“No greater opportunity, responsibility, or obligation can fall to the lot of a human being than to become a physician.” — Harrison’s Principles of Internal Medicine, 1950.
Though a medical school graduate possesses the same repository of knowledge as a physician with years of experience, they are poles apart as practitioners. Clinical experience hones information into learned intuition, transforming the practice of medicine from an applied science to an art. The doctor-patient relationship forms the crux of the art of medicine, wherein the patient is not an amalgam of symptoms, signs, and abnormal functions, but a fellow human being in need of care and comfort. Medicine as an art prioritizes patient welfare by balancing science with empathy, compassion, and ethics. It is rooted in humility that welcomes continual learning and respects patient autonomy.
However, as medical imaging, bioinformatics, robotics, and other breakthrough advancements revolutionize modern medicine, technologists and researchers have been increasingly seeing physicians as sources of error. In this shifting paradigm, human dynamism is seen as unpredictability, an urgency to help patients as irrational emotionality, and clinical judgment as “witchcraft.” The doctor-patient relationship no longer claims primacy (only large-scale Randomized Control Trials/RCTs count), and the art of medicine becomes a romanticized and obsolete relic of our analog past.
The objective then is to limit the scope of damage that physicians can unleash by standardizing their activities as per guidelines issued by administrators and regulatory bodies. The resulting bureaucratization of American medicine has been recasting doctors from expert clinicians to paper-pushers with technical know-how bound by top-down orders. In Vermont, the Green Mountain Care Board, the members of which lack medical training but exert comprehensive authority over the state’s healthcare landscape, epitomizes this phenomenon. Another example is OneCare Vermont — an experiment that has failed to achieve its goals to reduce healthcare costs and improve the overall health of Vermonters, but keeps increasing its yearly multimillion dollar budget to support its flourishing administrative size.
This subservience of the humanistic approach in medicine to biotechnology and red-tape reached its apogee when the COVID-19 pandemic broke out. Blind adherents of RCTs who maintain a “literal and intellectual distance from the I.C.U.,” and find it hard to believe that sound medical practice can originate at the bedside, discounted the observations and assessments of doctors on the front line. When a group of maverick clinicians applied their expertise, as pulmonologists and I.C.U. specialists, to repurpose existing generic drugs in treating COVID, they were ridiculed. Paul Marik, MD (Chief of Pulmonary and Critical Care Medicine at the Eastern Virginia Medical School) who formed the Front Line COVID-19 Critical Care Alliance (FLCCC) deserves special mention.
Off-patent drugs have been around for decades, carry well-known safety profiles, and are easier and cheaper to produce widely. Yet, neither the government nor pharmaceutical companies have invested in exploring generic drugs for antiviral and virucidal activity against SARS-CoV-2. Why not? Developing and bringing new drugs to market delivers an enormous pay off to multiple stakeholders. For example, Merck has struck a $1.2 billion deal with the US government to develop a coronavirus treatment.
In contrast, existing drugs make no money. As RCTs cost tens of millions, such trials become prohibitive for drugs that have a poor return on investment. By insisting on RCTs as the only acceptable evidence of efficacy, authorities can delay and derail the process of approving repurposed drugs for COVID treatment. Bryant et al. conducted a meta-analysis of fifteen trials to investigate the role of repurposed medicines in reducing mortality caused by SARS-CoV-2 (American Journal of Therapeutics, July-August 2021). They argue that arbitrary and impossibly high standards have been imposed on their effort. One the one hand, global health agencies approved corticosteroids as the standard of care for COVID based on one RCT of dexamethasone, but on the other hand, they have disregarded “two dozen RCTs” in support of low-cost, generic drugs that offer an “equitable and feasible global intervention” against COVID.
Once the focus of health care shifts from healing the patient (who seeks relief and reassurance) to chasing the next blockbuster medicinal product, it follows that financial gain should supersede efforts to eliminate this virus. Not surprisingly, it has been twenty months since SARS-CoV-2 first surfaced in China and health authorities still cannot recommend any treatment for persons that contract COVID.
In the US alone, the current seven-day moving average of daily new cases is 14,885. According to the CDC and NIH, non-hospitalized patients should avail of supportive care (Tylenol and Motrin), isolate to prevent transmission, and seek medical attention if they turn blue. COVID is not the harmless common cold. Providing no treatment causes needless suffering and is dangerous because it does not prevent patients from developing life-threatening complications and long-term lung injuries. Most hospitalized patients that need ventilators either die or if they survive, become respiratory cripples unable to breathe without the machine.
Further, around 25 percent of patients that recover from active COVID infection develop prolonged illness (lasting several months) in its aftermath. This condition is called Post-COVID syndrome or long haul COVID, and presents as a wide spectrum of persisting symptoms including fatigue, cough, shortness of breath, headache, and joint pains. This February, the NIH launched an initiative to study the condition; six months later, no treatment recommendations have been made. The CDC advises healthcare professionals to share information about patient support groups and online forums to “long haulers.”
Abandoning clinical treatment altogether, instead choosing to rely on one form of prevention, amounts to negligence and absolutism — both of which have no place in medicine. Denying alleviation of suffering to tens of thousands with active and long COVID, in spite of access to low-cost, safe drugs that kill this virus (as proven in numerous clinical trials across the world) can only be described as reprehensible.