The William Osler Lounge is back! This will be a place for brief, insightful thoughts on medical topics I find interesting or that have a special meaning. This month we will discuss the one topic the entire world cannot ignore, COVID19.
I admit I was wrong. Friends, family and patients would ask me for my thoughts early on when the virus first became a worldwide phenomenon. I casually would say, although a novel virus is unpredictable it likely will come and go pretty quickly like SARS or MERS and be less of a public concern compared to the annual flu. The R knot (or infectivity level) of this virus is higher than I presumed and is the reason why it has become a problem. But the mortality rate I knew had to be lower than the 1-2% that was reported because of insufficient testing. More recent evidence from Germany, Iceland and now New York suggests a mortality rate of 0.5%, which is much more manageable. As of Sunday April 26th, over 2 million infected, 200,000 worldwide deaths and 54000 US deaths. So what to do?
It has been fascinating to observe the response in different countries. Leadership styles, heroism, marketing opportunities, conspiracy theories, democratic versus dictatorial government policies, ghost towns, financial suffering, mental health crisis, environmental silver linings, technology boom (or should I say Zoom!), greed and altruism come to mind. Just like when tackling a disease like diabetes or high blood pressure, a multi-level and multi-step approach is needed. I would have press briefing structured to offer a variety of information such as update on COVID19 statistics; new social distancing or economic reopening guidelines; a national public health campaign for healthy lifestyle habits to boost the immune system such as 7.5 hours of sleep, more fruits and vegetables, less meat, daily exercise and stress reduction strategies; ways to boost social connectedness during this difficult period; create and show an algorithm that clearly indicates what to do based on symptoms, co-morbidities and testing availability; and create a map of resources available to those in need financially, medically, socially, mentally, spiritually, etc. These items should be broadcasted daily at briefings by experts in each of these fields and WITHOUT the President turning it into a TV show. So what happens now?
Regardless of the policies or tactics agreed upon by government officials or scientists of any country I think we will all end up in a similar scenario. The world will simply move on. In this social media age, attention span is ridiculously small and as we get numb to the word coronavirus and the unfortunate deaths it brings, people will simply go back to their lives and ignore. Just like they ignore the gun violence, domestic violence, car accidents, heart attacks, strokes, cancers, tobacco use, physical inactivity, suicide, poor diet, etc. that occurs daily and takes MILLIONS of lives. Now do not get me wrong, this virus came at such a rate that we had to shut down and pay attention to it. In our instant gratification world, I am afraid that attention is already fading.
This is my first ever blog! Before I talk about the topic at hand, I should say this is a very invigorating feeling to have one's own blog. I don't remember the last time I wrote something that wasn't for educational or occupational purposes. No one will be marking my blog, there is no deadline to finish this blog and I can say what I truly feel without too many repercussions (hopefully). I now appreciate how writing one's own thoughts can be a therapeutic exercise. I feel empowered and energized already and I've only written a few sentences so far. I may become a brand new person by the end of this blog! Yikes!
I have entered the world of Clinical Practice Guidelines (CPGs) and I am not coming back. Over the past year and a half, I have been exposed to the intricacies of clinical guideline development and worked with some of the top minds in the world in this realm. Creating a guideline is a difficult process that requires a multitude of factors before the final product is ready to be published. It requires financial resources and many hours from expert physicians, family doctors, epidemiologists, methodologists, statisticians, policy makers, IT experts etc. So it's a shame when I meet doctors and discuss guidelines and the first thing they say is 'guidelines are useless' or something similar. I, of course, immediately ask them why and I get a myriad of answers - 'Grade D or expert consensus is not good enough', 'The study or trial that the recommendation is based on does not represent my individual patient', 'Pharmaceutical companies are behind it all and so I don't trust the guideline', 'I have been doing this for awhile, I don't need a guideline to tell me what to do', 'I have no time to read a guideline, I am busy seeing real patients' , ' I don't like cookbook medicine' and I can go on and on.
These comments drive me nuts! Guidelines are not magical documents that are suppose to solve every little problem a doctor may have. They are what the name suggests, documents that GUIDE your clinical judgement. I admit, some clinical guidelines are more helpful than others and there are things that can be done to make guidelines more actionable, feasible and user-friendly. But some of these complaints I simply do not agree with.
'Grade D or expert consensus is not good enough'
You can't do a Randomized Control Trial(RCT) for everything! It is simply not possible. If 20 expert physicians who have been practicing medicine for over 25 years sit at a table and decide that Vitamin D should be taken by most adults on a daily basis, I am willing to follow their advice. I don't need an expensive RCT to convince me.
'The study or trial that the recommendation is based on does not represent my individual patient'
Of course it doesn't!! Would you like every trial ever done to include the entire patient panel at your clinic? Trials do their best to represent the general population. A trial cannot take into consideration patient values, religious beliefs, co-morbid conditions and the genetic variants your patient may have. This is why a guideline is not a rigid gold standard.
'Pharmaceutical companies are behind it all and so I don't trust the guideline'
This is a little tricky because even I am a little skeptical of this. But I am not paranoid and think pharmaceutical companies control every recommendation out there. Guidelines just need to be more transparent about the development process.
'I have been doing this for awhile, I don't need a guideline to tell me what to do'
I can see more experienced physicians using guidelines less then someone who just recently graduated from medical school. But how can you completely ignore guidelines? You aren't a historian. The renaissance era rarely changes and so a historian can afford to learn once and do his job perfectly. Doctors do not have that luxury.
'I have no time to read a guideline, I am busy seeing real patients'
' I don't like cookbook medicine'
Guidelines are not meant to be used as rigid documents with strict rules, so don't categorize them as such.
So I shall conclude by saying guidelines are simply the starting point for a physician. It should be used as an educational resource to learn principles that you may have forgotten or discover new principles based on the most recent literature. After this knowledge is obtained FROM THE GUIDELINE, the physician can incorporate his own values, patient preferences and any other factor before using it in practice. Does that sound reasonable?
Ananda Chatterjee MD
I am Family Medicine graduate of Michigan State University and currently work at AC/VC Wellness Clinic in Portland. My clinical interests include obesity medicine, lifestyle medicine and clinical lipidology. My hobbies include travel, fine dining, watching sports and binging movies and TV shows.