For my entire career and training I have always wanted to do what is best for my patients, I am willing to try new techniques or medications sometimes based on absolute scientific information but usually there is a component of hope and guesswork. There is always great controversy in medicine whether a medication or treatment actually works. I am usually trying to walk that fine line and that is where I believe the art of medicine is practiced.
The recent controversy of treatment for Covid 19 with hydroxychloroquine and azithromycin is a perfect example of art versus fact versus fiction. Many of you have heard the President talk about his hope in these medications while at the same time the doctors around him are skeptical and cautious. This interplay happens nearly all the time in medicine. Anecdotal reports are viewed skeptically, scientists require hard science to be supported but anecdotes can be very useful in practicing the art. In addition, patient pressure can result in improper treatment and can have bad consequences. I have seen both aspects many times and I would like to share with you some of these as well as my own recent anecdotal experience with treatment for Covid-19.
When I was in my residency in downtown Detroit I moonlighted in a local urgent care. A patient came in with an obvious viral upper respiratory infection and requested antibiotics. This same situation plays out millions of times a year. In some countries antibiotics are over the counter and don't require a prescription and are improperly used. I declined the request after explaining to the patient antibiotics don't cure viral infections (This was before Tamiflu and other antivirals). I counseled the patient to wait 7 to 10 days and if the sinus symptoms worsened that would be the time to consider antibiotics. A week later I was called in to the medical directors office. He told me the patient complained and he wanted to know why I didn't prescribe the patient antibiotics. I explained my reasoning and his response was "You should give the patient what they want, that is what they come here for. " I replied that I was going to practice medicine the way I was trained and if he did not want me to follow the standard of care I was willing to resign from his clinic. He decided to have me stay. Unfortunately, his approach to medical care along with many of my colleagues throughout the world has resulted in high rates of antibiotic resistant bacteria. To this day I see patients treated with oral antibiotics repeatedly for allergy symptoms and muscle aches and pains that have been incorrectly diagnosed as infections.
A different story occurred many years ago. During residency we were treating a patient for vertigo, at that time patients were often admitted to the hospital for medication. A new study was published about a treatment using a maneuver to roll the patient that could cure the most common version of vertigo, BPPV. We had a patient we consulted in the hospital that would have been a good candidate. My faculty thought the treatment was absurd and refused to give the treatment a try. Instead the patient stayed 3 days in the hospital on medication. I waited until I was in practice on my own before I was able to give the Epley maneuver a try and I was very successful. No more hospitalizations for that problem!
I have my own anecdotal treatment. I have seen patients for many years for allergies and I have seen many patients with migraine headaches. Migraine sufferers are usually pretty miserable. About 15 years ago a patient was seen for chronic allergies who also was having migraines twice a week. Her migraine meds only gave modest relief. In addition, her allergy meds barely helped her allergies. We did a workup and she tested positive to grasses, weeds, trees, mold and dust so I placed her on allergy shots. At her 3 month follow up she was starting to notice improvement in her allergies but the remarkable thing was that she was only having a couple of migraines a month. There isn't any great data to show that allergy shots help migraines but it certainly was intriguing. A few months later I saw a patient who's paperwork indicated she had migraines, she was seeing me for something completely unrelated to allergies or migraines. She reported twice weekly migraines while on migraine medicine. I offered to allergy test her even though she swore she didn't have allergies. She tested positive to everything and I put her on allergy shots, last time I saw her she hadn't had a migraine in over a year.
This last story happened recently. A family member texted me she had a horrible sore throat and laryngitis but no shortness of breath, cough or muscle pain. She did have a fever for 1 night. She was in a rural vacation area and couldn't get tested for Covid-19. She was doing well with sheltering in home but was a guest where she was staying. There was a visitor who was feeling fine but had been exposed to someone that had been recently treated for Covid-19. I decided to prescribe azithromycin since it has been used for Covid-19 and works for Strep. She did ok for a day but then texted me she was having shortness of breath. So, now I was faced with a decision whether to treat a problem that I did not have a positive test for and with medication that is currently a national controversy. I was extremely worried, the woman was young but in a rural location and I decided to prescribe hydroxychloroquine. I was worried about impacting the supply for rheumatoid arthritis patients but when I looked up the dosing she would only need 6 pills. I sent in the medication, warned her of the risk of a cardiac arrhythmia, and made several prayers. Within 24 hours all of her symptoms were improving and by the second day of treatment she felt completely cured.
This is the story of anecdotal medicine. Did my family member have Covid-19? Did the medication make a difference? I obviously used the medication for off label use which is allowed, despite some of the incorrect statements to the contrary. If Dr. Fauci's family member was ill would he do this? If you were my patient how would you want me to treat you?
In the ideal world we wait for double blind placebo controlled studies to prove the efficacy of treatment. Those studies usually take years. What should we do in a pandemic? I don't have the global answer to this, I guess I just have to keep practicing the art.
