Contemplating Retirement During COVID-19

The First Pandemic

I vividly remember a malnourished young man whose blue-tinged lips and nail beds recalled a textbook picture of hypoxia. His chest CT scan revealed the "ground glass" opacity we recognized as incompatible with life. I hesitantly explained that on the basis of my experience, he was going to die. He could prolong his life on a ventilator or just call it quits. His eyes widened as he heard the shocking news of his impending suffocation. I offered condolences but reluctantly had to hurry back to an overflowing emergency department.

It was 1983, and I was an internal medicine resident at Los Angeles County Hospital. Young, thin men came to the emergency department so ill they could no longer care for themselves. Some had suffered weeks of diarrhea and weight loss. A few had strange purple lesions on their skin. Others gasped for breath due to unexplained pneumonia, often dying within days.

During rare quiet moments, my fellow residents and I dared address the elephant in the room. Were we at risk? Many of these unfortunate souls worked as waiters and cooks in nearby restaurants. Had some poison affected the food? Some patients confessed to hundreds of sexual partners. Were these diverse symptoms due to a new, deadly sexually transmitted disease? Would daily patient contact lead to our collective demise, we guiltily asked ourselves?

Body fluids were everywhere, and the safety measure of "universal precautions" had not yet been proposed by the Centers for Disease Control and Prevention (CDC). We pushed the problematic pachyderm to the back of our minds and continued our work.

The first cases of this pandemic appeared in the medical literature in 1981. In 1983, researchers identified the retrovirus responsible, HTLV-III/LAV (human T-cell lymphotropic virus type III/lymphadenopathy-associated virus). Two years later, in 1985, a blood test became available. The CDC determined that HTLV-III/LAV, now renamed "human immunodeficiency virus" (HIV), was responsible for the acquired immune deficiency syndrome (AIDS). Until azidothymidine (zidovudine) became available in March 1987, AIDS was a death sentence.

Sleep-deprived and clumsy, I stuck my finger with a needle while drawing blood, an accident sufficient to put me at risk for AIDS, hepatitis B and C, and a variety of other nasty infections. Luckily, I was one of the 299 of 300 who didn't contract AIDS from a contaminated needle. But 1 in 300 do. Nowadays, needlestick victims immediately take antiretroviral medication, but postexposure prophylaxis was science fiction when I was a resident. All I had was months of worry.

The AIDS pandemic has to some degree departed the limelight, but of course has not disappeared. To date, AIDS has affected 75 million people worldwide, with 32 million deaths. In 2019, there were 1.7 million new HIV infections. Daily antiretroviral therapy allows everyday existence, but the disease still decreases life expectancy and accelerates age-related comorbidities. AIDS remains incurable, and after nearly 40 years, there is no vaccine. As the CDC accurately predicted almost 20 years ago, "AIDS will remain a major public health challenge worldwide in the 21st century."

The Second Pandemic

This time, it's different. The etiology of the respiratory illness that originated in Wuhan, China, was quickly identified as the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2). This medical mystery lasted just months, not years. And coronavirus disease 2019 (COVID-19) can strike just about anyone via casual contact: a cough on the subway, a sneeze on the street. In the right setting, merely breathing can be fatal.

Healthcare workers are at increased risk for infection just by showing up and doing their jobs. Social distancing is incompatible with clinical work – it's tough to examine a patient while standing 6 feet away. Telemedicine has successfully replaced in-person examinations in some situations, but most hospitalized patients require hands-on medicine. The stress of caring for pandemic victims has led to at least one physician suicide.

Unlike with the HIV pandemic, this time, progress toward treatment has approached "warp speed." The antiviral remdesivir was approved by the US Food and Drug Administration (FDA) in October 2020, less than a year after the first cases of COVID-19. In November, the FDA issued an emergency use authorization for the combination of the Janus kinase inhibitor baricitinib with remdesivir for critically ill patients with COVID-19. Pfizer's COVID-19 vaccine has already been approved in certain populations, with Moderna's right behind it, both of which are reported to be more than 90% effective. Additional vaccines are in the works.

Self-Preservation and…Retirement?

Although I'm a reasonably fit 65-year-old man with minimal comorbidities, I'm in a high-risk group for severe illness and death from COVID-19. That's sobering, because my job environment teems with a lethal infectious virus.

As a practicing physician, I cannot abandon my patients, but am I obligated to risk my life for them? I looked up the Hippocratic Oath, the time-honored declaration of professional ethics. The Hippocratic Oath prohibits exploiting patients and their families and demands loyalty to one's teachers. Contrary to popular belief, the Hippocratic Oath doesn't require physicians to elevate patient lives above their own. It doesn't even address the issue.

COVID-19 has triggered some physicians to hang up their stethoscopes. Although I've reached a respectable age to retire, that wasn't my plan. I've invested decades to acquire the specialized knowledge of neurology, clinical skills, and confidence to function as a clinician and teacher. I've even attained a smidgen of a national reputation. Wouldn't it be a shame to quit while I'm on top of my game?On the other hand, perhaps that's just hubris? Would one more physician really make a difference? It's difficult to justify months in the intensive care unit with multisystem failure and a painful, slow death vs the benefit of indulging in a few additional years of clinical practice. At home, I've got high-speed internet and a fish tank. A retreat into isolation and obscurity would be the safest plan. Would that be cowardice or common sense?

Engagement

Whether out of hubris or habit, I've decided to stick with clinical work. To limit my exposure to SARS-CoV-2, I wear a mask and face shield. A bottle of sanitizer lives in my pocket. My digital watch counts the recommended 20 seconds when I wash my hands. I attend to each patient with compassion but limit unnecessary contact — no shaking hands or comforting pats on the back. I strive to set a proper example for trainees who accompany me on hospital rounds.

Andrew N. Wilner, MD

My wife and child mostly stay at home. In an attempt to keep them virus-free, the washing machine and shower are my first stops after work. It's horrifying to realize that my family's greatest threat of acquiring COVID-19 is the one who loves them the most.

So far, I've survived two pandemics. Neither one is over. Training as a physician during the early years of the AIDS pandemic offered lessons in compassion, humility, and survival. I'm trying to apply what I've learned every day as we all confront COVID-19.

Once there's an effective vaccine, and enough people take it, COVID-19 will go the way of polio, a disease more common in textbooks than in the clinic. Until then, thousands, if not millions, will die owing to poor timing, catching the virus before a vaccine or treatment becomes available.

I embrace the imperfect defenses of handwashing, social distancing, and mask-wearing. I implore others to do the same until effective therapy and a vaccine become available. We need to return to our routines, hopes, and dreams, and prepare for the next pandemic.

Andrew N. Wilner, MD. is a professor of neurology at the University of Tennessee Health Science Center in Memphis, Tennessee.

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