in the United States, a lot of politicians, comparing how one state versus another did well, the United States did the worst and every state is bad. What do you want to do is compare. How did America do with, say, similar cultures, Canada, New Zealand, Australia? New Zealand stopped it in its tracks. Australia did great, Canada did the closest culture to ours. They did far, far better than we did, and the best was Japan, which had the worst circumstances, the most tightly packed society to transmit a disease. And yet their numbers are the best and they're reliable numbers in those three, those four countries.

Dr. Michael Koren: 6:46

Yeah, all the Asian countries did well, better than the US, including countries that are incredibly densely populated like. Hong Kong is a good example. Singapore is a good example. These are incredibly densely populated places, much more so than any place in the US, and they tend to do well Now. They had the advantage of being exposed to this issue through SARS, and so there was more preparation, more awareness going into it at the beginning, but, to your point, they had much lower infection rates and much lower death rates.

Dr. John Rowda: 7:19

And I think they have a history of that. If you're sick, they have a tradition of wearing a mask in their densely populated areas. So that was not a foreign concept and they knew to cover their nose.

Dr. Michael Koren: 7:31

Yeah, I actually visited Hong Kong in I think it was like 2015, after the SARS scare, and a lot of people in Hong Kong were wearing masks at that point. So, to your point, it was something that was generally socially accepted and you go in the subway there and have the people wearing masks even before the COVID-19 pandemic. So that I think that is insightful. But you know, the other point of that is it wasn't just the mask. So I always like to give both sides of the story. It was also contact tracing. So when somebody got sick, they did a much better job at isolating the person who was sick and then informing all the contacts that they could be at risk and they should separate themselves from people. And I know one of the first countries to be hit by COVID-19 with South Korea, but they did such a good job with contact tracing that they kind of isolated really, really quickly. They had an incident early on where there was a church in South Korea where a lot of people spread the virus and they were able to take all the contacts of those people and separate them from the rest of the population and fortunately, South Korea did extremely well throughout the pandemic because of this concept of contact tracing. That probably would not be accepted in the US for cultural and other reasons, but it does work. You know, these things are proven public health measures that, in fact, can be extraordinarily effective. So getting into another element of this discussion has to do with what we do here at Encore Research, which is clinical trials, and I always like to say that clinical trials are our answer box, and in a clinical trial you ask a question and then you just change one variable and you see the change of that one variable makes a difference in the world's results down the road. So for masks, there's different ways of asking the question, but basically what we're asking is under certain circumstances, does wearing a mask protect people compared to not wearing a mask? Or does an N95 mask do better than a paper mask? Or do people in the health care industry wear a mask all the time, or just certain amounts of time? Whatever the question may be, you just change that one variable and everything else stays the same, and we actually have a fair amount of clinical research results from masking and COVID-19 and their mixed results, quite frankly. So one of the papers that came out in the New England Journal I believe it was probably late 2020, was a Dutch study that looked at people at home wearing masks versus not wearing masks, and they showed a little bit of a difference between infection rates in a household of people wearing a mask, but not that much, and that was jumped on by people who didn't believe in masks to suggest that masks weren't necessary. But again, that's a tough situation. Where actually living with somebody and who knows what your compliance is and and doing other elements of social distancing and hand-washing and cleaning of surfaces is very difficult on those circumstances. But then there was another study that was done in Bangladesh that looked at randomizing communities. So Bangladesh is a densely populated country in in Asia. There's about 165 million people that live there and a lot of people live in densely populated villages, and the researchers gave everybody in a village randomly masks and compared though that group with people who did not have access to masks in another village, and they clearly show that the villages that had access to masks did better than the villages without it, although it wasn't a huge difference. But when the villages got N 95 masks, you saw the biggest difference, and it's always reassuring to see when clinical trial results mirror what your expectations are, and the reason for that is because if you get a result that makes sense, you know it's not only doing a clinical trial, but it's taking that clinical trial result and then matching it up with common sense.

Dr. John Rowda: 11:27

I agree.

Dr. Michael Koren: 11:27

Yeah, so to me, I found that interesting. So, in our next section, I want to explore more about other areas and particularly John has done a lot of study about how people should use the internet and how people should use different resources to come up with best solutions and really this very, very important concept that Mark Twain introduced in the beginning of our program, which is that there's a lot of stuff there that just ain't so.

Narrator: 11:58

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Narrator: 0:01

Welcome to MedEvidence, where we help you navigate the truth behind medical research with unbiased, evidence-proven facts, powered by ENCORE Research Group and hosted by cardiologist and top medical researcher, Dr. Michael Koren.

Dr. Michael Koren: 0:16

Hello, I'm Dr Michael Koren and I'm the host for this MedEvidence podcast, and I'm delighted to have Dr. John Rowda, who's an ophthalmologist and a long-standing colleague in clinical research, and he and I have been having this great conversation about critical thinking. We talked a lot about critical thinking research, clinical trial results with regard to COVID-19 and masks, and now I kind of want to move on to just sort of general areas where we seek out medical information and how we use critical thinking to make good decisions. So I know, John, you're very passionate about this, and why don't you share with us some of your insights in this area?

Dr. John Rowda: 0:54

Well, some of the inspiration behind this is that doctors or articles often quote doctors are saying don't search the internet, you're just going to get bad information, and so nobody's going to not search the internet. Everybody's going to Google it and look up their information, and what we're hoping to do is give you some guidelines on how to find quality information. And another inspiration I've just read in Canada they've started a high school course in critical thinking where the kids are given a fact or a quote and they're supposed to search the internet finding good information, and they're graded on the source of their information and the quality and breadth of their search, which I think is a terrific idea for all of us to learn how to do this. We're all biased and there's two basic ways I see of doing this. You can ask a fair, unbiased question on the internet, because if you throw a bias in your question then the answers are going to be biased. Worse is if you have, if you're well, pick a number to irritate both sides. If you're a far left wing or far right wing and that's what your majority or half of your searches have been the last two months you can ask a very unbiased question, but the computer has your history and it's going to lead you to a far right or a far left answer. So you could try an unbiased question. But another way is to, in any area, find yourself a source, hopefully multiple, that have good, hopefully unbiased, answers and information that is based on good research. I think that may be another way for people to find the best information.

Dr. Michael Koren: 2:42

Now, this is a biased answer, but the MedEvidence podcast is an example of what we consider Where's the best. Well, there you go. Well again, what we do that's unique, I believe, on the internet is that we explore things. We don't tell people what to do. We're not trying to sell you anything. What we are trying to do is explore all sides of the question, and you usually kind of get to the answer in a circle. You kind of move in slowly but surely and then you figure out the answer, and sometimes you can't put your finger on that one spot, but you have a general sense for what's right and what's wrong, and so that's the purpose of this. So rarely we'll tell people that they should do this or they should do that, but we like to tell people this is how you explore something and this is how you understand whether or not it's not right for you.

Dr. John Rowda: 3:31

I agree. We're the starting point and point you in a direction and hopefully teach you how we think is the best way to find the best information.

Dr. Michael Koren: 3:40

And we like to use the slogan. The truth behind the data says. We all know we generate data as clinical research professionals and data can be interpreted in different ways and the truth is never straight line. The truth is zigzags, the truth is elusive, but if you keep on looking, you keep on searching, you will eventually find it.

Dr. John Rowda: 4:01

An example I thought of while Mike was speaking is a friend was telling me about a broadcast where they had a family doctor from another country and he was talking about his 42 patients and his research results. Well, you can't do research on your own patients. It's not possible. The ideas weren't set up beforehand. It's just totally unscientific. Mike could probably talk a few days about how to do research, but I can tell you there was no research being done in this doctor's office and people listening to him as handing out the truth was just totally misled.

Dr. Michael Koren: 4:39

Right. Yeah, there are selection biases and these type of things. Observational research is usually a starting point, but not as powerful as a randomized clinical trial, and really one of the main things that we do as scientists is we try very, very hard to reduce ourselves from being biased, and it's not always easy, and it's just human nature to want to be proven right. But what we do in clinical research is we ask a hypothesis objectively and we let the answer box of a clinical trial decide what's right and what's wrong. So, John, tell us a few more stories. You and I were talking offhand. You had a number of very, very interesting stories about some of your searching on the Internet and things that came up in discussion in different searches and how you'd structure them. So give us a little bit more insight into that.

Dr. John Rowda: 5:29

Well, I was following the COVID numbers. There's several sites Johns Hopkins, new York Times do it. The Florida Health Department. Interestingly to me in the Health Department the one that jumped out you don't have to be a research scientist to understand these numbers. In the fall, I believe it was 2020, there was no vaccine for children at that time Nobody under 18, it hadn't been researched. Mike hadn't done the research yet, and so the mandate at that time was the kids in school wear a mask and they social distance and they cut down. I think the number of kids that were in classrooms at the time and where I followed was Citrus County and Jacksonville, Florida, Duval County and the first three weeks of the years with the mask and social distancing trying to do everything. There was about 30, some kids sick in Citrus County at first and Jacksonville was 40, some kids. A year later the mask was removed. The children were told not to wear a mask and it was the public sentiment was that they were not worthwhile. Citrus County the first three weeks again the year before is 30 some. The next year, the first three weeks, it was over 800 children sick. There was no statistics on how many were hospitalized or how seriously or if they had long term COVID. I did not see that. But that number, those two numbers alone, you don't have to be a bio statistician to understand there's a difference. Were well in Duval County went from 40 to 900 kids sick the first three weeks. Oddly, Citrus County Duval County, Citrus is far smaller but they had both counties had three staff members die from contracting COVID from the kids. So those are numbers that just jump out at you. That again the mask works and it was also social distancing, hand washing. I think there was a sanitizer at the door of every classroom, so it wasn't one thing. You layer these protections.

Dr. Michael Koren: 7:29

And again, as the clinical researcher, I would point out that the numbers are compelling but it's not proof, so that's why you have to do a randomized trial. So these were not randomized trials and of course, it could be coincidence that the activity of the disease in the community was a lot less and then just coincident with the changing in the mask rules, that it became more severe. So we want to be fair to say that when you have these observations, they should generate a hypothesis and, as we talked about in a previous section with regard to masks, there are randomized clinical trials that show that masks have some positive impact, that N95 masks work better than paper masks, but that no masking protocol in of itself is going to be perfect. So again, the truth is always buried in the details and related to your perspective to some degree. But I want to get back to some other things. Just general advice for people. So you mentioned when we started. Depending on how you ask the question, is coffee good for you? Is coffee bad for you? So I like coffee, so should I be worried? How many cups of coffee should I have? Should I cut out of my life? Give me the scoop, and how do I learn more about that?

Dr. John Rowda: 8:42

Well, the same thing. You can ask the same questions about chocolate, so that people usually like both of those things and they can look them up. And the truth is the reason they're on the TV every month a study is because the answers keep changing and usually the basis is the dose. People who have one or two cups of coffee a day seem to do well and oftentimes in some studies, and you realize, each question, as Mike mentioned, is usually one question. It's not answering all health, it's usually one health problem and sometimes one or two cups of coffee a day improve some people in some studies. Now, if you've had, you know, I don't know five stents in your coronaries, probably any coffee might be a problem. You don't want to. You probably don't want to. Well, if you did study those people probably would be a problem, but the vast majority of us one or two cups of coffee is probably not a problem. If you brew yourself a strong pot and then drink the whole pot, you're probably going to have symptoms. So it's dose-related basically, and in your own health, if you're an outlier, have significant health risks, then you have to be careful. If you're a bad diabetic, chocolate is probably bad for you, but most people, especially dark chocolate. I'm told by my wife that is good for you right.

Dr. Michael Koren: 9:59

So you bring up something really interesting. And this gets into critical thinking skills. So one of the ways of understanding problems is to look at the extremes. So with all these things such as coffee or chocolate or whether or not everybody should take an aspirin, you look at the extremes. And if we all would agree that if somebody drank, you know, 50 cups of coffee a day, they would get caffeine poisoning and that's well-established in clinical medicine. But then you look at the people who never touch coffee at all. Are they living longer? Are they living better? We don't have any data for that. So at both extremes we see that a large amount of coffee is not good and zero coffee is probably not great, because we don't have any data to suggest that over the course of, you know now, thousands of years. So that extreme analysis is part of critical thinking. The other part of critical thinking is internal inconsistencies. So if somebody says, well, diet coax, two diet coaxes is horrible for you, but two cups of coffee is fine, well, you know that may be an internal inconsistency, because probably the product in both of them that makes the product desirable is the caffeine. And so we always encourage people to use these type of critical thinking skills to look for internal inconsistencies. So John's an ophthalmologist, so I'm going to ask him a couple of quick questions in closing that again get into these same sorts of things. So I guess when I was growing up my parents would tell me to not stare too much at a piece of paper because it's going to hurt my eyes. That's like one of these myths out there, or maybe not. So how would I have known if my parents would give me good advice or bad advice?

Dr. John Rowda: 11:44

That's actually a controversy right now with the pandemic. The kids are at home and people and kids staring at their screens, their phone, their tablet, their laptop, even in the classroom. Some of this stuff is on PowerPoint. I guess they look across the room. But the point is these kids are watching too close, too close, and there's an epidemic of myopia, nearsightedness from the muscle strain of keep looking closer and closer. Actually, it seems to be a stimulus for the eyeball to grow, which becomes nearsighted, meaning you can see well up close, but you can't see in the distance. And actually one editorial that seems unbelievable to me was one of the solutions was to force your kids to go outside and play for 45 minutes a day, and I don't know about Mike, but when I was a kid, our parents had to force us to come inside.

Dr. Michael Koren: 12:40

Yeah, absolutely, isn't that crazy? That's crazy. So the other one and I'll end with this question mark sunglasses and protecting your eyes against cataracts and things of that nature. So that is one of these practical things, and should I be wearing sunglasses all the time? Should I wear indoors to protect my eyes against cataracts? Give us a little insight and what the data is showing for that.

Dr. John Rowda: 13:02

Yeah, I'll give you some population studies. Oddly, you realize, people in England, Great Britain it's a very cloudy area with people with blue eyes which tend to be more prone to problems. Well, the population of Australia are those people, that's, who mostly migrated there, and the incidence of cataract is not much different in the two populations where you have a very sunny desert type climate and there's not much difference. But oddly, the lower eyelid, because it's very thin, very fine and it's angled, is highly prone to skin cancer and so it may lower your risk a little bit of cataract slightly to wear sunglasses, but maybe for the to prevent ocular skin cancers, maybe even inside the eye. The eye is prone to melanomas and blue-eyed people tend to be prone to more skin cancer or eye cancers. So polarized sunglasses I always think are the best.

Dr. Michael Koren: 14:06

So, based on your advice, John, I probably should be wearing sunglasses now. Wouldn't it be nice if they just showed up?

Dr. John Rowda: 14:13

You make them look good.

Dr. Michael Koren: 14:16

The things you can do with video. Thank you everybody. Thank you for watching, Thank you for listening and wear your sunglasses and wear your mask when appropriate. We appreciate your attention.