There is a basic tenet about mistakes in medicine, brought to bear by a well-known family practitioner named David Hilfiker. Dr. Hilfiker cautions that a mistake in medicine is not looking back with new information and data to say that you’d now handle a circumstance differently. A mistake in medicine is when you look back and determine that, with the exact same knowledge and set of data that you had at that time, you should have made a different decision.
As scientists, we use data to drive decisions. As doctors, we combine science with humanity to try to achieve the best outcome using information we have from medical evidence as well as the person’s medical history and life circumstances. In the current climate of COVID-19, the challenge to determine what is best for each person individually and for all of us collectively is like none other we have faced before. With that said, even with information evolving on a daily basis, we still need to take Dr. Hilfiker’s approach to heart. Recognizing that the intervals between what we knew then vs. what we know now are becoming narrower and narrower, we can still apply existing knowledge to drive informed decisions.
This approach can serve as a backdrop to address the burning questions on every American’s mind: When can we safely return to work and our normal way of life? How do we balance the health of people individually with the health of our nation economically? We strive to get this right because lives are, literally, on the line.
That premise, however, should not tie our hands indefinitely. Nor should it paralyze us in the decision-making process as we weigh what has been positioned, in politics and the media, as competing objectives. They’re not; the health of people and the health of our economy are inextricably linked. They are not diametrically opposed.
There are two clashing principles, though, that seem to be universally understood right now in the U.S: (1) We cannot realistically imagine staying indoors and away from our interactive lives for the next 12 to 18 months while COVID-19 vaccines and treatments are tested, proven and become readily available. (2) Short of that, we — the doctors and the medical community — do not know 100 percent when it will be safe to resume activities.
On the interim road to recovery, in addition to the pending application of immunity (antibody) testing, hospitals can serve as a model for a sound, simple return-to-work protocol.
Because they must, hospitals and associated personnel are working. Every day, before reporting to work at Mass General Hospital (MGH), each employee — from the doctors and ICU nurses to the cleaning staff, maintenance teams and administrators — is required to complete an online questionnaire about personal health status. Given the gravity and importance of answering truthfully, each person takes this responsibility very seriously. If feeling well and symptom-free, a pass is issued that enables hospital entry to report for work that day. Everyone washes hands incessantly, dons their masks, and wears full personal protective equipment (PPE) when treating or in the presence of patients who have known or suspected COVID-19 infections. Some hospitals also check temperatures of those entering, including front-line workers who may be rechecked periodically during the day. When possible, certain colleagues work remotely, conducting telemedicine consultations.
Are these systems foolproof? Of course not. Are we protecting against all transmission of the virus between colleagues? That is highly unlikely. What we know, however, is that the prevalence of COVID-19 infection among health care workers from MGH who have symptoms consistent with a viral infection is roughly half that of the symptomatic general population tested at the hospital (12.4 percent compared with 23.2 percent, respectively). That number is somewhat reassuring. That number says that the steps being taken at MGH right now, with our current level of knowledge and understanding combined with available techniques for screening and protection, are helping.
As the system advances and we are equipped to test for antibodies to indicate who, at least temporarily, may be immune from the virus, we will adjust the process. Since hospital employees from all specialties, fulfilling every necessary role, are currently reporting for their jobs, we can serve as a model for rapid and adaptive implementation of a return-to-work policy for other key sectors of society who also need to urgently get back to work.
Please do not misconstrue what is shared here as an indication that this is ready for wide-scale application. Securing health, well-being and the adequacy to care for the sick is the top priority. Next is a system, as instituted at MGH, to ensure the safety, to the best of our knowledge and capabilities at a given point in time, of all those working at hospitals. Then, using the hospital as a gold standard, let’s apply this evolving protocol to food processing plants, nursing homes, grocery stores, first responders, funeral parlors, family members of ICU patients, essential businesses, etc. Immunity testing, once validated and available, also can be applied in a methodical, informed way, helping us march towards normalcy.
In sum, let’s be thoughtful, safe and careful, using science and humanity to manage the process. Let’s continue to secure ample hospital beds and ventilators in ICUs throughout the country to care for those who are critically ill, as well as PPE for clinicians and essential front-line workers. Let’s roll out adequate levels of testing and contact tracing to mirror other countries such as South Korea and Germany, and fully develop antibody tests, vaccines and treatments to steer health and safety. Let’s maintain protocols involving technology to facilitate distancing whenever possible. But let’s not make the perfect be the enemy of the good. Using the health care system and personnel as a microcosmic model, we have clues to drive the return of the workforce in other sectors, appropriately adjusting as we learn.
Mark C. Poznansky, M.D., Ph.D., is director of the Vaccine & Immunotherapy Center at Massachusetts General Hospital, Boston, which researches and develops novel vaccines and immunotherapies for cancer and infectious or immune-related diseases. He is the co-creator of VaxCelerate, a vaccine platform under study for use against COVID-19. An infectious diseases physician, he is associate professor of medicine at Harvard Medical School.
Jacqueline A. Hart, M.D., is director of the Bassuk Center on Homeless and Vulnerable Children, Families and Youth in Needham, Mass., which works with communities and organizations nationally to promote housing, health and other opportunities for individuals and families. She has more than 20 years experience working in lifestyle, behavioral and integrative medicine, applying those principles to vulnerable populations and marginalized communities.