Author Archives: Jon Zaid

Resident Perspective: Volunteering at a Testing Site

This is the continuation of a series of journal entries depicting what it’s like to be a part of the COVID pandemic from the medicine resident perspective.

 

With my office hours consolidated and no longer attending morning and noon teaching conferences, I find myself wanting to get back in the action. During my self-isolation I signed up for the Philadelphia Medical Reserve Corps. I signed up to be a “swabber” (obtaining samples from the back of the throat) at the South Philly screening site in the parking lot of Citizen’s Bank Park. I have Phillies tickets for a game that was supposed to take place this weekend. But instead I arrive at the stadium parking lot to see swathes of asphalt without cars. Instead they’re filled with tents, traffic cones, and people gowned from head to toe in PPE rather than tailgaters. This screening site is a joint venture between the Philly Department of Health, the Commonwealth of Pennsylvania, and the Federal Emergency Management Agency (FEMA). There is plenty of PPE to go around and I suspect this is due to FEMA’s presence because right now nobody seems to be overly concerned about limiting volunteer access to equipment.

Testing Site

I’m interested to see who comprises the volunteer corps because there is a wide variety of people in the Delaware Valley that suddenly have nothing to do. There are retired physicians, nurses, medical students (suddenly without any clinical duties), as well as people not at all involved in medicine who just want to help. Everyone is eager and energetic. You couldn’t tell there was a pandemic about to make its way to Philadelphia and the people that are most concerned they have an infection are driving to your current location.

There are multiple large white tents set up to receive cars to drive through. Each tent has the capacity to test about 100 people per day. The decision on how many tents to open each day is dictated by the number of volunteers available and the weather. On my first day it’s windy—very windy in South Philly. So windy in fact if you dropped a glove or a face shield you better start running because it would be 10 yards away before it hit the ground. Mornings start with huddles of teams where we begin the process of assigning volunteers to different stations and assign roles for the day. A woman in a vague military ensemble and standing up perfectly straight, presumably from FEMA, calls our medical director over after our huddle. There is a line of about 30 cars waiting for the entrance gate to the parking lot to be lifted to signal we’re ready to start testing. We typically start at 1pm on the dot but today things are dragging along. The Medical Director slowly walks back to the “swabbers” tent, facemask in hand, and dejectedly says that we have to close the operation today due to high winds which are anticipated to become worse as the day wears on. This is because the specimens may blow over and be scattered in the wind, putting Philly on the map as the first city to accidentally infect its own citizens with coronavirus. We have to go car by car to notify the inhabitants that if they are truly sick they should go to the nearest ED or come back at a future date. Demoralizing indeed.

Our positive rates with the nasal swab at the testing site are between 25% to 30%. If we had tested only 200 people that day, that’s still at least 50 people we would have identified as being COVID-19 positive. Who knows how many had to take off from work to come in or might not get the chance to come in tomorrow. The volunteers are pretty disappointed.

The screening site is a well-oiled machine by the time I arrive in late March. Through intake, data collection, verification, swabbing, etc. it takes about 8 to 10 volunteers to run one “lane” of cars. Ultimately the car completes its journey at our site in the swabbing tent where the specimen is collected. The more volunteers present, the more tents and lanes can be open,  which will greatly decrease wait time for the public to get screened—therefore enticing more people to receive testing. There are times when I volunteer and only two tents are open due to staffing issues. Additionally, I’m told by the Medical Director at the site that samples are now taking closer to 10 days to process, not the 5 to 7 that we had been telling the patients. Lastly, something that I find somewhat incomprehensible is that the FEMA guidelines for eligible patients to get tested do not align with those of the Philadelphia Department of Health. This leads to some people being taken out of line by FEMA representatives even though they’re eligible for testing according to the Department of Health. It never occurred to me that things like this can affect an overall city’s number of cases. Closing or decreasing screening capacity as well as delays in reporting can make numbers artificially lower.

I’m trying to find silver linings to come from the pandemic. Some are that the people being screened are overwhelmingly appreciative of our efforts. Local restaurants provide free lunch and dinner to the volunteers so it very much feels like a community coming together. I’m fortunate to observe the way people are supporting one another during these stressful times. Philadelphians are responding positively—for now. It likely won’t stay like this for the entirety of the pandemic as economic and other life-changes will exacerbate the anxiety that many people are feeling. I take comfort in knowing that there is potential for a lot to change in our society as we emerge from the pandemic.

It won’t be a surprise that our lives will be markedly different in the coming months and most likely years. For the foreseeable future,  society will no longer run as “business as usual” following the first wave of the pandemic. The way our healthcare system functions is something I’m most looking forward to seeing evolve as people realize that our employer-based model leaves millions behind is not equipped for delivering the most care to the most people. A new awareness of what we find important in life will also develop. This may entail rethinking the significance of the local community and each person’s role. We’ll be forced into introspection – things like where we get our food how we view work, and how we spend our free time will require reflection and evaluation – whether we like it or not.

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Resident Perspective: My Biggest Fear

This is the continuation of a series of journal entries depicting what it’s like to be a part of the COVID pandemic from the medicine resident perspective.

Monday, April 6th

Aside from the very real concerns over lack of personal protective equipment (PPE), ICU beds, and ventilators, I believe that the biggest cause for anxiety among healthcare professionals is not having answers. Traditionally, the public has turned to physicians during public health scares as they purportedly know how to approach all ailments. This virus is demonstrating that given all of our progress in the medical field from state-of-the-art imaging modalities to treatments utilizing personal genetic properties, we still can’t answer many basic questions about this new disease.

Philadelphia has a geographic advantage over many other regions in relation to the viral spread. We have an up-close view of the damage that the virus has wrought in New York without having nearly the number of cases or hospital burden at this time. The delay it takes for the virus to move westward globally and down I-95 not only allows us to stock up on PPE, prepare the hospitals, and practice social distancing, it also gives us the opportunity to analyze the studies that have come out of places like China and Italy. Although hospital beds in Philadelphia are now filling up with COVID-19 patients, it’s the barrage of images in the media of trashbag-wearing nurses, overflooded hallways and pleas from staff urging more supplies or more assistance that make this even more terrifying. The answers to our questions will come, but during the quarantine when each day feels like a week, data collection isn’t necessarily the issue — interpreting the data is.

As the pandemic ramps up in our region, the ever-present fear of not knowing which patients entering the hospital with upper respiratory infection symptoms are positive is anxiety-producing, not only because these patients can become sick quickly, but because it’s easy to let your guard down. When you know your patient is infected you know to be extra cautious. Also, determining whom to test prior to admission, given the tests’ continued scarcity, remains an issue, even as our own institutions’ guidelines continuously evolve.

In an ideal world we’d screen everyone and it would be an accurate test. However, right now we cannot screen everyone and we know the test has a high rate of false-negatives. Let’s say we do identify a COVID-19 patient through testing but who doesn’t require hospitalization. Our guideline for duration of self-isolation is just a recommendation as we simply don’t know if they are still infectious post-isolation. We can’t even tell patients that tested positive whether or not they are susceptible to getting re-infected, and if it will return in autumn; we can only posit given what we know about other viruses in these situations. Lastly, we don’t even have a proven treatment plan, only what experts surmise is the best approach given the information we have. Hydroxychloroquine, among many other proposed treatments, is still in the nascent stages of evaluation but the public wants answers quickly. This is not typically how the peer-review process works in academia as it often takes months to years to evaluate therapies. In this case public expectations need to be grounded to a reality in which even when expedited, implementation of new practices moves at a seemingly-glacial pace.

Residents get daily updates regarding our own institutional policies as well as new relevant findings that could be practice-changing. It’s amazing seeing the sausage being made, but it’s also terrifying because the Attendings and veteran physicians that we as trainees look to for answers are now looking to each other for answers and opening the floor to all ideas.

The good news is that while we don’t have the answers yet (and we may never have all the answers), we can take comfort in knowing that we are in the golden age of data- and knowledge-sharing. Pooling the resources of physicians, epidemiologists, researchers, and statisticians internationally has allowed us to make great strides in our understanding of COVID-19 in a relatively short time, and work toward mitigating our greatest fear – the unknown.

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Resident Perspective: Ready or not, time for telehealth

This is the continuation of a series of journal entries depicting what it’s like to be a part of the COVID pandemic from the medicine resident perspective.

Wednesday, April 1st

Medicine residents work in the hospital as well as the outpatient office. Cleared to go back to work, I’m scheduled to see some of my patients in the office. In an effort to limit the exposure to coronavirus for both the patients and the office staff, as many appointments as possible have been converted into telemedicine visits. These are essentially video-chat appointments using a HIPAA-compliant app where I can talk to a patient, ask about their symptoms and have them show me any relevant physical exam information, like using the camera on their phone to show me the back of their throat. I complete the online training modules that all providers have to pass and I think I’m as ready as I’ll ever be.

Something is off as I arrive at my clinic prior to my shift. First, it’s nearly empty, no front desk employees are there to wave to, and there are new standing hand sanitizer dispensers everywhere. Magazines from February populate the waiting room tables which may not be alarming for most businesses, but for my clinic, not having new editions of Philadelphia Magazine on display is shocking and noteworthy. No patients in the waiting room and doors to individual offices are closed, preventing natural light from gaining entry to the normally well-trafficked hallways. This place definitely feels more bunker-like than I remember. The few staff and attendings that are present are all wearing scrubs and face masks. Recognizable but unfamiliar, the pandemic has now officially warped and invaded every facet of my life and there is no sanctuary for normalcy.

Previously, only a small portion of physicians were utilizing telehealth visits. Fewer than 1% of Medicare beneficiaries used it prior to the pandemic.  Presumably because there is a learning curve on both the provider and the patient’s end, you have the opportunity to be more thorough during an in-person visit, and the big one: it wasn’t fully reimbursed by Medicare. Recently, under the Stafford Act and National Emergencies Act, Centers for Medicare & Medicaid Services (CMS) announced its beneficiaries will now be able to use telehealth to access their PCP for non-routine visits. Important to note, this is only temporary, as once the crisis is over (whatever that means), CMS will go back to its prior payment structure. Notably, other providers like social workers, psychologists, dieticians, etc. that are also integral to a person’s overall well-being will be covered.

Many of my appointments for the day involved patients interested in COVID testing. There’s an algorithm providers are to follow to determine who should be tested given the scarcity of tests. Mainly if the patient has symptoms, has other elevated risk factors such as coming into contact with a known COVID positive person, or recent travel to a coronavirus “hot spot”, they should be tested. This doesn’t cover a lot of other vulnerable people or others who should be tested, but the algorithm is designed to only catch the most likely positive cases at this point. The rapidity with things like which screening tests are performed and whom to test are just part of the equation in this constantly developing situation. Someone who is not eligible for testing one week, very well may be eligible the next.

I’d never performed a telehealth visit but the obvious problems that come to mind, like poor internet connection and not being able to get a gestalt on a patient that you can by an in-person exam, were apparent. In my first session I immediately encountered an  issue with a patient which our staff couldn’t get in touch with to see if they could convert their in-person appointment to telehealth. The patient’s partner had lost their job and couldn’t pay their cell phone bill so they were splitting the phone and the voicemail-box was full. The current economic crisis will of course exacerbate issues like this. Additionally, most commercial insurance as well as CMS will pay for audio/video calls but not necessarily only an audio (traditional telephone) call. My next patient actually was having difficulty accessing the proprietary HIPAA-compliant app on his phone, necessitating a phone call appointment which ultimately won’t be billable. Other appointments went smoothly and were unremarkable but already it’s clear there will be growing pains in moving patients to telehealth.

I’m a big believer in the future of telemedicine for many reasons but primarily because it provides a lower threshold for patients to access their providers, and this will be beneficial to delivering healthcare. These next few months will be telling if we can make it work nationally from a logistical standpoint. I’m not as convinced from a reimbursement standpoint as I’m sure there will be many kinks to work out. If my first foray into telehealth has shown me anything it’s that for my patients telehealth is a generally welcome idea in theory– many of whom did not grow up with cell phone technology– but in practice it’s a different story. Since the beginning of the quarantine, there’s been a surge in popularity of video and teleconferencing software connecting co-workers and friends alike. This current crisis will hasten the public’s comfort with interacting over the internet.  We’ll see how long it will take to successfully adopt and integrate into daily medical practice but the test has arrived regardless of whether insurance, the public, or providers are prepared.

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Resident Perspective: waiting for test results

This is the continuation of a series of journal entries depicting what it’s like to be a part of the COVID pandemic from the medicine resident perspective.

Sunday, March 29th

Although I’m a resident and I’m able to access my own medical chart through the electronic medical record, I’m not allowed, per hospital policy. I’m relegated to waiting for my results once “released” to me. While waiting for results in self-isolation, at a certain point you don’t really care whether it’s positive or negative, you just want to know something. Unfortunately, we still don’t know if being coronavirus positive prevents you from getting infected again so I’m not at the point where I would prefer to be positive just to get it over with.

Finally, five days after having the back of my throat swabbed I get an email saying my results are back: SARS CoV-2—undetected. Whew, negative. I was able to isolate for 5 days while my wife worked and took care of our baby simultaneously. Many other households aren’t that fortunate and either the other parent would have to take unpaid time off from their job (if they are able) or the person in quarantine would have to watch the kids and therefore expose the entire family to coronavirus. This is problematic for many obvious reasons.

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A picture of me and Jack at the tail-end of my quarantine. I still smiled under the mask for some reason.

The responsiveness from the government to obtaining and manufacturing tests was bungled from the very beginning. Quick turnaround time for testing is beneficial for giving patients a diagnosis promptly and is beneficial for epidemiologic prediction models that guide how much a region will be impacted and which locations that will be hit hardest next.

There are two main testing locations. In-patient testing for those that are hospitalized, where the test is performed in the hospital’s own microbiology labs (“in-house”) which have continuously improving turnaround times. Once the tests became available to hospital labs across the country, waiting times went from 48 hours down to about 4 or 5 hours (and in some hospitals turnaround is under an hour). The other main testing sites are commercial labs (LabCorp, Quest Diagnostic, etc.), where your test would be performed if your outpatient doc sent in a referral or if you went to a screening center. Unfortunately wait times are getting much longer as the public demand goes up for testing, and along with it, any part of the supply chain that is lacking—from swabs to reagents to protective gear for the providers—will back up everything.

The answer to better prediction models and better care isn’t just faster turnaround time for tests. The media has really honed in on getting quick results as a major issue in the epidemic because the news can show a long queue waiting to be swabbed or interview people frustrated by the lack of knowing their status. Arguably just as important is the accuracy of these tests. Swabs of the nose and throat are analyzed by something called polymerase chain reaction (PCR), which is designed to multiply the virus genetic material—RNA in the case of coronavirus—and detect the presence of the virus itself. A couple of problems arise from PCR as there have been reports of high rates of false negatives—meaning getting an inaccurate “undetected” reading when in fact, one is coronavirus positive. This is called low sensitivity in a test.

Because PCR looks for the virus itself from the swab, there have been studies in which essentially, if you go lower down the trachea (“wind pipe”) and obtain a sample closer to the lungs there are higher concentrations of virus located there so you will get a better sample and potentially provide more RNA material to amplify and detect with PCR. The issue with going down the trachea, in addition to being very unpleasant, can cause more of the virus to be coughed up during the procedure potentially infecting more people. So it seems not only possible, but likely that the swab going to the back of the throat either by way of mouth or nose just doesn’t pick up enough virus to be amenable to detection in many instances.

A blood test was recently approved by the FDA under Emergency Use Authorization which will test for antibodies (our own immune system response to the virus). These tests are already in use in China and other countries and can return results in under an hour. The benefit is that these tests aren’t dependent on obtaining an adequate swab and they could potentially tell us if someone’s been exposed in the past. It will also lead to more data regarding immunity to future infections with SARS CoV-2. The downside is that the test may not be accurate either and potentially detect non-COVID-causing coronavirus like CoV-1. There also arises questions like: is it better to know with 80% accuracy with one method vs 70% accuracy with another but it takes half the time to get the results back? There are no clear-cut answers because there are pros and cons to both.

The good news amongst all of this is that there is high “specificity” with these tests, meaning that if you get a positive result then you almost certainly have COVID, however comforting that may be. Keep in mind, for the time being these only apply to people that are having symptoms. I haven’t even touched upon the messed up screening guidelines and how they’ve morphed over the past few weeks. All of this is really to say we don’t know how many people are SARS CoV-2 positive currently for lots of reasons, and looking at the current positive cases on the news only tells part of the story.

At our institution there have been patients that we’ve been so sure are COVID positive that we’ve performed multiple PCR tests yet have all returned negative. Unfortunately, the answer to those that are so sure they are positive with coronavirus but have received negative testing is to assume the test is wrong. Given the rapidity with which this is all developing there just isn’t enough data regarding how accurate these tests are and how they should be employed.

I finally received a call from occupational health telling me the test results and to go back to work. Typically I’d be starting on outpatient weeks at this time, meaning I would be seeing patients in the office and go to morning and afternoon conferences with other residents. The pandemic has disfigured outpatient life for a resident, so now I start with telemedicine appointments and we’re given strict instructions to stay away from the hospital until it is our turn again—I’ll gladly oblige.

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Resident Perspective: Who is “Essential”?

This is the continuation of a series of journal entries depicting what it’s like to be a part of the COVID pandemic from the medicine resident perspective.

Friday, March 27th

I’m not having any symptoms at all at this point, really itching to get back to work. All residents have been instructed to check their temperatures before and after every shift since last week, in the hopes of catching any early signs of infection. We were not supplied any thermometers by the program, local drug stores are all sold out, and checking online the cheapest thermometers that will arrive in fewer than 4 days are all over $50. Luckily, I have my son’s infant forehead thermometer but I’m pretty sure doesn’t really work—I use it anyway and consistently have a temperature below 95 degrees, whatever that’s worth. I hadn’t felt feverish so I continued to go in to work at the hospital.

I’ve been reading a lot of self-congratulatory posts on social media from those in healthcare, selfies with a mask on, a team posing for a picture in all their protective gear, etc. For the most part it’s pretty benign but important stuff—reminding people to wash hands and stay home. The other intention is to self-promote and remind others they’re putting themselves at risk for the greater good. A troubling type of post I’ve been seeing is from providers (often not directly taking care of any COVID patients) excited and proud at the prospect for the medical community to come together to defeat this invisible foe. Maybe these sentiments are posted because morale is low and physician burnout is even higher than typical at this time? Bully for those that go into the fight ready, willing, and able. This mentality seems to say that as healthcare providers we should all rush to the frontlines as it’s a commendable action. I suspect many people not working in healthcare may not realize that residents are not really given a choice whether to participate or engage with high-risk coronavirus patients.

Residents are at an even higher risk of burning out at this time because all “non-essential” employees are not permitted in the hospital and they are limiting the number of employees for the essential roles as a way to decrease overall exposure. Medical students typically make discharge appointments, obtain outside hospital records, and other vital tasks—but medical students are no longer permitted in the hospitals because in many ways they’re paying for the privilege of being there. That topic in and of itself could be another blog post.  Gone or restricted hours also apply to many case managers, social workers, patient transporters, nutritionists, physical therapists, drug or alcohol rehab representatives, etc. The burden of caring for patients and providing a safe discharge now falls more squarely on the remaining, smaller medical teams, which includes residents (and more specifically the interns—first year residents). This is time-consuming and no doubt will hasten burnout. In our program we’ve been fortunate enough to be able to take certain measures to mitigate this, like shorter duration spent on COVID teams for residents, but we may not have that luxury in the coming weeks.

Is this what we signed up for as trainees? My institution for now has been remarkable in being able to accommodate residents that are particularly vulnerable or have vulnerable household members; others may not be so lucky. Hospital administrations have to make the decision as to who to put in harm’s way. It’s not always cut-and-dry—should we protect older attendings or younger trainees? Is the duty to provide the best care for these current patients or to minimize exposure of budding physicians who will be practicing for decades to come? We have no idea if there are any long-term repercussions to the lungs or any other organ systems in people with asymptomatic coronavirus, and they may confer a higher rate of complications not seen for years or decades—we just don’t know. The vast majority of residents and clinicians in Internal Medicine are very hesitant to jump right in, and understandably so. Initially no med students, interns, or residents were to take care of COVID patients. As the epidemic grew into a pandemic more and more hands needed to be on deck. But still, the decision regarding which specialties will be taking care of these patients is growing. The public may not realize it either, but some residents and even attendings from subspecialties that don’t have much clinical patient exposure (e.g. Radiology) may have to dust off their stethoscope and start taking care of loved ones in your hospital.

Similarly to reports about physicians having to decide which patients get a ventilator, we are also making the decision as to which providers get greater amounts of exposure, which is a morbid endeavor. In Philadelphia, we’re fortunate enough that we haven’t had the same patient burden as New York so it hasn’t been all-hands-on-deck, but we may have to start asking which residents can handle more exposure than others, sooner rather than later.  Does taking care of an elderly family member, or a child at home come into consideration? What about providers with immune system issues? Where does my duty to provide for my patients trump my duty to keep my family’s risk of exposure at a minimum? Is it moral to ask a young, healthy, single resident to have repeated exposure or is it better to spread it out over several residents but lessen their daily exposure?

Although I personally hope to continue to be at or near the front lines, I understand those that are in a compromised position, and they shouldn’t feel bad for wanting to protect themselves or their family. There is no portion of the Hippocratic oath that implicitly or explicitly states that physicians have a duty to patients above their own safety. This is a nuanced situation that doesn’t have a blueprint in place. There are many features that as a society we’re having to figure out in real-time, which is just adding to our collective anxiety.

Healthcare workers are put in an awkward situation in these times. We need to be discussing this openly, with transparency about the treatment of healthcare workers, especially nurses and residents. How to improve the healthcare system is an important topic that hopefully will not be able to be ignored after we pass the emergency of the pandemic. It will not be easy to address this because the goals of the industry are not aligned with the goals of the public or those providing care. Even though we’re in the midst of the pandemic it’s a beneficial practice to reflect and think about the way we can improve the safety and efficacy of those delivering care.

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Resident Perspective: It Begins

This is the continuation of a series of journal entries depicting what it’s like to be a part of the COVID pandemic from the medicine resident perspective.

Wednesday, March 25th

Today was my first day of quarantine and now I feel like I’m a part of society. In the prior weeks, working on the general hospital floor I was constrained by daily ritual –nothing said on the news or by the government about isolating or “staying home” applied to healthcare workers, or residents, more specifically. Those working in hospitals are in the thick of it, but we have a completely different experience because we have to continue to go to work and do our jobs while everyone else has just had drastic changes dictated for their daily lives. I was working long hours every day so I didn’t observe any special social distancing; my daily routine recently had been to come home and only have about an hour before turning in for the night so I wasn’t doing much socializing. Now home and quarantined, I found out quickly how fast things could change as I spend most of the day sequestered in our bedroom away from my family and where they typically are during the day.

My wife’s mother watches our son but we’ve collectively decided that while I might feel fine, because of my high risk exposures it would just be best for her to not come until things cool off. We’re lucky that we have the opportunity to actually have this option as many families in our situation would either have to choose exposing a loved one to potential coronavirus or have the parent take time from work to watch their kid. I fully appreciate we’re privileged enough to even have that possibility.

I look out my closed bedroom window and think it’s a shame that the weather’s so nice as I’m sure everyone is itching to be outside. Spring is in full swing even on our street, as the trees are approaching full bloom, and I’m pretty sure a bird’s nest is being built in our gutter as I hear constant chirping with rustling of leaves and tin behind the upper corner of my bedroom. I can hear neighborhood kids outside playing. I look down and see groups of 4 or 5 parents awkwardly try to stay 6 feet apart on our narrow street. I’d like to kindly remind them to keep their distance, but like Jimmy Stewart in Rear Window, I just gaze at them from the safety of my newly shuttered life.

Hearing the kids play, I wondered, what are they thinking is going on? How much have their parents told them? I don’t know what age you go from being elated you’re off from school to being worried about whether or not you and your family will survive. Do they think this is a normal occurrence and something they’ll have to deal with frequently in their lives? This must have a major impact in many different ways on kids of varying ages. I remember getting talks at school about fire safety and going home every night and practicing an escape plan with my family because I was so terrified. I don’t know what 8 year old me would be feeling about the invisible yet much more real confrontation with a virus. I couldn’t imagine having a 2 or 3-year-old that doesn’t understand that they can’t go outside to play with friends and then have to keep them entertained throughout the day. Then do it again the following day indefinitely.

I’m now realizing there will be so many unforeseen consequences, namely impacting those on the lower socioeconomic scale. When you work in healthcare during a crisis all you care about is how it impacts you and your patients. When suddenly removed, I’m forced to take a step back and come to grips with how this affects literally everything and everyone else in society. Maybe it’s because I now have my own child to look out for, but children have been on the forefront of my thoughts related to the pandemic. They may not be medically the most vulnerable in this case but they are in terms of long-lasting impact. Every facet of their lives are being disrupted—psychologically, educationally, nutritionally, and overall developmentally. Many families rely on food provided for kids at school. Expansion of SNAP benefits under Families First Coronavirus Response Act, which recently passed, may lead to unhealthier food choices for children as well, as this isn’t regulated like nutrition guidelines for school lunches. I’d also have to assume that kids aren’t getting the same quality of education if it’s all strictly remote, let alone the meaningful and necessary bonding that takes place at school. No doubt there will be a wealth of data to supply research to tell us what we intuitively know, which is when society stops functioning as usual the most vulnerable among us are impacted the greatest.

This time away from the hospital is allowing me to reflect on the many facets of life that are touched by this pandemic, so I’ll treat it like sabbatical.

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Resident Perspective, cont’d

This is the continuation of a series of journal entries depicting what it’s like to be a part of the COVID pandemic from the medicine resident perspective.

Tue March 24th 2020

I couldn’t sleep. I knew I would have to get tested in the morning.

 

I called our occupational health hotline when it opened up and I was instructed to go to the “walk-thru” testing facility that was set up outside in a parking lot adjacent to the hospital. All the staff there were wearing full body suits accompanied by masks, face shields, and bouffants. There were traffic cones strewn about seemingly directing the patients to different locations, various designated lanes for people to register, and about 3 dozen empty folding chairs spaced out to preserve social distancing. There was an ominous large Winnebago covered in sheet metal for some reason, and tents with presumably more staff inside them. Also, there were police officers, about 4 or 5 huddled together but they weren’t directing traffic and I couldn’t surmise what role they could possibly play in all this. Cars making their way along pothole-riddled Sansom street would now slow down to gawk at the impressive sterile facility not only for the sole intention of protecting the integrity of their tires and suspension. As a patient now, I was sitting in one of the empty 36 folding chairs while I waited for my name to be called. Outnumbered about 15 to one by occupational health employees, I could imagine the public believing this was overkill.

 

I was told I won’t find out the results for three to five days, but there was a rumor about occupational health potentially getting a 24 hour test up and running the following day. I didn’t want to risk being in the same boat again tomorrow so I took the swab today. My name was called, I went to the proper lane then was summoned into one of the tents where the very back of my throat was thoroughly wiped with an elongated Q-tip. Per hospital policy, I was now on mandatory leave to be on quarantine in my home until the results returned.

 

I called my wife and updated her. I would stay in the bedroom by myself for the next several days, leaving only for bathroom breaks, grab food from the kitchen, and to sanitize anything I touched. If I were to leave the room I had a facemask ready. I didn’t come close to my 7-month-old son, which was probably the hardest part of all this. On my way home I thought about how it felt like the virus had been preoccupying everyone for months but in reality it was only a couple weeks. I was exhausted by it already but this was only the beginning.

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Resident Perspective

I was encouraged by my wife to keep a journal for thoughts and feelings surrounding the developing coronavirus pandemic because I may be able to offer a unique perspective as a resident in medicine who is also a new parent and attempting to overcome fear of the unknown and what’s to come. I will try to update as frequently as I am able.

Monday March 23rd 2020

I found out that the Attending Physician I had been working with all last week and who was coughing during rounds was getting tested for coronavirus last night in the emergency department. I can convince myself I’m having symptoms of fatigue, sore throat and maybe a headache but I’ve also been working in the hospital for almost four weeks straight and this could just be general exhaustion mixed with a touch of seasonal allergies. I try not to think about it too much.

I haven’t been wearing any masks or other personal protective equipment around the hospital yet. At this point I feel like we are still in the nascent stages of the impending unknown so wearing a mask right now seems premature. The practice isn’t mandatory but I see more and more random staff in the hallways with facemasks on, many of whom aren’t clinicians which is a greater indication that I should probably get on board. Every now and then I’ll check a supply closet or outside a patient’s room to see what the surgical mask inventory is like. There are constant rumors floating around that, like the N95 facemasks, other equipment will be locked up and parsed out by a charge nurse on an “as needed basis”. If a run-on-the-banks situation were to occur, I want to make sure I hit the sweet spot where I don’t contribute too much to the hysteria but ensure I’ve got a mask without having to fight for scraps. I’ll continue to assess the situation.

Meanwhile, I observe more PAPRs (Powered Air-Purifying Respirator—special protective equipment) next to rooms on the wards, awaiting their donning by newly trained hands. They’ll be used for all COVID patients but since there aren’t any confirmed as of yet in our hospital, the purpose is to be used by all COVID “rule-outs” for now–those that are being tested and don’t have results back. We have a three to five day turnaround for test results right now, meaning we simply don’t know if the virus is already in our presence. The increasing numbers of PAPRs seen daily act as a surrogate for the proximity of the disease to Philadelphia and as a gauge for the level of concern amongst residents.

Over the last several days quite literally every discussion between residents in the hospital is about the coronavirus. Either discussing potential treatments; rumors as to what’s going on in China, Italy, or New York; sending memes or chatting about our trepidation and general anxiety that has gripped the entire hospital. Even when seeing my patients, every TV seems to be tuned into the news, all of which are giving up-to-the-minute global figures alternating between death tolls and economic indices. Patients ask questions for which I don’t have answers. No families or visitors are allowed in the premises. No students or “non-essential personnel” permitted to the hospital. Residents are instructed to follow social distancing protocols and there are to be no gatherings of more than five.

I went to a stroke alert today at a patient’s room for a patient that I wasn’t directly taking care of, I just happened to be nearby. The patient was in a designated “rule-out” room meaning all personnel involved need to treat the patient with extreme caution, and to limit those in contact with the patient to only those “essential.” Two nurses and a tech were in the cramped room already while the neurology resident was outside the room, not wanting to unnecessarily expose herself, miming the actions for a neurologic exam to one of the nurses. She gave instructions through the patient’s door window and into a speakerphone in a patient’s room a mere 4 or 5 feet away. The nurse and the tech cautiously proceeded to ask the patient to perform the maneuvers coached by the neurologist. It was an odd scene as clearly the patient could hear the instructions from the hallway through the door as well as the speakerphone but was polite enough to not mention that to the nurse directly in front of him. The nurse dutifully relayed the commands, “can you follow my finger with your eyes and keep your head still?” and the patient dutifully followed them. It would be funny if it weren’t so bizarre. Turns out he wasn’t having a stroke but it was good to have the opportunity to work out kinks regarding the protocol for patient emergencies. Residents are instructed to make note of instances in which normal protocols can’t be followed given the extra necessary precautions we now have to take. No doubt there will be plenty.

The hospital is both quiet but buzzing lately. Most of the services only have a few patients on each team and I walk down the wards and can find four-five-six! rooms in a row without any occupants. I’ve never seen more than two consecutive empty beds during my years here. The hospital policy is to discharge as many patients as possible with the impending influx of COVID cases to come. No elective surgeries and if you don’t absolutely need to be hospitalized you’d be safer at home. The atmosphere was akin to the episode of Game of Thrones just prior to the final battle in the last season. Nervous and anxious, we have no overflowing wine to keep us preoccupied and stumbling about. The morale is low and the silence in the hallways and in the former resident-gathering areas from our lounge to the cafeteria forces it to reverberate. Philadelphia has the temporary advantage of being able to watch from the shore as the tidal wave from China picks up steam as it makes its way across Europe, to New York City and crashing down I-95.

That night at home I continued to mentally scan my body for any possible symptoms. I hardly ever get sick so I don’t know if I’m short of breath at the top of the stairs because I’m out of shape or because I have a deadly infection. Best to push it to the back of my mind as there’s nothing I can do about it at this moment.

Bedtime routine completed. I get a text message at 10:00pm from a co-worker saying that the Attending I had been working with came back positive for coronavirus.

Image from Getty Images.

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Big Pharma: Don’t Hate the Player, Hate the Game

Martin Shkreli is a man I admire in an odd sort of way.

The recent controversy involving Mr. Shkreli and his price hike of the toxoplasmosis drug, Daraprim, seems to have caused misguided furor towards the 32-year-old CEO of Turing Pharmaceuticals. He may epitomize a major problem with the pharmaceutical industry but he is simply playing by the rules his pharmaceutical executive contemporaries and predecessors have helped set in place. Much like Donald Trump and his history of bankruptcies, he’d be foolish not to take advantage of every oversight weakness or loophole set up by a corrupt system that affords advantages to those who are shrewd enough and willing to exploit them. The public’s anger is directed at the man and not the system.

If Shkreli were to step down or be forced to resign, do people think that the next CEO of Turing Pharmaceuticals won’t be as zealous or brash in exploiting the system? People dislike him for the price hike, but loathe him for the way he defiantly acted in response. If I were a board member I would demand that my CEO rigorously investigate every pathway to make the company more profitable and therefore more financially stable, but I would also want them to exhibit a measure of temperance so as not to attract unwanted public spotlight. It seems as though people would be willing to forgive and forget a less brazen pharmaceutical executive. Every public dollar not claimed by Turing Pharmaceuticals is a dollar that will be spent elsewhere, or heaven forbid end up in the coffers of the competition.

As for the relationship to medical students, pharm and biotech industry sales reps are not seen or heard from during the first two years of our schooling. We are in the classroom and there is no official school-sanctioned time allotted to these groups unless specifically invited by a student organization. There are no events or talks sponsored by companies, and all faculty must divulge any real or perceived conflicts of interest when lecturing.

This changes in the clinical years (third and fourth year) when the students are out and about amongst the physicians, nurses, and patients in the hospitals and clinics. Students are left to their own devices and are sometimes in rooms with Big Pharma reps during presentations for a new product or during demonstrations of a new surgical device. The “good” reps will gravitate towards the students after they’ve made their pitch to the higher-ups and start chumming it up with those at the bottom of the totem pole and those with the least decision-making capacity.

My first encounter with a sales rep was right before entering the operating room (OR). Gowned in scrubs, all entrants into the OR look nearly identical and no hierarchy can be discerned readily, like it can be up on the patient floors. There doctors wear long white coats, nurses wear scrubs, and students wear short white coats paired with a look that can only be described as confident confusion. There the pecking order is clear. The OR is murkier—we’re all wearing blue scrubs so the nurses and students are dressed like the doctors are dressed like the students. The man approached me and asked if I was a student and we began chatting. I assumed this guy was of some import—he was tall, he spoke confidently, and he knew everyone’s name entering the OR. As the conversation shifted from what my first few days at the hospital were like, he started extolling the sophistication and ease of use of this new surgical device that would be employed for this particular operation. Then it hit me that this guy was just a salesman.

He knew who I was, right? Him selling me on his product would do absolutely nothing for his company’s bottom line and his quarterly sales wouldn’t see the slightest uptick whether or not he had ever spoken to me. He gave me his card and told me to be on the lookout for his company’s reps in all my future endeavors. Man, I thought, he was such a nice guy. As the weeks went on I encountered other reps while in the hospital. All of who were just as nice. What an endearing industry.

Drexel had done a superb job at shielding its first and second year students from the influences of third party companies. We had almost no exposure to the sales pitches coming out of the mouths of these charismatic salespeople. We were being released to the world as naïve students. Were these reps being nice for the sake of being nice? Of course that’s a possibility. What’s much more probable, however, is that they are all planting the seeds of merchandising as soon as they are able. I wouldn’t be advising any hospitals to buy any new surgical devices, nor would I be prescribing any meds for a few years, but when the time comes, I will already have that brand recognition stored somewhere in my brain.

As students we are never given formal training in how pharmaceutical companies operate and what we can expect to deal with for the rest of our careers, regardless of our specialty. We have a Business of Healthcare course that does a great job of outlining the history of US healthcare, how it came to be the way it is, and how insurance companies fit into the puzzle that is the US healthcare system. I once believed that it was a good thing that med school limited exposure to Big Pharma, and that this limited access to its students would offset some of the pernicious effects of physicians becoming beholden to a drug company. As our system is set up now, students or recent med school grads will be inundated with free luncheons, demonstrations, and gifts that are designed to both inform and persuade physicians and future physicians to prescribe certain medications. There seems to be real value in these demonstrations, as it is a way for those in healthcare to stay current with advances in research and technology.

The FDA and Big Pharma continue to battle about how much free speech the for-profit pharmaceutical companies can claim when marketing their drugs and devices. Students are not given much information regarding the politics of what is going on in Washington, D.C. It is important to learn about how our healthcare system works and to truly be advocates for our patients, doctors need to be versed in the discussions going on in the capital. Perhaps to steer clear of politics and controversy, medical schools opt to leave this discussion out altogether.

Or perhaps not; in order for physicians to best advocate for our patients and their health, we need to know the rules of the game. Med schools need to find the balance between creating competent, knowledgeable physicians who understand their field very well but that are also aware of all of the players in the game and what’s at stake. I’ve found that many of my colleagues find the political aspect of medicine tedious, boring, and too time consuming to delve into the intricacies of policy creation. It is this lack of knowledge or fundamental misunderstanding of the relationship between physicians, pharmaceuticals, and the government that makes doctors more susceptible to persuasion by the sales reps as conflicts of interest in the health practitioner field aren’t readily apparent.

The relationship between pharmaceutical and biotech companies with medical schools shouldn’t be adversarial, but when the goals of the healthcare provider and healthcare-related companies don’t coincide, the physician and the patients need to be made aware. Talks by prominent physicians that are on the payroll of drug companies need to be scrutinized. Papers applauding new breakthrough treatments need to be rigorously investigated because even peer-reviewed journals are not free from bias. There is no ideal time during the course of our education that this information would naturally fit, but it is vital and it should be taught early on so that when we are released into the hospitals we will have practice with critiquing sources and being mindful of current legislature concerning what parties are spending money and where they are spending it. If you set up a system that can be exploited you will attract those that are the best at this exploitation.

It is easy to set the ire and pent up aggravation at a wasteful system onto the figurehead with the likeness of a James Bond super-villian, but the release of the collective frustration still does not change the underlying current of how our healthcare system is run. If we’re not educating future doctors on how to effectively combat an (at best) unfair or (at worst) corrupt system, then who can we rely on to give patients a better handle on their own health?

As far as Mr. Shkreli is concerned, he’s just a example of what can happen when an arrogant, young, former hedge-fund manager gets his hands on a product that people need. He’s willing to be the face of a controversy and actually exemplify to the public how screwy the system is. Like Donald Trump proclaiming to donate heavily to both parties in order to personally benefit, Shkreli is opening our eyes to the nature of business side healthcare. Rather than being angry at why someone would do this, be angry at how someone could do this. Don’t hate the player, hate the game.

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Anti-Vaxxers: Why Medical Students Aren’t Being Trained to Weigh-in

With increasing frequency I have been asked by friends and well-wishers about how “anti-vaxxers” are being broached by my medical school professors. Simply put, we aren’t being taught anything on the matter. This is insight on how future physicians are being groomed to handle public misinformation and media outcry. Obviously we are given the molecular biology and public health angles as to how vaccinations work from the micro to macro scale, but we aren’t supplied with the tools on how to discuss these seemingly controversial topics with our patients. This could be for a few reasons.

First, the rising trend in vaccination refusals and recent measles outbreak, coupled with subsequent media hysteria, will raise awareness of the harm of not vaccinating children—and this trend will correct itself. After all, it seems affluent Millennials are seeing the greatest raise in foregoing vaccinations. They understand that chemicals are pervasive in today’s world, and while they might not buy that vaccines cause autism, they certainly don’t believe that injecting children with man-made concoctions at an early age increases their biological fitness. Therefore, when the educated anti-vaxxers see the harm they may be causing society as a whole, let alone their own kids, the trend will inevitably correct itself. One would hope.

It isn’t only the Millennials; some of the unvaccinated come from isolated religious communities, and the poorer counties within a state tend to have lower levels of vaccination rates. Each patient is unique and asks questions regarding vaccinations with different levels of background knowledge. Therefore different ways to convey the same message about the effectiveness of vaccines would need to be employed by the physician. This is a technique developed more during third and fourth year of med school (I’m still in my second year which is primarily classroom-based) so maybe it is more appropriate to have these discussions later in schooling. Sometimes a patient’s anecdotal evidence (e.g. “My friend’s sister had a normal child until they got vaccinated and then the child became autistic”) is too ingrained and no amount of sound evidence can dissuade them from their preset justification. My school might just be trying to allow its students to form their own ways of picking and choosing their battles when it comes to handling these issues with the patients.

Lastly, perhaps doctors feel that by and large they are above the entire “debate” about whether vaccinations are good or bad. Let the 24-hour news cycle run its course. Football just ended, it’s too early for 2016 elections, Russia and Ukraine’s ceasefire is mildly interesting, and by national news standards there’s not really much going on besides the latest ISIS comings and goings. By physicians engaging in a discussion about the merits of vaccinating your kids, it may lend credence to the extreme minority’s position as a legitimate conversation starter. Last year, noted scientist Bill Nye entered a debate with noted Amish-look-alike Young Earth Creationist (YEC) Ken Ham on whether creationism and a 6,000-year-old Earth is a viable model for our origin. Many people felt that Nye showing up to the debate was essentially giving YECs publicity and a form of legitimization, even though they are an extremely small and vocal minority without the backing of any evidence or scientific merit—much like the anti-vaxxers. The biggest difference being that someone believing Earth is 6,000 years old won’t necessarily raise the chance that my child gets a debilitating illness.

As far as med school teaching is concerned, we are urged to strongly recommend for vaccinations for inquiring patients, but maybe we should also be discussing issues on a larger scale and how it relates to public health. Although we have a bioethics course, which excels at giving students the facts regarding the law and why and how the law was passed, we are never given the tools for how to make more permanent change in the community. We are not instructed on how to engage in ethical discussions about whether or not something like vaccinations should be mandated by the government. In the last decade there have been failed or short-lived attempts at making HPV vaccinations mandatory throughout the U.S. The issue has been up for legislation in nearly half of the states and has failed in all but Virginia and D.C. (it was passed and later repealed in Texas). Perhaps not surprisingly, people would prefer to have the opportunity to make the wrong decision rather than having the right decision forced upon them.

I believe that people are very much products of their environment and will naturally gravitate towards the path of least resistance. Change on a macroscopic scale, like how society views public health mandates, can be unnecessarily slow to develop, except in rare cases like the polio vaccine—which was almost literally an overnight sensation. If many of the medical aspects of how we treat our bodies are dealt with in an “opt out” fashion I believe that we may see a significant increase in the quality of life across all strata of society. A great example of this is Spain’s organ donation rates. They have the highest rates of organ donation on the planet primarily due the country’s policy that each individual is automatically enrolled as an organ donor. If you want your organs to stay in your body to take them with you to heaven (or hell) after you die, you would have to fill out some paperwork. Well guess what? People generally find paperwork to be a nuisance and a tedious endeavor. You want me to fill out these forms just to be able to fill out more forms like we’re in some bureaucratic Soviet state? I’d rather just let you have my organs.

And that is the idea: create a society in which it is commonplace for people to generously donate their unneeded organs and they will eventually do so, not because it is the path of least resistance because it is the right thing to do to save other people’s lives. I envision after years or perhaps generations with a certain policy in place (like having to opt out of donating blood) that when the opt out policy is removed people still donate at the same rate because donating blood is something that people should feel compelled to do to help their fellow man. In the meantime, don’t incentivize performing a positive action, simply tack on some form of negative reinforcement to make a negative action (such as not donating blood or organs) more difficult. This way only those who have a true objection to the task will take these necessary steps.

In all likelihood there is no formal teaching for medical students on how to deal with anti-vaxxers in our pre-clinical years because it may not come up in doctors offices as much as the cable news-watching public may think. According to the CDC, vaccination rates have only had a very modest dip over the past decade and it should be far down the list of concerns doctors have for their patients. Some combination of it being a trendy topic, each patient’s situation being unique, and that it’s just beneath us as physicians to discuss, is what’s most likely being employed by our professors. There is already so much packed in our ever-expanding curriculum that we simply might not have time to really delve into the issues surrounding medical trends. Plus, by the time I actually become a doctor seeing my own patients, the medical landscape could be so vastly different that people questioning vaccinations would be a relic of a bygone era.

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