Weighing Risks for My Patients at a Time of Covid-19
Weighing Risks for My Patients at a Time of Covid-19
My patients continue to have medical problems that are not related to the coronavirus. But now, when I offer recommendations — especially those that possibly involve putting themselves at risk of contracting a Covid-19 infection — they often reject my advice.
Of course, my patients have a point. Not only has the coronavirus killed hundreds of thousands of people worldwide, it is especially stealthy and unpredictable, able to spread from carriers who have no symptoms. But when, if ever, should the fear of catching a virus, and one that usually causes a mild infection, outweigh the need to address urgent medical issues?
There is growing literature on risk in medicine. Studies consistently indicate that the actual risk of harm to a patient is often colored by perceptions of potential harm. For example, research has shown that women fear dying from breast cancer more than heart disease, although the latter is more likely to kill them. One reason for this discrepancy is the successful job done by breast cancer activists in drawing attention to the disease.
During my interactions with patients, it is clear that some are far more worried than others about the same condition. At a recent clinic session before the coronavirus outbreak, I saw one patient who thought her blood pressure reading of 130/90 was so good that she could stop one of her medications. Another patient with a similar reading was so certain she was going to get a stroke that she aggressively lobbied me to add another pill. These patients had opposite views of the risk posed by their blood pressure, which was on the high side.
My job as an internist is, first and foremost, to know the science about hypertension, strokes and other diseases. But it is impossible to use a “one size fits all” model that merely uses data to guide my decisions. Patients are entitled to their own perceptions of illness and risk. When these opinions stray too far from the science, however, I push back hard.
Given the above mortality data and the constant media coverage of the Covid-19 epidemic, it is hardly surprising that my patients are freaked out about possibly becoming ill. Most of them seem to be taking quite seriously the orders from Gov. Andrew M. Cuomo to stay home and otherwise socially distance.
But in several recent scenarios, I had to question my patients’ judgment. For example, a diabetic man called to tell me that he thought he had an infected toe. My ears shot up. Foot infections in diabetics are notoriously dangerous and, if not treated quickly enough, can lead to amputation of feet and even legs.
Because my clinic is not currently able to see patients in person, I informed my patient that he needed to go to an emergency room. Fortunately, there was one fairly near his home. But he immediately demurred.
“Doctor, can’t you just look up the antibiotic they gave to me last time and prescribe it?” he asked. “I’m afraid to go to an emergency room because I might get coronavirus.”
I tried to reason with him. “You have an actual infection that could be very dangerous,” I said. “That is more worrisome than potentially getting a different infection, even though it is a scary one.” Plus, I added that emergency rooms are doing everything they can to keep non-Covid cases apart from those who appear to have the new virus.
We went back and forth for a while, but I felt this was one of those occasions to vigorously push back. Eventually, he agreed to go. It turned out he had an abscess under his toenail that required drainage and antibiotics, exactly the type of infection that needs prompt treatment to avoid complications.
In another instance, I got a call about a man who was a kidney transplant patient on immunosuppressive drugs with a fever of 104. Although it was possible that he had a Covid-19 infection, he had no other suggestive symptoms.
Fever in a transplant patient is a medical emergency. Yet here, too, the patient and his wife were reluctant to go to an emergency room because they feared Covid-19 exposure. Fortunately, they eventually went, and the man was diagnosed with a urinary tract infection. Knowing the diagnosis, his doctors were able to prescribe the proper antibiotics.
Concerns about risk persist among patients who likely already have a coronavirus infection. I recently got a call from a family member of a patient with multiple medical problems who had both a high fever and lethargy. She was not eating or drinking very much.
Even though there were no respiratory symptoms, it sounded like coronavirus. Once again, I recommended going to the emergency room where they could draw blood, check her kidney function and possibly even do a Covid-19 test. But the patient and her family declined, preferring to try to treat her at home with Tylenol and fluids. Part of their reasoning was their fear of going to the hospital during this era of the virus — even though the patient almost certainly had it and the family had thus already been exposed.
None of the above should suggest that for patients with non-Covid issues, it is business as usual. I am constantly in touch with patients by phone who have diabetes, high blood pressure and other problems, and I usually discourage them from coming into the clinic. The reality is that many necessary treatments and procedures will have to wait until the hospital reopens. We are also delaying mammograms, colonoscopies and other screening tests that we normally urge patients to get promptly.
But for emergency medical issues, fear of Covid-19 should not cloud the judgment of patients or their caregivers. If patients need to go to the hospital, they should put on a mask and gloves, stay as far apart from others as possible, and let the emergency room staffs do their job of saving lives.
Barron H. Lerner, M.D., professor of medicine and population health at New York University Langone Medical Center, is the author of “The Good Doctor: A Father, a Son and the Evolution of Medical Ethics.”