Is Debate in Academic Medicine Dead?
It's on life support after the COVID years. Can it be revived?
Fear. That was the driving force behind much of what happened in early 2020. As a physician, this was the first pandemic I faced. True, there was the Ebola scare of 2014. I also witnessed H5N1 and other flu outbreaks. But COVID was different. This was a novel virus with no existing vaccination and no immunity. After watching and reading about the early experiences in Italy and New York, I told my friends that the coming period would likely be the worst of my career. What I didn’t realize was that the cost would extend beyond deaths and disability. It would damage the foundation of academic medicine.
Academic Medicine Pre-COVID
In my training, I remember hearing a consistent refrain from my professors and the physicians teaching me: remain skeptical when reviewing the medical literature. This was especially true when the trial was paid for by pharmaceutical companies. There was an accepted idea that there was a bias towards positive studies. What that means is that journals want to publish interesting research. So, if a study finds that an action has no effect on the health of patients, they are less likely to publish it. This is doubly true if the study is paid for by a pharmaceutical company. What incentive does a company have to publish a study that shows their drug has no benefit?
With this framework in mind, we progressed through training. We had Journal Clubs (a meeting where people meet to discuss specific articles and how they relate to medical practice) where one of the questions asked was “Is this article funded by a pharmaceutical company and how could that influence your interpretation of the results?”. We often discussed the caveats related to something called publication bias (studies with positive results are more likely to be published) and generalizability of the study population (does the group studied look similar to your patient population).
We also talked a lot about moving from a patriarchal “doctor knows best” approach to a more collaborative approach to medicine. There were discussions of informed consent for all procedures and even medication prescriptions. We were moving beyond the “do as I say” paradigm of medicine. This was not always popular with patients. I can recall patients being unhappy when I presented multiple options and discussed the risks and benefits of each approach. In some situations, patients simply wanted to be told what to do. For most patients, however, there was an appreciation for the nuanced approach. Not shockingly, being involved in decisions regarding their care made people more comfortable with any decision that was being made. And then came COVID.
COVID and the Changing Paradigm
I’ve said this before but it’s worth repeating, everyone gets a pass for the first months of COVID. The situation was chaotic and there was real concern that the mortality rate would be greater than 1%. For those that don’t consider 1% mortality significant, I’ll give you this statistic. The US population in 2020 was 330 million. Given how contagious the virus that causes COVID, SARS-CoV-2, is it was not unreasonable to assume that more than half of the US population would contract it. That amounts to 1.65 million deaths. My detractors will argue that we are around 1 million deaths as of this writing, but I think the critiques of those numbers will have to be saved for another post. Suffice it to say, had COVID itself had a 1% mortality rate across all groups, it would have been a disaster the likes of which modern medicine had never seen. Thankfully, that didn’t turn out to be the case.
Early on it became clear to those willing to look at the data that COVID primarily killed the elderly and those with multiple risk factors. My friend Car even performed a very prescient analysis that put the real mortality rate very close to what we have settled on today (read his amazing analysis from March 2020 here: Modeling Covid-19 in the US. Don’t panic). There was still a real concern that infections could overwhelm hospitals. Even more, there was concern that infections in hospital personnel could lead to short staffing and a lack of available resources. In fact, I would argue that a lack of resources and misunderstanding of the disease process is the reason for the high mortality rates seen in New York in early 2020. If there is a worse place in the US for COVID to start, I can’t think of it. New York City is densely populated with an extremely busy mass transit system, a perfect recipe for viral spread. On top of that, it has an aging medical infrastructure that struggles to meet the needs of New Yorkers on a good day. Put bad information regarding early intubation into the mix and you get a higher mortality rate than may have occurred in other areas.
All of this was reassuring to me. I am young and healthy and as a result, was not particularly concerned for my health if I became infected. I also lived in an area with better infrastructure than more densely populated areas. In fact, I was more concerned that if I was sick that it could result in coworkers at greater risk being put in harm’s way. If I can’t work a shift in the Emergency Department, someone else has to be there. There are no cancellations in the ER, staffing has to be maintained. That was a real concern, but the risk was not equal around the country, or even in different areas in an individual state.
Debate Will Not Be Tolerated
After those first days, the mood changed. A sense of uncertainty was replaced with a sense of dogmatic obedience. The public health officials were in charge, and disagreement with their pronouncements would not be tolerated. I’ll remind you of the idiocy that happened in those days. Outdoor masking, closure of public parks, closure of national parks, filling skateparks with sand, arresting lone paddleboards, the list goes on. If you cornered even the most ardent COVID restrictionist, they would have had a hard time justifying these actions. But they were only getting started.
I remember having a discussion with an infectious disease physician early on. They admitted that simple masks were unlikely to be effective for preventing infection if you were in close contact with a person with symptomatic COVID. Furthermore, they also agreed the asymptomatic spread was unlikely to be a significant driver of viral spread. Despite this, any vocal discussion would be met with shaming. I saw people I work with proclaiming those that disagreed with certain restrictions being “death cults” and not caring about public health. This was despite a discrete lack of data regarding any of the provisions they advocated for. This was only the beginning.
HCQ, Horse Paste, and Trump
It’s important to remember that until December 2020, there was no vaccine and only experimental treatments for COVID. We were effectively in the dark ages. Many of the early dogmas were rapidly proven to cause harm (see intubated early). We began to see treatments that may be effective for the treatment of severe illness such as steroids and remdesivir. Others were postulated based on lab-based studies. The treatments deemed acceptable often depended on who promoted the therapy. When President Trump discussed hydroxychloroquine as a possible treatment, it wasn’t without merit.
There was some evidence that hydroxychloroquine could decrease viral replication. It was also relatively safe when given under physician supervision. However, because of the messenger, it was ridiculed. People who could not even tell you the proposed mechanism dismissed it. It was a minor miracle that a well-designed study was actually performed. This study ended up showing no benefit, but the stage had been set for the politicization of COVID therapy.
I often marvel at the responses that physicians have had to some of the proposed therapies. In the case of hydroxychloroquine and ivermectin, there was a large amount of safety literature available. These medications were also cheap, relative to other available therapies. That is why it was so astounding to me to see people not just dismiss these potential treatments as ineffective but instead call them harmful and evidence of quackery. This position was taken by people I work with, prior to studies being performed. I have no doubt that the politicization of COVID therapies delayed, in some cases, and in others outright prevented good studies from being performed.
Contrast these with the monoclonal antibody therapies. These treatments have never made it past emergency use authorizations. They are incredibly expensive and have limited efficacy data beyond the highest risk populations. These treatments, along with many others (see convalescent plasma), were championed while others were scorned. Where did the skepticism of pharmaceutical companies go? It was washed away in a sea of fear and politicization.
COVID Vaccines and Risk Assessment
In late 2020, a medical miracle happened, or at least that’s what we were told. In record time a vaccine had been developed using mRNA technology. For those in the medical field, mRNA had long-held promise for the treatment of genetic disease and as a way to rapidly produce tailored vaccines. The efficacy data seemed too good to be true but what other options were available? Due to concerns regarding constant exposure and risks to colleagues and family members if I got sick, I signed up and got vaccinated on the first day. Was this a mistake? Only time will tell.
Put into the same situation, I would do it again. I understood the risks and understood that I was taking part in one of the largest medical experiments in human history. Was I afraid for my own health if I got COVID? No. I was lucky because I knew what put you at risk for death or serious illness. I also knew that most people didn’t have the baseline risk of infection that I did. So, I made an informed decision. I wish that others were afforded the same opportunity.
I have heard people say that you can’t get vaccinated and then have the moral authority to speak out against vaccine mandates. I think that’s bullshit. I have as much of a right to make an informed decision as anyone else while still advocating for your right to make your own decision. The difference is that I was informed, and many others weren’t.
In theory, when a treatment receives Emergency Use Authorization, it requires informed consent whenever it is used. This can be in the form of verbal consent with a discussion of risks/benefits and alternatives. However, it should always be left to the recipient of said treatment to make that decision. This concept extends to all therapies and treatments, even after full authorization by the FDA. This wasn’t the case for many people. Mandates forced people to decide between getting a vaccine or losing their job. This introduced a level of coercion into medical care that should never have gotten a foothold. Despite my dogmatic view that the government should not be able to mandate any medical treatments, it is worth steel-manning the initial argument. If the efficacy at preventing infections had turned out to be true, vaccination would have been a reasonable public health approach to end the pandemic. I say ‘if’ because it rapidly became clear that the vaccines were not as good as promised. Beyond that, the initial Pfizer study didn’t even look at asymptomatic infection, a fact that the people at the CDC and FDA clearly would have known. The fact that many in the medical field continue to spout clear falsehoods in favor of continuing or extending vaccine mandates is alarming to me.
After the initial period came the discussion of the vaccination of kids. That is where the academic debate went off the rails. If you dared to say that you weren’t sure that healthy kids should get a COVID vaccine you were called an anti-vaxxer. It doesn’t matter if you got the vaccine yourself, any debate would not be tolerated. This position continues. All you have to look at is the fervor for vaccines for kids under 5 years old and you see the story. Damn the evidence, damn the risk-benefit analysis, these vaccines must be approved.
I do think an aside is warranted before my conclusion. It remains evident that those at the highest risk, especially the elderly, experience benefits from the vaccines beyond infection prevention. This includes the prevention of serious illness, hospitalization, and death. This benefit may wane over time, but the risk-benefit clearly favored vaccination in these groups when the wild-type and delta variant virus was circulating. I also think that a thoughtful review of the initial data says that the risk-benefit of vaccination for most kids 5-11 does favor the benefit side. I have also often said that this calculation changes if you change the virulence of the virus, underlying infection rates, and the number of boosters required. At a certain number of boosters, the risk/benefit calculation flips. That number is different for every individual.
Misinformation, Disinformation, and Where We Go from Here
I have given you all of these thoughts to reach the current state of academic medicine. There are people out there who think that simply writing this post should result in the loss of my license to practice medicine. This position is based on the claim that spreading “disinformation” is against medical board rules that regulate ethical conduction. These people have formed non-profits and written op-eds in prominent newspapers (Opinion | State medical boards should punish doctors who spread false information about covid and vaccines - The Washington Post). The premise is that by challenging the status quo, I am harming patients. That is a dangerous precedent to set.
Many of those advocating these positions couldn’t tell you the lab data that initially supported hydroxychloroquine or ivermectin. They may have even been in favor of failed treatments such as convalescent plasma. Even worse, they may have advocated for early intubation of COVID patients in the first days of the pandemic, a practice that likely resulted in excess deaths. I don’t blame them for doing this, it was the generally recognized way to treat these patients based on limited information. I doubt they would give me the same grace.
I use the word grace intentionally. I think that the medical field is filled with unknowns. New diseases emerge, new treatments are found, and old dogmas are struck down. This is part of the medical field. In the ideal world, we are all trying to do what is best for our patients. This extends to fields that I view as misguided or plainly wrong (naturopathic medicine and homeopathy). Despite my view of the fields, I don’t doubt the genuine intentions of most of those who practice them. The primary reason is that I can’t impute motive. That gets us back to misinformation and disinformation.
Misinformation is data that is wrong but genuinely believed by the person that provided it while disinformation is known to be wrong from the start. There are genuine sources of what would now be called disinformation in the COVID pandemic, it’s just not from the sources you might think. Dr. Anthony Fauci said that “There’s no reason to be walking around with a mask. When you’re in the middle of an outbreak, wearing a mask might make people feel a little bit better and it might even block a droplet, but it’s not providing the perfect protection that people think that it is. And, often, there are unintended consequences — people keep fiddling with the mask and they keep touching their face.” (March 8, 2020. https://www.reuters.com/article/uk-factcheck-fauci-outdated-video-masks-idUSKBN26T2TR). He then stated that he said this because there was concern that there would not be enough masks for healthcare professionals (see the same post). You can argue egalitarianism but in the current definition, that was disinformation.
This brings us to the current state of medicine. Robust debate remains in many areas of medicine, but COVID is not one of them. You either tow the party line or you risk censure. Are there grifters out there? Absolutely. Does that warrant the current witch hunt? I say no. The history of medicine is a lesson in humility. There are treatments once viewed as the standard of care which are laughed at today just as there are current medical norms that will be laughed at 20 years from now. But progress requires room for robust debate. I challenge even the most fervent believer in mRNA vaccines to provide evidence that the current risk/benefit for a child under 5 being vaccinated is worth it for that child. It’s not there. Arguments can be made for communal benefits, but not for the individual child in most cases. This discussion should not be controversial. Yet, a physician can vocally say that the FDA needs to approve the vaccines for children under 5 without risk of censure while the opposite isn’t true.
Conclusion
Medicine needs to take a step back. The pandemic was a frightening time for many, particularly those in the medical field. Many have family members at high risk of death or serious disease. Many didn’t visit those family members for years out of fear of being the source of illness. I think these fears were, and are, rational. What isn’t rational is letting those fears infect the scientific debate.
There is a saying that the facts don’t care about your feelings. This is particularly true in the medical field. Personal fears have no bearing on actual risk. Evidence exists and should be robustly analyzed. This should be followed by robust criticism of the possible biases present in the data. Finally, we need a return to shared decision-making with a clear, easy-to-understand discussion of the risks and benefits of treatments. The medical field had made great strides in moving from a proscriptive field to one that aims to inform patients so they can make the best possible decisions regarding their health. It’s time to return to that approach before it’s too late.