Dr. Adarsh Bhimraj gets out of bed at 4 a.m. and spends virtually every waking moment of the day that follows fighting the COVID-19 pandemic.
As a physician in the Cleveland Clinic’s Department of Infectious Diseases, he treats about 10 patients a day. Cleveland hasn’t been hit as hard by COVID-19 as other locations, like Los Angeles and New York City. During some shifts, Bhimraj might see three COVID-19 patients. Some days, he doesn’t see any.
Treating COVID-19 patients is a team effort, he says. Because the disease can attack not just the respiratory system but also the heart, brain, kidneys and gut, an array of doctors typically treats COVID-19 patients. “A critical care doctor brings a different perspective than an infectious disease doctor like me,” he says. “A team of physicians is needed to take care of these patients.”
Treating dozens of patients a week would count as more than a full-time job for most people — but it’s only part of Bhimraj’s work.
As chairman of the COVID-19 Rapid Guidelines Expert Panel of the Infectious Diseases Society of America, Bhimraj leads the team that published and continues to frequently update the IDSA’s guidelines on the treatment and management of patients with the disease. At least once a week, he conducts virtual presentations about COVID-19 treatments, recounting the latest research developments to groups of clinicians around the globe.
When it comes to treating patients with COVID-19, the majority of physicians rely on the IDSA guidelines and guidance provided by the National Institutes of Health. “Most doctors rely on evidence-based guidelines by professional societies to guide their practice,” Bhimraj says. The IDSA and NIH guidelines are not in competition, Bhimraj says, and are similar in many ways. For example, both organizations rely on a panel of experts to analyze data to develop their respective recommendations. And both groups update their recommendations as new research becomes available.
The IDSA COVID-19 guideline panel doesn’t publish original research; rather, it parses through numerous scientific studies and determines which are high-quality, a judgment based on factors like evidence strength and lack of bias. The IDSA panel includes physicians with different specialties from various academic institutions and clinical practices.
For example, panel members include doctors who specialize in critical care and pediatric infectious diseases. There are also representatives from the Society of Infectious Diseases Pharmacists and the Pediatric Infectious Diseases Society, among other groups. And the panel includes five methodologists, who specialize in critically analyzing scientific evidence.
Responding to the need to provide current, evidence-based information to clinicians who treat COVID-19 patients has increased the demands on Bhimraj and his fellow panel members.
“This has totally changed (everyone’s) life,” he says. “I never thought I’d live through something like this. I can’t wait for the day when I can hang out with friends in a bar without a mask.”
The infectious disease doctor had to temporarily slow his pace in late June, when he was diagnosed with COVID-19. Bhimraj suffered symptoms that included fever, chills, nasal stuffiness, fatigue and shortness of breath when he exerted himself. He also temporarily lost his sense of taste and smell. He quarantined at home for two weeks and has since recovered, jumping back into his strenuous daily routine.
After waking in the predawn darkness, Bhimraj meditates and goes for a run. When he’s not treating patients at the clinic, he’s constantly on his laptop, iPad or smartphone, scouting for the latest peer-reviewed research published on treatments for COVID-19.
Determining which studies produce results worth evaluating and incorporating in the guidelines is a challenging task for Bhimraj and his fellow panel members. Currently, there are more than 1,000 ongoing clinical trials and many more observational studies seeking safe and effective treatments for COVID-19.
“I constantly check medical search engines like PubMed and get emails from trusted clinicians and methodologists,” he says. Twitter is another good source; news about new research into COVID-19 treatments is posted on the platform regularly.
Given the volume of research being conducted on COVID-19 treatments, it’s impossible for Bhimraj and his fellow panel members to read each one. The panel’s methodologists examine around 100 studies every two weeks to determine which are worth analyzing. If a study only has six patients, for example, the panel wouldn’t evaluate it. Clinical studies that involve 100 or more participants could make the cut.
The IDSA panel relies on the GRADE method for rating the quality of evidence for scientific research. (GRADE stands for Grading of Recommendations, Assessment, Development and Evaluation.) This approach involves evaluating such factors as whether studies have a risk of bias, and if they show inconsistent, unexplained variability in results from different trials and other factors. For example, studies based on clinical trials that were cut short could be biased, according to research published in the Journal of Evidence-Based Medicine.
The entire panel evaluates studies that have been identified as worth analyzing. IDSA can publish guidelines or updates based on new research within a couple days, Bhimraj says.
“Once we find good evidence and critically analyze it as a guideline committee, we have to disseminate the findings quickly to the clinicians who are on the front lines treating COVID-19,” Bhimraj says.
To help spread the word on the most recent COVID-19 research, Bhimraj delivers presentations at virtual seminars with groups of clinicians in the U.S. as well as overseas. Typically, he discusses the latest research for about an hour, then answers a few questions.
In April, shortly after IDSA published its COVID-19 treatment guidelines, Bhimraj explained them to a couple hundred clinicians across the country in a call organized by the Centers for Disease Control and Prevention.
Since then, he’s typically conducted one such call a week to groups of dozens, hundreds or even thousands of clinicians, including doctors, physician assistants and nurse practitioners. In May, Bhimraj spoke to more than 2,000 clinicians in Mexico, for example, and in late July, he discussed the guidelines with clinicians in India. During these calls, Bhimraj talks about the guidelines and the research that led to them.
“We talk about available evidence on benefits and harms of medications being considered for treatment of COVID-19, including drugs that have attracted a lot of attention like hydroxychloroquine,” he says, referring to the anti-malarial drug that President Donald Trump has touted as an effective treatment for COVID-19.
Several studies have concluded that hydroxychloroquine has no therapeutic benefits for COVID-19 patients and may be detrimental to some. In March, after Trump first spoke about hydroxychloroquine as a treatment for COVID-19, the Food and Drug Administration on an emergency basis approved the use of hydroxychloroquine and chloroquine to treat the disease. About two months later, in mid-June, the FDA pulled the approvals for the two drugs and said they should not be used to treat COVID-19 outside of clinical trials. (The FDA, a regulatory agency, approves new medications and vaccines, vouching for their safety. The agency does not publish guidelines for COVID-19 treatment.)
In June, the IDSA panel updated its guidelines to include that patients with COVID-19 should only use hydroxychloroquine or chloroquine in the context of a clinical trial.
Bhimraj says he tries to stay out of political discussions, but he’s not shy about discussing the importance of relying on scientific evidence to fight the pandemic.
“Anecdotes about the success or failure of a medication in clinical practice are just anecdotes, not scientific evidence,” he says. “Good studies measure what matters: Does a drug really save lives and alleviate suffering and not just make lab tests and X-rays look better? Such studies are also designed to minimize error and bias so we know the truth about a medication’s benefits and harms.”
A sound study includes a control group of people who receive a placebo rather than the drug being studied. For example, if 80 of 100 people in a study improve after taking a medication, that may seem like a good outcome. That’s a lot less impressive if there’s a control group of 100 people, 80 of whom also get better after taking a placebo.
“The people taking the medication may have gotten better without it,” he says. “You don’t know without having a control group.”
Bhimraj acknowledges that he and his panel won’t persuade everyone.
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“I’ve had some discussions with people who, no matter how much evidence you show them, can’t be convinced,” he says.
But he’s also talked to some people who are open-minded enough to be persuaded by science. “I believe there’s a seed of reason within us, and I think we can try to appeal to that in other human beings,” he says.
The 24/7 nature of his work means that, sometimes, the pandemic even invades Bhimraj’s dreams. He recalls dreams about journal articles he’s read on COVID-19 treatments and how to best present the information to front-line providers. The 45-year-old is single, and for now, battling COVID-19 is his constant companion.
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