The cost of providing care during a pandemic is seeing firsthand the evolution of medical knowledge, and wishing current data could have guided past decisions, says Eric Kutscher
When covid-19 hit New York City in March 2020, my first instinct as a doctor was to help my patients and my city. I read all the peer reviewed literature available about the virus (a very limited pool at the time), and started volunteering on a covid-19 hotline. I knew that responding to a novel pathogen would leave me facing many unknowns, but ultimately I hoped that communicating scientific evidence with the public would lead to better outcomes for all. Taking action, despite the limited knowledge we had, felt better than sitting on the sidelines.
My main role on the hotline was advising callers about when and where to seek care. The guidance and protocols we’d been given were simple. Given capacity constraints in New York City, covid-19 tests were only being offered to people sick enough to need hospital admission. Thus, in guiding the callers, we were to screen people for dyspnea over the phone. I would listen to the story of each caller and assess their breathing, and tell them: if you ever feel short of breath, seek medical care immediately. Otherwise, stay home.
But, as more evidence has emerged on covid-19, it appears that hypoxia caused by the virus doesn’t necessarily make people feel short of breath even if their oxygen saturations are dangerously low. People who may need medical intervention may not actually be dyspneic.
In retrospect, I can’t help but wonder: did the advice I and other volunteers gave—to stay home unless severely symptomatic—cause unintended morbidity and mortality? Were there people I spoke to who should have presented to a hospital earlier, and would they have had better outcomes if they had? What about the other symptoms I didn’t discuss with them: how many patients had electrolyte derangements from diarrhea? Or strokes with neurological features I never warned them to look out for? Data suggest that many people in New York died at home —and that they were disproportionately from black and minority ethnic groups. I was following guidelines, but even so, did I ever inadvertently exacerbate these inequalities by telling some of the most vulnerable people not to seek care?
My fears of the unintended consequences I may have been a part of don’t end there. When working in the hospital, the protocol for admitting patients with covid-19 included considering the use of azithromycin and hydroxychloroquine. I knew that the data behind using hydroxychloroquine were uncertain, but offering the medication to my patients meant at least I could provide them with something, even if it was a placebo pill to make us all feel more well equipped in our armourless battle against the virus.
Recent studies, however, have shown that hydroxychloroquine may not only be ineffective against covid-19, but also iatrogenic for other conditions. What harm did I, and other clinicians in my position, potentially do in believing a therapy could possibly work, on limited evidence, and offering it to patients? During this pandemic, have we negated the decades’ long tradition in medicine of prioritizing safety first? Or do the principles guiding medicine bend during this kind of crisis, when the ability of real time evidence to dictate patient care is tested by the unprecedented volume of loss and despair at our doorstep?
Practicing medicine in a pandemic brings many challenges. There are many patients, fewer resources, and an abundance of unknowns. Looking back to the start of covid-19, with the same amount of information I had then, I wouldn’t have changed my management. But that reasoning doesn’t entirely dispel the regrets. The pain of living through a pandemic is seeing what you could or should have done. If Mr P had come to the hospital two days sooner, maybe his intubation could’ve been avoided. If Mrs C had gotten sick only a few weeks later, she could’ve avoided hydroxychloroquine and instead been started on remdesivir.
As a doctor, I have dedicated my whole life to trying to do what’s best for my patients. In a pre-covid-19 world, there was clear evidence that doing everything I could for my patients resulted in improved care. But now, I wonder if in some situations the only real benefit I can give my patients is my time, support, and guidance.
The emotional burden of bearing witness to the mistakes of medicine is exhausting. As I welcome the new class of intern physicians below me who were spared from working during the peak of the pandemic, I am envious of the enthusiasm and curiosity they bring, which I’ve lately struggled to find in myself.
I know I’m not alone. As curves flatten and cases decrease, we frontline providers can finally come up for air and reflect on the past few months. As the world tries to move on and find a “new normal,” we live in the recent past. The epidemic of burnout among healthcare workers, who went all in as frontline providers during the worst of the pandemic, is only starting. Before covid-19, we were already spread thin and asked to do too much. But now many of us will have little energy left for it in the near future.
In jumping in to help during this crisis, it’s possible I also did harm. As we begin to process the sorrows we witnessed and were part of, I hope we can learn from our mistakes. For many of us, that may mean remembering the value of simply being present for our patients and their loved ones when there is no “magic bullet” to cure their problems. Through this growth, the pain of having been on the frontlines during covid-19 can strengthen us and the practice of medicine.
Competing interests: None declared.