COMMENTARY

Hope in the Time of COVID: Reflections on the Pandemic's Aftermath

Richard M. Plotzker, MD

Disclosures

July 14, 2020

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Until just a few months ago, physicians were primarily concerned with professional issues such as loss of status, decline of autonomy, indignities inflicted by managers, and the impersonal electronic health record that seemed to elevate navigational skills above painstakingly accumulated medical skills — all legitimate grievances of the contemporary physician experience, but suddenly not what needs to be conveyed to either the public or to each other.

Our professional dialogue has changed abruptly and in parallel with the public priority of controlling COVID-19's spread. As people seek information about the pandemic, it's the doctors or public health experts that people want to see on their televisions. Though preventive measures depend on public policies from elected officials, it's the medical teams who come to the rescue when illness arrives that are being celebrated as "heroes."

Despite the virulence of SARS-CoV-2, physicians and nurses have risen to the challenge of making critical decisions for large numbers of desperately ill individuals. Bedside providers have gotten the most praise, but they could not be successful without lab staff, radiologists, housekeeping workers, or people delivering food to patients who are able to eat. This care comes at personal risk to these on-site caregivers; indeed, many have contracted COVID-19 themselves, and many have even died.

Are Positive Changes on the Horizon?

Some of the antagonisms within the medical community have abated as the esteem of healthcare workers has risen. Administrators seem to have shifted their focus from threatening notices to a more collegial role of assuring patient and staff safety, providing equipment, and promoting teamwork.

Other welcome changes may be on the horizon. For instance, meetings divert clinical time from clinicians. This may be an opportunity to assess their utility relative to other tasks that doctors and nurses need to do. A better sense of how to allocate provider time may survive the crisis.

Moreover, as everyone's capacity gets tested, there is flattening of medical hierarchy. The distinctions — and sometimes turf battles — between certified physicians, trainees, and nonphysician clinicians tend to ease when everyone needs to pitch-in. Whether this forced shift from c'est moi to E Pluribus Unum lasts long-term is uncertain, but hopefully people at all places in the medical structure will try to retain some of the improved professional collegiality that the pandemic has required.

A Stronger Spotlight on Health Disparities

Another medical dilemma that will surely require reconsideration as we emerge from this emergency will be the approach to health disparities. Unlike the onset of AIDS, where certain physicians simply turned down consults with infected people, this does not seem to have happened with COVID-19 in America or anyplace else, at least from what I can see. Medical staff are approaching patients without disease-related stigmatization, undeterred by possible risks to themselves.

But despite the best of intentions and no apparent withholding of resources to any patient, COVID mortality is higher in certain groups. Elderly, debilitated individuals would be expected to have a disadvantage when respiratory compromise ensues. Racial clustering, as is seen in chronic disorders such as diabetes or heart disease, seems to affect this acute respiratory illness as well. This new window into a previously identified problem may present an opportunity to explore the observed inequities in a novel, fruitful way with applications to the disparities of outcome that have frustrated caregivers and patient advocates for generations.

The Mad Dash for Therapies

A new discussion may be emerging on the proper introduction of medicine for uses other than intended by prior testing. My residents are usually surprised when I ask them about uses of insulin for things other than diabetes. A few can remember insulin tolerance tests of pituitary function. None realize that insulin was once used in psychiatry (there's a very good reason why that has become an obscure footnote in medical history).

Expanding the use of a medicine based on observation of beneficial unintended effects has long had a place in widely accepted therapy. For diabetic sensory neuropathies, tricyclics were developed for depression and gabapentin for seizures. Before becoming common therapy, there was testing and literature outlining efficacy and safety.

The introduction of therapy for a disease without that prior assessment is something that physicians generally avoid. But in our desperation, are we trying to do more than we really know how to do? This opens up a very real discussion of risk, pressure to do something in the absence of other alternatives, liability for not treating in accord with popular but undemonstrated intervention, and determining legitimate or ill-conceived chains of medical authority.

Other Casualties of the Pandemic

Key healthcare workers have been lifesavers, but the universe of physicians goes far beyond the ICU, ER, and hospitalists. Medical care is a large component of American commerce. Each physician in crisis mode has a corresponding group of colleagues that are laying off office staff as elective procedures get postponed or periodic care for nonurgent chronic illnesses gets canceled, or telemedicine eliminates the jobs of the aides who measure the weights and blood pressures.

Although not urgent, management of chronic conditions or assessment of low-grade symptoms remains important. It's hard to tell how much depression will go unaddressed or how long people can self-treat with proton pump inhibitors before the needed endoscopy becomes overdue.

Even within hospitals, where capacity is stressed, there are furloughs. While patient care in high volume has urgency, meaningful use reports or cafeteria services may have less.

When the reset button finally gets pushed, the coronavirus experience will undoubtedly guide some reassessment on the types of skills — and at what cost — an institution really needs to take care of patients. It will probably be different from before.

Looking Forward to the Silver Lining

America's unfortunate experience with the hardships of the pandemic has clearly changed the status of healthcare workers for the better, but it has also changed the focus of the grievances from kvetches about physician working conditions —as a recent retiree, I also experienced some elements of descent — to the more fundamental questions of collegiality, support for each other, and the best use of our resources.

Some things went very well, some did not. Ever the optimist, I think there will be better consensus on interventions that make patient care and working conditions more favorable as a beneficial consequence of this difficult interlude.

Richard M. Plotzker, MD, is a retired endocrinologist with 40 years of experience treating patients in both private practice and hospital settings. He has been a Medscape contributor since 2012.

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