Drs. 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. Personally, whenever anyone starts out by saying, “I’m not an infectious disease expert or epidemiologist, but…” I respond, “You should have stopped after ‘I’m not I’m not an infectious disease expert or epidemiologist.” The problem, of course, is that estimating, for example, prevalence of exposure to COVID-19 and case fatality rates is very difficult in the middle of a pandemic in which there is insufficient testing, case numbers are still climbing, and the antibody tests likely have high false positive rates, and if you don’t have any training you don’t even know what you don’t know. That applies to physicians, too, most of whom have no training in epidemiology or virology. It goes double for the Bakerfield duo who’ve become the darlings of Fox News and COVID-19 deniers, Drs. Dan Erickson and Dr. Artin Massihi. Their toxic Dunning-Kruger ignorance is spreading via news stories like California urgent care doctor questions stay-at-home orders: ‘You can get to herd immunity without a vaccine’, Tucker Carlson: New Evidence Means The Coronavirus Far Less Deadly Than We Were Told, and Frontline doctors who administered 5,000 coronavirus tests want to reopen, say COVID-19 similar to flu, all based on this video, originally posted featuring Drs. Erickson and Massihi a week ago or so:

The original 52 minute video was removed from YouTube for violating its terms of service, but unfortunately you can find it everywhere, even elsewhere on YouTube, plus this 12 minute part 2:

Based on their “study” Drs. Erickson and Massihi have found themselves falsely elevated to the status of “experts” in the right wing COVID-19 denying crankosphere. They are in fact pseudoexperts. For one thing, from what I’ve been able to tell, although Dr. Massihi is a board-certified in emergency medicine, Dr. Erickson, who does all the talking in the first video, can’t even be viewed as an expert in emergency medicine, as he appears not to be board-certified in it based on my searches. For purposes of discussing epidemiology, it doesn’t really matter if Drs. Erickson or Massihi are boarded in emergency medicine anyway. In fact, Erickson and Massihi’s video, it turns out, is a slick mix of statements, made by doctors in that are mostly true mixed with misinformation and bad science thrown together to give a message that is probably true (COVID-19 likely has a case fatality rate considerably lower than estimates made early in the pandemic) but exaggerated (it’s as low as influenza), all in service of a political message (“we should reopen America because COVID-19 is not that dangerous”).

Erickson starts out by describing how the focus on COVID-19 means that a lot of people with other medical problems, such as heart attacks and the like, are afraid to come to the hospital (or their urgent care clinics) and may be dying at home or recovering without treatment that might have minimized the damage. This is true. Erickson also notes that we should quarantine the sick and not the people who are well, which is, of course, the way we will eventually have to remove the restrictions, while dismissing the current approach of in essence “quarantining” everyone with shelter-in-place orders as overkill. The problem is that to be able to quarantine the sick and allow the well to go about their business with lesser restrictions, we need accurate testing, a lot more accurate testing. Absent a lot of testing, and the robust ability to trace the contacts of those identified as having COVID-19, the only option was the one that most nations and most states in the US chose: Shelter-in-place orders of varying strictness. While Erickson is correct that a more targeted approach to quarantine is desirable, he barely mentions what is needed to achieve that.

At this point, Erickson states that Accelerated Urgent Care centers have tested 5,213 people and that 340 of them were positive, which he characterizes as “6.5% of the population” of the Central Valley in California, their cachement area around Bakersfield. He then mentions that 12% of the tests in California were positive and 39% in New York were positive, after which they make a really brain dead extrapolation. Based on California’s population of 39 million people, if 12% tested positive then 4.5 million people in California might have had COVID-19. This is, of course, utter nonsense. Similarly, Erickson extrapolates from his observation that 6.5% of their COVID-19 tests were positive that 6.5% of the people in Bakersfield have or have had COVID-19; i.e., about 58,000 cases, far more than the 700 confirmed cases in the area thus far. He then makes the argument that hospitalization and case fatality rates should be based on these numbers, estimating the COVID-19 case fatality rate to be around 0.02%, arguing that it’s five times less lethal than the 0.1% case fatality rate due to the flu. There is no facepalm large enough for this boneheaded claim, but this one comes close:

Finally, based on the “analysis” by himself and Dr. Massihi, Erickson identifies a number of economic and political implications, the most prominent of which is, unsurprisingly, echo the COVID-19 diminishment and denial machine’s call to “reopen America” based on the argument that the shutdown is doing more harm than good. (They also make a really brain dead claim about the harm shelter-in-place is supposedly doing to our health. More on that later.)

Perhaps the best deconstruction of this particular claim can be found here:

The point is that the assumption that the population served by these doctors’ urgent care centers is representative of the general population. As I said, this is Epidemiology 101 stuff, a mistake so egregious that it isn’t even worthy of being called a rookie mistake. I’ll quote Dr. Kasten fairly extensively:

Their fatal, immediate, obvious, rookie mistake is that their 5213 people are in NO WAY REPRESENTATIVE of the population at large. Although we don’t know how many (because the data was not that thorough)- we can assume a decent chunk of these people had symptoms of COVID, sought care, and were tested. Their urgent cares had the lion’s share of COVID tests for the entire Central Valley (which is awesome). So ANYONE in Bakersfield who felt worried would go there. Presumably doctors referred patients there whom they felt needed testing.

Walk around an ER on a Friday night. If 4 out of 50 patients had broken legs, and another 10 had heart attacks, you can’t assume 8% of the city fell off a ladder when drunk that night and a full quarter were clutching their chest in an armchair as we speak. In epidemiology terms, that’s selection bias- bias introduced by a non-random sample.

So, essentially their calculations are entirely invalid. If they could somehow prove that the 5213 were an entirely random sample of people which was perfectly representative of the age, sex, pre-existing conditions, ethnic background and degree of symptomatology of the Central Valley, that would be different.

Characterizing their mistake as a “rookie mistake” is too generous.

Echoing this analysis is Michael Falk:

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.

What is the selection bias? Who comes to urgent care clinics and get a COVID-19 test? Obviously, it’s those who were worried that they had been exposed to COVID-19 or who had COVID-like symptoms, such as cough, fever, and shortness of breath. Far more of their patients at their urgent care centers would be likely to have COVID-19 than the general population. We also don’t know the time frame during which they were doing these tests; so the percentage of the population with COVID-19 could have been rapidly increasing. Someone also pointed this out to me:

Which linked to this video from March 17, in which they announced that, having opened three new locations, their Accelerated Urgent Care centers would begin testing for COVID-19 because they had procured a lot of tests.

This TV news report could easily have spurred anyone with symptoms or concerned that they had been exposed to someone with COVID-19 to head on over to an Accelerated Urgent Care center location to be evaluated and tested. And guess what? In that video, they state that only symptomatic patients would be tested. Is it any wonder that they observed a high percentage of COVID-19 positive tests?

There are a number of other flagrant errors of science in the video, too. For instance, Erickson claims to have looked at the numbers in Sweden (at the time, with 1,765 deaths) compared to Norway (182 deaths) and claimed that this was statistically insignificant. As Michael Falk pointed out, that’s BS. Clearly, Drs. Erickson and Massihi are not statisticians, either. Erickson repeatedly claim to be “following the science.” What they’re doing is cherry picking and misanalyzing the science in order, in essence, to lie with statistics.

There are a number of other nonsense claims, such as dismissing academic physicians as not having seen a patient in 20 years. This, too, is utter nonsense and betrays an ignorance of the current state of academic medicine. The MD who can support himself through research grants alone has become so rare as to be an endangered species these days. Nearly every academic physician must bring in a certai amount of clinical revenue, their clinical productivity judged by a measure known as RVUs (Google it if you’re curious; for purposes of this post how RVUs are calculated doesn’t matter). If their RVUs are too low, their salary goes down. If they generate a lot of RVUs, they get bonuses. Indeed, if these “entrepreneurs” knew academic medicine, they’d know that the dependence on RVUs has made it very difficult for academic physicians to find the time to do research. Similarly, Erickson claims that “no one” does in-house testing. Actually, almost every major hospital now does in-house testing. The hospitals where I have privileges have been doing in-house testing at least three weeks now, for instance, and were doing it when this video first dropped.

The part at around 18 minutes is where this not-so-dynamic duo talk about the supposedly harmful effects of quarantine. Guess what? Like a quack, Erickson claims that it harms the immune system to shelter in place. Particularly amusing is the part where hes brag about all the experience and study in microbiology and immunology that he and Dr. Massihi have. As far as I can tell, though, they haven’t done any study beyond what a typical medical student would undertake in those areas, which means that they likely know as much as the average doctor about these topics, nothing more. That is not true “expertise.”

In any event, Dr. Erickson goes on about how the immune system develops through exposure to antigens. That is, of course, true. I’ve spoken about “immune amnesia” caused by the measles virus, wherein the measles virus erases a subset of memory cells providing immunity to antigens previously encountered, partially “resetting” the immune system so that it no longer has immunity to some previously encountered antigens. So, yes, exposure to antigens is important. Invoking “Immunology and Microbiology 101,” Erickson then goes on to claim that staying at home is bad for the immune system because one doesn’t encounter enough antigens. Too bad it’s also “Immunology and Microbiology 101” that there are trillions of bacteria in your home and yard. As Falk puts it:

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 itself will not harm your immune system.

I’ll also quote Dr. Kasten, because I love her all-caps line:

UNLESS YOU LIVE INSIDE AN AUTOCLAVE, YOUR HOME IS PLENTY PATHOGEN-RICH

The world is absolutely teeming with microbes. You’re coated in them, your house is coated in them, they enter your body with every breath you take and everything you eat. Your immune system is getting a perfectly adequate workout. You’re just restricting your exposure to a handful of things (respiratory pathogens) for a very short period of time.

I’d add that, even an autoclave can be a place where pathogens grow when it hasn’t been used in a day or two. Seriously, Erickson and Massihi don’t understand even “Immunology and Microbiology 101.”

There’s a lot of other nonsense in the video, so much so that I skipped over some parts. For instance, Erickson claims that doctors are being pressured to add COVID-19 to diagnoses, implying that we’re overcounting COVID-19 cases. In fact, the evidence is very strong that, due to insufficient testing, we’re undercounting cases and deaths due to COVID-19. Indeed, all-cause mortality statistics rose dramatically during the early weeks of the pandemic, suggesting a lot of excess deaths beyond what is normally expected at the same time of year, very likely the majority from COVID-19, that aren’t showing up in the statistics. In fact, case and death counts have likely been undercounted by quite a lot.

Then there’s Erickson’s claim that COVID-19 doesn’t kill people, but rather their pre-existing conditions do. At that point, I wondered: Is this guy really a physician? How can he be so obtuse? Of course, pre-existing comorbidities and age increase one’s risk of developing severe disease and dying from COVID-19, but COVID-19 has also killed young otherwise healthy people without significant comorbidities.

I could go on, but why bother? These are the key pieces of misinformation promulgated in this video. I can’t help but note, however, that Dr. Massihi, at least, appears to be a big fan of President Trump:

I also noted that Massihi also had at least one video by antivaccine leader Del Bigtree posted on his Facebook page, but he appears to have either deleted the post or made its access not public. Meanwhile, both have been appearing all over Fox News and right wing media sites pushing their bad science:

Amusingly, this not-so-dynamic duo of armchair epidemiologists always appear wearing scrubs emblazoned with the logo of their urgent care centers. In this, they remind me of Dr. Mehmet Oz, who always used to show up on Oprah’s TV show in scrubs, or Dr. Travis Stork, who frequently wears scrubs in his role as part of the panel on The Doctors, dressing up in a way that screams, “I’m a doctor! I have authority! Listen to me!” It’s a costume—and, make no mistake, for purposes of TV, wearing scrubs is a costume, even for doctors—that I frequently laugh at.

Meanwhile, the American College of Emergency Physicians and the American Academy of Emergency Medicine issued a devastating statement:

The American College of Emergency Physicians and the American Academy of Emergency Medicine provided a scathing rebuke of comments made last week by Accelerated Urgent Care Drs. Daniel Erickson and Artin Messihi.

The statement, in part, says, “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,” it continues. “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.”

The full statement is here.

I’ll conclude by quoting something that Dr. Erickson said that I actually agree with, “It takes work to understand this stuff.” It absolutely does take work to understand this stuff. The reason Drs. Erickson and Massihi owe me another irony meter is because they clearly haven’t done the work necessary to “understand this stuff.” Instead, as I said above, they’re fake experts, armchair epidemiologists who don’t even know enough to know what they don’t know. None of that has stopped them from being embraced by political forces that very much like their message and see their fake “results” as evidence that they can use to promote that message. Unsurprisingly, Drs. Erickson and Massihi appear to be very much enjoying their 15 minutes of fame and using it to promote their business and brand.

ADDENDUM (4/29/2020): I apparently misattributed Michael Falk’s post. He was quoting someone named Steve Lee, whose original post is here.

ADDENDUM #2 (4/30/2020): I see that over the past couple of days this post has resulted in a traffic to this blog 10-12X higher compared to the usual traffic this blog draws on an average Tuesday and Wednesday, as well as an influx of new commenters, some of whom appear to be Dr. Erickson and Dr. Massahi fans and/or people who take issue with what I wrote in this post. So I thought I’d just say a word to the newbies commenting about how things work around here.

If you’ve never commented on this blog, your first comment will automatically go to moderation. After I release the first comment, you can comment freely without moderation before the comment goes live. (After the comment is posted is another matter.) The reason for this feature is to cut down on comment spam. So, no, you’re not being “censored,” and if it’s several hours between your first attempt at commenting and your comment appearing on the blog, it’s usually because I was busy working or sleeping. If you’re interested, here is my comment policy.