The size and speed of the coronavirus disease 2019 (COVID-19) tsunami and associated public apprehension that slammed into health care systems worldwide blew in with it profound changes in how medical care is delivered inside and outside of hospitals.
Among the most notable of these deviations from traditional approaches is the way in which medical staffs across the world engaged with new “information” about COVID-19 derived from “alternative sources,” which in some cases was not actually “informative,” clarifying, or helpful. New treatment algorithms based on these new sources of “information” were adopted with breathtaking rapidity. Some are already a source of remorse for the introspective physician. Sidelined, at least temporarily, was the deliberative and iterative approach. Where was our healthy professional skepticism that serves so well in normal times? It was seemingly replaced by a new priority: “Don’t just stand there; do something.” In Joseph Conrad’s novel, Nostromo: A Tale of the Seaboard (1902), a character finds that a single death “filled his breast with a mournful and angry desire for action.” The author observes, “Action is consolatory. It is the enemy of thought and the friend of flattering illusions.”2 But we must pause and ask, “to whom was the action consolatory?” The public? Perhaps, but also to those of us shouldering the burden of direct patient care. It is understandable then that we err on the side of action when faced, not with a single death, but with a mass of mortality.
What oracles have replaced the accumulated clinical trial evidence that in normal times buttress professional society guidelines? A witches’ brew of press conferences,3 professional blogs, forwarded email chains, hospital websites, and manuscripts that are displayed on websites but sit unreviewed. Apparently, all practitioners are to be their own reviewer. All physicians are to be their own thresher. It is a form of crowdsourced medical care but, not in the best sense of that term wherein the many contribute data to achieve insights.
In these strange times, even the editorial and peer-review process has resulted in anomalies. Important but “preliminary” reports show up in journals weeks after being posted on the Internet, prolonging equipoise to those who seek clarity. Publications making broad declamations from small sample sizes5 or from observational methodologies arise like springtime mushrooms. One observational study of just 18 patients with cancer and COVID-19 found a high risk of mortality and injudiciously advocated for postponing elective cancer surgery and adjuvant chemotherapy in endemic areas.6 Most disappointing of all is the phenomenon of withdrawn publications that had been editorially assigned and peer-reviewed7, 8, 9 but with retrospectively obvious disqualifying gaffes. Alas, retraction is a late and weak remedy. As Jonathan Swift noted, more than 300 hundred years ago, “Falsehood flies, and the Truth comes limping after it; so that when Men come to be undeceiv’d, it is too late; the Jest is over, and the Tale has had its Effect.”
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-Barry R. Meisenberg, MD
