On the Front Lines
An Interview with a Physician Caring for COVID-19 Patients
Editor’s Note: In another commentary this month, “Large Numbers and Compassion Fatigue” we note that people have difficulty relating to tragedies that occur to large numbers of people. So we wondered if hearing the stories of a doctor taking care of individual patients with COVID-19, rather than just citing mortality statistics, might make it easier to comprehend the severity of the pandemic. So our Chief Operations Officer, Catherine DiDesidero, interviewed our Chief Medical Officer, David Scales, about his experiences as a hospitalist at a large New York City hospital. The transcript of the interview has been lightly edited for readability purposes. You can listen to the complete recording here.
Catherine: So I think the first thing we want to sort of cover is what does COVID look like from the inside? Because, you know, people do certain things because they understand the implications of it. I feel like with COVID, that's not necessarily the case, so what does it look like? What turns it from something that's as mild as a cold to something you are admitted to the hospital for?
David: Well, it's a couple of different things. And what's tough is kind of trying to look at COVID on an individual basis, like, if one patient in front of me has COVID, versus like looking at COVID at a population or like a statistical level. Because if I have one patient with COVID, in front of me, it's not all that different from a lot of other things that I do in the hospital. I have to look out for some specific things, like, they might have some breathing difficulties, they might have low oxygen levels, and also have to watch out for things like clots because the people with COVID kind of have a higher propensity for clots. But, to be honest, I would treat it in similar ways, as I treat people with other viral illnesses. Certain cold viruses, something we call RSV, rhinoviruses, which are cold viruses, influenza, so on a case by case basis, it's not that different from those things, just with a couple of added things that I have to watch out for. Because in a typical winter, for example, I'm going to be taking care of a lot of patients that come in with some sort of respiratory virus. And sometimes I know what it is, and sometimes I don't, and we treat them very similarly, we support their breathing. Like if they need oxygen, we give them oxygen, if they need things like nebulizers, to kind of help open up their airway a little bit, we can kind of give them medications, kind of similar medications that you might give somebody with asthma.
David: So any individual patient with COVID is actually like, not that unusual. We also look out for other infections, sometimes someone comes in with a virus, any virus and develops a bacterial pneumonia on top of that, so we're always watching out for that, too. But if I only have one patient with COVID, on my service, it's not any harder than taking care of a, you know, a patient with any other respiratory virus on my service. It's something we have a decent idea now of how to treat.
David: But the problem comes when you have more than one patient. You asked: how does it go from being a light illness to something that requires hospitalization? And the short answer is: we don't actually know. Why do some people have no symptoms at all, and others have a little bit of a cold and other people are devastated and in the hospital and requiring life support. It's really hard to predict why, I mean, we know certain things matter, right? Like age, diabetes, high blood pressure, some of those things matter. But you know, when a patient comes into the hospital, I can't predict how they're going to do. I can make an educated guess, based on some of those factors, to know if they're going to do well or they're not going to do well. And that's what was really tough in the beginning of the outbreak was we didn't know who was going to do well and who wouldn't. We would generally hear that people might get sick about five days after they were exposed. I had a couple of patients that knew pretty much when they were exposed to the virus, they would get sick about five days later. And then they would kind of have some cold like symptoms, but between day five and day 10 that's when things would get worse. I had a couple of people in the hospital who came in, they had some symptoms, a little bit of kind of like chest pressure, shortness of breath, and then they would wake up the next day or two days later, they were like, I feel better and we would check their oxygen and make sure everything was okay. And they would go home. But there are a lot of people that have some of those symptoms and then turn for the worse between day five and day 10. And that's when they would get really sick, some would have a lot of fevers, just like sweating all the time, like wake up in the middle of the night drenched in sweat. And a lot of people would talk about they would feel a certain kind of chest pressure, just like their chest was heavy, not like a heart attack, or anything, but almost like there was a small weight that was sitting on their chest. And I had a number of people tell me that they would get out of breath doing things that used to be simple for them. Like, you know, New York, right? So nobody, people don't have three level apartments or anything like that. So people would say, like, they would get up and go to the bathroom, or go to the kitchen, or they had a two story walk up and never had any problems. And they would do those simple things and find themselves short of breath. Why some people took a turn for the worse, we don't know. And then it was a question of what does that worse mean? How bad would they get? And that was how it worked on an individual level. What became really hard is, as I said, it's easy to do work with one patient that has this type of thing. But it's really hard when you have, like a hospital full. Because what started to happen, especially at the peak of the epidemic, was pretty much everybody had COVID. And you had to manage some other things like people have diabetes or hypertension, you have to manage some of those other things while they're in the hospital. But the hardest part was as the hospital got overwhelmed; it's just hard to take care of people at the level that they needed it.
So like to give an example, like on a typical day in the hospital, like a typical week, even, I might have, you know, somewhere between 10 and 15 patients on my service. And I would say maybe once or twice during the week, someone is sick enough on my service where I have to talk to the intensive care unit. And like talk about "Oh, I'm worried about this person," they might need to come to the intensive care unit. And maybe they go, maybe they don't, I'd say it's an unusual week if I'm sending even one, sometimes two people, to the intensive care unit. In the time of COVID, on a typical day, I would be talking to the ICU about somewhere between three and five patients that needed to go to the ICU. But there wasn't room in the ICU. So we had to keep them on the medical floor, and just watch them more closely. So what made COVID really hard was not any individual patient, it was that we were taking care of so many more sick people than usual, in settings that weren't really designed for people as sick as they were. And so like, that's what made it really, really tough.
Catherine: Okay, and so, you know, you hear about how people who were admitted for COVID. And who you know, were in serious condition in terms of needing ventilators, whatever, like the family wasn't permitted on the floor. So who made medical decisions for those people? Was it true that no family was able to visit? Or how did that work? It was this whole story about people just dying alone. Was that a reality that you saw?
David: Yeah, that was really tough. At the peak, and even for a few weeks after the peak, there were very severe visitor restrictions. And so only in extreme cases, like someone who was imminently dying, then we could get permission from the hospital who - they didn't have to run this by the state - but they had to, there were state guidelines around this. And so the hospital was very strict about who was allowed. And so even if someone was imminently dying, then it was a battle, and we could only get one family member to come in for a brief period of time. And this was really challenging because someone had to be - the stipulation was someone had to - we had to expect that they might pass away within the next 24 hours. And the problem is like doctors can be horrible at predicting that and so we tried our best to try to get family members in when we knew that someone was not doing well or there were a number of people who had decided that they wouldn't want to be intubated. Their oxygen levels are still dropping so you would normally intubate them, but that's not what they want, then you do other things to try to make sure that they're comfortable. So they don't just feel like they're suffocating. And you can give them medication so that they feel better. And, and that's kind of a period of time that we call comfort measures. And that's when it's very clear that they are probably going to pass away, but who knows when? But that's when we would talk to the hospital administration about like, we need to get a family member here. But I would say it was still a battle every time we wanted to do that. So there were a number of cases where people passed away in the hospital and didn't have a family member close. Which was really hard. It's hard to see. I mean, it's, I'm sure it's even harder for the families. So what did we do about this to try to make sure - especially for people that were on ventilators. Early on we were really concerned about this, and this was something like when I say we I mean, everybody in the hospital was worried about this. And because we'd heard reports out of Italy, where some people had gotten intubated, and like we're on a ventilator so quickly, but like, no one knew who to call or where their family was. So, we had a policy where, whenever we went down to admit somebody, we would have a conversation with them. And I would say this is something we normally do in normal times, but there's usually less urgency, we might like, go down and admit somebody, and then like have a conversation over the course of the next couple days, while they're in the hospital, especially if it seems like they're not doing well. But during the time of COVID, we had a policy where if you're going down to admit somebody, you have to have a conversation about if they were unconscious, who would they want to make medical decisions for them and get the contact information? And also talk to them about - essentially make a backup plan of like, you know, if, if you did start to have a lot of difficulty breathing, what would you want us to do? Would you want to be intubated, and be on a ventilator? Or is that something that you would really like to avoid? And so those conversations had to happen immediately when someone came in the hospital. And still challenging. We would try to kind of like, have discussions with the person that the patient would nominate. That person is called a health care proxy, or a surrogate. And so we would try to talk to them on a daily basis. But as you can imagine, as the hospital got overwhelmed and staff were really stretched, it didn't always happen. And so we just tried to kind of have discussions early. So like someone would come in the hospital, and we try to kind of update families almost daily, as much as we could. So that they wouldn't only be called if there was bad news. We were in an overwhelmed hospital. But our hospital wasn't nearly as bad as places like Elmhurst or New York Presbyterian Queens. And those hospitals were so overwhelmed, I'd heard from a number of people that being able to call family just wasn't possible. These people were just trying to do whatever they could for patient care. And so I think in those places, it was even worse in terms of families being updated, conversations happening with families, and patients being alone if they passed away.
Catherine: So at what point in the symptoms, would hospitalization become necessary? Let's say you come down with it, when did it turn from what feels like a light flu to something that's like, okay, you need to be admitted to a hospital now?
David: In the beginning of the pandemic, we didn't know. So in the beginning, I remember the first patient I took care of with COVID wasn't that sick, he was just COVID positive. And we just didn't know what to do with him. It was like, well, how long do we watch him? Do we just wait until he gets worse? So there were a lot of questions initially. We want to admit someone to the hospital when they're "sick enough," right, but like, what does "sick enough" mean? And the short version is essentially, if you have a viral illness, like, you know, we don't have a cure for COVID or other viral illnesses, right? So people need to come into a hospital in general, if the hospital has something that you can't give yourself at home. This is different for everybody, right? So if you're like 23 years old, and you have a great support system, so you live with your parents, and you have brothers and sisters at home, you really don't need to be in the hospital, unless you need something beyond the care you're getting at home, like maybe that's a diagnostic test, or oxygen or intravenous antibiotics or something like that. But if you're, say, homeless, or if you're 85 years old and you live alone, then like, the threshold changes, right? Because it becomes unsafe for you to be by yourself much more quickly, like, if you're 85, and you're too weak to make yourself food or to make it to the bathroom on your own, then even if you're "not that sick" as in, maybe you don't need oxygen, maybe you don't need intravenous antibiotics, then you might still need to come into the hospital for a few days, until you kind of get over the illness and get stronger. So, this was tough, because, at the peak of the epidemic, it was increasingly a question of - it would come down to, do you need oxygen? And so I would go down to the emergency room, and we would check your oxygen level. And if your oxygen level was okay, we would see if you could stand up and kind of walk around the emergency department. And if your oxygen levels didn't drop, then we would often send people home with an oxygen monitor, and say, Look you have to monitor this, and if this gets worse come back, but you don't right now meet criteria to come into the hospital. And that was more for the healthier people. Again, if it was an 85 year old, who couldn't even get up and walk around the emergency department, then we were in a situation where the safest thing was to admit them. So every hospital has a little bit of a different criteria of when someone should be admitted to the hospital. And I think even now, now that we're past the peak, I think the thresholds have changed a little bit more again. And like, you know, I wouldn't be surprised if it's a little bit back to kind of the normal criteria, which means that some people would get admitted to the hospital, even if they don't require oxygen, but they're just kind of in a situation where they can't take care of themselves very well at home.
Catherine: And so what is a typical day? I mean, were there COVID wards where everyone had it and what did it look like where that was happening? As a doctor what does it look like to you? Right? Because I can say, you know, what I know of COVID is the shortness of breath, and you can't taste anything. But if that's not exactly the reality of it, right? There's much more to it?
David: Yeah. So like, let's give an example of a day, at the peak of the pandemic. So I would bike to the hospital, because I wasn't taking the subway anymore, right. And I would get there. And immediately when I would walk in, they would give me a mask. And that was my mask for the day. Under normal circumstances, I obviously wouldn't be given a mask when I would walk in the hospital, and the masks would be outside of patient's rooms. If a patient had the flu or some other virus, you would put a mask on before you walk into the room, and you would take the mask off and throw it away as you left the room. So it was a big change to walk into the hospital and be given a mask, and you were expected to wear this mask all the time. And then I would go to the floor where I work with other hospitalists where I would sit at a computer and review patient's charts. Normally, we would all sit in a big room, right, and we're all a little bit crowded in this one room but to try to do some social distancing, we started taking over some other offices on the floor that we work in, so that people had a little bit more space. But we were still working in relatively close quarters having to wear a mask the entire time. And I would do kind of what I would do on typical mornings, which is review patient's charts. And then I and my team--and that would sometimes be another redeployed, hospitalist. At one point, I had a gastroenterologist who came with me who was taking care of some additional patients. And I had a physician assistant that was working with me and we'd go and we'd round on the different patients. And initially, what was weird was we felt kind of in a tough situation because initially, you know, rounding is where I just go and I see every patient And that can take a couple of hours. Often more than that to have a conversation with the patient, have a conversation sometimes with the family member, sometimes use an interpreter. But the biggest challenge initially was we had to - every time we walked into a room we had to put on PPE [personal protective equipment]. And so many of us were like " this is crazy," right? Because you're wasting so much PPE going in and out of rooms, is there a way that we can just kind of have like a hot zone where I put on PPE, and can just keep on seeing a lot of different patients without taking off a PPE, as long as they don't have some other kind of restriction? If they've got some multi drug resistant bacteria or something like that, then maybe I should take off my gown after I see them so I don't spread that bacteria to somebody else. But towards the peak of the pandemic, we finally got to a situation where we put some red tape on the floor, and basically cut the hallway in half, and we had a green zone and a red zone. And if you were in the green zone, that meant that you were not wearing PPE, and you have not touched anything that might be COVID contaminated. But if you were in the red zone, that meant you could and so what we would do is we would put on my PPE. I would walk into a patient's room, I would do what I needed to do in there, talk to the patient, things like that, I would usually double glove and I would take off the first set of gloves, I would use some hand sanitizer, and then I put on a new set of gloves and go to the next patient. I would leave the room, stay in the red area, and then go see the next patient with my new set of gloves. And then I would just do that kind of down the hallway. We had to kind of improvise with a couple of things, for example, I would put my phone in a plastic bag so I could call interpreter services, if I needed to talk. I had a lot of patients who spoke Spanish or Chinese. We had to navigate some of the challenges wearing gloves and a gown and two masks because we had both an N95 and a mask on top of the N95. While juggling a phone and trying not to get it contaminated. So that would be how I would round. And then after rounding, I would do what I normally do, which is: you've made the plans during rounds. And then after rounds, you're trying to implement those plans. So the physician assistant would go and write lots of orders, I would talk to a lot of consultants, I would spend a lot of time kind of talking to the intensive care unit folks about the patients that I was really the most worried about. And I would check in on them a lot because we just didn't have enough room in the intensive care unit. We would spend a lot of time running and checking on patients that we were very concerned about. And if they looked like they were getting worse, we were kind of in constant contact with the intensive care unit. So we could be, we could say "look, I just saw them an hour ago, now they're much worse, I really think we need to do something." And, we could make things happen if patients were getting worse. And then in the afternoon, that's when we would try to make a lot of phone calls. Just a little bit after the peak, we got a bunch of iPads. So we would try sometimes to go into a patient's room, and be able to have conversations with the patient and their family members, sometimes on an iPad, or even just over the phone. Because that was always a lot better if you could talk to both the patient and the family member at the same time. That made things a lot easier. We would sometimes be outside the room to kind of limit the number of times we would go in, we would sometimes call the patient on the phone and just check in and ask "how are you doing? how's your breathing? Has anything changed?" So that was something that I wouldn't normally do, but we started to do increasingly during COVID to try to preserve some PPE and minimize our risk of exposure.
Catherine: Wow. And did you see a lot of doctors and nurses coming down like contracting it? Or did you guys have a good enough system, it was sort of maintained or contained? I guess that’s the word.
David: Good question. So in our hospital, we actually, for a period of time, all of the COVID people were on two floors, and there was a floor that didn't have any COVID patients for a while. But what was interesting is, it was that floor with no COVID patients that there was a bit of an outbreak of COVID among the staff and it was basically because in the staff room, the staff would take off their masks to eat and to hang out. It was thought that like someone probably had COVID somehow, and spread it among a couple of the staff through the break room because the floors that had people, patients with COVID, it was an unusual thing - I heard of maybe I could think of one, maybe two cases of a provider that ended up getting COVID while they were working with COVID positive patients. I think it was because the PPE seemed to work pretty well. That's what it seemed to us. I mean, at first, we were very skeptical because we were put in a lot of a lot of situations where it was like, "Man, I'm sure I got it." We always talked about aerosolizing procedures. So if you did suctioning, or if you did a couple of other things, and I was wearing an N95 that I'd been wearing for four days, in rooms for a couple of hours sometimes because it was a very sick patient that we were trying to stabilize with aerosolizing procedures. And I was like, I am sure that I have been exposed. And yet I was shocked after the peak passed, and I got an antibody test and I was negative. A number of other people that were in similar risky situations were also negative. So it was surprising, but the PPE seemed to work. And to give an example of that is, my first week on the COVID service. This was a time very early in the outbreak, where we still kind of didn't know what we were dealing with. And there was a lot of fear that we were going to run out of PPE. And so they actually did not let us wear N95 masks when we were going to see patients unless we were going to be involved in aerosolizing procedures. And so I remember that very clearly because I had a lot of patients with bad coughs. And I was only wearing a regular surgical mask for the entire week. And so I was really surprised because a number of the patients that I saw that week were very sick, and ended up intubated for a couple of weeks. So I was really surprised that, you know, if I didn't get it that week, and I didn't get it the weeks that I was exposed to aerosolizing procedures. I was like, "man, I guess the proof is in the pudding, I guess the PPE works."
Catherine: So in terms of the people who were family members of people who had COVID, and people who, maybe were not medical staff, but would have been exposed to it; but for some reason, were more resistant. Was there a common trait among those people that would have been exposed to it, but didn't get it? That you guys were able to put together?
David: Hmm, not really. One of the things that was clear was, it was really challenging, just the living situations that people were in. Because it wasn't uncommon that we had a couple of situations where husband and wives were both in the hospital. Because they were living in a situation where kind of there was no way to really socially distance. And one person in the family had the virus, and then all the sudden everybody had it. And that was not an uncommon thing. We would talk to people and they'd be like, "Oh, my husband also has the virus. He's at home sick. And my son and daughter who live with us also are sick." But there were varying degrees of who was very sick and who wasn't. There was nothing that we could really pinpoint in terms of how the virus spread. But it made a lot of sense, people that were living in small apartments in New York, in close quarters where there were a bunch of people living there, it was a story we heard very commonly that everybody in the family had gotten sick. There weren’t situations that I'd encountered, where somehow somebody in the family had not gotten sick, even though everybody in the family was sick. That would have stood out because that would have been an unusual scenario. But that wasn't something that I encountered personally with my patients.
Catherine: And was there anything in terms of who contracted it and the severity of it in regard to lifestyle? As a personal trainer, from a fitness point of view, I'm very curious to know if people fared better if they typically had a healthier, more active lifestyle? And was there a way to push out of it or to help along the healing process, let's say, if you are a more active person?
David: Sure. I mean, this is completely anecdotal, but I did notice that, regardless of what age you were, if you were in kind of good shape, you seemed to weather the virus a little bit better. Especially for the younger people, all of the younger people I had. Anyone who was under the age of 50, they were generally obese, they may have had diabetes, maybe not, but they were generally obese, kind of out of shape. I had one patient who was in his 30s, a couple of patients in their 40s, and they all kind of had that. And even some of the older people, it was less a hard and fast rule, but the older you got it did also seem - I didn't have many 70 year olds who were pretty physically fit who came into the hospital. But the older you got, it wasn't a hard and fast rule. Because there were definitely some older people who had no - I'm thinking of people in their 60s, early 70s who had no medical problems at all, no known medical problems, like no diabetes, no hypertension, just pretty healthy, pretty active and I knew a number of people in that age group that passed away.
Catherine: Okay. So it didn't seem like there was any, like, there's no predictability really on it, regardless of what your health or activity status is.
David: Whatever it is, I think this is a hypothesis, like I can't say this for sure. It'd be really interesting to study this. But I think if you're young and physically fit, I'd be really interested to know your risk of a severe COVID outcome. My suspicion is it would be lower, but I'm not sure. And then the older you get, I think the less your physical fitness protects you would be my suspicion just based on my experience. I'd be really interested to see if there are any studies that looked at that formally. Because I could be wrong, but it would be really, I'd be really interested to know.
Catherine: All right. Um, I think that covered all the questions we talked about, is there anything that you feel like you wanted to add to it?
David: There's been some rumors out there about death certificates. And so I wanted to address that. What have you been hearing about these rumors?
Catherine: Um, so I've been hearing - and again, you know, it is anecdotal - however, my sister works, she's a hospital administrator. She was working upstate, and she heard nurses on her staff that were going through something where they needed to alter the death certificate to reflect something other than COVID; that somehow the patient had tested negative for COVID but that was listed as their cause of death. I had heard things like that. And then there was something that had come out also about a motorcycle accident, and they put COVID as the cause of death. Now, would they have eventually died of COVID? Who knows? But, obviously, it would be the motorcycle accident that killed them. So, you know, there were questions about that where, you know, even if COVID wasn't playing an active role in a person's death, it was being listed as a cause, you know?
David: Yeah, that's an interesting question. Because I had a couple of patients that it was like COVID was an incidental diagnosis, where they were clearly in the hospital with something else, like a hip fracture, right. But sometimes the link was there and COVID was very much part of it. For example, I had one patient who - I had a lot of patients, especially men, for some reason who the only presenting symptom they had, like the only symptom they had of COVID was they fainted. I had one guy who fainted at work, he was a young guy, obese security guard, he fainted at work, and so somebody called EMS. EMS brought him to the hospital, and he had COVID. And, he didn't realize it, but he also had really low oxygen levels. He had fainted, probably because his oxygen was low. And even though he didn't feel it, so it's one of those things where it's like, you know, just because of your symptoms, like, doesn't mean that COVID wasn't involved. So I had one patient who came in with a hip fracture, because he fainted, and broke his hip, right? Sure, the presenting diagnosis is a hip fracture, but he probably had the hip fracture because of COVID causing him to faint and lose consciousness. And that was one of the things that kind of happened a lot. It was an interesting thing to find patients that were doing well despite the COVID. I remember one patient that was, I think it was 93, and he was COVID positive, but it was like "wow, like he seems to be doing Okay, other than some of the other medical issues that we're treating him for," like he had some heart problems and kidney problems. And we tuned those up, and then he went home and the COVID was never really that big of an issue. For the people who got really sick, though. I can think of a couple of people where COVID started the cascade. And so even though COVID probably didn't kill them, it was what really started them down this pathway. And I can think of one person who - and this was not an atypical story - who had COVID, and his breathing was okay, but the COVID was bad enough that - this wasn't uncommon - where his kidneys failed, and he got some clots and the clots ended up in the wrong places like in his lungs, and that's what killed him. And so it wasn't directly COVID in the sense that it wasn't COVID attacking his lungs, and he died because he couldn't breathe, right? That is how a lot of people died. But it was COVID setting off this cascade of other things that happened. And I also remember one patient I saw in one of the intensive care units, who was a very young guy, who thankfully he did not pass away, but he came in because of a motorcycle accident. But they had found that he had COVID. And so it was one of these things where it's like, you know, did the COVID cause the motorcycle accident. And this was someone who he definitely had a lot of trauma. And so it was hard to tell whether or not some of the - he needed to be on a ventilator - well, did he need the ventilator because his body had experienced so much trauma? Or was it because of the COVID. And that's, that's actually something that can sometimes be difficult to tease out. Now, the other blood tests we did made me pretty certain that it was COVID. So even though he had a motorcycle accident and trauma, trauma wouldn't cause all of these other signs of inflammation in his blood that we found. That was the type of stuff we found in COVID.
Catherine: In a case like that would they label the death as COVID?
David: So if he had passed away, I would. Thankfully that patient didn't. But other patients where COVID set off that cascade, or COVID might have - and thankfully this did not happen - but the patient I had with the hip fracture who came in because he fainted. He fainted from COVID that caused a hip fracture. Hip fractures, you need surgery. If he had passed away during surgery, I think COVID was a contributing cause. And that's something that I would say in the time of COVID or if something similar had happened and someone had come in with some other kind of viral or bacterial illness. Yes, most proximally he died in surgery because of a hip fracture, but he wouldn't have had that hip fracture unless he had this illness. So the two are obviously linked.
Catherine: That makes sense in a way, but at the same time, it almost feels like a "Schrodinger's cat" kind of situation. Right? I mean, because It could be, but then, you know, I guess that's where people become skeptical of what's being told and what's being reported. Because if I have a friend who could have shortness of breath due to COVID, or they could have shortness of breath due to whatever, maybe they have high allergies, and, you know, so if they have high allergies, but they also have a COVID diagnosis and they get into a motorcycle accident, then it kind of seems like it could really go one way or the other. And so people are getting the impression that it's an inflated number because it doesn't make complete sense to them about why you would label that a COVID death because it also doesn't sound like it is a 100% of a certainty.
David: The thing we run into in the hospital, and this is why some of this information about death certificates is taken out of context, because it is actually really rare that we have 100% certainty on the cause of death. If you talk to people that are used to filling out death certificates, there wasn't anything unusual about the COVID situation except for probably the number. But in terms of how we attributed COVID as the likely cause of death and some of the other contributing factors, in the patients I saw that passed away in the hospital, it was quite routine. Now there's a lot of variation in terms of how people fill out death certificates. I wouldn't be surprised if there was a hospital or two that didn't have well-trained staff and didn't know what they were doing in this type of situation and maybe didn't fill them out super well. But in situations where people were used to this kind of thing, it was relatively routine in terms of how we filled this out and very routine in terms of how much uncertainty there was surrounding the diagnosis.
In the hospital we’re very used to being uncertain and you show that uncertainty to people who have the assumption that that process would be certain and it feels very weird.
I’ve had this conversation with researchers because a lot of researchers use data from death certificates to study a bunch of things. What’s funny is when you talk with these researchers and you tell them just how much uncertainty there is in the process of filling out a death certificate, how little you know sometimes about what some of the underlying factors or even what the main factor was. They’re always very surprised. It is not a completely certain process, and there’s some subjectivity to it. Was COVID the primary cause of death? Or was the primary cause of death something else and COVID was a contributing factor? That’s a judgment call. But I think what is key is recognizing that for the people who were very sick who came in the hospital, COVID was pretty severe, and was very much a contributing factor. But that’s a hard thing to get across if you’re not used to filling out death certificates.
Catherine: That makes sense, and I guess that’s also a public misconception of how that’s done.
David: In general, I think people believe there’s a lot more certainty in medicine than there is, and I think it can be very uncomfortable when people see just how much uncertainty there is. Physicians – a lot of our training – you can go on Google and learn all the stuff you need to know for a board exam. But what is really hard is the learning process we go through in med school is the learning process for how to make decisions in uncertainty. And you can’t learn that from a Google search. There’s a lot of debate about this, I wouldn’t say everybody does it perfectly. It’s something we always have to be conscious of, but there’s a large gap between how physicians think about uncertainty in situations in the hospital and how people perceive that uncertainty. And TV shows like House and ER and Scrubs haven’t really helped.