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What is a Doctor's Duty in a Pandemic?

Chenoweth, James MD

doi: 10.1097/01.EEM.0000669388.91693.ce
    coronavirus, COVID-19

    The COVID-19 epidemic crashed into the health care system like a freight train. Hospitals in hard-hit areas struggled to find appropriate ICU space and personal protective equipment to keep staff safe. Even in areas outside the hot zones, hospital administrators struggled to maintain their stocks of masks, gowns, and face shields. This led to a relaxation of stringent rules on using nonmedical N95 masks and respirators. Some systems were forced to resort to decontaminating and reusing N95 masks. These practices, which previously would have been cited as unsafe, suddenly became commonplace.

    Conflicting data on whether SARS-CoV-2 is spread via respiratory droplets or is airborne added to the confusion. The shifting information resulted in rapidly changing policies, sometimes directly conflicting with prior ones. Over just a couple of months, the Centers for Disease Control and Prevention went from saying that masks were not effective for halting the spread to recommending masks for everyone going out in public.

    The CDC estimates that 10-20 percent of all infections nationwide are in health care workers. It is nearly impossible to know where the exposure occurred, but at least some of these resulted from caring for COVID-19 patients. And that begs the question: At what point does a physician have the right to refuse to work during a pandemic?

    Graeme Wood, a writer at The Atlantic, recently called for physicians who refused to work during a pandemic to lose their medical licenses. (April 26, 2020; While understandable, this approach is inappropriate. Most students entering the medical field do not really understand the risks, and we were not given an informed consent document. Instead, we learned about the diseases we would treat, and then we cared for infectious patients and learned how to mitigate our risk. Many of these remained abstract because of the layers of protection provided by residents and attendings. I learned about the risks posed by communicable diseases, chemicals, medications, procedures, and the interpersonal violence associated with working in the ED, and I was taught how to protect myself. No one ever discussed the psychological effects of working in an ED: I see more people die each year than most people do in their entire life, and I have had to tell families that their loved one has died and then move on to my next patient. We cannot fully understand how this will affect us until we encounter it. There is no informed consent.

    Then came COVID-19. I do not have adequate PPE or a clear understanding of how communicable the disease is. These risks were never discussed during my training. I was not told that one day I might be asked to intubate a highly infectious patient without proper protection. I was not informed that I would risk my life and, perhaps of more concern, those of my loved ones just by doing my job.

    These new risks have resulted in some physicians taking precautions like living apart so they don't put their families at risk. This was not something they signed up for when entering medical school. I doubt most discussed this with their significant other. I know that my wife never imagined that a time would come when we would have to avoid seeing her parents and grandmother for months. Few health care workers really understood the full ramifications, so the question remains: At what point can physicians refuse to work?

    Tellingly, despite what The Atlantic article implies, there has been no overriding need to address this question in a legislative or formal fashion. Despite increased and unclear risk and marked limitations on PPE, there has been no abdication of professional responsibility by physicians during this pandemic. At most, we have seen physicians and nurses advocate for adequate equipment and entreaties from residents for increased pay. Instead, we have seen our colleagues volunteer to work more to help patients and colleagues who have become ill or died despite surprisingly frequent decreases in compensation.

    I continue to grapple with these risks. What if I lived in the same household as my wife's grandmother? What if someone in my household were high-risk? What if I were high-risk? Each of these considerations moves the needle in the constant cost-benefit analysis we all make. In the end, someone will have to care for these patients. Am I willing to put our colleagues into a situation in which I am unwilling to go? Almost universally, the answer is no. Am I willing to go into a situation when a colleague of mine cannot? So far, for me and for the vast majority of physicians, the answer has been yes. Still, we must address this issue directly, if not for COVID-19, then for future outbreaks.

    Many fields are more dangerous than medicine. TV shows even highlight how hazardous these are (like “Deadliest Catch”). In most cases, the hazards of working in these fields are known, and they discuss the consequences of not taking these dangers seriously, often in graphic detail. The medical field does not address risk in the same way. Maybe we should. Maybe it's time to explain the risks to every incoming medical student. Only then can you fully expect them to follow through when those risks present themselves.

    Even so, an even more dangerous epidemic than COVID-19 may arise. If it does, systems should be in place to allow those at high risk or with serious morbidity or mortality to opt out of working in high-risk environments. This should be coupled with compensation for those who put themselves at risk to care for the sickest patients. This could be vacation time, increased pay, or debt forgiveness. Every system should focus on rewarding those risking their lives and not punishing those who feel the risk is too great. The real risks should also be ameliorated by ensuring appropriate spaces for caring for patients and adequate stores of PPE.

    The Atlantic article would have you believe that there was a real risk of doctors running away in the time of need, but the reality is much different. Many were clamoring to help, but it took a suspension of rules preventing physicians from practicing in New York without a New York medical license even if they were licensed in another state to allow volunteers to help there. A similar effort could help fill holes left by physicians who decided they could not put themselves at risk.

    Everyone has a choice. It should never be the case that a physician who refused to work could lose his livelihood. If physicians find themselves forced to decide between giving up their livelihoods or putting their lives at undue risk, it is the health care system that has failed them, not the other way around.

    Dr. Chenowethis an emergency physician in Sacramento, CA. Following residency, he completed a combined medical toxicology and research fellowship, and his current focus of research is on evidence-based treatments for substance use disorders. Follow him on Twitter at@thisweekintox.

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