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A Piece of My Mind
April 3, 2020

Personal Risk and Societal Obligation Amidst COVID-19

Author Affiliations
  • 1University of California, San Francisco, Department of Medicine, San Francisco
JAMA. 2020;323(16):1555-1556. doi:10.1001/jama.2020.5450

I grew up as a fiercely atopic kid with red rashes and watery eyes. I would wheeze when I played sports or when I got a cold. During college, my asthmatic lungs faced the East Coast nemesis called winter.

Nowadays, I seek urgent care a couple times yearly for asthma exacerbations, and last winter, I found myself hospitalized with influenza A. I needed bilevel positive airway pressure (BiPAP) for a night during that admission as my tachypnea escalated despite the typical cocktail of inhalers, magnesium, solumedrol, and oseltamivir. I bounced back within a few days and was back to work the following week.

Months later, the world grapples with the COVID-19 pandemic. This March, I was assigned to nighttime shifts at the 3 distinct urban hospitals my residency program serves. As the weeks progressed, my evaluations of patients with respiratory complaints seemed less certain. Was this patient’s hypercarbia just another congestive heart failure exacerbation? Was symptomatic anemia just symptomatic anemia? I worried about finding viral undertones beneath presenting problems days after admission.

During this time, vulnerable patients—those at risk of complications from COVID-19 and those more susceptible to its acquisition—have been told to stay home. Older adults and adults with preexisting medical issues can fall ill and die from this disease. Yet some younger, apparently healthy adults fall ill too.

As the pandemic swells, I have reassessed my own risk as a frontline clinician with a preexisting lung condition. After discussion with my primary care physician and the residency program, I have transitioned off the inpatient service for now and am settling into a virtual world of telehealth primary care. In this realm, needs still surge—patients with chronic medical issues still must be seen for routine symptom assessment, and many patients with mild respiratory symptoms need virtual triage to better manage the influx of in-person presentations to emergency departments and urgent care offices.

Yet each passing day since this transition, I have deeply questioned my now virtual existence.

I view medicine as a privilege. I am privileged to have had the resources to seek the years of education that allow me to now practice medicine. Moreover though, I am privileged to sit with patients in moments of deep vulnerability—the authenticity that I witness in medicine does not always emerge in day-to-day society. Yet it glimmers constantly in the patient-physician relationship. As a first-year medical student in 2013, my classmates and I recited a modern rendition of the Hippocratic Oath by Dr Louis Lasagna—“I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.”1

Occupational hazards threaten workers in any career path; in medicine, the hazards range from infectious exposures to emotional stress. Yet despite these risks, I have never hesitated to move forward—medicine has been my choice, a privilege, an honor.

For the first time though, I am intentionally shifting my responsibilities in the face of this new viral menace. Fortunately, my residency program has a robust backup coverage system, and the program directors and chief residents have been stalwart advocates. I feel grateful to exist in this supportive realm.

These external validations nonetheless cannot suppress my internal struggle. Patients with underlying pulmonary comorbidities may suffer more complications from COVID-19. Yet some otherwise healthy patients have suffered complications, too. Transmission of the disease from infected patients to physicians and other health care workers is believed to be infrequent with the appropriate use of personal protective equipment, but scarcities in basic supplies jeopardize this otherwise reassuring narrative. I have been guided toward telemedicine based on the hypothesis that among a cohort of otherwise healthy residents, I am more likely to experience serious complications from COVID-19. I find moral distress, though, in shuffling my delegated responsibilities—and thereby correspondent risk of COVID-19 acquisition—to my colleagues on the basis of fuzzy deductions. Plainly, I fear that an otherwise healthy colleague who covers my role could too acquire COVID-19 and suffer similar if not more severe consequences of the infection.

In a time of pandemic and uncertainty, I wonder if I am shirking obligation. I fear caring for patients with COVID-19 because I fear my own risk, and a role wrapped in fear seems less wanted, less chosen. Yet do I have an obligation to patients to use my training to serve, despite fear and desire for distance?

Fundamentally, what risk should I accept as a necessary part of my path in medicine? During an ordinary time, I would purport that assessment of this question takes an inherently individual path—that no single rule can guide a physician’s involvement in high-risk scenarios. These, though, are uncertain and unnerving times, and I find myself seeking an impossible quantification of risk that might guide my personal assessment. I hope for a numeric determination of risk for the otherwise healthy 29-year-old physician caring for patients with COVID-19, and I wish I could find a concrete modifier for my asthma history. Even then, if, hypothetically, the risk of serious outcomes from COVID-19 patient care in the healthy 29-year-old pool is x% and my asthma history augments that x% to x plus 1%, vs x plus 5%, I do not know what the appropriate threshold should be to feel comfortable with my current virtual place in medicine.

I have observed that self-preservation and, perhaps more importantly, self-nurturing, buoy longevity in medicine and allow for many more years of service and contribution. Yet I struggle to find a comfortable middle ground in a time that is far from average.

For now, I settle into telehealth; at my institution, high need exists for virtual-based care, and, fortunately, the residency program has not yet felt overstretched by inpatient demands. I find comfort knowing that patients need my virtual aid and that my colleagues in the in-person world can still safely care for the current volume of patients.

Does a certain amount of public good outweigh risk in the medical field? How much risk in the career of medicine should be acceptable to physicians? I do not know that I will ever find the concrete answers to these questions that I desire, yet I do hope that the profession of medicine continues to examine this question and to always balance the obligations and duties of this profession with physicians’ fundamentally human limitations and fears.

Section Editor: Preeti Malani, MD, MSJ, Associate Editor.
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Article Information

Corresponding Author: Cynthia Tsai, MD, University of California, San Francisco, Department of Medicine, 505 Parnassus Ave, Box 0119, San Francisco, CA 94143 (cynthia.tsai@ucsf.edu).

Published Online: April 3, 2020. doi:10.1001/jama.2020.5450

Conflict of Interest Disclosures: None reported.

References
1.
Lasagna  L. Would Hippocrates rewrite his oath? New York Times. June 28, 1964. Accessed March 31, 2020. https://www.nytimes.com/1964/06/28/archives/would-hippocrates-rewrite-his-oath-after-2000-years-the-greek.html
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    4 Comments for this article
    EXPAND ALL
    Becoming Ill Adds Risk to Your Colleagues
    Reuben Cohen, MD | Deaconess Gateway Hospital, Evansville, IN
    I can appreciate this young doctor’s sense of responsibility. However, guilt is inappropriate. If she were to become ill, and most likely become critically ill and require ventilator support, she would be increasing the risk to her colleagues and other health professionals. If she were to die, relative to her underlying comorbidity, she would increase the burden of providing care to her community to her surviving colleagues.

    By doing what she is able to do, ie. telehealth, she is contributing to the greater good.
    CONFLICT OF INTEREST: None Reported
    Thank you
    Susan Womeldorf |
    Thank you for putting these thoughts out there. I think many of us will have the equivalent of survivor's guilt that soldiers can feel. May we all find ways to contribute, but also do our best to stay safe. Right now, those two ideals do not seem compatible.
    CONFLICT OF INTEREST: None Reported
    Wrestling with the guilt
    Matthew Yu, DO MPH | North Side Christian Health Center, Pittsburgh, PA
    I struggle with similar emotions each day entering the front lines having two infant twins whose futures and well-being are now the primary focus of my life. We each have a role to play and have taken an oath to serve. That said, each of us has a different co-morbidity risk. The author is certainly making the right choice to serve through telehealth, providing what is still necessary care. Thank you for sharing.
    CONFLICT OF INTEREST: None Reported
    Well and Rightly Expressed
    Jane Flint Bridgewater, MD | Retired Cardiologist and Physician
    Dear Cynthia,
    Well done for acknowledging your personal risk assessment and dilemma during the current COVID 19 crisis. Your fine example of the correct course taken I hope will be widely praised.
      
    Many face dilemmas at this time, and have to make a difficult decision based upon many factors. Retired doctors in the UK have been approached to return to practice and many have done so. I had my FaceTime interview with Health Education England last week and have offered telephone counselling support activities for staff, as I am shielding and isolating with a fit but 93
    yo husband. Our twin sons are both medics and have returned to the fray from anticipated travels this spring. I chaired a local hospice board via Microsoft Teams yesterday.

    We all have to make individual personal decisions, but my family has been grateful for the stance I have taken. As the days go by and the crisis deepens, I cannot help but take an active interest in reading around the situation, but I believe I can therefore be of use to talk over younger colleagues’ anxieties and life counsel.
    CONFLICT OF INTEREST: None Reported
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