Clinical Conversations

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We have Dr. Anthony Fauci of NIAID to talk with us about COVID-19, the disease caused by the 2019 novel coronavirus (also known as SARS-CoV-2). He’s full of sound advice in the midst of a rapidly changing epidemic.

We wanted to know, How do you talk with patients about this rapidly spreading infection? How do you keep informed about it?

Listen in.

Link:

The new federal website

Running time: 13 minutes

TRANSCRIPT OF THE INTERVIEW

Joe Elia: 

This is Joe Elia.

 

If you’re like the clinician I heard from last week who said she’s spending half her time counseling patients about COVID-19, you’re probably wondering how best to discuss the problem with your patients.

 

This time my co-host, Dr Ali Raja, and I are talking with Dr Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases about how clinicians might approach these conversations and about how both parties — clinician and patient — can best inform themselves about the developing details of this widespread illness.

 

Dr Raja is helping to direct the Mass. General Hospital’s emergency department’s response. He’s Executive Vice Chairman of the Department of Emergency Medicine and he edits the NEJM Journal Watch Emergency Medicine newsletter.

 

Dr Fauci has directed NIAID for some 25 years, arriving in the early years of the HIV/AIDS epidemic. He has advised six US Presidents on health issues. Most recently we’ve all noticed that he’s become the principal clinical voice in this country’s response to the threat of COVID-19 as a member of the White House Coronavirus Task Force.

 

Dr Anthony Fauci:

Well, first of all I’ve directed the Institute for 36 years, not 25 years.

 

Joe Elia:

I’m sorry, Dr Fauci.

 

Dr Anthony Fauci:

You’re making me younger than I am!

 

Joe Elia:

Time flies when you’re having fun, right?

 

Well, so welcome to Clinical Conversations, and we’ll try to get other facts right as we talk to you! We’re going to keep this simple and frontline-clinical to respect your time and preserve your voice. I’ll have Dr Raja ask the first question.

 

Dr Ali Raja:

Thanks, Joe. Welcome, Dr Fauci.

 

Dr Anthony Fauci:

Good to be with you.

 

Dr Ali Raja:

You can imagine that we’ve been getting a lot of patients coming into emergency departments around the country, I’ve seen them here at MGH, with questions and with concerns. Honestly, I’ve struggled with the best way to advise them, so let me ask you. Beyond good hand hygiene and common sense regarding reducing transmission, what can we tell our patients about COVID-19 both to make them aware of the potential risks but also to hopefully calm them and help with the sense of panic that we’re feeling?

 

Dr Anthony Fauci:

Yeah. I mean, obviously a pivotal and great question that every one of us are facing.

 

So I think to give them the broad picture without unnecessarily sugar-coating because we’re in a really serious situation here.

 

But for the individual patient I try to explain that they should not take upon themselves the burden of the broader global health issue. So if you look at the situation of what it means to get infected, in the United States as a country in general the risk of getting infected is clearly very low.

 

However, the situation is changing, it’s evolving, and the difference of sitting in a place where there are either no cases or two or three easily documented cases. Like a travel case: Someone comes in from Iran to New York, they nail it, they isolate them, it isn’t in the community yet. You have a cluster there.

 

But for somebody who walks into an ER in an area where there isn’t community spread, the risk of getting infected is low. However, if you do get infected we need to look at the data that we have now and the data predominantly are from China, South Korea, northern Italy, and Japan, and that is about 80 percent of the people who get infected do well. I mean, they’re not asymptomatic, they have a flu-like illness but they recover spontaneously without any specific medical intervention, so to give them a feel.

 

However if you are an individual who has an underlying condition of which you’re all familiar with — chronic obstructive pulmonary disease, cardiovascular disease, congestive failure, diabetes, anything that could compromise your immune system — if you get infected then you have a much higher chance of having a complication, and then if you look at the serious disease and death it’s totally weighted to that group with the occasional one-off outlier that we even see with flu: A 35-year-old person who’s perfectly well gets the flu and then gets really sick and might die. That can happen, but different from flu, children and young people do really, really well with this.

 

So you give them the broad picture, that should take like two minutes in the office to tell them that. Then you tell them what do you need to do. Right now in places like Seattle, LA, New York, and Florida there’s clear community spread so what you need to do is start already what we call social distancing which some people don’t understand what that means. It just means separating yourself as best you can. No crowds, don’t get on crowded planes if you’re a senior citizen, particularly with an underlying condition. Don’t get on a cruise ship for sure. Wash your hands as much as you possibly can, and if you have a person in your own home who is immunocompromised or falls into that compromised group, you almost have to act like you yourself are infected.

 

So if you’re a 35-year-old person who feels healthy and you have someone in your home that’s on cancer chemotherapy, you’ve got to protect them. You’ve got to physically distance yourself from them. Now that’s now in Massachusetts.

 

If you happen to be in Seattle you’ve got to do more than that. You yourself have to do a lot of social distancing because when you have community spread then you just don’t know the penetration in the community unless you do a massive screening in the community, and that’s where we really need to catch up because what I’d like to see is just flooding the system with testing to see what percentage of people who come into any emergency room actually have COVID-19. If that’s 0.1 percent, okay. If that’s four percent, time out, we really have a problem.

 

Anyway, I was a little bit more long-winded than my usual answer but…

 

Dr Ali Raja:

That was exactly what we needed. Thank you.

 

Joe Elia:

Thank you, and Ali, what’s the situation at Mass General?

 

Dr Ali Raja:

Well, Joe, as an example let me tell you about the kinds of things that we’ve done in anticipation of a more widespread impact of this virus. As Dr Fauci mentioned we aren’t Seattle yet but we’ve already converted our ambulance bay to a large sealed-off treatment area that allows us to screen and test for patients separate from the rest of the emergency department when they meet the current CDC criteria.

 

And I want to emphasize that last part because the target seems to constantly be evolving and changing and so in addition we’re having daily meetings with all of our clinicians and our clinical leadership but also our supply chain leaders, our hospital administrators to make sure that the hospital keeps transforming based on the information that seems to be changing every day.

 

Dr Anthony Fauci:

That’s a really good point. This is not a static situation. It literally changes every day and that’s so difficult to do when you’re trying to put into place the kind of things that Ali just mentioned. You got to, as you say, meet every day and figure, Do we have to turn the knob one way or the other? That’s really important message.

 

Joe Elia:

I’d like to ask you, Dr Fauci, what do you consider the best sources of information for clinicians and the public who want to keep abreast of that changing information? Is it the CDC site or is it MMWR? What would you recommend?

 

Dr Anthony Fauci:

You know, the CDC has put up a site, the Federal government, it’s an all-of-government site. It’s called Coronavirus.gov. They just put it up. I mean, we said at the press conference yesterday “Just dial coronavirus.gov,” and I did and it wasn’t where I needed it to be. But it should be there today. The other thing is that what we’re putting up on the website is something that we literally put together yesterday and it is what to do at home, what to do at the workplace, what to do in the hospital, what to do here, and really simple talk that not only physicians can benefit from but the general public.

 

So I would do CDC.gov and coronavirus.gov.

 

Dr Ali Raja: 

Perfect. I’ll go there today actually. Dr Fauci, what about our listeners? The public isn’t typically going to listen to our podcast but a lot of clinicians do. What do the clinicians themselves do? What should they be doing given the conflicting ongoing need to be able to continue to screen and treat patients who are potentially affected, but also avoiding getting ill themselves? We know the basics of wearing the masks and the gowns, but what else can we be doing or what should we be doing as a system to protect our clinicians?

 

Dr Anthony Fauci:

Yeah. I mean, obviously that is so critical because if you look at what happened in China, the healthcare providers, I mean, there was like 1700 of them in just in the city of Wuhan who got infected. I would do as strict precautions as you possibly can. I would clearly wear an N95 mask, absolutely. I would wash your hands until it starts getting chaffed. I mean, we do that anyway with universal precautions but I would clearly do that.

 

The other thing, if you start and you will, guys. You’re going to start seeing cases come in. I mean, it’s inevitable.

 

Yeah, I would just…when people call in, and I know you’re doing that, you got to tell them and you said you have a system that’s segregated, that if you feel sick don’t just come into the emergency room. Stay at home for now and if you’re going to come in, figure out a way that they don’t come in and essentially infect five other people when they come in. That I think the clinicians need to know.

 

First instinct is that if this person has it I want to take care of them. You can take care of them but you got to be careful about essentially making the matter worse.

 

Joe Elia:

Dr Fauci, I wanted to ask you, what is the one thing you hope that people listening to this podcast will do differently in response to COVID-19?

 

Dr Anthony Fauci:

You know, it’s a binary thing. I want them not to panic because panic gets people to do unreasonable things that are even counterproductive to what you’re trying to do from a public health standpoint. You might overwhelm systems when you don’t need to overwhelm systems. But on the other hand without panicking and without making it dominate your life, pay attention to the fact that you have to act differently like you’ve never acted before. You’ve really got to be socially distant.

 

You know, it’s very interesting that my deputy was one of the two Americans who went to China as part of the WHO umbrella group that visited and in China now, they got hit badly, they had a few missteps in the beginning but they’re getting it right now. I mean, they’re really being super, super careful. They don’t allow anyone to eat at a common  table. They have these little tables that are separated from each other in the hospital and other places where people don’t mingle. I mean, we’re all social beings but for the next few months, and I hope it does go down, it might not, but I hope it does the way flu does, we just got to hunker down. It’s part of what we need to do, we need to hunker down.

 

Joe Elia:

All right. I want to thank you, Dr Fauci, for talking with us today.

 

Dr Anthony Fauci:

It’s my pleasure.

 

Joe Elia:

Best of luck to you and to you, Ali, in the coming months. Thank you again.

 

Dr Anthony Fauci:

Thank you both. Thank you, Ali. It’s a pleasure to meet you.

 

Dr Ali Raja:

You as well. Thank you.

 

Dr Anthony Fauci:

Take care.

 

Joe Elia:

That was our 256^th episode. The whole collection is searchable and available free at podcasts.jwatch.org. Clinical Conversations is a production of the NEJM Group and we come to you from NEJM Journal Watch. The Executive Producer is Kristin Kelley. I’m Joe Elia.

 

Dr Ali Raja:

And I’m Ali Raja. Thanks for listening.