Slow medicine

The COVID-19 pandemic has, appropriately, triggered fast thinking, action, and research. This approach has not only been justified by the circumstances but has also been critical for ensuring a timely response to this new disease.

Yet, as is so often the case, fast thinking and actions can lead to sloppiness, corner-cutting, and errors. Predictably, this is happening. While these missteps may represent necessary collateral, with the basics now in place, it is time to shift from "sprint" pace to "marathon stride" and reinstitute a "slow medicine" mindset.

Below, we offer guidance -- using "slow medicine" principles -- for regaining balance in the approach to COVID-19.

Drug Treatment

In the initial months of this pandemic, drug-makers, medical experts, and politicians alike scrambled to propose the use of antiviral medications to treat COVID-19. Preliminary findings have appeared, at times, encouraging. Experts have called for expedited drug approval processes and consumer groups have advocated for "right to try" policies to address immediate patient needs. Yet, as is so often the case, the initial promising results have proven less impressive with more careful evaluation. One of the most widely touted drug therapies -- hydroxychloroquine -- now appears to be ineffective based on the results of more recent and rigorous studies, and the FDA issued a safety communication cautioning "against use of hydroxychloroquine or chloroquine ... outside of the hospital setting or a clinical trial due to risk of heart rhythm problems." Early results from a new trial of remdesivir seem promising and may lead to an emergency use authorization, but the drug does not appear to be a "home run," and more work is needed to clarify the benefits and harms before recommending its widespread use. Newly released NIH COVID-19 treatment guidelines do not recommend the use of any specific antiviral therapies.

"Slow Medicine" Recommendations: There continues to be strong pressure to fast-track antiviral treatments for COVID-19, and we strongly support aggressive research on potential pharmacological treatments. However, we believe it is critical to adhere to rigorous scientific methods -- similar to those under normal circumstances -- when evaluating these new therapies. Taking short cuts may lead to widespread use of ineffective treatments with unintended consequences. Similarly, "right to try" policies may expose patients to safety concerns without offering benefits.

Diagnosis

Medical experts, policy wonks, public health officials, the media, and the lay public have lamented the shortage of COVID-19 testing supplies -- both direct viral tests and serology. There may prove to be an important role for testing in the public health control of COVID-19 through contact tracing (though given how readily the virus spreads, particularly among presymptomatic and asymptomatic individuals, this approach may prove trickier than many believe). However, for individual patients, COVID-19 testing provides minimal benefit and may have downsides.

Why? First, as noted above, since there is no specific treatment for COVID-19 (aside from supportive care), treatment is unaffected by testing results. Additionally, patients seeking tests may expose themselves and others to the virus. Moreover, testing requires healthcare resources -- both personnel and protective equipment -- that might be better utilized for other purposes. Finally, tests are far from perfect and may be misleading. For example, if serology tests are 95% specific, in a low-risk population where 5% have been infected, there could be almost as many false positives as true positives (out of 100 individuals, on average there would be 5 with true positive tests and another 4.75 with false positives). Testing in such an environment would provide little benefit.

"Slow Medicine" Recommendations: Rather than predominately relying on laboratory testing to diagnose COVID-19, we instead favor careful clinical assessment. This approach not only helps avoid many of the pitfalls of laboratory testing but also promotes the connection between clinicians and their patients. When patients are tested -- which may occur commonly and appropriately for public health purposes -- it is important to be mindful of the possibility of false positives and negatives, particularly if test results are inconsistent with clinical findings. From an infection control standpoint, it should be assumed that all patients with common COVID-19 symptoms are infected, and appropriate precautions should be taken regardless of test results (e.g., home quarantine, mask use, notification of those who may have been exposed).

Other Diagnostic Studies

In caring for patients with COVID-19 disease, clinicians have routinely been ordering extensive batteries of diagnostic tests and studies. For example, some experts have advocated for the use of non-specific tests like D-dimer studies, and universal chest imaging to guide management. Yet these tests are unlikely to be helpful in guiding care, and may identify incidental findings and trigger invasive downstream evaluation and treatment -- leading to more harm than good.

"Slow Medicine" Recommendations: When caring for patients with COVID-19, use the same parsimonious approach to testing as for any other viral respiratory illness. Non-specific tests have little value unless there is specific reason for testing (e.g., D-dimer for a patient with suspected thromboembolic disease). Consistent with a published international consensus statement, routine chest imaging is not indicated for those with mild symptoms and should be reserved for those with worsening respiratory status, regardless of their COVID-19 test results.

Home Pulse Oximetry

Because COVID-19 may cause hypoxemia -- in some cases even among patients with relatively mild symptoms -- some experts have proposed using home pulse oximetry to identify those with significant desaturation. While such recommendations might seem intuitive, they have potential downsides. Because oximeters may be inaccurate -- e.g., due to nail polish or poor circulation in the fingers -- they can trigger false alarms, leading to unnecessary emergency room visits, along with the attendant risks, including greater chances for viral transmission. Conversely, normal readings may cause a false sense of security among those who are otherwise quite ill and do require medical consultation. Some clinicians may even substitute oximeters in lieu of close clinical follow-up, a critical step for identifying complications. The pros and cons of home pulse oximetry among patients with COVID-19 requires rigorous controlled evaluation, and until such studies have been completed, their role remains uncertain.

"Slow Medicine" Recommendations: We advocate for close clinical follow-up and monitoring of patients with COVID-19 disease, e.g., check-in calls from a clinician or even from a clinic staff member or volunteer. This approach is likely to provide greater value compared to home pulse oximetry. When home pulse oximeters are used, it is important to recognize that the results represent only a single number rather than a full assessment of the patient. Clinical assessment should remain the bedrock of decision making.

Supplemental Oxygen

Rigorous studies have consistently failed to demonstrate a benefit of home oxygen except among patients with a resting arterial oxygen tension of ≤55 mm Hg or an oxygen saturation ≤88%. Unnecessary supplemental oxygen can cause injury to the airways and may even increase mortality among acutely ill patients. Anecdotally, we have observed overzealous use of supplemental oxygen among patients with COVID-19 who do not meet the proven indications. Though many clinicians may appropriately worry about their patients desaturating, it is important to abide by evidence-based protocols for supplementary oxygen use -- both in the hospital and at home.

"Slow Medicine" Recommendations: While patients with COVID-19 should be clinically monitored for pulmonary complications (as described above), clinicians should use the usual stringent criteria for supplemental oxygen, just as they do for other respiratory illnesses.

Mechanical Ventilation

Like all medical interventions, intubation and mechanical ventilation offer both benefits and harms. While mechanical ventilation may be life-saving in the right circumstances, it can also lead to lung injury due to barotrauma; ventilator-associated pneumonia; mental status changes (due in part to sedating medications); and deconditioning, among other complications. These risks may be particularly relevant among patients with severe COVID-19 infections, many of whom are elderly or who have comorbidities that place them at increased risk of harms from mechanical ventilation.

"Slow Medicine" Recommendations: Clinicians should use the same cautious approach to intubation and mechanical ventilation as they would for any other respiratory illness, attempting non-invasive measures -- including prone positioning and non-invasive positive pressure ventilation -- prior to resorting to intubation and mechanical ventilation.

Goals of Care

As we have written about in the past, too often healthcare fails to align with patients' goals and values. This mismatch is often exacerbated in times of haste, when quick decisions must be made -- e.g., when an older patient with chronic conditions experiences a sudden decompensation and ends up receiving aggressive care, such as mechanical ventilation, which they likely would not have opted for had there been adequate time for shared decision making.

COVID-19 disproportionately impacts the elderly and those with comorbidities who often require a nuanced approach to care. The sudden emergence of this pandemic, coupled with increased burdens on the healthcare system and understandably high rates of anxiety among the public, has created a "perfect storm" for misaligned care.

"Slow Medicine" Recommendations: In the face of haste, panic, and chaos, clinicians must be vigilant to ensure that care aligns with patients' goals and values. For those at high risk for COVID-19-related complications, primary care clinicians might begin goals of care discussions early, even among those who are asymptomatic.

COVID-19 is a fast-moving and dynamic situation; however, "slow medicine" principles remain just as important as ever. As the pandemic unfolds, we must continue to be thorough in our clinical evaluations, balanced in our interpretation of the evidence, and cautious in our use of invasive -- and potentially harmful -- medical services. The urgency of the pandemic should not cause us to abandon our fundamental approach to care.

Michael Hochman, MD, MPH, directs the Gehr Center for Health Systems Science at the University of Southern California's Keck School of Medicine.

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