Perspectives

With the COVID-19 pandemic, we are experiencing a once-in-a-100-year event. Dr. Steven A. Schulz, who is serving children on the front line in upstate New York, and I outline some of the challenges primary care pediatricians have been facing and solutions that have succeeded.

Reduction in direct patient care and its consequences

Geber86/E+

Because of the unknowns of COVID-19, many parents have not wanted to bring their children to a medical office because of fear of contracting SARS-CoV-2. At the same time, pediatricians have restricted in-person visits to prevent spread of SARS-CoV-2 and to help flatten the curve of infection. Use of pediatric medical professional services, compared with last year, dropped by 52% in March 2020 and by 58% in April, according to FAIR Health, a nonprofit organization that manages a database of 31 million claims. This is resulting in decreased immunization rates, which increases concern for secondary spikes of other preventable illnesses; for example, data from the Centers for Disease Control and Prevention showed that, from mid-March to mid-April 2020, physicians in the Vaccines for Children program ordered 2.5 million fewer doses of vaccines and 250,000 fewer doses of measles-containing vaccines, compared with the same period in 2019. Fewer children are being seen for well visits, which means opportunities are lost for adequate monitoring of growth, development, physical wellness, and social determinants of health.

This is occurring at a time when families have been experiencing increased stress in terms of finances, social isolation, finding adequate child care, and serving as parent, teacher, and breadwinner. An increase in injuries is occurring because of inadequate parental supervision because many parents have been distracted while working from home. An increase in cases of severe abuse is occurring because schools, child care providers, physicians, and other mandated reporters in the community have decreased interaction with children. Children’s Hospital Colorado in Colorado Springs saw a 118% increase in the number of trauma cases in its ED between January and April 2020. Some of these were accidental injuries caused by falls or bicycle accidents, but there was a 200% increase in nonaccidental trauma, which was associated with a steep fall in calls to the state’s child abuse hotline. Academic gains are being lost, and there has been worry for a prolonged “summer slide” risk, especially for children living in poverty and children with developmental disabilities.

The COVID-19 pandemic also is affecting physicians and staff. As frontline personnel, we are at risk to contract the virus, and news media reminds us of severe illness and deaths among health care workers. The pandemic is affecting financial viability; estimated revenue of pediatric offices fell by 45% in March 2020 and 48% in April, compared with the previous year, according to FAIR Health. Nurses and staff have been furloughed. Practices have had to apply for grants and Paycheck Protection Program funds while extending credit lines.
 

Limited testing capability for SARS-CoV-2

Testing for SARS-CoV-2 has been variably available. There have been problems with false positive and especially false negative results (BMJ. 2020 May 12. doi: 10.1136/bmj.m1808).The best specimen collection method has yet to be determined. Blood testing for antibody has been touted, but it remains unclear if there is clinical benefit because a positive result offers no guarantee of immunity, and immunity may quickly wane. Perhaps widespread primary care office–based testing will be in place by the fall, with hope for future reliable point of care results.

Evolving knowledge regarding SARS-CoV-2 and MIS-C

It initially was thought that children were relatively spared from serious illness caused by COVID-19. Then reports of cases of newly identified multisystem inflammatory syndrome of children occurred. It has been unclear how children contribute to the spread of COVID-19 illness, although emerging evidence indicates it is lower than adult transmission. What will happen when children return to school and daycare in the fall?

The challenges have led to creative solutions for how to deliver care.
 

Adapting to telehealth to provide care

At least for the short term, HIPAA regulations have been relaxed to allow for video visits using platforms such as FaceTime, Skype, Zoom, Doximity, and Doxy.me. Some of these platforms are HIPAA compliant and will be long-term solutions; however, electronic medical record portals allowing for video visits are the more secure option, according to HIPAA.

It has been a learning experience to see what can be accomplished with a video visit. Taking a history and visual examination of injuries and rashes has been possible. Addressing mental health concerns through the video exchange generally has been effective.

However, video visits change the provider-patient interpersonal dynamic and offer only visual exam capabilities, compared with an in-person visit. We cannot look in ears, palpate a liver and spleen, touch and examine a joint or bone, or feel a rash. Video visits also are dependent on the quality of patient Internet access, sufficient data plans, and mutual capabilities to address the inevitable technological glitches on the provider’s end as well. Expanding information technology infrastructure ability and added licensure costs have occurred. Practices and health systems have been working with insurance companies to ensure telephone and video visits are reimbursed on a comparable level to in-office visits.
 

A new type of office visit and developing appropriate safety plans

As understanding of SARS-CoV-2 transmission evolved, office work flows have been modified. Patients must be universally screened prior to arrival during appointment scheduling for well and illness visits. Patients aged older than 2 years and caregivers must wear masks on entering the facility. In many practices, patients are scheduled during specific sick or well visit time slots throughout the day. Waiting rooms chairs need to be spaced for 6-foot social distancing, and cars in the parking lot often serve as waiting rooms until staff can meet patients at the door and take them to the exam room. Alternate entrances, car-side exams, and drive-by and/or tent testing facilities often have become part of the new normal everyday practice. Creating virtual visit time blocks in provider’s schedules has allowed for decreased office congestion. Patients often are checked out from their room, as opposed to waiting in a line at a check out desk. Nurse triage protocols also have been adapted and enhanced to meet needs and concerns.

With the need for summer physicals and many regions opening up, a gradual return toward baseline has been evolving, although some of the twists of a “new normal” will stay in place. The new normal has been for providers and staff to wear surgical masks and face shields; sometimes N95 masks, gloves, and gowns have been needed. Cleaning rooms and equipment between patient visits has become a major, new time-consuming task. Acquiring and maintaining adequate supplies has been a challenge.
 

Summary

The American Academy of Pediatrics, CDC, and state and local health departments have been providing informative and regular updates, webinars, and best practices guidelines. Pediatricians, community organizations, schools, and mental health professionals have been collaborating, overcoming hurdles, and working together to help mitigate the effects of the pandemic on children, their families, and our communities. Continued education, cooperation, and adaptation will be needed in the months ahead. If there is a silver lining to this pandemic experience, it may be that families have grown closer together as they sheltered in place (and we have grown closer to our own families as well). One day perhaps a child who lived through this pandemic might be asked what it was like, and their recollection might be that it was a wonderful time because their parents stayed home all the time, took care of them, taught them their school work, and took lots of long family walks.

Dr. Schulz is pediatric medical director, Rochester (N.Y.) Regional Health. Dr. Pichichero is a specialist in pediatric infectious diseases and director of the Research Institute at Rochester (N.Y.) General Hospital. Dr. Schulz and Dr. Pichichero said they have no relevant financial disclosures. Email them at pdnews@mdedge.com.

This article was updated 7/16/2020.

With the COVID-19 pandemic, we are experiencing a once-in-a-100-year event. Dr. Steven A. Schulz, who is serving children on the front line in upstate New York, and I outline some of the challenges primary care pediatricians have been facing and solutions that have succeeded.

Reduction in direct patient care and its consequences

Geber86/E+

Because of the unknowns of COVID-19, many parents have not wanted to bring their children to a medical office because of fear of contracting SARS-CoV-2. At the same time, pediatricians have restricted in-person visits to prevent spread of SARS-CoV-2 and to help flatten the curve of infection. Use of pediatric medical professional services, compared with last year, dropped by 52% in March 2020 and by 58% in April, according to FAIR Health, a nonprofit organization that manages a database of 31 million claims. This is resulting in decreased immunization rates, which increases concern for secondary spikes of other preventable illnesses; for example, data from the Centers for Disease Control and Prevention showed that, from mid-March to mid-April 2020, physicians in the Vaccines for Children program ordered 2.5 million fewer doses of vaccines and 250,000 fewer doses of measles-containing vaccines, compared with the same period in 2019. Fewer children are being seen for well visits, which means opportunities are lost for adequate monitoring of growth, development, physical wellness, and social determinants of health.

This is occurring at a time when families have been experiencing increased stress in terms of finances, social isolation, finding adequate child care, and serving as parent, teacher, and breadwinner. An increase in injuries is occurring because of inadequate parental supervision because many parents have been distracted while working from home. An increase in cases of severe abuse is occurring because schools, child care providers, physicians, and other mandated reporters in the community have decreased interaction with children. Children’s Hospital Colorado in Colorado Springs saw a 118% increase in the number of trauma cases in its ED between January and April 2020. Some of these were accidental injuries caused by falls or bicycle accidents, but there was a 200% increase in nonaccidental trauma, which was associated with a steep fall in calls to the state’s child abuse hotline. Academic gains are being lost, and there has been worry for a prolonged “summer slide” risk, especially for children living in poverty and children with developmental disabilities.

The COVID-19 pandemic also is affecting physicians and staff. As frontline personnel, we are at risk to contract the virus, and news media reminds us of severe illness and deaths among health care workers. The pandemic is affecting financial viability; estimated revenue of pediatric offices fell by 45% in March 2020 and 48% in April, compared with the previous year, according to FAIR Health. Nurses and staff have been furloughed. Practices have had to apply for grants and Paycheck Protection Program funds while extending credit lines.
 

Limited testing capability for SARS-CoV-2

Testing for SARS-CoV-2 has been variably available. There have been problems with false positive and especially false negative results (BMJ. 2020 May 12. doi: 10.1136/bmj.m1808).The best specimen collection method has yet to be determined. Blood testing for antibody has been touted, but it remains unclear if there is clinical benefit because a positive result offers no guarantee of immunity, and immunity may quickly wane. Perhaps widespread primary care office–based testing will be in place by the fall, with hope for future reliable point of care results.

Evolving knowledge regarding SARS-CoV-2 and MIS-C

It initially was thought that children were relatively spared from serious illness caused by COVID-19. Then reports of cases of newly identified multisystem inflammatory syndrome of children occurred. It has been unclear how children contribute to the spread of COVID-19 illness, although emerging evidence indicates it is lower than adult transmission. What will happen when children return to school and daycare in the fall?

The challenges have led to creative solutions for how to deliver care.
 

Adapting to telehealth to provide care

At least for the short term, HIPAA regulations have been relaxed to allow for video visits using platforms such as FaceTime, Skype, Zoom, Doximity, and Doxy.me. Some of these platforms are HIPAA compliant and will be long-term solutions; however, electronic medical record portals allowing for video visits are the more secure option, according to HIPAA.

It has been a learning experience to see what can be accomplished with a video visit. Taking a history and visual examination of injuries and rashes has been possible. Addressing mental health concerns through the video exchange generally has been effective.

However, video visits change the provider-patient interpersonal dynamic and offer only visual exam capabilities, compared with an in-person visit. We cannot look in ears, palpate a liver and spleen, touch and examine a joint or bone, or feel a rash. Video visits also are dependent on the quality of patient Internet access, sufficient data plans, and mutual capabilities to address the inevitable technological glitches on the provider’s end as well. Expanding information technology infrastructure ability and added licensure costs have occurred. Practices and health systems have been working with insurance companies to ensure telephone and video visits are reimbursed on a comparable level to in-office visits.
 

A new type of office visit and developing appropriate safety plans

As understanding of SARS-CoV-2 transmission evolved, office work flows have been modified. Patients must be universally screened prior to arrival during appointment scheduling for well and illness visits. Patients aged older than 2 years and caregivers must wear masks on entering the facility. In many practices, patients are scheduled during specific sick or well visit time slots throughout the day. Waiting rooms chairs need to be spaced for 6-foot social distancing, and cars in the parking lot often serve as waiting rooms until staff can meet patients at the door and take them to the exam room. Alternate entrances, car-side exams, and drive-by and/or tent testing facilities often have become part of the new normal everyday practice. Creating virtual visit time blocks in provider’s schedules has allowed for decreased office congestion. Patients often are checked out from their room, as opposed to waiting in a line at a check out desk. Nurse triage protocols also have been adapted and enhanced to meet needs and concerns.

With the need for summer physicals and many regions opening up, a gradual return toward baseline has been evolving, although some of the twists of a “new normal” will stay in place. The new normal has been for providers and staff to wear surgical masks and face shields; sometimes N95 masks, gloves, and gowns have been needed. Cleaning rooms and equipment between patient visits has become a major, new time-consuming task. Acquiring and maintaining adequate supplies has been a challenge.
 

Summary

The American Academy of Pediatrics, CDC, and state and local health departments have been providing informative and regular updates, webinars, and best practices guidelines. Pediatricians, community organizations, schools, and mental health professionals have been collaborating, overcoming hurdles, and working together to help mitigate the effects of the pandemic on children, their families, and our communities. Continued education, cooperation, and adaptation will be needed in the months ahead. If there is a silver lining to this pandemic experience, it may be that families have grown closer together as they sheltered in place (and we have grown closer to our own families as well). One day perhaps a child who lived through this pandemic might be asked what it was like, and their recollection might be that it was a wonderful time because their parents stayed home all the time, took care of them, taught them their school work, and took lots of long family walks.

Dr. Schulz is pediatric medical director, Rochester (N.Y.) Regional Health. Dr. Pichichero is a specialist in pediatric infectious diseases and director of the Research Institute at Rochester (N.Y.) General Hospital. Dr. Schulz and Dr. Pichichero said they have no relevant financial disclosures. Email them at pdnews@mdedge.com.

This article was updated 7/16/2020.

With the COVID-19 pandemic, we are experiencing a once-in-a-100-year event. Dr. Steven A. Schulz, who is serving children on the front line in upstate New York, and I outline some of the challenges primary care pediatricians have been facing and solutions that have succeeded.

Reduction in direct patient care and its consequences

Geber86/E+

Because of the unknowns of COVID-19, many parents have not wanted to bring their children to a medical office because of fear of contracting SARS-CoV-2. At the same time, pediatricians have restricted in-person visits to prevent spread of SARS-CoV-2 and to help flatten the curve of infection. Use of pediatric medical professional services, compared with last year, dropped by 52% in March 2020 and by 58% in April, according to FAIR Health, a nonprofit organization that manages a database of 31 million claims. This is resulting in decreased immunization rates, which increases concern for secondary spikes of other preventable illnesses; for example, data from the Centers for Disease Control and Prevention showed that, from mid-March to mid-April 2020, physicians in the Vaccines for Children program ordered 2.5 million fewer doses of vaccines and 250,000 fewer doses of measles-containing vaccines, compared with the same period in 2019. Fewer children are being seen for well visits, which means opportunities are lost for adequate monitoring of growth, development, physical wellness, and social determinants of health.

This is occurring at a time when families have been experiencing increased stress in terms of finances, social isolation, finding adequate child care, and serving as parent, teacher, and breadwinner. An increase in injuries is occurring because of inadequate parental supervision because many parents have been distracted while working from home. An increase in cases of severe abuse is occurring because schools, child care providers, physicians, and other mandated reporters in the community have decreased interaction with children. Children’s Hospital Colorado in Colorado Springs saw a 118% increase in the number of trauma cases in its ED between January and April 2020. Some of these were accidental injuries caused by falls or bicycle accidents, but there was a 200% increase in nonaccidental trauma, which was associated with a steep fall in calls to the state’s child abuse hotline. Academic gains are being lost, and there has been worry for a prolonged “summer slide” risk, especially for children living in poverty and children with developmental disabilities.

The COVID-19 pandemic also is affecting physicians and staff. As frontline personnel, we are at risk to contract the virus, and news media reminds us of severe illness and deaths among health care workers. The pandemic is affecting financial viability; estimated revenue of pediatric offices fell by 45% in March 2020 and 48% in April, compared with the previous year, according to FAIR Health. Nurses and staff have been furloughed. Practices have had to apply for grants and Paycheck Protection Program funds while extending credit lines.
 

Limited testing capability for SARS-CoV-2

Testing for SARS-CoV-2 has been variably available. There have been problems with false positive and especially false negative results (BMJ. 2020 May 12. doi: 10.1136/bmj.m1808).The best specimen collection method has yet to be determined. Blood testing for antibody has been touted, but it remains unclear if there is clinical benefit because a positive result offers no guarantee of immunity, and immunity may quickly wane. Perhaps widespread primary care office–based testing will be in place by the fall, with hope for future reliable point of care results.

Evolving knowledge regarding SARS-CoV-2 and MIS-C

It initially was thought that children were relatively spared from serious illness caused by COVID-19. Then reports of cases of newly identified multisystem inflammatory syndrome of children occurred. It has been unclear how children contribute to the spread of COVID-19 illness, although emerging evidence indicates it is lower than adult transmission. What will happen when children return to school and daycare in the fall?

The challenges have led to creative solutions for how to deliver care.
 

Adapting to telehealth to provide care

At least for the short term, HIPAA regulations have been relaxed to allow for video visits using platforms such as FaceTime, Skype, Zoom, Doximity, and Doxy.me. Some of these platforms are HIPAA compliant and will be long-term solutions; however, electronic medical record portals allowing for video visits are the more secure option, according to HIPAA.

It has been a learning experience to see what can be accomplished with a video visit. Taking a history and visual examination of injuries and rashes has been possible. Addressing mental health concerns through the video exchange generally has been effective.

However, video visits change the provider-patient interpersonal dynamic and offer only visual exam capabilities, compared with an in-person visit. We cannot look in ears, palpate a liver and spleen, touch and examine a joint or bone, or feel a rash. Video visits also are dependent on the quality of patient Internet access, sufficient data plans, and mutual capabilities to address the inevitable technological glitches on the provider’s end as well. Expanding information technology infrastructure ability and added licensure costs have occurred. Practices and health systems have been working with insurance companies to ensure telephone and video visits are reimbursed on a comparable level to in-office visits.
 

A new type of office visit and developing appropriate safety plans

As understanding of SARS-CoV-2 transmission evolved, office work flows have been modified. Patients must be universally screened prior to arrival during appointment scheduling for well and illness visits. Patients aged older than 2 years and caregivers must wear masks on entering the facility. In many practices, patients are scheduled during specific sick or well visit time slots throughout the day. Waiting rooms chairs need to be spaced for 6-foot social distancing, and cars in the parking lot often serve as waiting rooms until staff can meet patients at the door and take them to the exam room. Alternate entrances, car-side exams, and drive-by and/or tent testing facilities often have become part of the new normal everyday practice. Creating virtual visit time blocks in provider’s schedules has allowed for decreased office congestion. Patients often are checked out from their room, as opposed to waiting in a line at a check out desk. Nurse triage protocols also have been adapted and enhanced to meet needs and concerns.

With the need for summer physicals and many regions opening up, a gradual return toward baseline has been evolving, although some of the twists of a “new normal” will stay in place. The new normal has been for providers and staff to wear surgical masks and face shields; sometimes N95 masks, gloves, and gowns have been needed. Cleaning rooms and equipment between patient visits has become a major, new time-consuming task. Acquiring and maintaining adequate supplies has been a challenge.
 

Summary

The American Academy of Pediatrics, CDC, and state and local health departments have been providing informative and regular updates, webinars, and best practices guidelines. Pediatricians, community organizations, schools, and mental health professionals have been collaborating, overcoming hurdles, and working together to help mitigate the effects of the pandemic on children, their families, and our communities. Continued education, cooperation, and adaptation will be needed in the months ahead. If there is a silver lining to this pandemic experience, it may be that families have grown closer together as they sheltered in place (and we have grown closer to our own families as well). One day perhaps a child who lived through this pandemic might be asked what it was like, and their recollection might be that it was a wonderful time because their parents stayed home all the time, took care of them, taught them their school work, and took lots of long family walks.

Dr. Schulz is pediatric medical director, Rochester (N.Y.) Regional Health. Dr. Pichichero is a specialist in pediatric infectious diseases and director of the Research Institute at Rochester (N.Y.) General Hospital. Dr. Schulz and Dr. Pichichero said they have no relevant financial disclosures. Email them at pdnews@mdedge.com.

This article was updated 7/16/2020.

The coronavirus pandemic has fundamentally altered American health care. At our academic medical center in Brooklyn, a large safety net institution, clinical year medical students are normally integral members of the team consistent with the model of “value-added medical education.”¹ With the suspension of clinical rotations on March 13, 2020, a key part of the workforce was suddenly withdrawn while demand skyrocketed.

In response, students self-organized into numerous remote support projects, including the project described below.

Under infection control regulations, a “no-visitor” policy was instituted. Concurrently, the dramatic increase in patient volume left clinicians unable to regularly update patients’ families. To address this gap, a family contact line was created.

A dedicated phone number was distributed to key hospital personnel to share with families seeking information. The work flow for returning calls is shown in the figure. After verifying patient information and the caller’s relation, students provide updates based on chart review. Calls are prefaced with the disclaimer that students are not part of the treatment team and can only give information that is accessible via the electronic medical record.

Students created a phone script in conjunction with faculty, as well as a referral system for those seeking specific information from other departments. This script undergoes daily revision after the student huddle to address new issues. Flow of information is bidirectional: students relay patient updates as well as quarantine precautions and obtain past medical history. This proved essential during the surge of patients, unknown to the hospital and frequently altered, arriving by ambulance. Students document these conversations in the EMR, including family concerns and whether immediate provider follow-up is needed.

Two key limitations were quickly addressed: First, patients requiring ICU-level care have fluctuating courses, and an update based solely on chart review is insufficient. In response, students worked with intensivist teams to create a dedicated call line staffed by providers.

Second, conversations regarding goals of care and end of life concerns were beyond students’ scope. Together with palliative care teams, students developed criteria for flagging families for follow-up by a consulting palliative care attending.

Through working the call line, students received a crash course in empathetically communicating over the phone. Particularly during the worst of the surge, families were afraid and often frustrated at the lack of communication up to that point. Navigating these emotions, learning how to update family members while removed from the teams, and educating callers on quarantine precautions and other concerns was a valuable learning experience.

As students, we have been exposed to many of the realities of communicating as a physician. Relaying updates and prognosis to family while also providing emotional support is not something we are taught in medical school, but is something we will be expected to handle our first night on the wards as an intern. This experience has prepared us well for that and has illuminated missing parts of the medical school curriculum we are working on emphasizing moving forward.

Over the first 2 weeks, students put in 848 volunteer-hours, making 1,438 calls which reached 1,114 different families. We hope our experience proves instructive for other academic medical centers facing similar concerns in coming months. This model allows medical students to be directly involved in patient care during this crisis and shifts these time-intensive conversations away from overwhelmed primary medical teams.
 

Reference

1. Gonzalo JD et al. Value-added clinical systems learning roles for 355 medical students that transform education and health: A guide for building partnerships between 356 medical schools and health systems. Acad Med. 2017;92(5):602-7.
 

Ms. Jaiman is an MD candidate at State University of New York, Brooklyn and a PhD candidate at the National Center of Biological Sciences in Bangalore, India. Mr. Hessburg is an MD/PhD candidate at State University of New York, Brooklyn. Dr. Egelko is a recent graduate of State University of New York, Brooklyn.

The coronavirus pandemic has fundamentally altered American health care. At our academic medical center in Brooklyn, a large safety net institution, clinical year medical students are normally integral members of the team consistent with the model of “value-added medical education.”¹ With the suspension of clinical rotations on March 13, 2020, a key part of the workforce was suddenly withdrawn while demand skyrocketed.

In response, students self-organized into numerous remote support projects, including the project described below.

Under infection control regulations, a “no-visitor” policy was instituted. Concurrently, the dramatic increase in patient volume left clinicians unable to regularly update patients’ families. To address this gap, a family contact line was created.

A dedicated phone number was distributed to key hospital personnel to share with families seeking information. The work flow for returning calls is shown in the figure. After verifying patient information and the caller’s relation, students provide updates based on chart review. Calls are prefaced with the disclaimer that students are not part of the treatment team and can only give information that is accessible via the electronic medical record.

Students created a phone script in conjunction with faculty, as well as a referral system for those seeking specific information from other departments. This script undergoes daily revision after the student huddle to address new issues. Flow of information is bidirectional: students relay patient updates as well as quarantine precautions and obtain past medical history. This proved essential during the surge of patients, unknown to the hospital and frequently altered, arriving by ambulance. Students document these conversations in the EMR, including family concerns and whether immediate provider follow-up is needed.

Two key limitations were quickly addressed: First, patients requiring ICU-level care have fluctuating courses, and an update based solely on chart review is insufficient. In response, students worked with intensivist teams to create a dedicated call line staffed by providers.

Second, conversations regarding goals of care and end of life concerns were beyond students’ scope. Together with palliative care teams, students developed criteria for flagging families for follow-up by a consulting palliative care attending.

Through working the call line, students received a crash course in empathetically communicating over the phone. Particularly during the worst of the surge, families were afraid and often frustrated at the lack of communication up to that point. Navigating these emotions, learning how to update family members while removed from the teams, and educating callers on quarantine precautions and other concerns was a valuable learning experience.

As students, we have been exposed to many of the realities of communicating as a physician. Relaying updates and prognosis to family while also providing emotional support is not something we are taught in medical school, but is something we will be expected to handle our first night on the wards as an intern. This experience has prepared us well for that and has illuminated missing parts of the medical school curriculum we are working on emphasizing moving forward.

Over the first 2 weeks, students put in 848 volunteer-hours, making 1,438 calls which reached 1,114 different families. We hope our experience proves instructive for other academic medical centers facing similar concerns in coming months. This model allows medical students to be directly involved in patient care during this crisis and shifts these time-intensive conversations away from overwhelmed primary medical teams.
 

Reference

1. Gonzalo JD et al. Value-added clinical systems learning roles for 355 medical students that transform education and health: A guide for building partnerships between 356 medical schools and health systems. Acad Med. 2017;92(5):602-7.
 

Ms. Jaiman is an MD candidate at State University of New York, Brooklyn and a PhD candidate at the National Center of Biological Sciences in Bangalore, India. Mr. Hessburg is an MD/PhD candidate at State University of New York, Brooklyn. Dr. Egelko is a recent graduate of State University of New York, Brooklyn.

The coronavirus pandemic has fundamentally altered American health care. At our academic medical center in Brooklyn, a large safety net institution, clinical year medical students are normally integral members of the team consistent with the model of “value-added medical education.”¹ With the suspension of clinical rotations on March 13, 2020, a key part of the workforce was suddenly withdrawn while demand skyrocketed.

In response, students self-organized into numerous remote support projects, including the project described below.

Under infection control regulations, a “no-visitor” policy was instituted. Concurrently, the dramatic increase in patient volume left clinicians unable to regularly update patients’ families. To address this gap, a family contact line was created.

A dedicated phone number was distributed to key hospital personnel to share with families seeking information. The work flow for returning calls is shown in the figure. After verifying patient information and the caller’s relation, students provide updates based on chart review. Calls are prefaced with the disclaimer that students are not part of the treatment team and can only give information that is accessible via the electronic medical record.

Students created a phone script in conjunction with faculty, as well as a referral system for those seeking specific information from other departments. This script undergoes daily revision after the student huddle to address new issues. Flow of information is bidirectional: students relay patient updates as well as quarantine precautions and obtain past medical history. This proved essential during the surge of patients, unknown to the hospital and frequently altered, arriving by ambulance. Students document these conversations in the EMR, including family concerns and whether immediate provider follow-up is needed.

Two key limitations were quickly addressed: First, patients requiring ICU-level care have fluctuating courses, and an update based solely on chart review is insufficient. In response, students worked with intensivist teams to create a dedicated call line staffed by providers.

Second, conversations regarding goals of care and end of life concerns were beyond students’ scope. Together with palliative care teams, students developed criteria for flagging families for follow-up by a consulting palliative care attending.

Through working the call line, students received a crash course in empathetically communicating over the phone. Particularly during the worst of the surge, families were afraid and often frustrated at the lack of communication up to that point. Navigating these emotions, learning how to update family members while removed from the teams, and educating callers on quarantine precautions and other concerns was a valuable learning experience.

As students, we have been exposed to many of the realities of communicating as a physician. Relaying updates and prognosis to family while also providing emotional support is not something we are taught in medical school, but is something we will be expected to handle our first night on the wards as an intern. This experience has prepared us well for that and has illuminated missing parts of the medical school curriculum we are working on emphasizing moving forward.

Over the first 2 weeks, students put in 848 volunteer-hours, making 1,438 calls which reached 1,114 different families. We hope our experience proves instructive for other academic medical centers facing similar concerns in coming months. This model allows medical students to be directly involved in patient care during this crisis and shifts these time-intensive conversations away from overwhelmed primary medical teams.
 

Reference

1. Gonzalo JD et al. Value-added clinical systems learning roles for 355 medical students that transform education and health: A guide for building partnerships between 356 medical schools and health systems. Acad Med. 2017;92(5):602-7.
 

Ms. Jaiman is an MD candidate at State University of New York, Brooklyn and a PhD candidate at the National Center of Biological Sciences in Bangalore, India. Mr. Hessburg is an MD/PhD candidate at State University of New York, Brooklyn. Dr. Egelko is a recent graduate of State University of New York, Brooklyn.

Having been a bench research scientist 30 years ago, I am flabbergasted at what is and is not currently possible. In a few weeks, scientists sequenced a novel coronavirus and used the genetic sequence to select candidate molecules for a vaccine. But we still can’t reliably say how much protection a cloth mask provides. Worse yet, even if/when we could reliably quantify contagion, it isn’t clear that the public will believe us anyhow.

Thinkstock

The good news is that the public worldwide did believe scientists about the threat of a pandemic and the need to flatten the curve. Saving lives has not been about the strength of an antibiotic or the skill in managing a ventilator, but the credibility of medical scientists. The degree of acceptance was variable and subject to a variety of delays caused by regional politicians, but overall the scientific advice on social distancing has had a gigantic impact on the spread of the pandemic in the February to June time frame. The bad news is that the public’s trust in that scientific advice has waned, the willingness to accept onerous restrictions has fatigued, and the cooperation for maintaining these social changes is evaporating.

I will leave pontificating about the spread of COVID-19 to other experts in other forums. My focus is on the public’s trust in the professionalism of physicians, nurses, medical scientists, and the health care industry as a whole. That trust has been our most valuable tool in fighting the pandemic so far. There have been situations in which weaknesses in modern science have let society down during the pandemic of the century. In my February 2020 column, at the beginning of the outbreak, a month before it was declared a pandemic, when its magnitude was still unclear, I emphasized the importance of having a trusted scientific spokesperson providing timely, accurate information to the public. That, obviously, did not happen in the United States and the degree of the ensuing disaster is still to be revealed.

Scientists have made some wrong decisions about this novel threat. The advice on masks is an illustrative example. For many years, infection control nurses have insisted that medical students wear a mask to protect themselves, even if they were observing rounds from just inside the doorway of a room of a baby with bronchiolitis. The landfills are full of briefly worn surgical masks. Now the story goes: Surgical masks don’t protect staff; they protect others. Changes like that contribute to a credibility gap.

For 3 months, there was conflicting advice about the appropriateness of masks. In early March 2020, some health care workers were disciplined for wearing personal masks. Now, most scientists recommend the public use masks to reduce contagion. Significant subgroups in the U.S. population have refused, mostly to signal their contrarian politics. In June there was an anecdote of a success story from the Show Me state of Missouri, where a mask is credited for preventing an outbreak from a sick hair stylist.

It is hard to find something more reliable than an anecdote. On June 1, a meta-analysis funded by the World Health Organization was published online by Lancet. It supports the idea that masks are beneficial. It is mostly forest plots, so you can try to interpret it yourself. There were 172 observational studies in the systematic review, and the meta-analysis contains 44 relevant comparative studies and 0 randomized controlled trials. Most of those forest plots have an I2 of 75% or worse, which to me indicates that they are not much more reliable than a good anecdote. My primary conclusion was that modern academic science, in an era with a shortage of toilet paper, should convert to printing on soft tissue paper.

It is important to note that the guesstimated overall benefit of cloth masks was a relative risk of 0.30. That benefit is easily nullified if the false security of a mask causes people to congregate together in groups three times larger or for three times more minutes. N95 masks were more effective.

A different article was published in PNAS on June 11. Its senior author was awarded the Nobel Prize in Chemistry in 1995. That article touted the benefits of masks. The article is facing heavy criticism for flaws in methodology and flaws in the peer review process. A long list of signatories have joined a letter asking for the article’s retraction.

This article, when combined with the two instances of prominent articles being retracted in the prior month by the New England Journal of Medicine and The Lancet, is accumulating evidence the peer review system is not working as intended.

There are many heroes in this pandemic, from the frontline health care workers in hotspots to the grocery workers and cleaning staff. There is hope, indeed some faith, that medical scientists in the foreseeable future will provide treatments and a vaccine for this viral plague. This month, the credibility of scientists again plays a major role as communities respond to outbreaks related to reopening the economy. Let’s celebrate the victories, resolve to fix the impure system, and restore a high level of public trust in science. Lives depend on it.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He has no relevant financial disclosures. Email him at pdnews@mdedge.com.

Having been a bench research scientist 30 years ago, I am flabbergasted at what is and is not currently possible. In a few weeks, scientists sequenced a novel coronavirus and used the genetic sequence to select candidate molecules for a vaccine. But we still can’t reliably say how much protection a cloth mask provides. Worse yet, even if/when we could reliably quantify contagion, it isn’t clear that the public will believe us anyhow.

Thinkstock

The good news is that the public worldwide did believe scientists about the threat of a pandemic and the need to flatten the curve. Saving lives has not been about the strength of an antibiotic or the skill in managing a ventilator, but the credibility of medical scientists. The degree of acceptance was variable and subject to a variety of delays caused by regional politicians, but overall the scientific advice on social distancing has had a gigantic impact on the spread of the pandemic in the February to June time frame. The bad news is that the public’s trust in that scientific advice has waned, the willingness to accept onerous restrictions has fatigued, and the cooperation for maintaining these social changes is evaporating.

I will leave pontificating about the spread of COVID-19 to other experts in other forums. My focus is on the public’s trust in the professionalism of physicians, nurses, medical scientists, and the health care industry as a whole. That trust has been our most valuable tool in fighting the pandemic so far. There have been situations in which weaknesses in modern science have let society down during the pandemic of the century. In my February 2020 column, at the beginning of the outbreak, a month before it was declared a pandemic, when its magnitude was still unclear, I emphasized the importance of having a trusted scientific spokesperson providing timely, accurate information to the public. That, obviously, did not happen in the United States and the degree of the ensuing disaster is still to be revealed.

Scientists have made some wrong decisions about this novel threat. The advice on masks is an illustrative example. For many years, infection control nurses have insisted that medical students wear a mask to protect themselves, even if they were observing rounds from just inside the doorway of a room of a baby with bronchiolitis. The landfills are full of briefly worn surgical masks. Now the story goes: Surgical masks don’t protect staff; they protect others. Changes like that contribute to a credibility gap.

For 3 months, there was conflicting advice about the appropriateness of masks. In early March 2020, some health care workers were disciplined for wearing personal masks. Now, most scientists recommend the public use masks to reduce contagion. Significant subgroups in the U.S. population have refused, mostly to signal their contrarian politics. In June there was an anecdote of a success story from the Show Me state of Missouri, where a mask is credited for preventing an outbreak from a sick hair stylist.

It is hard to find something more reliable than an anecdote. On June 1, a meta-analysis funded by the World Health Organization was published online by Lancet. It supports the idea that masks are beneficial. It is mostly forest plots, so you can try to interpret it yourself. There were 172 observational studies in the systematic review, and the meta-analysis contains 44 relevant comparative studies and 0 randomized controlled trials. Most of those forest plots have an I2 of 75% or worse, which to me indicates that they are not much more reliable than a good anecdote. My primary conclusion was that modern academic science, in an era with a shortage of toilet paper, should convert to printing on soft tissue paper.

It is important to note that the guesstimated overall benefit of cloth masks was a relative risk of 0.30. That benefit is easily nullified if the false security of a mask causes people to congregate together in groups three times larger or for three times more minutes. N95 masks were more effective.

A different article was published in PNAS on June 11. Its senior author was awarded the Nobel Prize in Chemistry in 1995. That article touted the benefits of masks. The article is facing heavy criticism for flaws in methodology and flaws in the peer review process. A long list of signatories have joined a letter asking for the article’s retraction.

This article, when combined with the two instances of prominent articles being retracted in the prior month by the New England Journal of Medicine and The Lancet, is accumulating evidence the peer review system is not working as intended.

There are many heroes in this pandemic, from the frontline health care workers in hotspots to the grocery workers and cleaning staff. There is hope, indeed some faith, that medical scientists in the foreseeable future will provide treatments and a vaccine for this viral plague. This month, the credibility of scientists again plays a major role as communities respond to outbreaks related to reopening the economy. Let’s celebrate the victories, resolve to fix the impure system, and restore a high level of public trust in science. Lives depend on it.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He has no relevant financial disclosures. Email him at pdnews@mdedge.com.

Having been a bench research scientist 30 years ago, I am flabbergasted at what is and is not currently possible. In a few weeks, scientists sequenced a novel coronavirus and used the genetic sequence to select candidate molecules for a vaccine. But we still can’t reliably say how much protection a cloth mask provides. Worse yet, even if/when we could reliably quantify contagion, it isn’t clear that the public will believe us anyhow.

Thinkstock

The good news is that the public worldwide did believe scientists about the threat of a pandemic and the need to flatten the curve. Saving lives has not been about the strength of an antibiotic or the skill in managing a ventilator, but the credibility of medical scientists. The degree of acceptance was variable and subject to a variety of delays caused by regional politicians, but overall the scientific advice on social distancing has had a gigantic impact on the spread of the pandemic in the February to June time frame. The bad news is that the public’s trust in that scientific advice has waned, the willingness to accept onerous restrictions has fatigued, and the cooperation for maintaining these social changes is evaporating.

I will leave pontificating about the spread of COVID-19 to other experts in other forums. My focus is on the public’s trust in the professionalism of physicians, nurses, medical scientists, and the health care industry as a whole. That trust has been our most valuable tool in fighting the pandemic so far. There have been situations in which weaknesses in modern science have let society down during the pandemic of the century. In my February 2020 column, at the beginning of the outbreak, a month before it was declared a pandemic, when its magnitude was still unclear, I emphasized the importance of having a trusted scientific spokesperson providing timely, accurate information to the public. That, obviously, did not happen in the United States and the degree of the ensuing disaster is still to be revealed.

Scientists have made some wrong decisions about this novel threat. The advice on masks is an illustrative example. For many years, infection control nurses have insisted that medical students wear a mask to protect themselves, even if they were observing rounds from just inside the doorway of a room of a baby with bronchiolitis. The landfills are full of briefly worn surgical masks. Now the story goes: Surgical masks don’t protect staff; they protect others. Changes like that contribute to a credibility gap.

For 3 months, there was conflicting advice about the appropriateness of masks. In early March 2020, some health care workers were disciplined for wearing personal masks. Now, most scientists recommend the public use masks to reduce contagion. Significant subgroups in the U.S. population have refused, mostly to signal their contrarian politics. In June there was an anecdote of a success story from the Show Me state of Missouri, where a mask is credited for preventing an outbreak from a sick hair stylist.

It is hard to find something more reliable than an anecdote. On June 1, a meta-analysis funded by the World Health Organization was published online by Lancet. It supports the idea that masks are beneficial. It is mostly forest plots, so you can try to interpret it yourself. There were 172 observational studies in the systematic review, and the meta-analysis contains 44 relevant comparative studies and 0 randomized controlled trials. Most of those forest plots have an I2 of 75% or worse, which to me indicates that they are not much more reliable than a good anecdote. My primary conclusion was that modern academic science, in an era with a shortage of toilet paper, should convert to printing on soft tissue paper.

It is important to note that the guesstimated overall benefit of cloth masks was a relative risk of 0.30. That benefit is easily nullified if the false security of a mask causes people to congregate together in groups three times larger or for three times more minutes. N95 masks were more effective.

A different article was published in PNAS on June 11. Its senior author was awarded the Nobel Prize in Chemistry in 1995. That article touted the benefits of masks. The article is facing heavy criticism for flaws in methodology and flaws in the peer review process. A long list of signatories have joined a letter asking for the article’s retraction.

This article, when combined with the two instances of prominent articles being retracted in the prior month by the New England Journal of Medicine and The Lancet, is accumulating evidence the peer review system is not working as intended.

There are many heroes in this pandemic, from the frontline health care workers in hotspots to the grocery workers and cleaning staff. There is hope, indeed some faith, that medical scientists in the foreseeable future will provide treatments and a vaccine for this viral plague. This month, the credibility of scientists again plays a major role as communities respond to outbreaks related to reopening the economy. Let’s celebrate the victories, resolve to fix the impure system, and restore a high level of public trust in science. Lives depend on it.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He has no relevant financial disclosures. Email him at pdnews@mdedge.com.

The COVID-19 pandemic is one of the defining moments in history for this generation’s health care leaders. In 2019, most of us wrongly assumed that this virus would be similar to the past viral epidemics and pandemics such as 2002 severe acute respiratory syndrome–CoV in Asia, 2009 H1N1 influenza in the United States, 2012 Middle East respiratory syndrome–CoV in Saudi Arabia, and 2014-2016 Ebola in West Africa. Moreover, we understood that the 50% fatality rate of Ebola, a single-stranded RNA virus, was deadly on the continent of Africa, but its transmission was through direct contact with blood or other bodily fluids. Hence, the infectivity of Ebola to the general public was lower than SARS-CoV-2, which is spread by respiratory droplets and contact routes in addition to being the virus that causes COVID-19.¹ Many of us did not expect that SARS-CoV-2, a single-stranded RNA virus consisting of 32 kilobytes, would reach the shores of the United States from the Hubei province of China, the northern Lombardy region of Italy, or other initial hotspots. We could not imagine its effects would be so devastating from an economic and medical perspective. Until it did.

The first reported case of SARS-CoV-2 was on Jan. 20, 2020 in Snohomish County, Wash., and the first known death from COVID-19 occurred on Feb. 6, 2020 in Santa Clara County, Calif.^2,3 Since then, the United States has lost over 135,000 people from COVID-19 with death(s) reported in every state and the highest number of overall deaths of any country in the world.⁴ At the beginning of 2020, at our institution, Wake Forest Baptist Health System in Winston-Salem, N.C., we began preparing for the wave, surge, or tsunami of inpatients that was coming. Plans were afoot to increase our staff, even perhaps by hiring out-of-state physicians and nurses if needed, and every possible bed was considered within the system. It was not an if, but rather a when, as to the arrival of COVID-19.

Epidemiologists and biostatisticians developed predictive COVID-19 models so that health care leaders could plan accordingly, especially those patients that required critical care or inpatient medical care. These predictive models have been used across the globe and can be categorized into three groups: Susceptible-Exposed-Infectious-Recovered, Agent-Based, and Curve Fitting Extrapolation.⁵ Our original predictions were based on the Institute for Health Metrics and Evaluation model from Washington state (Curve Fitting Extrapolation). It creates projections from COVID-19 mortality data and assumes a 3% infection rate. Other health systems in our region used the COVID-19 Hospital Impact Model for Epidemics–University of Pennsylvania model. It pins its suppositions on hospitalized COVID-19 patients, regional infection rates, and hospital market shares. Lastly, the agent-based mode, such as the Global Epidemic and Mobility Project, takes simulated populations and forecasts the spread of SARS-CoV-2 anchoring on the interplay of individuals and groups. The assumptions are created secondary to the interactions of people, time, health care interventions, and public health policies.

Based on these predictive simulations, health systems have spent countless hours of planning and have utilized resources for the anticipated needs related to beds, ventilators, supplies, and staffing. Frontline staff were retrained how to don and doff personal protective equipment. Our teams were ready if we saw a wave of 250, a surge of 500, or a tsunami of 750 COVID-19 inpatients. We were prepared to run into the fire fully knowing the personal risks and consequences.

But, as yet, the tsunami in North Carolina has never come. On April 21, 2020, the COVID-19 mortality data in North Carolina peaked at 34 deaths, with the total number of deaths standing at 1,510 as of July 13, 2020.⁶ A surge did not hit our institutional shores at Wake Forest Baptist Health. As we looked through the proverbial back window and hear about the tsunami in Houston, Texas, we are very thankful that the tsunami turned out to be a small wave so far in North Carolina. We are grateful that there were fewer deaths than expected. The dust is settling now and the question, spoken or unspoken, is: “How could we be so wrong with our predictions?”

Models have strengths and weaknesses and none are perfect.⁷ There is an old aphorism in statistics that is often attributed to George Box that says: “All models are wrong but some are useful.”⁸ Predictions and projections are good, but not perfect. Our measurements and tests should not only be accurate, but also be as precise as possible.⁹ Moreover, the assumptions we make should be on solid ground. Since the beginning of the pandemic, there may have been undercounts and delays in reporting. The assumptions of the effects of social distancing may have been inaccurate. Just as important, the lack of early testing in our pandemic and the relatively limited testing currently available provide challenges not only in attributing past deaths to COVID-19, but also with planning and public health measures. To be fair, the tsunami that turned out to be a small wave in North Carolina may be caused by the strong leadership from politicians, public health officials, and health system leaders for their stay-at-home decree and vigorous public health measures in our state.

Some of the health systems in the United States have created “reemergence plans” to care for those patients who have stayed at home for the past several months. Elective surgeries and procedures have begun in different regions of the United States and will likely continue reopening into the late summer. Nevertheless, challenges and opportunities continue to abound during these difficult times of COVID-19. The tsunamis or surges will continue to occur in the United States and the premature reopening of some of the public places and businesses have not helped our collective efforts. In addition, the personal costs have been and will be immeasurable. Many of us have lost loved ones, been laid off, or face mental health crises because of the social isolation and false news.

COVID-19 is here to stay and will be with us for the foreseeable future. Health care providers have been literally risking their lives to serve the public and we will continue to do so. Hitting the target of needed inpatient beds and critical care beds is critically important and is tough without accurate data. We simply have inadequate and unreliable data of COVID-19 incidence and prevalence rates in the communities that we serve. More available testing would allow frontline health care providers and health care leaders to match hospital demand to supply, at individual hospitals and within the health care system. Moreover, contact tracing capabilities would give us the opportunity to isolate individuals and extinguish population-based hotspots.

We may have seen the first wave, but other waves of COVID-19 in North Carolina are sure to come. Since the partial reopening of North Carolina on May 8, 2020, coupled with pockets of nonadherence to social distancing and mask wearing, we expect a second wave sooner rather than later. Interestingly, daily new lab-confirmed COVID-19 cases in North Carolina have been on the rise, with the highest one-day total occurring on June 12, 2020 with 1,768 cases reported.⁶ As a result, North Carolina Gov. Roy Cooper and Secretary of the North Carolina Department of Health and Human Services, Dr. Mandy Cohen, placed a temporary pause on the Phase 2 reopening plan and mandated masks in public on June 24, 2020. It is unclear whether these intermittent daily spikes in lab-confirmed COVID-19 cases are a foreshadowing of our next wave, surge, or tsunami, or just an anomaly. Only time will tell, but as Jim Kim, MD, PhD, has stated so well, there is still time for social distancing, contact tracing, testing, isolation, and treatment.¹⁰ There is still time for us, for our loved ones, for our hospital systems, and for our public health system.

Dr. Huang is the executive medical director and service line director of general medicine and hospital medicine within the Wake Forest Baptist Health System and associate professor of internal medicine at Wake Forest School of Medicine. Dr. Lippert is assistant professor of internal medicine at Wake Forest School of Medicine. Mr. Payne is the associate vice president of Wake Forest Baptist Health. He is responsible for engineering, facilities planning & design as well as environmental health and safety departments. Dr. Pariyadath is comedical director of the Patient Flow Operations Center which facilitates patient placement throughout the Wake Forest Baptist Health system. He is also the associate medical director for the adult emergency department. Dr. Sunkara is assistant professor of internal medicine at Wake Forest School of Medicine. He is the medical director for hospital medicine units and the newly established PUI unit.

Acknowledgments

The authors would like to thank Julie Freischlag, MD; Kevin High, MD, MS; Gary Rosenthal, MD; Wayne Meredith, MD;Russ Howerton, MD; Mike Waid, Andrea Fernandez, MD; Brian Hiestand, MD; the Wake Forest Baptist Health System COVID-19 task force, the Operations Center, and the countless frontline staff at all five hospitals within the Wake Forest Baptist Health System.

References

1. World Health Organization. Modes of transmission of virus causing COVID-19: Implications for IPC precaution recommendations. 2020 June 30. https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations.

2. Holshue et al. First case of 2019 novel coronavirus in the United States. N Engl J Med. 2020;382: 929-36.

3. Fuller T, Baker M. Coronavirus death in California came weeks before first known U.S. death. New York Times. 2020 Apr 22. https://www.nytimes.com/2020/04/22/us/coronavirus-first-united-states-death.html.

4. Johns Hopkins Coronavirus Resource Center. https://coronavirus.jhu.edu/us-map. Accessed 2020 May 28.

5. Michaud J et al. COVID-19 models: Can they tell us what we want to know? 2020 April 16. https://www.kff.org/coronavirus-policy-watch/covid-19-models.

6. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html. Accessed 2020 June 30.

7. Jewell N et al. Caution warranted: Using the Institute for Health Metrics and Evaluation Model for predicting the course of the COVID-19 pandemic. Ann Intern Med. 2020;173:1-3.

8. Box G. Science and statistics. J Am Stat Assoc. 1972;71:791-9.

9. Shapiro DE. The interpretation of diagnostic tests. Stat Methods Med Res. 1999;8:113-34.

10. Kim J. It is not too late to go on the offense against the coronavirus. The New Yorker. 2020 Apr 20. https://www.newyorker.com/science/medical-dispatch/its-not-too-late-to-go-on-offense-against-the-coronavirus.

The COVID-19 pandemic is one of the defining moments in history for this generation’s health care leaders. In 2019, most of us wrongly assumed that this virus would be similar to the past viral epidemics and pandemics such as 2002 severe acute respiratory syndrome–CoV in Asia, 2009 H1N1 influenza in the United States, 2012 Middle East respiratory syndrome–CoV in Saudi Arabia, and 2014-2016 Ebola in West Africa. Moreover, we understood that the 50% fatality rate of Ebola, a single-stranded RNA virus, was deadly on the continent of Africa, but its transmission was through direct contact with blood or other bodily fluids. Hence, the infectivity of Ebola to the general public was lower than SARS-CoV-2, which is spread by respiratory droplets and contact routes in addition to being the virus that causes COVID-19.¹ Many of us did not expect that SARS-CoV-2, a single-stranded RNA virus consisting of 32 kilobytes, would reach the shores of the United States from the Hubei province of China, the northern Lombardy region of Italy, or other initial hotspots. We could not imagine its effects would be so devastating from an economic and medical perspective. Until it did.

The first reported case of SARS-CoV-2 was on Jan. 20, 2020 in Snohomish County, Wash., and the first known death from COVID-19 occurred on Feb. 6, 2020 in Santa Clara County, Calif.^2,3 Since then, the United States has lost over 135,000 people from COVID-19 with death(s) reported in every state and the highest number of overall deaths of any country in the world.⁴ At the beginning of 2020, at our institution, Wake Forest Baptist Health System in Winston-Salem, N.C., we began preparing for the wave, surge, or tsunami of inpatients that was coming. Plans were afoot to increase our staff, even perhaps by hiring out-of-state physicians and nurses if needed, and every possible bed was considered within the system. It was not an if, but rather a when, as to the arrival of COVID-19.

Epidemiologists and biostatisticians developed predictive COVID-19 models so that health care leaders could plan accordingly, especially those patients that required critical care or inpatient medical care. These predictive models have been used across the globe and can be categorized into three groups: Susceptible-Exposed-Infectious-Recovered, Agent-Based, and Curve Fitting Extrapolation.⁵ Our original predictions were based on the Institute for Health Metrics and Evaluation model from Washington state (Curve Fitting Extrapolation). It creates projections from COVID-19 mortality data and assumes a 3% infection rate. Other health systems in our region used the COVID-19 Hospital Impact Model for Epidemics–University of Pennsylvania model. It pins its suppositions on hospitalized COVID-19 patients, regional infection rates, and hospital market shares. Lastly, the agent-based mode, such as the Global Epidemic and Mobility Project, takes simulated populations and forecasts the spread of SARS-CoV-2 anchoring on the interplay of individuals and groups. The assumptions are created secondary to the interactions of people, time, health care interventions, and public health policies.

Based on these predictive simulations, health systems have spent countless hours of planning and have utilized resources for the anticipated needs related to beds, ventilators, supplies, and staffing. Frontline staff were retrained how to don and doff personal protective equipment. Our teams were ready if we saw a wave of 250, a surge of 500, or a tsunami of 750 COVID-19 inpatients. We were prepared to run into the fire fully knowing the personal risks and consequences.

But, as yet, the tsunami in North Carolina has never come. On April 21, 2020, the COVID-19 mortality data in North Carolina peaked at 34 deaths, with the total number of deaths standing at 1,510 as of July 13, 2020.⁶ A surge did not hit our institutional shores at Wake Forest Baptist Health. As we looked through the proverbial back window and hear about the tsunami in Houston, Texas, we are very thankful that the tsunami turned out to be a small wave so far in North Carolina. We are grateful that there were fewer deaths than expected. The dust is settling now and the question, spoken or unspoken, is: “How could we be so wrong with our predictions?”

Models have strengths and weaknesses and none are perfect.⁷ There is an old aphorism in statistics that is often attributed to George Box that says: “All models are wrong but some are useful.”⁸ Predictions and projections are good, but not perfect. Our measurements and tests should not only be accurate, but also be as precise as possible.⁹ Moreover, the assumptions we make should be on solid ground. Since the beginning of the pandemic, there may have been undercounts and delays in reporting. The assumptions of the effects of social distancing may have been inaccurate. Just as important, the lack of early testing in our pandemic and the relatively limited testing currently available provide challenges not only in attributing past deaths to COVID-19, but also with planning and public health measures. To be fair, the tsunami that turned out to be a small wave in North Carolina may be caused by the strong leadership from politicians, public health officials, and health system leaders for their stay-at-home decree and vigorous public health measures in our state.

Some of the health systems in the United States have created “reemergence plans” to care for those patients who have stayed at home for the past several months. Elective surgeries and procedures have begun in different regions of the United States and will likely continue reopening into the late summer. Nevertheless, challenges and opportunities continue to abound during these difficult times of COVID-19. The tsunamis or surges will continue to occur in the United States and the premature reopening of some of the public places and businesses have not helped our collective efforts. In addition, the personal costs have been and will be immeasurable. Many of us have lost loved ones, been laid off, or face mental health crises because of the social isolation and false news.

COVID-19 is here to stay and will be with us for the foreseeable future. Health care providers have been literally risking their lives to serve the public and we will continue to do so. Hitting the target of needed inpatient beds and critical care beds is critically important and is tough without accurate data. We simply have inadequate and unreliable data of COVID-19 incidence and prevalence rates in the communities that we serve. More available testing would allow frontline health care providers and health care leaders to match hospital demand to supply, at individual hospitals and within the health care system. Moreover, contact tracing capabilities would give us the opportunity to isolate individuals and extinguish population-based hotspots.

We may have seen the first wave, but other waves of COVID-19 in North Carolina are sure to come. Since the partial reopening of North Carolina on May 8, 2020, coupled with pockets of nonadherence to social distancing and mask wearing, we expect a second wave sooner rather than later. Interestingly, daily new lab-confirmed COVID-19 cases in North Carolina have been on the rise, with the highest one-day total occurring on June 12, 2020 with 1,768 cases reported.⁶ As a result, North Carolina Gov. Roy Cooper and Secretary of the North Carolina Department of Health and Human Services, Dr. Mandy Cohen, placed a temporary pause on the Phase 2 reopening plan and mandated masks in public on June 24, 2020. It is unclear whether these intermittent daily spikes in lab-confirmed COVID-19 cases are a foreshadowing of our next wave, surge, or tsunami, or just an anomaly. Only time will tell, but as Jim Kim, MD, PhD, has stated so well, there is still time for social distancing, contact tracing, testing, isolation, and treatment.¹⁰ There is still time for us, for our loved ones, for our hospital systems, and for our public health system.

Dr. Huang is the executive medical director and service line director of general medicine and hospital medicine within the Wake Forest Baptist Health System and associate professor of internal medicine at Wake Forest School of Medicine. Dr. Lippert is assistant professor of internal medicine at Wake Forest School of Medicine. Mr. Payne is the associate vice president of Wake Forest Baptist Health. He is responsible for engineering, facilities planning & design as well as environmental health and safety departments. Dr. Pariyadath is comedical director of the Patient Flow Operations Center which facilitates patient placement throughout the Wake Forest Baptist Health system. He is also the associate medical director for the adult emergency department. Dr. Sunkara is assistant professor of internal medicine at Wake Forest School of Medicine. He is the medical director for hospital medicine units and the newly established PUI unit.

Acknowledgments

The authors would like to thank Julie Freischlag, MD; Kevin High, MD, MS; Gary Rosenthal, MD; Wayne Meredith, MD;Russ Howerton, MD; Mike Waid, Andrea Fernandez, MD; Brian Hiestand, MD; the Wake Forest Baptist Health System COVID-19 task force, the Operations Center, and the countless frontline staff at all five hospitals within the Wake Forest Baptist Health System.

References

1. World Health Organization. Modes of transmission of virus causing COVID-19: Implications for IPC precaution recommendations. 2020 June 30. https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations.

2. Holshue et al. First case of 2019 novel coronavirus in the United States. N Engl J Med. 2020;382: 929-36.

3. Fuller T, Baker M. Coronavirus death in California came weeks before first known U.S. death. New York Times. 2020 Apr 22. https://www.nytimes.com/2020/04/22/us/coronavirus-first-united-states-death.html.

4. Johns Hopkins Coronavirus Resource Center. https://coronavirus.jhu.edu/us-map. Accessed 2020 May 28.

5. Michaud J et al. COVID-19 models: Can they tell us what we want to know? 2020 April 16. https://www.kff.org/coronavirus-policy-watch/covid-19-models.

6. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html. Accessed 2020 June 30.

7. Jewell N et al. Caution warranted: Using the Institute for Health Metrics and Evaluation Model for predicting the course of the COVID-19 pandemic. Ann Intern Med. 2020;173:1-3.

8. Box G. Science and statistics. J Am Stat Assoc. 1972;71:791-9.

9. Shapiro DE. The interpretation of diagnostic tests. Stat Methods Med Res. 1999;8:113-34.

10. Kim J. It is not too late to go on the offense against the coronavirus. The New Yorker. 2020 Apr 20. https://www.newyorker.com/science/medical-dispatch/its-not-too-late-to-go-on-offense-against-the-coronavirus.

The COVID-19 pandemic is one of the defining moments in history for this generation’s health care leaders. In 2019, most of us wrongly assumed that this virus would be similar to the past viral epidemics and pandemics such as 2002 severe acute respiratory syndrome–CoV in Asia, 2009 H1N1 influenza in the United States, 2012 Middle East respiratory syndrome–CoV in Saudi Arabia, and 2014-2016 Ebola in West Africa. Moreover, we understood that the 50% fatality rate of Ebola, a single-stranded RNA virus, was deadly on the continent of Africa, but its transmission was through direct contact with blood or other bodily fluids. Hence, the infectivity of Ebola to the general public was lower than SARS-CoV-2, which is spread by respiratory droplets and contact routes in addition to being the virus that causes COVID-19.¹ Many of us did not expect that SARS-CoV-2, a single-stranded RNA virus consisting of 32 kilobytes, would reach the shores of the United States from the Hubei province of China, the northern Lombardy region of Italy, or other initial hotspots. We could not imagine its effects would be so devastating from an economic and medical perspective. Until it did.

The first reported case of SARS-CoV-2 was on Jan. 20, 2020 in Snohomish County, Wash., and the first known death from COVID-19 occurred on Feb. 6, 2020 in Santa Clara County, Calif.^2,3 Since then, the United States has lost over 135,000 people from COVID-19 with death(s) reported in every state and the highest number of overall deaths of any country in the world.⁴ At the beginning of 2020, at our institution, Wake Forest Baptist Health System in Winston-Salem, N.C., we began preparing for the wave, surge, or tsunami of inpatients that was coming. Plans were afoot to increase our staff, even perhaps by hiring out-of-state physicians and nurses if needed, and every possible bed was considered within the system. It was not an if, but rather a when, as to the arrival of COVID-19.

Epidemiologists and biostatisticians developed predictive COVID-19 models so that health care leaders could plan accordingly, especially those patients that required critical care or inpatient medical care. These predictive models have been used across the globe and can be categorized into three groups: Susceptible-Exposed-Infectious-Recovered, Agent-Based, and Curve Fitting Extrapolation.⁵ Our original predictions were based on the Institute for Health Metrics and Evaluation model from Washington state (Curve Fitting Extrapolation). It creates projections from COVID-19 mortality data and assumes a 3% infection rate. Other health systems in our region used the COVID-19 Hospital Impact Model for Epidemics–University of Pennsylvania model. It pins its suppositions on hospitalized COVID-19 patients, regional infection rates, and hospital market shares. Lastly, the agent-based mode, such as the Global Epidemic and Mobility Project, takes simulated populations and forecasts the spread of SARS-CoV-2 anchoring on the interplay of individuals and groups. The assumptions are created secondary to the interactions of people, time, health care interventions, and public health policies.

Based on these predictive simulations, health systems have spent countless hours of planning and have utilized resources for the anticipated needs related to beds, ventilators, supplies, and staffing. Frontline staff were retrained how to don and doff personal protective equipment. Our teams were ready if we saw a wave of 250, a surge of 500, or a tsunami of 750 COVID-19 inpatients. We were prepared to run into the fire fully knowing the personal risks and consequences.

But, as yet, the tsunami in North Carolina has never come. On April 21, 2020, the COVID-19 mortality data in North Carolina peaked at 34 deaths, with the total number of deaths standing at 1,510 as of July 13, 2020.⁶ A surge did not hit our institutional shores at Wake Forest Baptist Health. As we looked through the proverbial back window and hear about the tsunami in Houston, Texas, we are very thankful that the tsunami turned out to be a small wave so far in North Carolina. We are grateful that there were fewer deaths than expected. The dust is settling now and the question, spoken or unspoken, is: “How could we be so wrong with our predictions?”

Models have strengths and weaknesses and none are perfect.⁷ There is an old aphorism in statistics that is often attributed to George Box that says: “All models are wrong but some are useful.”⁸ Predictions and projections are good, but not perfect. Our measurements and tests should not only be accurate, but also be as precise as possible.⁹ Moreover, the assumptions we make should be on solid ground. Since the beginning of the pandemic, there may have been undercounts and delays in reporting. The assumptions of the effects of social distancing may have been inaccurate. Just as important, the lack of early testing in our pandemic and the relatively limited testing currently available provide challenges not only in attributing past deaths to COVID-19, but also with planning and public health measures. To be fair, the tsunami that turned out to be a small wave in North Carolina may be caused by the strong leadership from politicians, public health officials, and health system leaders for their stay-at-home decree and vigorous public health measures in our state.

Some of the health systems in the United States have created “reemergence plans” to care for those patients who have stayed at home for the past several months. Elective surgeries and procedures have begun in different regions of the United States and will likely continue reopening into the late summer. Nevertheless, challenges and opportunities continue to abound during these difficult times of COVID-19. The tsunamis or surges will continue to occur in the United States and the premature reopening of some of the public places and businesses have not helped our collective efforts. In addition, the personal costs have been and will be immeasurable. Many of us have lost loved ones, been laid off, or face mental health crises because of the social isolation and false news.

COVID-19 is here to stay and will be with us for the foreseeable future. Health care providers have been literally risking their lives to serve the public and we will continue to do so. Hitting the target of needed inpatient beds and critical care beds is critically important and is tough without accurate data. We simply have inadequate and unreliable data of COVID-19 incidence and prevalence rates in the communities that we serve. More available testing would allow frontline health care providers and health care leaders to match hospital demand to supply, at individual hospitals and within the health care system. Moreover, contact tracing capabilities would give us the opportunity to isolate individuals and extinguish population-based hotspots.

We may have seen the first wave, but other waves of COVID-19 in North Carolina are sure to come. Since the partial reopening of North Carolina on May 8, 2020, coupled with pockets of nonadherence to social distancing and mask wearing, we expect a second wave sooner rather than later. Interestingly, daily new lab-confirmed COVID-19 cases in North Carolina have been on the rise, with the highest one-day total occurring on June 12, 2020 with 1,768 cases reported.⁶ As a result, North Carolina Gov. Roy Cooper and Secretary of the North Carolina Department of Health and Human Services, Dr. Mandy Cohen, placed a temporary pause on the Phase 2 reopening plan and mandated masks in public on June 24, 2020. It is unclear whether these intermittent daily spikes in lab-confirmed COVID-19 cases are a foreshadowing of our next wave, surge, or tsunami, or just an anomaly. Only time will tell, but as Jim Kim, MD, PhD, has stated so well, there is still time for social distancing, contact tracing, testing, isolation, and treatment.¹⁰ There is still time for us, for our loved ones, for our hospital systems, and for our public health system.

Dr. Huang is the executive medical director and service line director of general medicine and hospital medicine within the Wake Forest Baptist Health System and associate professor of internal medicine at Wake Forest School of Medicine. Dr. Lippert is assistant professor of internal medicine at Wake Forest School of Medicine. Mr. Payne is the associate vice president of Wake Forest Baptist Health. He is responsible for engineering, facilities planning & design as well as environmental health and safety departments. Dr. Pariyadath is comedical director of the Patient Flow Operations Center which facilitates patient placement throughout the Wake Forest Baptist Health system. He is also the associate medical director for the adult emergency department. Dr. Sunkara is assistant professor of internal medicine at Wake Forest School of Medicine. He is the medical director for hospital medicine units and the newly established PUI unit.

Acknowledgments

The authors would like to thank Julie Freischlag, MD; Kevin High, MD, MS; Gary Rosenthal, MD; Wayne Meredith, MD;Russ Howerton, MD; Mike Waid, Andrea Fernandez, MD; Brian Hiestand, MD; the Wake Forest Baptist Health System COVID-19 task force, the Operations Center, and the countless frontline staff at all five hospitals within the Wake Forest Baptist Health System.

References

1. World Health Organization. Modes of transmission of virus causing COVID-19: Implications for IPC precaution recommendations. 2020 June 30. https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations.

2. Holshue et al. First case of 2019 novel coronavirus in the United States. N Engl J Med. 2020;382: 929-36.

3. Fuller T, Baker M. Coronavirus death in California came weeks before first known U.S. death. New York Times. 2020 Apr 22. https://www.nytimes.com/2020/04/22/us/coronavirus-first-united-states-death.html.

4. Johns Hopkins Coronavirus Resource Center. https://coronavirus.jhu.edu/us-map. Accessed 2020 May 28.

5. Michaud J et al. COVID-19 models: Can they tell us what we want to know? 2020 April 16. https://www.kff.org/coronavirus-policy-watch/covid-19-models.

6. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html. Accessed 2020 June 30.

7. Jewell N et al. Caution warranted: Using the Institute for Health Metrics and Evaluation Model for predicting the course of the COVID-19 pandemic. Ann Intern Med. 2020;173:1-3.

8. Box G. Science and statistics. J Am Stat Assoc. 1972;71:791-9.

9. Shapiro DE. The interpretation of diagnostic tests. Stat Methods Med Res. 1999;8:113-34.

10. Kim J. It is not too late to go on the offense against the coronavirus. The New Yorker. 2020 Apr 20. https://www.newyorker.com/science/medical-dispatch/its-not-too-late-to-go-on-offense-against-the-coronavirus.

What do you do now?

Your waiting room is filled with mask-wearing individuals, except for one person. Your staff offers a mask to this person, citing your office policy of requiring masks for all persons in order to prevent asymptomatic COVID-19 spread, and the patient refuses to put it on.

What can you/should you/must you do? Are you required to see a patient who refuses to wear a mask? If you ask the patient to leave without being seen, can you be accused of patient abandonment? If you allow the patient to stay, could you be liable for negligence for exposing others to a deadly illness?

The rules on mask-wearing, while initially downright confusing, have inexorably come to a rough consensus. By governors’ orders, masks are now mandatory in most states, though when and where they are required varies. For example, effective July 7, the governor of Washington has ordered that a business not allow a customer to enter without a face covering.

So far, there are no cases or court decisions to guide us about whether it is negligence to allow an unmasked patient to commingle in a medical practice. Nor do we have case law to help us determine whether patient abandonment would apply if a patient is sent home without being seen.

We can apply the legal principles and cases from other situations to this one, however, to tell us what constitutes negligence or patient abandonment. The practical questions, legally, are who might sue and on what basis?

Who might sue?

Someone who is injured in a public place may sue the owner for negligence if the owner knew or should have known of a danger and didn’t do anything about it. For example, individuals have sued grocery stores successfully after they slipped on a banana peel and fell. If, say, the banana peel was black, that indicates that it had been there for a while, and judges have found that the store management should have known about it and removed it.

Compare the banana peel scenario with the scenario where most news outlets and health departments are telling people, every day, to wear masks while in indoor public spaces, yet owners of a medical practice or facility allow individuals who are not wearing masks to sit in their waiting room. If an individual who was also in the waiting room with the unmasked individual develops COVID-19 2 days later, the ill individual may sue the medical practice for negligence for not removing the unmasked individual.

What about the individual’s responsibility to move away from the person not wearing a mask? That is the aspect of this scenario that attorneys and experts could argue about, for days, in a court case. But to go back to the banana peel case, one could argue that a customer in a grocery store should be looking out for banana peels on the floor and avoid them, yet courts have assigned liability to grocery stores when customers slip and fall.

Let’s review the four elements of negligence which a plaintiff would need to prove:

• Duty: Obligation of one person to another
• Breach: Improper act or omission, in the context of proper behavior to avoid imposing undue risks of harm to other persons and their property
• Damage
• Causation: That the act or omission caused the harm

Those who run medical offices and facilities have a duty to provide reasonably safe public spaces. Unmasked individuals are a risk to others nearby, so the “breach” element is satisfied if a practice fails to impose safety measures. Causation could be proven, or at least inferred, if contact tracing of an individual with COVID-19 showed that the only contact likely to have exposed the ill individual to the virus was an unmasked individual in a medical practice’s waiting room, especially if the unmasked individual was COVID-19 positive before, during, or shortly after the visit to the practice.

What about patient abandonment?

“Patient abandonment” is the legal term for terminating the physician-patient relationship in such a manner that the patient is denied necessary medical care. It is a form of negligence.

Refusing to see a patient unless the patient wears a mask is not denying care, in this attorney’s view, but rather establishing reasonable conditions for getting care. The patient simply needs to put on a mask.

What about the patient who refuses to wear a mask for medical reasons? There are exceptions in most of the governors’ orders for individuals with medical conditions that preclude covering nose and mouth with a mask. A medical office is the perfect place to test an individual’s ability or inability to breathe well while wearing a mask. “Put the mask on and we’ll see how you do” is a reasonable response. Monitor the patient visually and apply a pulse oximeter with mask off and mask on.

One physician recently wrote about measuring her own oxygen levels while wearing four different masks for 5 minutes each, with no change in breathing.

Editor’s note: Read more about mask exemptions in a Medscape interview with pulmonologist Albert Rizzo, MD, chief medical officer of the American Lung Association.

What are some practical tips?

Assuming that a patient is not in acute distress, options in this scenario include:

• Send the patient home and offer a return visit if masked or when the pandemic is over.
• Offer a telehealth visit, with the patient at home.

What if the unmasked person is not a patient but the companion of a patient? What if the individual refusing to wear a mask is an employee? In neither of these two hypotheticals is there a basis for legal action against a practice whose policy requires that everyone wear masks on the premises.

A companion who arrives without a mask should leave the office. An employee who refuses to mask up could be sent home. If the employee has a disability covered by the Americans with Disabilities Act, then the practice may need to make reasonable accommodations so that the employee works in a room alone if unable to work from home.

Those who manage medical practices should check the websites of the state health department and medical societies at least weekly, to see whether the agencies have issued guidance. For example, the Texas Medical Association has issued limited guidance.

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

What do you do now?

Your waiting room is filled with mask-wearing individuals, except for one person. Your staff offers a mask to this person, citing your office policy of requiring masks for all persons in order to prevent asymptomatic COVID-19 spread, and the patient refuses to put it on.

What can you/should you/must you do? Are you required to see a patient who refuses to wear a mask? If you ask the patient to leave without being seen, can you be accused of patient abandonment? If you allow the patient to stay, could you be liable for negligence for exposing others to a deadly illness?

The rules on mask-wearing, while initially downright confusing, have inexorably come to a rough consensus. By governors’ orders, masks are now mandatory in most states, though when and where they are required varies. For example, effective July 7, the governor of Washington has ordered that a business not allow a customer to enter without a face covering.

So far, there are no cases or court decisions to guide us about whether it is negligence to allow an unmasked patient to commingle in a medical practice. Nor do we have case law to help us determine whether patient abandonment would apply if a patient is sent home without being seen.

We can apply the legal principles and cases from other situations to this one, however, to tell us what constitutes negligence or patient abandonment. The practical questions, legally, are who might sue and on what basis?

Who might sue?

Someone who is injured in a public place may sue the owner for negligence if the owner knew or should have known of a danger and didn’t do anything about it. For example, individuals have sued grocery stores successfully after they slipped on a banana peel and fell. If, say, the banana peel was black, that indicates that it had been there for a while, and judges have found that the store management should have known about it and removed it.

Compare the banana peel scenario with the scenario where most news outlets and health departments are telling people, every day, to wear masks while in indoor public spaces, yet owners of a medical practice or facility allow individuals who are not wearing masks to sit in their waiting room. If an individual who was also in the waiting room with the unmasked individual develops COVID-19 2 days later, the ill individual may sue the medical practice for negligence for not removing the unmasked individual.

What about the individual’s responsibility to move away from the person not wearing a mask? That is the aspect of this scenario that attorneys and experts could argue about, for days, in a court case. But to go back to the banana peel case, one could argue that a customer in a grocery store should be looking out for banana peels on the floor and avoid them, yet courts have assigned liability to grocery stores when customers slip and fall.

Let’s review the four elements of negligence which a plaintiff would need to prove:

• Duty: Obligation of one person to another
• Breach: Improper act or omission, in the context of proper behavior to avoid imposing undue risks of harm to other persons and their property
• Damage
• Causation: That the act or omission caused the harm

Those who run medical offices and facilities have a duty to provide reasonably safe public spaces. Unmasked individuals are a risk to others nearby, so the “breach” element is satisfied if a practice fails to impose safety measures. Causation could be proven, or at least inferred, if contact tracing of an individual with COVID-19 showed that the only contact likely to have exposed the ill individual to the virus was an unmasked individual in a medical practice’s waiting room, especially if the unmasked individual was COVID-19 positive before, during, or shortly after the visit to the practice.

What about patient abandonment?

“Patient abandonment” is the legal term for terminating the physician-patient relationship in such a manner that the patient is denied necessary medical care. It is a form of negligence.

Refusing to see a patient unless the patient wears a mask is not denying care, in this attorney’s view, but rather establishing reasonable conditions for getting care. The patient simply needs to put on a mask.

What about the patient who refuses to wear a mask for medical reasons? There are exceptions in most of the governors’ orders for individuals with medical conditions that preclude covering nose and mouth with a mask. A medical office is the perfect place to test an individual’s ability or inability to breathe well while wearing a mask. “Put the mask on and we’ll see how you do” is a reasonable response. Monitor the patient visually and apply a pulse oximeter with mask off and mask on.

One physician recently wrote about measuring her own oxygen levels while wearing four different masks for 5 minutes each, with no change in breathing.

Editor’s note: Read more about mask exemptions in a Medscape interview with pulmonologist Albert Rizzo, MD, chief medical officer of the American Lung Association.

What are some practical tips?

Assuming that a patient is not in acute distress, options in this scenario include:

• Send the patient home and offer a return visit if masked or when the pandemic is over.
• Offer a telehealth visit, with the patient at home.

What if the unmasked person is not a patient but the companion of a patient? What if the individual refusing to wear a mask is an employee? In neither of these two hypotheticals is there a basis for legal action against a practice whose policy requires that everyone wear masks on the premises.

A companion who arrives without a mask should leave the office. An employee who refuses to mask up could be sent home. If the employee has a disability covered by the Americans with Disabilities Act, then the practice may need to make reasonable accommodations so that the employee works in a room alone if unable to work from home.

Those who manage medical practices should check the websites of the state health department and medical societies at least weekly, to see whether the agencies have issued guidance. For example, the Texas Medical Association has issued limited guidance.

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

What do you do now?

Your waiting room is filled with mask-wearing individuals, except for one person. Your staff offers a mask to this person, citing your office policy of requiring masks for all persons in order to prevent asymptomatic COVID-19 spread, and the patient refuses to put it on.

What can you/should you/must you do? Are you required to see a patient who refuses to wear a mask? If you ask the patient to leave without being seen, can you be accused of patient abandonment? If you allow the patient to stay, could you be liable for negligence for exposing others to a deadly illness?

The rules on mask-wearing, while initially downright confusing, have inexorably come to a rough consensus. By governors’ orders, masks are now mandatory in most states, though when and where they are required varies. For example, effective July 7, the governor of Washington has ordered that a business not allow a customer to enter without a face covering.

So far, there are no cases or court decisions to guide us about whether it is negligence to allow an unmasked patient to commingle in a medical practice. Nor do we have case law to help us determine whether patient abandonment would apply if a patient is sent home without being seen.

We can apply the legal principles and cases from other situations to this one, however, to tell us what constitutes negligence or patient abandonment. The practical questions, legally, are who might sue and on what basis?

Who might sue?

Someone who is injured in a public place may sue the owner for negligence if the owner knew or should have known of a danger and didn’t do anything about it. For example, individuals have sued grocery stores successfully after they slipped on a banana peel and fell. If, say, the banana peel was black, that indicates that it had been there for a while, and judges have found that the store management should have known about it and removed it.

Compare the banana peel scenario with the scenario where most news outlets and health departments are telling people, every day, to wear masks while in indoor public spaces, yet owners of a medical practice or facility allow individuals who are not wearing masks to sit in their waiting room. If an individual who was also in the waiting room with the unmasked individual develops COVID-19 2 days later, the ill individual may sue the medical practice for negligence for not removing the unmasked individual.

What about the individual’s responsibility to move away from the person not wearing a mask? That is the aspect of this scenario that attorneys and experts could argue about, for days, in a court case. But to go back to the banana peel case, one could argue that a customer in a grocery store should be looking out for banana peels on the floor and avoid them, yet courts have assigned liability to grocery stores when customers slip and fall.

Let’s review the four elements of negligence which a plaintiff would need to prove:

• Duty: Obligation of one person to another
• Breach: Improper act or omission, in the context of proper behavior to avoid imposing undue risks of harm to other persons and their property
• Damage
• Causation: That the act or omission caused the harm

Those who run medical offices and facilities have a duty to provide reasonably safe public spaces. Unmasked individuals are a risk to others nearby, so the “breach” element is satisfied if a practice fails to impose safety measures. Causation could be proven, or at least inferred, if contact tracing of an individual with COVID-19 showed that the only contact likely to have exposed the ill individual to the virus was an unmasked individual in a medical practice’s waiting room, especially if the unmasked individual was COVID-19 positive before, during, or shortly after the visit to the practice.

What about patient abandonment?

“Patient abandonment” is the legal term for terminating the physician-patient relationship in such a manner that the patient is denied necessary medical care. It is a form of negligence.

Refusing to see a patient unless the patient wears a mask is not denying care, in this attorney’s view, but rather establishing reasonable conditions for getting care. The patient simply needs to put on a mask.

What about the patient who refuses to wear a mask for medical reasons? There are exceptions in most of the governors’ orders for individuals with medical conditions that preclude covering nose and mouth with a mask. A medical office is the perfect place to test an individual’s ability or inability to breathe well while wearing a mask. “Put the mask on and we’ll see how you do” is a reasonable response. Monitor the patient visually and apply a pulse oximeter with mask off and mask on.

One physician recently wrote about measuring her own oxygen levels while wearing four different masks for 5 minutes each, with no change in breathing.

Editor’s note: Read more about mask exemptions in a Medscape interview with pulmonologist Albert Rizzo, MD, chief medical officer of the American Lung Association.

What are some practical tips?

Assuming that a patient is not in acute distress, options in this scenario include:

• Send the patient home and offer a return visit if masked or when the pandemic is over.
• Offer a telehealth visit, with the patient at home.

What if the unmasked person is not a patient but the companion of a patient? What if the individual refusing to wear a mask is an employee? In neither of these two hypotheticals is there a basis for legal action against a practice whose policy requires that everyone wear masks on the premises.

A companion who arrives without a mask should leave the office. An employee who refuses to mask up could be sent home. If the employee has a disability covered by the Americans with Disabilities Act, then the practice may need to make reasonable accommodations so that the employee works in a room alone if unable to work from home.

Those who manage medical practices should check the websites of the state health department and medical societies at least weekly, to see whether the agencies have issued guidance. For example, the Texas Medical Association has issued limited guidance.

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

Do you want to know what keeps us up at night? As 4th-year medical students born, raised, and living in Haiti, we worry about the impact of COVID-19 on our patients.

The pandemic has shaken the world, and Haiti is no exception.

Courtesy Schneider Dorcela

It has taken several months for the disease to spread, and it began with two confirmed cases, one from France and the other from Belgium, on March 19.¹ Much of the spread of COVID-19 in Haiti has been tied to workers returning from the Dominican Republic. As of June 29, Haiti had 5,975 confirmed cases and 105 deaths.² Of course, those numbers sound minuscule, compared with those in the United States, where the number of deaths from COVID-19 surpassed 100,000 several weeks ago. But the population of Haiti is 30 times smaller than that of the United States, and Haiti is the poorest country in the Western Hemisphere. We have watched in horror as the virus has ravaged marginalized groups in the United States and worry that it will do the same in our own country.

Just as the Haitian Ministry of Health worked with various groups to reach the 1-year free of cholera mark in Haiti, groups such as Doctors Without Borders must mobilize to rein in COVID-19.
 

Community transmission rapid

After the first two cases were confirmed, a state of health emergency was immediately declared. Haitian President Jovenel Moïse and other government officials called for the implementation of several measures aimed at limiting the spread of COVID-19.

Schools, universities, clinical training programs, vocational centers, factories, airports, and ports, except for the transport of goods, were all ordered to close until further notice. Gatherings of larger than 10 people were banned. A curfew from 8 p.m. EST time to 5 a.m. EST was imposed. Measures such as those encouraged by U.S. Centers for Disease Control and Prevention, such as hand washing, physical distancing, and staying at home were also encouraged by the Haitian Ministry of Health. Mask wearing in public places was deemed mandatory.

The latest testing data show that community spread has been occurring among the Haitian population at a rapid rate. According to Jean William Pape, MD, Haiti’s top infectious diseases expert and founder of GHESKIO, an iconic infectious disease center that cares for people with HIV-AIDS and tuberculosis, a COVID-19 simulation from Cornell University in New York shows that about 35% of the Haitian population will be infected by the end of August 2020. A simulation by the University of Oxford (England) paints an even more dire picture. That simulation shows that 86% of the population could be infected, More than 9,000 additional hospital beds would be needed, and 20,000 people would be likely to die from COVID-19, Dr. Pape said in an interview with Haiti’s Nouvelliste newspaper.³
 

Medical response

We know that there is a global shortage of health care workers^,4 and Haiti is no exception. According to a 2018 report from the Haitian Ministry of Health, the country has 11,775 health care professionals, including about 3,354 medical doctors, to care for more than 11 million people. That translates to about 23.4 physicians per 100,000.⁵

The pandemic has led some members of this already anemic health care workforce to stay home because of a lack of personal protective equipment. Others, because of reduced hospital or clinic budgets, have been furloughed, making the COVID-19 national health emergency even harder to manage. The rationing of electricity and limited access to clean water⁶ in some areas are other complications that undermine our ability to provide quality care.

But a severe health care shortage is not the only challenge facing Haiti. It spends about $131 U.S. per capita, which makes Haiti one of most vulnerable among low- and middle-income countries in the world. As a poor country,⁷ its health care infrastructure is among the most inadequate and weakest. Prior to COVID-19, medical advocacy groups already had started movements and strikes demanding that the government improve the health care system. The country’s precarious health care infrastructure includes a lack of hospital beds, and basic medical supplies and equipment, such as oxygen and ventilators.⁸ The emergence of COVID-19 has only exacerbated the situation.

Clinical training programs have been suspended, many doctors and nurses are on quarantine, and some hospitals and clinics are closing. We have witnessed makeshift voodoo clinics built by Haitian voodoo leaders to receive, hospitalize, and treat COVID-19 patients through rituals and herbal remedies. In some areas of the country, residents have protested against the opening of several COVID-19 treatment and management centers.
 

Unique cultural challenges

Public health officials around the world are facing challenges persuading citizens to engage in behaviors that could protect them from the virus.

Just as in America, where many people opt to not wear face coverings^9,10 despite the public health risks, deep distrust of the Haitian government has undermined the messages of President Moïse and public healthofficials about the role of masks in limiting the spread of COVID.We see large numbers of unmasked people on the streets in the informal markets every day. Crammed tap-taps and overloaded motorcycles are moving everywhere. This also could be tied to cultural attitudes about COVID that persist among some Haitians.For example, many people with signs and symptoms of COVID-19 are afraid of going to the hospital to get tested and receive care, and resort to going to the voodoo clinics. Along with rituals, voodoo priests have been serving up teas with ingredients, including moringa, eucalyptus, ginger, and honey to those seeking COVID-19 care in the centers. The voodoo priests claim that the teas they serve strengthen the immune system.

In addition, it is difficult for poor people who live in small quarters with several other people to adhere to physical distancing.¹¹
 

Stigma and violence

Other barriers in the fight against COVID-19 in Haiti are stigma and violence. If widespread testing were available, some Haitians would opt not to do so – despite clear signs and symptoms of the infection. Some people who would get tested if they could are afraid to do so because of fears tied to being attacked by neighbors.

When Haitian University professor Bellamy Nelson and his girlfriend returned to Haiti from the United States in March and began experiencing some pain and fever, he experienced attacks from neighbors, he said in an interview. He said neighbors threatened to burn down his house. When an ambulance arrived at his house to transport him to a hospital, it had to drive through back roads to avoid people armed with rocks, fire, and machetes, he told us. No hospital wanted to admit him. Eventually, Professor Nelson self-quarantined at home, he said.

In another incident, a national ambulance center in Gonaïves, a town toward the northern region of Haiti, reportedly was vandalized, because COVID-19 equipment and supplies used to treat people had been stored there. Hospital Bernard Mevs, along with many other hospitals, was forced by the area’s residents to suspend the plan to open a center for COVID-19 management. Threats to burn down the hospitals caused the leaders of the hospitals to back down and give up a plan to build a 20-bed COVID-19 response center.
 

Maternal health

Another concern we have about the pandemic is the risk it could be to pregnant women. On average, 94,000 deaths occur annually in Haiti. Out of this number, maternal mortality accounts for 1,000. In 2017, for every 100,000 live births for women of reproductive age from 15 to 49 years old, 480 women died. In contrast, in the Dominican Republic, 95 women died per 100,000 that same year. In the United States, 19 died, and in Norway, no more than 2 died that year.¹²

Some of the primary factors contributing to the crisis are limited accessibility, inadequate health care facilities, and an inadequate number of trained health care practitioners; low percentages of skilled attendants at deliveries and of prenatal and postnatal visits; and high numbers of high-risk deliveries in nonqualified health facilities.

During the COVID-19 national health emergency, with most hospitals reducing their health care personnel either because of budget-related reasons or because they are on quarantine, this maternal-fetal health crisis has escalated.

One of the biggest hospitals in Jacmel, a town in the southern region of Haiti, has stopped its prenatal care program. In Delmas, the city with the highest incidence and prevalence of COVID-19, Hôpital Universitaire de la Paix has reduced this program to 50% of its capacity and gynecologic care has been completely suspended. Hôpital St. Luc, one of the first hospitals in the western region of Haiti to open its doors to care for COVID-19 patients, has recently shut down the entire maternal-fetal department.

So, access to prenatal and postnatal care, including the ability to deliver babies in health care institutions, is significantly reduced because of COVID-19. This leaves thousands of already vulnerable pregnant women at risk and having to deliver domestically with little to no health care professional assistance. We worry that, in light of the data, more women and babies will die because of the COVID-19 pandemic.
 

A call to action

Despite these conditions, there are reasons for hope. Various groups, both from the international community and locally have mobilized to respond to the pandemic.

International health care organizations such as Doctors Without Borders and Partners in Health, and local groups such as GHESKIO, the St. Luke Foundation for Haiti, and others have been collaborating with the Haitian Ministry of Health to devise and strategic plans and deploy valuable resources with the common goal of saving lives from COVID-19.

GHESKIO, for example, under Dr. Pape’s leadership, currently has one of the three COVID-19 testing centers in the country. It also has two COVID-19 treatment centers in full operation, in Port-au-Prince, the capital city, managing and treating 520 patients with confirmed COVID-19. GHESKIO, which has been in the front lines of previous major infectious disease outbreaks,¹³ has trained about 200 clinicians from both public and private health care institutions to care for COVID-19 patients.

Doctors Without Borders has been investing in efforts to support the Ministry of Health by converting and renovating its Burn Center in Drouillard, a small section of the city of Cité Soleil, one of the country’s biggest slums. In May, as part of its COVID-19 response, it launched a 20-bed capacity center that can accommodate up to 45 beds to care for patients who have tested positive for COVID-19.

Partners in Health, the Boston-based nonprofit health care organization cofounded in 1987 by American anthropologist and infectious disease specialist, Paul Farmer, MD, and the largest nonprofit health care provider in Haiti, also joined the Ministry of Health through its national and public health efforts to tackle COVID-19 in Haiti. Partners in Health, through its sister organization, Zanmi Lasante, has pioneered the movement of diagnosing and treating people with HIV-AIDS and TB. Since the late 1990s, its efforts against both infectious diseases have helped 15,000 HIV-positive patients begin and remain on treatment. And every year, 1,500 TB patients have started treatment on the path to a cure.

Early in the pandemic in Haiti, Partners in Health, through its state-of-the-art 300-bed university hospital (Hôpital Universitaire de Mirebalais de Mirebalais), was the first to open a COVID-19 center with a 20-bed capacity and has been caring for COVID-19 patients since then. In June, Partners in Health supported and inaugurated the renovation of the internal medicine department at one of its affiliated community hospitals, Hôpital Saint-Nicolas de Saint Marc. That department will have a 24-bed capacity that can extend up to 36 beds to manage and treat COVID-19 patients.

In total, currently, 26 COVID-19 centers with a capacity of 1,011 beds are available to serve, manage, and treat Haitian patients affected with COVID-19. But are those efforts enough? No.

Haiti, as a weak state even before COVID-19, continues to need funding from the international community so it can strengthen its health care infrastructure to be effective and strong in fighting against COVID-19.

In addition, we would like to see preventive initiatives implemented on the local level. Our family has taken on a role that, we think, could help conquer COVID-19 if others followed suit on a large scale.

As part of our contribution in tackling COVID-19, the two of us have launched a small-scale community experiment. We have educated our family in Delmas about COVID-19 and subsequently launched an awareness campaign in the community. We dispatched small groups that go door to door in the community to educate neighbors about the disease in an effort to help them understand that COVID-19 is real and it is normal for people that feel they may have the disease to seek medical care. This approach helps suppress the transmission of the virus. This pilot project could be reproduced in several other communities. It is easy to operate, rapid, effective, and cost-free. The community has been very receptive to and grateful for our efforts.

Like other countries across the world, Haiti was not ready for COVID-19. But we are confident that, with help from the international community, organizations such as GHESKIO,¹⁴ and with due diligence on the local level, we are strong and resilient enough to beat COVID. We must act together – quickly.

 

References

1. Sénat JD. Coronavirus: 2 cas confirmés en Haïti, Jovenel Moïse décrète l’état d’ur-gence sanitaire. 2020 Le Nouvelliste.

2. Haitian Ministry of Health.

3. “Entre appel a la solidarite et de sombres previsions, le Dr William Pape fait le point.” Le Nouvelliste.

4. Darzi A and Evans T. Lancet. 2016 Nov-Dec 26. 388;10060:2576-7.

5. Rapport Statistique 2018. 2019 Republic of Haiti.

6. Sentlinger K. “Water Crisis in Haiti.” The Water Project.

7. The World Bank in Haiti. worldbank.org.

8. Cenat JM. Travel Med Infect Dis. 2020 Mar 28. doi: 10.1016/jtmaid.2020.101684.

9. Block D. “Why some Americans resist wearing face masks.” voanews.com. 2020 May 31.

10. Panceski B and Douglas J. “Masks could help stop coronavirus. So why are they still controversial?” wsj.com. Updated 29 Jun 2020.

11. Bojarski S. “Social distancing: A luxury Haiti’s poor cannot afford. The Haitian Times. 2020 Apr.

12. World Health Organization, UNICEF, World Bank Group, and the U.N. Population Division. Maternal mortality ratio, Haiti.

13. Feliciano I and Kargbo C. “As COVID cases surge, Haiti’s Dr. Pape is on the front line again.” PBS NewsHour Weekend. 2020 Jun 13.

14. Liautaud B and Deschamps MM. New Engl J Med. 2020 Jun 16.
 

Mr. Dorcela is a senior medical student at Faculté des Sciences de la Santé Université Quisqueya in Port-au-Prince, Haiti. He also is a medical intern at Unité de Médecine Familiale Hôpital Saint Nicolas in Saint-Marc. Mr. Dorcela has no disclosures. Mr. St. Jean, who is Mr. Dorcela’s brother, is also a senior medical student at Faculté des Sciences de la Santé Université Quisqueya in Port-au-Prince. He has no disclosures.

Do you want to know what keeps us up at night? As 4th-year medical students born, raised, and living in Haiti, we worry about the impact of COVID-19 on our patients.

The pandemic has shaken the world, and Haiti is no exception.

Courtesy Schneider Dorcela

It has taken several months for the disease to spread, and it began with two confirmed cases, one from France and the other from Belgium, on March 19.¹ Much of the spread of COVID-19 in Haiti has been tied to workers returning from the Dominican Republic. As of June 29, Haiti had 5,975 confirmed cases and 105 deaths.² Of course, those numbers sound minuscule, compared with those in the United States, where the number of deaths from COVID-19 surpassed 100,000 several weeks ago. But the population of Haiti is 30 times smaller than that of the United States, and Haiti is the poorest country in the Western Hemisphere. We have watched in horror as the virus has ravaged marginalized groups in the United States and worry that it will do the same in our own country.

Just as the Haitian Ministry of Health worked with various groups to reach the 1-year free of cholera mark in Haiti, groups such as Doctors Without Borders must mobilize to rein in COVID-19.
 

Community transmission rapid

After the first two cases were confirmed, a state of health emergency was immediately declared. Haitian President Jovenel Moïse and other government officials called for the implementation of several measures aimed at limiting the spread of COVID-19.

Schools, universities, clinical training programs, vocational centers, factories, airports, and ports, except for the transport of goods, were all ordered to close until further notice. Gatherings of larger than 10 people were banned. A curfew from 8 p.m. EST time to 5 a.m. EST was imposed. Measures such as those encouraged by U.S. Centers for Disease Control and Prevention, such as hand washing, physical distancing, and staying at home were also encouraged by the Haitian Ministry of Health. Mask wearing in public places was deemed mandatory.

The latest testing data show that community spread has been occurring among the Haitian population at a rapid rate. According to Jean William Pape, MD, Haiti’s top infectious diseases expert and founder of GHESKIO, an iconic infectious disease center that cares for people with HIV-AIDS and tuberculosis, a COVID-19 simulation from Cornell University in New York shows that about 35% of the Haitian population will be infected by the end of August 2020. A simulation by the University of Oxford (England) paints an even more dire picture. That simulation shows that 86% of the population could be infected, More than 9,000 additional hospital beds would be needed, and 20,000 people would be likely to die from COVID-19, Dr. Pape said in an interview with Haiti’s Nouvelliste newspaper.³
 

Medical response

We know that there is a global shortage of health care workers^,4 and Haiti is no exception. According to a 2018 report from the Haitian Ministry of Health, the country has 11,775 health care professionals, including about 3,354 medical doctors, to care for more than 11 million people. That translates to about 23.4 physicians per 100,000.⁵

The pandemic has led some members of this already anemic health care workforce to stay home because of a lack of personal protective equipment. Others, because of reduced hospital or clinic budgets, have been furloughed, making the COVID-19 national health emergency even harder to manage. The rationing of electricity and limited access to clean water⁶ in some areas are other complications that undermine our ability to provide quality care.

But a severe health care shortage is not the only challenge facing Haiti. It spends about $131 U.S. per capita, which makes Haiti one of most vulnerable among low- and middle-income countries in the world. As a poor country,⁷ its health care infrastructure is among the most inadequate and weakest. Prior to COVID-19, medical advocacy groups already had started movements and strikes demanding that the government improve the health care system. The country’s precarious health care infrastructure includes a lack of hospital beds, and basic medical supplies and equipment, such as oxygen and ventilators.⁸ The emergence of COVID-19 has only exacerbated the situation.

Clinical training programs have been suspended, many doctors and nurses are on quarantine, and some hospitals and clinics are closing. We have witnessed makeshift voodoo clinics built by Haitian voodoo leaders to receive, hospitalize, and treat COVID-19 patients through rituals and herbal remedies. In some areas of the country, residents have protested against the opening of several COVID-19 treatment and management centers.
 

Unique cultural challenges

Public health officials around the world are facing challenges persuading citizens to engage in behaviors that could protect them from the virus.

Just as in America, where many people opt to not wear face coverings^9,10 despite the public health risks, deep distrust of the Haitian government has undermined the messages of President Moïse and public healthofficials about the role of masks in limiting the spread of COVID.We see large numbers of unmasked people on the streets in the informal markets every day. Crammed tap-taps and overloaded motorcycles are moving everywhere. This also could be tied to cultural attitudes about COVID that persist among some Haitians.For example, many people with signs and symptoms of COVID-19 are afraid of going to the hospital to get tested and receive care, and resort to going to the voodoo clinics. Along with rituals, voodoo priests have been serving up teas with ingredients, including moringa, eucalyptus, ginger, and honey to those seeking COVID-19 care in the centers. The voodoo priests claim that the teas they serve strengthen the immune system.

In addition, it is difficult for poor people who live in small quarters with several other people to adhere to physical distancing.¹¹
 

Stigma and violence

Other barriers in the fight against COVID-19 in Haiti are stigma and violence. If widespread testing were available, some Haitians would opt not to do so – despite clear signs and symptoms of the infection. Some people who would get tested if they could are afraid to do so because of fears tied to being attacked by neighbors.

When Haitian University professor Bellamy Nelson and his girlfriend returned to Haiti from the United States in March and began experiencing some pain and fever, he experienced attacks from neighbors, he said in an interview. He said neighbors threatened to burn down his house. When an ambulance arrived at his house to transport him to a hospital, it had to drive through back roads to avoid people armed with rocks, fire, and machetes, he told us. No hospital wanted to admit him. Eventually, Professor Nelson self-quarantined at home, he said.

In another incident, a national ambulance center in Gonaïves, a town toward the northern region of Haiti, reportedly was vandalized, because COVID-19 equipment and supplies used to treat people had been stored there. Hospital Bernard Mevs, along with many other hospitals, was forced by the area’s residents to suspend the plan to open a center for COVID-19 management. Threats to burn down the hospitals caused the leaders of the hospitals to back down and give up a plan to build a 20-bed COVID-19 response center.
 

Maternal health

Another concern we have about the pandemic is the risk it could be to pregnant women. On average, 94,000 deaths occur annually in Haiti. Out of this number, maternal mortality accounts for 1,000. In 2017, for every 100,000 live births for women of reproductive age from 15 to 49 years old, 480 women died. In contrast, in the Dominican Republic, 95 women died per 100,000 that same year. In the United States, 19 died, and in Norway, no more than 2 died that year.¹²

Some of the primary factors contributing to the crisis are limited accessibility, inadequate health care facilities, and an inadequate number of trained health care practitioners; low percentages of skilled attendants at deliveries and of prenatal and postnatal visits; and high numbers of high-risk deliveries in nonqualified health facilities.

During the COVID-19 national health emergency, with most hospitals reducing their health care personnel either because of budget-related reasons or because they are on quarantine, this maternal-fetal health crisis has escalated.

One of the biggest hospitals in Jacmel, a town in the southern region of Haiti, has stopped its prenatal care program. In Delmas, the city with the highest incidence and prevalence of COVID-19, Hôpital Universitaire de la Paix has reduced this program to 50% of its capacity and gynecologic care has been completely suspended. Hôpital St. Luc, one of the first hospitals in the western region of Haiti to open its doors to care for COVID-19 patients, has recently shut down the entire maternal-fetal department.

So, access to prenatal and postnatal care, including the ability to deliver babies in health care institutions, is significantly reduced because of COVID-19. This leaves thousands of already vulnerable pregnant women at risk and having to deliver domestically with little to no health care professional assistance. We worry that, in light of the data, more women and babies will die because of the COVID-19 pandemic.
 

A call to action

Despite these conditions, there are reasons for hope. Various groups, both from the international community and locally have mobilized to respond to the pandemic.

International health care organizations such as Doctors Without Borders and Partners in Health, and local groups such as GHESKIO, the St. Luke Foundation for Haiti, and others have been collaborating with the Haitian Ministry of Health to devise and strategic plans and deploy valuable resources with the common goal of saving lives from COVID-19.

GHESKIO, for example, under Dr. Pape’s leadership, currently has one of the three COVID-19 testing centers in the country. It also has two COVID-19 treatment centers in full operation, in Port-au-Prince, the capital city, managing and treating 520 patients with confirmed COVID-19. GHESKIO, which has been in the front lines of previous major infectious disease outbreaks,¹³ has trained about 200 clinicians from both public and private health care institutions to care for COVID-19 patients.

Doctors Without Borders has been investing in efforts to support the Ministry of Health by converting and renovating its Burn Center in Drouillard, a small section of the city of Cité Soleil, one of the country’s biggest slums. In May, as part of its COVID-19 response, it launched a 20-bed capacity center that can accommodate up to 45 beds to care for patients who have tested positive for COVID-19.

Partners in Health, the Boston-based nonprofit health care organization cofounded in 1987 by American anthropologist and infectious disease specialist, Paul Farmer, MD, and the largest nonprofit health care provider in Haiti, also joined the Ministry of Health through its national and public health efforts to tackle COVID-19 in Haiti. Partners in Health, through its sister organization, Zanmi Lasante, has pioneered the movement of diagnosing and treating people with HIV-AIDS and TB. Since the late 1990s, its efforts against both infectious diseases have helped 15,000 HIV-positive patients begin and remain on treatment. And every year, 1,500 TB patients have started treatment on the path to a cure.

Early in the pandemic in Haiti, Partners in Health, through its state-of-the-art 300-bed university hospital (Hôpital Universitaire de Mirebalais de Mirebalais), was the first to open a COVID-19 center with a 20-bed capacity and has been caring for COVID-19 patients since then. In June, Partners in Health supported and inaugurated the renovation of the internal medicine department at one of its affiliated community hospitals, Hôpital Saint-Nicolas de Saint Marc. That department will have a 24-bed capacity that can extend up to 36 beds to manage and treat COVID-19 patients.

In total, currently, 26 COVID-19 centers with a capacity of 1,011 beds are available to serve, manage, and treat Haitian patients affected with COVID-19. But are those efforts enough? No.

Haiti, as a weak state even before COVID-19, continues to need funding from the international community so it can strengthen its health care infrastructure to be effective and strong in fighting against COVID-19.

In addition, we would like to see preventive initiatives implemented on the local level. Our family has taken on a role that, we think, could help conquer COVID-19 if others followed suit on a large scale.

As part of our contribution in tackling COVID-19, the two of us have launched a small-scale community experiment. We have educated our family in Delmas about COVID-19 and subsequently launched an awareness campaign in the community. We dispatched small groups that go door to door in the community to educate neighbors about the disease in an effort to help them understand that COVID-19 is real and it is normal for people that feel they may have the disease to seek medical care. This approach helps suppress the transmission of the virus. This pilot project could be reproduced in several other communities. It is easy to operate, rapid, effective, and cost-free. The community has been very receptive to and grateful for our efforts.

Like other countries across the world, Haiti was not ready for COVID-19. But we are confident that, with help from the international community, organizations such as GHESKIO,¹⁴ and with due diligence on the local level, we are strong and resilient enough to beat COVID. We must act together – quickly.

 

References

1. Sénat JD. Coronavirus: 2 cas confirmés en Haïti, Jovenel Moïse décrète l’état d’ur-gence sanitaire. 2020 Le Nouvelliste.

2. Haitian Ministry of Health.

3. “Entre appel a la solidarite et de sombres previsions, le Dr William Pape fait le point.” Le Nouvelliste.

4. Darzi A and Evans T. Lancet. 2016 Nov-Dec 26. 388;10060:2576-7.

5. Rapport Statistique 2018. 2019 Republic of Haiti.

6. Sentlinger K. “Water Crisis in Haiti.” The Water Project.

7. The World Bank in Haiti. worldbank.org.

8. Cenat JM. Travel Med Infect Dis. 2020 Mar 28. doi: 10.1016/jtmaid.2020.101684.

9. Block D. “Why some Americans resist wearing face masks.” voanews.com. 2020 May 31.

10. Panceski B and Douglas J. “Masks could help stop coronavirus. So why are they still controversial?” wsj.com. Updated 29 Jun 2020.

11. Bojarski S. “Social distancing: A luxury Haiti’s poor cannot afford. The Haitian Times. 2020 Apr.

12. World Health Organization, UNICEF, World Bank Group, and the U.N. Population Division. Maternal mortality ratio, Haiti.

13. Feliciano I and Kargbo C. “As COVID cases surge, Haiti’s Dr. Pape is on the front line again.” PBS NewsHour Weekend. 2020 Jun 13.

14. Liautaud B and Deschamps MM. New Engl J Med. 2020 Jun 16.
 

Mr. Dorcela is a senior medical student at Faculté des Sciences de la Santé Université Quisqueya in Port-au-Prince, Haiti. He also is a medical intern at Unité de Médecine Familiale Hôpital Saint Nicolas in Saint-Marc. Mr. Dorcela has no disclosures. Mr. St. Jean, who is Mr. Dorcela’s brother, is also a senior medical student at Faculté des Sciences de la Santé Université Quisqueya in Port-au-Prince. He has no disclosures.

Do you want to know what keeps us up at night? As 4th-year medical students born, raised, and living in Haiti, we worry about the impact of COVID-19 on our patients.

The pandemic has shaken the world, and Haiti is no exception.

Courtesy Schneider Dorcela

It has taken several months for the disease to spread, and it began with two confirmed cases, one from France and the other from Belgium, on March 19.¹ Much of the spread of COVID-19 in Haiti has been tied to workers returning from the Dominican Republic. As of June 29, Haiti had 5,975 confirmed cases and 105 deaths.² Of course, those numbers sound minuscule, compared with those in the United States, where the number of deaths from COVID-19 surpassed 100,000 several weeks ago. But the population of Haiti is 30 times smaller than that of the United States, and Haiti is the poorest country in the Western Hemisphere. We have watched in horror as the virus has ravaged marginalized groups in the United States and worry that it will do the same in our own country.

Just as the Haitian Ministry of Health worked with various groups to reach the 1-year free of cholera mark in Haiti, groups such as Doctors Without Borders must mobilize to rein in COVID-19.
 

Community transmission rapid

After the first two cases were confirmed, a state of health emergency was immediately declared. Haitian President Jovenel Moïse and other government officials called for the implementation of several measures aimed at limiting the spread of COVID-19.

Schools, universities, clinical training programs, vocational centers, factories, airports, and ports, except for the transport of goods, were all ordered to close until further notice. Gatherings of larger than 10 people were banned. A curfew from 8 p.m. EST time to 5 a.m. EST was imposed. Measures such as those encouraged by U.S. Centers for Disease Control and Prevention, such as hand washing, physical distancing, and staying at home were also encouraged by the Haitian Ministry of Health. Mask wearing in public places was deemed mandatory.

The latest testing data show that community spread has been occurring among the Haitian population at a rapid rate. According to Jean William Pape, MD, Haiti’s top infectious diseases expert and founder of GHESKIO, an iconic infectious disease center that cares for people with HIV-AIDS and tuberculosis, a COVID-19 simulation from Cornell University in New York shows that about 35% of the Haitian population will be infected by the end of August 2020. A simulation by the University of Oxford (England) paints an even more dire picture. That simulation shows that 86% of the population could be infected, More than 9,000 additional hospital beds would be needed, and 20,000 people would be likely to die from COVID-19, Dr. Pape said in an interview with Haiti’s Nouvelliste newspaper.³
 

Medical response

We know that there is a global shortage of health care workers^,4 and Haiti is no exception. According to a 2018 report from the Haitian Ministry of Health, the country has 11,775 health care professionals, including about 3,354 medical doctors, to care for more than 11 million people. That translates to about 23.4 physicians per 100,000.⁵

The pandemic has led some members of this already anemic health care workforce to stay home because of a lack of personal protective equipment. Others, because of reduced hospital or clinic budgets, have been furloughed, making the COVID-19 national health emergency even harder to manage. The rationing of electricity and limited access to clean water⁶ in some areas are other complications that undermine our ability to provide quality care.

But a severe health care shortage is not the only challenge facing Haiti. It spends about $131 U.S. per capita, which makes Haiti one of most vulnerable among low- and middle-income countries in the world. As a poor country,⁷ its health care infrastructure is among the most inadequate and weakest. Prior to COVID-19, medical advocacy groups already had started movements and strikes demanding that the government improve the health care system. The country’s precarious health care infrastructure includes a lack of hospital beds, and basic medical supplies and equipment, such as oxygen and ventilators.⁸ The emergence of COVID-19 has only exacerbated the situation.

Clinical training programs have been suspended, many doctors and nurses are on quarantine, and some hospitals and clinics are closing. We have witnessed makeshift voodoo clinics built by Haitian voodoo leaders to receive, hospitalize, and treat COVID-19 patients through rituals and herbal remedies. In some areas of the country, residents have protested against the opening of several COVID-19 treatment and management centers.
 

Unique cultural challenges

Public health officials around the world are facing challenges persuading citizens to engage in behaviors that could protect them from the virus.

Just as in America, where many people opt to not wear face coverings^9,10 despite the public health risks, deep distrust of the Haitian government has undermined the messages of President Moïse and public healthofficials about the role of masks in limiting the spread of COVID.We see large numbers of unmasked people on the streets in the informal markets every day. Crammed tap-taps and overloaded motorcycles are moving everywhere. This also could be tied to cultural attitudes about COVID that persist among some Haitians.For example, many people with signs and symptoms of COVID-19 are afraid of going to the hospital to get tested and receive care, and resort to going to the voodoo clinics. Along with rituals, voodoo priests have been serving up teas with ingredients, including moringa, eucalyptus, ginger, and honey to those seeking COVID-19 care in the centers. The voodoo priests claim that the teas they serve strengthen the immune system.

In addition, it is difficult for poor people who live in small quarters with several other people to adhere to physical distancing.¹¹
 

Stigma and violence

Other barriers in the fight against COVID-19 in Haiti are stigma and violence. If widespread testing were available, some Haitians would opt not to do so – despite clear signs and symptoms of the infection. Some people who would get tested if they could are afraid to do so because of fears tied to being attacked by neighbors.

When Haitian University professor Bellamy Nelson and his girlfriend returned to Haiti from the United States in March and began experiencing some pain and fever, he experienced attacks from neighbors, he said in an interview. He said neighbors threatened to burn down his house. When an ambulance arrived at his house to transport him to a hospital, it had to drive through back roads to avoid people armed with rocks, fire, and machetes, he told us. No hospital wanted to admit him. Eventually, Professor Nelson self-quarantined at home, he said.

In another incident, a national ambulance center in Gonaïves, a town toward the northern region of Haiti, reportedly was vandalized, because COVID-19 equipment and supplies used to treat people had been stored there. Hospital Bernard Mevs, along with many other hospitals, was forced by the area’s residents to suspend the plan to open a center for COVID-19 management. Threats to burn down the hospitals caused the leaders of the hospitals to back down and give up a plan to build a 20-bed COVID-19 response center.
 

Maternal health

Another concern we have about the pandemic is the risk it could be to pregnant women. On average, 94,000 deaths occur annually in Haiti. Out of this number, maternal mortality accounts for 1,000. In 2017, for every 100,000 live births for women of reproductive age from 15 to 49 years old, 480 women died. In contrast, in the Dominican Republic, 95 women died per 100,000 that same year. In the United States, 19 died, and in Norway, no more than 2 died that year.¹²

Some of the primary factors contributing to the crisis are limited accessibility, inadequate health care facilities, and an inadequate number of trained health care practitioners; low percentages of skilled attendants at deliveries and of prenatal and postnatal visits; and high numbers of high-risk deliveries in nonqualified health facilities.

During the COVID-19 national health emergency, with most hospitals reducing their health care personnel either because of budget-related reasons or because they are on quarantine, this maternal-fetal health crisis has escalated.

One of the biggest hospitals in Jacmel, a town in the southern region of Haiti, has stopped its prenatal care program. In Delmas, the city with the highest incidence and prevalence of COVID-19, Hôpital Universitaire de la Paix has reduced this program to 50% of its capacity and gynecologic care has been completely suspended. Hôpital St. Luc, one of the first hospitals in the western region of Haiti to open its doors to care for COVID-19 patients, has recently shut down the entire maternal-fetal department.

So, access to prenatal and postnatal care, including the ability to deliver babies in health care institutions, is significantly reduced because of COVID-19. This leaves thousands of already vulnerable pregnant women at risk and having to deliver domestically with little to no health care professional assistance. We worry that, in light of the data, more women and babies will die because of the COVID-19 pandemic.
 

A call to action

Despite these conditions, there are reasons for hope. Various groups, both from the international community and locally have mobilized to respond to the pandemic.

International health care organizations such as Doctors Without Borders and Partners in Health, and local groups such as GHESKIO, the St. Luke Foundation for Haiti, and others have been collaborating with the Haitian Ministry of Health to devise and strategic plans and deploy valuable resources with the common goal of saving lives from COVID-19.

GHESKIO, for example, under Dr. Pape’s leadership, currently has one of the three COVID-19 testing centers in the country. It also has two COVID-19 treatment centers in full operation, in Port-au-Prince, the capital city, managing and treating 520 patients with confirmed COVID-19. GHESKIO, which has been in the front lines of previous major infectious disease outbreaks,¹³ has trained about 200 clinicians from both public and private health care institutions to care for COVID-19 patients.

Doctors Without Borders has been investing in efforts to support the Ministry of Health by converting and renovating its Burn Center in Drouillard, a small section of the city of Cité Soleil, one of the country’s biggest slums. In May, as part of its COVID-19 response, it launched a 20-bed capacity center that can accommodate up to 45 beds to care for patients who have tested positive for COVID-19.

Partners in Health, the Boston-based nonprofit health care organization cofounded in 1987 by American anthropologist and infectious disease specialist, Paul Farmer, MD, and the largest nonprofit health care provider in Haiti, also joined the Ministry of Health through its national and public health efforts to tackle COVID-19 in Haiti. Partners in Health, through its sister organization, Zanmi Lasante, has pioneered the movement of diagnosing and treating people with HIV-AIDS and TB. Since the late 1990s, its efforts against both infectious diseases have helped 15,000 HIV-positive patients begin and remain on treatment. And every year, 1,500 TB patients have started treatment on the path to a cure.

Early in the pandemic in Haiti, Partners in Health, through its state-of-the-art 300-bed university hospital (Hôpital Universitaire de Mirebalais de Mirebalais), was the first to open a COVID-19 center with a 20-bed capacity and has been caring for COVID-19 patients since then. In June, Partners in Health supported and inaugurated the renovation of the internal medicine department at one of its affiliated community hospitals, Hôpital Saint-Nicolas de Saint Marc. That department will have a 24-bed capacity that can extend up to 36 beds to manage and treat COVID-19 patients.

In total, currently, 26 COVID-19 centers with a capacity of 1,011 beds are available to serve, manage, and treat Haitian patients affected with COVID-19. But are those efforts enough? No.

Haiti, as a weak state even before COVID-19, continues to need funding from the international community so it can strengthen its health care infrastructure to be effective and strong in fighting against COVID-19.

In addition, we would like to see preventive initiatives implemented on the local level. Our family has taken on a role that, we think, could help conquer COVID-19 if others followed suit on a large scale.

As part of our contribution in tackling COVID-19, the two of us have launched a small-scale community experiment. We have educated our family in Delmas about COVID-19 and subsequently launched an awareness campaign in the community. We dispatched small groups that go door to door in the community to educate neighbors about the disease in an effort to help them understand that COVID-19 is real and it is normal for people that feel they may have the disease to seek medical care. This approach helps suppress the transmission of the virus. This pilot project could be reproduced in several other communities. It is easy to operate, rapid, effective, and cost-free. The community has been very receptive to and grateful for our efforts.

Like other countries across the world, Haiti was not ready for COVID-19. But we are confident that, with help from the international community, organizations such as GHESKIO,¹⁴ and with due diligence on the local level, we are strong and resilient enough to beat COVID. We must act together – quickly.

 

References

1. Sénat JD. Coronavirus: 2 cas confirmés en Haïti, Jovenel Moïse décrète l’état d’ur-gence sanitaire. 2020 Le Nouvelliste.

2. Haitian Ministry of Health.

3. “Entre appel a la solidarite et de sombres previsions, le Dr William Pape fait le point.” Le Nouvelliste.

4. Darzi A and Evans T. Lancet. 2016 Nov-Dec 26. 388;10060:2576-7.

5. Rapport Statistique 2018. 2019 Republic of Haiti.

6. Sentlinger K. “Water Crisis in Haiti.” The Water Project.

7. The World Bank in Haiti. worldbank.org.

8. Cenat JM. Travel Med Infect Dis. 2020 Mar 28. doi: 10.1016/jtmaid.2020.101684.

9. Block D. “Why some Americans resist wearing face masks.” voanews.com. 2020 May 31.

10. Panceski B and Douglas J. “Masks could help stop coronavirus. So why are they still controversial?” wsj.com. Updated 29 Jun 2020.

11. Bojarski S. “Social distancing: A luxury Haiti’s poor cannot afford. The Haitian Times. 2020 Apr.

12. World Health Organization, UNICEF, World Bank Group, and the U.N. Population Division. Maternal mortality ratio, Haiti.

13. Feliciano I and Kargbo C. “As COVID cases surge, Haiti’s Dr. Pape is on the front line again.” PBS NewsHour Weekend. 2020 Jun 13.

14. Liautaud B and Deschamps MM. New Engl J Med. 2020 Jun 16.
 

Mr. Dorcela is a senior medical student at Faculté des Sciences de la Santé Université Quisqueya in Port-au-Prince, Haiti. He also is a medical intern at Unité de Médecine Familiale Hôpital Saint Nicolas in Saint-Marc. Mr. Dorcela has no disclosures. Mr. St. Jean, who is Mr. Dorcela’s brother, is also a senior medical student at Faculté des Sciences de la Santé Université Quisqueya in Port-au-Prince. He has no disclosures.

Changing times

After more than 20 years, my leadership role as CEO at the Society of Hospital Medicine (SHM) has ended with the transition to Dr. Eric Howell as the new SHM CEO on July 1, 2020. Looking back, I think we can all be proud of how we have helped to shape the specialty of hospital medicine over these two decades and of how strong SHM has become to support our new specialty.

In 2000, few people knew what a hospitalist was (or more importantly what we could become) and the specialty of hospital medicine had not even been named yet. Today the reputation of SHM is firmly established and the specialty has been defined by a unique curriculum through the Core Competencies in Hospital Medicine for both adult and pediatric patients, and by several textbooks in hospital medicine. There are divisions or departments of hospital medicine at many hospitals and academic medical centers. We even managed to convince the American Board of Internal Medicine, the American Board of Family Medicine, and the American Board of Medical Specialties to create a credential of Focused Practice in Hospital Medicine as the first-ever certification not tied to specific fellowship training.

To recognize the contributions of our members, SHM has established Awards of Excellence and the Fellow and Senior Fellow in Hospital Medicine (FHM and SFHM) designations. We have gone from a small national association in Philadelphia to create 68 active chapters and more than 20 Special Interest Groups. In my time at SHM I have attended more than 75-chapter meetings and met with thousands of hospitalists in 46 states. We now have over 20,000 members at SHM, making us the fastest growing medical specialty ever.

When I started at the National Association of Inpatient Physicians (NAIP) our only meeting was an annual CME meeting for about 150-200 people. We now hold a national meeting every year for more than 4,000 attendees that is the “Center of the Universe for Hospital Medicine.” Understanding that we needed to educate the people who will lead change in our health care system, we developed from scratch a set of Leadership Academies that has already educated more than 2,500 hospitalist leaders. To train the educators in quality improvement in medical education we developed our Quality and Safety Educator Academy (QSEA) programs, and to promote career development of academic hospitalists we created our Academic Hospitalist Academy.

SHM is the leader in adult in-practice learning, specifically designed for hospitalists. SHM members have access to a state-of-the-art comprehensive hospitalist-based online education system as well as board review and maintenance of certification (MOC) review tools in our SPARK program, specifically for hospital medicine.

In the area of quality improvement, most medical societies convene a panel of experts, develop guidelines, publish them, and hope that change will occur. SHM has been much more proactive, creating the Center for Quality Improvement that has raised more than $10 million and developed Quality Improvement programs in more than 400 hospitals over the years, winning the prestigious Eisenberg Award along the way.

When I started at NAIP in 2000, our only communication tools were a 4-page newsletter and an email listserv. Along the way we have developed a broadly read newsmagazine (The Hospitalist), a well-recognized peer reviewed journal (Journal of Hospital Medicine), a robust website, and a significant social media presence.

From the very early days we knew that our specialty would not be totally successful by only facing inward. Change was coming to our health care system and hospitalists were going to be right in the middle. Despite our young age and limited resources, we have always hit above our weight class in advocacy. We actively participated in the development of the Affordable Care Act (Obamacare), making suggestions in payment reform, expanding the workforce with visa reform, and expanding the team of clinicians. Along the way SHM members rose to run the Centers for Medicare & Medicaid Services (CMS) and the Food and Drug Administration (FDA), and serve as U.S. Surgeon General.

Today in these troubled times, SHM continues to be a positive voice in promoting the use of PPE, the need for increased COVID-19 testing, and the recognition of our nation’s 60,000 hospitalists as essential frontline workers in the COVID-19 pandemic. With its longstanding role in promoting diversity and overcoming social injustice, SHM has had a positive national voice during the protests over police brutality.

We have proved to be a good partner with many other organizations and consistently were invited to partner in coalitions with the ED physicians (ACEP), the critical care docs (SCCM), the hospitals (AHA), the house of medicine (AMA), other internists (ACP), surgeons (ACS), and pediatricians (AAP), and so many other much more established societies, because we could be an active, flexible, and knowledgeable partner for more than 20 years.

Today, SHM and hospital medicine are clearly recognized as a force in the rapidly evolving health care system. With this comes not only influence but also responsibility, and I am certain the SHM Board, membership, and staff are ready for this challenge. The economic toll of our current pandemic will see colleges and other major companies and institutions go out of business and leave the landscape. SHM has a deep foundation and a well of strength to call on and will survive and thrive into the future.

SHM has been a good fit for me professionally and personally. Many of my skills and strengths have served SHM in our “early” years. I am very proud of what we have been able to accomplish TOGETHER. In the end it is the people I have been fortunate enough to meet and work with throughout these past 20 years that will stay with me, many of whom are lifelong friends. My mother, even today at 93, has always asked me to leave anything I do better off than when I came in the door. As I look back at my time helping to shape and lead SHM, I am sure I have answered my mother’s challenge and more.

I look forward to seeing many of you at a future SHM meeting and reveling in the way that hospitalists will actively play an important role in shaping our health care system in the future.
 

Dr. Wellikson is retiring as CEO of SHM.

Live long and prosper

Back in 2000, I was extremely fortunate to land my dream job as a hospitalist at Johns Hopkins Bayview in Baltimore. That dream exceeded my wildest aspirations. During my 20-year career as faculty in the Johns Hopkins School of Medicine I grew our tiny, 4 physician hospitalist group at Johns Hopkins Bayview into a multihospital program, complete with more than 150 physicians. That exceedingly rewarding work helped to shape the field of hospital medicine nationally and provided the foundation for my promotion to professor of medicine at Johns Hopkins in 2016.

Most professionals are lucky if they find one inspiring institution; I have found two. SHM has been my professional home since I became a hospitalist in 2000, and in that time I have dedicated as much creative energy to SHM as I have at Johns Hopkins.

Even at this time when the medical profession, and the entire world, has been rocked by the coronavirus, the fundamentals that have made SHM so successful will serve us well through the effects of this pandemic and beyond. It takes a skilled leader to nurture a professional society through the growth from only a few hundred members to thousands upon thousands, and at the same time crafting the profession into one of quality and high impact. These past 22 years Dr. Larry Wellikson, our retiring CEO, has skillfully accomplished just that by building lasting programs and people.

As you might imagine, my approach will work to add onto the legacy that Larry has left us. Yes, we will have to adapt SHM to the realities of the near future: virtual meetings, in-person events (yes, those will return one day) with appropriate social distancing until the coronavirus has faded, modified chapter meetings, and more. Someday the world will find a new normal, and SHM will evolve to meet the needs of our members and the patients we serve.

Through this pandemic and beyond, my vision – in partnership with the Board of Directors – will be to:

• Continue the work to enhance member engagement. We are primarily a membership organization, after all.
• Maintain our profession’s leadership role in the care continuum, particularly acute care.
• Be a deliberate sponsor of diversity and inclusion. I believe social justice is a moral imperative, and good business.
• Invest in teams: Chapters, special interest groups, and committees are key to success.
• Be financially prudent, so that this organization can serve its members through the best of times and those most challenging times.

Back in 2000 I joined my dream society, the Society of Hospital Medicine. That society exceeded my wildest aspirations. During my 20-year membership I started an SHM Chapter, was a leader in the Leadership Academies, joined the Board of Directors, participated in Annual Conferences, and helped lead the SHM Center for Quality Improvement. That exceedingly rewarding partnership helped shape the field of hospital medicine nationally and provided the foundation for my next role at SHM. I am excited and grateful to be the CEO of SHM.

I’ll end with something I use every day – “Eric Howell’s Core Values”:

• Make the world a better place.
• Invest in people.
• Be ethical and transparent.
• Do what you love.
• Try to use Star Trek references whenever possible. (Okay, this last one is not really a core value, but maybe a character trait?) At least the Vulcan greeting is appropriate for our times: Live long and prosper.

Dr. Howell is the new CEO for SHM as of July 1, 2020.

Changing times

After more than 20 years, my leadership role as CEO at the Society of Hospital Medicine (SHM) has ended with the transition to Dr. Eric Howell as the new SHM CEO on July 1, 2020. Looking back, I think we can all be proud of how we have helped to shape the specialty of hospital medicine over these two decades and of how strong SHM has become to support our new specialty.

In 2000, few people knew what a hospitalist was (or more importantly what we could become) and the specialty of hospital medicine had not even been named yet. Today the reputation of SHM is firmly established and the specialty has been defined by a unique curriculum through the Core Competencies in Hospital Medicine for both adult and pediatric patients, and by several textbooks in hospital medicine. There are divisions or departments of hospital medicine at many hospitals and academic medical centers. We even managed to convince the American Board of Internal Medicine, the American Board of Family Medicine, and the American Board of Medical Specialties to create a credential of Focused Practice in Hospital Medicine as the first-ever certification not tied to specific fellowship training.

To recognize the contributions of our members, SHM has established Awards of Excellence and the Fellow and Senior Fellow in Hospital Medicine (FHM and SFHM) designations. We have gone from a small national association in Philadelphia to create 68 active chapters and more than 20 Special Interest Groups. In my time at SHM I have attended more than 75-chapter meetings and met with thousands of hospitalists in 46 states. We now have over 20,000 members at SHM, making us the fastest growing medical specialty ever.

When I started at the National Association of Inpatient Physicians (NAIP) our only meeting was an annual CME meeting for about 150-200 people. We now hold a national meeting every year for more than 4,000 attendees that is the “Center of the Universe for Hospital Medicine.” Understanding that we needed to educate the people who will lead change in our health care system, we developed from scratch a set of Leadership Academies that has already educated more than 2,500 hospitalist leaders. To train the educators in quality improvement in medical education we developed our Quality and Safety Educator Academy (QSEA) programs, and to promote career development of academic hospitalists we created our Academic Hospitalist Academy.

SHM is the leader in adult in-practice learning, specifically designed for hospitalists. SHM members have access to a state-of-the-art comprehensive hospitalist-based online education system as well as board review and maintenance of certification (MOC) review tools in our SPARK program, specifically for hospital medicine.

In the area of quality improvement, most medical societies convene a panel of experts, develop guidelines, publish them, and hope that change will occur. SHM has been much more proactive, creating the Center for Quality Improvement that has raised more than $10 million and developed Quality Improvement programs in more than 400 hospitals over the years, winning the prestigious Eisenberg Award along the way.

When I started at NAIP in 2000, our only communication tools were a 4-page newsletter and an email listserv. Along the way we have developed a broadly read newsmagazine (The Hospitalist), a well-recognized peer reviewed journal (Journal of Hospital Medicine), a robust website, and a significant social media presence.

From the very early days we knew that our specialty would not be totally successful by only facing inward. Change was coming to our health care system and hospitalists were going to be right in the middle. Despite our young age and limited resources, we have always hit above our weight class in advocacy. We actively participated in the development of the Affordable Care Act (Obamacare), making suggestions in payment reform, expanding the workforce with visa reform, and expanding the team of clinicians. Along the way SHM members rose to run the Centers for Medicare & Medicaid Services (CMS) and the Food and Drug Administration (FDA), and serve as U.S. Surgeon General.

Today in these troubled times, SHM continues to be a positive voice in promoting the use of PPE, the need for increased COVID-19 testing, and the recognition of our nation’s 60,000 hospitalists as essential frontline workers in the COVID-19 pandemic. With its longstanding role in promoting diversity and overcoming social injustice, SHM has had a positive national voice during the protests over police brutality.

We have proved to be a good partner with many other organizations and consistently were invited to partner in coalitions with the ED physicians (ACEP), the critical care docs (SCCM), the hospitals (AHA), the house of medicine (AMA), other internists (ACP), surgeons (ACS), and pediatricians (AAP), and so many other much more established societies, because we could be an active, flexible, and knowledgeable partner for more than 20 years.

Today, SHM and hospital medicine are clearly recognized as a force in the rapidly evolving health care system. With this comes not only influence but also responsibility, and I am certain the SHM Board, membership, and staff are ready for this challenge. The economic toll of our current pandemic will see colleges and other major companies and institutions go out of business and leave the landscape. SHM has a deep foundation and a well of strength to call on and will survive and thrive into the future.

SHM has been a good fit for me professionally and personally. Many of my skills and strengths have served SHM in our “early” years. I am very proud of what we have been able to accomplish TOGETHER. In the end it is the people I have been fortunate enough to meet and work with throughout these past 20 years that will stay with me, many of whom are lifelong friends. My mother, even today at 93, has always asked me to leave anything I do better off than when I came in the door. As I look back at my time helping to shape and lead SHM, I am sure I have answered my mother’s challenge and more.

I look forward to seeing many of you at a future SHM meeting and reveling in the way that hospitalists will actively play an important role in shaping our health care system in the future.
 

Dr. Wellikson is retiring as CEO of SHM.

Live long and prosper

Back in 2000, I was extremely fortunate to land my dream job as a hospitalist at Johns Hopkins Bayview in Baltimore. That dream exceeded my wildest aspirations. During my 20-year career as faculty in the Johns Hopkins School of Medicine I grew our tiny, 4 physician hospitalist group at Johns Hopkins Bayview into a multihospital program, complete with more than 150 physicians. That exceedingly rewarding work helped to shape the field of hospital medicine nationally and provided the foundation for my promotion to professor of medicine at Johns Hopkins in 2016.

Most professionals are lucky if they find one inspiring institution; I have found two. SHM has been my professional home since I became a hospitalist in 2000, and in that time I have dedicated as much creative energy to SHM as I have at Johns Hopkins.

Even at this time when the medical profession, and the entire world, has been rocked by the coronavirus, the fundamentals that have made SHM so successful will serve us well through the effects of this pandemic and beyond. It takes a skilled leader to nurture a professional society through the growth from only a few hundred members to thousands upon thousands, and at the same time crafting the profession into one of quality and high impact. These past 22 years Dr. Larry Wellikson, our retiring CEO, has skillfully accomplished just that by building lasting programs and people.

As you might imagine, my approach will work to add onto the legacy that Larry has left us. Yes, we will have to adapt SHM to the realities of the near future: virtual meetings, in-person events (yes, those will return one day) with appropriate social distancing until the coronavirus has faded, modified chapter meetings, and more. Someday the world will find a new normal, and SHM will evolve to meet the needs of our members and the patients we serve.

Through this pandemic and beyond, my vision – in partnership with the Board of Directors – will be to:

• Continue the work to enhance member engagement. We are primarily a membership organization, after all.
• Maintain our profession’s leadership role in the care continuum, particularly acute care.
• Be a deliberate sponsor of diversity and inclusion. I believe social justice is a moral imperative, and good business.
• Invest in teams: Chapters, special interest groups, and committees are key to success.
• Be financially prudent, so that this organization can serve its members through the best of times and those most challenging times.

Back in 2000 I joined my dream society, the Society of Hospital Medicine. That society exceeded my wildest aspirations. During my 20-year membership I started an SHM Chapter, was a leader in the Leadership Academies, joined the Board of Directors, participated in Annual Conferences, and helped lead the SHM Center for Quality Improvement. That exceedingly rewarding partnership helped shape the field of hospital medicine nationally and provided the foundation for my next role at SHM. I am excited and grateful to be the CEO of SHM.

I’ll end with something I use every day – “Eric Howell’s Core Values”:

• Make the world a better place.
• Invest in people.
• Be ethical and transparent.
• Do what you love.
• Try to use Star Trek references whenever possible. (Okay, this last one is not really a core value, but maybe a character trait?) At least the Vulcan greeting is appropriate for our times: Live long and prosper.

Dr. Howell is the new CEO for SHM as of July 1, 2020.

Changing times

After more than 20 years, my leadership role as CEO at the Society of Hospital Medicine (SHM) has ended with the transition to Dr. Eric Howell as the new SHM CEO on July 1, 2020. Looking back, I think we can all be proud of how we have helped to shape the specialty of hospital medicine over these two decades and of how strong SHM has become to support our new specialty.

In 2000, few people knew what a hospitalist was (or more importantly what we could become) and the specialty of hospital medicine had not even been named yet. Today the reputation of SHM is firmly established and the specialty has been defined by a unique curriculum through the Core Competencies in Hospital Medicine for both adult and pediatric patients, and by several textbooks in hospital medicine. There are divisions or departments of hospital medicine at many hospitals and academic medical centers. We even managed to convince the American Board of Internal Medicine, the American Board of Family Medicine, and the American Board of Medical Specialties to create a credential of Focused Practice in Hospital Medicine as the first-ever certification not tied to specific fellowship training.

To recognize the contributions of our members, SHM has established Awards of Excellence and the Fellow and Senior Fellow in Hospital Medicine (FHM and SFHM) designations. We have gone from a small national association in Philadelphia to create 68 active chapters and more than 20 Special Interest Groups. In my time at SHM I have attended more than 75-chapter meetings and met with thousands of hospitalists in 46 states. We now have over 20,000 members at SHM, making us the fastest growing medical specialty ever.

When I started at the National Association of Inpatient Physicians (NAIP) our only meeting was an annual CME meeting for about 150-200 people. We now hold a national meeting every year for more than 4,000 attendees that is the “Center of the Universe for Hospital Medicine.” Understanding that we needed to educate the people who will lead change in our health care system, we developed from scratch a set of Leadership Academies that has already educated more than 2,500 hospitalist leaders. To train the educators in quality improvement in medical education we developed our Quality and Safety Educator Academy (QSEA) programs, and to promote career development of academic hospitalists we created our Academic Hospitalist Academy.

SHM is the leader in adult in-practice learning, specifically designed for hospitalists. SHM members have access to a state-of-the-art comprehensive hospitalist-based online education system as well as board review and maintenance of certification (MOC) review tools in our SPARK program, specifically for hospital medicine.

In the area of quality improvement, most medical societies convene a panel of experts, develop guidelines, publish them, and hope that change will occur. SHM has been much more proactive, creating the Center for Quality Improvement that has raised more than $10 million and developed Quality Improvement programs in more than 400 hospitals over the years, winning the prestigious Eisenberg Award along the way.

When I started at NAIP in 2000, our only communication tools were a 4-page newsletter and an email listserv. Along the way we have developed a broadly read newsmagazine (The Hospitalist), a well-recognized peer reviewed journal (Journal of Hospital Medicine), a robust website, and a significant social media presence.

From the very early days we knew that our specialty would not be totally successful by only facing inward. Change was coming to our health care system and hospitalists were going to be right in the middle. Despite our young age and limited resources, we have always hit above our weight class in advocacy. We actively participated in the development of the Affordable Care Act (Obamacare), making suggestions in payment reform, expanding the workforce with visa reform, and expanding the team of clinicians. Along the way SHM members rose to run the Centers for Medicare & Medicaid Services (CMS) and the Food and Drug Administration (FDA), and serve as U.S. Surgeon General.

Today in these troubled times, SHM continues to be a positive voice in promoting the use of PPE, the need for increased COVID-19 testing, and the recognition of our nation’s 60,000 hospitalists as essential frontline workers in the COVID-19 pandemic. With its longstanding role in promoting diversity and overcoming social injustice, SHM has had a positive national voice during the protests over police brutality.

We have proved to be a good partner with many other organizations and consistently were invited to partner in coalitions with the ED physicians (ACEP), the critical care docs (SCCM), the hospitals (AHA), the house of medicine (AMA), other internists (ACP), surgeons (ACS), and pediatricians (AAP), and so many other much more established societies, because we could be an active, flexible, and knowledgeable partner for more than 20 years.

Today, SHM and hospital medicine are clearly recognized as a force in the rapidly evolving health care system. With this comes not only influence but also responsibility, and I am certain the SHM Board, membership, and staff are ready for this challenge. The economic toll of our current pandemic will see colleges and other major companies and institutions go out of business and leave the landscape. SHM has a deep foundation and a well of strength to call on and will survive and thrive into the future.

SHM has been a good fit for me professionally and personally. Many of my skills and strengths have served SHM in our “early” years. I am very proud of what we have been able to accomplish TOGETHER. In the end it is the people I have been fortunate enough to meet and work with throughout these past 20 years that will stay with me, many of whom are lifelong friends. My mother, even today at 93, has always asked me to leave anything I do better off than when I came in the door. As I look back at my time helping to shape and lead SHM, I am sure I have answered my mother’s challenge and more.

I look forward to seeing many of you at a future SHM meeting and reveling in the way that hospitalists will actively play an important role in shaping our health care system in the future.
 

Dr. Wellikson is retiring as CEO of SHM.

Live long and prosper

Back in 2000, I was extremely fortunate to land my dream job as a hospitalist at Johns Hopkins Bayview in Baltimore. That dream exceeded my wildest aspirations. During my 20-year career as faculty in the Johns Hopkins School of Medicine I grew our tiny, 4 physician hospitalist group at Johns Hopkins Bayview into a multihospital program, complete with more than 150 physicians. That exceedingly rewarding work helped to shape the field of hospital medicine nationally and provided the foundation for my promotion to professor of medicine at Johns Hopkins in 2016.

Most professionals are lucky if they find one inspiring institution; I have found two. SHM has been my professional home since I became a hospitalist in 2000, and in that time I have dedicated as much creative energy to SHM as I have at Johns Hopkins.

Even at this time when the medical profession, and the entire world, has been rocked by the coronavirus, the fundamentals that have made SHM so successful will serve us well through the effects of this pandemic and beyond. It takes a skilled leader to nurture a professional society through the growth from only a few hundred members to thousands upon thousands, and at the same time crafting the profession into one of quality and high impact. These past 22 years Dr. Larry Wellikson, our retiring CEO, has skillfully accomplished just that by building lasting programs and people.

As you might imagine, my approach will work to add onto the legacy that Larry has left us. Yes, we will have to adapt SHM to the realities of the near future: virtual meetings, in-person events (yes, those will return one day) with appropriate social distancing until the coronavirus has faded, modified chapter meetings, and more. Someday the world will find a new normal, and SHM will evolve to meet the needs of our members and the patients we serve.

Through this pandemic and beyond, my vision – in partnership with the Board of Directors – will be to:

• Continue the work to enhance member engagement. We are primarily a membership organization, after all.
• Maintain our profession’s leadership role in the care continuum, particularly acute care.
• Be a deliberate sponsor of diversity and inclusion. I believe social justice is a moral imperative, and good business.
• Invest in teams: Chapters, special interest groups, and committees are key to success.
• Be financially prudent, so that this organization can serve its members through the best of times and those most challenging times.

Back in 2000 I joined my dream society, the Society of Hospital Medicine. That society exceeded my wildest aspirations. During my 20-year membership I started an SHM Chapter, was a leader in the Leadership Academies, joined the Board of Directors, participated in Annual Conferences, and helped lead the SHM Center for Quality Improvement. That exceedingly rewarding partnership helped shape the field of hospital medicine nationally and provided the foundation for my next role at SHM. I am excited and grateful to be the CEO of SHM.

I’ll end with something I use every day – “Eric Howell’s Core Values”:

• Make the world a better place.
• Invest in people.
• Be ethical and transparent.
• Do what you love.
• Try to use Star Trek references whenever possible. (Okay, this last one is not really a core value, but maybe a character trait?) At least the Vulcan greeting is appropriate for our times: Live long and prosper.

Dr. Howell is the new CEO for SHM as of July 1, 2020.

Coronavirus disease 2019 (COVID-19) is affecting every aspect of medical care. Much has been written about overwhelmed hospital settings, the financial devastation to outpatient treatment centers, and an impending pandemic of mental illness that the existing underfunded and fragmented mental health system would not be prepared to weather. Although COVID-19 has undeniably affected the practice of emergency psychiatry, its impact has been surprising and complex. In this article, I describe the effects COVID-19 has had on our psychiatric emergency service, and how the pandemic has affected me personally.

How the pandemic affected our psychiatric ED

The Comprehensive Psychiatric Emergency Program (CPEP) in Buffalo, New York, is part of the emergency department (ED) in the local county hospital and is staffed by faculty from the Department of Psychiatry at the University at Buffalo. It was developed to provide evaluations of acutely psychiatrically ill individuals, to determine their treatment needs and facilitate access to the appropriate level of care.

Before COVID-19, as the only fully staffed psychiatric emergency service in the region, CPEP would routinely be called upon to serve many functions for which it was not designed. For example, people who had difficulty accessing psychiatric care in the community might come to CPEP expecting treatment for chronic conditions. Additionally, due to systemic deficiencies and limited resources, police and other community agencies refer individuals to CPEP who either have illnesses unrelated to current circumstances or who are not psychiatrically ill but unmanageable because of aggression or otherwise unresolvable social challenges such as homelessness, criminal behavior, poor parenting and other family strains, or general dissatisfaction with life. Parents unable to set limits with bored or defiant children might leave them in CPEP, hoping to transfer the parenting role, just as law enforcement officers who feel impotent to apply meaningful sanctions to non-felonious offenders might bring them to CPEP seeking containment. Labeling these problems as psychiatric emergencies has made it more palatable to leave these individuals in our care. These types of visits have contributed to the substantial growth of CPEP in recent years, in terms of annual patient visits, number of children abandoned and their lengths of stay in the CPEP, among other metrics.

The impact of the COVID-19 pandemic on an emergency psychiatry service that is expected to be all things to all people has been interesting. For the first few weeks of the societal shutdown, the patient flow was unchanged. However, during this time, the usual overcrowding created a feeling of vulnerability to contagion that sparked an urgency to minimize the census. Superhuman efforts were fueled by an unspoken sense of impending doom, and wait times dropped from approximately 17 hours to 3 or 4 hours. This state of hypervigilance was impossible to sustain indefinitely, and inevitably those efforts were exhausted. As adrenaline waned, the focus turned toward family and self-preservation. Nursing and social work staff began cancelling shifts, as did part-time physicians who contracted services with our department. Others, however, were drawn to join the front-line fight.

Trends in psychiatric ED usage during the pandemic

As COVID-19 spread, local media reported the paucity of personal protective equipment (PPE) and created the sense that no one would receive hospital treatment unless they were on the brink of death. Consequently, total visits to the ED began to slow. During April, CPEP saw 25% fewer visits than average. This reduction was partly attributable to cohorting patients with any suspicion of infection in a designated area within the medical ED, with access to remote evaluation by CPEP psychiatrists via telemedicine. In addition, the characteristics and circumstances of patients presenting to CPEP began to change (Table).

Children/adolescents. In the months before COVID-19’s spread to the United States, there had been an exponential surge in child visits to CPEP, with >200 such visits in January 2020. When schools closed on March 13, school-related stress abruptly abated, and during April, child visits dropped to 89. This reduction might have been due in part to increased access to outpatient treatment via telemedicine or telephone appointments. In our affiliated clinics, both new patient visits and remote attendance to appointments by established patients increased substantially, likely contributing to a decreased reliance on the CPEP for treatment. Limited Family Court operations, though, left already-frustrated police without much recourse when called to intervene with adolescent offenders. CPEP once again served an untraditional role, facilitating the removal of these disruptive individuals from potentially dangerous circumstances, under the guise of behavioral emergencies.

Suicidality. While nonemergent visits declined, presentations related to suicidality persisted. In the United States, suicide rates have increased annually for decades. This trend has also been observed locally, with early evidence suggesting that the changes inflicted by COVID-19 perpetuated the surge in suicidal thinking and behavior, but with a change in character. Some of this is likely related to financial stress and social disruption, though job loss seems more likely to result in increased substance use than suicidality. Even more distressing to those coming to CPEP was anxiety about the illness itself, social isolation, and loss. The death of a loved one is painful enough, but disrupting the grief process by preventing people from visiting family members dying in hospitals or gathering for funerals has been devastating. Reports of increased gun sales undoubtedly associated with fears of social decay caused by the pandemic are concerning with regard to patients with suicidality, because shooting has emerged as the means most likely to result in completed suicide.¹ The imposition of social distancing directly isolated some individuals, increasing suicidality. Limitations on gathering in groups disrupted other sources of social support as well, such as religious services, clubhouses, and meetings of 12-step programs such as Alcoholics Anonymous. This could increase suicidality, either directly for more vulnerable patients or indirectly by compromising sobriety and thereby adding to the risk for suicide.

Continue to: Substance use disorders (SUDs)

Substance use disorders (SUDs). Present­ations to CPEP by patients with SUDs surged, but the patient profile changed, undoubtedly influenced by the pandemic. Requests for detoxification became less frequent because people who were not in severe distress avoided the hospital. At the same time, alcohol-dependent individuals who might typically avoid clinical attention were requiring emergent medical attention for delirium. This is attributable to a combination of factors, including nutritional depletion, and a lack of access to alcohol leading to abrupt withdrawal or consumption of unconventional sources of alcohol, such as hand sanitizer, or hard liquor (over beer). Amphetamine use appears to have increased, although the observed surge may simply be related to the conspicuousness of stimulant intoxication for someone who is sheltering in place. There was a noticeable uptick in overdoses (primarily with opioids) requiring CPEP evaluation, which was possibly related to a reduction of available beds in inpatient rehabilitation facilities as a result of social distancing rules.

Patients with chronic mental illness. Many experts anticipated an increase in hospital visits by individuals with chronic mental illness expected to decompensate as a result of reduced access to community treatment resources.² Closing courts did not prevent remote sessions for inpatient retention and treatment over objection, but did result in the expiration of many Assisted Outpatient Treatment orders by restricting renewal hearings, which is circuitously beginning to fulfill this prediction. On the other hand, an impressive community response has managed to continue meeting the needs of most of these patients. Dedicated mental health clinics have recruited mobile teams or developed carefully scheduled, nursing-run “shot clinics” to ensure that patients who require long-acting injectable medications or medication-assisted treatment for SUDs continue to receive treatment.

New-onset psychosis. A new population of patients with acute mania and psychosis also seems to have surfaced during this pandemic. Previously high-functioning individuals in their 30s, 40s, and 50s without a history of mental illness were presenting with new-onset psychotic symptoms. These are individuals who may have been characteristically anxious, or had a “Type A personality,” but were social and employed. The cause is unclear, but given the extreme uncertainty and the political climate COVID-19 brings, it is possible that the pandemic may have triggered these episodes. These individuals and their families now have the stress of learning to navigate the mental health system added to the anxiety COVID-19 brings to most households.

Homelessness. Limitations on occupancy have reduced the availability of beds in shelters and residences, resulting in increased homelessness. Locally, authorities estimated that the homeless population has grown nearly threefold as a result of bussing in from neighboring counties with fewer resources, flight from New York City, and the urgent release from jail of nonviolent offenders, many of whom had no place to go for shelter. New emergency shelter beds have not fully compensated for the relative shortage, leading individuals who had been avoiding the hospital due to fear of infection to CPEP looking for a place to stay.

Home stressors. Whereas CPEP visits by children initially decreased, after 6 weeks, the relief from school pressures appears to have been replaced by weariness from stresses at home, and the number of children presenting with depression, SUDs, and behavioral disruptions has increased. Domestic violence involving children and adults increased. Factors that might be contributing to this include the forced proximity of family members who would typically need intermittent interpersonal distance, and an obligation to care for children who would normally be in school or for disabled loved ones now unable to attend day programs or respite services. After months of enduring the pressure of these conflicts and the resulting emotional strain, patient volumes in CPEP have begun slowly returning toward the expected average, particularly since the perceived threat of coming to the hospital has attenuated.

Continue to: Personal challenges

Personal challenges

For me, COVID-19 has brought the chance to grow and learn, fumbling at times to provide the best care when crisis abounds and when not much can be said to ease the appropriate emotional distress our patients experience. The lines between what is pathological anxiety, what level of anxiety causes functional impairment, and what can realistically be expected to respond to psychiatric treatment have become blurred. At the same time, I have come across some of the sickest patients I have ever encountered.

In some ways, my passion for psychiatry has been rekindled by COVID-19, sparking an enthusiasm to teach and inspire students to pursue careers in this wonderful field of medicine. Helping to care for patients in the absence of a cure can necessitate the application of creativity and thoughtfulness to relieve suffering, thereby teaching the art of healing above offering treatment alone. Unfortunately, replacing actual patient contact with remote learning deprives students of this unique educational opportunity. Residents who attempt to continue training while limiting exposure to patients may mitigate their own risk but could also be missing an opportunity to learn how to balance their needs with making their patients’ well-being a priority. This raises the question of how the next generation of medical students and residents will learn to navigate future crises. Gruesome media depictions of haunting experiences witnessed by medical professionals exposed to an enormity of loss and death, magnified by the suicide deaths of 2 front-line workers in New York City, undoubtedly contribute to the instinct driving the protection of students and residents in this way.

The gratitude the public expresses toward me for simply continuing to do my job brings an expectation of heroism I did not seek, and with which I am uncomfortable. For me, exceptionally poised to analyze and over-analyze myriad aspects of an internal conflict that is exhausting to balance, it all generates frustration and guilt more than anything.

I am theoretically at lower risk than intubating anesthesiologists, emergency medicine physicians, and emergency medical technicians who face patients with active COVID-19. Nevertheless, daily proximity to so many patients naturally generates fear. I convince myself that performing video consultations to the medical ED is an adaptation necessary to preserve PPE, to keep me healthy through reduced exposure, to be available to patients longer, and to support the emotional health of the medical staff who are handing over that headset to patients “under investigation.” At the same time, I am secretly relieved to avoid entering those rooms and taunting death, or even worse, risking exposing my family to the virus. The threat of COVID-19 can be so consuming that it becomes easy to forget that most individuals infected are asymptomatic and therefore difficult to quickly identify.

So I continue to sit with patients face-to-face all day. Many of them are not capable of following masking and distancing recommendations, and are more prone to spitting and biting than their counterparts in the medical ED. I must ignore this threat and convince myself I am safe to be able to place my responsibility to patient care above my own needs and do my job.

Continue to: Most of my colleagues exhibit...

Most of my colleagues exhibit an effortless bravery, even if we all naturally waver briefly at times. I am proud to stand shoulder-to-shoulder every day with these clinicians, and other staff, from police to custodians, as we continue to care for the people of this community. Despite the lower clinical burden, each day we expend significant emotional energy struggling with unexpected and unique challenges, including the burden of facing the unknown. Everyone is under stress right now. For most, the effects will be transient. For some, the damage might be permanent. For others, this stress has brought out the best in us. But knowing that physicians are particularly prone to burnout, how long can the current state of hypervigilance be maintained?

What will the future hold?

The COVID-19 era has brought fewer patients through the door of my psychiatric ED; however, just like everywhere else in the world, everything has changed. The only thing that is certain is that further change is inevitable, and we must adapt to the challenge and learn from it. As unsettling as disruptions to the status quo can be, human behavior dictates that we have the option to seize opportunities created by instability to produce superior outcomes, which can be accomplished only by looking at things anew. The question is whether we will revert to the pre-COVID-19 dysfunctional use of psychiatric emergency services, or can we use what we have learned—particularly about the value of telepsychiatry—to pursue a more effective system based on an improved understanding of the mental health treatment needs of our community. While technology is proving that social distancing requires only space between people, and not necessarily social separation, there is a risk that excessive use of remote treatment could compromise the therapeutic relationship with our patients. Despite emerging opportunities, it is difficult to direct change in a productive way when the future is uncertain.

The continuous outpouring of respect for clinicians is morale-boosting. Behind closed doors, however, news that this county hospital failed to qualify for any of the second round of federal support funding because the management of COVID-19 patients has been too effective brought a new layer of unanticipated stress. This is the only hospital in 7 counties operating a psychiatric emergency service. The mandatory, “voluntary” furloughs expected of nursing and social work staff are only now being scheduled to occur over the next couple of months. And just in time for patient volumes to return to normal. How can we continue to provide quality care, let alone build changes into practice, with reduced nursing and support staff?

It is promising, however, that in the midst of social distancing, the shared experience of endeavoring to overcome COVID-19 has promoted a connectedness among individuals who might otherwise never cross paths. This observation has bolstered my confidence in the capacity for resilience of the mental health system and the individuals within it. The reality is that we are all in this together. Differences should matter less in the face of altered perceptions of mortality. Despite the stress, suicide becomes a less reasonable choice when the value of life is magnified by pandemic circumstances. Maybe there will be even less of a need for psychiatric emergency services in the wake of COVID-19, rather than the anticipated wave of mental health crises. Until we know for sure, it is only through fellowship and continued dedication to healing that the ED experience will continue to be a positive one.

Bottom Line

Coronavirus disease 2019 (COVID-19) led to changes in the characteristics and circumstances of patients presenting to our psychiatric emergency service. Despite a lower clinical burden, each day we expended significant emotional energy struggling with unexpected and unique challenges. We can use what we have learned from COVID-19 to pursue a more effective system based on an improved understanding of the mental health treatment needs of our community.

Related Resource

• American Association for Emergency Psychiatry, American College of Emergency Physicians, American Psychiatric Association, Coalition on Psychiatric Emergencies, Crisis Residential Association, and the Emergency Nurses Association. Joint statement for care of patients with behavioral health emergencies and suspected or confirmed COVID-19. https://aaep.memberclicks.net/assets/joint-statement-covid-behavioral-health.pdf.

Coronavirus disease 2019 (COVID-19) is affecting every aspect of medical care. Much has been written about overwhelmed hospital settings, the financial devastation to outpatient treatment centers, and an impending pandemic of mental illness that the existing underfunded and fragmented mental health system would not be prepared to weather. Although COVID-19 has undeniably affected the practice of emergency psychiatry, its impact has been surprising and complex. In this article, I describe the effects COVID-19 has had on our psychiatric emergency service, and how the pandemic has affected me personally.

How the pandemic affected our psychiatric ED

The Comprehensive Psychiatric Emergency Program (CPEP) in Buffalo, New York, is part of the emergency department (ED) in the local county hospital and is staffed by faculty from the Department of Psychiatry at the University at Buffalo. It was developed to provide evaluations of acutely psychiatrically ill individuals, to determine their treatment needs and facilitate access to the appropriate level of care.

Before COVID-19, as the only fully staffed psychiatric emergency service in the region, CPEP would routinely be called upon to serve many functions for which it was not designed. For example, people who had difficulty accessing psychiatric care in the community might come to CPEP expecting treatment for chronic conditions. Additionally, due to systemic deficiencies and limited resources, police and other community agencies refer individuals to CPEP who either have illnesses unrelated to current circumstances or who are not psychiatrically ill but unmanageable because of aggression or otherwise unresolvable social challenges such as homelessness, criminal behavior, poor parenting and other family strains, or general dissatisfaction with life. Parents unable to set limits with bored or defiant children might leave them in CPEP, hoping to transfer the parenting role, just as law enforcement officers who feel impotent to apply meaningful sanctions to non-felonious offenders might bring them to CPEP seeking containment. Labeling these problems as psychiatric emergencies has made it more palatable to leave these individuals in our care. These types of visits have contributed to the substantial growth of CPEP in recent years, in terms of annual patient visits, number of children abandoned and their lengths of stay in the CPEP, among other metrics.

The impact of the COVID-19 pandemic on an emergency psychiatry service that is expected to be all things to all people has been interesting. For the first few weeks of the societal shutdown, the patient flow was unchanged. However, during this time, the usual overcrowding created a feeling of vulnerability to contagion that sparked an urgency to minimize the census. Superhuman efforts were fueled by an unspoken sense of impending doom, and wait times dropped from approximately 17 hours to 3 or 4 hours. This state of hypervigilance was impossible to sustain indefinitely, and inevitably those efforts were exhausted. As adrenaline waned, the focus turned toward family and self-preservation. Nursing and social work staff began cancelling shifts, as did part-time physicians who contracted services with our department. Others, however, were drawn to join the front-line fight.

Trends in psychiatric ED usage during the pandemic

As COVID-19 spread, local media reported the paucity of personal protective equipment (PPE) and created the sense that no one would receive hospital treatment unless they were on the brink of death. Consequently, total visits to the ED began to slow. During April, CPEP saw 25% fewer visits than average. This reduction was partly attributable to cohorting patients with any suspicion of infection in a designated area within the medical ED, with access to remote evaluation by CPEP psychiatrists via telemedicine. In addition, the characteristics and circumstances of patients presenting to CPEP began to change (Table).

Children/adolescents. In the months before COVID-19’s spread to the United States, there had been an exponential surge in child visits to CPEP, with >200 such visits in January 2020. When schools closed on March 13, school-related stress abruptly abated, and during April, child visits dropped to 89. This reduction might have been due in part to increased access to outpatient treatment via telemedicine or telephone appointments. In our affiliated clinics, both new patient visits and remote attendance to appointments by established patients increased substantially, likely contributing to a decreased reliance on the CPEP for treatment. Limited Family Court operations, though, left already-frustrated police without much recourse when called to intervene with adolescent offenders. CPEP once again served an untraditional role, facilitating the removal of these disruptive individuals from potentially dangerous circumstances, under the guise of behavioral emergencies.

Suicidality. While nonemergent visits declined, presentations related to suicidality persisted. In the United States, suicide rates have increased annually for decades. This trend has also been observed locally, with early evidence suggesting that the changes inflicted by COVID-19 perpetuated the surge in suicidal thinking and behavior, but with a change in character. Some of this is likely related to financial stress and social disruption, though job loss seems more likely to result in increased substance use than suicidality. Even more distressing to those coming to CPEP was anxiety about the illness itself, social isolation, and loss. The death of a loved one is painful enough, but disrupting the grief process by preventing people from visiting family members dying in hospitals or gathering for funerals has been devastating. Reports of increased gun sales undoubtedly associated with fears of social decay caused by the pandemic are concerning with regard to patients with suicidality, because shooting has emerged as the means most likely to result in completed suicide.¹ The imposition of social distancing directly isolated some individuals, increasing suicidality. Limitations on gathering in groups disrupted other sources of social support as well, such as religious services, clubhouses, and meetings of 12-step programs such as Alcoholics Anonymous. This could increase suicidality, either directly for more vulnerable patients or indirectly by compromising sobriety and thereby adding to the risk for suicide.

Continue to: Substance use disorders (SUDs)

Substance use disorders (SUDs). Present­ations to CPEP by patients with SUDs surged, but the patient profile changed, undoubtedly influenced by the pandemic. Requests for detoxification became less frequent because people who were not in severe distress avoided the hospital. At the same time, alcohol-dependent individuals who might typically avoid clinical attention were requiring emergent medical attention for delirium. This is attributable to a combination of factors, including nutritional depletion, and a lack of access to alcohol leading to abrupt withdrawal or consumption of unconventional sources of alcohol, such as hand sanitizer, or hard liquor (over beer). Amphetamine use appears to have increased, although the observed surge may simply be related to the conspicuousness of stimulant intoxication for someone who is sheltering in place. There was a noticeable uptick in overdoses (primarily with opioids) requiring CPEP evaluation, which was possibly related to a reduction of available beds in inpatient rehabilitation facilities as a result of social distancing rules.

Patients with chronic mental illness. Many experts anticipated an increase in hospital visits by individuals with chronic mental illness expected to decompensate as a result of reduced access to community treatment resources.² Closing courts did not prevent remote sessions for inpatient retention and treatment over objection, but did result in the expiration of many Assisted Outpatient Treatment orders by restricting renewal hearings, which is circuitously beginning to fulfill this prediction. On the other hand, an impressive community response has managed to continue meeting the needs of most of these patients. Dedicated mental health clinics have recruited mobile teams or developed carefully scheduled, nursing-run “shot clinics” to ensure that patients who require long-acting injectable medications or medication-assisted treatment for SUDs continue to receive treatment.

New-onset psychosis. A new population of patients with acute mania and psychosis also seems to have surfaced during this pandemic. Previously high-functioning individuals in their 30s, 40s, and 50s without a history of mental illness were presenting with new-onset psychotic symptoms. These are individuals who may have been characteristically anxious, or had a “Type A personality,” but were social and employed. The cause is unclear, but given the extreme uncertainty and the political climate COVID-19 brings, it is possible that the pandemic may have triggered these episodes. These individuals and their families now have the stress of learning to navigate the mental health system added to the anxiety COVID-19 brings to most households.

Homelessness. Limitations on occupancy have reduced the availability of beds in shelters and residences, resulting in increased homelessness. Locally, authorities estimated that the homeless population has grown nearly threefold as a result of bussing in from neighboring counties with fewer resources, flight from New York City, and the urgent release from jail of nonviolent offenders, many of whom had no place to go for shelter. New emergency shelter beds have not fully compensated for the relative shortage, leading individuals who had been avoiding the hospital due to fear of infection to CPEP looking for a place to stay.

Home stressors. Whereas CPEP visits by children initially decreased, after 6 weeks, the relief from school pressures appears to have been replaced by weariness from stresses at home, and the number of children presenting with depression, SUDs, and behavioral disruptions has increased. Domestic violence involving children and adults increased. Factors that might be contributing to this include the forced proximity of family members who would typically need intermittent interpersonal distance, and an obligation to care for children who would normally be in school or for disabled loved ones now unable to attend day programs or respite services. After months of enduring the pressure of these conflicts and the resulting emotional strain, patient volumes in CPEP have begun slowly returning toward the expected average, particularly since the perceived threat of coming to the hospital has attenuated.

Continue to: Personal challenges

Personal challenges

For me, COVID-19 has brought the chance to grow and learn, fumbling at times to provide the best care when crisis abounds and when not much can be said to ease the appropriate emotional distress our patients experience. The lines between what is pathological anxiety, what level of anxiety causes functional impairment, and what can realistically be expected to respond to psychiatric treatment have become blurred. At the same time, I have come across some of the sickest patients I have ever encountered.

In some ways, my passion for psychiatry has been rekindled by COVID-19, sparking an enthusiasm to teach and inspire students to pursue careers in this wonderful field of medicine. Helping to care for patients in the absence of a cure can necessitate the application of creativity and thoughtfulness to relieve suffering, thereby teaching the art of healing above offering treatment alone. Unfortunately, replacing actual patient contact with remote learning deprives students of this unique educational opportunity. Residents who attempt to continue training while limiting exposure to patients may mitigate their own risk but could also be missing an opportunity to learn how to balance their needs with making their patients’ well-being a priority. This raises the question of how the next generation of medical students and residents will learn to navigate future crises. Gruesome media depictions of haunting experiences witnessed by medical professionals exposed to an enormity of loss and death, magnified by the suicide deaths of 2 front-line workers in New York City, undoubtedly contribute to the instinct driving the protection of students and residents in this way.

The gratitude the public expresses toward me for simply continuing to do my job brings an expectation of heroism I did not seek, and with which I am uncomfortable. For me, exceptionally poised to analyze and over-analyze myriad aspects of an internal conflict that is exhausting to balance, it all generates frustration and guilt more than anything.

I am theoretically at lower risk than intubating anesthesiologists, emergency medicine physicians, and emergency medical technicians who face patients with active COVID-19. Nevertheless, daily proximity to so many patients naturally generates fear. I convince myself that performing video consultations to the medical ED is an adaptation necessary to preserve PPE, to keep me healthy through reduced exposure, to be available to patients longer, and to support the emotional health of the medical staff who are handing over that headset to patients “under investigation.” At the same time, I am secretly relieved to avoid entering those rooms and taunting death, or even worse, risking exposing my family to the virus. The threat of COVID-19 can be so consuming that it becomes easy to forget that most individuals infected are asymptomatic and therefore difficult to quickly identify.

So I continue to sit with patients face-to-face all day. Many of them are not capable of following masking and distancing recommendations, and are more prone to spitting and biting than their counterparts in the medical ED. I must ignore this threat and convince myself I am safe to be able to place my responsibility to patient care above my own needs and do my job.

Continue to: Most of my colleagues exhibit...

Most of my colleagues exhibit an effortless bravery, even if we all naturally waver briefly at times. I am proud to stand shoulder-to-shoulder every day with these clinicians, and other staff, from police to custodians, as we continue to care for the people of this community. Despite the lower clinical burden, each day we expend significant emotional energy struggling with unexpected and unique challenges, including the burden of facing the unknown. Everyone is under stress right now. For most, the effects will be transient. For some, the damage might be permanent. For others, this stress has brought out the best in us. But knowing that physicians are particularly prone to burnout, how long can the current state of hypervigilance be maintained?

What will the future hold?

The COVID-19 era has brought fewer patients through the door of my psychiatric ED; however, just like everywhere else in the world, everything has changed. The only thing that is certain is that further change is inevitable, and we must adapt to the challenge and learn from it. As unsettling as disruptions to the status quo can be, human behavior dictates that we have the option to seize opportunities created by instability to produce superior outcomes, which can be accomplished only by looking at things anew. The question is whether we will revert to the pre-COVID-19 dysfunctional use of psychiatric emergency services, or can we use what we have learned—particularly about the value of telepsychiatry—to pursue a more effective system based on an improved understanding of the mental health treatment needs of our community. While technology is proving that social distancing requires only space between people, and not necessarily social separation, there is a risk that excessive use of remote treatment could compromise the therapeutic relationship with our patients. Despite emerging opportunities, it is difficult to direct change in a productive way when the future is uncertain.

The continuous outpouring of respect for clinicians is morale-boosting. Behind closed doors, however, news that this county hospital failed to qualify for any of the second round of federal support funding because the management of COVID-19 patients has been too effective brought a new layer of unanticipated stress. This is the only hospital in 7 counties operating a psychiatric emergency service. The mandatory, “voluntary” furloughs expected of nursing and social work staff are only now being scheduled to occur over the next couple of months. And just in time for patient volumes to return to normal. How can we continue to provide quality care, let alone build changes into practice, with reduced nursing and support staff?

It is promising, however, that in the midst of social distancing, the shared experience of endeavoring to overcome COVID-19 has promoted a connectedness among individuals who might otherwise never cross paths. This observation has bolstered my confidence in the capacity for resilience of the mental health system and the individuals within it. The reality is that we are all in this together. Differences should matter less in the face of altered perceptions of mortality. Despite the stress, suicide becomes a less reasonable choice when the value of life is magnified by pandemic circumstances. Maybe there will be even less of a need for psychiatric emergency services in the wake of COVID-19, rather than the anticipated wave of mental health crises. Until we know for sure, it is only through fellowship and continued dedication to healing that the ED experience will continue to be a positive one.

Bottom Line

Coronavirus disease 2019 (COVID-19) led to changes in the characteristics and circumstances of patients presenting to our psychiatric emergency service. Despite a lower clinical burden, each day we expended significant emotional energy struggling with unexpected and unique challenges. We can use what we have learned from COVID-19 to pursue a more effective system based on an improved understanding of the mental health treatment needs of our community.

Related Resource

• American Association for Emergency Psychiatry, American College of Emergency Physicians, American Psychiatric Association, Coalition on Psychiatric Emergencies, Crisis Residential Association, and the Emergency Nurses Association. Joint statement for care of patients with behavioral health emergencies and suspected or confirmed COVID-19. https://aaep.memberclicks.net/assets/joint-statement-covid-behavioral-health.pdf.

Coronavirus disease 2019 (COVID-19) is affecting every aspect of medical care. Much has been written about overwhelmed hospital settings, the financial devastation to outpatient treatment centers, and an impending pandemic of mental illness that the existing underfunded and fragmented mental health system would not be prepared to weather. Although COVID-19 has undeniably affected the practice of emergency psychiatry, its impact has been surprising and complex. In this article, I describe the effects COVID-19 has had on our psychiatric emergency service, and how the pandemic has affected me personally.

How the pandemic affected our psychiatric ED

The Comprehensive Psychiatric Emergency Program (CPEP) in Buffalo, New York, is part of the emergency department (ED) in the local county hospital and is staffed by faculty from the Department of Psychiatry at the University at Buffalo. It was developed to provide evaluations of acutely psychiatrically ill individuals, to determine their treatment needs and facilitate access to the appropriate level of care.

Before COVID-19, as the only fully staffed psychiatric emergency service in the region, CPEP would routinely be called upon to serve many functions for which it was not designed. For example, people who had difficulty accessing psychiatric care in the community might come to CPEP expecting treatment for chronic conditions. Additionally, due to systemic deficiencies and limited resources, police and other community agencies refer individuals to CPEP who either have illnesses unrelated to current circumstances or who are not psychiatrically ill but unmanageable because of aggression or otherwise unresolvable social challenges such as homelessness, criminal behavior, poor parenting and other family strains, or general dissatisfaction with life. Parents unable to set limits with bored or defiant children might leave them in CPEP, hoping to transfer the parenting role, just as law enforcement officers who feel impotent to apply meaningful sanctions to non-felonious offenders might bring them to CPEP seeking containment. Labeling these problems as psychiatric emergencies has made it more palatable to leave these individuals in our care. These types of visits have contributed to the substantial growth of CPEP in recent years, in terms of annual patient visits, number of children abandoned and their lengths of stay in the CPEP, among other metrics.

The impact of the COVID-19 pandemic on an emergency psychiatry service that is expected to be all things to all people has been interesting. For the first few weeks of the societal shutdown, the patient flow was unchanged. However, during this time, the usual overcrowding created a feeling of vulnerability to contagion that sparked an urgency to minimize the census. Superhuman efforts were fueled by an unspoken sense of impending doom, and wait times dropped from approximately 17 hours to 3 or 4 hours. This state of hypervigilance was impossible to sustain indefinitely, and inevitably those efforts were exhausted. As adrenaline waned, the focus turned toward family and self-preservation. Nursing and social work staff began cancelling shifts, as did part-time physicians who contracted services with our department. Others, however, were drawn to join the front-line fight.

Trends in psychiatric ED usage during the pandemic

As COVID-19 spread, local media reported the paucity of personal protective equipment (PPE) and created the sense that no one would receive hospital treatment unless they were on the brink of death. Consequently, total visits to the ED began to slow. During April, CPEP saw 25% fewer visits than average. This reduction was partly attributable to cohorting patients with any suspicion of infection in a designated area within the medical ED, with access to remote evaluation by CPEP psychiatrists via telemedicine. In addition, the characteristics and circumstances of patients presenting to CPEP began to change (Table).

Children/adolescents. In the months before COVID-19’s spread to the United States, there had been an exponential surge in child visits to CPEP, with >200 such visits in January 2020. When schools closed on March 13, school-related stress abruptly abated, and during April, child visits dropped to 89. This reduction might have been due in part to increased access to outpatient treatment via telemedicine or telephone appointments. In our affiliated clinics, both new patient visits and remote attendance to appointments by established patients increased substantially, likely contributing to a decreased reliance on the CPEP for treatment. Limited Family Court operations, though, left already-frustrated police without much recourse when called to intervene with adolescent offenders. CPEP once again served an untraditional role, facilitating the removal of these disruptive individuals from potentially dangerous circumstances, under the guise of behavioral emergencies.

Suicidality. While nonemergent visits declined, presentations related to suicidality persisted. In the United States, suicide rates have increased annually for decades. This trend has also been observed locally, with early evidence suggesting that the changes inflicted by COVID-19 perpetuated the surge in suicidal thinking and behavior, but with a change in character. Some of this is likely related to financial stress and social disruption, though job loss seems more likely to result in increased substance use than suicidality. Even more distressing to those coming to CPEP was anxiety about the illness itself, social isolation, and loss. The death of a loved one is painful enough, but disrupting the grief process by preventing people from visiting family members dying in hospitals or gathering for funerals has been devastating. Reports of increased gun sales undoubtedly associated with fears of social decay caused by the pandemic are concerning with regard to patients with suicidality, because shooting has emerged as the means most likely to result in completed suicide.¹ The imposition of social distancing directly isolated some individuals, increasing suicidality. Limitations on gathering in groups disrupted other sources of social support as well, such as religious services, clubhouses, and meetings of 12-step programs such as Alcoholics Anonymous. This could increase suicidality, either directly for more vulnerable patients or indirectly by compromising sobriety and thereby adding to the risk for suicide.

Continue to: Substance use disorders (SUDs)

Substance use disorders (SUDs). Present­ations to CPEP by patients with SUDs surged, but the patient profile changed, undoubtedly influenced by the pandemic. Requests for detoxification became less frequent because people who were not in severe distress avoided the hospital. At the same time, alcohol-dependent individuals who might typically avoid clinical attention were requiring emergent medical attention for delirium. This is attributable to a combination of factors, including nutritional depletion, and a lack of access to alcohol leading to abrupt withdrawal or consumption of unconventional sources of alcohol, such as hand sanitizer, or hard liquor (over beer). Amphetamine use appears to have increased, although the observed surge may simply be related to the conspicuousness of stimulant intoxication for someone who is sheltering in place. There was a noticeable uptick in overdoses (primarily with opioids) requiring CPEP evaluation, which was possibly related to a reduction of available beds in inpatient rehabilitation facilities as a result of social distancing rules.

Patients with chronic mental illness. Many experts anticipated an increase in hospital visits by individuals with chronic mental illness expected to decompensate as a result of reduced access to community treatment resources.² Closing courts did not prevent remote sessions for inpatient retention and treatment over objection, but did result in the expiration of many Assisted Outpatient Treatment orders by restricting renewal hearings, which is circuitously beginning to fulfill this prediction. On the other hand, an impressive community response has managed to continue meeting the needs of most of these patients. Dedicated mental health clinics have recruited mobile teams or developed carefully scheduled, nursing-run “shot clinics” to ensure that patients who require long-acting injectable medications or medication-assisted treatment for SUDs continue to receive treatment.

New-onset psychosis. A new population of patients with acute mania and psychosis also seems to have surfaced during this pandemic. Previously high-functioning individuals in their 30s, 40s, and 50s without a history of mental illness were presenting with new-onset psychotic symptoms. These are individuals who may have been characteristically anxious, or had a “Type A personality,” but were social and employed. The cause is unclear, but given the extreme uncertainty and the political climate COVID-19 brings, it is possible that the pandemic may have triggered these episodes. These individuals and their families now have the stress of learning to navigate the mental health system added to the anxiety COVID-19 brings to most households.

Homelessness. Limitations on occupancy have reduced the availability of beds in shelters and residences, resulting in increased homelessness. Locally, authorities estimated that the homeless population has grown nearly threefold as a result of bussing in from neighboring counties with fewer resources, flight from New York City, and the urgent release from jail of nonviolent offenders, many of whom had no place to go for shelter. New emergency shelter beds have not fully compensated for the relative shortage, leading individuals who had been avoiding the hospital due to fear of infection to CPEP looking for a place to stay.

Home stressors. Whereas CPEP visits by children initially decreased, after 6 weeks, the relief from school pressures appears to have been replaced by weariness from stresses at home, and the number of children presenting with depression, SUDs, and behavioral disruptions has increased. Domestic violence involving children and adults increased. Factors that might be contributing to this include the forced proximity of family members who would typically need intermittent interpersonal distance, and an obligation to care for children who would normally be in school or for disabled loved ones now unable to attend day programs or respite services. After months of enduring the pressure of these conflicts and the resulting emotional strain, patient volumes in CPEP have begun slowly returning toward the expected average, particularly since the perceived threat of coming to the hospital has attenuated.

Continue to: Personal challenges

Personal challenges

For me, COVID-19 has brought the chance to grow and learn, fumbling at times to provide the best care when crisis abounds and when not much can be said to ease the appropriate emotional distress our patients experience. The lines between what is pathological anxiety, what level of anxiety causes functional impairment, and what can realistically be expected to respond to psychiatric treatment have become blurred. At the same time, I have come across some of the sickest patients I have ever encountered.

In some ways, my passion for psychiatry has been rekindled by COVID-19, sparking an enthusiasm to teach and inspire students to pursue careers in this wonderful field of medicine. Helping to care for patients in the absence of a cure can necessitate the application of creativity and thoughtfulness to relieve suffering, thereby teaching the art of healing above offering treatment alone. Unfortunately, replacing actual patient contact with remote learning deprives students of this unique educational opportunity. Residents who attempt to continue training while limiting exposure to patients may mitigate their own risk but could also be missing an opportunity to learn how to balance their needs with making their patients’ well-being a priority. This raises the question of how the next generation of medical students and residents will learn to navigate future crises. Gruesome media depictions of haunting experiences witnessed by medical professionals exposed to an enormity of loss and death, magnified by the suicide deaths of 2 front-line workers in New York City, undoubtedly contribute to the instinct driving the protection of students and residents in this way.

The gratitude the public expresses toward me for simply continuing to do my job brings an expectation of heroism I did not seek, and with which I am uncomfortable. For me, exceptionally poised to analyze and over-analyze myriad aspects of an internal conflict that is exhausting to balance, it all generates frustration and guilt more than anything.

I am theoretically at lower risk than intubating anesthesiologists, emergency medicine physicians, and emergency medical technicians who face patients with active COVID-19. Nevertheless, daily proximity to so many patients naturally generates fear. I convince myself that performing video consultations to the medical ED is an adaptation necessary to preserve PPE, to keep me healthy through reduced exposure, to be available to patients longer, and to support the emotional health of the medical staff who are handing over that headset to patients “under investigation.” At the same time, I am secretly relieved to avoid entering those rooms and taunting death, or even worse, risking exposing my family to the virus. The threat of COVID-19 can be so consuming that it becomes easy to forget that most individuals infected are asymptomatic and therefore difficult to quickly identify.

So I continue to sit with patients face-to-face all day. Many of them are not capable of following masking and distancing recommendations, and are more prone to spitting and biting than their counterparts in the medical ED. I must ignore this threat and convince myself I am safe to be able to place my responsibility to patient care above my own needs and do my job.

Continue to: Most of my colleagues exhibit...

Most of my colleagues exhibit an effortless bravery, even if we all naturally waver briefly at times. I am proud to stand shoulder-to-shoulder every day with these clinicians, and other staff, from police to custodians, as we continue to care for the people of this community. Despite the lower clinical burden, each day we expend significant emotional energy struggling with unexpected and unique challenges, including the burden of facing the unknown. Everyone is under stress right now. For most, the effects will be transient. For some, the damage might be permanent. For others, this stress has brought out the best in us. But knowing that physicians are particularly prone to burnout, how long can the current state of hypervigilance be maintained?

What will the future hold?

The COVID-19 era has brought fewer patients through the door of my psychiatric ED; however, just like everywhere else in the world, everything has changed. The only thing that is certain is that further change is inevitable, and we must adapt to the challenge and learn from it. As unsettling as disruptions to the status quo can be, human behavior dictates that we have the option to seize opportunities created by instability to produce superior outcomes, which can be accomplished only by looking at things anew. The question is whether we will revert to the pre-COVID-19 dysfunctional use of psychiatric emergency services, or can we use what we have learned—particularly about the value of telepsychiatry—to pursue a more effective system based on an improved understanding of the mental health treatment needs of our community. While technology is proving that social distancing requires only space between people, and not necessarily social separation, there is a risk that excessive use of remote treatment could compromise the therapeutic relationship with our patients. Despite emerging opportunities, it is difficult to direct change in a productive way when the future is uncertain.

The continuous outpouring of respect for clinicians is morale-boosting. Behind closed doors, however, news that this county hospital failed to qualify for any of the second round of federal support funding because the management of COVID-19 patients has been too effective brought a new layer of unanticipated stress. This is the only hospital in 7 counties operating a psychiatric emergency service. The mandatory, “voluntary” furloughs expected of nursing and social work staff are only now being scheduled to occur over the next couple of months. And just in time for patient volumes to return to normal. How can we continue to provide quality care, let alone build changes into practice, with reduced nursing and support staff?

It is promising, however, that in the midst of social distancing, the shared experience of endeavoring to overcome COVID-19 has promoted a connectedness among individuals who might otherwise never cross paths. This observation has bolstered my confidence in the capacity for resilience of the mental health system and the individuals within it. The reality is that we are all in this together. Differences should matter less in the face of altered perceptions of mortality. Despite the stress, suicide becomes a less reasonable choice when the value of life is magnified by pandemic circumstances. Maybe there will be even less of a need for psychiatric emergency services in the wake of COVID-19, rather than the anticipated wave of mental health crises. Until we know for sure, it is only through fellowship and continued dedication to healing that the ED experience will continue to be a positive one.

Bottom Line

Coronavirus disease 2019 (COVID-19) led to changes in the characteristics and circumstances of patients presenting to our psychiatric emergency service. Despite a lower clinical burden, each day we expended significant emotional energy struggling with unexpected and unique challenges. We can use what we have learned from COVID-19 to pursue a more effective system based on an improved understanding of the mental health treatment needs of our community.

Related Resource

• American Association for Emergency Psychiatry, American College of Emergency Physicians, American Psychiatric Association, Coalition on Psychiatric Emergencies, Crisis Residential Association, and the Emergency Nurses Association. Joint statement for care of patients with behavioral health emergencies and suspected or confirmed COVID-19. https://aaep.memberclicks.net/assets/joint-statement-covid-behavioral-health.pdf.

We were delighted to read Dr. Nasrallah’s coruscating editorial about the deceptive, unethical, and clinically harmful practice of insurance companies requiring pre-authorization before granting coverage of psychotropic medications that are not on their short list of inexpensive alternatives (“Pre-authorization is illegal, unethical, and adversely disrupts patient care.” From the Editor, Current Psychiatry. April 2020, p. 5,10-11). Obtaining pre-authorization is time-consuming for busy doctors, often prohibitively so—and sometimes simply impossible, regardless of the time and effort invested. In this way, insurers can cleverly withhold optimal treatment while still being able to assert that they will cover all “medically necessary” treatments, as initially determined by a nonphysician reviewer working from a checklist. In a recently published survey of 1,000 psychiatrists we conducted (Barnett BS, Bodkin JA. A survey of American psychiatrists concerning medication prior authorization requirements. J Nerv Ment Dis. 2020;208(7):566-573), respondents predominantly believed the obligation to obtain prior authorization negatively impacts patient care and reduces psychiatrists’ job satisfaction.

Brian S. Barnett, MD
Staff Psychiatrist
Cleveland Clinic
Lutheran Hospital
Cleveland, Ohio

J. Alexander Bodkin, MD
Chief
Clinical Psychopharmacology
Research Program
McLean Hospital
Harvard Medical School
Belmont, Massachusetts

Disclosures: The authors report no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

I thank Dr. Nasrallah for bringing up the issue of pre-authorization in his editorial and could not agree with him more. As a practicing geriatric psychiatrist—for several decades—I experienced all of what he so nicely summarized, and more. The amount and degree of humiliation, frustration, and (mainly) waste of time have been painful and unacceptable. As he said: It must be stopped! The question is “How?” Hopefully this editorial triggers some activity against pre-authorization. It was time somebody addressed this problem.

Istvan Boksay, MD, PhD
Private psychiatric practice
New York, New York

Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

Continue to: I thank Dr. Nasrallah...

I thank Dr. Nasrallah for his editorial about pre-authorization, which was well organized and had a perfect headline. In succinct paragraphs, it says what we practitioners have wanted to say for years. If only the American Psychiatric Association and American Medical Association would take up the cause, perhaps some limitations might be put on this corporate intrusion into our practice. Pre-authorization may save insurance companies money, but its cost in time, frustration, and clinical outcomes adds a considerable burden to the financial problems of health care in the United States.

John Buckley, MD
Private psychiatric practice
Glen Arm, Maryland

Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

I thank Dr. Nasrallah so much for his editorial. These types of clinically useless administrative tasks are invisible barriers to mental health care access, because the time utilized to complete these tasks can easily be used to see one more patient who needs to be treated. However, I also wonder how we as psychiatrists can move forward so that our psychiatric organizations and legislative bodies can take further action to the real barriers to health care and effective interventions. 

Ranvinder Kaur Rai, MD
Private psychiatric practice
Fremont, California

Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

Continue to: I read with interest...

I read with interest Dr. Nasrallah’s editorials “We are physicians, not providers, and we treat patients, not clients!” (From the Editor, Current Psychiatry. February 2020, p. 5,10-11) and “Pre-authorization is illegal, unethical, and adversely disrupts patient care.” I can’t help but link the 2 editorials together.

Dr. Nasrallah’s strong advocacy against the use of the term “provider” is long overdue. I distinctly remember the insidious onset of the use of the terms provider and “consumer” during my years as a medical director of a mental health center. The inception of the provider/consumer terminology can be construed as striving for cultural correctness when psychiatry was going through its own identity crisis in response to deinstitutionalization and the destruction of the so-called myth of psychiatrists as paternalistic and all-powerful. Managed care as the business model of medicine further destroyed the perception of the psychiatric physician as noble and caring, and demythologized the physician–patient relationship. It is amazing how the term provider has persisted and become part of the language of medicine. During the last 20 years or so, psychiatric and medical professional organizations have done little to squash the usage of the term.

Furthermore, the concept of pre-authorization is not new to medicine, but has insidiously become part of the tasks of the psychiatric physician. It has morphed into more than having to obtain approval for using a branded medication over a cheaper generic alternative to having to obtain approval for the use of any medication that does not fall under the approved tier. Even antipsychotics (generally a protected class) have not been immune.

Both the use of the term provider and the concept of pre-authorization require more than the frustration and indignation of a clinical psychiatrist. It requires the determination of professional psychiatric organizations and those with power to fight the gradual but ever-deteriorating authority of medical practice and the role of the psychiatric physician.

Elizabeth A. Varas, MD
Private psychiatric practice
Westwood, New Jersey

Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

We were delighted to read Dr. Nasrallah’s coruscating editorial about the deceptive, unethical, and clinically harmful practice of insurance companies requiring pre-authorization before granting coverage of psychotropic medications that are not on their short list of inexpensive alternatives (“Pre-authorization is illegal, unethical, and adversely disrupts patient care.” From the Editor, Current Psychiatry. April 2020, p. 5,10-11). Obtaining pre-authorization is time-consuming for busy doctors, often prohibitively so—and sometimes simply impossible, regardless of the time and effort invested. In this way, insurers can cleverly withhold optimal treatment while still being able to assert that they will cover all “medically necessary” treatments, as initially determined by a nonphysician reviewer working from a checklist. In a recently published survey of 1,000 psychiatrists we conducted (Barnett BS, Bodkin JA. A survey of American psychiatrists concerning medication prior authorization requirements. J Nerv Ment Dis. 2020;208(7):566-573), respondents predominantly believed the obligation to obtain prior authorization negatively impacts patient care and reduces psychiatrists’ job satisfaction.

Brian S. Barnett, MD
Staff Psychiatrist
Cleveland Clinic
Lutheran Hospital
Cleveland, Ohio

J. Alexander Bodkin, MD
Chief
Clinical Psychopharmacology
Research Program
McLean Hospital
Harvard Medical School
Belmont, Massachusetts

Disclosures: The authors report no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

I thank Dr. Nasrallah for bringing up the issue of pre-authorization in his editorial and could not agree with him more. As a practicing geriatric psychiatrist—for several decades—I experienced all of what he so nicely summarized, and more. The amount and degree of humiliation, frustration, and (mainly) waste of time have been painful and unacceptable. As he said: It must be stopped! The question is “How?” Hopefully this editorial triggers some activity against pre-authorization. It was time somebody addressed this problem.

Istvan Boksay, MD, PhD
Private psychiatric practice
New York, New York

Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

Continue to: I thank Dr. Nasrallah...

I thank Dr. Nasrallah for his editorial about pre-authorization, which was well organized and had a perfect headline. In succinct paragraphs, it says what we practitioners have wanted to say for years. If only the American Psychiatric Association and American Medical Association would take up the cause, perhaps some limitations might be put on this corporate intrusion into our practice. Pre-authorization may save insurance companies money, but its cost in time, frustration, and clinical outcomes adds a considerable burden to the financial problems of health care in the United States.

John Buckley, MD
Private psychiatric practice
Glen Arm, Maryland

Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

I thank Dr. Nasrallah so much for his editorial. These types of clinically useless administrative tasks are invisible barriers to mental health care access, because the time utilized to complete these tasks can easily be used to see one more patient who needs to be treated. However, I also wonder how we as psychiatrists can move forward so that our psychiatric organizations and legislative bodies can take further action to the real barriers to health care and effective interventions. 

Ranvinder Kaur Rai, MD
Private psychiatric practice
Fremont, California

Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

Continue to: I read with interest...

I read with interest Dr. Nasrallah’s editorials “We are physicians, not providers, and we treat patients, not clients!” (From the Editor, Current Psychiatry. February 2020, p. 5,10-11) and “Pre-authorization is illegal, unethical, and adversely disrupts patient care.” I can’t help but link the 2 editorials together.

Dr. Nasrallah’s strong advocacy against the use of the term “provider” is long overdue. I distinctly remember the insidious onset of the use of the terms provider and “consumer” during my years as a medical director of a mental health center. The inception of the provider/consumer terminology can be construed as striving for cultural correctness when psychiatry was going through its own identity crisis in response to deinstitutionalization and the destruction of the so-called myth of psychiatrists as paternalistic and all-powerful. Managed care as the business model of medicine further destroyed the perception of the psychiatric physician as noble and caring, and demythologized the physician–patient relationship. It is amazing how the term provider has persisted and become part of the language of medicine. During the last 20 years or so, psychiatric and medical professional organizations have done little to squash the usage of the term.

Furthermore, the concept of pre-authorization is not new to medicine, but has insidiously become part of the tasks of the psychiatric physician. It has morphed into more than having to obtain approval for using a branded medication over a cheaper generic alternative to having to obtain approval for the use of any medication that does not fall under the approved tier. Even antipsychotics (generally a protected class) have not been immune.

Both the use of the term provider and the concept of pre-authorization require more than the frustration and indignation of a clinical psychiatrist. It requires the determination of professional psychiatric organizations and those with power to fight the gradual but ever-deteriorating authority of medical practice and the role of the psychiatric physician.

Elizabeth A. Varas, MD
Private psychiatric practice
Westwood, New Jersey

Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

We were delighted to read Dr. Nasrallah’s coruscating editorial about the deceptive, unethical, and clinically harmful practice of insurance companies requiring pre-authorization before granting coverage of psychotropic medications that are not on their short list of inexpensive alternatives (“Pre-authorization is illegal, unethical, and adversely disrupts patient care.” From the Editor, Current Psychiatry. April 2020, p. 5,10-11). Obtaining pre-authorization is time-consuming for busy doctors, often prohibitively so—and sometimes simply impossible, regardless of the time and effort invested. In this way, insurers can cleverly withhold optimal treatment while still being able to assert that they will cover all “medically necessary” treatments, as initially determined by a nonphysician reviewer working from a checklist. In a recently published survey of 1,000 psychiatrists we conducted (Barnett BS, Bodkin JA. A survey of American psychiatrists concerning medication prior authorization requirements. J Nerv Ment Dis. 2020;208(7):566-573), respondents predominantly believed the obligation to obtain prior authorization negatively impacts patient care and reduces psychiatrists’ job satisfaction.

Brian S. Barnett, MD
Staff Psychiatrist
Cleveland Clinic
Lutheran Hospital
Cleveland, Ohio

J. Alexander Bodkin, MD
Chief
Clinical Psychopharmacology
Research Program
McLean Hospital
Harvard Medical School
Belmont, Massachusetts

Disclosures: The authors report no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

I thank Dr. Nasrallah for bringing up the issue of pre-authorization in his editorial and could not agree with him more. As a practicing geriatric psychiatrist—for several decades—I experienced all of what he so nicely summarized, and more. The amount and degree of humiliation, frustration, and (mainly) waste of time have been painful and unacceptable. As he said: It must be stopped! The question is “How?” Hopefully this editorial triggers some activity against pre-authorization. It was time somebody addressed this problem.

Istvan Boksay, MD, PhD
Private psychiatric practice
New York, New York

Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

Continue to: I thank Dr. Nasrallah...

I thank Dr. Nasrallah for his editorial about pre-authorization, which was well organized and had a perfect headline. In succinct paragraphs, it says what we practitioners have wanted to say for years. If only the American Psychiatric Association and American Medical Association would take up the cause, perhaps some limitations might be put on this corporate intrusion into our practice. Pre-authorization may save insurance companies money, but its cost in time, frustration, and clinical outcomes adds a considerable burden to the financial problems of health care in the United States.

John Buckley, MD
Private psychiatric practice
Glen Arm, Maryland

Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

I thank Dr. Nasrallah so much for his editorial. These types of clinically useless administrative tasks are invisible barriers to mental health care access, because the time utilized to complete these tasks can easily be used to see one more patient who needs to be treated. However, I also wonder how we as psychiatrists can move forward so that our psychiatric organizations and legislative bodies can take further action to the real barriers to health care and effective interventions. 

Ranvinder Kaur Rai, MD
Private psychiatric practice
Fremont, California

Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

Continue to: I read with interest...

I read with interest Dr. Nasrallah’s editorials “We are physicians, not providers, and we treat patients, not clients!” (From the Editor, Current Psychiatry. February 2020, p. 5,10-11) and “Pre-authorization is illegal, unethical, and adversely disrupts patient care.” I can’t help but link the 2 editorials together.

Dr. Nasrallah’s strong advocacy against the use of the term “provider” is long overdue. I distinctly remember the insidious onset of the use of the terms provider and “consumer” during my years as a medical director of a mental health center. The inception of the provider/consumer terminology can be construed as striving for cultural correctness when psychiatry was going through its own identity crisis in response to deinstitutionalization and the destruction of the so-called myth of psychiatrists as paternalistic and all-powerful. Managed care as the business model of medicine further destroyed the perception of the psychiatric physician as noble and caring, and demythologized the physician–patient relationship. It is amazing how the term provider has persisted and become part of the language of medicine. During the last 20 years or so, psychiatric and medical professional organizations have done little to squash the usage of the term.

Furthermore, the concept of pre-authorization is not new to medicine, but has insidiously become part of the tasks of the psychiatric physician. It has morphed into more than having to obtain approval for using a branded medication over a cheaper generic alternative to having to obtain approval for the use of any medication that does not fall under the approved tier. Even antipsychotics (generally a protected class) have not been immune.

Both the use of the term provider and the concept of pre-authorization require more than the frustration and indignation of a clinical psychiatrist. It requires the determination of professional psychiatric organizations and those with power to fight the gradual but ever-deteriorating authority of medical practice and the role of the psychiatric physician.

Elizabeth A. Varas, MD
Private psychiatric practice
Westwood, New Jersey

Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

As the life-altering coronavirus disease 2019 (COVID-19) pandemic gradually ebbs, we are all its survivors. Now, we are experiencing COVID-19 fatigue, trying to emerge from its dense fog that pervaded every facet of our lives. We are fully cognizant that there will not be a return to the previous “normal.” The pernicious virus had a transformative effect that did not spare any component of our society. Full recovery will not be easy.

As the uncertainty lingers about another devastating return of the pandemic later this year, we can see the reverberation of this invisible assault on human existence. Although a relatively small fraction of the population lost their lives, the rest of us are valiantly trying to readjust to the multiple ways our world has changed. Consider the following abrupt and sweeping burdens inflicted by the pandemic within a few short weeks:

Mental health. The acute stress of thanatophobia generated a triad of anxiety, depression, and nosophobia on a large scale. The demand for psychiatric care rapidly escalated. Suicide rate increased not only because of the stress of being locked down at home (alien to most people’s lifestyle) but because of the coincidental timing of the pandemic during April and May, the peak time of year for suicide. Animal researchers use immobilization as a paradigm to stress a rat or mouse. Many humans immobilized during the pandemic have developed exquisite empathy towards those rodents! The impact on children may also have long-term effects because playing and socializing with friends is a vital part of their lives. Parents have noticed dysphoria and acting out among their children, and an intense compensatory preoccupation with video games and electronic communications with friends.

Physical health. Medical care focused heavily on COVID-19 victims, to the detriment of all other medical conditions. Non-COVID-19 hospital admissions plummeted, and all elective surgeries and procedures were put on hold, depriving many people of medical care they badly needed. Emergency department (ED) visits also declined dramatically, including the usual flow of heart attacks, stroke, pulmonary embolus, asthma attacks, etc. The minimization of driving greatly reduced the admission of accident victims to EDs. Colonoscopies, cardiac stents, hip replacements, MRIs, mammography, and other procedures that are vital to maintain health and quality of life were halted. Dentists shuttered their practices due to the high risk of infection from exposure to oral secretions and breathing. One can only imagine the suffering of having a toothache with no dental help available, and how that might lead to narcotic abuse.

Social health. The imperative of social distancing disrupted most ordinary human activities, such as dining out, sitting in an auditorium for Grand Rounds or a lecture, visiting friends at their homes, the cherished interactions between grandparents and grandchildren (the lack of which I painfully experienced), and even seeing each other’s smiles behind the ubiquitous masks. And forget about hugging or kissing. The aversion to being near anyone who is coughing or sneezing led to an adaptive social paranoia and the social shunning of anyone who appeared to have an upper respiratory infection, even if it was unrelated to COVID-19.

Redemption for the pharmaceutical industry. The deadly pandemic intensified the public’s awareness of the importance of developing treatments and vaccines for COVID-19. The often-demonized pharmaceutical companies, with their extensive R&D infrastructure, emerged as a major source of hope for discovering an effective treatment for the coronavirus infection, or—better still—one or more vaccines that will enable society to return to its normal functions. It was quite impressive how many pharmaceutical companies “came to the rescue” with clinical trials to repurpose existing medications or to develop new ones. It was very encouraging to see multiple vaccine candidates being developed and expedited for testing around the world. A process that usually takes years was reduced to a few months, thanks to the existing technical infrastructure and thousands of scientists who enable rapid drug development. It is possible that the public may gradually modify its perception of the pharmaceutical industry from a “corporate villain” to an “indispensable health industry” for urgent medical crises such as a pandemic, and also for hundreds of medical diseases that are still in need of safe, effective therapies.

Economic burden. The unimaginable nightmare scenario of a total shutdown of all businesses led to the unprecedented loss of millions of jobs and livelihoods, reflected in miles-long lines of families at food banks. Overnight, the government switched from worrying about its $20-trillion deficit to printing several more trillion dollars to rescue the economy from collapse. The huge magnitude of a trillion can be appreciated if one is aware that it takes roughly 32 years to count to 1 billion, and 32,000 years to count to 1 trillion. Stimulating the economy while the gross domestic product threatens to sink by terrifying percentages (20% to 30%) was urgently needed, even though it meant mortgaging the future, especially when interest rates, and servicing the debt, will inevitably rise from the current zero to much higher levels in the future. The collapse of the once-thriving airline industry (bookings were down an estimated 98%) is an example of why desperate measures were needed to salvage an economy paralyzed by a viral pandemic.

Continue to: Political repercussions

Political repercussions. In our already hyperpartisan country, the COVID-19 crisis created more fissures across party lines. The blame game escalated as each side tried to exploit the crisis for political gain during a presidential election year. None of the leaders, from mayors to governors to the president, had any notion of how to wisely manage an unforeseen catastrophic pandemic. Thus, a political cacophony has developed, further exacerbating the public’s anxiety and uncertainty, especially about how and when the pandemic will end.

Education disruption. Never before have all schools and colleges around the country abruptly closed and sent students of all ages to shelter at home. Massive havoc ensued, with a wholesale switch to solitary online learning, the loss of the unique school and college social experience in the classroom and on campus, and the loss of experiencing commencement to receive a diploma (an important milestone for every graduate). Even medical students were not allowed to complete their clinical rotations and were sent home to attend online classes. A complete paradigm shift emerged about entrance exams: the SAT and ACT were eliminated for college applicants, and the MCAT for medical school applicants. This was unthinkable before the pandemic descended upon us, but benchmarks suddenly evaporated to adjust to the new reality. Then there followed disastrous financial losses by institutions of higher learning as well as academic medical centers and teaching hospitals, all slashing their budgets, furloughing employees, cutting salaries, and eliminating programs. Even the “sacred” tenure of senior faculty became a casualty of the financial “exigency.” Children’s nutrition suffered, especially among those in lower socioeconomic groups for whom the main meal of the day was the school lunch, and was made worse by their parents’ loss of income. For millions of people, the emotional toll was inevitable following the draconian measure of closing all educational institutions to contain the spread of the pandemic.

Family burden. Sheltering at home might have been fun for a few days, but after many weeks, it festered into a major stress, especially for those living in a small house, condominium, or apartment. The resilience of many families was tested as the exercise of freedoms collided with the fear of getting infected. Families were deprived of celebrating birthdays, weddings, funerals, graduation parties, retirement parties, Mother’s Day, Father’s Day, and various religious holidays, including Easter, Passover, and Eid al-Fitr.

Sexual burden. Intimacy and sexual contact between consenting adults living apart were sacrificed on the altar of the pernicious viral pandemic. Mandatory social distancing of 6 feet or more to avoid each other’s droplets emanating from simple speech, not just sneezing or coughing, makes intimacy practically impossible. Thus, physical closeness became taboo, and avoiding another person’s saliva or body secretions became a must to avoid contracting the virus. Being single was quite a lonely experience during this pandemic!

Entertainment deprivation. Americans are known to thrive on an extensive diet of spectator sports. Going to football, basketball, baseball, or hockey games to root for one’s team is intrinsically American. The pursuit of happiness extends to attending concerts, movies, Broadway shows, theme parks, and cruises with thousands of others. The pandemic ripped all those pleasurable leisure activities from our daily lives, leaving a big hole in people’s lives at the precise time fun activities were needed as a useful diversion from the dismal stress of a pandemic. To make things worse, it is uncertain when (if ever) such group activities will be restored, especially if the pandemic returns with another wave. But optimists would hurry to remind us that the “Roaring 20s” blossomed in the decade following the 1918 Spanish Flu pandemic.

Continue to: Legal system

Legal system. Astounding changes were instigated by the pandemic, such as the release of thousands of inmates, including felons, to avoid the spread of the virus in crowded prisons. For us psychiatrists, the silver lining in that unexpected action is that many of those released were patients with mental illness who were incarcerated because of the lack of hospitals that would take them. The police started issuing citations instead of arresting and jailing violators. Enforcement of the law was welcome when it targeted those who gouged the public for personal profit during the scarcity of masks, sanitizers, or even toilet paper and soap.

Medical practice. In addition to delaying medical care for patients, the freeze on so-called elective surgeries or procedures (many of which were actually necessary) was financially ruinous for physicians. Another regrettable consequence of the pandemic is a drop in pediatric vaccinations because parents were reluctant to take their children to the pediatrician. On a more positive note, the massive switch to telehealth was advantageous for both patients and psychiatrists because this technology is well-suited for psychiatric care. Fortunately, regulations that hampered telepsychiatry practice were substantially loosened or eliminated, and even the usually sacrosanct HIPAA regulations were temporarily sidelined.

Medical research. Both human and animal research came to a screeching halt, and many research assistants were furloughed. Data collection was disrupted, and a generation of scientific and medical discoveries became a casualty of the pandemic.

Medical literature. It was stunning to see how quickly COVID-19 occupied most of the pages of prominent journals. The scholarly articles were frankly quite useful, covering topics ranging from risk factors to early symptoms to treatment and pathophysiology across multiple organs. As with other paradigm shifts, there was an accelerated publication push, sometimes with expedited peer reviews to inform health care workers and the public while the pandemic was still raging. However, a couple of very prominent journals had to retract flawed articles that were hastily published without the usual due diligence and rigorous peer review. The pandemic clearly disrupted the science publishing process.

Travel effects. The steep reduction of flights (by 98%) was financially catastrophic, not only for airline companies but to business travel across the country. However, fewer cars on the road resulted in fewer accidents and deaths, and also reduced pollution. Paradoxically, to prevent crowding in subways, trains, and buses, officials reversed their traditional instructions and advised the public to drive their own cars instead of using public transportation!

Continue to: Heroism of front-line medical personnel

Heroism of front-line medical personnel. Everyone saluted and prayed for the health care professionals working at the bedside of highly infectious patients who needed 24/7 intensive care. Many have died while carrying out the noble but hazardous medical duties. Those heroes deserve our lasting respect and admiration.

The COVID-19 pandemic insidiously permeated and altered every aspect of our complex society and revealed how fragile our “normal lifestyle” really is. It is possible that nothing will ever be the same again, and an uneasy sense of vulnerability will engulf us as we cautiously return to a “new normal.” Even our language has expanded with the lexicon of pandemic terminology (Table). We all pray and hope that this plague never returns. And let’s hope one or more vaccines are developed soon so we can manage future recurrences like the annual flu season. In the meantime, keep your masks and sanitizers close by…

Postscript: Shortly after I completed this editorial, the ongoing COVID-19 plague was overshadowed by the scourge of racism, with massive protests, at times laced by violence, triggered by the death of a black man in custody of the police, under condemnable circumstances. The COVID-19 pandemic and the necessary social distancing it requires were temporarily ignored during the ensuing protests. The combined effect of those overlapping scourges are jarring to the country’s psyche, complicating and perhaps sabotaging the social recovery from the pandemic.

As the life-altering coronavirus disease 2019 (COVID-19) pandemic gradually ebbs, we are all its survivors. Now, we are experiencing COVID-19 fatigue, trying to emerge from its dense fog that pervaded every facet of our lives. We are fully cognizant that there will not be a return to the previous “normal.” The pernicious virus had a transformative effect that did not spare any component of our society. Full recovery will not be easy.

As the uncertainty lingers about another devastating return of the pandemic later this year, we can see the reverberation of this invisible assault on human existence. Although a relatively small fraction of the population lost their lives, the rest of us are valiantly trying to readjust to the multiple ways our world has changed. Consider the following abrupt and sweeping burdens inflicted by the pandemic within a few short weeks:

Mental health. The acute stress of thanatophobia generated a triad of anxiety, depression, and nosophobia on a large scale. The demand for psychiatric care rapidly escalated. Suicide rate increased not only because of the stress of being locked down at home (alien to most people’s lifestyle) but because of the coincidental timing of the pandemic during April and May, the peak time of year for suicide. Animal researchers use immobilization as a paradigm to stress a rat or mouse. Many humans immobilized during the pandemic have developed exquisite empathy towards those rodents! The impact on children may also have long-term effects because playing and socializing with friends is a vital part of their lives. Parents have noticed dysphoria and acting out among their children, and an intense compensatory preoccupation with video games and electronic communications with friends.

Physical health. Medical care focused heavily on COVID-19 victims, to the detriment of all other medical conditions. Non-COVID-19 hospital admissions plummeted, and all elective surgeries and procedures were put on hold, depriving many people of medical care they badly needed. Emergency department (ED) visits also declined dramatically, including the usual flow of heart attacks, stroke, pulmonary embolus, asthma attacks, etc. The minimization of driving greatly reduced the admission of accident victims to EDs. Colonoscopies, cardiac stents, hip replacements, MRIs, mammography, and other procedures that are vital to maintain health and quality of life were halted. Dentists shuttered their practices due to the high risk of infection from exposure to oral secretions and breathing. One can only imagine the suffering of having a toothache with no dental help available, and how that might lead to narcotic abuse.

Social health. The imperative of social distancing disrupted most ordinary human activities, such as dining out, sitting in an auditorium for Grand Rounds or a lecture, visiting friends at their homes, the cherished interactions between grandparents and grandchildren (the lack of which I painfully experienced), and even seeing each other’s smiles behind the ubiquitous masks. And forget about hugging or kissing. The aversion to being near anyone who is coughing or sneezing led to an adaptive social paranoia and the social shunning of anyone who appeared to have an upper respiratory infection, even if it was unrelated to COVID-19.

Redemption for the pharmaceutical industry. The deadly pandemic intensified the public’s awareness of the importance of developing treatments and vaccines for COVID-19. The often-demonized pharmaceutical companies, with their extensive R&D infrastructure, emerged as a major source of hope for discovering an effective treatment for the coronavirus infection, or—better still—one or more vaccines that will enable society to return to its normal functions. It was quite impressive how many pharmaceutical companies “came to the rescue” with clinical trials to repurpose existing medications or to develop new ones. It was very encouraging to see multiple vaccine candidates being developed and expedited for testing around the world. A process that usually takes years was reduced to a few months, thanks to the existing technical infrastructure and thousands of scientists who enable rapid drug development. It is possible that the public may gradually modify its perception of the pharmaceutical industry from a “corporate villain” to an “indispensable health industry” for urgent medical crises such as a pandemic, and also for hundreds of medical diseases that are still in need of safe, effective therapies.

Economic burden. The unimaginable nightmare scenario of a total shutdown of all businesses led to the unprecedented loss of millions of jobs and livelihoods, reflected in miles-long lines of families at food banks. Overnight, the government switched from worrying about its $20-trillion deficit to printing several more trillion dollars to rescue the economy from collapse. The huge magnitude of a trillion can be appreciated if one is aware that it takes roughly 32 years to count to 1 billion, and 32,000 years to count to 1 trillion. Stimulating the economy while the gross domestic product threatens to sink by terrifying percentages (20% to 30%) was urgently needed, even though it meant mortgaging the future, especially when interest rates, and servicing the debt, will inevitably rise from the current zero to much higher levels in the future. The collapse of the once-thriving airline industry (bookings were down an estimated 98%) is an example of why desperate measures were needed to salvage an economy paralyzed by a viral pandemic.

Continue to: Political repercussions

Political repercussions. In our already hyperpartisan country, the COVID-19 crisis created more fissures across party lines. The blame game escalated as each side tried to exploit the crisis for political gain during a presidential election year. None of the leaders, from mayors to governors to the president, had any notion of how to wisely manage an unforeseen catastrophic pandemic. Thus, a political cacophony has developed, further exacerbating the public’s anxiety and uncertainty, especially about how and when the pandemic will end.

Education disruption. Never before have all schools and colleges around the country abruptly closed and sent students of all ages to shelter at home. Massive havoc ensued, with a wholesale switch to solitary online learning, the loss of the unique school and college social experience in the classroom and on campus, and the loss of experiencing commencement to receive a diploma (an important milestone for every graduate). Even medical students were not allowed to complete their clinical rotations and were sent home to attend online classes. A complete paradigm shift emerged about entrance exams: the SAT and ACT were eliminated for college applicants, and the MCAT for medical school applicants. This was unthinkable before the pandemic descended upon us, but benchmarks suddenly evaporated to adjust to the new reality. Then there followed disastrous financial losses by institutions of higher learning as well as academic medical centers and teaching hospitals, all slashing their budgets, furloughing employees, cutting salaries, and eliminating programs. Even the “sacred” tenure of senior faculty became a casualty of the financial “exigency.” Children’s nutrition suffered, especially among those in lower socioeconomic groups for whom the main meal of the day was the school lunch, and was made worse by their parents’ loss of income. For millions of people, the emotional toll was inevitable following the draconian measure of closing all educational institutions to contain the spread of the pandemic.

Family burden. Sheltering at home might have been fun for a few days, but after many weeks, it festered into a major stress, especially for those living in a small house, condominium, or apartment. The resilience of many families was tested as the exercise of freedoms collided with the fear of getting infected. Families were deprived of celebrating birthdays, weddings, funerals, graduation parties, retirement parties, Mother’s Day, Father’s Day, and various religious holidays, including Easter, Passover, and Eid al-Fitr.

Sexual burden. Intimacy and sexual contact between consenting adults living apart were sacrificed on the altar of the pernicious viral pandemic. Mandatory social distancing of 6 feet or more to avoid each other’s droplets emanating from simple speech, not just sneezing or coughing, makes intimacy practically impossible. Thus, physical closeness became taboo, and avoiding another person’s saliva or body secretions became a must to avoid contracting the virus. Being single was quite a lonely experience during this pandemic!

Entertainment deprivation. Americans are known to thrive on an extensive diet of spectator sports. Going to football, basketball, baseball, or hockey games to root for one’s team is intrinsically American. The pursuit of happiness extends to attending concerts, movies, Broadway shows, theme parks, and cruises with thousands of others. The pandemic ripped all those pleasurable leisure activities from our daily lives, leaving a big hole in people’s lives at the precise time fun activities were needed as a useful diversion from the dismal stress of a pandemic. To make things worse, it is uncertain when (if ever) such group activities will be restored, especially if the pandemic returns with another wave. But optimists would hurry to remind us that the “Roaring 20s” blossomed in the decade following the 1918 Spanish Flu pandemic.

Continue to: Legal system

Legal system. Astounding changes were instigated by the pandemic, such as the release of thousands of inmates, including felons, to avoid the spread of the virus in crowded prisons. For us psychiatrists, the silver lining in that unexpected action is that many of those released were patients with mental illness who were incarcerated because of the lack of hospitals that would take them. The police started issuing citations instead of arresting and jailing violators. Enforcement of the law was welcome when it targeted those who gouged the public for personal profit during the scarcity of masks, sanitizers, or even toilet paper and soap.

Medical practice. In addition to delaying medical care for patients, the freeze on so-called elective surgeries or procedures (many of which were actually necessary) was financially ruinous for physicians. Another regrettable consequence of the pandemic is a drop in pediatric vaccinations because parents were reluctant to take their children to the pediatrician. On a more positive note, the massive switch to telehealth was advantageous for both patients and psychiatrists because this technology is well-suited for psychiatric care. Fortunately, regulations that hampered telepsychiatry practice were substantially loosened or eliminated, and even the usually sacrosanct HIPAA regulations were temporarily sidelined.

Medical research. Both human and animal research came to a screeching halt, and many research assistants were furloughed. Data collection was disrupted, and a generation of scientific and medical discoveries became a casualty of the pandemic.

Medical literature. It was stunning to see how quickly COVID-19 occupied most of the pages of prominent journals. The scholarly articles were frankly quite useful, covering topics ranging from risk factors to early symptoms to treatment and pathophysiology across multiple organs. As with other paradigm shifts, there was an accelerated publication push, sometimes with expedited peer reviews to inform health care workers and the public while the pandemic was still raging. However, a couple of very prominent journals had to retract flawed articles that were hastily published without the usual due diligence and rigorous peer review. The pandemic clearly disrupted the science publishing process.

Travel effects. The steep reduction of flights (by 98%) was financially catastrophic, not only for airline companies but to business travel across the country. However, fewer cars on the road resulted in fewer accidents and deaths, and also reduced pollution. Paradoxically, to prevent crowding in subways, trains, and buses, officials reversed their traditional instructions and advised the public to drive their own cars instead of using public transportation!

Continue to: Heroism of front-line medical personnel

Heroism of front-line medical personnel. Everyone saluted and prayed for the health care professionals working at the bedside of highly infectious patients who needed 24/7 intensive care. Many have died while carrying out the noble but hazardous medical duties. Those heroes deserve our lasting respect and admiration.

The COVID-19 pandemic insidiously permeated and altered every aspect of our complex society and revealed how fragile our “normal lifestyle” really is. It is possible that nothing will ever be the same again, and an uneasy sense of vulnerability will engulf us as we cautiously return to a “new normal.” Even our language has expanded with the lexicon of pandemic terminology (Table). We all pray and hope that this plague never returns. And let’s hope one or more vaccines are developed soon so we can manage future recurrences like the annual flu season. In the meantime, keep your masks and sanitizers close by…

Postscript: Shortly after I completed this editorial, the ongoing COVID-19 plague was overshadowed by the scourge of racism, with massive protests, at times laced by violence, triggered by the death of a black man in custody of the police, under condemnable circumstances. The COVID-19 pandemic and the necessary social distancing it requires were temporarily ignored during the ensuing protests. The combined effect of those overlapping scourges are jarring to the country’s psyche, complicating and perhaps sabotaging the social recovery from the pandemic.

As the life-altering coronavirus disease 2019 (COVID-19) pandemic gradually ebbs, we are all its survivors. Now, we are experiencing COVID-19 fatigue, trying to emerge from its dense fog that pervaded every facet of our lives. We are fully cognizant that there will not be a return to the previous “normal.” The pernicious virus had a transformative effect that did not spare any component of our society. Full recovery will not be easy.

As the uncertainty lingers about another devastating return of the pandemic later this year, we can see the reverberation of this invisible assault on human existence. Although a relatively small fraction of the population lost their lives, the rest of us are valiantly trying to readjust to the multiple ways our world has changed. Consider the following abrupt and sweeping burdens inflicted by the pandemic within a few short weeks:

Mental health. The acute stress of thanatophobia generated a triad of anxiety, depression, and nosophobia on a large scale. The demand for psychiatric care rapidly escalated. Suicide rate increased not only because of the stress of being locked down at home (alien to most people’s lifestyle) but because of the coincidental timing of the pandemic during April and May, the peak time of year for suicide. Animal researchers use immobilization as a paradigm to stress a rat or mouse. Many humans immobilized during the pandemic have developed exquisite empathy towards those rodents! The impact on children may also have long-term effects because playing and socializing with friends is a vital part of their lives. Parents have noticed dysphoria and acting out among their children, and an intense compensatory preoccupation with video games and electronic communications with friends.

Physical health. Medical care focused heavily on COVID-19 victims, to the detriment of all other medical conditions. Non-COVID-19 hospital admissions plummeted, and all elective surgeries and procedures were put on hold, depriving many people of medical care they badly needed. Emergency department (ED) visits also declined dramatically, including the usual flow of heart attacks, stroke, pulmonary embolus, asthma attacks, etc. The minimization of driving greatly reduced the admission of accident victims to EDs. Colonoscopies, cardiac stents, hip replacements, MRIs, mammography, and other procedures that are vital to maintain health and quality of life were halted. Dentists shuttered their practices due to the high risk of infection from exposure to oral secretions and breathing. One can only imagine the suffering of having a toothache with no dental help available, and how that might lead to narcotic abuse.

Social health. The imperative of social distancing disrupted most ordinary human activities, such as dining out, sitting in an auditorium for Grand Rounds or a lecture, visiting friends at their homes, the cherished interactions between grandparents and grandchildren (the lack of which I painfully experienced), and even seeing each other’s smiles behind the ubiquitous masks. And forget about hugging or kissing. The aversion to being near anyone who is coughing or sneezing led to an adaptive social paranoia and the social shunning of anyone who appeared to have an upper respiratory infection, even if it was unrelated to COVID-19.

Redemption for the pharmaceutical industry. The deadly pandemic intensified the public’s awareness of the importance of developing treatments and vaccines for COVID-19. The often-demonized pharmaceutical companies, with their extensive R&D infrastructure, emerged as a major source of hope for discovering an effective treatment for the coronavirus infection, or—better still—one or more vaccines that will enable society to return to its normal functions. It was quite impressive how many pharmaceutical companies “came to the rescue” with clinical trials to repurpose existing medications or to develop new ones. It was very encouraging to see multiple vaccine candidates being developed and expedited for testing around the world. A process that usually takes years was reduced to a few months, thanks to the existing technical infrastructure and thousands of scientists who enable rapid drug development. It is possible that the public may gradually modify its perception of the pharmaceutical industry from a “corporate villain” to an “indispensable health industry” for urgent medical crises such as a pandemic, and also for hundreds of medical diseases that are still in need of safe, effective therapies.

Economic burden. The unimaginable nightmare scenario of a total shutdown of all businesses led to the unprecedented loss of millions of jobs and livelihoods, reflected in miles-long lines of families at food banks. Overnight, the government switched from worrying about its $20-trillion deficit to printing several more trillion dollars to rescue the economy from collapse. The huge magnitude of a trillion can be appreciated if one is aware that it takes roughly 32 years to count to 1 billion, and 32,000 years to count to 1 trillion. Stimulating the economy while the gross domestic product threatens to sink by terrifying percentages (20% to 30%) was urgently needed, even though it meant mortgaging the future, especially when interest rates, and servicing the debt, will inevitably rise from the current zero to much higher levels in the future. The collapse of the once-thriving airline industry (bookings were down an estimated 98%) is an example of why desperate measures were needed to salvage an economy paralyzed by a viral pandemic.

Continue to: Political repercussions

Political repercussions. In our already hyperpartisan country, the COVID-19 crisis created more fissures across party lines. The blame game escalated as each side tried to exploit the crisis for political gain during a presidential election year. None of the leaders, from mayors to governors to the president, had any notion of how to wisely manage an unforeseen catastrophic pandemic. Thus, a political cacophony has developed, further exacerbating the public’s anxiety and uncertainty, especially about how and when the pandemic will end.

Education disruption. Never before have all schools and colleges around the country abruptly closed and sent students of all ages to shelter at home. Massive havoc ensued, with a wholesale switch to solitary online learning, the loss of the unique school and college social experience in the classroom and on campus, and the loss of experiencing commencement to receive a diploma (an important milestone for every graduate). Even medical students were not allowed to complete their clinical rotations and were sent home to attend online classes. A complete paradigm shift emerged about entrance exams: the SAT and ACT were eliminated for college applicants, and the MCAT for medical school applicants. This was unthinkable before the pandemic descended upon us, but benchmarks suddenly evaporated to adjust to the new reality. Then there followed disastrous financial losses by institutions of higher learning as well as academic medical centers and teaching hospitals, all slashing their budgets, furloughing employees, cutting salaries, and eliminating programs. Even the “sacred” tenure of senior faculty became a casualty of the financial “exigency.” Children’s nutrition suffered, especially among those in lower socioeconomic groups for whom the main meal of the day was the school lunch, and was made worse by their parents’ loss of income. For millions of people, the emotional toll was inevitable following the draconian measure of closing all educational institutions to contain the spread of the pandemic.

Family burden. Sheltering at home might have been fun for a few days, but after many weeks, it festered into a major stress, especially for those living in a small house, condominium, or apartment. The resilience of many families was tested as the exercise of freedoms collided with the fear of getting infected. Families were deprived of celebrating birthdays, weddings, funerals, graduation parties, retirement parties, Mother’s Day, Father’s Day, and various religious holidays, including Easter, Passover, and Eid al-Fitr.

Sexual burden. Intimacy and sexual contact between consenting adults living apart were sacrificed on the altar of the pernicious viral pandemic. Mandatory social distancing of 6 feet or more to avoid each other’s droplets emanating from simple speech, not just sneezing or coughing, makes intimacy practically impossible. Thus, physical closeness became taboo, and avoiding another person’s saliva or body secretions became a must to avoid contracting the virus. Being single was quite a lonely experience during this pandemic!

Entertainment deprivation. Americans are known to thrive on an extensive diet of spectator sports. Going to football, basketball, baseball, or hockey games to root for one’s team is intrinsically American. The pursuit of happiness extends to attending concerts, movies, Broadway shows, theme parks, and cruises with thousands of others. The pandemic ripped all those pleasurable leisure activities from our daily lives, leaving a big hole in people’s lives at the precise time fun activities were needed as a useful diversion from the dismal stress of a pandemic. To make things worse, it is uncertain when (if ever) such group activities will be restored, especially if the pandemic returns with another wave. But optimists would hurry to remind us that the “Roaring 20s” blossomed in the decade following the 1918 Spanish Flu pandemic.

Continue to: Legal system

Legal system. Astounding changes were instigated by the pandemic, such as the release of thousands of inmates, including felons, to avoid the spread of the virus in crowded prisons. For us psychiatrists, the silver lining in that unexpected action is that many of those released were patients with mental illness who were incarcerated because of the lack of hospitals that would take them. The police started issuing citations instead of arresting and jailing violators. Enforcement of the law was welcome when it targeted those who gouged the public for personal profit during the scarcity of masks, sanitizers, or even toilet paper and soap.

Medical practice. In addition to delaying medical care for patients, the freeze on so-called elective surgeries or procedures (many of which were actually necessary) was financially ruinous for physicians. Another regrettable consequence of the pandemic is a drop in pediatric vaccinations because parents were reluctant to take their children to the pediatrician. On a more positive note, the massive switch to telehealth was advantageous for both patients and psychiatrists because this technology is well-suited for psychiatric care. Fortunately, regulations that hampered telepsychiatry practice were substantially loosened or eliminated, and even the usually sacrosanct HIPAA regulations were temporarily sidelined.

Medical research. Both human and animal research came to a screeching halt, and many research assistants were furloughed. Data collection was disrupted, and a generation of scientific and medical discoveries became a casualty of the pandemic.

Medical literature. It was stunning to see how quickly COVID-19 occupied most of the pages of prominent journals. The scholarly articles were frankly quite useful, covering topics ranging from risk factors to early symptoms to treatment and pathophysiology across multiple organs. As with other paradigm shifts, there was an accelerated publication push, sometimes with expedited peer reviews to inform health care workers and the public while the pandemic was still raging. However, a couple of very prominent journals had to retract flawed articles that were hastily published without the usual due diligence and rigorous peer review. The pandemic clearly disrupted the science publishing process.

Travel effects. The steep reduction of flights (by 98%) was financially catastrophic, not only for airline companies but to business travel across the country. However, fewer cars on the road resulted in fewer accidents and deaths, and also reduced pollution. Paradoxically, to prevent crowding in subways, trains, and buses, officials reversed their traditional instructions and advised the public to drive their own cars instead of using public transportation!

Continue to: Heroism of front-line medical personnel

Heroism of front-line medical personnel. Everyone saluted and prayed for the health care professionals working at the bedside of highly infectious patients who needed 24/7 intensive care. Many have died while carrying out the noble but hazardous medical duties. Those heroes deserve our lasting respect and admiration.

The COVID-19 pandemic insidiously permeated and altered every aspect of our complex society and revealed how fragile our “normal lifestyle” really is. It is possible that nothing will ever be the same again, and an uneasy sense of vulnerability will engulf us as we cautiously return to a “new normal.” Even our language has expanded with the lexicon of pandemic terminology (Table). We all pray and hope that this plague never returns. And let’s hope one or more vaccines are developed soon so we can manage future recurrences like the annual flu season. In the meantime, keep your masks and sanitizers close by…

Postscript: Shortly after I completed this editorial, the ongoing COVID-19 plague was overshadowed by the scourge of racism, with massive protests, at times laced by violence, triggered by the death of a black man in custody of the police, under condemnable circumstances. The COVID-19 pandemic and the necessary social distancing it requires were temporarily ignored during the ensuing protests. The combined effect of those overlapping scourges are jarring to the country’s psyche, complicating and perhaps sabotaging the social recovery from the pandemic.