Don’t Let the Perfect be the Enemy of the Good
MEDICAL AND MENTAL HEALTH UPDATE
My kids will tell you that when I have a point to make, I always overdo it.
Me this weekend to my daughter Stella: “Hey Stell, this is such a weird time. I hope you know it’s normal to have fee…” Stella: “...feelings? Yeah, mom, we know. You’ve said that, like, a hundred times.” (Bikes away.)
So today I’m gonna do what I do best: beat a dead horse—this time on COVID testing.
I can’t say this enough times: We need a paradigm shift in the testing arena to tame this COVID beast.
You’ve all heard about the lack of adequate testing in the U.S. In July, I shared the story of my patient whose positive COVID test result came back a WEEK after she took the test, during which she potentially infected a new cluster of people. YIKES!!!
As a result of long turnaround times, the rapid COVID tests seem VERY alluring, right?
And they are, but wait. First it’s essential to understand that the rapid COVID-19 tests are not sensitive enough to be able to trust a negative result in a patient without symptoms when taken once (regardless of method: saliva or nasal swab; self-administered or done in a clinic). Please read that sentence again if you would be so kind. Again: I’m a big believer in repetition. Did I already say that?
Let me explain. The rapid tests will miss people who are in the incubation period—the time between exposure to the virus and infection. The rapid tests will ALSO miss people who are infected but not yet contagious.
HOWEVER, if we were to make these less sensitive rapid tests cheap enough so we could use them DAILY, we could make EXCELLENT use of them for broad surveillance of populations.
Why? Because the rapid tests’ strength is their ability to detect contagious levels of coronavirus. They do that very, very well.
In fact, I think the only way we can open schools safely at this point is to have this type of testing available—but only if done frequently.
Enter the dead horse: all summer I (and many others in public health and medicine) have been yakking about the need for cheap, frequent, safe, and less-sensitive rapid testing as a critical method to end the pandemic.
It took me a while to come around to this concept myself. At first glance it doesn’t make sense to use a less sensitive test for a potentially deadly disease, right? After all, doctors aren’t trained to tolerate “good enough.” In fact we tend to be a set of perfectionistic, type-A-personality, pocket-protector-wearing slaves to gold standards in, well, everything.
But I’ve done enough therapy to call myself a “recovering perfectionist” (cue uproarious laughter from my friends), and I have accumulated enough life experience to know this: GOOD ENOUGH IS EVEN BETTER THAN PERFECT—especially when perfect isn’t on the menu.
What’s my point, and how does anti-perfectionism have anything to do with COVID-19? Hang on.
Among the three hot-to-trot horses in the current race to get us through this hot mess—a vaccine, therapeutics, and widespread surveillance testing—I’ve put my Monopoly money down on frequent, cheap rapid-result testing as the likely winner. (Of course, we need all three strategies racing to the finish line together.)
But without a vaccine or medications to treat non-hospitalized patients (yet), crushing COVID-19 hinges on regularly testing large numbers of people—and quickly detecting and isolating cases to prevent spread by people with and without symptoms.
We need to know in real-time who is sick, who is contagious, and who can go to work, school, and social gatherings.
So far we’ve also been relying on the gold-standard polymerase chain reaction or “PCR” nasal swab testing which is highly sensitive and indeed essential to make a diagnosis in a sick patient but is NOT necessary—and clearly not feasible in the U.S. right now—as a screening tool for broad swaths of the population.
We’ve not been able to ramp up PCR testing because we’ve relied on nasopharyngeal swabs which are uncomfortable (aka “brain biopsy”), require special kits and chemicals, and are logistically challenging in that they must be collected by a trained healthcare professional who is also at risk during the testing process. The turnaround times are long, rendering them useless in so many cases.
Long story short: We still need PCR testing for sick patients AND to confirm a diagnosis when a rapid test is positive; but right now our national testing strategy needs a hard pivot to be able to screen broad swaths of the population.
Just as in life, we need not let the perfect be the enemy of the good. We need what’s realistic and good enough right now. (Bonus for overachievers anonymous: just like letting go of perfectionism will lead to a more fulfilling life, this “good enough” testing strategy would save lives and defeat COVID-19!!)
So what’s new and why am I excited today? This concept is finally catching on. Epidemiologist Michael Mina, MD, PhD at the Harvard School of Public Health is on FIRE! It’s great to finally see his ideas on rapid testing taking flight beyond academic circles. Letter-writing campaigns to Congressional Representatives, Senators, and Governors are finally getting the message out to policymakers!
Click here for a sample letter to add your voice! And see https://www.rapidtests.org/ for more information.
In the meantime, the horse race is far from over. For now, our ONLY defense against COVID-19 continues to be our own behavior. So be sure to wear your MASK, spend time OUTDOORS when able, SOCIALLY DISTANCE, and HANDWASH. (In the spirit of repetition, here’s MOSH PIT—again.)
So place your bet on your favored horse to gallop across the finish line, join me on the testing pony ride if you wish, and GIDDY UP for more progress along the way. The race is on.
I will check in later in the week. Until then, be well.