By Leora Haber
In September 2019, I helped care for a man with a possible diagnosis of tuberculosis. While I walked into his room wearing an N95 respirator mask, his four young children entered in ill-fitting medical masks. This was in line with the hospital policy at the time. It stated that the family members of those hospitalized with tuberculosis didn’t require personal protective equipment when visiting because they’d likely already been exposed at home. This blanket policy unfortunately could not account for the particulars of our case, such as the fact that our patient had become estranged from his family 6 months prior. Therefore, in all likelihood, his children had not been previously exposed to his disease. It also didn’t account for the linguistic and educational barriers that prevented clear communication between his family and our medical team. There were compelling reasons to allow for free family entry without digging further into the intricacies of our hospital’s personal protective equipment policy: Our patient was imminently dying of liver failure, and this brief window was likely his children’s last opportunity to see him. Even so, as I stood wearing my own N95 mask in the negative pressure room with them, I couldn’t shake the feeling that, once again, a generic systems approach was failing one of our most vulnerable populations.
A year later, such a decision seems unheard of; COVID-19 has drastically changed the way we think about infection exposure. We are tasked with focusing increasingly on the health of the population, but the only question that remains is how to do so.
Back in February when COVID-19 first began to garner public attention in the United States, I searched the literature for information on the efficacy of personal protective equipment to help friends and family better understand the spread of disease. I was disappointed to find little practical information available. Most studies were conducted in basic science laboratories or health care settings. This felt irrelevant to my friends, who wanted to know whether they should be wearing masks around town. Often, the participant pools were small and produced incongruous results. I began to wonder where our public health recommendations came from in the first place and thought back to my patient with tuberculosis from last fall. Who had developed our hospital policy, and how? As much as medicine prioritizes evidence-based practice, there are still many times when we don’t have rigorous studies to provide answers. At such times, it seems we often rely on logic and the nebulous idea of “clinical judgment.”
This pandemic has been an exercise in rapid decision making, with policies and guidelines changing on a weekly basis. It has raised important questions about the strength of evidence we require before making practice-changing recommendations when the stakes are this high. Rush to judgment, and we risk making the wrong pronouncement. Delay, and we risk losing the opportunity to preserve community health. With regards to safeguarding public health, the pandemic has highlighted how much we still must learn about the efficacy of our existing preventive strategies. A recent meta-analysis found 21 studies on the topic of face masks and rated 19 of them as “high quality.” Though these ratings were promising, the total number of participants examined according to the meta-analysis was discouragingly 8,686. To put that number in perspective, a typical recent meta-analysis on coronary artery disease screening looked at 23 studies involving 22,350 patients, and a practice-changing meta-analysis—such as the 2002 analysis of antiplatelet therapy—looked at 287 studies involving 135,000 patients. Lately, we’ve been making sweeping national recommendations on the basis of relatively limited evidence.
For years, I scoffed internally at those who wore medical masks on the subway. What did they know about disease transmission? Now I must question what I know. In January, mine had been the loudest voice proclaiming that coronavirus was not dangerous to healthy adults and criticizing my friends for “overreacting.” My intentions were good: I worried about the xenophobia beginning to surround the stories of disease spread. I felt that what was best was to dismiss what, at the time, I considered to be baseless fears. Even so, it had been hubris at its most dangerous, an insidious force that compelled me to believe that knowing the shape of the viral capsid or its most common presentation made me a relative expert on the disease among my nonmedical friends.
The COVID-19 pandemic has been a call to action in so many ways. Among them, it has demanded improved studies in the field of transmission prevention. More broadly, however, it has called for renewed commitment to dependable research and individual critical appraisal of primary literature. Only through independent review and a nuanced understanding of the populations for whom studies are designed can we hope to provide compassionate, responsible care to all patients—especially those who are underrepresented in the field of clinical research. Similarly, only by learning from where my hospital’s tuberculosis policy had originated could I have helped my patient’s family make a truly informed decision last fall. A year ago, I chose not to question hospital policy in part because it was easier not to but also in part because I felt it was the compassionate action at the time. I worried that looking too closely at the generic policy and finding that it did not apply to my case would rob a dying man of his chance to say goodbye to his family.
Critical investigation can be daunting because it often leads to admitting the rules may not apply to your case and facing the unknown. In 2019, I thought revealing that lack of direction would be paralyzing. Now, having experienced the ways in which we’re able to push forward and make decisions despite the unknowns of COVID-19, I believe I underestimated both myself and my patient’s family. We had both deserved the opportunity to make decisions on the basis of a full understanding of the case, even if that meant admitting that we had no high-quality evidence upon which to base our decisions. We had both deserved the truth.
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Leora Haber
Weill Medical College of Cornell University
Graduating Class of 2021
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