About Those Urgent Care Doctors in Bakersfield: They're Wrong. Here's Why.

Important update 90 minutes after this first posted at : a strongly condemning press release from both the American College of Emergency Physicians (ACEP) and the American Academy of Emergency Medicine (AAEM). This is a big deal; such professional guilds/bodies don't do this

About those two doctors in Bakersfield, California, Dan Erickson and Artin Massihi. They released a video Wednesday April 22, 2020, claiming that their data from "early testing" showed that it was time to start reopening California, and that "sheltering in place" could weaken the immune system. (I'm not linking to the video; it's easy to find on YouTube.).

The very short critique

1. They are not epidemiolpgists or infectious disease experts. I believe only Massihi is board certified. They lack the specialized training to analyze their test results (see discussion below).
2. They own a chain of urgent care centers (Accelerated Urgent Care) that are reported to be struggling financially because of the shut down.
3. They don't identify which of the current tests they used. Some of the tests are more reliable than others, and all tests have significant error ranges.
4. Erickson and Massihi did not test a random sample of the population, but tested sick people who presented to their clinics. This renders their analysis invalid.
5. The calculations they used were highly inaccurate. "Erickson compared Norway to Sweden and did the math wrong. Norway has 37 deaths per million so far and Sweden has 253 per million so far. Sweden also has the steepest curve and is 7th in the world in deaths per.million of their population and rising the fastest in percentage"
6. There is no evidence "sheltering in place" weakens the immune system.There are hundreds of millions of organisms to challenge the immune system, even in the cleanest house

Local infectious disease expert Navin Amin,critiqued their analysis on April 23.

On April 25,  Jennifer Kasten, MD, a pathologist with degrees in infectious disease epidemiology, mathematical modeling of epidemics, and fieldwork in epidemic control, published an in-depth critique of Drs. Erickson and Massihion on Facebook

If Dr. Kasten's analysis is too long for you to read, here is my summary:

They made two epidemiology/immunology claims:

1. That based on their testing, 6.5% of the entire Central Valley is positive.
2. Prolonged social distancing damages the immune system, and we are all becoming weaker for staying at home.

Both of their claims are false.

Also on April 25, on Twitter Professor of Public Policy and Sociology Richard M. Carpiano remarked

Got #COVID19 findings? Report them as scientists do? Nah! Go for press hype, public view, evid. be damned!

• hold press conference at urgent care clinic you own
• wear scrubs (looks expert-y)
• get news to lead w/your creds bf your epid. 101 weak finding

Feel free to copy and paste the above as needed. Now I'm going to get (as was my wont) a lot more detailed critiques. A record, if you will, of reactions. It's long, and detailed, and may not be of interest to you, but there should be a record.

Carl T. Bergstrom started a twitter thread the morning of April 26. His twitter bio reads:

Prof. Biol. @UW. Information flow in biology, society, & science. I love crows and ravens. he/him Book *Calling Bullshit* coming Aug 4th.

I am doing this as a text file, rather than something like Thread Reader App, because... well, I lost a lot of valuable content when Storify shuttered. You can read the originals in the Twitter link above.

Dr. Bergstom's Tweet Thread

Unfortunately the misleading claims of those two doctors in Bakersfield keep making the rounds, so I want to very briefly address the problem with what they are saying.

I won't get into their possible motives, past political activity, etc.

What they did was simple: they looked at the fraction of patients who tested positive for #COVID19 at the clinics they own. They found 340 out of 5213 tests were postive, about 6.6%

Then they assume the same fraction of the whole population are infected.

From there, they scale up to the state level and claim 12% incidence statewide. The news story says it is using the same calculation, but it can't be—how did they get from 6.6% to 12%? Perhaps they estimating infected *ever* versus infected *currently*. It's not clear.

Using that 12% infected figure, and a known 1400 deaths in California, they assume 1400 out of 4.7 million have died. That gives them an infection fatality rate of 0.03%. That is, they think that if 10,000 are infected, 3 will die on average. .

The problem with this approach is that during a pandemic, the people who come into an urgent care clinic are not a random sample of the population.

A large fraction of them are coming in precisely because they suspect that they have the disease.

This generates sampling bias.

Estimating that fraction infected from patients at an urgent care facility is a bit like estimating the average height of Americans from the players on an NBA court.

It's not a random sample, and it gives a highly biased estimate.

Moreover the estimate does not pass even a basic plausibility check.

In New York City, 12,067 people are known to have died from the virus, out of a population of 8.4 million.

This is a rate of 0.14% of all people. Not just infected people. All people.

That gives us a lower bound on the death rate in New York. Not an estimate, a lower bound.

The death rate for infected people is obviously higher than 0.14%, because not everyone in New York has been infected.

And yet that 0.14% lower bound is nearly *five times as high* as the 0.03% that the Bakerfield duo are claiming. They've used absurd methodology to arrive at an implausible number.

If the pandemic were not so severely politicized, this would be a non-issue from the start.

. . /fin



 . 


This is a much longer, detailed critique, with timestamps

From a physician, reposted by his friend Michael Falk MD on Monday, April 27

OK, since this video by Drs. Erickson and Massihi has been making the rounds on facebook, I feel like I need to respond. Now first of all, I actually agree with the basic premise that this is not as dangerous as we first thought and we should probably move to open. However they make many false and misleading claims so I feel like I need to respond.

This video is I believe making the rounds because it sounds internally logical and has many facts that are either deliberately or inadvertantly misinterpreted and about 95% of the things they are saying are true and then there's the 5% that's the gotcha.

So let's go through it point by point.

1. at around the 3 minute mark, he says that we should quarantine the people that are sick and not the people that are well. ABSOLUTELY CORRECT. However in order to quarantine the sick and not the well, you need to know who is sick and who is well. That's the problem with Covid-19 is that unlike measles or most other infectious diseases, people can spread the disease when they are asymptomatic so how do you know who needs to be quarantined and who doesn't? Ideally, you do what South Korea did and have lots of testing available and you test everyone and then you trace all their contacts and test them and now you know who has the virus and who doesn't and you quarantine those who have the virus and let the others go about their business. We did not have testing and we still do not have enough testing to test everyone. so what do you do when you don't know who has the virus? yeah, you quarantine everyone.

2. around the 4 minute mark, they say that they had 340 out of 5213 tests positive (6.5%). Then they talk about how 12% of the tests in california were positive and 39% of the tests in new york were positive. Then they say that Ca has 39 million people and 12% of them being positive means 4.5 million people have covid-19. THIS IS THE SINGLE GREATEST PROBLEM WITH THIS VIDEO.

Either they are being purposely misleading or they completely forgot statistics 101. They are confusing testing within a high pretest probability cohort with a random sample of the population that can be extrapolated to the general population. Let me explain. Until now, the way covid testing worked was that there were so few tests that we only tested people that we were pretty sure had the disease. And even if we were pretty sure they had the disease, if they had mild symptoms, we didn't test them. Therefore the tested samples will have a much higher rate of positivity than the general population.

This kind of thought process would be like I run an emergency room and tonight 10% of the people have a stroke. Then I extrapolate that to mean that 10% of the world is having a stroke tonight. That's obviously ludicrous. The sample of people coming to the ER is not representative of the entire population.

There are currently random testing studies being done to look at prevalence in the general population and I've discussed them and they think the prevalence is about 2-3 percent. These are early studies and still should not be used to extrapolate nationwide and have problems dealing with bayesian probability and testing specificity but are FAR FAR better than using testing data in a hospital setting to the population. That's just plain wrong.

He keeps saying he's following the science and using data. The problem is that he doesn't understand data and is misinterpreting it and is NOT following the science.

3. Around 13 minutes, they discuss Norway and Sweden. Sweden has 1,765 deaths. Norway has 182 deaths. He claims this is statistically insignificant. I have no idea what statistical test he used and I'm pretty sure he has no idea either because he didn't do one. The correct test to do would be a chi squared test with Yates correction. That gives a P value of <0.0001. That's about as statistically significant as it gets! In fact, you don't even need to do a statistical test on it. Sweden has 10 times the deaths as Norway. No one looks at a ten fold increase and says "BAH, that's nothing!"

4. Around 16 minutes he talks about the downsides of the shutdown. These are valid points there are DEFINITELY downsides.

5. Around 18 he starts talking about the immune system. He talks about how the immune system needs to be exposed to pathogens to develop. ABSOLUTELY TRUE. But then he takes immunological development in a child to adults in quarantine. NOT TRUE. Unless you live inside a bubble, your home and your yard have TRILLIONS of pathogens. No amount of lysol and handwashing is going to remove pathogens that you breathe in and touch all the time. Your own mouth has billions of microbes. Your skin is teeming with microbes. Fungal spores and viruses in the air. Your immune system will 100% not be weaker by being at home. Your immune system might get weaker if you stay home, don't exercise and eat candy all day but the fact of being home in an of it self will not harm your immune system.

6. Around 26 minutes he says academics and reality are two different things. This appeals to some people but in this case, they need to go back to academics to learn basic statistics.

7. Around 27 minutes he talks about all the fomites you bring from costco to your house and totally contradicts his own point from 18 minutes (#5)

8. Around 28 he talks about the logical inconsistency for being able to go to costco but not to work or church. Because you're going to be interacting with people at either place. YES, ABSOLUTELY TRUE. Ideally, people should go nowhere. But we do need to eat and there's no other mechanism available to get food so they are letting what they consider "essential" continue. Now what's considered essential is up for debate since they've said liquor stores are essential which I personally disagree with but there is a logic in that.

9. Around 30, he claims doctors are being pressured to add covid to the diagnosis. That is definitely not happening at Loma Linda University or any other institution that I've spoken to.

10. Around the same time he talks about how covid doesn't kill people, their preexisting condition kills them. well we know for a fact that young healthy people have died. not often and definitely having poor health before makes you more likely to succumb.

11. Around 33. they said widespread testing is needed to open the economy. YUP. THAT'S WHAT EVERYONE IS SAYING.

12. Around 34, he says that covid and flu kill people. Completely contradicting himself from 3 minutes ago.

13. Around 37 he talks about quarantining the sick. YES, but no one knows who is infected or not right now and THAT is the biggest problem.

14. Around 41 minutes, they said that no one does in house testing. Actually every major hospital does in house testing. Loma Linda, USC, UCLA, Stanford, U of Washington, etc.

15. Around 45 minutes he talks about staying home if you have symptoms. Yes, but maybe he's not aware that people are infectious and shedding virus when they have no symptoms and a significant proportion NEVER get symptoms but are still spreading the virus. That's what makes covid-19 harder to get a handle on. If people didn't shed virus until AFTER they had symptoms it would be very easy. Just tell everyone to stay home once they get symptoms. problem solved. Unfortunately, this one transmits before symptoms are evident.

16. Around 47 they claim the virus will mutate and become less and less virulent. There is absolutely zero basis for that claim. None WHATSOEVER. It's possible that it will mutate and become less virulent but then that virus will be out-competed by the parental strain that is more virulent. It's also possible that it will mutate and become MORE virulent. There is no basis for which to say that a virus will mutate and become less virulent.

17. Around 48 minutes, they make a claim saying that academics haven't seen a patient in 20 years. That's not how academic medicine works. I see patients every day. And I see the patients that are too complex for the doctors in the community to deal with.

18. Around 50 minutes, they claim that wearing masks and gloves reduces your bacterial flora. You get your bacterial flora from the food you eat, the clothes you wear, the air you breathe. Wearing masks and gloves have minimal impact on that especially since most people take those things off once they get home.

They also claim that they spoke to Kern County public health commissioner who agrees with them. That's not true either.

Source: https://www.theblaze.com/news/doctor-dan-erickson-coronavirus-reopen

(Updated April 28, 2020, at 5:21 pm  to add this anonymous account.  I can't reveal specifics, but it is from a medical person in the Central Valley. )

I am publishing this at 6:48 pm, April 27, 2020. I will add content as I find it, and will specifically state when content is added. I may also make sources more visible (making visible the URLs hidden in links). All errors are my own. In the future, updates will be noted at the bottom of the post

Articles and other media critical of Drs. Erickson and Messihi's messages

April 27, 2020: The announcemnt

The American College of Emergency Physicians (ACEP) and the American Academy of Emergency Medicine (AAEM) jointly and emphatically condemn the recent opinions released by Dr. Daniel Erickson and Dr. Artin Messihi. These reckless and untested musings do not speak for medical societies and are inconsistent with current science and epidemiology regarding COVID-19. As owners of local urgent care clinics, it appears these two individuals are releasing biased, non-peer reviewed data to advance their personal financial interests without regard for the public’s health.

COVID-19 misinformation is widespread and dangerous. Members of ACEP and AAEM are first-hand witnesses to the human toll that COVID-19 is taking on our communities. ACEP and AAEM strongly advise against using any statements of Drs. Erickson and Messihi as a basis for policy and decision making.

April 26, 2020 I posted a shorter version of this post to my wall on Facebook. It was shared a LOT which was heartening.

April 27, 2020 Barbara Feder Ostrov at Cal Matters: Cue the debunking: Two Bakersfield doctors go viral with dubious COVID test conclusions

But already the Bakersfield doctors — who tout their support of President Donald Trump and refuse to wear masks in public — had become heroes on social platforms and conservative media outlets, with some commenters calling them “brave.” Others who support continuing to shelter-in-place described the doctors as self-promoters whose chain of urgent care centers would benefit from reopening. Non-COVID medical visits have plummeted during the pandemic, endangering the practices of many doctors.

“As struggling business owners, their economic frustration is understandable. But it can’t be mistaken for science. People trust doctors,” Michigan emergency room doctor Rob Davidson wrote on Twitter. “When they tell Fox viewers to ignore recommendations from real experts, many will believe them…The impact of rejecting science-proven recommendations in exchange for these erroneous ideas would overwhelm health systems and cost lives. While re-opening the economy might be good for their Urgent Care Centers (sic), it would kill medical personnel on the actual front lines.”

April 27, 2020 Ari Allyn-Feuer at The Prepared Dr. Erickson’s viral “COVID-19 Briefing” video is dangerously wrong

The video, which is better browsed in transcript form, is a catalog of errors that range from the blatantly wrong to the subtly misleading. But the central and most inexcusable flaw of the entire video is this. Erickson confuses test positivity rates (i.e., the percentage of positive PCR tests among a group of people who were actually able to get tested for COVID-19) with community attack rates  (i.e., the percentage of people in a whole population who have had COVID-19).

April 28, 2020: From David Gorski MD at Respectful Insolence: Dr. Dan Erickson and Artin Massihi: Promoting dangerously bogus pseudo-epidemiology about COVID-19

There’s a pandemic of more than just COVID-19 right now. There’s also a pandemic of pseudoscience, misinformation, disinformation, and just plain bad science. There’s also a pandemic of armchair epidemiologists confidently spouting off about infection rates and case fatality rates, people who self-assuredly say, “I’m not an epidemiologist or infectious disease expert, but…” and then proceed to make opine about the incidence, prevalence, and treatment as though they were experts. 

April 29, 2020 From FallacyMan at Logic of Science blog: Shoddy statistics and false claims: Dr. Erickson dangerously misled the public on coronavirus</p>

Their entire argument rests on the notion that the mortality rate from COVID is actually very low, even less than 0.1% (roughly the typical mortality rate from the flu). Actual studies have found that the mortality rate varies from 3.6% (Baud et al. 2020) to 1.4% (Wu et al. 2020). I have yet to see an estimate based on confirmed cases that was anywhere near the number these emergency doctors came up with (see Note 3). So how did they get such a low number? Easy: they’re bad at statistics.

Articles and other media supporting or amplifying Drs. Erickson and Messihi's messages

April 24, 2020: Brit Hume, a Fox News commentator with 1,190,000 followers, tweeted out a link to the physicians' press conference. Mr. Hume's link was re-tweeted more than a thousand times. 

April 27, 2020: Drs Erickson and Messihi appear on Ingraham Angle

April 27, 2020: Tucker Carlson: New Evidence Means The Coronavirus Far Less Deadly Than We Were Told,, calls Dan Erickson "a researcher"

April 28, 2020: Charles Creitz at FoxNews: "California urgent care doctor questions stay-at-home orders: 'You can get to herd immunity without a vaccine'"

News Coverage

April 29, 2020 Anna-Maja CNN Wire Service, Dubious coronavirus claims by California doctors condemned by health experts
April 29, 2020 Stacey Shepard, Bakersfield dot com,   Local doctors spark widespread debate over virus's death rate, when to reopen