Trust and Hope in the COVID-19 Era
“Trust starts with truth and ends with truth.” Santosh Kalwar, Nepalese writer and poet
“I don’t think of all the misery, but of the beauty that still remains.” Anne Frank
In the early years of my practice as an internist and an infectious diseases specialist, there were no computers and, obviously, no Internet. Back then we physicians went to the medical library to research issues, communicated via telephone, and handwrote notes in medical charts. (Yes, I am that old.) There have been extraordinary technological advances since then that have changed the practice of medicine. In addition, practicing physicians face a myriad of new health challenges in the COVID-19 era. Nonetheless, two cornerstones of medical practice remain constant: the mandate to earn the trust of your patients and to always provide hope—hope for both the patient and their loved ones. This Germ Gem addresses how COVID-19 is impacting these essential values of the doctor-patient relationship.
Who can you trust? As an attending physician in two academic teaching hospitals, I suggested to medical trainees over the years that their main job when confronted with a difficult medical problem was to find the right answer fast. COVID-19 hasn’t changed that precept. But this job had become even more difficult given the fact that this is a new disease caused by a novel (and very nasty) virus. As new data and evidence are constantly emerging, the right answer may also change.
The Internet has revolutionized one’s ability to get answers fast. It has an explosion of information readily available at the click of a “mouse.” Therefore, I was not surprised to learn that many patients search “Dr. Google” for answers to their medical questions. (And physicians use this same tool.) But the Internet doesn’t evaluate the medical information that is put on it and cannot judge what information is reliable and what isn’t. That is what you should expect of your physician; that is their role. They have been trained to find the right answer based on scientific evidence and facts.
A scourge of medical misinformation abounds on the Internet. This is a relatively new phenomenon that everyone (doctors and patients alike) needs to deal with because it interferes with getting the right answers to medical questions. In fact, the World Health Organization (WHO) has a full-time staff that works on dislodging wrong, and often harmful, public health or medical misinformation. Such misinformation has reached pandemic proportions (WHO calls it an infodemic). Its spread is greatly facilitated by social media and often by offenders who have a political or financial incentive.
A case in point is the misinformation that apparently is still circulating about the use of the drug hydrochloroquine (HCQ) to treat or prevent COVID-19. President Donald Trump was (and still may be) taking HCQ prophylactically. Early in this pandemic, he promulgated enthusiasm for the widespread use of this drug. And, he pressured the U.S. Food and Drug Agency (FDA) to issue an emergency use authorization (EUA) of HCQ for COVID-19 treatment. (It now appears he is endorsing one of his supporter’s hawking of a dangerous extract of the oleander plant as a COVID-19 cure.)
In the early months of the COVID-19 pandemic when doctors were grasping at straws for treatment of this life-threating disease, HCQ was used anecdotally in small case series of patients. Its use was based on the reasonable hypothesis that it would help quell the damage caused by the ‘cytokine storm’ associated with the disease. But, as not infrequently happens in medicine, when the hypothesis was tested in larger randomized clinical trials (RCTs), it was found to have no therapeutic benefit. Thus, it is considered by all highly respected authorities, e.g., the FDA, the National Institute of Allergy and Infectious Diseases (NIAID), and the Infectious Diseases Society of America (IDSA), to be of no value and potentially harmful.
It is worrisome, in my opinion, that recently President Trump has again pressured the FDA to issue an EUA for another COVID-19 treatment—convalescent blood plasma containing antibodies to the coronavirus that causes COVID-19—based on preliminary data showing marginal benefit in survival in a non-controlled clinical trial. To me, putting such political pressure on the FDA to prematurely authorize widespread use of this treatment modality is extraordinarily disturbing. The FDA’s mission is to protect the public. To ensure the public’s trust, the FDA should not bend to the whim of any political leader or the influence of any political party (not even during a pandemic when time is of the essence in finding therapies). Nonetheless, it appears that that is what the FDA has done yet again. Moreover, the President’s announcement came on the eve of the Republican National Convention and less than a week after officials at the National Institute of Health (NIH) staged a rare intervention to stop the FDA from issuing the EUA. The reasoning of the NIH was that evidence-based data from RCTs of convalescent plasma were not yet available to make a fully informed decision.
I hope that RCTs of convalescent plasma will ultimately support its value in the treatment of COVID-19. Until that time, doctors will weigh the quality of the evidence and are likely to await the results of the RCTs before prescribing it.
Trust and confidence go hand-in-hand. Although the Center for Disease Control (CDC) was off to a somewhat shaky start when the COVID-19 pandemic emerged, I’m now confident that it provides superb guidance both for medical practitioners and patients. And despite the recent hiccups (some would use a stronger term) at the FDA, I’m also confident they are generally on track. At a global level, I have the same opinion of the WHO. Throughout the pandemic the NIH as well as the NIAID have done an outstanding job coordinating therapeutic and vaccine trials. (As I’m sure you’re well aware, the NIAID director, Anthony Fauci, has been a steadfast advocate for science- and evidence-based approaches to all aspects of COVID-19, as has been the Director of the NIH, Francis Collins.)
So where’s the hope? I’ve witnessed with awe what the NIAID, together with its clinical research partners and the pharmaceutical industry, have accomplished in taming the HIV/AIDS pandemic. The COVID-19 pandemic can be tamed in the same manner…through scientific research and evidence-based medicine. Currently, 29 potential COVID-19 vaccines are being tested in human clinical trials in 13 countries. I’m hopeful the goal of having a vaccine available to prevent COVID-19 will be achieved within the next six months, and if this is achieved it will be an unparalleled scientific and clinical research accomplishment.
I’m also hopeful that lessons being learned from the COVID-19 pandemic can be applied to future health challenges, not only to doing a better job preparing for the next pandemic but also to addressing an even bigger threat to human health—climate change. On a final hopeful note, during my career nothing made me happier than seeing bright young medical students eager to learn how to care for the sick. Thus, I’m very encouraged by the recent announcement by the Association of American Medical Colleges that applications to medical schools are up 14% this year.