When a patient’s oxygen level falls below 90, it has a marked effect not only on anesthesiologists such as myself, but all doctors. Going from 92 to 91, or 91 to 90, elicits some concern, but when going from 90 to 89, doctors often grow anxious and breathe heavily, as if they were soldiers suddenly crossing the frontier into enemy territory. Their unease stems mostly from low oxygen’s physiological consequences, but I’ve often thought, amazingly enough, that the number 90 triggers in their subconscious distant but desperate memories of trying to preserve their GPA to get into medical school. A score of 90 is the bare minimum for an A; below that one descends into dangerous B territory.
This neurotic reflex in doctors, whatever the cause, matters. Reports suggest that doctors have been too aggressive in intubating COVID-19 patients whose oxygen levels have fallen into the 80s. (Normal oxygen levels hover in the upper 90s.) Some patients were reportedly talking on their cell phones when doctors rushed in and told them they had to be intubated. The patients were in no great distress. Their monitors simply displayed numbers that panicked their caregivers.
This has caused some patients harm. On a wider scale, the practice may have boosted COVID-19’s mortality rate. The positive pressure associated with mechanical ventilation can injure a patient’s lungs. A breathing tube also eliminates a patient’s natural cough, making it hard to clear the lungs of mucus and debris.
The practice also suggests that inadequate ventilator supply, once the major reason for flattening the infection curve, may no longer be operative. If going on a ventilator is now recognized to be practically a death sentence—a New York study reported that 89 percent of COVID-19 patients placed on ventilators eventually died—then ventilator therapy either unnecessarily injures (even kills) an infected person, or the infected person was likely pre-terminal to begin with, so the intervention made no difference. Either way, ventilator treatment no longer appears to be a crucial factor in saving lives. Flattening the curve remains important, at the very least to push inevitable infections into the future, when better treatments for COVID-19 may exist, but doing so to decrease ventilator demand is no longer a justification for lockdowns.
In one month, we have gone from worrying about not having enough ventilators to possibly overusing them. Still, rigid thinking may have played a role in both situations. When too few ventilators existed, the problem was policymakers refusing to think innovatively—for example, allowing family, friends, or National Guard reservists to function as human bellows to compensate for the shortage. In ventilator overuse, a similar inability to think outside the box may be at work.
Because I am not working in an ICU setting right now, I do not have a good sense of how many COVID-19 patients were intubated because they were tiring from respiratory distress, with all other modalities having been exhausted (and a good reason to intubate), and how many patients only had bad numbers, which panicked their doctors into intubating them. Anecdotal reports suggest the latter is not uncommon. I have faced the “bad number” situation before. Once, when I signed out to another doctor upon finishing my shift in obstetrics, I told him about a patient on the floor who suffered from morbid obesity and a history of asthma, whose oxygen level was 88. “What?” he screamed. “An asthmatic whose oxygen is 88? She’s deteriorating! She needs to be intubated now!” He rushed into the patient’s room carrying a scope and a breathing tube, with me lagging behind, crying, “Wait, wait, you don’t understand!” Rather than gasping for air like a fish flung ashore, the patient was sitting up comfortably in bed, doing her nails. My partner confessed embarrassment that he had jumped to conclusions based solely on a number.
If this error has occurred on a wide scale with COVID-19 patients, it should not come as a surprise, given the direction of medical education over the past 40 years. That education increasingly consists of protocols and algorithms: If a patient exhibits this, then do this; if the patient exhibits that, then do that. In fact, many doctors enjoy this form of medical practice. They want to know protocols, typically expressed in vector form. There is security in vectors. Nothing abstract. No innovative thinking required. These are the decision trees. That is understandable.
The pattern is often repeated when doctors learn new approaches to disease management. I’m as guilty as the next doctor in this regard. Doctors eagerly await the last slide at a conference, when everything is summed up in the form of a therapeutic algorithm. Although patients resent being crammed into a treatment algorithm, they overlook the peace of mind that many doctors enjoy when they know what to do, at all times and in all cases, based on an algorithm.
The problem’s scope widens. In many fields today, professionals hate vagueness and crave rules. True, rules are important; without them, all professional activity would cease. Chemists could not safely mix substances. Pilots could not safely fly airplanes. Yet an element of neurotic behavior haunts this reverence for rules. It has already revealed itself in play at the FDA and CDC, where a rigid adherence to rules slowed response times during the pandemic. In my own field of medicine, doctors often rigidly follow rules and algorithms, and by doing so hope to get through an entire career unscathed. They want to hear, “It is forbidden to do this,” or “It is the duty of the doctor to do that”—the kind of straightforward counsel that comes with an algorithm.
More rules and guidelines are written all the time. Almost every activity in medical practice has been carefully tabulated. Nothing has been overlooked; nothing has escaped the eye of the rule-givers. There are detailed instructions for everything. Yet some doctors wrongly see these rules as information, something with a clear right and wrong, like an irrefutable math demonstration, something that comes with a sure path toward success. They forget that rules and guidelines are only an approximation of truth, and that at every step they need a doctor’s considered judgment to make them more exact.
Then comes a moment like COVID-19, when a novel situation presents itself. Some doctors grow uncomfortable with the new logic: follow medicine’s rules, but sometimes don’t follow them; sometimes act as if they don’t exist. You’ll never come to any grief by disregarding them, up to a point—only it’s impossible to fix that point. When pondering whether to intubate a COVID-19 patient with an oxygen level in the high 80s, but without distress, doctors suddenly realize there is nothing safe in the world of medical practice, nothing that is not subject to the law of “up to a point.” Follow the algorithm that says to intubate patients whenever their oxygen falls below 90—but only up to a point. This qualifier makes many doctors uneasy. They would prefer not only to be given clear direction about when to intubate, but also to be made aware of the penalties for not following that direction, and to have the magnitude of those penalties defined beforehand. Sadly, the COVID-19 crisis teaches them that rules and guidelines come with exceptions and gray areas that they are responsible for navigating through. This scares them.
It also threatens modern medical education’s cornerstone. A scientific algorithm is supposed to mean the same thing to everyone. But to allow an algorithm to be interpreted in different ways and mean different things to different people risks making the algorithm useless, even dangerous, for a doctor never knows for sure how much individual judgment to use when working with a vague algorithm. The algorithm becomes like a map whose contours are confused and whose boundaries keep shifting; nevertheless one feels obligated to use the map constantly.
Practicing medicine (or any profession) is about living in a state of uncertainty, in the knowledge that rules must be followed but only “up to a point,” and what that point is a doctor never knows for sure. Doctors hope in their imaginations that someone will tell them what that point is, that a colleague will say, “Don’t worry, this is one of those exceptions to the rule. Ignore the rule,” or “If you follow the rule, you may suffer a penalty, but at most that penalty will be a small misfortune,” or “This time you better follow the rule.” But doctors hope in vain. They are sentenced to doubt, often and at a moment’s notice, for rules and algorithms exist everywhere in medicine—to guide them, but also to worry them, to paralyze them, and possibly to ruin them. It is the burden of all professionals.
This includes government officials. They, too, must follow rules, but they must also know when to flout them. Knowing this is the difference between the mere administrator and the true professional. Administrators tend to think rules exist for their benefit, while professionals know some rules exist for someone else’s benefit, which may or may not be theirs. We saw examples of this bias early on in the pandemic, when the FDA refused to bend the rules that limited the manufacture of N95 masks, or when the CDC refused to bend the rules that allowed only certain labs to test for coronavirus. The administrators in these agencies viewed the rules as something to serve them, to protect them, and to keep them from having to do something out of the ordinary, when, in fact, the rules served whoever created them, because it was the latter’s job to create rules. At a crucial moment, the administrators forgot the great paradox about rules: A rule belongs to that class of things that are of the highest value, that perform a vital function, that are, in fact, an essential part of the planning mechanism, but which should only be applied with the greatest circumspection.
Things are getting better on the intubation front. Doctors have grown less aggressive about intubating people as new data come forward. This is good for COVID-19 patients. It is also good for doctors. To change one’s views, to admit to the change, and to appear changeable was always the professional side of being a doctor, compared to the scientific side, where precise laws and algorithms determined a course of action.
Still, the new consensus risks another variation on the rules’ problem. Doctors, like all professionals, think with their bodies, but sometimes, like animals, they also think with the herd. If panic seizes a flock of sheep, each animal runs with the flock, not because it understands the reason for panic, but because it thinks it will be at the mercy of its enemies if it fails to follow the flock. Is this logic now operative in the doctors’ newfound resistance to the old rule for intubating COVID-19 patients? Are we witnessing the dawn of a new rule that anxious doctors will worship, replacing the old one?
Doctors love their rules and algorithms. I love my rules and algorithms. Yet the underlying difference between doctors is typically less one of who knows the rules and more a matter of personal taste. In delicate and difficult matters of patient care, individual variations of temperament and personality, including the ability to withstand the pressure to follow algorithms blindly, are really the dominant elements in any physician judgment.
During my first year of anesthesiology residency, I took care of a patient whose oxygen slipped from her baseline of 91, where she lived, to 89. The monitor’s alarm rang out and I began to panic, as the “90 threshold” had been crossed. My patient was under mask anesthesia; I thought maybe I should intubate her. I paged my attending to come quickly. When he arrived he pointed his finger at the monitors I was staring at, and asked, “Which alarm is bothering you?” I motioned toward a stack of three monitors on the right. Moving his pointed finger closer to that stack, he asked, “Which alarm among these three monitors is bothering you?” I pointed to the oxygen monitor. He advanced his pointed finger again, until it reached the oxygen monitor’s on/off button. Then he put his pointed finger on the button and advanced again, thereby turning off the monitor. “There you go,” he said. “That should help you feel better.” As he left, he said, “Spend more time looking at your patient than your monitors,” he said.
The patient did fine.