I write this letter during a time of great stress, given the ongoing COVID-19 crisis. As an oncologist, I must confess that my situation is far less stressful than that of many of my colleagues. I have continued to care for my own outpatients via video visits, and when redeployed within the hospital was assigned to cover the oncology floor. Additionally, I have been working on activating clinical trials for COVID-19 patients, akin to what I do every day for my CLL patients. The furthest I have landed from my typical routine during this crisis is several overnight shifts as a general hospitalist, which is not too far from my comfort zone.
Numerous friends and colleagues have been deployed from other areas of medicine—including radiation oncology, neurosurgery, and orthopedics—to function in capacities far outside of their comfort zone. This brings to mind a scene from Grey’s Anatomy, which my daughter enjoys watching, in which the neurosurgeon Derek Shepherd diagnoses a tension pneumothorax in a premature newborn in the NICU and walks an intern through its management. I am still waiting for the scene in which the medical oncologist ends up having to do a heart transplant in midair because a plane is unable to land. (That would make for an amazing episode.)
During this time of crisis, we are seeing many examples of heroism by healthcare workers—the longer, more stressful hours; the fear of placing ourselves and our families in harm’s way; and the anguish of dealing with what is often a losing battle. Unlike the superhuman physicians of Hollywood, real-life physicians have limits on our abilities, and most of us are stressed by being outside of our comfort zone. I commend each of you for rising to the occasion and playing a role in combating this crisis.
When Andrew Cuomo, the governor here in New York, announced his idea to graduate fourth-year medical students early in an effort to rapidly deploy resources, I worried that we had overstepped our good sensibilities. The interest and efforts of these newly minted physicians are commendable, but the beginning of internship is already one of the most stressful times for a physician. The safety net that each training program establishes to help these interns beginning on July 1 is not yet present, so the risk of an inexperienced physician harming patients is too great. Fortunately, the regulatory bodies overseeing residencies recognized this as a poor idea, and intervened.
The next step after mobilizing resources is figuring out how best to use them. We have put a great deal of effort into determining how to maximize supportive care for patients with COVID-19. Although these efforts have been great, my concern is that maximizing the standard-of-care treatment is not having a significant impact on these critically ill patients. We must instead turn to identifying therapeutic interventions to prevent patients from becoming critically ill. Although I am impressed by the number of different ideas put forth, I am disappointed that we are not taking more of a nationally organized approach to testing these interventions. With the current onslaught of patients, there is no shortage of eligible participants—often the first obstacle in oncology clinical trials. So why are we squandering this opportunity?
Severe disease, which occurs in 5% to 10% of patients with COVID-19, is similar to a widely metastatic solid tumor in that we have many approaches we can try, but little hope of cure. As oncologists, we appreciate the essential nature of clinical trials. We have had to construct large, national cooperative groups across multiple institutions to accrue enough patients for studies of rare cancers. Although inadequate patient numbers are certainly not an issue with COVID-19, I would argue that large cooperative group efforts are even more important in this setting. The urgency and impact of COVID-19 are too great for us to risk wasting time and effort. Searching for COVID on ClinicalTrials.gov generates a list of more than 800 trials, many of which are redundant. Do we really think that siltuximab will act any differently than sarilumab? Are trials examining agents that are likely to bring only marginal improvement, if any?
Every night at 7 pm, people lean out of their windows to applaud healthcare providers and other essential workers for the care and service we are providing during this time of crisis. Everyone, no matter how small the role, deserves the appreciation and thanks being offered for putting themselves in harm’s way to help others. Let us not fall short in our efforts to identify new therapeutics, however. We need a nationally organized and coordinated approach for testing novel therapeutics. We need leaders who are going to push through regulatory red tape and overcome the hurdles of costs and insufficient manpower that normally limit clinical research. Only then will medicine be able to fully respond to the COVID-19 crisis with all of our brilliance. I will be the first one to applaud when that happens.
Sincerely,
Richard R. Furman, MD