Managing the President's COVID-19

The treatment given to POTUS is the abstraction we all desire – personalized medicine. Just the right treatment, at the right time, in the right way. Of course, physicians' day-to-day dilemma is translating guidelines and treatments tested upon populations into efficacious care for the individual sitting across from your desk. And that dilemma is compounded when you deal with VIPs

It is not March; when the virus didn't respond to the treatments that had always worked so well for influenza - we threw everything we had at the problem. While we have made significant progress in treating COVID-19, I do not believe we have a set-in-place protocol for what to do when. There is a broad outline of medications that may reduce symptoms, improve outcomes, and reduce the length of stay – lots of ingredients, lots of chefs, but no classic recipe.

All of the medications that the President has been publically acknowledged as receiving reduce symptoms.

Ethical medicine, "shared decision making" between patient and physician requires that I provide you with options, state which I feel is the best approach and why, and together we choose a path forward. The President's care, as with most VIPs, involves lots of chefs. Many chefs with nuanced opinions that by consensus, majority vote, or eminence eventually become a treatment plan. [1] One of the difficulties in treating VIPs, in general, is that in many instances, they believe their eminence extends to being a chef too. They can be very "hands-on" when it comes to choosing treatments and what to pursue. 

The patient applies any factors they feel are relevant in that calculus. I think it is apparent that the President has included a political component to his choices. This is not the time to appear weak physically or emotionally. His motorcade to his supporters is an example of powerful eminence in action. As a rule, hospitals don't allow you to leave for a few hours and return; in many cases, chronic smokers with significant addiction to nicotine are not allowed to go outside for a cigarette. 

Of course, it takes two to make a medical decision; you still need a physician. Can we reasonably believe that the phrase "an abundance of caution" has not impacted their clinical judgment? Additionally, by my count, the President has had at least three physicians, including his private one, since taking office. The idea that he has a deep enough long-term relationship with any of them that would allow for considered choice is silly; in that way, the President echoes some of our behavior, honoring primary care in word but not deed. 

Words matter and their meaning varies significantly from one context to another. Consider Chris Christie, who "checked himself in" to a hospital over the weekend. Hospitals are not hotels; you don't check-in; you are admitted to the hospital by an attending physician who has determined you have met the admission criteria. You only would describe admission to the hospital as checking-in to make it seem more an optional vacation choice, less a medical need. 

Or the announcement that the President may go home to continue care, you shouldn't take that to mean he is like a typical COVID-19 patient being discharged from the hospital; unless, of course, that patient has a fully equipped Emergency Department and physicians standing by in their home.

It is a fool's errand to guess at the President's clinical status based on his receiving treatment. Whether he received supplemental oxygen doesn't necessarily mean he was more ill or that the doctors acted out of an abundance of caution. What is supplemental oxygen, 2 liters/min or 8, nasal prongs, or face mask? We cannot tell.

He is receiving personalized care, not care from some guidelines that haven't even been formulated. His treatment, like ours, is or should be, is personalized to his needs. It may very well be that his perception of his non-medical needs overrides his physicians' medical judgment, but that is a problem all doctors and patients face. 

[1] One of the problems for VIPS is that, in some cases, "too many cooks do spoil the soup." If you don't believe me take a look at the medical decisions surrounding President Garfield, "At least a dozen medical experts probed the president's wound, often with unsterilized metal instruments or bare hands, as was common at the time." Or look at the care of the Shah of Iran, whose cancer was treated by the world's best cardiac surgeon, with a very poor outcome.