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Social distancing is slowing the spread of COVID-19, but it will undoubtedly have negative consequences for mental health and well-being in both the short- and long-term, public health experts say.

In an article published online April 10 in JAMA Internal Medicine on the mental health consequences of COVID-19, the authors warn of a “pandemic” of behavioral problems and mental illness.

“COVID-19 is a traumatic event that we are all experiencing. We can well expect there to be a rise in mental illness nationwide,” first author Sandro Galea, MD, dean of the School of Public Health at Boston University, said in an interview.

“Education about this, screening for those with symptoms, and availability of treatment are all important to mitigate the mental health consequences of COVID-19,” Dr. Galea added.
 

Anxiety, depression, child abuse

The COVID-19 pandemic will likely result in “substantial” increases in anxiety and depression, substance use, loneliness, and domestic violence. In addition, with school closures, the possibility of an epidemic of child abuse is “very real,” the authors noted.

As reported online, a recent national survey by the American Psychiatric Association showed COVID-19 is seriously affecting Americans’ mental health, with half of U.S. adults reporting high levels of anxiety.

The authors suggest that three steps, taken now, can help prepare for the coming mental health problems and associated problems that will result from the pandemic.

The first step is to plan for the inevitability of loneliness and its sequelae as populations physically and socially isolate and to find ways to intervene.

To prepare, the authors suggest the use of digital technologies to mitigate the impact of social distancing, even while physical distancing. They also encourage places of worship, gyms, yoga studios, and other places people normally gather to offer regularly scheduled online activities.

Employers also can help by offering virtual technologies that enable employees to work from home, and schools should develop and implement online learning for children.

“Even with all of these measures, there will still be segments of the population that are lonely and isolated. This suggests the need for remote approaches for outreach and screening for loneliness and associated mental health conditions so that social support can be provided,” the authors noted.

Need for creative thinking

The authors noted the second “critical” step is to have mechanisms in place for surveillance, reporting, and intervention, particularly when it comes to domestic violence and child abuse.

“Individuals at risk for abuse may have limited opportunities to report or seek help when shelter-in-place requirements demand prolonged cohabitation at home and limit travel outside of the home,” they wrote.

“Systems will need to balance the need for social distancing with the availability of safe places to be for people who are at risk, and social services systems will need to be creative in their approaches to following up on reports of problems,” they noted.

Finally, the authors note that now is the time to bolster the U.S. mental health system in preparation for the challenges posed by the COVID-19 pandemic.

“Scaling up treatment in the midst of crisis will take creative thinking. Communities and organizations could consider training nontraditional groups to provide psychological first aid, helping teach the lay public to check in with one another and provide support,” they wrote.

“This difficult moment in time nonetheless offers the opportunity to advance our understanding of how to provide prevention-focused, population-level, and indeed national-level psychological first aid and mental health care, and to emerge from this pandemic with new ways of doing so.”
 

Invaluable advice

Reached for comment, Lloyd I. Sederer, MD, psychiatrist and adjunct professor at Columbia University Mailman School of Public Health in New York, described the article as “invaluable” noting that it “clearly and concisely describes the mental health consequences we can expect in the wake of the COVID-19 pandemic – and what can (and needs) to be done to mitigate them.”

Dr. Sederer added that Dr. Galea has “studied and been part of the mental health responses to previous disasters, and is a leader in public health, including public mental health. His voice truly is worth listening to (and acting upon).”

Dr. Sederer offers additional suggestions on addressing mental health after disasters in a recent perspective article

Dr. Galea and Dr. Sederer have reported no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

Social distancing is slowing the spread of COVID-19, but it will undoubtedly have negative consequences for mental health and well-being in both the short- and long-term, public health experts say.

In an article published online April 10 in JAMA Internal Medicine on the mental health consequences of COVID-19, the authors warn of a “pandemic” of behavioral problems and mental illness.

“COVID-19 is a traumatic event that we are all experiencing. We can well expect there to be a rise in mental illness nationwide,” first author Sandro Galea, MD, dean of the School of Public Health at Boston University, said in an interview.

“Education about this, screening for those with symptoms, and availability of treatment are all important to mitigate the mental health consequences of COVID-19,” Dr. Galea added.
 

Anxiety, depression, child abuse

The COVID-19 pandemic will likely result in “substantial” increases in anxiety and depression, substance use, loneliness, and domestic violence. In addition, with school closures, the possibility of an epidemic of child abuse is “very real,” the authors noted.

As reported online, a recent national survey by the American Psychiatric Association showed COVID-19 is seriously affecting Americans’ mental health, with half of U.S. adults reporting high levels of anxiety.

The authors suggest that three steps, taken now, can help prepare for the coming mental health problems and associated problems that will result from the pandemic.

The first step is to plan for the inevitability of loneliness and its sequelae as populations physically and socially isolate and to find ways to intervene.

To prepare, the authors suggest the use of digital technologies to mitigate the impact of social distancing, even while physical distancing. They also encourage places of worship, gyms, yoga studios, and other places people normally gather to offer regularly scheduled online activities.

Employers also can help by offering virtual technologies that enable employees to work from home, and schools should develop and implement online learning for children.

“Even with all of these measures, there will still be segments of the population that are lonely and isolated. This suggests the need for remote approaches for outreach and screening for loneliness and associated mental health conditions so that social support can be provided,” the authors noted.

Need for creative thinking

The authors noted the second “critical” step is to have mechanisms in place for surveillance, reporting, and intervention, particularly when it comes to domestic violence and child abuse.

“Individuals at risk for abuse may have limited opportunities to report or seek help when shelter-in-place requirements demand prolonged cohabitation at home and limit travel outside of the home,” they wrote.

“Systems will need to balance the need for social distancing with the availability of safe places to be for people who are at risk, and social services systems will need to be creative in their approaches to following up on reports of problems,” they noted.

Finally, the authors note that now is the time to bolster the U.S. mental health system in preparation for the challenges posed by the COVID-19 pandemic.

“Scaling up treatment in the midst of crisis will take creative thinking. Communities and organizations could consider training nontraditional groups to provide psychological first aid, helping teach the lay public to check in with one another and provide support,” they wrote.

“This difficult moment in time nonetheless offers the opportunity to advance our understanding of how to provide prevention-focused, population-level, and indeed national-level psychological first aid and mental health care, and to emerge from this pandemic with new ways of doing so.”
 

Invaluable advice

Reached for comment, Lloyd I. Sederer, MD, psychiatrist and adjunct professor at Columbia University Mailman School of Public Health in New York, described the article as “invaluable” noting that it “clearly and concisely describes the mental health consequences we can expect in the wake of the COVID-19 pandemic – and what can (and needs) to be done to mitigate them.”

Dr. Sederer added that Dr. Galea has “studied and been part of the mental health responses to previous disasters, and is a leader in public health, including public mental health. His voice truly is worth listening to (and acting upon).”

Dr. Sederer offers additional suggestions on addressing mental health after disasters in a recent perspective article

Dr. Galea and Dr. Sederer have reported no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

Social distancing is slowing the spread of COVID-19, but it will undoubtedly have negative consequences for mental health and well-being in both the short- and long-term, public health experts say.

In an article published online April 10 in JAMA Internal Medicine on the mental health consequences of COVID-19, the authors warn of a “pandemic” of behavioral problems and mental illness.

“COVID-19 is a traumatic event that we are all experiencing. We can well expect there to be a rise in mental illness nationwide,” first author Sandro Galea, MD, dean of the School of Public Health at Boston University, said in an interview.

“Education about this, screening for those with symptoms, and availability of treatment are all important to mitigate the mental health consequences of COVID-19,” Dr. Galea added.
 

Anxiety, depression, child abuse

The COVID-19 pandemic will likely result in “substantial” increases in anxiety and depression, substance use, loneliness, and domestic violence. In addition, with school closures, the possibility of an epidemic of child abuse is “very real,” the authors noted.

As reported online, a recent national survey by the American Psychiatric Association showed COVID-19 is seriously affecting Americans’ mental health, with half of U.S. adults reporting high levels of anxiety.

The authors suggest that three steps, taken now, can help prepare for the coming mental health problems and associated problems that will result from the pandemic.

The first step is to plan for the inevitability of loneliness and its sequelae as populations physically and socially isolate and to find ways to intervene.

To prepare, the authors suggest the use of digital technologies to mitigate the impact of social distancing, even while physical distancing. They also encourage places of worship, gyms, yoga studios, and other places people normally gather to offer regularly scheduled online activities.

Employers also can help by offering virtual technologies that enable employees to work from home, and schools should develop and implement online learning for children.

“Even with all of these measures, there will still be segments of the population that are lonely and isolated. This suggests the need for remote approaches for outreach and screening for loneliness and associated mental health conditions so that social support can be provided,” the authors noted.

Need for creative thinking

The authors noted the second “critical” step is to have mechanisms in place for surveillance, reporting, and intervention, particularly when it comes to domestic violence and child abuse.

“Individuals at risk for abuse may have limited opportunities to report or seek help when shelter-in-place requirements demand prolonged cohabitation at home and limit travel outside of the home,” they wrote.

“Systems will need to balance the need for social distancing with the availability of safe places to be for people who are at risk, and social services systems will need to be creative in their approaches to following up on reports of problems,” they noted.

Finally, the authors note that now is the time to bolster the U.S. mental health system in preparation for the challenges posed by the COVID-19 pandemic.

“Scaling up treatment in the midst of crisis will take creative thinking. Communities and organizations could consider training nontraditional groups to provide psychological first aid, helping teach the lay public to check in with one another and provide support,” they wrote.

“This difficult moment in time nonetheless offers the opportunity to advance our understanding of how to provide prevention-focused, population-level, and indeed national-level psychological first aid and mental health care, and to emerge from this pandemic with new ways of doing so.”
 

Invaluable advice

Reached for comment, Lloyd I. Sederer, MD, psychiatrist and adjunct professor at Columbia University Mailman School of Public Health in New York, described the article as “invaluable” noting that it “clearly and concisely describes the mental health consequences we can expect in the wake of the COVID-19 pandemic – and what can (and needs) to be done to mitigate them.”

Dr. Sederer added that Dr. Galea has “studied and been part of the mental health responses to previous disasters, and is a leader in public health, including public mental health. His voice truly is worth listening to (and acting upon).”

Dr. Sederer offers additional suggestions on addressing mental health after disasters in a recent perspective article

Dr. Galea and Dr. Sederer have reported no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

Jails provide ideal conditions for the spread of COVID-19, as made clear by the distressing stories coming out of New York City. Beyond the very substantial risks posed by the virus itself, practitioners tasked with attending to the large proportion of inmates with mental illness now face additional challenges.

Medscape Psychiatry editorial director Bret Stetka, MD, spoke with Elizabeth Ford, MD, former chief of psychiatry for NYC Health + Hospitals/Correctional Health Services and current chief medical officer for the Center for Alternative Sentencing and Employment Services (CASES), a community organization focused on the needs of people touched by the criminal justice system, to find out how COVID-19 may be reshaping the mental health care of incarcerated patients. As noted by Ford, who authored the 2017 memoir Sometimes Amazing Things Happen: Heartbreak and Hope on the Bellevue Hospital Psychiatric Prison Ward, the unique vulnerabilities of this population were evident well before the coronavirus pandemic’s arrival on our shores.
 

What are the unique health and mental health challenges that can arise in correctional facilities during crises like this, in particular, infectious crises? Or are we still learning this as COVID-19 spreads?

I think it’s important to say that they are still learning it, and I don’t want to speak for them. I left Correctional Health Services on Feb. 14, and we weren’t aware of [all the risks posed by COVID-19] at that point.

I worked in the jail proper for five and a half years. Prior to that I spent a decade at Bellevue Hospital, where I took care of the same patients, who were still incarcerated but also hospitalized. In those years, the closest I ever came to managing something like this was Superstorm Sandy, which obviously had much different health implications.

All of the things that the community is struggling with in terms of the virus also apply in jails and prisons: identifying people who are sick, keeping healthy people from getting sick, preventing sick people from getting worse, separating populations, treatment options, testing options, making sure people follow the appropriate hygiene recommendations. It’s just amplified immensely because these are closed systems that tend to be poorly sanitized, crowded, and frequently forgotten or minimized in public health and political conversations.

A really important distinction is that individuals who are incarcerated do not have control over their behavior in the way that they would in the outside world. They may want to wash their hands frequently and to stay six feet away from everybody, but they can’t because the environment doesn’t allow for that. I know that everyone – correctional officers, health staff, incarcerated individuals, the city – is trying to figure out how to do those things in the jail. The primary challenge is that you don’t have the ability to do the things that you know are right to prevent the spread of the infection.
 

I know you can’t speak to what’s going on at specific jails at the moment, but what sort of psychiatric measures would a jail system put forth in a time like this?

It’s a good question, because like everybody, they’re having to balance the safety of the staff and the patients. Mental health interventions are mostly in person and very time intensive, and social distancing guidelines don’t allow for that now.

I expect that the jails are trying to stratify patients based on severity, both physical and psychological, although increasingly it’s likely harder to separate those who are sick from those who aren’t. In areas where patients are sick, I think the mental health staff are likely doing as much intervention as they can safely, including remote work like telehealth. Telehealth actually got its start in prisons, because they couldn’t get enough providers to come in and do the work in person.
 

I’ve read a lot of the criticism around this, specifically at Rikers Island, where inmates are still closely seated at dining tables, with no possibility of social distancing. [Editor’s note: At the time of this writing, Rikers Island experienced its first inmate death due to COVID-19.] But I see the other side of it. What are jails supposed to do when limited to such a confined space?

That’s correct. I think it is hard for someone who has not lived or worked intensely in these settings to understand how difficult it can be to implement even the most basic hygiene precautions. There are all sorts of efforts happening to create more space, to reduce admissions coming into the jail, to try to expedite discharges out, to offer a lot more sanitation options. I think they may have opened up a jail that was empty to allow for more space.
 

In a recent Medscape commentary, Jeffrey Lieberman, MD, from Columbia University detailed how a crisis like this may affect those in different tiers of mental illness. Interestingly, there are data showing that those with serious mental illness – schizophrenia, severe mania – often aren’t panicked by disasters. I assume that a sizable percentage of the jail population has severe mental illness, so I was curious about what your experience is, about how they may handle it psychologically.

The rate of serious mental illness in jail is roughly 16% or so, which is three or four times higher than the general population.

Although I don’t know if these kinds of crises differentially affect people with serious mental illness, I do believe very strongly that situations like this, for those who are and who are not incarcerated, can exacerbate or cause symptoms like anxiety, depression, and elevated levels of fear – fear about the unknown, fear of illness or death, fear of isolation.

For people who are incarcerated and who understandably may struggle with trusting the system that is supposed to be keeping them safe, I am concerned that this kind of situation will make that lack of trust worse. I worry that when they get out of jail they will be less inclined to seek help. I imagine that the staff in the jails are doing as much as they can to support the patients, but the staff are also likely experiencing some version of the abandonment and frustration that the patients may feel.

I’ve also seen – not in a crisis of this magnitude but in other crisis situations – that a community really develops among everybody in incarcerated settings. A shared crisis forces everybody to work together in ways that they may not have before. That includes more tolerance for behaviors, more understanding of differences, including mental illness and developmental delay. More compassion.
 

Do you mean between prisoners and staff? Among everybody?

Everybody. In all of the different relationships you can imagine.
 

That speaks to the vulnerability and good nature in all of us. It’s encouraging.

It is, although it’s devastating to me that it happens because they collectively feel so neglected and forgotten. Shared trauma can bind people together very closely.
 

What psychiatric conditions did you typically see in New York City jails?

For the many people with serious mental illness, it’s generally schizophrenia-spectrum illnesses and bipolar disorder – really severe illnesses that do not do well in confinement settings. There’s a lot of anxiety and depression, some that rises to the level of serious illness. There is near universal substance use among the population.

There is also almost universal trauma exposure, whether early-childhood experiences or the ongoing trauma of incarceration. Not everyone has PTSD, but almost everyone behaves in a traumatized way. As you know, in the United States, incarceration is very racially and socioeconomically biased; the trauma of poverty can be incredibly harsh.

What I didn’t see were lots of people with antisocial personality disorder or diagnoses of malingering. That may surprise people. There’s an idea that everybody in jail is a liar and lacks empathy. I didn’t experience that. People in jail are doing whatever they can to survive.
 

What treatments are offered to these patients?

In New York City, all of the typical treatments that you would imagine for people with serious mental illness are offered in the jails: individual and group psychotherapy, medication management, substance use treatment, social work services, even creative art therapy. Many other jails are not able to do even a fraction of that.

In many jails there also has to be a lot of supportive therapy. This involves trying to help people get through a very anxiety-provoking and difficult time, when they frequently don’t know when they are going to be able to leave. I felt the same way as many of the correction officers – that the best thing for these patients is to be out of the jail, to be out of that toxic environment.
 

We have heard for years that the jail system and prison system is the new psych ward. Can you speak to how this occurred and the influence of deinstitutionalization?

When deinstitutionalization happened, there were not enough community agencies available that were equipped to take care of patients who were previously in hospitals. But I think a larger contributor to the overpopulation of people with mental illness in jails and prisons was the war on drugs. It disproportionately affected people who were poor, of color, and who had mental illness. Mental illness and substance use frequently occur together.

At the same time as deinstitutionalization and the war on drugs, there was also a tightening up of the laws relating to admission to psychiatric hospitals. The civil rights movement helped define the requirements that someone had to be dangerous and mentally ill in order to get admitted against their will. While this was an important protection against more indiscriminate admissions of the past, it made it harder to get into hospitals; the state hospitals were closed but the hospitals that were open were now harder to get into.
 

You mentioned that prisoners are undergoing trauma every day. Is this inherent to punitive confinement, or is it something that can be improved upon in the United States?

It’s important that you said “in the United States” as part of that question. Our approach to incarceration in the U.S. is heavily punishment based.
 

Compared to somewhere like Scandinavia, where inmates and prisoners are given a lot more support?

Or England or Canada. The challenge with comparing the United States to Scandinavia is that we are socioeconomically, demographically, and politically so different. But yes, my understanding about the Scandinavian systems are that they have a much more rehabilitative approach to incarceration. Until the U.S. can reframe the goals of incarceration to focus on helping individuals behave in a socially acceptable way, rather than destroy their sense of self-worth, we will continue to see the impact of trauma on generations of lives.

Now, that doesn’t mean that every jail and prison in this country is abusive. But taking away autonomy and freedom, applying inconsistent rules, using solitary confinement, and getting limited to no access to people you love all really destroy a person’s ability to behave in a way that society has deemed acceptable.
 

Assuming that mental health professionals such as yourself have a more compassionate understanding of what’s going on psychologically with the inmates, are you often at odds with law enforcement in the philosophy behind incarceration?

That’s an interesting question. When I moved from the hospital to the jail, I thought that I would run into a lot of resistance from the correction officer staff. I just thought, we’re coming at this from a totally different perspective: I’m trying to help these people and see if there’s a way to safely get them out, and you guys want to punish them.

It turns out that I was very misguided in that view, because it seemed to me that everybody wanted to do what was right for the patient. My perspective about what’s right involved respectful care, building self-esteem, treating illness. The correction officer’s perspective seemed to be keeping them safe, making sure that they can get through the system as quickly as possible, not having them get into fights. Our perspectives may have been different, but the goals were the same. I want all that stuff that the officers want as well.

It’s important to remember that the people who work inside jails and prisons are usually not the ones who are making the policies about who goes in. I haven’t had a lot of exposure working directly with many policymakers. I imagine that my opinions might differ from theirs in some regards.
 

For those working in the U.S. psychiatric healthcare system, what do you want them to know about mental health care in the correctional setting?

Patients in correctional settings are mostly the same patients seen in the public mental health system setting. The vast majority of people who spend time in jail or prison return to the community. But there’s a difference in how patients are perceived by many mental health professionals, including psychiatrists, depending on whether they have criminal justice experience or not.

I would encourage everybody to try to keep an open mind and remember that these patients are cycling through a very difficult system, for many reasons that are at least rooted in community trauma and poverty, and that it doesn’t change the nature of who they are. It doesn’t change that they’re still human beings and they still deserve care and support and treatment.

In this country, patients with mental illness and incarceration histories are so vulnerable and are often black, brown, and poor. It’s an incredible and disturbing representation of American society. But I feel like you can help a lot by getting involved in the frequently dysfunctional criminal justice system. Psychiatrists and other providers have an opportunity to fix things from the inside out.
 

What’s your new role at CASES?

I’m the chief medical officer at CASES [Center for Alternative Sentencing and Employment Services]. It’s a large community organization that provides mental health treatment, case management, employment and education services, alternatives to incarceration, and general support for people who have experienced criminal justice involvement. CASES began operating in the 1960s, and around 2000 it began developing programs specifically addressing the connection between serious mental illness and criminal justice system involvement. For example, we take care of the patients who are coming out of the jails or prisons, or managing patients that the courts have said should go to treatment instead of incarceration.

I took the job because as conditions for individuals with serious mental illness started to improve in the jails, I started to hear more frequently from patients that they were getting better treatment in the jail than out in the community. That did not sit well with me and seemed to be almost the opposite of how it should be.

I also have never been an outpatient public psychiatrist. Most of the patients I treat live most of their lives outside of a jail or a hospital. It felt really important for me to understand the lives of these patients and to see if all of the resistance that I’ve heard from community psychiatrists about taking care of people who have been in jail is really true or not.

It was a logical transition for me. I’m following the patients and basically deinstitutionalizing [them] myself.

This article was first published on Medscape.com.

Jails provide ideal conditions for the spread of COVID-19, as made clear by the distressing stories coming out of New York City. Beyond the very substantial risks posed by the virus itself, practitioners tasked with attending to the large proportion of inmates with mental illness now face additional challenges.

Medscape Psychiatry editorial director Bret Stetka, MD, spoke with Elizabeth Ford, MD, former chief of psychiatry for NYC Health + Hospitals/Correctional Health Services and current chief medical officer for the Center for Alternative Sentencing and Employment Services (CASES), a community organization focused on the needs of people touched by the criminal justice system, to find out how COVID-19 may be reshaping the mental health care of incarcerated patients. As noted by Ford, who authored the 2017 memoir Sometimes Amazing Things Happen: Heartbreak and Hope on the Bellevue Hospital Psychiatric Prison Ward, the unique vulnerabilities of this population were evident well before the coronavirus pandemic’s arrival on our shores.
 

What are the unique health and mental health challenges that can arise in correctional facilities during crises like this, in particular, infectious crises? Or are we still learning this as COVID-19 spreads?

I think it’s important to say that they are still learning it, and I don’t want to speak for them. I left Correctional Health Services on Feb. 14, and we weren’t aware of [all the risks posed by COVID-19] at that point.

I worked in the jail proper for five and a half years. Prior to that I spent a decade at Bellevue Hospital, where I took care of the same patients, who were still incarcerated but also hospitalized. In those years, the closest I ever came to managing something like this was Superstorm Sandy, which obviously had much different health implications.

All of the things that the community is struggling with in terms of the virus also apply in jails and prisons: identifying people who are sick, keeping healthy people from getting sick, preventing sick people from getting worse, separating populations, treatment options, testing options, making sure people follow the appropriate hygiene recommendations. It’s just amplified immensely because these are closed systems that tend to be poorly sanitized, crowded, and frequently forgotten or minimized in public health and political conversations.

A really important distinction is that individuals who are incarcerated do not have control over their behavior in the way that they would in the outside world. They may want to wash their hands frequently and to stay six feet away from everybody, but they can’t because the environment doesn’t allow for that. I know that everyone – correctional officers, health staff, incarcerated individuals, the city – is trying to figure out how to do those things in the jail. The primary challenge is that you don’t have the ability to do the things that you know are right to prevent the spread of the infection.
 

I know you can’t speak to what’s going on at specific jails at the moment, but what sort of psychiatric measures would a jail system put forth in a time like this?

It’s a good question, because like everybody, they’re having to balance the safety of the staff and the patients. Mental health interventions are mostly in person and very time intensive, and social distancing guidelines don’t allow for that now.

I expect that the jails are trying to stratify patients based on severity, both physical and psychological, although increasingly it’s likely harder to separate those who are sick from those who aren’t. In areas where patients are sick, I think the mental health staff are likely doing as much intervention as they can safely, including remote work like telehealth. Telehealth actually got its start in prisons, because they couldn’t get enough providers to come in and do the work in person.
 

I’ve read a lot of the criticism around this, specifically at Rikers Island, where inmates are still closely seated at dining tables, with no possibility of social distancing. [Editor’s note: At the time of this writing, Rikers Island experienced its first inmate death due to COVID-19.] But I see the other side of it. What are jails supposed to do when limited to such a confined space?

That’s correct. I think it is hard for someone who has not lived or worked intensely in these settings to understand how difficult it can be to implement even the most basic hygiene precautions. There are all sorts of efforts happening to create more space, to reduce admissions coming into the jail, to try to expedite discharges out, to offer a lot more sanitation options. I think they may have opened up a jail that was empty to allow for more space.
 

In a recent Medscape commentary, Jeffrey Lieberman, MD, from Columbia University detailed how a crisis like this may affect those in different tiers of mental illness. Interestingly, there are data showing that those with serious mental illness – schizophrenia, severe mania – often aren’t panicked by disasters. I assume that a sizable percentage of the jail population has severe mental illness, so I was curious about what your experience is, about how they may handle it psychologically.

The rate of serious mental illness in jail is roughly 16% or so, which is three or four times higher than the general population.

Although I don’t know if these kinds of crises differentially affect people with serious mental illness, I do believe very strongly that situations like this, for those who are and who are not incarcerated, can exacerbate or cause symptoms like anxiety, depression, and elevated levels of fear – fear about the unknown, fear of illness or death, fear of isolation.

For people who are incarcerated and who understandably may struggle with trusting the system that is supposed to be keeping them safe, I am concerned that this kind of situation will make that lack of trust worse. I worry that when they get out of jail they will be less inclined to seek help. I imagine that the staff in the jails are doing as much as they can to support the patients, but the staff are also likely experiencing some version of the abandonment and frustration that the patients may feel.

I’ve also seen – not in a crisis of this magnitude but in other crisis situations – that a community really develops among everybody in incarcerated settings. A shared crisis forces everybody to work together in ways that they may not have before. That includes more tolerance for behaviors, more understanding of differences, including mental illness and developmental delay. More compassion.
 

Do you mean between prisoners and staff? Among everybody?

Everybody. In all of the different relationships you can imagine.
 

That speaks to the vulnerability and good nature in all of us. It’s encouraging.

It is, although it’s devastating to me that it happens because they collectively feel so neglected and forgotten. Shared trauma can bind people together very closely.
 

What psychiatric conditions did you typically see in New York City jails?

For the many people with serious mental illness, it’s generally schizophrenia-spectrum illnesses and bipolar disorder – really severe illnesses that do not do well in confinement settings. There’s a lot of anxiety and depression, some that rises to the level of serious illness. There is near universal substance use among the population.

There is also almost universal trauma exposure, whether early-childhood experiences or the ongoing trauma of incarceration. Not everyone has PTSD, but almost everyone behaves in a traumatized way. As you know, in the United States, incarceration is very racially and socioeconomically biased; the trauma of poverty can be incredibly harsh.

What I didn’t see were lots of people with antisocial personality disorder or diagnoses of malingering. That may surprise people. There’s an idea that everybody in jail is a liar and lacks empathy. I didn’t experience that. People in jail are doing whatever they can to survive.
 

What treatments are offered to these patients?

In New York City, all of the typical treatments that you would imagine for people with serious mental illness are offered in the jails: individual and group psychotherapy, medication management, substance use treatment, social work services, even creative art therapy. Many other jails are not able to do even a fraction of that.

In many jails there also has to be a lot of supportive therapy. This involves trying to help people get through a very anxiety-provoking and difficult time, when they frequently don’t know when they are going to be able to leave. I felt the same way as many of the correction officers – that the best thing for these patients is to be out of the jail, to be out of that toxic environment.
 

We have heard for years that the jail system and prison system is the new psych ward. Can you speak to how this occurred and the influence of deinstitutionalization?

When deinstitutionalization happened, there were not enough community agencies available that were equipped to take care of patients who were previously in hospitals. But I think a larger contributor to the overpopulation of people with mental illness in jails and prisons was the war on drugs. It disproportionately affected people who were poor, of color, and who had mental illness. Mental illness and substance use frequently occur together.

At the same time as deinstitutionalization and the war on drugs, there was also a tightening up of the laws relating to admission to psychiatric hospitals. The civil rights movement helped define the requirements that someone had to be dangerous and mentally ill in order to get admitted against their will. While this was an important protection against more indiscriminate admissions of the past, it made it harder to get into hospitals; the state hospitals were closed but the hospitals that were open were now harder to get into.
 

You mentioned that prisoners are undergoing trauma every day. Is this inherent to punitive confinement, or is it something that can be improved upon in the United States?

It’s important that you said “in the United States” as part of that question. Our approach to incarceration in the U.S. is heavily punishment based.
 

Compared to somewhere like Scandinavia, where inmates and prisoners are given a lot more support?

Or England or Canada. The challenge with comparing the United States to Scandinavia is that we are socioeconomically, demographically, and politically so different. But yes, my understanding about the Scandinavian systems are that they have a much more rehabilitative approach to incarceration. Until the U.S. can reframe the goals of incarceration to focus on helping individuals behave in a socially acceptable way, rather than destroy their sense of self-worth, we will continue to see the impact of trauma on generations of lives.

Now, that doesn’t mean that every jail and prison in this country is abusive. But taking away autonomy and freedom, applying inconsistent rules, using solitary confinement, and getting limited to no access to people you love all really destroy a person’s ability to behave in a way that society has deemed acceptable.
 

Assuming that mental health professionals such as yourself have a more compassionate understanding of what’s going on psychologically with the inmates, are you often at odds with law enforcement in the philosophy behind incarceration?

That’s an interesting question. When I moved from the hospital to the jail, I thought that I would run into a lot of resistance from the correction officer staff. I just thought, we’re coming at this from a totally different perspective: I’m trying to help these people and see if there’s a way to safely get them out, and you guys want to punish them.

It turns out that I was very misguided in that view, because it seemed to me that everybody wanted to do what was right for the patient. My perspective about what’s right involved respectful care, building self-esteem, treating illness. The correction officer’s perspective seemed to be keeping them safe, making sure that they can get through the system as quickly as possible, not having them get into fights. Our perspectives may have been different, but the goals were the same. I want all that stuff that the officers want as well.

It’s important to remember that the people who work inside jails and prisons are usually not the ones who are making the policies about who goes in. I haven’t had a lot of exposure working directly with many policymakers. I imagine that my opinions might differ from theirs in some regards.
 

For those working in the U.S. psychiatric healthcare system, what do you want them to know about mental health care in the correctional setting?

Patients in correctional settings are mostly the same patients seen in the public mental health system setting. The vast majority of people who spend time in jail or prison return to the community. But there’s a difference in how patients are perceived by many mental health professionals, including psychiatrists, depending on whether they have criminal justice experience or not.

I would encourage everybody to try to keep an open mind and remember that these patients are cycling through a very difficult system, for many reasons that are at least rooted in community trauma and poverty, and that it doesn’t change the nature of who they are. It doesn’t change that they’re still human beings and they still deserve care and support and treatment.

In this country, patients with mental illness and incarceration histories are so vulnerable and are often black, brown, and poor. It’s an incredible and disturbing representation of American society. But I feel like you can help a lot by getting involved in the frequently dysfunctional criminal justice system. Psychiatrists and other providers have an opportunity to fix things from the inside out.
 

What’s your new role at CASES?

I’m the chief medical officer at CASES [Center for Alternative Sentencing and Employment Services]. It’s a large community organization that provides mental health treatment, case management, employment and education services, alternatives to incarceration, and general support for people who have experienced criminal justice involvement. CASES began operating in the 1960s, and around 2000 it began developing programs specifically addressing the connection between serious mental illness and criminal justice system involvement. For example, we take care of the patients who are coming out of the jails or prisons, or managing patients that the courts have said should go to treatment instead of incarceration.

I took the job because as conditions for individuals with serious mental illness started to improve in the jails, I started to hear more frequently from patients that they were getting better treatment in the jail than out in the community. That did not sit well with me and seemed to be almost the opposite of how it should be.

I also have never been an outpatient public psychiatrist. Most of the patients I treat live most of their lives outside of a jail or a hospital. It felt really important for me to understand the lives of these patients and to see if all of the resistance that I’ve heard from community psychiatrists about taking care of people who have been in jail is really true or not.

It was a logical transition for me. I’m following the patients and basically deinstitutionalizing [them] myself.

This article was first published on Medscape.com.

Jails provide ideal conditions for the spread of COVID-19, as made clear by the distressing stories coming out of New York City. Beyond the very substantial risks posed by the virus itself, practitioners tasked with attending to the large proportion of inmates with mental illness now face additional challenges.

Medscape Psychiatry editorial director Bret Stetka, MD, spoke with Elizabeth Ford, MD, former chief of psychiatry for NYC Health + Hospitals/Correctional Health Services and current chief medical officer for the Center for Alternative Sentencing and Employment Services (CASES), a community organization focused on the needs of people touched by the criminal justice system, to find out how COVID-19 may be reshaping the mental health care of incarcerated patients. As noted by Ford, who authored the 2017 memoir Sometimes Amazing Things Happen: Heartbreak and Hope on the Bellevue Hospital Psychiatric Prison Ward, the unique vulnerabilities of this population were evident well before the coronavirus pandemic’s arrival on our shores.
 

What are the unique health and mental health challenges that can arise in correctional facilities during crises like this, in particular, infectious crises? Or are we still learning this as COVID-19 spreads?

I think it’s important to say that they are still learning it, and I don’t want to speak for them. I left Correctional Health Services on Feb. 14, and we weren’t aware of [all the risks posed by COVID-19] at that point.

I worked in the jail proper for five and a half years. Prior to that I spent a decade at Bellevue Hospital, where I took care of the same patients, who were still incarcerated but also hospitalized. In those years, the closest I ever came to managing something like this was Superstorm Sandy, which obviously had much different health implications.

All of the things that the community is struggling with in terms of the virus also apply in jails and prisons: identifying people who are sick, keeping healthy people from getting sick, preventing sick people from getting worse, separating populations, treatment options, testing options, making sure people follow the appropriate hygiene recommendations. It’s just amplified immensely because these are closed systems that tend to be poorly sanitized, crowded, and frequently forgotten or minimized in public health and political conversations.

A really important distinction is that individuals who are incarcerated do not have control over their behavior in the way that they would in the outside world. They may want to wash their hands frequently and to stay six feet away from everybody, but they can’t because the environment doesn’t allow for that. I know that everyone – correctional officers, health staff, incarcerated individuals, the city – is trying to figure out how to do those things in the jail. The primary challenge is that you don’t have the ability to do the things that you know are right to prevent the spread of the infection.
 

I know you can’t speak to what’s going on at specific jails at the moment, but what sort of psychiatric measures would a jail system put forth in a time like this?

It’s a good question, because like everybody, they’re having to balance the safety of the staff and the patients. Mental health interventions are mostly in person and very time intensive, and social distancing guidelines don’t allow for that now.

I expect that the jails are trying to stratify patients based on severity, both physical and psychological, although increasingly it’s likely harder to separate those who are sick from those who aren’t. In areas where patients are sick, I think the mental health staff are likely doing as much intervention as they can safely, including remote work like telehealth. Telehealth actually got its start in prisons, because they couldn’t get enough providers to come in and do the work in person.
 

I’ve read a lot of the criticism around this, specifically at Rikers Island, where inmates are still closely seated at dining tables, with no possibility of social distancing. [Editor’s note: At the time of this writing, Rikers Island experienced its first inmate death due to COVID-19.] But I see the other side of it. What are jails supposed to do when limited to such a confined space?

That’s correct. I think it is hard for someone who has not lived or worked intensely in these settings to understand how difficult it can be to implement even the most basic hygiene precautions. There are all sorts of efforts happening to create more space, to reduce admissions coming into the jail, to try to expedite discharges out, to offer a lot more sanitation options. I think they may have opened up a jail that was empty to allow for more space.
 

In a recent Medscape commentary, Jeffrey Lieberman, MD, from Columbia University detailed how a crisis like this may affect those in different tiers of mental illness. Interestingly, there are data showing that those with serious mental illness – schizophrenia, severe mania – often aren’t panicked by disasters. I assume that a sizable percentage of the jail population has severe mental illness, so I was curious about what your experience is, about how they may handle it psychologically.

The rate of serious mental illness in jail is roughly 16% or so, which is three or four times higher than the general population.

Although I don’t know if these kinds of crises differentially affect people with serious mental illness, I do believe very strongly that situations like this, for those who are and who are not incarcerated, can exacerbate or cause symptoms like anxiety, depression, and elevated levels of fear – fear about the unknown, fear of illness or death, fear of isolation.

For people who are incarcerated and who understandably may struggle with trusting the system that is supposed to be keeping them safe, I am concerned that this kind of situation will make that lack of trust worse. I worry that when they get out of jail they will be less inclined to seek help. I imagine that the staff in the jails are doing as much as they can to support the patients, but the staff are also likely experiencing some version of the abandonment and frustration that the patients may feel.

I’ve also seen – not in a crisis of this magnitude but in other crisis situations – that a community really develops among everybody in incarcerated settings. A shared crisis forces everybody to work together in ways that they may not have before. That includes more tolerance for behaviors, more understanding of differences, including mental illness and developmental delay. More compassion.
 

Do you mean between prisoners and staff? Among everybody?

Everybody. In all of the different relationships you can imagine.
 

That speaks to the vulnerability and good nature in all of us. It’s encouraging.

It is, although it’s devastating to me that it happens because they collectively feel so neglected and forgotten. Shared trauma can bind people together very closely.
 

What psychiatric conditions did you typically see in New York City jails?

For the many people with serious mental illness, it’s generally schizophrenia-spectrum illnesses and bipolar disorder – really severe illnesses that do not do well in confinement settings. There’s a lot of anxiety and depression, some that rises to the level of serious illness. There is near universal substance use among the population.

There is also almost universal trauma exposure, whether early-childhood experiences or the ongoing trauma of incarceration. Not everyone has PTSD, but almost everyone behaves in a traumatized way. As you know, in the United States, incarceration is very racially and socioeconomically biased; the trauma of poverty can be incredibly harsh.

What I didn’t see were lots of people with antisocial personality disorder or diagnoses of malingering. That may surprise people. There’s an idea that everybody in jail is a liar and lacks empathy. I didn’t experience that. People in jail are doing whatever they can to survive.
 

What treatments are offered to these patients?

In New York City, all of the typical treatments that you would imagine for people with serious mental illness are offered in the jails: individual and group psychotherapy, medication management, substance use treatment, social work services, even creative art therapy. Many other jails are not able to do even a fraction of that.

In many jails there also has to be a lot of supportive therapy. This involves trying to help people get through a very anxiety-provoking and difficult time, when they frequently don’t know when they are going to be able to leave. I felt the same way as many of the correction officers – that the best thing for these patients is to be out of the jail, to be out of that toxic environment.
 

We have heard for years that the jail system and prison system is the new psych ward. Can you speak to how this occurred and the influence of deinstitutionalization?

When deinstitutionalization happened, there were not enough community agencies available that were equipped to take care of patients who were previously in hospitals. But I think a larger contributor to the overpopulation of people with mental illness in jails and prisons was the war on drugs. It disproportionately affected people who were poor, of color, and who had mental illness. Mental illness and substance use frequently occur together.

At the same time as deinstitutionalization and the war on drugs, there was also a tightening up of the laws relating to admission to psychiatric hospitals. The civil rights movement helped define the requirements that someone had to be dangerous and mentally ill in order to get admitted against their will. While this was an important protection against more indiscriminate admissions of the past, it made it harder to get into hospitals; the state hospitals were closed but the hospitals that were open were now harder to get into.
 

You mentioned that prisoners are undergoing trauma every day. Is this inherent to punitive confinement, or is it something that can be improved upon in the United States?

It’s important that you said “in the United States” as part of that question. Our approach to incarceration in the U.S. is heavily punishment based.
 

Compared to somewhere like Scandinavia, where inmates and prisoners are given a lot more support?

Or England or Canada. The challenge with comparing the United States to Scandinavia is that we are socioeconomically, demographically, and politically so different. But yes, my understanding about the Scandinavian systems are that they have a much more rehabilitative approach to incarceration. Until the U.S. can reframe the goals of incarceration to focus on helping individuals behave in a socially acceptable way, rather than destroy their sense of self-worth, we will continue to see the impact of trauma on generations of lives.

Now, that doesn’t mean that every jail and prison in this country is abusive. But taking away autonomy and freedom, applying inconsistent rules, using solitary confinement, and getting limited to no access to people you love all really destroy a person’s ability to behave in a way that society has deemed acceptable.
 

Assuming that mental health professionals such as yourself have a more compassionate understanding of what’s going on psychologically with the inmates, are you often at odds with law enforcement in the philosophy behind incarceration?

That’s an interesting question. When I moved from the hospital to the jail, I thought that I would run into a lot of resistance from the correction officer staff. I just thought, we’re coming at this from a totally different perspective: I’m trying to help these people and see if there’s a way to safely get them out, and you guys want to punish them.

It turns out that I was very misguided in that view, because it seemed to me that everybody wanted to do what was right for the patient. My perspective about what’s right involved respectful care, building self-esteem, treating illness. The correction officer’s perspective seemed to be keeping them safe, making sure that they can get through the system as quickly as possible, not having them get into fights. Our perspectives may have been different, but the goals were the same. I want all that stuff that the officers want as well.

It’s important to remember that the people who work inside jails and prisons are usually not the ones who are making the policies about who goes in. I haven’t had a lot of exposure working directly with many policymakers. I imagine that my opinions might differ from theirs in some regards.
 

For those working in the U.S. psychiatric healthcare system, what do you want them to know about mental health care in the correctional setting?

Patients in correctional settings are mostly the same patients seen in the public mental health system setting. The vast majority of people who spend time in jail or prison return to the community. But there’s a difference in how patients are perceived by many mental health professionals, including psychiatrists, depending on whether they have criminal justice experience or not.

I would encourage everybody to try to keep an open mind and remember that these patients are cycling through a very difficult system, for many reasons that are at least rooted in community trauma and poverty, and that it doesn’t change the nature of who they are. It doesn’t change that they’re still human beings and they still deserve care and support and treatment.

In this country, patients with mental illness and incarceration histories are so vulnerable and are often black, brown, and poor. It’s an incredible and disturbing representation of American society. But I feel like you can help a lot by getting involved in the frequently dysfunctional criminal justice system. Psychiatrists and other providers have an opportunity to fix things from the inside out.
 

What’s your new role at CASES?

I’m the chief medical officer at CASES [Center for Alternative Sentencing and Employment Services]. It’s a large community organization that provides mental health treatment, case management, employment and education services, alternatives to incarceration, and general support for people who have experienced criminal justice involvement. CASES began operating in the 1960s, and around 2000 it began developing programs specifically addressing the connection between serious mental illness and criminal justice system involvement. For example, we take care of the patients who are coming out of the jails or prisons, or managing patients that the courts have said should go to treatment instead of incarceration.

I took the job because as conditions for individuals with serious mental illness started to improve in the jails, I started to hear more frequently from patients that they were getting better treatment in the jail than out in the community. That did not sit well with me and seemed to be almost the opposite of how it should be.

I also have never been an outpatient public psychiatrist. Most of the patients I treat live most of their lives outside of a jail or a hospital. It felt really important for me to understand the lives of these patients and to see if all of the resistance that I’ve heard from community psychiatrists about taking care of people who have been in jail is really true or not.

It was a logical transition for me. I’m following the patients and basically deinstitutionalizing [them] myself.

This article was first published on Medscape.com.

Senate Democrats are calling on the Trump Administration to develop a comprehensive strategy for nationwide COVID-19 testing.

Lawmakers released a “roadmap” document with the goal of including its provisions in the next legislative aid package for COVID-19. Sen. Patty Murray (D-Wash.), the ranking member of the Health, Education, Labor & Pensions committee, noted during an April 15 press conference call that testing in the United States is actually slowing because of shortages and glitches.

“At our current pace, getting 100 million tests done would already take far too long,” she said. “We absolutely cannot afford any backsliding.”

The components of the roadmap include requiring the federal government to develop and communicate a detailed strategic plan to rapidly scale and optimize COVID-19 testing, Sen. Murray said. “This is a national crisis. We need a federally coordinated, whole-of-society response, not one that leaves each state to fend for itself.”

The strategic plan called for in the roadmap would need to establish a high-functioning supply chain with a sufficient amount of available testing materials and supplies; assess potential bottlenecks in the supply chain and communicate them to all stakeholders; and develop and validate accurate and reliable tests for COVID-19, with an emphasis on tests that can deliver rapid results.

Legislation would be used to bolster the supply chain enhancements, according to the roadmap, and would include incentives for domestic manufacturing of testing supplies and compel the sharing of intellectual property and guarantees on the purchase of testing materials.

Testing would be available to patients at no cost sharing under this proposal. The plan also calls for strengthening the price gouging policy in the CARES (Coronavirus Aid, Relief, and Economic Security) Act to ensure that health care professionals are fairly reimbursed by insurers.

The roadmap calls for $30 billion in new emergency funding to enable faster scaling of testing and development of different types of test, with an emphasis on rapid response tests. The funding would also be used to address supply chain issues, according to the roadmap document.

Sen. Lamar Alexander (R.-Tenn.), who chairs the Senate Health, Education, Labor & Pensions committee, echoed the need for more testing to be done, but suggested that the funding that has already been approved by Congress should be exhausted before more is allocated.

“In the last month, Congress has given federal agencies up to $38 billion to develop tests, treatments, and vaccines. Nothing is more important than finding a new diagnostic technology that will make it possible to test tens of millions of Americans, something our country has never tried to do before,” he said in a statement issued after the roadmap’s release. “We should start by using the money Congress has already provided, put politics aside, and work together on more tests with quick results.”

gtwachtman@mdedge.com

Senate Democrats are calling on the Trump Administration to develop a comprehensive strategy for nationwide COVID-19 testing.

Lawmakers released a “roadmap” document with the goal of including its provisions in the next legislative aid package for COVID-19. Sen. Patty Murray (D-Wash.), the ranking member of the Health, Education, Labor & Pensions committee, noted during an April 15 press conference call that testing in the United States is actually slowing because of shortages and glitches.

“At our current pace, getting 100 million tests done would already take far too long,” she said. “We absolutely cannot afford any backsliding.”

The components of the roadmap include requiring the federal government to develop and communicate a detailed strategic plan to rapidly scale and optimize COVID-19 testing, Sen. Murray said. “This is a national crisis. We need a federally coordinated, whole-of-society response, not one that leaves each state to fend for itself.”

The strategic plan called for in the roadmap would need to establish a high-functioning supply chain with a sufficient amount of available testing materials and supplies; assess potential bottlenecks in the supply chain and communicate them to all stakeholders; and develop and validate accurate and reliable tests for COVID-19, with an emphasis on tests that can deliver rapid results.

Legislation would be used to bolster the supply chain enhancements, according to the roadmap, and would include incentives for domestic manufacturing of testing supplies and compel the sharing of intellectual property and guarantees on the purchase of testing materials.

Testing would be available to patients at no cost sharing under this proposal. The plan also calls for strengthening the price gouging policy in the CARES (Coronavirus Aid, Relief, and Economic Security) Act to ensure that health care professionals are fairly reimbursed by insurers.

The roadmap calls for $30 billion in new emergency funding to enable faster scaling of testing and development of different types of test, with an emphasis on rapid response tests. The funding would also be used to address supply chain issues, according to the roadmap document.

Sen. Lamar Alexander (R.-Tenn.), who chairs the Senate Health, Education, Labor & Pensions committee, echoed the need for more testing to be done, but suggested that the funding that has already been approved by Congress should be exhausted before more is allocated.

“In the last month, Congress has given federal agencies up to $38 billion to develop tests, treatments, and vaccines. Nothing is more important than finding a new diagnostic technology that will make it possible to test tens of millions of Americans, something our country has never tried to do before,” he said in a statement issued after the roadmap’s release. “We should start by using the money Congress has already provided, put politics aside, and work together on more tests with quick results.”

gtwachtman@mdedge.com

Senate Democrats are calling on the Trump Administration to develop a comprehensive strategy for nationwide COVID-19 testing.

Lawmakers released a “roadmap” document with the goal of including its provisions in the next legislative aid package for COVID-19. Sen. Patty Murray (D-Wash.), the ranking member of the Health, Education, Labor & Pensions committee, noted during an April 15 press conference call that testing in the United States is actually slowing because of shortages and glitches.

“At our current pace, getting 100 million tests done would already take far too long,” she said. “We absolutely cannot afford any backsliding.”

The components of the roadmap include requiring the federal government to develop and communicate a detailed strategic plan to rapidly scale and optimize COVID-19 testing, Sen. Murray said. “This is a national crisis. We need a federally coordinated, whole-of-society response, not one that leaves each state to fend for itself.”

The strategic plan called for in the roadmap would need to establish a high-functioning supply chain with a sufficient amount of available testing materials and supplies; assess potential bottlenecks in the supply chain and communicate them to all stakeholders; and develop and validate accurate and reliable tests for COVID-19, with an emphasis on tests that can deliver rapid results.

Legislation would be used to bolster the supply chain enhancements, according to the roadmap, and would include incentives for domestic manufacturing of testing supplies and compel the sharing of intellectual property and guarantees on the purchase of testing materials.

Testing would be available to patients at no cost sharing under this proposal. The plan also calls for strengthening the price gouging policy in the CARES (Coronavirus Aid, Relief, and Economic Security) Act to ensure that health care professionals are fairly reimbursed by insurers.

The roadmap calls for $30 billion in new emergency funding to enable faster scaling of testing and development of different types of test, with an emphasis on rapid response tests. The funding would also be used to address supply chain issues, according to the roadmap document.

Sen. Lamar Alexander (R.-Tenn.), who chairs the Senate Health, Education, Labor & Pensions committee, echoed the need for more testing to be done, but suggested that the funding that has already been approved by Congress should be exhausted before more is allocated.

“In the last month, Congress has given federal agencies up to $38 billion to develop tests, treatments, and vaccines. Nothing is more important than finding a new diagnostic technology that will make it possible to test tens of millions of Americans, something our country has never tried to do before,” he said in a statement issued after the roadmap’s release. “We should start by using the money Congress has already provided, put politics aside, and work together on more tests with quick results.”

gtwachtman@mdedge.com

African Americans are overrepresented among patients who have died as a result of the COVID-19 pandemic, but the current crisis puts a spotlight on long-standing racial disparities in health care and health access in the United States, according to David R. Williams, PhD, a professor of public health at the Harvard T.H. Chan School of Public Health in Boston.

Dr. Williams, a social scientist specializing in the link between race and health, is a professor of African and African American Studies and of Sociology at Harvard. He spoke on the topic of racial disparities amid the COVID-19 pandemic in a teleconference sponsored by the Robert Wood Johnson Foundation.

“Many Americans are shocked” by the higher mortality rates among African American COVID-19 patients, said Dr. Williams. However, data from decades of research show that “black people in America live sicker and shorter lives,” he said.

Keys to the increased mortality among African Americans include an increased prevalence of risk factors, increased risk for exposure to the virus because of socioeconomic factors, and less access to health care if they do become ill, he said.

Many minority individuals work outside the home in areas deemed essential during the pandemic, such as transit, delivery, maintenance, cleaning, and in businesses such as grocery stores, although in general “race continues to matter for health at every level of income and education,” Dr. Williams said.

In addition, social distance guidelines are not realistic for many people in high-density, low-income areas, who often live in shared, multigenerational housing, he said.

Data show that individuals with chronic conditions such as diabetes and cardiovascular disease are more likely to die as a result of COVID-19, and minority populations are more likely to develop these conditions at younger ages, Dr. Williams noted. Access to health care also plays a role. Many minority individuals of lower socioeconomic status are less likely to have health insurance, or if they do, may have Medicaid, which is not consistently accepted, he said. Also, some low-income neighborhoods lack convenient access to primary care and thus to screening services, he noted.

A recent study from the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report cited COVID-NET (the COVID-19 Associated Hospitalization Surveillance Network) as showing that, in their catchment population, “approximately 59% of residents are white, 18% are black, and 14% are Hispanic; however, among 580 hospitalized COVID-19 patients with race/ethnicity data, approximately 45% were white, 33% were black, and 8% were Hispanic, suggesting that black populations might be disproportionately affected by COVID-19,” the researchers said.

“These findings, including the potential impact of both sex and race on COVID-19–associated hospitalization rates, need to be confirmed with additional data,” according to the report.

Collecting racial/ethnic information is not always feasible on the front lines, and many areas still face shortages of ventilators and protective equipment, said Dr. Williams.

“I want to salute the providers on the front lines of this pandemic, many putting their own lives at risk, I want to acknowledge the good that they are doing,” Dr. Williams emphasized. He noted that all of us, himself included, may have conscious or unconscious stereotypes, but the key is to acknowledge the potential for these thoughts and feelings and continue to provide the best care.

“Why is this uniquely important to me? I am an academic cardiologist; I study health care disparities; and I am a black man,” he wrote.

“Even though these data are preliminary and further study is warranted, the pattern is irrefutable: Underrepresented minorities are developing COVID-19 infection more frequently and dying disproportionately,” said Dr. Yancy.

Dr. Williams’ and Dr. Yancy’s comments were supported by an analysis of COVID-19 patient data from several areas of the country conducted by the Washington Post. In that analysis, data showed that several counties with a majority black population showed three times the rate of COVID-19 infections and approximately six times as many deaths compared with counties with a majority of white residents.

“The U.S. has needed a trigger to fully address health care disparities; COVID-19 may be that bellwether event,” said Dr. Yancy. “Certainly, within the broad and powerful economic and legislative engines of the US, there is room to definitively address a scourge even worse than COVID-19: health care disparities. It only takes will. It is time to end the refrain,” he said.

Dr. Williams had no financial conflicts to disclose. Dr. Yancy had no financial conflicts to disclose.

SOURCES: Yancy CW. JAMA 2020 Apr 15. doi: 10.1001/jama.2020.6548Garg S et al. MMWR Morb Mortal Wkly Rep 2020 Apr 8;69:458-64.

Thebault R et al. The coronavirus is infecting and killing black Americans at an alarmingly high rate. Washington Post. 2020 Apr 7.

African Americans are overrepresented among patients who have died as a result of the COVID-19 pandemic, but the current crisis puts a spotlight on long-standing racial disparities in health care and health access in the United States, according to David R. Williams, PhD, a professor of public health at the Harvard T.H. Chan School of Public Health in Boston.

Dr. Williams, a social scientist specializing in the link between race and health, is a professor of African and African American Studies and of Sociology at Harvard. He spoke on the topic of racial disparities amid the COVID-19 pandemic in a teleconference sponsored by the Robert Wood Johnson Foundation.

“Many Americans are shocked” by the higher mortality rates among African American COVID-19 patients, said Dr. Williams. However, data from decades of research show that “black people in America live sicker and shorter lives,” he said.

Keys to the increased mortality among African Americans include an increased prevalence of risk factors, increased risk for exposure to the virus because of socioeconomic factors, and less access to health care if they do become ill, he said.

Many minority individuals work outside the home in areas deemed essential during the pandemic, such as transit, delivery, maintenance, cleaning, and in businesses such as grocery stores, although in general “race continues to matter for health at every level of income and education,” Dr. Williams said.

In addition, social distance guidelines are not realistic for many people in high-density, low-income areas, who often live in shared, multigenerational housing, he said.

Data show that individuals with chronic conditions such as diabetes and cardiovascular disease are more likely to die as a result of COVID-19, and minority populations are more likely to develop these conditions at younger ages, Dr. Williams noted. Access to health care also plays a role. Many minority individuals of lower socioeconomic status are less likely to have health insurance, or if they do, may have Medicaid, which is not consistently accepted, he said. Also, some low-income neighborhoods lack convenient access to primary care and thus to screening services, he noted.

A recent study from the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report cited COVID-NET (the COVID-19 Associated Hospitalization Surveillance Network) as showing that, in their catchment population, “approximately 59% of residents are white, 18% are black, and 14% are Hispanic; however, among 580 hospitalized COVID-19 patients with race/ethnicity data, approximately 45% were white, 33% were black, and 8% were Hispanic, suggesting that black populations might be disproportionately affected by COVID-19,” the researchers said.

“These findings, including the potential impact of both sex and race on COVID-19–associated hospitalization rates, need to be confirmed with additional data,” according to the report.

Collecting racial/ethnic information is not always feasible on the front lines, and many areas still face shortages of ventilators and protective equipment, said Dr. Williams.

“I want to salute the providers on the front lines of this pandemic, many putting their own lives at risk, I want to acknowledge the good that they are doing,” Dr. Williams emphasized. He noted that all of us, himself included, may have conscious or unconscious stereotypes, but the key is to acknowledge the potential for these thoughts and feelings and continue to provide the best care.

“Why is this uniquely important to me? I am an academic cardiologist; I study health care disparities; and I am a black man,” he wrote.

“Even though these data are preliminary and further study is warranted, the pattern is irrefutable: Underrepresented minorities are developing COVID-19 infection more frequently and dying disproportionately,” said Dr. Yancy.

Dr. Williams’ and Dr. Yancy’s comments were supported by an analysis of COVID-19 patient data from several areas of the country conducted by the Washington Post. In that analysis, data showed that several counties with a majority black population showed three times the rate of COVID-19 infections and approximately six times as many deaths compared with counties with a majority of white residents.

“The U.S. has needed a trigger to fully address health care disparities; COVID-19 may be that bellwether event,” said Dr. Yancy. “Certainly, within the broad and powerful economic and legislative engines of the US, there is room to definitively address a scourge even worse than COVID-19: health care disparities. It only takes will. It is time to end the refrain,” he said.

Dr. Williams had no financial conflicts to disclose. Dr. Yancy had no financial conflicts to disclose.

SOURCES: Yancy CW. JAMA 2020 Apr 15. doi: 10.1001/jama.2020.6548Garg S et al. MMWR Morb Mortal Wkly Rep 2020 Apr 8;69:458-64.

Thebault R et al. The coronavirus is infecting and killing black Americans at an alarmingly high rate. Washington Post. 2020 Apr 7.

African Americans are overrepresented among patients who have died as a result of the COVID-19 pandemic, but the current crisis puts a spotlight on long-standing racial disparities in health care and health access in the United States, according to David R. Williams, PhD, a professor of public health at the Harvard T.H. Chan School of Public Health in Boston.

Dr. Williams, a social scientist specializing in the link between race and health, is a professor of African and African American Studies and of Sociology at Harvard. He spoke on the topic of racial disparities amid the COVID-19 pandemic in a teleconference sponsored by the Robert Wood Johnson Foundation.

“Many Americans are shocked” by the higher mortality rates among African American COVID-19 patients, said Dr. Williams. However, data from decades of research show that “black people in America live sicker and shorter lives,” he said.

Keys to the increased mortality among African Americans include an increased prevalence of risk factors, increased risk for exposure to the virus because of socioeconomic factors, and less access to health care if they do become ill, he said.

Many minority individuals work outside the home in areas deemed essential during the pandemic, such as transit, delivery, maintenance, cleaning, and in businesses such as grocery stores, although in general “race continues to matter for health at every level of income and education,” Dr. Williams said.

In addition, social distance guidelines are not realistic for many people in high-density, low-income areas, who often live in shared, multigenerational housing, he said.

Data show that individuals with chronic conditions such as diabetes and cardiovascular disease are more likely to die as a result of COVID-19, and minority populations are more likely to develop these conditions at younger ages, Dr. Williams noted. Access to health care also plays a role. Many minority individuals of lower socioeconomic status are less likely to have health insurance, or if they do, may have Medicaid, which is not consistently accepted, he said. Also, some low-income neighborhoods lack convenient access to primary care and thus to screening services, he noted.

A recent study from the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report cited COVID-NET (the COVID-19 Associated Hospitalization Surveillance Network) as showing that, in their catchment population, “approximately 59% of residents are white, 18% are black, and 14% are Hispanic; however, among 580 hospitalized COVID-19 patients with race/ethnicity data, approximately 45% were white, 33% were black, and 8% were Hispanic, suggesting that black populations might be disproportionately affected by COVID-19,” the researchers said.

“These findings, including the potential impact of both sex and race on COVID-19–associated hospitalization rates, need to be confirmed with additional data,” according to the report.

Collecting racial/ethnic information is not always feasible on the front lines, and many areas still face shortages of ventilators and protective equipment, said Dr. Williams.

“I want to salute the providers on the front lines of this pandemic, many putting their own lives at risk, I want to acknowledge the good that they are doing,” Dr. Williams emphasized. He noted that all of us, himself included, may have conscious or unconscious stereotypes, but the key is to acknowledge the potential for these thoughts and feelings and continue to provide the best care.

“Why is this uniquely important to me? I am an academic cardiologist; I study health care disparities; and I am a black man,” he wrote.

“Even though these data are preliminary and further study is warranted, the pattern is irrefutable: Underrepresented minorities are developing COVID-19 infection more frequently and dying disproportionately,” said Dr. Yancy.

Dr. Williams’ and Dr. Yancy’s comments were supported by an analysis of COVID-19 patient data from several areas of the country conducted by the Washington Post. In that analysis, data showed that several counties with a majority black population showed three times the rate of COVID-19 infections and approximately six times as many deaths compared with counties with a majority of white residents.

“The U.S. has needed a trigger to fully address health care disparities; COVID-19 may be that bellwether event,” said Dr. Yancy. “Certainly, within the broad and powerful economic and legislative engines of the US, there is room to definitively address a scourge even worse than COVID-19: health care disparities. It only takes will. It is time to end the refrain,” he said.

Dr. Williams had no financial conflicts to disclose. Dr. Yancy had no financial conflicts to disclose.

SOURCES: Yancy CW. JAMA 2020 Apr 15. doi: 10.1001/jama.2020.6548Garg S et al. MMWR Morb Mortal Wkly Rep 2020 Apr 8;69:458-64.

Thebault R et al. The coronavirus is infecting and killing black Americans at an alarmingly high rate. Washington Post. 2020 Apr 7.

While working in health care has never been easy, the COVID-19 pandemic has brought on an entirely new dimension to the challenges that clinicians face. Many of the daily concerns we once had now pale in comparison with the weight of this historic pandemic. Anxiety about the survival of our patients is compounded by our own physical and emotional exhaustion, concern for our loved ones, and fear for our own safety while on the front lines. Through this seemingly insurmountable array of challenges, survival mode kicks in. We come into the hospital every day, put on our mask and gowns, and focus on providing the care we’ve been trained for. That’s what we do best – keeping on.

However, the sheer volume of patients grows by the day, including those who are critically ill and ventilated. With hundreds of deaths every day in New York City, and ICUs filled beyond three times capacity, our frontline clinicians are overstretched, exhausted, and in need of additional help. Emergency codes are called overhead at staggering frequencies. Our colleagues on the front lines are unfortunately becoming sick themselves, and those who are healthy are working extra shifts, at a pace they can only keep up for so long.

The heartbreaking reality of this pandemic is that our connection with our patients and families is fading amid the chaos. Many infection prevention policies prohibit families from physically visiting the hospitals. The scariest parts of a hospitalization – gasping for air, before intubation, and the final moments before death – are tragically occurring alone. The support we are able to give occurs behind masks and fogged goggles. There’s not a clinician I know who doesn’t want better for patients and families – and we can mobilize to do so.

At NYC Health + Hospitals, the largest public health system in the United States, and a hot zone of the COVID-19 pandemic, we’ve taken major steps to mitigate this tragedy. Our palliative care clinicians have stepped up to help reconnect the patients with their families. We secured hundreds of tablets to enable video calls, and improved inpatient work flows to facilitate updates to families. We bolstered support from our palliative care clinicians to our ICU teams and are expanding capacity to initiate goals of care conversations earlier, through automatic triggers and proactive discussions with our hospitalist teams. Last but certainly not least, we are calling out across the country for our willing colleagues who can volunteer their time remotely via telehealth to support our patients, families, and staff here in NYC Health + Hospitals.

We have been encouraged by the resolve and commitment of our friends and colleagues from all corners of the country. NYC Health + Hospitals is receiving many brave volunteers who are rising to the call and assisting in whatever way they can. If you are proficient in goals-of-care conversations and/or trained in palliative care and willing, please sign up here to volunteer remotely via telemedicine. We are still in the beginning of this war; this struggle will continue for months even after public eye has turned away. Our patients and frontline staff need your help.

Thank you and stay safe.
 

Dr. Cho is chief value officer at NYC Health + Hospitals, and clinical associate professor of medicine at New York University. He is a member of the Hospitalist’s editorial advisory board. Ms. Israilov is the inaugural Quality and Safety Student Scholar at NYC Health + Hospitals. She is an MD candidate at the Icahn School of Medicine at Mount Sinai, New York.

While working in health care has never been easy, the COVID-19 pandemic has brought on an entirely new dimension to the challenges that clinicians face. Many of the daily concerns we once had now pale in comparison with the weight of this historic pandemic. Anxiety about the survival of our patients is compounded by our own physical and emotional exhaustion, concern for our loved ones, and fear for our own safety while on the front lines. Through this seemingly insurmountable array of challenges, survival mode kicks in. We come into the hospital every day, put on our mask and gowns, and focus on providing the care we’ve been trained for. That’s what we do best – keeping on.

However, the sheer volume of patients grows by the day, including those who are critically ill and ventilated. With hundreds of deaths every day in New York City, and ICUs filled beyond three times capacity, our frontline clinicians are overstretched, exhausted, and in need of additional help. Emergency codes are called overhead at staggering frequencies. Our colleagues on the front lines are unfortunately becoming sick themselves, and those who are healthy are working extra shifts, at a pace they can only keep up for so long.

The heartbreaking reality of this pandemic is that our connection with our patients and families is fading amid the chaos. Many infection prevention policies prohibit families from physically visiting the hospitals. The scariest parts of a hospitalization – gasping for air, before intubation, and the final moments before death – are tragically occurring alone. The support we are able to give occurs behind masks and fogged goggles. There’s not a clinician I know who doesn’t want better for patients and families – and we can mobilize to do so.

At NYC Health + Hospitals, the largest public health system in the United States, and a hot zone of the COVID-19 pandemic, we’ve taken major steps to mitigate this tragedy. Our palliative care clinicians have stepped up to help reconnect the patients with their families. We secured hundreds of tablets to enable video calls, and improved inpatient work flows to facilitate updates to families. We bolstered support from our palliative care clinicians to our ICU teams and are expanding capacity to initiate goals of care conversations earlier, through automatic triggers and proactive discussions with our hospitalist teams. Last but certainly not least, we are calling out across the country for our willing colleagues who can volunteer their time remotely via telehealth to support our patients, families, and staff here in NYC Health + Hospitals.

We have been encouraged by the resolve and commitment of our friends and colleagues from all corners of the country. NYC Health + Hospitals is receiving many brave volunteers who are rising to the call and assisting in whatever way they can. If you are proficient in goals-of-care conversations and/or trained in palliative care and willing, please sign up here to volunteer remotely via telemedicine. We are still in the beginning of this war; this struggle will continue for months even after public eye has turned away. Our patients and frontline staff need your help.

Thank you and stay safe.
 

Dr. Cho is chief value officer at NYC Health + Hospitals, and clinical associate professor of medicine at New York University. He is a member of the Hospitalist’s editorial advisory board. Ms. Israilov is the inaugural Quality and Safety Student Scholar at NYC Health + Hospitals. She is an MD candidate at the Icahn School of Medicine at Mount Sinai, New York.

While working in health care has never been easy, the COVID-19 pandemic has brought on an entirely new dimension to the challenges that clinicians face. Many of the daily concerns we once had now pale in comparison with the weight of this historic pandemic. Anxiety about the survival of our patients is compounded by our own physical and emotional exhaustion, concern for our loved ones, and fear for our own safety while on the front lines. Through this seemingly insurmountable array of challenges, survival mode kicks in. We come into the hospital every day, put on our mask and gowns, and focus on providing the care we’ve been trained for. That’s what we do best – keeping on.

However, the sheer volume of patients grows by the day, including those who are critically ill and ventilated. With hundreds of deaths every day in New York City, and ICUs filled beyond three times capacity, our frontline clinicians are overstretched, exhausted, and in need of additional help. Emergency codes are called overhead at staggering frequencies. Our colleagues on the front lines are unfortunately becoming sick themselves, and those who are healthy are working extra shifts, at a pace they can only keep up for so long.

The heartbreaking reality of this pandemic is that our connection with our patients and families is fading amid the chaos. Many infection prevention policies prohibit families from physically visiting the hospitals. The scariest parts of a hospitalization – gasping for air, before intubation, and the final moments before death – are tragically occurring alone. The support we are able to give occurs behind masks and fogged goggles. There’s not a clinician I know who doesn’t want better for patients and families – and we can mobilize to do so.

At NYC Health + Hospitals, the largest public health system in the United States, and a hot zone of the COVID-19 pandemic, we’ve taken major steps to mitigate this tragedy. Our palliative care clinicians have stepped up to help reconnect the patients with their families. We secured hundreds of tablets to enable video calls, and improved inpatient work flows to facilitate updates to families. We bolstered support from our palliative care clinicians to our ICU teams and are expanding capacity to initiate goals of care conversations earlier, through automatic triggers and proactive discussions with our hospitalist teams. Last but certainly not least, we are calling out across the country for our willing colleagues who can volunteer their time remotely via telehealth to support our patients, families, and staff here in NYC Health + Hospitals.

We have been encouraged by the resolve and commitment of our friends and colleagues from all corners of the country. NYC Health + Hospitals is receiving many brave volunteers who are rising to the call and assisting in whatever way they can. If you are proficient in goals-of-care conversations and/or trained in palliative care and willing, please sign up here to volunteer remotely via telemedicine. We are still in the beginning of this war; this struggle will continue for months even after public eye has turned away. Our patients and frontline staff need your help.

Thank you and stay safe.
 

Dr. Cho is chief value officer at NYC Health + Hospitals, and clinical associate professor of medicine at New York University. He is a member of the Hospitalist’s editorial advisory board. Ms. Israilov is the inaugural Quality and Safety Student Scholar at NYC Health + Hospitals. She is an MD candidate at the Icahn School of Medicine at Mount Sinai, New York.

My patients and their families have never been more anxious. In the pediatric ED where I practice, everyone is on edge. The COVID-19 pandemic has amplified the feelings of anxious anticipation and uncertainty that families have when they bring their child to the ED. People are scared that their children have the virus or that they will contract it in this high-risk environment. Both are reasonable fears. As a doctor, it has never been more difficult for me to lessen that anxiety.

Every doctor has a version of an interpersonal toolkit they use to project confidence, maintain calm, and convey empathy. Parts of it are taught in medical school, but most components are learned by trial and error. For me, it starts with speaking clearly and directly. If I can do this successfully, it allows parents to understand my recommendations and feel comfortable with my expertise. But words alone are rarely enough to gain trust. For most people, trusting a doctor requires believing that the physician is empathetic and invested in their care or the care of their loved one.

My experience is that, in the short, high-intensity interactions of the ED, this often has to be achieved with body language and facial expressions. We use so many little movements in interactions with patients: a knowing smile, kind eyes, a timely frown, open arms. These gestures would typically show parents I understand how they feel, and I am invested in the health of their child. Hidden behind my mask, face shield, gown, and gloves, I remain a black box. I dispense advice but struggle to convey that it comes from someone who cares.

At the beginning of the pandemic, I would skirt the rules of personal protective equipment (PPE) usage to try and get a moment of human connection. I might appear in the doorway of a patient’s room, smile, and introduce myself before putting on my mask and goggles. If a parent seemed to expect a firm handshake, I would give one, careful to wash my hands before and after. As the guidelines around PPE usage have become more consistent and the danger of the virus increasingly evident, I have cut out these little indulgences. I wear a mask and eye protection from the moment I enter the ED until I leave. I touch as few patients as possible and generally stand 6 feet or more from everyone I talk to.

I believe most providers would agree; these precautions are the only ethical way to see patients during the pandemic. Patients and families are entitled to health care workers who are doing everything they can to protect themselves and those around them. As long as the pandemic lasts, patients and providers will need to recalibrate their expectations of interpersonal interactions. For the time being, good doctors might be defined as much by their PPE adherence as by their ability to connect with patients.

Dr. Shapiro is a clinical instructor of pediatrics at the George Washington University and a clinical associate in the division of emergency medicine at Children’s National Hospital, both in Washington. He said he had no relevant financial disclosures. Email Dr. Shapiro at pdnews@mdedge.com.

My patients and their families have never been more anxious. In the pediatric ED where I practice, everyone is on edge. The COVID-19 pandemic has amplified the feelings of anxious anticipation and uncertainty that families have when they bring their child to the ED. People are scared that their children have the virus or that they will contract it in this high-risk environment. Both are reasonable fears. As a doctor, it has never been more difficult for me to lessen that anxiety.

Every doctor has a version of an interpersonal toolkit they use to project confidence, maintain calm, and convey empathy. Parts of it are taught in medical school, but most components are learned by trial and error. For me, it starts with speaking clearly and directly. If I can do this successfully, it allows parents to understand my recommendations and feel comfortable with my expertise. But words alone are rarely enough to gain trust. For most people, trusting a doctor requires believing that the physician is empathetic and invested in their care or the care of their loved one.

My experience is that, in the short, high-intensity interactions of the ED, this often has to be achieved with body language and facial expressions. We use so many little movements in interactions with patients: a knowing smile, kind eyes, a timely frown, open arms. These gestures would typically show parents I understand how they feel, and I am invested in the health of their child. Hidden behind my mask, face shield, gown, and gloves, I remain a black box. I dispense advice but struggle to convey that it comes from someone who cares.

At the beginning of the pandemic, I would skirt the rules of personal protective equipment (PPE) usage to try and get a moment of human connection. I might appear in the doorway of a patient’s room, smile, and introduce myself before putting on my mask and goggles. If a parent seemed to expect a firm handshake, I would give one, careful to wash my hands before and after. As the guidelines around PPE usage have become more consistent and the danger of the virus increasingly evident, I have cut out these little indulgences. I wear a mask and eye protection from the moment I enter the ED until I leave. I touch as few patients as possible and generally stand 6 feet or more from everyone I talk to.

I believe most providers would agree; these precautions are the only ethical way to see patients during the pandemic. Patients and families are entitled to health care workers who are doing everything they can to protect themselves and those around them. As long as the pandemic lasts, patients and providers will need to recalibrate their expectations of interpersonal interactions. For the time being, good doctors might be defined as much by their PPE adherence as by their ability to connect with patients.

Dr. Shapiro is a clinical instructor of pediatrics at the George Washington University and a clinical associate in the division of emergency medicine at Children’s National Hospital, both in Washington. He said he had no relevant financial disclosures. Email Dr. Shapiro at pdnews@mdedge.com.

My patients and their families have never been more anxious. In the pediatric ED where I practice, everyone is on edge. The COVID-19 pandemic has amplified the feelings of anxious anticipation and uncertainty that families have when they bring their child to the ED. People are scared that their children have the virus or that they will contract it in this high-risk environment. Both are reasonable fears. As a doctor, it has never been more difficult for me to lessen that anxiety.

Every doctor has a version of an interpersonal toolkit they use to project confidence, maintain calm, and convey empathy. Parts of it are taught in medical school, but most components are learned by trial and error. For me, it starts with speaking clearly and directly. If I can do this successfully, it allows parents to understand my recommendations and feel comfortable with my expertise. But words alone are rarely enough to gain trust. For most people, trusting a doctor requires believing that the physician is empathetic and invested in their care or the care of their loved one.

My experience is that, in the short, high-intensity interactions of the ED, this often has to be achieved with body language and facial expressions. We use so many little movements in interactions with patients: a knowing smile, kind eyes, a timely frown, open arms. These gestures would typically show parents I understand how they feel, and I am invested in the health of their child. Hidden behind my mask, face shield, gown, and gloves, I remain a black box. I dispense advice but struggle to convey that it comes from someone who cares.

At the beginning of the pandemic, I would skirt the rules of personal protective equipment (PPE) usage to try and get a moment of human connection. I might appear in the doorway of a patient’s room, smile, and introduce myself before putting on my mask and goggles. If a parent seemed to expect a firm handshake, I would give one, careful to wash my hands before and after. As the guidelines around PPE usage have become more consistent and the danger of the virus increasingly evident, I have cut out these little indulgences. I wear a mask and eye protection from the moment I enter the ED until I leave. I touch as few patients as possible and generally stand 6 feet or more from everyone I talk to.

I believe most providers would agree; these precautions are the only ethical way to see patients during the pandemic. Patients and families are entitled to health care workers who are doing everything they can to protect themselves and those around them. As long as the pandemic lasts, patients and providers will need to recalibrate their expectations of interpersonal interactions. For the time being, good doctors might be defined as much by their PPE adherence as by their ability to connect with patients.

Dr. Shapiro is a clinical instructor of pediatrics at the George Washington University and a clinical associate in the division of emergency medicine at Children’s National Hospital, both in Washington. He said he had no relevant financial disclosures. Email Dr. Shapiro at pdnews@mdedge.com.

The COVID-19 pandemic is putting a strain on the blood supply and could be putting people – including those who normally get transfusions, such as patients with sickle cell disease and cancer – at risk.

“Around the beginning of March, the hematology community got wind of what was going on because the blood banks were saying think about your patients and begin to restrict blood usage because we are expecting an increase in usage for COVID-positive ICU patients,” Ifeyinwa (Ify) Osunkwo, MD, a specialist in hematology and sickle cell disease at Levine Cancer Institute in Charlotte, N.C., said in an interview.

“I think that was the first call to arms around hematology ... you don’t want to shortchange somebody who is well and who is being sustained by life-giving transfusions and cut out their transfusion therapy because you are hoping to use the blood for people who are coming in with COVID-19,” she continued. “That is an ethical dilemma that no doctor wants to have to go through. But the reality is we have to do something to make it work for everybody.”

And the timing of the social restrictions due to the pandemic has added additional strain on the blood supply.

“Over the winter, traditionally, blood drives slow down because of the flu and different viruses,” she noted. “The spring and the summer are when we see the biggest recruitment and uptake of blood donation. COVID-19 hit [and] a lot of the blood drives that were traditionally scheduled to supply blood for the country have been canceled because of the new guidance for social distancing.”

Another big source of blood are health care professionals themselves and they may not be able to donate because of the extra hours being worked because of the pandemic.

In speaking about the needs for traditional patients such as those who are dealing with cancer or leukemia or sickle cell diseases as well as those who are being treated for COVID-19 in North Carolina, “we are not at the critical point, but I am a little bit nervous that we may get there because they are not going to up the usual blood drives anytime this summer. We project [sometime] in the fall, but maybe not even then. So there needs to be a significant call-out for people to make every effort to donate blood,” said Dr. Osunkwo. She added that in places such as New York City that are hot spots for the COVID-19 outbreak, the need is likely a lot greater.

She recalled a recent incident at a New York hospital that highlighted how those managing blood supplies are being restrictive and how this could be harming patients.

“A sickle cell patient came in with COVID-19 and the treatment recommendation was do a red blood cell exchange but the blood bank was nervous about getting enough blood to supply for that exchange transfusion,” she said, noting that the doctor still went to bat for that patient to get the needed treatment. “We gave her the supporting evidence that when you are on treatment for sickle cell disease, you tend to do better if you get COVID-19 or any other viral infection. The symptoms of COVID-19 in sickle cell disease is acute chest syndrome, for which the treatment is red blood cell exchange. Not doing that for [these patients] is really not giving them the optimal way of managing their disease, and managing their disease in the setting of COVID-19.”

To that end, Dr. Osunkwo stressed that doctors need to be doing all they can to get the word out that blood is needed and that the American Red Cross and other donation organizations are making it safe for people to donate. She has been using social media to highlight when her fellow doctors and others make donations as a way to motivate individuals.

“Everybody can do something during this pandemic,” she said. “Don’t feel like you are not working, that you are not a frontline worker, that you have nothing to contribute. You can donate blood. Your cousin can donate blood. You can tell your friends, your neighbors, your relatives, your enemies to go donate. We will take every kind of blood we can get because people are needing it more now. Even though we canceled elective surgeries, my patients when they get COVID-19, they need more blood ... than they usually do during their regular sickle cell admission. It is going to be the same for people who have other blood disorders like cancer and leukemia. We can’t stop life-saving treatments just because we have the COVID pandemic.”

Dr. Osunkwo also praised recent actions taken by the Food and Drug Administration to lessen some of the deferral periods for when an individual can donate.

The FDA on April 2 issued three sets of revised recommendations aimed at getting more people eligible to donate blood. All of the revised recommendations will remain in effect after the COVID-19 health emergency is declared over.

The first revised recommendation makes changes to December 2015 guidance.

For male blood donors who would have been deferred for having sex with another male partner, the deferral period has been reduced from 12 months to 3 months. That deferral period change also applies to female donors who had sex with a man who had sex with another man as well as for those with recent tattoos and piercings.

The second recommendation revises guidance from August 2013 and relates to the risk of transfusion-transmitted malaria.

Under the new recommendations, for those who traveled to malaria-endemic areas (and are residents of malaria non-endemic countries), the FDA is lowering the recommended deferral period from 12 months to 3 months, and also provides notices of an alternate procedure that permits donations without a deferral period provided the blood components are pathogen-reduced using an FDA-approved pathogen reduction device.

The third recommendation finalizes draft guidance from January that eliminates the referral period for donors who spent time in certain European countries or were on military bases in Europe and were previously considered to have been exposed to a potential risk of transmission of Creutzfeldt-Jakob Disease or Variant Creutzfeldt-Jakob Disease.

Dr. Osunkwo reports consultancy and being on the speakers bureau and participating in the advisory board for Novartis, and relationships with a variety of other pharmaceutical companies. She is the editor-in-chief for Hematology News.

gtwachtman@mdedge.com

The COVID-19 pandemic is putting a strain on the blood supply and could be putting people – including those who normally get transfusions, such as patients with sickle cell disease and cancer – at risk.

“Around the beginning of March, the hematology community got wind of what was going on because the blood banks were saying think about your patients and begin to restrict blood usage because we are expecting an increase in usage for COVID-positive ICU patients,” Ifeyinwa (Ify) Osunkwo, MD, a specialist in hematology and sickle cell disease at Levine Cancer Institute in Charlotte, N.C., said in an interview.

“I think that was the first call to arms around hematology ... you don’t want to shortchange somebody who is well and who is being sustained by life-giving transfusions and cut out their transfusion therapy because you are hoping to use the blood for people who are coming in with COVID-19,” she continued. “That is an ethical dilemma that no doctor wants to have to go through. But the reality is we have to do something to make it work for everybody.”

And the timing of the social restrictions due to the pandemic has added additional strain on the blood supply.

“Over the winter, traditionally, blood drives slow down because of the flu and different viruses,” she noted. “The spring and the summer are when we see the biggest recruitment and uptake of blood donation. COVID-19 hit [and] a lot of the blood drives that were traditionally scheduled to supply blood for the country have been canceled because of the new guidance for social distancing.”

Another big source of blood are health care professionals themselves and they may not be able to donate because of the extra hours being worked because of the pandemic.

In speaking about the needs for traditional patients such as those who are dealing with cancer or leukemia or sickle cell diseases as well as those who are being treated for COVID-19 in North Carolina, “we are not at the critical point, but I am a little bit nervous that we may get there because they are not going to up the usual blood drives anytime this summer. We project [sometime] in the fall, but maybe not even then. So there needs to be a significant call-out for people to make every effort to donate blood,” said Dr. Osunkwo. She added that in places such as New York City that are hot spots for the COVID-19 outbreak, the need is likely a lot greater.

She recalled a recent incident at a New York hospital that highlighted how those managing blood supplies are being restrictive and how this could be harming patients.

“A sickle cell patient came in with COVID-19 and the treatment recommendation was do a red blood cell exchange but the blood bank was nervous about getting enough blood to supply for that exchange transfusion,” she said, noting that the doctor still went to bat for that patient to get the needed treatment. “We gave her the supporting evidence that when you are on treatment for sickle cell disease, you tend to do better if you get COVID-19 or any other viral infection. The symptoms of COVID-19 in sickle cell disease is acute chest syndrome, for which the treatment is red blood cell exchange. Not doing that for [these patients] is really not giving them the optimal way of managing their disease, and managing their disease in the setting of COVID-19.”

To that end, Dr. Osunkwo stressed that doctors need to be doing all they can to get the word out that blood is needed and that the American Red Cross and other donation organizations are making it safe for people to donate. She has been using social media to highlight when her fellow doctors and others make donations as a way to motivate individuals.

“Everybody can do something during this pandemic,” she said. “Don’t feel like you are not working, that you are not a frontline worker, that you have nothing to contribute. You can donate blood. Your cousin can donate blood. You can tell your friends, your neighbors, your relatives, your enemies to go donate. We will take every kind of blood we can get because people are needing it more now. Even though we canceled elective surgeries, my patients when they get COVID-19, they need more blood ... than they usually do during their regular sickle cell admission. It is going to be the same for people who have other blood disorders like cancer and leukemia. We can’t stop life-saving treatments just because we have the COVID pandemic.”

Dr. Osunkwo also praised recent actions taken by the Food and Drug Administration to lessen some of the deferral periods for when an individual can donate.

The FDA on April 2 issued three sets of revised recommendations aimed at getting more people eligible to donate blood. All of the revised recommendations will remain in effect after the COVID-19 health emergency is declared over.

The first revised recommendation makes changes to December 2015 guidance.

For male blood donors who would have been deferred for having sex with another male partner, the deferral period has been reduced from 12 months to 3 months. That deferral period change also applies to female donors who had sex with a man who had sex with another man as well as for those with recent tattoos and piercings.

The second recommendation revises guidance from August 2013 and relates to the risk of transfusion-transmitted malaria.

Under the new recommendations, for those who traveled to malaria-endemic areas (and are residents of malaria non-endemic countries), the FDA is lowering the recommended deferral period from 12 months to 3 months, and also provides notices of an alternate procedure that permits donations without a deferral period provided the blood components are pathogen-reduced using an FDA-approved pathogen reduction device.

The third recommendation finalizes draft guidance from January that eliminates the referral period for donors who spent time in certain European countries or were on military bases in Europe and were previously considered to have been exposed to a potential risk of transmission of Creutzfeldt-Jakob Disease or Variant Creutzfeldt-Jakob Disease.

Dr. Osunkwo reports consultancy and being on the speakers bureau and participating in the advisory board for Novartis, and relationships with a variety of other pharmaceutical companies. She is the editor-in-chief for Hematology News.

gtwachtman@mdedge.com

The COVID-19 pandemic is putting a strain on the blood supply and could be putting people – including those who normally get transfusions, such as patients with sickle cell disease and cancer – at risk.

“Around the beginning of March, the hematology community got wind of what was going on because the blood banks were saying think about your patients and begin to restrict blood usage because we are expecting an increase in usage for COVID-positive ICU patients,” Ifeyinwa (Ify) Osunkwo, MD, a specialist in hematology and sickle cell disease at Levine Cancer Institute in Charlotte, N.C., said in an interview.

“I think that was the first call to arms around hematology ... you don’t want to shortchange somebody who is well and who is being sustained by life-giving transfusions and cut out their transfusion therapy because you are hoping to use the blood for people who are coming in with COVID-19,” she continued. “That is an ethical dilemma that no doctor wants to have to go through. But the reality is we have to do something to make it work for everybody.”

And the timing of the social restrictions due to the pandemic has added additional strain on the blood supply.

“Over the winter, traditionally, blood drives slow down because of the flu and different viruses,” she noted. “The spring and the summer are when we see the biggest recruitment and uptake of blood donation. COVID-19 hit [and] a lot of the blood drives that were traditionally scheduled to supply blood for the country have been canceled because of the new guidance for social distancing.”

Another big source of blood are health care professionals themselves and they may not be able to donate because of the extra hours being worked because of the pandemic.

In speaking about the needs for traditional patients such as those who are dealing with cancer or leukemia or sickle cell diseases as well as those who are being treated for COVID-19 in North Carolina, “we are not at the critical point, but I am a little bit nervous that we may get there because they are not going to up the usual blood drives anytime this summer. We project [sometime] in the fall, but maybe not even then. So there needs to be a significant call-out for people to make every effort to donate blood,” said Dr. Osunkwo. She added that in places such as New York City that are hot spots for the COVID-19 outbreak, the need is likely a lot greater.

She recalled a recent incident at a New York hospital that highlighted how those managing blood supplies are being restrictive and how this could be harming patients.

“A sickle cell patient came in with COVID-19 and the treatment recommendation was do a red blood cell exchange but the blood bank was nervous about getting enough blood to supply for that exchange transfusion,” she said, noting that the doctor still went to bat for that patient to get the needed treatment. “We gave her the supporting evidence that when you are on treatment for sickle cell disease, you tend to do better if you get COVID-19 or any other viral infection. The symptoms of COVID-19 in sickle cell disease is acute chest syndrome, for which the treatment is red blood cell exchange. Not doing that for [these patients] is really not giving them the optimal way of managing their disease, and managing their disease in the setting of COVID-19.”

To that end, Dr. Osunkwo stressed that doctors need to be doing all they can to get the word out that blood is needed and that the American Red Cross and other donation organizations are making it safe for people to donate. She has been using social media to highlight when her fellow doctors and others make donations as a way to motivate individuals.

“Everybody can do something during this pandemic,” she said. “Don’t feel like you are not working, that you are not a frontline worker, that you have nothing to contribute. You can donate blood. Your cousin can donate blood. You can tell your friends, your neighbors, your relatives, your enemies to go donate. We will take every kind of blood we can get because people are needing it more now. Even though we canceled elective surgeries, my patients when they get COVID-19, they need more blood ... than they usually do during their regular sickle cell admission. It is going to be the same for people who have other blood disorders like cancer and leukemia. We can’t stop life-saving treatments just because we have the COVID pandemic.”

Dr. Osunkwo also praised recent actions taken by the Food and Drug Administration to lessen some of the deferral periods for when an individual can donate.

The FDA on April 2 issued three sets of revised recommendations aimed at getting more people eligible to donate blood. All of the revised recommendations will remain in effect after the COVID-19 health emergency is declared over.

The first revised recommendation makes changes to December 2015 guidance.

For male blood donors who would have been deferred for having sex with another male partner, the deferral period has been reduced from 12 months to 3 months. That deferral period change also applies to female donors who had sex with a man who had sex with another man as well as for those with recent tattoos and piercings.

The second recommendation revises guidance from August 2013 and relates to the risk of transfusion-transmitted malaria.

Under the new recommendations, for those who traveled to malaria-endemic areas (and are residents of malaria non-endemic countries), the FDA is lowering the recommended deferral period from 12 months to 3 months, and also provides notices of an alternate procedure that permits donations without a deferral period provided the blood components are pathogen-reduced using an FDA-approved pathogen reduction device.

The third recommendation finalizes draft guidance from January that eliminates the referral period for donors who spent time in certain European countries or were on military bases in Europe and were previously considered to have been exposed to a potential risk of transmission of Creutzfeldt-Jakob Disease or Variant Creutzfeldt-Jakob Disease.

Dr. Osunkwo reports consultancy and being on the speakers bureau and participating in the advisory board for Novartis, and relationships with a variety of other pharmaceutical companies. She is the editor-in-chief for Hematology News.

gtwachtman@mdedge.com

Medicine, as often said, is a business.

That’s often forgotten in a crisis, such as COVID-19, and with good reason. Our training in medicine is needed to care for the sick and find ways to prevent disease. Things like money are in the background when it comes to the emergencies of saving lives and helping the sick.

But that doesn’t mean finances don’t matter. They’re always in the background for medical practices of all sizes – just like any business.

Some practices have closed for patient and staff safety. I haven’t gone that far, as some people still need me. I am, after all, a doctor.

So I’m alone in my office, my staff working from home. That helps cut some lines of transmission there.

Like everyone else, I’m also doing telemedicine, and even a few phone appointments. These keep all involved safe, but also have a lot of limitations. They’re fine for checking up on stable, established patients, or following up on test results. But certainly not for new patients or established ones with new problems.

After all, you can’t evaluate a foot drop, extrapyramidal rigidity, or do an EMG/NCV over the video-phone connection.

In-person appointments are spaced out to minimize the number of people in my waiting room. Patients are told not to come in if they’re sick, and I insist we both be wearing masks (of pretty much any kind at this point). Common-use pens, such as those out in the waiting room, are wiped down with alcohol between uses.

People need to be seen, in both good and bad times. That’s the nature of medicine. But the business of medicine is always there, too. So, as the coronavirus emergency plays out, I have to watch my bank accounts closely.

With only two staff members, there really isn’t anyone extraneous to cut. I’ve stopped taking a paycheck so I can keep paying them, my rent, and the other miscellaneous costs of running an office.

I’ve always taken a bonus only at the end of the year, after all the other accounts have been paid, and take only a modest regular salary. In this case, that’s worked to my advantage, as I had more cash on hand when the emergency started. While not a huge amount, it’s enough to buy me some time, maybe several weeks, to see how this plays out. After that I’d have to tap into a line of credit, which obviously no one wants to do.

Telemedicine and the few office patients I’m seeing are a trickle of revenue. It’s better than nothing, but certainly isn’t enough to keep the door open and lights on.

That said, I’m not ungrateful. I’m well aware how fortunate my practice and family are compared to many others during this time. I haven’t had to ask for a pass on a mortgage or rent payment – yet. My staff and I have been together since 2004. I’m not going to break up a great team now.

I have no idea when things will turn around and people will start to come in. Your guess is as good as mine. I suspect the trickle will slowly increase at some point, then suddenly there will be a surge of calls for appointments from people who’ve been putting off coming in. Even then, though, I’ll likely space appointments apart and keep using a mask until it appears things are stable. There are going to be further waves of infections, and we don’t know how bad they’ll be.

Like everyone else, I can only hope for the best.

Dr. Block has a solo neurology practice in Scottsdale, Ariz. He has no relevant disclosures.

Medicine, as often said, is a business.

That’s often forgotten in a crisis, such as COVID-19, and with good reason. Our training in medicine is needed to care for the sick and find ways to prevent disease. Things like money are in the background when it comes to the emergencies of saving lives and helping the sick.

But that doesn’t mean finances don’t matter. They’re always in the background for medical practices of all sizes – just like any business.

Some practices have closed for patient and staff safety. I haven’t gone that far, as some people still need me. I am, after all, a doctor.

So I’m alone in my office, my staff working from home. That helps cut some lines of transmission there.

Like everyone else, I’m also doing telemedicine, and even a few phone appointments. These keep all involved safe, but also have a lot of limitations. They’re fine for checking up on stable, established patients, or following up on test results. But certainly not for new patients or established ones with new problems.

After all, you can’t evaluate a foot drop, extrapyramidal rigidity, or do an EMG/NCV over the video-phone connection.

In-person appointments are spaced out to minimize the number of people in my waiting room. Patients are told not to come in if they’re sick, and I insist we both be wearing masks (of pretty much any kind at this point). Common-use pens, such as those out in the waiting room, are wiped down with alcohol between uses.

People need to be seen, in both good and bad times. That’s the nature of medicine. But the business of medicine is always there, too. So, as the coronavirus emergency plays out, I have to watch my bank accounts closely.

With only two staff members, there really isn’t anyone extraneous to cut. I’ve stopped taking a paycheck so I can keep paying them, my rent, and the other miscellaneous costs of running an office.

I’ve always taken a bonus only at the end of the year, after all the other accounts have been paid, and take only a modest regular salary. In this case, that’s worked to my advantage, as I had more cash on hand when the emergency started. While not a huge amount, it’s enough to buy me some time, maybe several weeks, to see how this plays out. After that I’d have to tap into a line of credit, which obviously no one wants to do.

Telemedicine and the few office patients I’m seeing are a trickle of revenue. It’s better than nothing, but certainly isn’t enough to keep the door open and lights on.

That said, I’m not ungrateful. I’m well aware how fortunate my practice and family are compared to many others during this time. I haven’t had to ask for a pass on a mortgage or rent payment – yet. My staff and I have been together since 2004. I’m not going to break up a great team now.

I have no idea when things will turn around and people will start to come in. Your guess is as good as mine. I suspect the trickle will slowly increase at some point, then suddenly there will be a surge of calls for appointments from people who’ve been putting off coming in. Even then, though, I’ll likely space appointments apart and keep using a mask until it appears things are stable. There are going to be further waves of infections, and we don’t know how bad they’ll be.

Like everyone else, I can only hope for the best.

Dr. Block has a solo neurology practice in Scottsdale, Ariz. He has no relevant disclosures.

Medicine, as often said, is a business.

That’s often forgotten in a crisis, such as COVID-19, and with good reason. Our training in medicine is needed to care for the sick and find ways to prevent disease. Things like money are in the background when it comes to the emergencies of saving lives and helping the sick.

But that doesn’t mean finances don’t matter. They’re always in the background for medical practices of all sizes – just like any business.

Some practices have closed for patient and staff safety. I haven’t gone that far, as some people still need me. I am, after all, a doctor.

So I’m alone in my office, my staff working from home. That helps cut some lines of transmission there.

Like everyone else, I’m also doing telemedicine, and even a few phone appointments. These keep all involved safe, but also have a lot of limitations. They’re fine for checking up on stable, established patients, or following up on test results. But certainly not for new patients or established ones with new problems.

After all, you can’t evaluate a foot drop, extrapyramidal rigidity, or do an EMG/NCV over the video-phone connection.

In-person appointments are spaced out to minimize the number of people in my waiting room. Patients are told not to come in if they’re sick, and I insist we both be wearing masks (of pretty much any kind at this point). Common-use pens, such as those out in the waiting room, are wiped down with alcohol between uses.

People need to be seen, in both good and bad times. That’s the nature of medicine. But the business of medicine is always there, too. So, as the coronavirus emergency plays out, I have to watch my bank accounts closely.

With only two staff members, there really isn’t anyone extraneous to cut. I’ve stopped taking a paycheck so I can keep paying them, my rent, and the other miscellaneous costs of running an office.

I’ve always taken a bonus only at the end of the year, after all the other accounts have been paid, and take only a modest regular salary. In this case, that’s worked to my advantage, as I had more cash on hand when the emergency started. While not a huge amount, it’s enough to buy me some time, maybe several weeks, to see how this plays out. After that I’d have to tap into a line of credit, which obviously no one wants to do.

Telemedicine and the few office patients I’m seeing are a trickle of revenue. It’s better than nothing, but certainly isn’t enough to keep the door open and lights on.

That said, I’m not ungrateful. I’m well aware how fortunate my practice and family are compared to many others during this time. I haven’t had to ask for a pass on a mortgage or rent payment – yet. My staff and I have been together since 2004. I’m not going to break up a great team now.

I have no idea when things will turn around and people will start to come in. Your guess is as good as mine. I suspect the trickle will slowly increase at some point, then suddenly there will be a surge of calls for appointments from people who’ve been putting off coming in. Even then, though, I’ll likely space appointments apart and keep using a mask until it appears things are stable. There are going to be further waves of infections, and we don’t know how bad they’ll be.

Like everyone else, I can only hope for the best.

Dr. Block has a solo neurology practice in Scottsdale, Ariz. He has no relevant disclosures.

These are tough times for families, children, and practices. In this case, the entire world is going through it at the same time, leaving no escape. There are so many new things each of us needs to do, and for some of the challenges, we are completely thwarted by safety restrictions from doing anything. Adults and children alike are trying to work or learn at home in new ways. This also means that old daily routines have been broken. The sense of disorientation is pervasive. Although it is only one part of what is needed, reestablishing routines can go a long way toward restoring a sense of control and meaning that you can institute for yourself and recommend to your patients.

Wavebreakmedia/Thinkstock

Routines are important for both physical and mental health at every age and time, but especially when a major change is occurring. Examples of such change include natural disasters such as COVID-19, deaths, or separations from loved ones, but also moving, job loss, or new financial instability. Many families and many doctors and staff are experiencing several of these at once these days.

Evidence from studies of times of major disruption such as divorce, a death, war, and natural disasters show that parenting tends to shift to being less organized, with less overall discipline or more arbitrary punishment, and, in some cases, less parent-child connection. Children, on their part, also tend to act differently under these conditions. They are more irritable, upset, anxious, clingy, and aggressive, and also tend to regress in recent developmental achievements such as maintaining toileting and sleep patterns. Parents often do not see the connection to the stress and react to these behaviors in ways that may make things worse by scolding or punishing.

I was really surprised to hear Daniel Kahneman, PhD, Nobel laureate in economics, talk about how even he has trouble judging risk based on mathematical probability. Instead, he recognizes that adults decide about risk based on the behavior of the people around them – when others act worried or agitated, the person does too. Children, even more than adults, must decide if they are safe based on the behavior of the adults around them. When parents maintain routines as closely as possible after a major disruption, children feel reassured that they can expect continuity of their relationship – their most important lifeboat. If their parents keep doing the things they are used to, children basically feel safe.

Simple aspects of sameness important to children are very familiar to pediatricians: always wanting the same spoon, the sandwich cut the same way, only chicken nuggets from a certain store. This tends to be true in typically developing toddlers, preschool, and some school-aged children. The desire to have the same story read to them multiple times – until parents are ready to scream! – is another sign of the importance of predictable routines to children. All of these are best accommodated during times of stress rather than trying to “avoid making a bad habit.” All disruptions of routine are even more disorienting for children with intellectual disabilities or those on the autism spectrum who are generally less able to understand or control their world. Children and adults with preexisting anxiety disorders also are more likely to have more severe reactions to major disruptions and need extra understanding.

Routines for eating at least something at regular times – even if the food is not as interesting as prior fare – provide a sense of security, as well as stabilizing blood sugar and bowel patterns. Keeping patterns of washing hands, sitting together as a family, and interacting in conversation, rather than watching TV news, allow an oasis of respite from ongoing stresses. Family meals are also known to promote learning, vocabulary growth, and better behavior.

Setting a schedule for schooling, play, hygiene, and exercise may seem silly when parents and children are home all day, but it instills a sense of meaning to the day. Making a visual schedule for younger children or a written or online one for older children can be a shared activity in itself. I remember hearing about how important changing clothes and cleaning teeth were to prisoners of war during World War II in maintaining a sense of normalcy in that time of chaos.

Exercise is particularly important to set as a routine as it directly reduces stress – even if it may need to take new forms. While there are lots of online exercise programs for adults, it is better for everyone to go outside if they can manage adequate personal spacing. There they can experience the orderly changing of the seasons and the weather, as well as soak up some sunshine. Interactive parent-child play serves multiple purposes of stress relief, seeing each other more relaxed, interacting, and having fun!

Routines for sleep are especially important. To fall asleep under normal circumstances requires a sense of safety, perhaps for evolutionary reasons because of the vulnerability of the paralysis that is part of REM sleep stages. Fear at bedtime is common in young children, as is disorientation in the elderly. Both respond to reassuring bedtime routines done the same way every night, such as brushing teeth, changing clothes, washing up, reading or being read to, and praying – if these were the previous habit. When there has been a major disruption, these routines take on added importance, even if some modifications need to be made in sleep location, privacy, etc. Keeping schedules for naps, bedtime, and wake time as stable as possible makes sleep onset easier and sleep maintenance more likely. It also increases the chances of adequate sleep duration. Getting enough sleep stabilizes mood, reduces irritability, and improves daytime concentration and problem-solving skills. These all are especially needed by adults as well as children when there are major disruptions.

Maintaining chores at times of disruption can be extra difficult, plus this may seem to parents like an added stress for their already-stressed child. But in fact, children are reassured by adults’ continuing these requirements. Not only is an expectation that chores be done a signal that life can be expected to proceed normally, but having children do things to help – such as cleaning up, restocking soap and towels, or emptying trash – gives them an active role and hence some sense of control.

Discipline is, in essence, also a routine. Maintaining standards for kindness to others and following rules can be especially difficult when life has been disrupted because emotional lability is more likely in both adults and children when severely stressed. It is important for parents to consider the source of the misbehavior as possibly stress related and to interrupt it in a gentle and understanding way. A parent might say: “I know you are upset by all the changes. It is even more important now than ever to be kind to your brother.” Under stressful conditions, it is especially important to ask how the child was feeling when acting up, but also to “speak for them” about possible stress-related reasons for their behavior. While parents may correctly say that their child will “take advantage of this excuse,” it is still a teaching opportunity. Children have little insight into these connections to their feelings and actions, but they can learn.

Times when old patterns are disrupted also are times for making new habits. The main new habit I recommend for stress relief and overall mental health are the practices of mindfulness or meditation. Mindfulness may be easier to teach children as it involves paying close attention to one’s thoughts, feelings, and sensations, but doing this without judgment. Children often are naturally better at this than adults, who have layered on more experiences to their thoughts. We pediatricians, as well as the parents we serve, can benefit – especially in stressful times – from sharing in the simple ways children experience the world.

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. Email her at pdnews@mdedge.com.

These are tough times for families, children, and practices. In this case, the entire world is going through it at the same time, leaving no escape. There are so many new things each of us needs to do, and for some of the challenges, we are completely thwarted by safety restrictions from doing anything. Adults and children alike are trying to work or learn at home in new ways. This also means that old daily routines have been broken. The sense of disorientation is pervasive. Although it is only one part of what is needed, reestablishing routines can go a long way toward restoring a sense of control and meaning that you can institute for yourself and recommend to your patients.

Wavebreakmedia/Thinkstock

Routines are important for both physical and mental health at every age and time, but especially when a major change is occurring. Examples of such change include natural disasters such as COVID-19, deaths, or separations from loved ones, but also moving, job loss, or new financial instability. Many families and many doctors and staff are experiencing several of these at once these days.

Evidence from studies of times of major disruption such as divorce, a death, war, and natural disasters show that parenting tends to shift to being less organized, with less overall discipline or more arbitrary punishment, and, in some cases, less parent-child connection. Children, on their part, also tend to act differently under these conditions. They are more irritable, upset, anxious, clingy, and aggressive, and also tend to regress in recent developmental achievements such as maintaining toileting and sleep patterns. Parents often do not see the connection to the stress and react to these behaviors in ways that may make things worse by scolding or punishing.

I was really surprised to hear Daniel Kahneman, PhD, Nobel laureate in economics, talk about how even he has trouble judging risk based on mathematical probability. Instead, he recognizes that adults decide about risk based on the behavior of the people around them – when others act worried or agitated, the person does too. Children, even more than adults, must decide if they are safe based on the behavior of the adults around them. When parents maintain routines as closely as possible after a major disruption, children feel reassured that they can expect continuity of their relationship – their most important lifeboat. If their parents keep doing the things they are used to, children basically feel safe.

Simple aspects of sameness important to children are very familiar to pediatricians: always wanting the same spoon, the sandwich cut the same way, only chicken nuggets from a certain store. This tends to be true in typically developing toddlers, preschool, and some school-aged children. The desire to have the same story read to them multiple times – until parents are ready to scream! – is another sign of the importance of predictable routines to children. All of these are best accommodated during times of stress rather than trying to “avoid making a bad habit.” All disruptions of routine are even more disorienting for children with intellectual disabilities or those on the autism spectrum who are generally less able to understand or control their world. Children and adults with preexisting anxiety disorders also are more likely to have more severe reactions to major disruptions and need extra understanding.

Routines for eating at least something at regular times – even if the food is not as interesting as prior fare – provide a sense of security, as well as stabilizing blood sugar and bowel patterns. Keeping patterns of washing hands, sitting together as a family, and interacting in conversation, rather than watching TV news, allow an oasis of respite from ongoing stresses. Family meals are also known to promote learning, vocabulary growth, and better behavior.

Setting a schedule for schooling, play, hygiene, and exercise may seem silly when parents and children are home all day, but it instills a sense of meaning to the day. Making a visual schedule for younger children or a written or online one for older children can be a shared activity in itself. I remember hearing about how important changing clothes and cleaning teeth were to prisoners of war during World War II in maintaining a sense of normalcy in that time of chaos.

Exercise is particularly important to set as a routine as it directly reduces stress – even if it may need to take new forms. While there are lots of online exercise programs for adults, it is better for everyone to go outside if they can manage adequate personal spacing. There they can experience the orderly changing of the seasons and the weather, as well as soak up some sunshine. Interactive parent-child play serves multiple purposes of stress relief, seeing each other more relaxed, interacting, and having fun!

Routines for sleep are especially important. To fall asleep under normal circumstances requires a sense of safety, perhaps for evolutionary reasons because of the vulnerability of the paralysis that is part of REM sleep stages. Fear at bedtime is common in young children, as is disorientation in the elderly. Both respond to reassuring bedtime routines done the same way every night, such as brushing teeth, changing clothes, washing up, reading or being read to, and praying – if these were the previous habit. When there has been a major disruption, these routines take on added importance, even if some modifications need to be made in sleep location, privacy, etc. Keeping schedules for naps, bedtime, and wake time as stable as possible makes sleep onset easier and sleep maintenance more likely. It also increases the chances of adequate sleep duration. Getting enough sleep stabilizes mood, reduces irritability, and improves daytime concentration and problem-solving skills. These all are especially needed by adults as well as children when there are major disruptions.

Maintaining chores at times of disruption can be extra difficult, plus this may seem to parents like an added stress for their already-stressed child. But in fact, children are reassured by adults’ continuing these requirements. Not only is an expectation that chores be done a signal that life can be expected to proceed normally, but having children do things to help – such as cleaning up, restocking soap and towels, or emptying trash – gives them an active role and hence some sense of control.

Discipline is, in essence, also a routine. Maintaining standards for kindness to others and following rules can be especially difficult when life has been disrupted because emotional lability is more likely in both adults and children when severely stressed. It is important for parents to consider the source of the misbehavior as possibly stress related and to interrupt it in a gentle and understanding way. A parent might say: “I know you are upset by all the changes. It is even more important now than ever to be kind to your brother.” Under stressful conditions, it is especially important to ask how the child was feeling when acting up, but also to “speak for them” about possible stress-related reasons for their behavior. While parents may correctly say that their child will “take advantage of this excuse,” it is still a teaching opportunity. Children have little insight into these connections to their feelings and actions, but they can learn.

Times when old patterns are disrupted also are times for making new habits. The main new habit I recommend for stress relief and overall mental health are the practices of mindfulness or meditation. Mindfulness may be easier to teach children as it involves paying close attention to one’s thoughts, feelings, and sensations, but doing this without judgment. Children often are naturally better at this than adults, who have layered on more experiences to their thoughts. We pediatricians, as well as the parents we serve, can benefit – especially in stressful times – from sharing in the simple ways children experience the world.

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. Email her at pdnews@mdedge.com.

These are tough times for families, children, and practices. In this case, the entire world is going through it at the same time, leaving no escape. There are so many new things each of us needs to do, and for some of the challenges, we are completely thwarted by safety restrictions from doing anything. Adults and children alike are trying to work or learn at home in new ways. This also means that old daily routines have been broken. The sense of disorientation is pervasive. Although it is only one part of what is needed, reestablishing routines can go a long way toward restoring a sense of control and meaning that you can institute for yourself and recommend to your patients.

Wavebreakmedia/Thinkstock

Routines are important for both physical and mental health at every age and time, but especially when a major change is occurring. Examples of such change include natural disasters such as COVID-19, deaths, or separations from loved ones, but also moving, job loss, or new financial instability. Many families and many doctors and staff are experiencing several of these at once these days.

Evidence from studies of times of major disruption such as divorce, a death, war, and natural disasters show that parenting tends to shift to being less organized, with less overall discipline or more arbitrary punishment, and, in some cases, less parent-child connection. Children, on their part, also tend to act differently under these conditions. They are more irritable, upset, anxious, clingy, and aggressive, and also tend to regress in recent developmental achievements such as maintaining toileting and sleep patterns. Parents often do not see the connection to the stress and react to these behaviors in ways that may make things worse by scolding or punishing.

I was really surprised to hear Daniel Kahneman, PhD, Nobel laureate in economics, talk about how even he has trouble judging risk based on mathematical probability. Instead, he recognizes that adults decide about risk based on the behavior of the people around them – when others act worried or agitated, the person does too. Children, even more than adults, must decide if they are safe based on the behavior of the adults around them. When parents maintain routines as closely as possible after a major disruption, children feel reassured that they can expect continuity of their relationship – their most important lifeboat. If their parents keep doing the things they are used to, children basically feel safe.

Simple aspects of sameness important to children are very familiar to pediatricians: always wanting the same spoon, the sandwich cut the same way, only chicken nuggets from a certain store. This tends to be true in typically developing toddlers, preschool, and some school-aged children. The desire to have the same story read to them multiple times – until parents are ready to scream! – is another sign of the importance of predictable routines to children. All of these are best accommodated during times of stress rather than trying to “avoid making a bad habit.” All disruptions of routine are even more disorienting for children with intellectual disabilities or those on the autism spectrum who are generally less able to understand or control their world. Children and adults with preexisting anxiety disorders also are more likely to have more severe reactions to major disruptions and need extra understanding.

Routines for eating at least something at regular times – even if the food is not as interesting as prior fare – provide a sense of security, as well as stabilizing blood sugar and bowel patterns. Keeping patterns of washing hands, sitting together as a family, and interacting in conversation, rather than watching TV news, allow an oasis of respite from ongoing stresses. Family meals are also known to promote learning, vocabulary growth, and better behavior.

Setting a schedule for schooling, play, hygiene, and exercise may seem silly when parents and children are home all day, but it instills a sense of meaning to the day. Making a visual schedule for younger children or a written or online one for older children can be a shared activity in itself. I remember hearing about how important changing clothes and cleaning teeth were to prisoners of war during World War II in maintaining a sense of normalcy in that time of chaos.

Exercise is particularly important to set as a routine as it directly reduces stress – even if it may need to take new forms. While there are lots of online exercise programs for adults, it is better for everyone to go outside if they can manage adequate personal spacing. There they can experience the orderly changing of the seasons and the weather, as well as soak up some sunshine. Interactive parent-child play serves multiple purposes of stress relief, seeing each other more relaxed, interacting, and having fun!

Routines for sleep are especially important. To fall asleep under normal circumstances requires a sense of safety, perhaps for evolutionary reasons because of the vulnerability of the paralysis that is part of REM sleep stages. Fear at bedtime is common in young children, as is disorientation in the elderly. Both respond to reassuring bedtime routines done the same way every night, such as brushing teeth, changing clothes, washing up, reading or being read to, and praying – if these were the previous habit. When there has been a major disruption, these routines take on added importance, even if some modifications need to be made in sleep location, privacy, etc. Keeping schedules for naps, bedtime, and wake time as stable as possible makes sleep onset easier and sleep maintenance more likely. It also increases the chances of adequate sleep duration. Getting enough sleep stabilizes mood, reduces irritability, and improves daytime concentration and problem-solving skills. These all are especially needed by adults as well as children when there are major disruptions.

Maintaining chores at times of disruption can be extra difficult, plus this may seem to parents like an added stress for their already-stressed child. But in fact, children are reassured by adults’ continuing these requirements. Not only is an expectation that chores be done a signal that life can be expected to proceed normally, but having children do things to help – such as cleaning up, restocking soap and towels, or emptying trash – gives them an active role and hence some sense of control.

Discipline is, in essence, also a routine. Maintaining standards for kindness to others and following rules can be especially difficult when life has been disrupted because emotional lability is more likely in both adults and children when severely stressed. It is important for parents to consider the source of the misbehavior as possibly stress related and to interrupt it in a gentle and understanding way. A parent might say: “I know you are upset by all the changes. It is even more important now than ever to be kind to your brother.” Under stressful conditions, it is especially important to ask how the child was feeling when acting up, but also to “speak for them” about possible stress-related reasons for their behavior. While parents may correctly say that their child will “take advantage of this excuse,” it is still a teaching opportunity. Children have little insight into these connections to their feelings and actions, but they can learn.

Times when old patterns are disrupted also are times for making new habits. The main new habit I recommend for stress relief and overall mental health are the practices of mindfulness or meditation. Mindfulness may be easier to teach children as it involves paying close attention to one’s thoughts, feelings, and sensations, but doing this without judgment. Children often are naturally better at this than adults, who have layered on more experiences to their thoughts. We pediatricians, as well as the parents we serve, can benefit – especially in stressful times – from sharing in the simple ways children experience the world.

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. Email her at pdnews@mdedge.com.

Patients with type 2 diabetes who take metformin may have lower risk-adjusted mortality and readmission rates after surgery than do those who don’t take metformin, findings from a large retrospective cohort study suggest.

Of 10,088 individuals with diabetes who underwent a major surgery requiring hospital admission between January 1, 2010, and January 1, 2016, a total of 5,962 (59%) had received a prescription for metformin in the 180 days before surgery, and 5,460 of those patients were propensity score–matched to controls who did not receive a metformin prescription.

The study participants had a mean age of 67.7 years and underwent surgery requiring general anesthesia and postoperative admission at any of 15 hospitals in a single Pennsylvania health system. In addition to being prescribed metformin within 180 days before surgery, they also had metformin on their list of active medications at their most recent preoperative encounter before the surgery. The were followed until December 18, 2018.

In all, the 90-day and 5-year mortality hazards were reduced by 28% and 26%, respectively, in the metformin prescription recipients, compared with the propensity score–matched controls (hazard ratios, 0.72 and 0.74, respectively), Katherine M. Reitz, MD, and colleagues at the University of Pittsburgh reported in JAMA Surgery.

The readmission hazard – with mortality as a competing risk – was reduced by 16% at 30 days and 14% at 90 days (sub-HRs, 0.84 and 0.86, respectively), the researchers found.

“Hospital readmissions among those with preoperative metformin prescriptions were observed by postdischarge days 30 and 90 (304 [11%] and 538 [20.1%], respectively), whereas among those without prescriptions, 361 readmissions (13%) occurred by day 30 and 614 (23%) by day 90,” they wrote.

The investigators also noted that inflammation was reduced in patients who received a metformin prescription, compared with those who did not (mean preoperative neutrophil to leukocyte ratio, 4.5 vs. 5.0, respectively).

“In the full cohort, multivariable regression analysis similarly demonstrated that metformin was associated with a reduced hazard for both 90-day and 5-year mortality (adjusted HRs, 0.77 and 0.80, respectively) and for 30-day and 90-day readmission (aHR, 0.83 and 0.86), with mortality as a competing risk,” they added.

The findings support those from previous studies showing a decrease in all-cause mortality among diabetes patients taking metformin, said the researchers, noting that those patients had fewer age-related chronic diseases.

“These associations may reflect the anti-aging properties of metformin against the onset of disease or diabetes-associated complications. This study extends these finding by demonstrating that preoperative metformin prescriptions were associated with a reduction in postoperative mortality and readmission, a surrogate for postoperative complications, and with long-term mortality,” they wrote.

The study was limited by a number of factors, such as the potential for residual confounding inherent in retrospective analyses and a lack of adequate power to evaluate the association between metformin use and outcomes for individual surgical procedures. But the authors added that the findings are of note, because adults with comorbidities, such as diabetes, have less physiological reserve and an increased postoperative mortality and readmission rate. The results, therefore, warrant investigation with a prospective randomized clinical trial, they concluded.

In an accompanying editorial, Elizabeth L. George, MD, and Sherry M. Wren, MD, of Stanford (Calif.) University wrote that the study “demonstrates how variables, besides coexisting medical diseases, can affect surgical outcomes.”

“Metformin now joins beta-blockers, statins, and immunonutrition as preoperative agents associated with improved surgical outcomes,” they wrote, adding that future studies should factor in statin use and whether those and other medications should be continued postoperatively because metformin is often held after surgery owing to concerns about contrast agent interactions, whereas statin continuation is recommended.

Future studies of metformin in this setting should exclude patients who are taking statins, or look at possible interactions between the two agents, they said, adding that they would be “interested in seeing a subanalysis of this data set that excludes patients who were prescribed statins.”

“Those data would further solidify the role of metformin as a possible modifiable perioperative factor,” they wrote.

The study was funded by the University of Pittsburgh Medical Center and by grants from the National Heart, Lung, and Blood Institute and the National Institutes of Health. Dr. Reitz reported having no disclosures. Dr. George and Dr. Wren also reported having no disclosures.
 

sworcester@mdedge.com

SOURCE: Reitz K et al. JAMA Surg. 2020 Apr 8. doi: 10.1001/jamasurg.2020.0416.

Patients with type 2 diabetes who take metformin may have lower risk-adjusted mortality and readmission rates after surgery than do those who don’t take metformin, findings from a large retrospective cohort study suggest.

Of 10,088 individuals with diabetes who underwent a major surgery requiring hospital admission between January 1, 2010, and January 1, 2016, a total of 5,962 (59%) had received a prescription for metformin in the 180 days before surgery, and 5,460 of those patients were propensity score–matched to controls who did not receive a metformin prescription.

The study participants had a mean age of 67.7 years and underwent surgery requiring general anesthesia and postoperative admission at any of 15 hospitals in a single Pennsylvania health system. In addition to being prescribed metformin within 180 days before surgery, they also had metformin on their list of active medications at their most recent preoperative encounter before the surgery. The were followed until December 18, 2018.

In all, the 90-day and 5-year mortality hazards were reduced by 28% and 26%, respectively, in the metformin prescription recipients, compared with the propensity score–matched controls (hazard ratios, 0.72 and 0.74, respectively), Katherine M. Reitz, MD, and colleagues at the University of Pittsburgh reported in JAMA Surgery.

The readmission hazard – with mortality as a competing risk – was reduced by 16% at 30 days and 14% at 90 days (sub-HRs, 0.84 and 0.86, respectively), the researchers found.

“Hospital readmissions among those with preoperative metformin prescriptions were observed by postdischarge days 30 and 90 (304 [11%] and 538 [20.1%], respectively), whereas among those without prescriptions, 361 readmissions (13%) occurred by day 30 and 614 (23%) by day 90,” they wrote.

The investigators also noted that inflammation was reduced in patients who received a metformin prescription, compared with those who did not (mean preoperative neutrophil to leukocyte ratio, 4.5 vs. 5.0, respectively).

“In the full cohort, multivariable regression analysis similarly demonstrated that metformin was associated with a reduced hazard for both 90-day and 5-year mortality (adjusted HRs, 0.77 and 0.80, respectively) and for 30-day and 90-day readmission (aHR, 0.83 and 0.86), with mortality as a competing risk,” they added.

The findings support those from previous studies showing a decrease in all-cause mortality among diabetes patients taking metformin, said the researchers, noting that those patients had fewer age-related chronic diseases.

“These associations may reflect the anti-aging properties of metformin against the onset of disease or diabetes-associated complications. This study extends these finding by demonstrating that preoperative metformin prescriptions were associated with a reduction in postoperative mortality and readmission, a surrogate for postoperative complications, and with long-term mortality,” they wrote.

The study was limited by a number of factors, such as the potential for residual confounding inherent in retrospective analyses and a lack of adequate power to evaluate the association between metformin use and outcomes for individual surgical procedures. But the authors added that the findings are of note, because adults with comorbidities, such as diabetes, have less physiological reserve and an increased postoperative mortality and readmission rate. The results, therefore, warrant investigation with a prospective randomized clinical trial, they concluded.

In an accompanying editorial, Elizabeth L. George, MD, and Sherry M. Wren, MD, of Stanford (Calif.) University wrote that the study “demonstrates how variables, besides coexisting medical diseases, can affect surgical outcomes.”

“Metformin now joins beta-blockers, statins, and immunonutrition as preoperative agents associated with improved surgical outcomes,” they wrote, adding that future studies should factor in statin use and whether those and other medications should be continued postoperatively because metformin is often held after surgery owing to concerns about contrast agent interactions, whereas statin continuation is recommended.

Future studies of metformin in this setting should exclude patients who are taking statins, or look at possible interactions between the two agents, they said, adding that they would be “interested in seeing a subanalysis of this data set that excludes patients who were prescribed statins.”

“Those data would further solidify the role of metformin as a possible modifiable perioperative factor,” they wrote.

The study was funded by the University of Pittsburgh Medical Center and by grants from the National Heart, Lung, and Blood Institute and the National Institutes of Health. Dr. Reitz reported having no disclosures. Dr. George and Dr. Wren also reported having no disclosures.
 

sworcester@mdedge.com

SOURCE: Reitz K et al. JAMA Surg. 2020 Apr 8. doi: 10.1001/jamasurg.2020.0416.

Patients with type 2 diabetes who take metformin may have lower risk-adjusted mortality and readmission rates after surgery than do those who don’t take metformin, findings from a large retrospective cohort study suggest.

Of 10,088 individuals with diabetes who underwent a major surgery requiring hospital admission between January 1, 2010, and January 1, 2016, a total of 5,962 (59%) had received a prescription for metformin in the 180 days before surgery, and 5,460 of those patients were propensity score–matched to controls who did not receive a metformin prescription.

The study participants had a mean age of 67.7 years and underwent surgery requiring general anesthesia and postoperative admission at any of 15 hospitals in a single Pennsylvania health system. In addition to being prescribed metformin within 180 days before surgery, they also had metformin on their list of active medications at their most recent preoperative encounter before the surgery. The were followed until December 18, 2018.

In all, the 90-day and 5-year mortality hazards were reduced by 28% and 26%, respectively, in the metformin prescription recipients, compared with the propensity score–matched controls (hazard ratios, 0.72 and 0.74, respectively), Katherine M. Reitz, MD, and colleagues at the University of Pittsburgh reported in JAMA Surgery.

The readmission hazard – with mortality as a competing risk – was reduced by 16% at 30 days and 14% at 90 days (sub-HRs, 0.84 and 0.86, respectively), the researchers found.

“Hospital readmissions among those with preoperative metformin prescriptions were observed by postdischarge days 30 and 90 (304 [11%] and 538 [20.1%], respectively), whereas among those without prescriptions, 361 readmissions (13%) occurred by day 30 and 614 (23%) by day 90,” they wrote.

The investigators also noted that inflammation was reduced in patients who received a metformin prescription, compared with those who did not (mean preoperative neutrophil to leukocyte ratio, 4.5 vs. 5.0, respectively).

“In the full cohort, multivariable regression analysis similarly demonstrated that metformin was associated with a reduced hazard for both 90-day and 5-year mortality (adjusted HRs, 0.77 and 0.80, respectively) and for 30-day and 90-day readmission (aHR, 0.83 and 0.86), with mortality as a competing risk,” they added.

The findings support those from previous studies showing a decrease in all-cause mortality among diabetes patients taking metformin, said the researchers, noting that those patients had fewer age-related chronic diseases.

“These associations may reflect the anti-aging properties of metformin against the onset of disease or diabetes-associated complications. This study extends these finding by demonstrating that preoperative metformin prescriptions were associated with a reduction in postoperative mortality and readmission, a surrogate for postoperative complications, and with long-term mortality,” they wrote.

The study was limited by a number of factors, such as the potential for residual confounding inherent in retrospective analyses and a lack of adequate power to evaluate the association between metformin use and outcomes for individual surgical procedures. But the authors added that the findings are of note, because adults with comorbidities, such as diabetes, have less physiological reserve and an increased postoperative mortality and readmission rate. The results, therefore, warrant investigation with a prospective randomized clinical trial, they concluded.

In an accompanying editorial, Elizabeth L. George, MD, and Sherry M. Wren, MD, of Stanford (Calif.) University wrote that the study “demonstrates how variables, besides coexisting medical diseases, can affect surgical outcomes.”

“Metformin now joins beta-blockers, statins, and immunonutrition as preoperative agents associated with improved surgical outcomes,” they wrote, adding that future studies should factor in statin use and whether those and other medications should be continued postoperatively because metformin is often held after surgery owing to concerns about contrast agent interactions, whereas statin continuation is recommended.

Future studies of metformin in this setting should exclude patients who are taking statins, or look at possible interactions between the two agents, they said, adding that they would be “interested in seeing a subanalysis of this data set that excludes patients who were prescribed statins.”

“Those data would further solidify the role of metformin as a possible modifiable perioperative factor,” they wrote.

The study was funded by the University of Pittsburgh Medical Center and by grants from the National Heart, Lung, and Blood Institute and the National Institutes of Health. Dr. Reitz reported having no disclosures. Dr. George and Dr. Wren also reported having no disclosures.
 

sworcester@mdedge.com

SOURCE: Reitz K et al. JAMA Surg. 2020 Apr 8. doi: 10.1001/jamasurg.2020.0416.