I spent some time this week looking back at our year of pandemic and considering the question of how evolutionary medicine can help guide treatment in the emergency department. My first reaction to this question was: “of course evolutionary medicine is useful during every step of the patient encounter.” It changes how we might think about prescribing antibiotics, thinking about host defenses, and what is normal in human physiology, and why some patient groups are at higher risk for bad outcomes than others. As I have been mulling this over during the last few days, taking care of my patients, my thinking has changed. Maybe I am not so different after all. My practice pattern is well within the bounds of the community standard of care. I prescribe antibiotics during my shifts in the ER, I use tylenol and opioid pain medicines, and I order CT scans very much like my coworkers. Indeed, if my practice were way out of line, I would surely get a call from our clinical director or my department chair.
So is evolutionary medicine of no consequence to patient care? No, that’s not right either. The biggest impact of evolutionary medicine on my thinking, and for my patients, is to help guide decisions where there is uncertainty. Uncertainty reigns in the emergency department. Almost by definition, our patients are undifferentiated – we don’t know what they have. And yet we make decisions in the setting of incomplete information all the time. My contention is that evolutionary medicine can do the most good in guiding informed decisions in the setting of incomplete data. Often that leads to a less is more approach.
It is worth pointing out that both doctors and patients have a significant bias. That is to overestimate the effectiveness of any given medical intervention, and to underestimate the value of our body’s host defenses during illnesses. This is why we do too many wasteful and harmful interventions. There has been a proliferation of clinical guidelines that are too often box checking exercises instead of good evidence-based care. Evolutionary medicine tends to push us in the opposite direction. It often fuels a healthy skepticism for low value interventions, and it provides a rationale for a less is more approach.
Nowhere has this been more stark as in the COVID-19 pandemic. A multitude of low-value interventions have been proposed for this infection. Think no further than hydroxychloroquine and azithromycin which were part of the COVID orderset that popped up when taking care of these patients last summer. We don’t use those drugs anymore. Less is more. Even today, virtually every patient admitted with COVID-19 receives antipyretics for fever. My colleagues and I have written about why our enthusiasm for tylenol and NSAIDS is misplaced. Many anti-cytokine therapies for COVID-19 also turned out to do more harm than good.
Along the same lines, I vividly remember the first few patients brought in by ambulance with respiratory failure. We intubated the first few almost immediately and put them on the ventilator. Later, we discovered that we could and should try non invasive interventions first. Here too, less is more. We also gave way too many broad spectrum antibiotics to patients with COVID-19 pneumonia. These drugs increase the risk of super-infection with drug resistant bacterial and fungal diseases. A little evolutionary medicine would have predicted that outcome. Less is more.
Ultimately we will find that much of what we did early in the pandemic harmed our patients, and only a tiny subset of our interventions will prove life-saving. It is our job, as researchers, to speed that process. This is an area where evolutionary medicine can shine. This academic area can speed the de-adoption of useless therapies. It might encourage good practices where we do too little. Public health is one such area. Evolutionary insights can help illuminate some of the social, ethnic, and demographic reasons for health disparities that have been in sharp relief during the COVID-19 pandemic. We need to vastly increase our efforts to reverse these causes of suffering where we can.
This pandemic year, from the perspective of this front line physician, has two main lessons. Much of what we do is trivial, or has negative value. Evolutionary insights can encourage us to do less of these things. Meanwhile, some areas, especially in public health, are neglected. This neglect has led to an enormous cost in lives lost and suffering. Evolutionary medicine and public health have the potential to steer us in a more healthy direction.
Emergency Physician, Educator, Researcher, interested in the microbiome, evolution, and medicine