Sensible Medicine—Balancing Intervention and Inaction During the COVID-19 Pandemic

“Sensible medicine is an approach to treatment that seeks a balance along the spectrum of the strength of evidence and the pace of knowledge translation. On one hand, a hawkish interventionist has little doubt about the effectiveness of a new treatment and rapidly adopts it into practice. There is a tendency to favor adoption of the new, acceptance of less rigor in research methods and results, and a glance away from subconscious biases. This contrasts with the medical nihilist who is highly skeptical of new evidence and hopes to intervene even less. The medical nihilist is certain of the futility of treatment, ineffectiveness of most medications, and corrupting influence of financial incentives. In the middle is a sensible approach, which acknowledges that some interventions are effective but, perhaps, confidence should be tempered. With sensible medicine, the translation of knowledge to the bedside is appropriately calibrated to the rigor and reasoning of the available evidence and the severity of the outcome to be avoided.

How to Practice Sensible Medicine During a Pandemic

  1. Medicine without magic
  2. No single mechanism or pathway yet discovered accounts for all of the [COVID-19] pathophysiology. Similar to acute respiratory distress syndrome caused by sepsis or trauma, a single mechanism or pathway is unlikely to be found. To date, only nonselective and mechanism-agnostic drugs like corticosteroids or antiviral medications have been associated with an improved course in patients with severe COVID-19. To be sensible, clinicians must recognize that highly selective, fully effective treatments are uncommon in acute care.

  3. Practice doing (almost) nothing
  4. Clinicians should advocate for randomized trials with appropriate controls, and counsel patients that standard care may be as effective as tomorrow’s best idea. Clinicians must learn while doing, and accept that (almost) nothing is in fact something.

  5. Elevate usual care
  6. Focus on high-quality evidence
  7. Think Bayesian
  8. [..] assume H is a hypothesis that a new COVID-19 treatment is effective and E is the evidence for that treatment being effective. By the Bayes theorem, the odds that the new treatment is effective given the evidence is:

    P (E|H)/P (E|not H) × Prior Odds

    During the pandemic, the following assumptions would be expected:

    The prior odds are low given the lack of a unifying biological mechanism and multiple neutral clinical trials.

    P (E|H)/P (E|not H)

    This is the ratio of observing the (weak) evidence assuming the treatment is or is not effective, and this ratio is close to 1.

    Thus, the posterior odds that a new COVID-19 treatment is effective should be low and hardly changed from a small prior value. It follows that treatment guidelines, national mandates, and bedside care adapt to new data only when the evidence is rigorous, reproducible, and sufficiently strong.

To be clear, sensible medicine does not mean clinicians should not intervene. Rather, it proposes a gentler, moderate, and humble view of available treatment options and their effectiveness in patients with COVID-19. The approach encourages clinicians to elevate usual care, reduce unnecessary interventionism, and focus and rely on scientific rigor. Rather than choose between action and inaction, sensible medicine encourages supportive restraint and heightened therapeutic humility.”

Full editorial, Seymour CW, McCreary EK and Stegenga J. JAMA 2020.10.15