On Being a Doctor During the Pandemic

On Being a Doctor During the Pandemic

Author’s note:  I initially sat down to write an article concerning treatment options for COVID-19, particularly hydroxychloroquine.  It became clear to me, however, that some preface was needed.  Why is there no clear direction from physicians regarding these treatment options?  I hope this gives a little insight from my perspective, even if it doesn’t provide any definitive answers…

As a primary care physician on the front lines of this COVID-19 pandemic, I get asked many questions related to all aspects of this virus.  As I do my best to respond, I find myself frequently saying something like, “We are doing our best to figure this out as we go along.”

And while that is absolutely true – we are doing our best to provide appropriate, careful care during these unprecedented times – I hate saying it.  It doesn’t feel comfortable, or right.  After years of training and then 12 years of experience in the practice of Internal Medicine, I am used to being in a position to provide answers.  Perhaps solutions are not always possible, and a physician has to become accustomed to some degree of uncertainty in practice, but I can usually lean on evidence, research, experience, training, knowledge, etc. to be able to care for patients with confidence.

But now – during this pandemic where people are desperate for guidance and looking fervently to their physicians to find it – I find that I have little concrete guidance to give.  Where I’m accustomed to having the Weight of Evidence-Based Medicine behind me, I now find myself in much more unstable and frightening waters, where conflicting data is coming in from all directions, and nothing is clear.  It’s hard not to feel like I’m letting everyone down, in their hour of greatest need. 

Allow me to explain the predicament we are facing in medicine right now, especially as it relates to the outpatient treatment of COVID-19.  A lot of ongoing research and study is devoted to the care of the very sick with this illness – those who are admitted to the hospital, requiring supplemental oxygen or mechanical ventilation.  Comparatively little research has been devoted to treatment options for higher risk patients who are not sick enough to be in a hospital – there is a significant proportion of these patients who will eventually become sick enough to be in a hospital, but until then, they are under my care.

From the perspective of a patient, this is the way you want your doctor to practice medicine.  Don’t misunderstand me – medical care should never be “cookie cutter” or “one size fits all.”  The best doctors are able to individualize care specific to the patient sitting in front of them, taking into consideration all the unique aspects of you.  But there has to be a balance.  You don’t want your doctor to forego standards of care in order to blaze his own trail and “try new things out.”  You also don’t want your doctor to jump “all in” on a new medication or therapy, without carefully considering the validity of the research behind it.  Done correctly, a physician can draw on the knowledge generated by high-powered studies and then apply that knowledge appropriately to each individual.

This feels right.  This is the way medicine should be practiced, and I want this for my treatment of COVID-19.  But I don’t have it.

There are many treatment options that are being considered for early treatment of mild to moderate COVID-19.  Hydroxychloroquine (HCQ)?  Azithromycin?  Zinc?  Vitamin D?  MMR booster?  Many of these have shown promise, and the mechanism of action of some of these treatments is intriguing, but none are yet validated to work by these large randomized controlled trials.  This takes time – we will eventually have answers to these treatment options, but doing these studies correctly takes time.  So what to do?  One answer is to wait.  Medical research will show which of these regimens – or perhaps others – are most effective and safe for the treatment of COVID-19, and when that data emerges I can then approach my patients with confidence and offer a treatment strategy.  There is a large part of my brain that tells me that this feels right.  This satisfies my desire to provide correct treatment (not just any treatment), satisfies my oath to “first do no harm,” satisfies my years of training that point me in this direction. 

But there’s another part of my brain that is screaming just as loudly that this DOESN’T feel right.  What is going on while we wait for the answers to come?  Thousands and thousands of people are continuing to get infected with the SARS-CoV-2 virus, and many of these will go on to be hospitalized with severe illness, and some will die.  If one of the treatment options mentioned above turn out to be safe and effective – and eventually become standard of care – are we unnecessarily withholding that treatment right now?  And if we did adopt those treatments right now, could we prevent many of these severe illnesses?  Could we save lives?  What if medical history looks back on us, shakes its head solemnly, and says “Man, they should’ve started using <fill in the blank> so much sooner…”

And what else is happening while we wait for the answers to come?  There is so much more suffering as a result of COVID-19 – social, economic, psychological, educational.  Our lives have been truly turned upside down.  We all know from Stranger Things that Upside Down can be scary.

On the one hand, I can wait.  The research will eventually give us confident, safe treatment options.  In the meantime, we do our best to slow down the spread of COVID-19 by wearing masks, hand washing, social distancing, and careful decisions regarding things like church, school, sports, etc.  This ensures that we don’t provide premature treatment that turns out to be unsafe or ineffective.  This option feels right, but at the same time it doesn’t feel right.

On the other hand, I can go out of my comfort zone and attempt some of these treatment options that potentially show promise.  We could carefully implement these strategies while at the same time re-evaluating them in real-time as data continues to emerge.  There is a risk here of potentially doing harm with these treatments, but also the potential for great benefit.  This option feels right, but at the same time it doesn’t feel right.

This dissonance is, quite frankly, uncomfortable.  I do think that some of these treatment options have potential.  However, I do not like feeling that I am experimenting on my patients.  In a previous post, I mentioned using the “risk-benefit ratio” as a decision-making tool – whether or not to proceed with an intervention depends on weighing the risks and the benefits.  How can I have this conversation with my patients when I’m not sure of the risks, and even less sure of the potential benefits?  On the other hand, what do I say to my medically vulnerable elderly patient when her COVID-19 test comes back positive and she looks at me and asks, “Is there anything you can do to help me?”

Listen, let me make something clear.  If there was a treatment out there that was showing clear benefit, I would be using it.  I have no interest in withholding treatment for my patients that are ill.  I am also not concerned about political or media influences when it comes to medical care.  The fact of the matter is that there is no clear front-runner as a candidate for treatment.

If you were perhaps looking for The Answer at the End of the Article, I am afraid that I will have to disappoint you.  I have frequent conversations with my doctor friends and colleagues, and we are all sincerely trying to make the best decisions with the information we have.  To make matters even more complicated, there seem to be strong influences – both within the medical community and without – that make it very difficult to critically analyze and consider these options.  I have had a very hard time understanding these influences, or even definitively recognizing their source.  There is strong pressure from patients to be open to new treatments, and strong pressure from the medical community to not yet use these treatments outside of the context of a clinical study.

Doctors should be decisive – an indecisive and unsure physician does not inspire much confidence.  However, I feel like our profession has been plagued with indecision when it comes to many aspects of the COVID-19 pandemic.  For that, please forgive us.  But I also request that you be patient with us (no pun intended).  The vast majority of us are really trying to wade through all the noise, clutter, and politics to make the best decisions for our patients.  We do feel the pressure of time as this continues.

After all, we are doing our best to figure this out as we go along.