Argument Summary

Premise 1: The rate of mortality for the coronavirus starts to go up dramatically for the population of those above age of 60 years old

Premise 2. The rate of mortality for the coronavirus dramatically increases in those with comorbidities.

Premise 3: As much outpatient healthcare as possible will shift to tele-therapy during the pandemic.

Conclusion: The safest use of clinician resources during the pandemic is for clinicians above a certain age, or with certain comorbidities to focus on outpatient care, and younger clinicians to focus on inpatient care.

Argument Details

Premise 1a. The rate of mortality for the coronavirus starts to go up dramatically for the population of those above the age of 60 years old.

We have seen this among all the data sets from all the countries to date.

Below is the Chinese data of 55,824 laboratory cases in China from the WHO report.

Mortality in the age of 60-69 is 18x higher than that of 30-39.

Mortality in the age of 70-79 is 40x higher than that of 30-39.

What does this mean in reality?

If you have a clinical staff of 30:

• If the clinicians are all above the age of 60, one person may die of coronavirus
• If the clinicians are below the age of 59 no-one should die within the group 30.

This is the Italian data to date from Feb 27 2020 (still early in the pandemic) from 619 deaths (early numbers still…).  

Again age 60-69 is 25 times more lethal as age 30-49.

Premise 1b. The rate of mortality for the coronavirus dramatically increases in those with comorbidities.

The Chinese WHO data shows a case fatality rate (CFR)

• 1.4% - no comorbidities
• 13.2% - cardiovascular disease
• 9.2% - diabetes
• 8.4% - hypertension
• 8.0% chronic respiratory disease
• 7.6% cancer

This suggests those with comorbidities are at highest risk. This WHO Feb 24 2020 report doesn’t comment if these are independent risks or mixed.

Premise 3. As much outpatient healthcare as possible will shift to tele-therapy during the pandemic.

Hospitals and departments are aggressively looking at how they can shift their outpatient services to be offered by remote care (FaceTime, Telephone, Email, Skype, etc).

It is important that routine medical visits continue. Consider the many subspecialties of internal medicine where patients may attend weekly, bi-weekly, monthly, quarterly appoints to make critical adjustments to medications, and evaluate and diagnose conditions.

We cannot put on hold all of this regular outpatient care. Much of this is not ‘elective’ and can just wait. Heart failure medications need adjustment. Immunosuppressants need adjustment.

Failing to take care of our chronic patient population adequately, will only result in these patients becoming unstable, getting off the tracks, and showing up in the emergency department requiring admission. This is costly and dangerous to their health.

We cannot have a surge of chronic patients getting sick because of being underserved during the pandemic. This will only exacerbate the situation.

Therefore care has (in other countries), and is/must (in Canada) shift to teletherapy.

Conclusion: The safest use of clinician resources during the pandemic is for clinicians above a certain age, or with certain comorbidities to focus on outpatient care, and younger clinicians to focus on inpatient care.

Given the fact that outpatient care must go on (through virtual telemedicine appointments), it would be the safest use of clinician resources to prioritize older clinicians and those with comorbidities to focus on the outpatient care. Younger clinicians and those who are healthier could focus on inpatient care.

What does this look like in practice?

Let’s suppose your city has a rheumatology division of 30 people. Encourage those clinicians who are older to focus on outpatient teletherapy. Encourage the younger clinicians to focus on in-patient consults.

What should the age cut-off be?

This is a super difficult question. One may argue that if you are using the precautionary principle, that an EVEN LOWER age threshold should be used.

For instance. The age of 50. or 55.

The mortality data presented is based predominantly at the country level. I haven’t seen data specifically focused on healthcare workers.

There is a thesis that if healthcare workers are exposed to higher dosages of the virus when they get it, that it may be more lethal than the average community exposure. This means that using an even lower age bracket (such as above 50 years or above 55 years) may be a good idea.

Counter-arguments

CA-1: “What about a healthy person over the age of 60?”

The age data I have presented in these graphs are not comorbidity adjusted. We see increased age corresponds with increased risk, and that increased comorbidities correspond with increased risk. But we also know comorbidities increase with age.

Therefore, we assume a health 70 year old will have a lower risk than a 50 or 60 year old with several comorbidities. But I haven’t yet seen the exact data that can quantify this.

Therefore, using a blanket age range cut-off may be more safety inclined risk decision at this time.

CA-2: “We won’t have enough staff?”

First - I’m not recommending clinicians over a certain age stop practicing. I’m suggesting that it may make most sense for them to provide care entirely by teletherapy means. This could be done from their own home.

Second - this is a rearrangement of healthcare staff to hopefully ensure that we have the highest number of physicians able to practice the longest. Exposing older physicians to the virus puts them at higher risk of death.

Third - You can crunch the numbers yourself based on Canadian Physicians by specialty by age as presented here in the CMA 2018 data.  

• It looks like only 16% of all specialists are above the age of 65. (Though this number goes up to 20% if you include the ‘unknown age’ category with the 65+ category.
• If you combine the 55-64+ and 65+ categories together, it represents 38% of the total number of specialist physicians in Canada.

CA-3: “We really need Physician-X on inpatient service with us”

Let’s get creative. Cell phone and video conferencing technology has come a long way. Remote access to patient charts is available.

Put the two together and high quality inpatient care can be provided by physicians remotely in special cases where a particular physician is required who falls into a high risk group.

I can’t take credit (good or bad for the idea). It’s from my brother Robert Schmidt.

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