How Is COVID-19 Changing the Practice of Medicine?

John Whyte, MD, MPH; Robert A. Harrington, MD; Bob Brisco

Disclosures

June 03, 2020

Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

  • COVID-19 prompted the rapid movement to telemedicine, although adoption varies by specialty.

  • Video technology such as breakout rooms allows multiple physician interactions in one telemedicine patient visit.

  • Video technology also provides an opportunity for universities to interview a more diverse group of resident applicants, without the burdens and cost of travel.

  • The communication of science has accelerated during the pandemic, which is both good and challenging.

  • Virtual grand rounds has led to increased participation and more interaction.

This transcript has been edited for clarity.

John Whyte, MD, MPH: You're watching Coronavirus in Context. I'm Dr John Whyte, chief medical officer at WebMD. Today we're going to talk about how COVID is changing the practice of medicine. I'm joined by Dr Bob Harrington, chair of the Department of Medicine at Stanford, and Bob Brisco, CEO of Internet Brands and WebMD. Gentlemen, thanks for joining me.

Robert A. Harrington, MD: Thanks for having me.

Whyte: Dr Harrington, COVID-19 certainly has had a tremendous impact on the practice of medicine. How do you see COVID changing your practice?

Harrington: Certainly here at Stanford, it changed a lot and it changed really quickly. Probably the most notable example of how it changed was the rapid movement to telemedicine. Across the system we were maybe making a couple of—a low percentage of—video visits a day. Fast-forward to about a month ago at the peak, and we were doing almost 80% video visits across the practice.

Over the past couple of weeks, as we've begun to reopen the ambulatory practices, you can see us increasing the number of face-to-face visits, but we're still over 60% televisits, mostly video. And I think that acceleration was something that probably wouldn't have happened without a catastrophe like the pandemic. So in some ways, that's a little bit of a silver lining; something that was long needed was forced upon us. And I think we adapted as a community pretty quickly.

Bob Brisco: Bob, is it too early to know where that percentage lands ultimately? Do you think it settles back to a certain rate?

Harrington: We've been looking across the practice. If you look at the entirety of Stanford Medicine, we have about 600 separate clinics across our network, across our faculty practice, for both the adults and the pediatric side. We're estimating that in some of the groups—primary care, for example—it might end up pretty high, maybe as much as 70%, 80%. Other practices, say oncology, it's a lot lower. When I talked to my oncology faculty during the past month, they were in the clinic seeing patients because they needed to do imaging. They needed to get physical examinations. They needed to start people on therapy.

In my practice—I just ran over here from my own clinic today—the first three or four people I saw were via video. Then I saw a couple of new patients. For the next foreseeable future of months, it'll probably be, in our particular practice—I do mainly general cardiology these days—maybe 50%-60% video visits. [There may be] a lot of follow-up for things like secondary prevention and more face-to-face visits for things like evaluation and heart failure, evaluation of valvular heart disease. I think it's going to depend on the specialty, Bob.

Whyte: Dr Harrington, you're at a teaching hospital. Part of your mission is educating students and residents. How does telemedicine impact their training?

Harrington: It's a great question. First, in the inpatient area, when we started surging up, it was really the residents who were trying to make sure the teams have residents, that they have fellows, that they have attending staff in some way because, as you know, that allows us to extend the reach of an attending. An attending can see patients if he or she has a couple of residents to do a lot of the early groundwork. So that piece was really dependent upon the resident.

In the clinics, it's a little tougher with telemedicine. We're beginning to explore things like breakout rooms. There are some programs where my fellow, for example, can go into a room, see the patient, the patient can then get passed over to another room and I can see them. In my own clinic today, as I mentioned, I was there with one of our cardiology fellows who's been with me for the past few years. He's a senior fellow, very capable. He goes in, sees the patient on video, comes out and talks to me for a few minutes, and I go right back into that exam room and see the patient via video. So we've had to adapt. There are some innovative learnings.

Brisco: That brings us a little bit to the education topic. You're starting to get to it there. How do you see that changing?

Harrington: I think there's going to be an opportunity to expand how many people we reach. We have a great example this summer. We've just received word from the Match program for residents that they do not want any face-to-face live interview visits over this coming interview season for internship. We're going to do all of our interviews for residency here across the country, including here at Stanford, via Zoom technology and other technology.

I think that's a great opportunity to show off some of the innovation that's going on at Stanford. I also think, frankly, that it's a great opportunity to reach some students who would like to take a look at Stanford but maybe can't afford to fly around the country, going to different places. Maybe, for whatever reason, they couldn't get the time off, maybe they had family obligations, etc.

I'm actually excited about the opportunity to see a more diverse group of students apply to our residency program, which I think would be beneficial for us and might level the playing field a bit—that students who wouldn't ordinarily have a chance to come here on an elective rotation can now be with us virtually and we can interview them. And I'm really hopeful that we're going to see some students and maybe land some interns that we wouldn't have otherwise.

Whyte: As you know, Dr Harrington, some folks who are watching will say that they don't get to have those informal conversations with current residents or current students and get a real feel for what they're like.

Harrington: Yeah.

Whyte: See, I'm old and being old-school. But I guess it's that balance while still trying to respond to a new normal.

Harrington: I completely agree with you. One of the hallmarks of our residency interview days was the night before we hosted a reception and a dinner, largely attended by our residents to meet with prospective interns. And I do think you're right. That's where you get the best feel for a program. We're having a lot of internal discussions now: How do we re-create some of that? How do we re-create that opportunity to have a little bit more of that informal network? It's definitely not as good as visiting. But how might we be able to add some things via technology that will get them excited about the kind of things we have to offer here?

It is a bit of the new norm. I'm hopeful that over the long run, the new norm is a bit of a hybrid. It's funny—I was talking with my patients this morning, and I said, "I'm a social person." I miss seeing patients in the exam room and talking to them and just hanging out for a few minutes to hear how they're doing. I do miss that. Video doesn't replace that.

Brisco: You mentioned that COVID has accelerated the adoption of telemedicine. What else do you see that has been catalyzed? Are clinical trials different now? Are there other things you could talk about that you think have been transformed because of necessity right now?

Harrington: I think the communication of science has accelerated. And there have been both good and bad features of that—maybe not bad, maybe challenging. I read somewhere over the weekend that there have been something like 10,000 scientific articles, viewpoints, original research, observations put forward over the past couple of months. That's just an explosion of science.

Now, a lot of that is good. A lot of that rapid exchange of information is really helpful. What did we learn from the folks in China that we could take advantage of here in the US before it hit us? What did we learn from our colleagues in Boston and New York, who were harder hit than we were here in California? That rapid exchange of information is fantastic and facilitated by technology. Some of the bad things are that a lot of bad research got out there into the public sphere and was roundly criticized quickly by the peer review of Twitter and other social media indicators.

Whyte: National meetings have always been a big part of your communication strategy. You've always been very popular at national meetings. With the cancellation of national meetings, how are you getting that education to your colleagues? How are you getting the information out?

Harrington: I happen to be president of the American Heart Association (AHA) this year, and the last big meeting I went to was the Scientific Sessions in November. And then in this part of the year, there's a lot of what we call our specialty meetings. There's our Quality of Care and Outcomes Research meeting, our Vascular Discovery meeting. There's a lot of meetings. Our epidemiology meeting was the last one I actually attended live, back in February in Arizona. This was at the beginning of things, where the hotel had sanitizer everywhere. We had moved from handshaking to what we called the "epidemiology elbow bump" to greet our colleagues. That was the last time we did a face-to-face meeting.

Now what I do is just what we're doing here. For each of the AHA smaller meetings, I've been recording my presidential address, and then I join the leadership of the meetings online to have some conversation. I've participated in some panels, things like that. We're planning scientific sessions for November now as a potential hybrid, where there may be some people on site in Dallas and some people, maybe the majority, watching virtually. We don't know where that's going to fall out yet.

We know that the European Society of Cardiology this summer has moved to completely virtual. That's the world's largest cardiovascular meeting. How is that going to be received? Thirty thousand–plus people typically attend that. There are things I miss. I don't miss being on planes and I don't miss being in hotel rooms. But I do miss seeing colleagues and friends from around the globe to do that informal networking, to learn from them, to talk about new things in science, etc.

Brisco: Bob, as you know, we work very closely with the largest pharmaceutical manufacturers. Do you have thoughts or advice for them and how they approach interacting with HCPs on a post-COVID basis?

Harrington: Post-COVID, we're going to spend a lot of time trying to figure out the optimal ways to deliver education. I think it is going to be some hybrid of face-to-face and virtual. I hope that we take some lessons learned from these virtual experiences, and I'll give you a couple of examples that I think have been pretty good.

The chat function on virtual meetings has really opened up to people who might not otherwise ask questions. We now do our medical grand rounds virtually—this is typical medical grand rounds; you both have been to more of these than you probably care to admit. And they are 150, 200 people on a busy day. We're getting upwards of 2000 people coming to our medical grand rounds. And now we've developed a format where we get a lot of people participating as panelists who are answering the questions that are coming in during chat, so then we can reserve the open forum for the really hot questions: What are the ones in voting that rise to the top?

There have been people speaking who wouldn't otherwise speak, who are asking questions who might have been reticent to do so. We're getting a lot of great engagement. We don't want to lose this. When we go back to having our face-to-face, how do we make sure we don't lose the participatory, the engagement piece?

I would ask our friends who do a lot of sponsorship of educational events, what are they trying to achieve, and how can we work together to get great engagement, to communicate science? What I've learned throughout this is that people want to discuss science; they don't just want to hear it. They want to discuss it. They want to hear what you think, what John thinks, what I think, and then they want to discuss it with us, not just see three more PowerPoint slides. So that's something I think we all talked about, but this has really forced us to do it.

Brisco: That's how people really learn, isn't it?

Harrington: It is.

Whyte: I want to thank you both for joining me.

Harrington: Thank you for having me.

Whyte: And thank you for watching Coronavirus in Context.

Follow Medscape on Facebook, Twitter, Instagram, and YouTube

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as:

processing....