Patients continue to come to our offices begging for prescriptions for hydroxychloroquine (HCQ). Some even think there's a conspiracy to prevent them from getting one.
Perhaps this shouldn't come as a surprise. The COVID-19 pandemic has revealed much about health care and our society. We have a crisis of trust and truth; it can be hard to know who to rely on. To help restore our faith in one another, it's important that we health care providers admit something out loud: We often get it wrong.
In the case of coronavirus, first we said no masks, but now we say masks for everyone. First we said no to steroids, especially if you are very sick, now we say yes to steroids, but only if you're sick enough.
And at first we said HCQ might work. In fact, some providers were guilty of self-prescribing and hoarding it. Now we say it doesn't work for COVID-19 and could actually do harm. But not everyone believes us, including the president and several members of his administration, as well as many of our own patients.
We in health care are quick to dismiss our mixed messages by saying, "Oh, that's just how science works." And, yes, science is a messy process. But that's not the only reason we get things wrong. The truth is, we're human and influenced by more than just science.
Sometimes, we engage in wishful thinking. We assume that because something should work, it will work. For example, if you have chronic chest pain due to a blocked coronary artery, doesn't it just make sense to prop it open with a stent? And if you come in with knee pain, and we see torn cartilage on MRI, surely an operation to fix it will give you relief? Well, it turns out that in many cases, those stents are no better than low-cost medications and that knee surgery is no better than physical therapy. We have had to learn (and re-learn) the hard lesson that intuition is not always a reliable guide to illness and health.
Sometimes, we succumb to conflicts of interest, even if we are not always conscious of them. When there is more money to be made in stenting an artery or operating on a knee, it makes it harder for us to simply prescribe a medication or send a patient to physical therapy.
Sometimes, we just want to make our patients happy. In fact, our livelihoods can depend on it. Providing evidence based care does not always correlate with patient satisfaction. Without stellar reputations and high ratings, we might not get referrals. Because of these reasons, we might avoid hard conversations.
Sometimes, we're simply pressed for time. It might take 30 seconds for a clinician to say yes to a patient's request for an antibiotic to treat the common cold, but 30 minutes to have a conversation explaining why it won't help.
And sometimes, we just don't know the right answer. Medical knowledge is constantly evolving, and it is impossible for any of us to learn it all.
Here's what we can say about HCQ: There is no conflict of interest at play. Hospitals don't make money taking care of COVID-19 patients. In fact, they lose money, even with government bailouts. Health care professionals are taking pay cuts or getting laid off.
If cheap HCQ could get us back to business as usual—making money doing elective surgical procedures—and writing these prescriptions would help us secure our jobs and our pay, hospitals would be giving it out for free given the amazing return on investment.
Furthermore, the easiest and quickest thing to do for providers would be to just write the prescription, which some are. But it's not the right thing to do.
Let's say you were to go into a fatal heart rhythm, a known side effect of HCQ, and die. How could we defend our decision to a jury, let alone to your bereaved family? Referencing a video posted on Twitter, even a viral one, would be woefully insufficient. To prescribe something that can harm without helping violates our most fundamental oath.
We were hopeful at first that HCQ would work for COVID-19. It showed promise in the lab and in small human studies. But, ultimately, our wishful thinking did not pan out.
Multiple randomized clinical trials—our best tool to tell the difference between luck, placebo and actual treatment effect—showed that HCQ neither prevents infection nor treats it, regardless of whether someone has mild symptoms or is sick enough to be hospitalized, either by itself or in combination with other drugs.
We rely on the scientific method not as a matter of faith, but because it works. It has provided us all of the marvels in modern medicine that have increased longevity and reduced suffering. It also helps us identify and avoid succumbing to our own biases and potential conflicts of interest.
Like us, science is not infallible. A large number of papers related to COVID-19 were published and then had to be retracted, many for glaring oversights. But instead of decreasing credibility, the willingness to correct course and call out questionable research, identify outright fraud and hold editorial boards accountable is a sign of a healthy, self-policing scientific community.
Time, mistakes, missteps and dead ends are fundamental to this process. That is why one or two studies' findings aren't enough: We follow trends in a growing body of evidence. Reproducibility, repetition and critical reviews are essential. Whatever its flaws, science is the best process we have.
Usually medical practice changes in a gradual, gentle U-turn. However, the compressed research timeline around the pandemic has made this feel like whiplash for all of us (which, by the way, we no longer treat with a neck brace).
We are as disappointed as our patients that HCQ didn't work. Our lives are also on the line. If another well-designed large scale trial, bigger and better than any others, shows a positive effect for HCQ, we might change course again, just like we have in the past.
In the meantime, we're going to keep doing right by our patients, which doesn't always mean doing what's popular.
Dr. Hemal N. Sampat
Dr. Lucas X. Marinacci
Dr. Jeff Liao
Dr. Monique Tello
Dr. Sarah Matathia
Dr. Daniel M Horn
Dr. Jing Ren
Dr. Stephanie Eisenstat
Dallas Ducar, NP
Dr. Carolina Abuelo
Dr. Li Tso
Dr. Michael F. Bierer
Dr. Jennifer Haas
Dr. Nancy Rigotti
Dr. Sejal Hathi
Dr. Amy Wheeler
Dr. Marya Cohen
Dr. Andrea Reilly
Dr. Audrey Provenzano
Dr. Melinda Mesmer
The authors are public voices fellows at The OpEd Project. The views expressed in this article are the authors' own and do not necessarily reflect the official opinions of Massachusetts General Hospital.
