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Eric J Topol, MD: Hello. This is Eric Topol at Medscape, with our new episode of Medicine and the Machine.
Abraham Verghese, MD: And this is Abraham Verghese. I'm pleased to welcome our guest today, Dr Danielle Ofri, returning for a second visit. Danielle has been right in the thick of things in New York City at Bellevue Hospital Center.
We're delighted to have her back, this time in an entirely different timeframe. It seems like we're in another world than the one we were in when we first spoke with you. Danielle, how are you and how have you weathered the storm?
Danielle Ofri, MD, PhD: Thanks. It's great to be back. It does feel like another world. When we last talked, it was before we even started with COVID-19. There is a meme going around, that this is a leap year: February had 29 days, March had 300 days, and April had 10 years. And that is what it has felt like in the clinical world.
Everything really picked up toward the end of March. I've never seen our hospital move like this before. For context, I think it used to take about 2 years to get a water cooler at Bellevue. But in the space of 2 weeks, we almost tripled our ICU capacity, added about 50 negative-pressure rooms, doubled our inpatient capacity, increased our medical teams from 8 to 22, and went from one medical intensive care unit (MICU) team to 10 MICU teams. It was something like I've never seen before.
In retrospect, I realized that one of the reasons we were able to survive is because back when Ebola emerged, Bellevue opened a special pathogens unit. We treated the one patient in New York with Ebola, Dr Craig Spencer. But that special pathogens unit never closed. In fact, the special pathogens team was meeting weekly since Ebola, often with not much to do, but keeping tabs on MERS, SARS, Lassa fever, yellow fever—all the things that are happening around the world that can definitely turn up at a place like Bellevue. So when the novel coronavirus appeared in China in December, it was already on our radar. That gave us maybe a week and a half to a 2-week head start on many other hospitals. That was critical and enabled us to keep ahead of the tide.
Now, thankfully, we're at a plateau—not exactly back from the abyss, because this plateau is really sticking. We still have about 50 patients in the ICU with COVID who are not extubatable, and probably 180 on the wards. Nevertheless, we're now approaching the idea of what happens next because we have the rest of our patients to take care of. What do we do now?
Verghese: That's just incredible. Most of our hospitals in California also went through this huge gearing up and getting ready. But the difference is, we never saw the numbers that we were worried about, never got to really use our surge ICUs. And to think that you have 50 patients still on ventilators in your hospital... That is staggering, considering we have one patient on a ventilator at this point.
Ofri: The issue now is long-term acute care facilities for these patients. The number of codes and rapid responses have gone down, so you can really feel that there's not the churn of patients coming in, patients going out; patients, sadly, dying. That has lessened considerably. But now we have a core of patients who are experiencing the long-term issues like renal problems.
No one was prepared for up to a third of patients in the ICU needing some kind of dialysis. You simply can't ramp up dialysis that quickly. You need staff, machines, nurses, and space. We ended up doing a ton of peritoneal dialysis in the ICU; it really saved the day. We had dermatologists doing peritoneal dialysis. Everyone was trained in it. It was quite something to see.
Topol: There's a lot to unpack there. For one, COVID-19 was first thought of as purely a lung problem and now we recognize that there's essentially no organ spared; and the kidney especially, because it has high ACE2 levels for the virus to target. The other thing is these prolonged intubations, often from 2 to 3 weeks, and sometimes much longer. It seems extraordinary and challenging, given all of the other things that can happen while a person is intubated for so long.
Ofri: Right. And all of these patients, of course, have to be sedated or paralyzed. Many have tracheostomies, so that's changing the dynamic slightly, but it doesn't take away from the long-term damage of intubation. Plus, there are major vascular complications, which is probably why the kidneys are being affected so much. And we've been seeing COVID encephalitis and now the pediatric issues that have suddenly arisen.
We went into this thinking that kids were relatively spared, but now we're seeing this multisystem inflammatory disease that seems to combine inflammatory and vascular issues and is quite terrifying. It has changed the landscape for what we'll do about schools, camps, and pediatric clinics. It's scared everyone.
Topol: I believe that more than 100 of these cases have been reported in New York alone, plus a few who have already died. It's extraordinary. And another miscue—there have been so many of those—the idea early on, in February and March, was that children would be spared. That's not the case.
Ofri: And right now we're scared about a second wave, as all the states begin to loosen restrictions. We haven't changed the treatment options at all; we've only changed the spread. So now that we open up, we're fully expecting another wave. And it may not be in New York City because we're still staying put, but the rest of the country may see the surge they haven't gotten so far.
Verghese: I happened to visit New York City in the third week of February. That was when we had several cases here in our county in California. I was meeting with my publisher and going out for lunch and dinner, and I was struck by how relatively unaware they were of it then. They were aware but it seemed far away. My hotel was in the center of Times Square, and I kept thinking, This is unreal; there is no way this is not going to come here. Now I find myself thinking about all of the waiters and the various hotel people I saw whose livelihoods have been completely altered by this.
Give us a sense of the economy around you, at Bellevue and that wonderful, earthy neighborhood where Bellevue sits.
Ofri: We call it "bedpan alley," that stretch of First Avenue, because we have NYU Medical Center, we have Bellevue, we have the VA Medical Center. A little down the road is Beth Israel Hospital and Beekman Hospital. And a few blocks up are Cornell and Sloan Kettering. So First Avenue is still hopping. There are people coming and going more than usual because of all the staff surges. But go out a block or two and it's like permanent Sunday morning in New York City—that early Sunday morning feeling when everything is quiet and the birds are chirping. It's remarkable in both this beautiful and terrifying way because you recognize that the economic effect on people is powerful.
There was just a piece in the BMJ with statistics on the mortality in the UK population. Low-income men had disproportionately high mortality rates, with security guards being the highest, then taxi drivers, bus drivers, and chefs. And these are the people we're seeing here in New York. They're taking the economic and the medical hit all at the same time. I think it's going to lead to a permanent change in our society.
Topol: One other thing to note is the fear that patients have about coming to the hospital and the potential for all the collateral damage. There was a report of a big drop in heart attacks within the Kaiser Permanente system during March and April. I wonder what your experience is. Certainly in San Diego or in hospitals outside of COVID hotspots, we're seeing many fewer patients, and I presume that represents people's fears about coming in. What have you seen?
Ofri: I'm seeing this. Absolutely. Now that we're coming down from the acute phase, we're turning to all of our outpatients who have been "missing in action." I have 1400 patients in my panel and I'm trying to call the ones who have scheduled visits, but I also am trying to call the ones I'm worried about. I've uncovered several patients who have died, some of COVID, some of other things. I called a patient who sent a message about needing a medication refill, which I almost passed off to a PA to take care of but thought, No, I'll call her. And she was doubled over in pain, having had a hysterectomy 2 or 3 weeks ago, and she wouldn't go to the hospital. I had to force her to go, really get her family to take her. And she was in surgery that night with an abdominal intraoperative infection and a pulmonary embolism.
Yesterday I got a call from an adult child of a patient with dementia who was being abused in her home by another relative. I spent an hour getting protective services involved. All of these things are happening. And the more I call my patients, the more I am learning. It's terrifying because there are so many of them and they're all hiding out, terrified to come to the hospital.
I spoke to another patient today with severe anxiety and asthma, and they're setting each other off. Every time she wears a mask, that sets off her anxiety and asthma, and makes it hard to breathe. Her psychiatrist has upped her psych meds, but now she's sleepier. She's sleeping all day and doesn't even know what day it is, and all these things feed on each other.
The last thing I've been discovering is food insecurity. I now ask every patient, "Do you have enough food?" For many of them, the answer is no or very little, or they're living on rice and potatoes. So you can imagine that their A1c and glucose levels are off the wall, and some are rationing insulin because they're too afraid to go to the pharmacy.
Getting INRs for patients on warfarin has been an unbelievable task. I've tried to switch as many patients to DOACs [direct oral anticoagulants] as possible, but some people need to be on warfarin. They don't want to come in. And, of course, many of the patients on warfarin are extremely high-risk and they're the last patients we want coming in to the hospital. Trying to get home labs is a whole byzantine insurance nightmare. The collateral structural issues that we have to face are killing us and they take so much time.
The hospitals are hemorrhaging money. None of this work is reimbursable. We're putting in hours and hours of work but there is no way to capture the work that we're doing. Physicians, nurses, social workers—no one is sitting on their hands, but it's not capturable. There's a note in the chart, but no one's being reimbursed for this.
Verghese: For me, one of the things that's been striking about this epidemic is watching the way leadership has stepped forward at small and big hospitals alike. The principles that seem to carry the day are clear communication, transparency, and assigning clear responsibilities—all the things we're not seeing in the federal government's response. At our hospital, we have seen similar problems with a big deficit and worries about how to make money. I know you don't have a crystal ball, but as you look ahead, what are some things that small and big hospitals might be doing strategically? What is your leadership doing? What do you see a year from now?
Ofri: The whole experiment in telehealth, which we've been tiptoeing toward, now we've been thrown into it. But a patient called me today and said, "I have a telehealth visit with you, but when do I come in for my physical exam?" And I thought of you, Abraham. We just can't do a tele-physical exam. I said, "We'll try our best to get your blood pressure checked and a finger stick. But you're not going to have a physical exam yet." And I do worry that we're going to miss a lot in our patients. Nevertheless, we don't have a choice.
We have to ramp up the infrastructure for doing televisits. The hospital can't survive unless we find a way that insurance can be covering the amount of clinical work involved. That will require some political muscle. The hospitals need to band together to make this point because I don't think our political leaders recognize this.
I saw an article saying that some of the New York City public hospitals may have to close because the economic hit is so powerful. Many of the bigger private hospitals have larger endowments. They have money in the bank from elective procedures, even though those are on hold now; but there's a cushion. City hospitals don't have endowments or that cushion.
We also need to rethink some of the elective care we have been doing—all those gray-zone procedures like knee arthroscopy and back surgeries. For some patients, these procedures may provide some benefit, but on average, they don't. We can survive medically without them, but I'm not sure we can survive financially without them. That just points to our priorities being backwards. We want to be surviving on the real care of patients with diabetes, vascular disease, obesity, and depression. But that's a big political lift.
Topol: The greatest reduction in GDP and hit to the economy has been from the healthcare sector, and it's isolated to the elective procedures and operations. There has been a dramatic reduction—close to zero for this stretch. Will we rethink these procedures? We know that, certainly in the United States, there's overutilization of surgeries and procedures. So that will be interesting.
To your point about the physical exam in telemedicine: Telemedicine exists today as this video chat. But it could be transformed to a better version, with sensors and the ability to do imaging through smartphones, and through all sorts of things where we could get objective data.
It wouldn't be the same as a hands-on physical exam. But we should be thinking about those innovations, because the reliance on telemedicine over the next year or two—as we confront the ongoing pandemic—may become a better way to approach our patients rather than having no objective data without sending people to labs or for scans. And you know, Abraham, there is a tradeoff: With a televisit, or video visit, you actually are looking at the patient instead of a keyboard. You aren't wearing a mask. And while it's not ideal, I wonder if it's as bad as some people have portrayed it.
Ofri: I find that it's actually not so bad. I'm not doing video right now; we're still piloting that, so I can type while I'm talking to the patient, whereas when I'm with them, I very much want to maintain eye contact. So in some ways it frees me up a bit, and maybe I feel a tad guilty about that. The other efficiency it's brought is that we're not so tied to the schedule because we don't have the crush of patients in the waiting room. I find that so anxiety-provoking. With a phone call, if we call 10 minutes late or 10 minutes early, it isn't an issue, although that may change when people get back to their real lives and aren't home most of the time.
But I've found time to do chart digs in the moment, which normally I could never do in real time with the patient in my office. I'd have to wait until later and, of course, later never comes. Now, because the patient is not being inconvenienced by waiting in the waiting room, I can take the 10 minutes. And I've found a number of clinically relevant things that would have been missed in the previous world.
The tradeoff for me is that in addition to the physical exam being helpful for diagnosis, I find that it's also extremely useful for the history. Now that most of our histories take place with a computer between us, we aren't having a strong, close conversation. In my experience, the physical exam becomes the locus for the very intense conversation. Countless times it's during the physical that the patient will tell me things they didn't reveal before: sexual symptoms, depression issues, abuse, things they've forgotten. A lot of things that are very uncomfortable to talk about only come out when we're in this more intimate environment of touching and talking. "Oh, yes, I was beaten up by my spouse" or "Oh, yes, I'm having erection issues." That doesn't come up in the sitting-across-the-desk kind of conversation.
Verghese: Here at Stanford, we have a lot of experience with virtual visits, because that's pretty much all we were doing until very recently. People are in two camps. There are those who are increasingly frustrated with it, and there are those who are showing us how to do it well.
We have championed something called the Presence 5, a sort of mental checklist of things one does with a real patient at the first moment of meeting to optimize the relationship. We've now adapted that to the virtual visit. There are certain things you can do, such as making sure you're looking into the camera and not picking up other things on your desk, for example. Some people pointed out that you actually get to see the patient in their home environment. You get a sense of their own sense of safety. You get to ask them, how are you doing? How do you feel about the quarantine?
It will take a few more months for us to digest the nature of the experience. We ramped up the virtual visits 100-fold. It was something we were just thinking about in the past. But now it has scaled up massively.
I think in the future there will be a role for a mixed model of physical visits. Along with the sort of intimate glimpse into people's homes, this also gives our providers who have children the opportunity to do this in the after-hours. Patients also want to have visits in the late evenings. We'll see a lot of changes to medicine because of this experience.
Ofri: In June, I believe we're hoping to have 10%-20% in-person visits and 80% televisits. Then we can prioritize those who truly need the physical presence and those for whom we can do a televisit. For patients, the televisit is extremely convenient. They don't have to take a half-day off from work or wait in the waiting room.
Topol: To circle back, because of patients needing a much higher threshold to get care, to be seen in person, the telemedical route will help to reduce that problem and some of the harm that can occur without medical attention. We've geared up for this substantially at Scripps.
Ofri: But there are downsides. Many patients don't have privacy in their homes. Right now they're quarantining with family, kids, parents, and other relatives. To find a quiet spot to talk about personal things can be difficult. The upside is that the patients can grab their bottles of medicines and read off what the label says. They usually forget to bring them to the visit.
Because we used to see patients more frequently, messages between the visits were relatively limited—"Just need a refill of Flonase," for example. Now, with this big gap, these messages in between are often quite serious. So a lot of us have this panicky feeling that we can't take a day off because there could be a message that could reveal something horrific and horrible, as so many of these messages turn out to uncover.
We were told this week that we need to actually take vacation during the summer. Nobody really wants to and, of course, there's no place to go. I'm technically part-time, but I can't seem to abide by that now because I know patients are sending and leaving messages all the time. All of my colleagues report the same thing. They can't stop obsessively checking for messages because everything seems so fragile and friable right now.
Esprit de Corps in the Pandemic
Topol: Another question I had is about the esprit de corps. Before the pandemic arrived, there already was a global crisis of physician burnout, clinical depression, and suicides. Now the healthcare workforce has gone through a stress test like no other: not just having to confront patients who are so desperately sick, but all of the unknowns when there wasn't testing to know whether someone even had an infection. And then the lack of gear. I wonder how that has settled in on your colleagues at Bellevue. Has this made things even worse where they were already bad? Or has this united people against a common enemy, the virus?
Ofri: It's actually a bit of both. The esprit de corps on the ramp-up was incredible. I believe the sense of purpose overshadowed everything. I'm sure it varies in different places. We never ran short of personal protective equipment (PPE), although we were economizing at times. For places that ran out of PPE, it was a very different experience of losing faith in the ability to protect staff. So, knock on wood, we didn't run out. Our clinical leaders were out front and that helped a lot.
Working in a city hospital, you're used to rolling up your sleeves and doing what it takes, whether it's transporting a stool sample yourself, wheeling the patient down to x-ray; no one's ever been too high and mighty for that. So it wasn't much of a stretch to start doing whatever it takes, like open up a MICU in the endoscopy suite—whatever you need. You can be an attending and go help out with the nursing duties. Or you can be an ophthalmologist and go be a medical intern. People's egos were put aside, which was remarkable to see. It was an amazing esprit de corps.
I think there was more existential terror. We were comparing this to HIV, which many of the people who are in leadership positions trained under, and which also was a terrifying time with an incredible immersion in death and destruction. It wasn't quite as contagious in the same way. It wasn't respiratory, but it was certainly frightening. For this generation of house staff, this was their first foray into the world that many of us faced. We didn't know if we were fully protected. Now we know that we were. We did our first round of antibody testing and our rate is actually lower than the general population in New York. So our PPE and procedures worked. Those who got it probably got it in March before we were handling it well. Once we knew what we were doing, other than a small subset under difficult circumstances, the PPE worked out.
In a third area, the residents were requesting hazard pay. I think they should have gotten it. There is some pushback from higher-ups saying it's unseemly to talk about money. But it was less about money than about recognition that we've been asked to perform above and beyond the call of duty. The same for the nursing staff. So, yes, esprit de corps is great. I think what we're seeing now, as the adrenalin stops flowing, now is when the issues are coming up, when people have time to look at their hands, look at their lives, look at their kids who've been struggling at home with schooling, remember their relatives who are isolated. Many people are finding that the issues are arising only now that the tide has come out a bit.
Verghese: I believe that one of the most distressing things for our residents [at Stanford] has been feeling guilty as they watch and hear stories from their colleagues, their friends, their classmates in New York and elsewhere, who are in the thick of things. I'm so glad to hear that the esprit de corps has sustained you.
What's most distressing to many of our house staff, I suspect, is the dichotomy between the science that we're aware of and the way the government portrays that science and the way politics gets in the way of what seem like clear-cut decisions. This may be their first moment of disillusionment with the realities of how policy and facts don't line up. Maybe I'm mistaken and they knew this a long, long time ago. But I certainly feel it.
Ofri: I think this is the first time they actually felt it. We've seen it, but it's when you feel it in action. As you look now, you see the rise in cases in places that are not abiding by the public health recommendations—you can see it happening. And for sure it will happen. It is painful to see. People keep slamming their heads against the wall when something seems so obvious. One of the frustrations is that a lot of people on the clinical side feel that the American public hasn't seen the bodies. If you think back to the Vietnam War, what really turned the tide was that the public had a visceral and visual view of what war meant. That really swung public opinion.
Right now, the public sees "healthcare heroes," a phrase that is so uncomfortable for most of us, but the public is not seeing the true devastation. I think that would change if the nightly news was showing us the bodies, the deaths, the funerals every night. Right now, people see these beautiful graphs at the governors' updates, but they're not seeing the people. That would change the politics of what's going on now.
Verghese: That's profound, Danielle. You're so right. I have to remind our listeners that you are a writer as well as an extraordinary physician. I imagine that the writer in you is processing all of this. What are some things you see yourself writing about or tucking away for future reference?
Ofri: I've been trying to assemble my thoughts now as we're beginning to emerge from the abyss. The day-to-day life has been chronicled very well. Sheri Fink and many other reporters have brought people into what the ICU life is like.
I want to think about the larger picture. You mentioned the issue of guilt, and that's still present here in New York—trust me. If you're on the wards, you feel guilty that you weren't in the ICU; and if you're doing the outpatient calls, you feel guilty that you weren't on the wards. If you're doing leadership—someone's got to do the scheduling; the scheduling has been critical—you feel guilty because you weren't doing any clinical work. So there's plenty of guilt. If you have the weekend off, you feel guilty because your colleagues are in-house. We're all grappling with that. I'm trying to step back a little and see more the totality of how we're all being affected. It's still in progress.
The weirdest thing for me is that my new book was published on April 21 in the midst of this. The funny thing is that my previous book, What Patients Say, What Doctors Hear, came out a week after the inauguration of Donald Trump. And as you can probably remember, the media was completely sucked in, and all the books that came out in those weeks and months just completely sank. So this time we said, okay, let's pull the publication date as far back from the 2020 elections as possible. How about the spring? What could possibly happen in March and April? And so we fixed a publication date of April 21. It's a bit like a baby coming out; that is, you can't stop it now. So it's been a weird thing. How can you even think about it? But, you know, here it is.
Topol: Your book, When We Do Harm, is amazing. I don't know that there is a better book written about medical errors. The stories and personal vignettes that you relate make it outstanding. I hope it will get, in spite of the pandemic background, the recognition it deserves.
Ofri: One thing I have been thinking about as a confluence of these are the errors that have been made in the wake of COVID and how our approach to a pandemic, an urgent situation, does make us prone to certain kinds of errors. Which are justified? Which could we have done better? I'm trying to kind of pull these two things together, if at all possible.
Topol: We've covered a lot of ground. I appreciate your perspective, wisdom, and this look not only to the present but to where medicine in America is headed. Thank you for joining us, Danielle.
Abraham, as always, terrific to be with you. I will look forward to our next Medicine and the Machine podcast, where we will continue to delve into the most important aspects of medicine and how to move forward.
Eric J. Topol, MD, is one of the top 10 most cited researchers in medicine and frequently writes about technology in healthcare, including in his latest book, Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again.
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.
Danielle Ofri, MD, is clinical professor of medicine at New York University School of Medicine. She writes regularly about healthcare and the doctor-patient relationship for several publications, including The New York Times, and is cofounder of The Bellevue Literary Review.
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Cite this: Up From the Abyss: Bellevue Starts to Reopen After COVID Peak - Medscape - May 27, 2020.