426 - Zinc and URIs, Discrimination in Healthcare, No Feeling is Final

From the Literature

1) Zinc to Prevent/Treat Upper Respiratory Infections (URI)

In 2015, a Cochrane systematic review on zinc for the common cold had seemed to indicate some beneficial effect but was withdrawn due to issues of plagiarism and statistical techniques. Fortunately, two recent systematic reviews have filled the void.

2021 – Abioye et al., Effect of micronutrient supplements on influenza and other respiratory tract infections among adults (only zinc data shown here).

• Both oral and nasal zinc was studied.
• The review methods were good but the risk of bias in the studies was high.
• 5 studies (n = 554) on zinc supplements to prevent URI (either naturally acquired or lab-induced). No reduction in incidence of URI
• 9 studies (n = 1038 adults) on zinc supplements to reduce the duration of URI symptoms. Average of 47% reduction in duration of symptoms. With an average placebo group URI duration of 7.5-9.0 days, this means 3-4 days fewer sx.
• Lots of zinc was required! 13 to 23 mg orally every 2-3 waking hours.

2021 – Hunter et al. Zinc for the prevention or treatment of acute viral respiratory tract infections in adults

• Rapid review methods were employed to incorporate evidence on COVID-19, but no COVID-19 studies met criteria for inclusion. Risk of bias in studies was high.
• Both nasal gels/sprays and oral lozenges were studied.
• When used for prevention (4 studies, ~2700 patients):
  • Risk of developing mild to moderate symptoms of a URI were reduced (NNT=20 over a month), but avg. daily symptom score was not improved.
  • There was more reduction in risk of moderate to severe symptoms but these symptoms are rarer, so the NNT was ~100 over a month.
  • There were no significant differences based on age, route of zinc administration or dose, and there were no differences in adverse events.
• When used for treatment (17 studies, N varied with outcome):
  • Symptom scores were reduced by more than a point (clinically and statistically significant).
  • Symptom duration was reduced by 2 days.
  • Chance of recovery within one week was improved by 83%.
  • There was no consistent evidence about different zinc salts, doses, route of administration.
• Non-serious adverse events were common with zinc (RR 1.41, NNH = 7) – mostly taste aversion, nausea and GI discomfort and mouth irritation – compared to placebo, but not compared to “active controls” (such as quinine tablets and naphazoline spray; it is not surprising that there was no difference).

John’s Comments:

Keeping in mind that the overall quality of the studies was poor, zinc likely has a modest effect at preventing severe symptoms and reducing duration of symptoms in URI. If you don’t mind the non-serious side effects and are willing to take lots of zinc per day, it might be worth it. Unfortunately, there is no good evidence in these reviews on preventing or treating COVID with zinc.

References:

• Abioye AI, Bromage S, Fawzi W. Effect of micronutrient supplements on influenza and other respiratory tract infections among adults: a systematic review and meta-analysis. BMJ Global Health. 2021;6(1). doi:10.1136/bmjgh-2020-003176. Link
• Hunter J, Arentz S, Goldenberg J, et al. Zinc for the prevention or treatment of acute viral respiratory tract infections in adults: a rapid systematic review and meta-analysis of randomised controlled trials. BMJ Open. 2021;11(11). Link

Question From A Colleague 

2) Handling Discrimination in Healthcare Like a Professional

Question:

“I am a physician from a minority group who experiences substantial challenges from both colleagues/staff and patients. What would be an effective approach to helping colleagues to better understand the challenges of those healthcare professionals who are from a different ethnic, racial, or gender-identifying group?”

Answer:

Those with different identities can often feel that they are on the outside, and the constant struggle to belong or be included can feel exhausting. Representation matters because it enables those with non-dominant identities to see others like them in medicine and recognize that they, too, belong.

Over the past several years, conversations about implicit bias in medicine and the need for health equity have become more commonplace, and workplaces are increasingly developing strategies to address this problem. As awareness grows, many professionals are looking for tools and techniques to unlearn harmful thought processes, correct common misperceptions, and address bias when it arises.

All too often, discriminatory behaviors go unaddressed because they are either not recognized or there is a failure to respond. A recent article in the Family Practice Management Journal offered 4 skills and tactics to help spot and tactfully address discriminatory behavior in the healthcare workspace, whether that action comes from a colleague or a patient. These include:

1. Spot it. The first step in handling discrimination is to develop a lens for identifying it at the individual and organizational level. Although discriminatory behavior can be overt, often it is more subtle, indirect, or implicit. If you are not personally the target of the discrimination, it may be difficult for you to recognize that it is happening to others.

A helpful exercise is to think through a number of privileges you may or may not be afforded by your personal identity, including but not limited to your race, age, gender, sexual orientation, religious beliefs, professional training, work title, and the manner in which you groom and dress.

2. Don't ignore it. Incidents of bias may seem small to others in the moment, but they are often harmful because of the cumulative impact they have over time. This is particularly true of small comments or behaviors referred to as “microaggressions,” which unwittingly affect others. By sweeping them under the rug, we give implicit approval for them, perhaps in front of colleagues, learners, or patients who were harmed. Responding can be as simple as checking in on the person affected and saying, “I heard what that patient said, and I'm sorry. I didn't know exactly how to respond, and I'll need to reflect on that, but I recognize that it was harmful and want you to know that you are a valued member of our team.”

3. Call in vs. call out. One helpful tactic for addressing discrimination is the concept of “calling in” versus “calling out.” Instead of attacking someone for a behavior, which puts the other person on the defense and shuts down the conversation, start from a place of curiosity and assume good intent.

When “calling in,” here are some suggestions to consider:

• Start from curiosity, not certainty,
• Recognize that we all make mistakes, and speak from this shared experience,
• Be specific and direct, using personal stories if possible,
• Choose a time and place that supports conversation and learning,
• Disagree with the statement or action, not the person.

4. Use your judgment. The situations health care professionals face every day in their institutions can be challenging. When we address issues of race, gender, and other identifying characteristics, we often collide with complex power dynamics. There are no “right answers” for handling these situations, but unfortunately there are some wrong ones. Remember, recognizing and understanding context is important.

Mark’s Comments:

I’m grateful for our colleague who reached out with this concern. As we experience increased awareness and even a consciousness shift regarding discrimination, we are all learning and growing together. A good first step is to reflect as to who and how we want to be together and begin to notice and discuss when this is not happening, being curious as to what might be getting in the way.

In a recent podcast interview, Michael Bush, the CEO of the company Great Places to Work, provided a new perspective on what we presently call DEI (diversity, equity, and inclusion) which I found helpful. He added a 4^th component which he called “belonging,” in which differences are not only “tolerated” or “accepted,” but embraced. For me, this added a greater depth and richness to what I understand to be the intention of DEI.

Reference:

Byrne M and Wheat S. How to Spot and Tactfully Handle Discrimination in the Healthcare Setting. Fam Pract Manag. 2021 Sep-Oct;28(5):21-24. Article Introduction

From PeerR_xMed ( www.PeerRxMed.org )

3) Remembering that No Feeling is Final

“Let everything happen to you: beauty and terror. Just keep going. No feeling is final.” Rainer Maria Rilke (from the poem “Go to the Limits of Your Longing”) Full Poem

Over the past few weeks I’ve been experiencing a “surge” of a different kind, that of an unusual amount of negatively charged and emotionally draining patient interactions, which have left me feeling frustrated and quite weary. Even as I know that our psyches are hardwired to overemphasize the “negative” and therefore have been consciously attempting to counter that tendency, these interactions have often overwhelmed my emotional circuits.

It is in times like this that I find it helpful to revisit the psychological posture of “equanimity,” which is powerfully demonstrated by a favorite parable I have shared in this blog before and for my own sake, needed to revisit this week. Perhaps it will be a good reminder for you as well.

The Parable of the Farmer:

A farmer and his son had a beloved stallion who helped the family earn a living. One day, the horse ran away, and their neighbors exclaimed, “Your horse ran away, what terrible luck!” The farmer replied, “Maybe so, maybe not. We’ll see.”

A few days later, the horse returned home, leading a few wild mares back to the farm as well. The neighbors shouted out, “Your horse has returned, and brought several horses home with him. What great luck!” The farmer replied, “Maybe so, maybe not. We’ll see.”

Later that week, the farmer’s son was trying to break one of the mares and she threw him to the ground, breaking his leg. The villagers cried, “Your son broke his leg, what terrible luck!” The farmer replied, “Maybe so, maybe not. We’ll see.”

A few weeks later, soldiers from the national army marched through town, recruiting all the able-bodied boys for the army. They did not take the farmer’s son, who was still recovering from his injury. Friends shouted, “Your boy is spared, what tremendous luck!” To which the farmer replied, “Maybe so, maybe not. We’ll see.”

The word equanimity comes from the Latin aequanimitās, meaning “with an even mind; imperturbable.” It was during my residency training that I was first introduced to this concept in the context of medical practice when my department Chair shared Sir William Osler’s classic essay “Aequanimitās” with me. Dr. Osler considered equanimity as an essential quality for anyone in medicine, but not one that is easily attained. In the essay, he made it clear that equanimity was not a matter of denying our emotions, but rather in our consciously “owning” them rather than having them control us.

In reality, any circumstance we experience has the potential to elicit a wide spectrum of emotions. How we interpret and express them, however, is up to us, remembering that no feeling is final. After all, it’s our story, not theirs, as the parable so wisely demonstrates. How might the wisdom of the farmer inform the story that you (and they) are telling right now? We’ll see …

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Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org