Treatment of Covid is getting better. Doctors are learning what treatments work and what doesn’t and patients are benefiting from this learning curve. The graphic below reflects these improvements that result in declining lengths of hospital stays.
Nevertheless, there are those who believe we could be doing even better. One of those is Dr. Joseph Ladapo, associate professor at UCLA’s David Geffen School of Medicine. He believes that pre-occupation with “evidence-based medicine” is keeping doctors from initiating life-saving treatment early enough to make a difference.
As an “old school” physician, I understand Dr. Ladapo’s concerns. We were taught to treat people on the basis of our best judgment. Sometimes that meant initiating treatment before our diagnosis, or our treatment methods, could be completely verified. Years of training and experience usually produced sound judgments that were rewarded with patient improvement.
Today’s younger doctors are lectured on treatment protocols backed by “evidence-based medicine,” a term coined by those academics who insist there is only one way to treat people – their way – based on proven randomized clinical trials. Unfortunately, this kind of “cook-book” medicine is often unrealistic. Many patients didn’t read the book!
Ladapo says a hearing took place on November 19 before the Senate Homeland Security and Governmental Affairs Committee. The testimony given underscored an important issue which Ladapo explains: “Too many doctors have interpreted the term “evidence-based medicine” to mean that the evidence for a treatment must be certain and definitive before it can be given to patients. Because accusing a physician of not being “evidence-based” can be a career-damaging allegation, fear of straying from the pack has prevailed, favoring inertia and inaction amid uncertainty about Covid-19 treatments. For diseases with established treatment options, holding out for certainty may be prudent. But when options are limited and there are safe treatments with evidence for effectiveness, holding out for certainty can be catastrophic. Requiring a high degree of certainty during a crisis may elevate the augustness of medical organizations and appease the sensibilities of medical professionals, but it does nothing for patients who need help.”
This is especially a problem in academic medical institutions where every treatment is scrutinized by well-meaning, but hypercritical, colleagues. It is there that medical elites want to control what their colleagues are doing, lest breakthroughs in treatment occur without their approval.
The penchant for certainty, says Ladapo, is visible in the frequently updated treatment guidelines for Covid-19 from the National Institutes of Health. These guidelines were developed by scientists around the country, but because of a mentality that is biased toward virtually irrefutable evidence, no distinction is made for treatments with evidence for effectiveness that falls below the mark of certainty. He believes this framework has almost certainly contributed to many avoidable deaths during this pandemic.
He gives the following examples:
- Hydroxychloroquine – A meta-analysis of five randomized clinical trials showed that early use of this drug reduced infection, hospitalization and death by 24%. As a medication used for decades, including for pregnant women and breast-feeding mothers, it had a well-established safety record. Yet many criticized the use of it because double-blind trials had not established its efficacy. When President Trump promoted the drug, and used it personally, many criticized its use even more.
- Fluvoxamine – This anti-depressant showed great promise in a high-quality randomized clinical trial of 152 patients published in JAMA which found zero patients treated within seven days of onset of symptoms experienced deterioration compared with 8% of those receiving placebo.
- Ivermectin – This anti-parasitic showed promising results in a randomized trial of 200 healthcare workers at high-risk of exposure to Covid. Only 2% developed Covid infections compared to 10% of the placebo group.
- Quercetin – This drug is being studied in a clinical trial and was used by Senator Ron Johnson, chairman of the Homeland Security Committee, after his Covid diagnosis in October.
- Bromhexine – This congestion medication reduced death rates among hospitalized patients in a randomized study published by BioImpacts.
Ladapo urges local and state governments, research institutions, community clinics, and Covid-19 testing sites to provide patients with access to promising outpatient treatments while collecting data about health outcomes. With almost 200,000 new Covid-19 cases daily in the U.S., uncertainly about effectiveness could be resolved within a few weeks. Until then, it is up to patients to demand outpatient treatment. Unfortunately, most physicians have simply advised patients to quarantine and hope for the best rather than prescribing early treatment.
With hospital facilities once again under the strain of rising case numbers, it seems prudent to do all we can to treat people early and before hospitalization is necessary. That’s the kind of sound judgment I was trained to apply before anyone ever heard of “evidence-based medicine.”