A guest column by the American College of Physicians, exclusive to KevinMD.
If nothing else, the ongoing COVID-19 pandemic has brought crystal clarity to something that all physicians are aware of but don’t often think about – that because we deal closely with communicable diseases, physicians (along with other health care workers) are clearly at risk of contracting, and potentially dying from, the very diseases we are called upon to treat.
Although this risk has confronted physicians across millennia, improved public health measures, and the introduction of antibiotics have markedly decreased the risk for individual doctors caring for patients, particularly over the past century. The result is that many physicians now care for chronic illnesses such as cardiovascular disease, hypertension, and diabetes, and have not been compelled to seriously consider the possibility that they could die from the work they do. And even with periodic outbreaks of more isolated but deadly epidemics such as SARS, MERS, and Ebola, most of us have been able to remain isolated from the risks posed by these infections unless we choose to work with them directly. But a pandemic changes this equation completely, giving us no choice but to be on the front lines of experiencing the risks involved in dealing with COVID-19.
For those of us who are older and worked with patients through the AIDS epidemic, the current situation, while different, is hauntingly familiar. I was in training in the mid-to-late 1980s relatively early into the AIDS epidemic, completing medical school and residency in two large, urban-based medical centers in cities hit hard by HIV infection – at times, almost my entire service was made up of AIDS patients. For those who have not lived through the initial manifestations of a new, poorly understood, and terrifying disease, it’s difficult to imagine what it was like to be a physician-in-training during that time.
Beyond the heartbreak of caring for huge and, at times, overwhelming numbers of patients for whom the illness was uniformly fatal following a prolonged and difficult medical course, it was also a frightening time to be a caregiver. At some level, we all lived in utter fear of contracting the disease ourselves, knowing that no effective treatments were available and that becoming infected with HIV at that time was almost certainly a “death sentence.” I can still feel the deeply visceral, gut-wrenching anxiety of awaiting my own HIV test results after a needlestick from a carelessly discarded syringe from a known AIDS patient. As COVID-19 is doing now for so many, it quite frankly made me reflect on my commitment to medicine and what I was willing to give of myself to others.
When we enter medicine, we dedicate ourselves to use the expertise that we uniquely possess to care for individuals who are compromised by the misfortunes of disease, and this commitment is reflected in a moral duty to treat the sick during times of pestilence despite the personal risks we might encounter in doing so. But accepting this risk is a challenging proposition for each of us. Despite our genuine commitment to patient care, it is neither appropriate nor realistic to expect physicians (or any health care worker) to treat patients without regard to their own safety. And beyond the potential for individual morbidity and mortality, accepting this risk also includes consideration of the possibility of exposing loved ones and significant others to infection, particularly during a pandemic.
In order to carry out the moral imperatives of our work, the risks we accept must be reasonable – the level of danger we are willing to encounter must be proportional to the likelihood that our efforts will truly benefit the patients and society we serve. Only then can we weigh the balance of risk between our professional commitments and the competing obligations we have to our own health and that of our friends and families.
I believe that this is one of the reasons the current pandemic has been so difficult for physicians and all health care professionals. The lack of a clear, coordinated, and evidence-based approach to address this particular contagion has resulted in profound issues such as uncontrolled spread due to a lack of testing and contact tracing, and horribly inadequate access to personal protective equipment and other resources needed to care for our patients that would minimize the threat to the health and safety of ourselves and our loved ones. This distorts our ability to strike an appropriate balance between our own risk and potential for personal sacrifice with the benefits that may ultimately result from the work we do. This places many of us, particularly those immersed in the front lines of direct patient care, in a truly conflicted and extremely difficult position.
One of the lessons learned from the AIDS epidemic is that physicians and other health care workers are indeed willing to step up to the daunting challenge of caring for patients with poorly-defined and potentially lethal infections, and accept the personal risks involved; at that time, the health care system evolved rapidly to seek to minimize risk to caregivers through the implementation of measures such as universal precautions and needlestick avoidance procedures.
In the current pandemic, we know what steps need to be taken to care for and protect those who follow their professional commitment to care for the sick, and we simply need to implement them. Only by maximizing the care and safety of those bearing the brunt of personal risk in this evolving pandemic will physicians and all health care workers be able to reasonably live up to the individual commitments we each made when entering medicine without suffering the angst of taking on additional risks beyond those we already know and are willing to accept.
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