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(Acute on Chronic) on (Chronic on Acute)

To my boys:

One of the more underrated skills learned during medical school and residency is that of producing "one-liners". Not to be confused with the one-liners that comedians and trolls use onstage and online, respectively, in medicine the term refers to providing much patient information in a single sentence so as to give colleagues and co-workers as much information in as little time as possible.

One of the more common phrases is the term "acute on chronic". For example, a patient who had asthma previously and is suffering from an upper respiratory infection would have acute on chronic respiratory distress. The idea is to convey the fact that the current symptoms a patient is having is likely exacerbated (and linked to) previous illness in the same area/organ/system.

One of the things about the present moment that is so remarkably stressful to Americans is that not only are there multiple major stress-inducing events (COVID and its accompanying public health and economic impacts) but also what economists refer to as "second-order concerns", ie the relative rates of change of these stressors in conjunction with one another.

In the case of the killing of George Floyd, there is the long-felt stress by those in the African American community and others in the context of systemic racism, especially when it comes to relations with law enforcement agencies. There, the horror of the video generated a wave of emotion on top of long standing stress, a classic acute on chronic situation. At the same time, for those in the medical field (and especially for persons of color) there is the concurrent issue of COVID, which has gone from this profound stressor in March and April (at least in Boston) and now, while having ebbed significantly, is not going anywhere and is likely to return in the fall. As such, there is no "end" to COVID, making it for now a chronic stressor placed on top of an acute one.

This kind of fatigue alternating with emotional whiplash makes the overall stress, in my experience much more than even the significant sum of its parts, because there is no way to adjust to both issues at the same time. I cannot imagine what this is like for those communities like the AfAm community that have been hit so hard by both.


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