A recent conversation among a group of physicians gave me a fair amount of distress and discomfort.
The topic was an unproven treatment for COVID-19. The discomfort was the disinformation — in my opinion — being shared. The distress was that the discussion likely reflected what some doctors are actually doing for the treatment of patients infected with the coronavirus. Evidence was left at the doorstep.
As I reflected on the conversation, I realized it was not unlike what I have experienced over decades as a medical oncologist, especially in years past where there was literally very little if anything we could do for most patients with advanced cancer after our limited treatment options were exhausted.
Almost inevitably, as the end of the journey approached, there would be pleas for “one more thing,” or “can’t you try another treatment?” to save the life of a loved one. And, almost equally, when another treatment was tried, it was futile. In fact, I cannot remember a single instance when a “miracle cure” or treatment had any positive effect under those circumstances.
Now we find ourselves in the era of COVID-19. In some respects, we have seen the same scenario play out on a much more rapid and much larger scale: millions of people have been infected, many have recovered uneventfully while hundreds of thousands, if not more, have gone on to have serious illness, some surviving, some not.
And in all of this, there is the inevitable question: “Doctor, can’t you do something?”
The better news today compared to the early days of the pandemic — when we really could do nothing and knew much more than nothing — is that there are treatments and approaches we can offer which do help reduce the odds of death for many people with COVID.
We have a better idea of the risk factors. We have a better idea of when someone will benefit from hospitalization. We have a better idea of how to care for patients in the hospital. And yes, we do have better ideas of what treatments really do offer benefit.
But along the way, we have also learned what treatments don’t make much difference, based on the best studies we can perform, which are not perfect, but when taken in totality show, there really isn’t much evidence of benefit for certain medicines. And, yet, those treatments continue to be touted as life-saving or disease altering, evidence to the contrary notwithstanding.
That’s the part I don’t get: If the evidence shows some treatments don’t work, or they may not accomplish what people thought they would, then why do many clinicians continue to tout their absent effectiveness?
My oncology experience suggests that when little can be offered, there is an assumption there is always something out there that will make a difference. Sometimes, there is something out there: a new drug or other therapy in a clinical trial, for example.
Sadly, many times there are not. Yet hope and prayer demand, we try treatments even when we know the chances of success are very limited, if any at all.
Which brings me to an article recently published online in JAMA that frames this dilemma in terms of “sensible medicine.”
The core of the discussion:
The natural response at the bedside of a patient with COVID-19 is to act and to act decisively. Imbued with determination, clinicians seek to make a difference for patients who are seriously ill. In 2012, Taleb described an ‘illusion of control that leads to a default to action rather than inaction.’ For many medical emergencies … this illusion is a reality for clinicians because immediate intervention can prevent avoidable death. But what if it is unclear what to do? What if no medication or device will lead to a cure? Should clinicians do something, when the best option may be measured or supportive care? During the COVID-19 pandemic, clinicians’ tension between interventionism and measured action is ever-present.
The authors go on to outline several elements of “sensible medicine,” including:
- Medicine Without Magic
- Practice Doing (Almost) Nothing
- Elevate Usual Care
- Focus on High-quality Evidence
- Think Bayesian (that’s statistical jargon to deal with the reality that although “new treatments are a bit like the proverbial new kid on the block: they have an allure that is hard to resist.” But in reality, the odds of their success is low.)
The authors continue: “It should follow that treatment guidelines, national mandates, and bedside care adapt to new data only when the evidence is rigorous, reproducible, and sufficiently strong.”
Those are important messages based on lessons learned from so many past experiences. To date, the overwhelming evidence is that we don’t have a single magic bullet that is going to make a big difference in the treatment of COVID-19 — at least, not yet. We will get there, hopefully, sooner rather than later.
In the meantime, we have learned through careful analysis which medicines do have some benefit and which do not.
Although that inconvenient truth may not be in synch with our innate desire as doctors to “do something,” we must avoid the allure of the shiny object on the hill, one where we convince ourselves that if a particular treatment was used just a bit differently, it would give us the golden results we seek.
Cancer has taught us a lot. It has taught us about devastating illness, where we cannot offer everything possible to save a life. It has taught us time and again that although miracles can happen, they don’t often happen (at least in the past, before the current era of targeted and immunotherapies). Cancer has taught us that careful research, careful analysis, and careful clinical trials can indeed make a genuine difference in outcomes for those with certain cancers.
In many ways, COVID is similar to cancer, except that the progress we have made against COVID over the past several months has been remarkably swift, even if, at times, it does not feel that way.
We need to keep that progress in mind and not succumb to the siren song of the magicians who would have us believe — just as with cancer — that they have a miracle drug or cure that has eluded everyone else, and has escaped recognition notwithstanding multiple trials which have failed to show benefit.
Miracles in medicine usually don’t happen miraculously. They usually happen from patience and perseverance. We can never forget the need to be sensible in moments of extreme desperation.
A “hail Mary” in medicine — just as in football or basketball — rarely changes the outcome of the game.
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