Know Thy Patient

How Intensity Mismatch Explains the CDC's Shortcomings

I love Paul Fenyves’ essays. He is a practicing internist and that makes him a pragmatist. Like all great internists, he understands risk and benefit, and the times in medicine you need to push hard, and when you must accept things as they are.

The only thing I mildly disagree with him on in this essay is masking kids. My sense is that if you ran 10 cluster RCTs of kids masking: for flu, influenza, RSV, you name it, you will have null results every time. The actual effect is 0. Why do I feel that way: that’s the nature of behavioral interventions and kids. But, his point is also fair: best case scenario the gain is modest. What should that mean for policy?

Hope you enjoy

Vinay Prasad MD MPH

Know Thy Patient

By Paul Fenyves, Cornell University

Throughout the pandemic, the CDC has been out of step with the American patient. This is a call for the CDC to become more aligned with the people it serves.

We all have a “medical personality” — our unique approach to healthcare marked by our worries, our risk tolerance, and our inclination to do more or less.

Both doctors and patients bring their medical personality into the exam room. Good doctors tailor their care to better match their patient’s medical personality. The intensity of medical care, whether to be aggressive or “less-is-more”, should be adjusted within reason to match the patient’s needs and desires. 

Some doctors are unable to match the intensity of care to fit the patient. They add a third blood pressure medication without realizing the patient barely takes the first two. Ultimately, the patient becomes frustrated and finds another doctor. 

Applying this exam room philosophy to our country’s pandemic response, national public health did not sufficiently align with the American patient, frequently making recommendations that were far too intense for the average American. 

I suspect that this “intensity mismatch” led many Americans to ignore the advice of public health. Had we asked for less of the American patient, we might have gotten more in return – more respect for and acceptance of public health recommendations. Two examples:

Childhood Masking: We continue to debate the efficacy of childhood masking. There is no randomized controlled trial to answer this question (and importantly to estimate the effect size), but we do have RCTs in adults showing a modest reduction in transmission. 

And like all of you, I have a gut feeling, which was informed by my experiences. For two years, I masked up and shared small exam rooms with coughing Covid patients and never got sick. When I did finally contract Covid in April 2022, I got it the way I get all my respiratory infections: from my kids. 

Despite this, my gut also tells me that covering kid’s faces for years on end would negatively impact their social and emotional development. Of course, I’m not ready to run a five year study to prove this. Many Americans seem to share this concern. 

For the sake of argument, let’s assume that childhood masking modestly reduces transmission. Was it prudent for the CDC to recommend continuous school masking through February 2022? 

We saw that many Americans were opposed to masking kids. And we also saw that many European nations did not mask their school children at all, so the “standard of care” was quite broad. 

When you have a broad standard of care, and a patient who is asking for a less intense approach, you should not offer the most aggressive intervention. 

Rather than dismiss those concerned as “anti-maskers,” public health might have split the difference, only recommending childhood masks for a few weeks during the times of highest community spread. I suspect most Americans would have obliged, and we could have enjoyed most of the upside with much less downside. By asking for less, we might have gotten more.

Currently, there are some calls to bring back school masking in order to prevent hospitals from becoming overwhelmed by other pediatric respiratory illnesses, namely RSV and influenza. So far, this proposal is not getting much traction even in most pro-mask cities. I suspect this is because just about everyone is done with masks. By overdosing the intervention, the CDC has turned away even many of its adherents.

Pediatric Covid Vaccinations: The American people are not enthusiastic about getting their children vaccinated against Covid. At the time of writing, less than a third of kids 5-11 have completed the primary series, and for kids 2-4 it’s below 5%. 

Again, there is a broad standard of care: Germany recommends just a single dose of mRNA vaccine for kids 5-11. Norway makes vaccines available to kids 5-11 without making a recommendation. Denmark only offers vaccines to kids who are at high risk. 

In contrast, the CDC recommends all kids five and up get the initial two doses plus a bivalent booster.

Again, we have the American people asking for a less aggressive approach, but the CDC recommending the most aggressive approach. Do we really want the American people to develop a habit of ignoring the CDC’s vaccine recommendations as being “too aggressive?” 

Already we are seeing suggestions that Covid vaccine hesitancy might be spilling over into other more essential vaccines. Why not communicate which vaccines are optional and which are critical? By asking for less, we might get more.

Those of us in medicine have all seen doctors who are unable to dial down the intensity to match the patient’s preference. Doctors who add a second cholesterol medication when the patient barely takes the first. 

During the Covid pandemic, the CDC has been such a doctor. This is dangerous. When patients become frustrated with a doctor who is unable to meet them where they’re at, they go find a different one.

Please don’t needlessly turn away the American patient.