Clinical Conversations

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We talk with Susan Sadoughi, an internist at Brigham & Women’s Hospital in Boston, about how quickly things have changed over the past week.

Last week, I introduced the Fauci interview by saying that I’d heard a clinician complain that she’d spent half her time answering questions about COVID-19. This week, she’s our guest, and she’s looking back from the vantage point of a completely changed health system. She describes that change as “enormous.”

She’s doing lots of telephone consultations with her patients, talking about sending her kids to be with relatives at the other end of the country, and being wistful about the sound of a cello in her hospital’s corridors.

She’s learning to live with uncertainty, she tells us.

Listen in, clinicians, and see whether these observations resonate with you.

LINKS:

Last week’s interview with Anthony Fauci

Running time: 18 minutes

TRANSCRIPT OF THE CONVERSATION WITH DR. SUSAN SADOUGHI

(Please remember, this is a conversation and not an essay. As such, it can seem incoherent when presented as prose, but perfectly understandable when heard. We present it essentially as spoken in order to get it to you quickly.)

Joe Elia:

You’re listening to Clinical Conversations. I’m your host, Joe Elia.

While many of us work from home, some of us — such as first responders, mail carriers, supermarket clerks, and cooks — continue working during the uncertain course of the COVID-19 epidemic. Clinicians, of course, also continue their services, and we have with us today Susan Sadoughi an internist in the division of General Medicine at Brigham and Women’s Hospital in Boston, where she teaches residents and medical students. Dr. Sadoughi is a deputy editor of the daily Physician’s First Watch and has a been a colleague of mine there for many years.

The other day, during one of her phone calls with the First Watch newsroom she expressed some frustration with the problems the COVID-19 epidemic has created, and I thought it would be useful for other clinicians to hear about those problems or to know at least they were not suffering alone. She’s kindly agreed to talk with us. Welcome to Clinical Conversations, Susan.

Susan Sadoughi:

Thanks for inviting me.

Joe Elia:

It’s my pleasure. Tell us a little bit about your experience these days. Last week, as I said, you said you were spending about half your time answering patients and possibly clinicians’ questions about COVID-19, and I’m guessing you’re probably spending much more time this week.

Susan Sadoughi:

I have to say a week’s span of time has been an enormous difference from last week to this week. A week ago, I would say my clinical experience, in a lot of ways, was similar to the week prior in that I still had scheduled patients. I was seeing patients in the office, and I was seeing 15 patients a day. And last week I was frustrated, I remember, primarily because added to the usual business of seeing patients and filling in regular questions there was all of the discussion around, “Doc, what do you think this is? Can you tell me more about it? How do I protect myself?” It blows my mind how much things are different this week compared to last week.

Suffice it to say, if I were to just highlight the fact that this week I had zero patients that I saw in the office for routine visits. So beginning on Sunday night we actually screened all of our patients for the next two weeks and contacted all of our patients to let them know that almost all patient visits will take place on telephone. So we sort of divided our patients into three categories. If you’re just here to get your physical and you have no complaints or no problems that have to be followed, we will reschedule you for a month from now.

And then there was this category of patients that had problems, that were going to see me for routine follow-up, and we converted it to phone calls. Now, we have been advocating for phone visits forever and we’ve been told about all the barriers of phone visit. Lo and behold, in the middle of crisis, today I had six visits that were phone visits out of the 12 that I was supposed to see in the morning. So six of the visits were completely rescheduled. Six of them were converted to phone visits. And then I had the third category of patients, which are the patients who are symptomatic and need to physically be seen.

We divided those patients into patients with respiratory symptoms, which go to a completely separate wing of our clinic for whom I have to completely use preventive protection. And then symptomatic patients who, say, if they had a headache or other things that are non-respiratory. So our clinic, in the span of one week, has been utterly transformed.

So last week, it was absolutely overwhelming because there was the routine stuff and then the added counseling of the patients around COVID concerns as well as 100 questions on the emails that I was getting via our gateway messages. Ninety percent of those questions are now being triaged by a separate group of clinicians and nurses. There’s a whole hotline that has been developed who basically screen all my messages and if they’re COVID-related questions they’ll triage those questions.

So I think the structure of the clinic is utterly different. The feeling around the hospital is absolutely eerie. You walk around and there are not many people around. All of us are on this standby. The residents have all been pulled off the clinic. No routine visits. Waiting in case they’re needed, and then all the attendings who don’t have urgent care responsibility…so for example, I had urgent care responsibility today so I physically came to the hospital but tomorrow all of my patients are going to be phone visits. So I don’t have to come to the hospital. So they’re not…it’s just absolutely surreal. There’s no other way to describe it.

Joe Elia:

So what do you do to protect yourself? I mean in the absence of readily available testing for the presence of the virus.

Susan Sadoughi:

So essentially, I would say 80 percent of the patient visits have been converted into future visits or phone visits. The people who are being seen are the people who have acute respiratory symptoms. Those people, we pretend as if they do have COVID, and we have universal precautions for them. Other patients who are being seen in urgent care, which are very few…very few patients that are being seen in urgent care are not absolutely necessarily respiratory-type symptoms. Those people we stay away six feet. We wash our hands constantly. We have a ton of Purell and are wiping surfaces constantly. These are completely low-risk to no-risk for possible respiratory process.

And then all the other respiratory symptoms, be it that you have sore throat, be it you have some nasal congestion, be it you have some ear pain, we get dressed as if it could be COVID. So it’s so different this week.

Joe Elia:

So you’re kind of waiting around for the other shoe to drop, aren’t you?

Susan Sadoughi:

Yeah. I have to say, even my residents are like I can’t believe…because I see the same residents from last week to this week, and we were all saying I just can’t believe where we are in one week. Where we all are doing our phone visits and we’re sort of on this standby. Today, as I was going to a different section of the hospital, Brigham has this music-therapist cello player. They only usually come once every week or so. She’s been playing every day, it seems like, all day. And you walk around and I had ran into another colleague who was upstairs. You know, you vacillate between, oh, my God, this is so profoundly sad. Look at what is happening to our hospital.

Then you look around and there will be a message that makes you feel like, okay, I’m a soldier. I’m here. If something happens, I’m going to step up and I have to tell you, at times, I get so teary-eyed listening to that cellist playing because — I don’t know — there’s something incredibly patriotic about it. It’s so crazy because the whole atmosphere has changed.

Joe Elia:

You have a family at home.

Susan Sadoughi:

Yes.

Joe Elia:

And youngish children.

Susan Sadoughi:

Yes.

Joe Elia:

So how are you protecting yourself? Tell me a little bit, if you would, what that’s like.

Susan Sadoughi:

I’m in a little bit of a unique position, knowing that they have three weeks off and I have family in Florida we’re actually contemplating sending the rest of the family to Florida because there is very good chance I will be among the few urgent care doctors who will be assigned to see all the respiratory patients, meaning like every day I will be testing symptomatic people. I think that is high-risk enough that it might mean they’re better off distant from me. If they were home, I would probably, in addition to frequenthandwashing, etcetera, I’m in favor of keeping that six foot distance because what if I am one of those asymptomatic people who will contract it?

Luckily, the data around the young people are pretty encouraging every day, but I probably would be in favor of just keep a safe distance from me and in addition to the usual handwashing, the usual wiping off a surface. I’ve been really good about reminding the residents and also reminding the staff that we should consider ourselves as one of the scarce resources and we don’t want us to be quarantined or furloughed, never mind anything else.

Joe Elia:

The New Yorker has a daily newsletter. Benjamin Wallace Wells, in The New Yorker (who, by the way, lives in Boston) was talking with ethicists about some of the decisions that people might have to make about the use of respirators if things became as bad as they are, say, in Italy. I know that you’ve probably thought about that. Have you had conversations with your residents about that?

Susan Sadoughi:

Yeah. You know, to be honest with you, we’re in a different phase right now in the sense that we are commenting about how we’ve been able to reduce census in the hospital. The hospital feels empty because we really have been so proactive to divert patients who could be managed at home or elsewhere and also I think patients have been really good about trying to avoid the ER and keeping the staff available. So I think at this point, we’re just shocked by, “my God, we’re in this prep mode and we don’t know what to expect.” I think we haven’t prepared ourselves for the other side of the equation where we were totally overwhelmed. I don’t think we’re there yet. So I don’t think we played that scenario as much.

I’ll tell you one thing about my experience with these phone calls, which has been so unique. We’ve been asking to try and have phone visits for years, especially in primary care because so much of it can take place on the phone. Number one, the patients are so incredibly appreciative — Joe, I cannot even tell you — that they don’t have to come in. But also, just how much we can get done on the phone. Literally 90 percent of what we need to get done could get done on the phone for various patients. Then I was struck by every conversation at the end comes to a COVID discussion and the level of the discussion has changed, and it’s really interesting because last week the general public was uninformed. So a lot of the questions were very basic questions. What should I do?

Now, it’s so much different and it’s so unique to their own situation. I spoke to my 75-year-old who has to babysit for the grandchildren and what should he says to his daughter about limiting the little kids’ playdates. Then I had one other patient today, this woman who’s working from home, but she has some mental health struggles and she usually runs outside and exercises, and the gym has closed. And in talking to her about what you could do instead, “You could do this, you could do that, I want you to still do your exercise etcetera, it’s just a completely different discussion from last week. It’s much more advanced around how to protect themselves.

I think people…my own sense of it right now, the mindset is different. I think people have a mindset of what can I do instead? How can I protect myself? What can I do instead? I think there’s basic knowledge and then they’ve come to acceptance. It’s almost this is acceptance. If they’re worried, like I’ve been really trying to emphasize maybe you can do A, B, and C but you can do X, Y, and Z and you should feel good you’re being flexible. You’re being resilient. You’re still trying to find your way to do the things you need to do.

People have been so incredibly appreciative. I think it makes me much stronger and in a much better mindset this week compared to last week.

Joe Elia:

But for the clinicians who haven’t yet seen their first case or their first presumptive case yet, what’s the best advice that you could offer them?

Susan Sadoughi:

You know, I think the very first few times that I was seeing patients and trying to make decisions, should I send this person for COVID testing, should I not test them? It was so unsettling because it seemed like every two hours the guideline was changing. I would reach out to our infectious disease expert and after about the second or the third time where I heard them say, you know what, there is no clear-cut answer right now. Here’s what we need to deal with and there’s no easy answer, I finally realized as physicians we want certainty and in these times you have to understand the guidelines are changing. We don’t have the availability of testing all the people we want, and we have to be comfortable with some uncertainty. I’m better at that now because if the infectious disease person didn’t know the answer and says to me, “This is my best advice I can give you, and these are all hard decisions and we just have to live with that,” I think there’s something calming about that.

Whereas, last week I was terrified that I was making the wrong decision and now I realize this is such a fluid decision that there’s not a black and white answer and there is some comfort in knowing that we have to make decisions with some level of uncertainty, and it just feels different.

Joe Elia:

All right. Well, I want to thank you very much, Susan, for talking with me today about all this.

Susan Sadoughi:

Sure. Sure. There’s a lot to be learned over the next week or so.

Joe Elia:

Or maybe the next several months.

Susan Sadoughi:

Yes.

Joe Elia:

I wish you and your family well.

That was our 258th episode, all of which are searchable and available free at Podcasts.JWatch.org. We come to you from the NEJM Group. Our executive producer is Kristin Kelley, and I’m Joe Elia. Thanks for listening.