COMMENTARY

Stanford Hospitalist: 'What I Wish I'd Known 2 Weeks Ago'

Abraham Verghese, MD; Neera K. Ahuja, MD

Disclosures

March 27, 2020

This transcript has been edited for clarity.

Abraham Verghese, MD: It's my pleasure today to be speaking with a colleague, Neera Ahuja, who heads the hospital medicine division at Stanford University.

Neera, on every media avenue we turn to, we have experts pontificating about this and that, but my admiration has been for the frontline folks. This must be true all across the country, but at our institution, it's the folks in the emergency room and it's the folks who receive the inpatients, namely your team. So it's truly an honor to have you share that perspective. Also, watching you the past few weeks mobilize for something that even though we may have had some sense of what was coming, I don't think anybody truly could tell the dimensions that it might take, so we're delighted for you to join us.

I want to begin by asking you very simply, how are you? How are you coping with what must have been an extraordinary couple of weeks?

Neera K. Ahuja, MD: Thank you, Abraham. Thank you for making the time to speak with me and hear the stories that are going on both in the front line and with those who are trying to help support everyone.

I will say that I'm energized and exhausted. I had no idea, like you said, what we were walking into. Had I known it would be this hectic, I would have started preparing our teams, education, and training around all of this months in advance. But we weren't quite aware of how fast this would come.

I'm sleep-deprived, but I will say that the energy and the excitement of keeping things going and knowing that people need me to respond quickly has been, in a way, invigorating. And although I can't see them face-to-face like I used to, because of the shelter-in-place mandates, I am periodically going to the hospital when I need to take care of some issues and trying to make sure that I do lay eyes on people when I can. That face-to-face contact, even without words, is so much more powerful than a simple email or text.

Verghese: Absolutely. And you're also managing to juggle family and young children all in the midst of this. Frankly, I just don't know how. Most of my women colleagues manage this as well, but you more than anybody else.

Ahuja: Yes. And that's in large part to them understanding and respecting what I'm doing. They know how important this work is. They know to kind of tiptoe around when I'm on a call, and my amazing husband has been greatly supportive.

Verghese: Well, please thank all of them for being the support that they are to you.

Trying to Get Ahead of the Wave

Verghese: I want to sort of step back—and I'm sure that we'll be doing a lot of this in the years to come—and look at how you've had to respond. The hospitalist movement in America has pretty much become the model for care of inpatients once they get past the emergency room. So walk us through the timeline of how, at various stages, you've had to respond to the increasing realization that COVID-19 is coming.

Ahuja: Over the holidays, that's the November-December time, particularly in late December, we had a dramatic increase in our patient volumes. It was almost the imperfect time to have such a situation because it's mostly skeleton crew and people are focused on getting in, rounding, and getting home to their families for the holidays. That started to make us a little more aware that we need to make sure that we have adequate staffing should volumes increase with any type of COVID-19 infection in the United States.

Conversations started to happen over the course of January and escalate a little more in terms of what we would prepare for in terms of which wards would be the COVID-19–containing wards. But those conversations didn't really actualize until March. And, as you know, we had our first cases in our hospital only about 10 days ago [around March 10], as the COVID reagent development and testing abilities became much more accessible due to the amazing work of Ben Pinsky and his lab.

It's almost like we were backtracking and thinking, Do we have enough staff activated? Who else can we recruit in? Within the division, everyone has stepped up and said, "I want to help. What can I do? I could even double-cover two services," which has been nice. But we've already had a few providers who have taken care of COVID-positive patients and then have had symptoms, so we have to be protective of them.

Staffing has been one huge part of this that we're still evolving with. We are preparing for potentially how we would function if there was a 40% loss of staff. But in talking to some of my colleagues at other hospitals, they're already at that number and they're wondering whether they should look at 70% loss of staff.

Some providers have young children who are no longer in school, and they're having to stay home and take care of them. They're rounding early in the morning, having their spouse cover the family, and then rushing back home to take care of the children while being available via telemedicine or telephone. Some very unique rounding modalities.

Fortunately, with the Stafford Act, we now have the ability to be more flexible and utilize telemedicine in the care of certain patients. In the inpatient setting, it's a little more challenging. But with CMS patients in the inpatient setting, every third day, a telemedicine visit is considered appropriate as long as the patient is stable.

Another thing that we've had to look at is education. I know that you're well aware of this, given your large role in education at our institution, but how has that been compromised? And how can we compensate in a way that's meaningful? Instead of just sending modules to trainees and saying, "Review this on your own time," how can we make it effective and a dialogue in real time? We do have a couple of apps that we're utilizing and tracking their usage. That way we know how they did, and this is through the help of the Human Diagnosis app.

Protecting Trainees

Verghese: One of the things that was a bit controversial, as you know, was that we decided to take medical students off the clerkships. That happened a few days before the AAMC and the LCME and others came out with the same recommendation. It was controversial. There was a sense that on the one hand, students needed to experience this because this was the life that they were choosing. But then many of us felt strongly that we had a responsibility to them. And the educational imperative was overwhelmed and canceled out by the imperative to keep them safe.

But I think it also came about because we're still so unsure about this virus, and we're still unsure about having protective equipment.

I'd like to talk about two things with you. First, testing. It seemed like, unlike almost anything else that we were dealing with, the great difficulty was not knowing who had it and who didn't. I'm sure this is mirrored all across the country. Talk a little bit, if you would, about the testing challenges and then maybe we can get into the issue of personal protection.

Ahuja: Initially, the testing criteria that were created were a little more stringent. It was fever or influenza-like illness, sore throat, shortness of breath, body aches, myalgias, that sort of thing. Now it's become a little looser in the sense of if you're concerned a patient could have COVID positivity based on those symptoms, or adding cough to that list, you could just test. But there were some reagent shortages.

In fact, today I toured the lab where this is all done. I was touring it more because of our NIH site visit today for our remdesivir study. But what I learned was, there has been an influx of people willing to help this lab to get more reagent. Other labs around the area have done what they can because they know how important the testing is. What we're also finding, though, is that we don't want to overtest. Now that Stanford is known to be a site of testing, the community thought, "Well, you know what, I've got symptoms. Let me come to my Stanford PCP." But in the outpatient setting, there have been some very nice measures taken to sort of control and restrict testing to just those who need it.

One interesting thing I learned in this process was that this virus actually moves from proximal upper airway nasal-pharyngeal down to the lower lungs. The test is very sensitive. But if you catch it in a stage in which it's already progressed, you may have a false negative. We actually did have an incidence of that. It was originally falsely negative, and then in the bronchial secretions a couple of days later, it turned out to be positive.

In regard to the medical student question, this is a generation of learners that is so civic and social and wants to help. But I personally feel that we do need to protect them. They're also very vulnerable. And if illness incapacitates them, how can they continue on their education trajectory and keep within the timelines? So while I do agree with the decision that was made, what was unexpected was how many students came out to help in other ways. They made proposals saying, "We can serve in capacities that may not be officially physician skills. Let us help with carrying supplies. Let us help with babysitting the children of faculty who are restricted from their work because their children's schools have closed down." It's just been so touching to see the outreach from the medical student group.

Verghese: It truly has.

Donning PPE

Verghese: Let's switch to an issue that I think is very much on all our minds. We need to have the confidence, when walking in to see a patient, that we are protected. On the other hand, we're not always certain who has the virus or who is incubating and evolving. Talk a bit about how that imperfect knowledge translates into practicalities in terms of protecting the people who work with you and for you.

Ahuja: I think I had my moment of truth last Friday when I had to don on—that's the proper terminology to describe putting on the PPE—the personal protective equipment and walk into the room of a PUI patient, a person under investigation for potential COVID infection. This patient ended up being negative, but just as you're placing that mask and the gloves and the gown on, you have that sense of, I could potentially be exposed. Then imagine young faculty going into patient rooms that are COVID-positive, and having to do it day after day, because they're on service for a length of time. And knowing also that you know that person's infection may be getting worse or the viral replication may be increasing over the course of their hospitalization, potentially increasing exposure to that provider.

I will say our hospitalist faculty have just stepped up to the plate. There hasn't been anyone that said, "You know what, I'm not going to do this." In fact, they've said, "Are we safe enough? Are we gowning on properly? Are the masks the right thing to do? Should we build a COVID-containment unit so that it's just a smaller number of providers caring for these patients, and not exposing other providers that may be older or potentially pregnant?" That sense of how do we protect ourselves, as well as take care of the patients, was a very nice common theme among everyone unifying in the care of COVID-positive patients.

The other aspect is that nationally, there's a lot of talk about the PPE shortages. While we don't want to overutilize the personal protective equipment, we want to make sure that we're adequately protecting our staff. That conversation has been very loud, on email, via text, via phone, and I think the institution is clearly addressing it. I was on a call the other day. There's a hospital in New York that said they have 71 COVID-positive patients and only a 2-day supply of PPE. So we're trying to learn from other institutions and countries about how we can avoid getting there.

Verghese: Part of the problem is that no one knows what the correct level of gowning and protection is. Does one need a hazmat suit with a separate oxygen supply or is that excessive? In the absence of data, I think we're all kind of hoping and guessing. Also, we don't simply have that much equipment in this country to allow everybody to be so suited. Is that right?

Ahuja: Exactly. We know that there is aerosolization of the virus, potentially for a few hours. We also know that it lives longer on certain plastics and steel than it does on cardboard. We take all of that into consideration as we navigate through our environment.

I'll tell you a really touching story of a nurse who had had a beard for many years and who was going to be involved with the care of a COVID-positive patient. The difference between the patients that we take care of and those that are receiving airway treatments in the ICU or bronchoscopies is that our patients don't require use of a CAPR [controlled air-purifying respirator], which is a lot more protective equipment and more expensive equipment. This gentleman with the beard was going to have to use one of those, just because the mask didn't fit his bearded face properly. He actually went to the bathroom, shaved his beard, and came out and said, "I don't want to overutilize any equipment. We need to preserve everything we can."

It's just stories like that that I find truly amazing because I think people get it.

Verghese: What is lovely to watch, and I think this is probably true across the country, is that most hospitalists tend to be younger folks. I mean, this is in comparison to me—I'm 65 this year. But it does seem to me that many of these folks are my former trainees who are now assistant and associate professors. It's a generation of younger folks. In many ways, this is their HIV moment, if you like, and it's just wonderful to see how they're stepping up.

Would you share with us one of your hardest moments? I know you just shared one of the nice moments that was about somebody else. But share with us one of your hardest moments and one of your nicest, most uplifting moments of these past few weeks.

Ahuja: I think one of the hardest moments was when a faculty member said that she felt there needed to be more guidelines around what we're wearing and that potentially, in her mind, we should be wearing masks even as we're walking through the hospital because of the aerosolization risk. Even though we're not walking into a COVID-positive patient's room, how can we say for certain that the virus is not hanging around? And just knowing that the mandate from not only our hospital, but every hospital, is that we need to preserve PPE and not wear it unnecessarily. The CDC guidelines do not require that we wear it when we're walking around, as long as we're not infected. Having to say, "I hear you, but I want you to use your best judgment along with what the protocol says" was sort of my wink to her saying that "I hear you, I understand that you will do what you think is best, but we're not supposed to overutilize," and I felt very conflicted. Because what she was clearly telling me is, "I want to walk around with a mask and I want my colleagues to walk around with a mask. I don't want to lose anyone to this illness, either just by 2 weeks of sickness or something more serious." That is actually something I'm still struggling with, because those conversations are so prevalent even now.

I think one of my brightest moments—there've been a lot—is the philanthropy that has come in from so many different sites. I've had people I barely know reach out through just Googling "Stanford hospitalist" and say, "How can we help? What can we do? What do you need?" Today we had a restaurant in San Francisco reach out to one of our colleagues, saying, "We want to deliver food to the physicians." Two days ago, we had someone on standby to deliver well over a million sources of PPE and N95 masks. So those types of stories are really what keeps us going and make us realize that we are one big community going through this together, and everyone's trying to help out in a way that their education, their business, and their heart lets them.

Verghese: Neera, you're a leader in hospital medicine nationwide and publish a lot. I just got a call from somebody in Nevada who I don't know very well, but at a small hospital as a hospitalist, is asking what might they do. What advice would you give to places that perhaps are maybe a week or two behind us in terms of the arrival of the numbers that we are seeing or expect to see in our community? What are some things that they might start doing systematically to be prepared on the hospital medicine service?

Ahuja: That's a great question, sort of what I wish I knew 2 months ago or 2 weeks ago. I think one is to start staffing up providers, train them for PPE, and emotionally prepare them for what's to come. They may be sleep-deprived, they may be stressed—how to handle that. What I'm also learning through this process is that we need to carve out time for sleep and for connecting with our family. So I would tell them that's important. If it's an academic medical center, focus on how to educate the vulnerable younger trainees and learners in a way that's effective. Utilizing telemedicine and getting that infrastructure set up would be key.

As we launch our NIH study on remdesivir, we are doing this very fast-track because of the timeline of all this. Try to prepare for what things you can study both in a quality-improvement and a patient-safety realm, as well as clinical trials. We have so many ideas coming through now. It's often as an incident happens when someone reflects on it: Why did that happen? What could we have done better? Perhaps we should study this. I think being a little more prospective will help get the groundwork done so that these studies could move faster and more can be built on top of them.

Verghese: Neera, we couldn't have asked for a better overview of what things look like from your point of view. Speaking for hospitalists everywhere, I thank you for being so generous with your time because I have no doubt that you're going right into something else after this. I also thank you on behalf of our Medscape audience, who I think would be anxious to hear your perspective. You really have a unique perspective. My suggestion is that you take good care of yourself.

Ahuja: Will do, and thank you for your time and for getting the stories out there. Thank you to the entire Medscape team.

Abraham Verghese, MD, is a critically acclaimed best-selling author and a physician with an international reputation for his focus on healing in an era when technology often overwhelms the human side of medicine.

Neera Ahuja, MD, helped build a hospital medicine program at Stanford University where she is currently chief of the Division of Hospital Medicine. She is widely recognized as an outstanding clinician and has won awards for her teaching.

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