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On Becoming a Plague Doctor Mark Earnest, M.D., Ph.D.​​

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On Becoming a Plague Doctor Mark Earnest, M.D., Ph.D.​​ The NEW ENGLAND JOURNAL of MEDICINE Perspective On Becoming a Plague Doctor Mark Earnest, M.D., Ph.D.​​ On Becoming a Plague Doctor first glimpsed a plague doctor years ago, in a how far the doctor would stand framed etching on the wall of a Venetian gift from the patient and allowed him to examine patients from that I shop. The image was macabre: a sinister, masked distance.1 figure draped in a dark robe. The head was covered I never had much sympathy for the plague doctor. To me, the with a broad-brimmed hat with a about the competence and com- image represented the triumph flat crown. The most striking fea- mand portrayed in the erect sur- of fear and superstition over the ture was the mask, with its gog- geon surveying the operating more noble impulses I hoped gled eyes and bizarre pointed beak. theater in Thomas Eakins’s “The would drive me in a time of cri- The hands were depicted with Gross Clinic”? There is nothing sis. How could a physician don long, curving fingernails. One inspiring or comforting about the such a terrifying costume to ap- hand grasped a cane (see image). image of the plague doctor. The proach a suffering or dying pa- Since that introduction, I’ve seen figure seems to come straight from tient? And the cane? Formalizing similar depictions dozens of times central casting for a nightmare. a distance between doctor and pa- — the plague doctor is one of the Despite its fearsome appear- tient seemed egregious; prodding more common costumes in the ance, the plague doctor’s costume the patient with a cane as a means Venetian Carnival and a stock — the “personal protective equip- of examination was unthinkable. character in the commedia ment” of the Middle Ages — had On a Tuesday morning in dell’arte. The same gift shop of- a noble purpose. It was intended March, I stood for the first time fered a paper-mache version of the to enable physicians to safely care outside the door of a patient who mask for sale to tourists like me. for patients during the Black I suspected had Covid-19. I was The plague doctor stands in Death. The beak was stuffed wearing two layers of gloves, a stark contrast to most other icon- with fragrant herbs or sprinkled gown, an N95 mask, and goggles. ic images of medicine. Where are with perfume to combat the mias- While taking her history and ex- the dedication and devotion of ma that was thought to be the amining her, I felt a wave of guilt the man sitting vigil at a child’s cause of the plague. The waxed and a sense that I was betraying bedside in Sir Luke Fildes’s clas- robe was intended to be similarly something important. I was a sic painting “The Doctor”? What protective. The cane determined walking hazmat suit, unrecog- n engl j med nejm.org 1 The New England Journal of Medicine Downloaded from nejm.org at Strauss Health Sciences Library, CU Anschutz on June 24, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved. PERSPECTIVE On Becoming a Plague Doctor I had done the math. From what I could gather, an other- wise healthy man my age with Covid-19 has a risk of death of about 1%. Most models predict that 40 to 60% of the world’s population will ultimately be- come infected. The infection rate among health care workers will probably be higher. Combining my risk with my wife’s in a back- of-the-envelope calculation, I con- servatively estimated our family’s Covid-19–specific risk of death to be a bit over 1%. Roughly 1 chance in 100 that one of us wouldn’t see our daughter graduate from high school next year. Though these aren’t Russian-roulette num- bers, I’d never in my life con- sciously taken a risk with 1-in- 100 odds of death. So yes, a sense of foreboding was part of what felt different in that exam room — maybe “fear” would be a more honest word. Yet if I could measure the fear in the room, my patient’s would be logarithmically higher than mine. Sitting there with her, I felt some- thing else: purpose. She was in need, and I could help. While the fear felt foreign, the rest did not. Engraving of the Plague Doctor, Paul Fürst, c. 1656. I was in the right place. When I finished my assess- nizable beneath heavy gear that and uncaring to treat her as a ment, I shared my thoughts with was not for her protection but for walking biohazard, and yet that’s her and her husband. She might my own. exactly what she was in that mo- well have Covid-19. We would test I introduced myself and im- ment. All week, we had been re- her, but we might not know the mediately stepped into the com- viewing and revising isolation results for a week. The good news fortable, familiar choreography protocols for patients with symp- was that she was doing well. It of a history and physical exam. toms like hers and training our was very unlikely that she would When did the symptoms start? staff to don and doff personal need to be hospitalized. We talked What was the first indication she protective equipment safely. I’d about the warning signs she should was unwell? What came next? seen this moment coming for watch for and how she should The usual intimacy of an exam weeks. I was well prepared, but quarantine herself in her home. was gone. I probed her neck underneath what I hoped was my We reviewed the steps her fami- through the same blue gloves calm, measured exterior and the ly should take to care for them- that pressed my stethoscope to comforting routine of an evalua- selves to avoid acquiring the ill- her chest and placed the oxime- tion I’ve done a thousand times, ness or to avoid infecting others ter on her finger. It felt callous this interaction felt different. if they were already infected. As 2 n engl j med nejm.org The New England Journal of Medicine Downloaded from nejm.org at Strauss Health Sciences Library, CU Anschutz on June 24, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved. PERSPECTIVE On Becoming a Plague Doctor we finished, she peered at me Perhaps my error was imagining gion hangs over everything. I’m above her mask and said “Thank that patients were more terrorized resigned to these realities now you. Thank you for being here. I than comforted by the arrival of and trying to let go of the guilt I can’t imagine this is easy for you, such a fearsome figure. Maybe feel behind the mask and the and I want you to know how that’s just wrong — maybe pa- gown. It is enough to be present, grateful I am.” tients were comforted that some- sharing this mortal risk with my That night, as I tossed rest- one had the commitment to set patients. A masked face, I can now lessly in my bed, I imagined what aside his own fear and come to see, is better than none at all. it would have been like to care for them in their moment of need. Disclosure forms provided by the author patients during the Black Death. Perhaps they were just grateful are available at NEJM.org. I realized I’d been far too hard on they were no longer suffering From the Division of General Internal Medi- my predecessors from the Middle alone. cine, University of Colorado Anschutz Med- Ages. A 14th-century plague doc- A quick, clear casualty of this ical Campus, Aurora. tor faced risks far higher than pandemic is the intimacy of pa- mine. Of the 18 men registered as tient care. We look at each other This article was published on May 20, 2020, at NEJM.org. plague doctors in Venice in 1348, behind masks and think, con- 1 five died. Twelve fled. I can sciously or not, of the infectious 1. Mussap CJ. The plague doctor of Venice. scarcely imagine how terrifying contrail we each leave behind. Intern Med J 2019; 49: 671-6. it must have been to live in a city Our clinics and wards feel haz- DOI: 10.1056/NEJMp2011418 terrorized by bubonic plague. ardous, and the threat of conta- CopyrightOn Becoming a Plague Doctor © 2020 Massachusetts Medical Society. n engl j med nejm.org 3 The New England Journal of Medicine Downloaded from nejm.org at Strauss Health Sciences Library, CU Anschutz on June 24, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved. .
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