Clinical Conversations

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This week’s guests, Dr. Andre Sofair and Dr. William (“Rusty”) Chavey are physician-editors on the daily clinical news alert called Physician’s First Watch.

I went back through the recent issues and found this January 10 entry, which began “The CDC is requesting that clinicians ask their patients with severe respiratory disease about any travel to Wuhan City, China. That city has seen at least 59 cases of pneumonia caused by an unknown pathogen since December. Seven of the 59 are critically ill.”

How quaint that all seems now — so three months ago!

Both our guests are being kept busy by that mysterious pathogen, and I thought I’d check in with them.

Running time: 20 minutes

Other interviews in this series:

1. Dr. Anthony Fauci
2. Dr. Susan Sadoughi
3. Dr. Matthew Young
4. Dr. Julian Flores
5. Dr. Kristi Koenig
6. Dr. Renee Salas

TRANSCRIPT:

Joe Elia:     Welcome to Clinical Conversations. I’m your host, Joe Elia. This week’s guests, Andre Sofair and William Chavey are physician-editors on Physician’s First Watch, a daily clinical news alert. They are part of a larger group of clinicians collaborating with First Watch’s writers — people like me.

Dr. Sofair and Chavey have the unique task of looking back over the weeks’ stories and choosing the most important. Their choices and the reasons for them show up first thing in Saturday morning’s email edition. I went back through recent issues and found this January 10 entry, which began “The CDC is requesting that clinicians ask their patients with respiratory disease about any travel to Wuhan City, China. That city has seen at least 59 cases of pneumonia caused by an unknown pathogen since December. Seven of the 59 are critically ill.”

How quaint that all seems now. It’s so three months ago!

Both guests are now being kept quite busy by that mysterious pathogen and I thought I’d check in with them.

Dr. Sofair is a Professor of General Medicine at Yale Medical School where he also holds appointments in the School of Public Health, and Dr. Chavey is an Associate Professor and Service Chief in the Department of Family Medicine at the University of Michigan, Ann Arbor.

Welcome to Clinical Conversations, my friends.

Dr. William Chavey:     Thank you for having us, Joe.

Dr. Andre Sofair:     Thanks for having us.

Joe Elia:     Dr. Sofair, you’re in New Haven, so what are you seeing on the ground there? Connecticut’s cases have more than tripled since the beginning of April and now hover around 13,500. The universities have emptied of students, but what’s the atmosphere on the wards?

Dr. Andre Sofair:     I would say that the atmosphere is quite positive. Our hospital and medical school have done a really good job, I think, in terms of communicating the situation with all of the frontline providers — nurses, clinical techs, the physicians — and I think we have a very good supply of personal protective equipment, which has been critical. And I think that we started our planning process very early on before we started seeing cases, so I think that the frontline staff feels supported and I think that the atmosphere is as good as one would expect. given the circumstances.

Joe Elia:     And Dr. Chavey, you’re just west of Detroit, of all places, in Wayne County, and that’s a hotspot. Ann Arbor must also be pretty quiet with the students gone, but you’re in family medicine there, and that’s an area with lots of closed businesses because of the national quarantine that we’re in. What feels unique about this experience to you?

Dr. William Chavey:     Well. We could probably talk for hours on that, Joe. I think the first most unusual thing for us was the contraction of ambulatory services, so we went from having seven clinic sites to contracting them down to two. Scrubbing schedules and moving everything that was not urgent, either to be deferred for later or to be done by telemedicine, and as this happened everywhere the escalation of telemedicine has been remarkable and dramatic over such a short period of time once the barriers were removed. In juxtaposition with that, we are also active at the University of Michigan Hospital, so we were preparing for what we thought was going to be a surge of historic proportions at the hospital. I was on a planning committee for a field hospital and we were looking at having 1500-bed field hospital. At this point, we’re not planning to have a field hospital at all. We are going to obviously record the efforts that we put in place in case we have to do that at some point, but the social distancing has helped quite a bit.

Our numbers are relatively flat. We are now living in an eerie world where we have a hospital that’s typically about 95 to 98% at capacity, and by cancelling all of the elective surgeries and so forth we now have a hospital that’s at about 65% capacity, and an ER that is seeing patients at a much lower rate than expected. And no one really knows what’s happening with the strokes, and the heart attacks, and the trauma that were coming in before, because they’re not coming in now. And the other interesting phenomenon — because in family medicine we also do obstetrics — a very unexpected phenomenon has evolved there where, when women come in, the thought now is that during part of labor that is an aspect where healthcare professionals might be a particular risk from aerosolizing the virus, and so there have been some studies looking at what percent of pregnant women, when they present to labor and delivery, are positive even if asymptomatic, and those numbers are somewhere between the mid-teens and 30%, so there are some protocols where they were screening every woman who would come in.

Well. The interesting part is a lot of women were declining that, because if they get tested their husband may not be able to come in with them and they don’t want to labor alone. So you now have this odd tension between wanting to protect the healthcare professionals who want to know if a woman is positive and a woman not wanting to be tested because she would then have to labor alone. So from the family medicine perspective we have all of these different areas, all of which have very unique, very unexpected tensions and things that have evolved.

Joe Elia:     So, how are you navigating that, Rusty? How are some of those conflicts resolved?

Dr. William Chavey:     Well. I’ve described a lot of what people are seeing in the literature as “science, thinking out loud,” and I think what we’re also seeing is “medicine responding out loud.” Each of these is unique and idiotypic in its own way and something that we had…I mean, no one ever was anticipating this dynamic in labor and delivery, so the obvious question is how do you handle a woman who refuses to be tested, and how do you protect the healthcare personnel? This is a dynamic we had never considered before.

Joe Elia:     Andre, you’ve spent time in Rwanda setting up medical education facilities and other places, too. Do developing countries have lessons for the first world about how to behave during a pandemic?

Dr. Andre Sofair:     I’m sure that they do. You know, they have different pandemics. For instance, I was recently in Rwanda and they had an outbreak of dengue, the first significant outbreak that they’ve had in years, and so they’re able to mobilize things and do things in the hospital much faster than we’re able to, I think, because the hospitals tend to be smaller and the bureaucracy tends to be not as robust as ours, so I saw them mobilize the units and set up bed nets at the hospital very, very quickly for in-patients to try and prevent nosocomial transmission of dengue, for instance. They also have a lot of experience with the use of personal protective equipment that we don’t have as much, and as especially masking. For instance, they have a lot of tuberculosis and other infectious diseases that we don’t have here, so there are certainly things that they teach us that we can learn from them.

Joe Elia:     Now, in both places, Connecticut and Michigan, are visitors allowed into the hospital? I’m reading reports that for instance at Mass. General everybody’s got to be wearing a mask when they go into the hospital, whether you’re a visitor, or patient, physician. Is that true now, pretty generally?

Dr. Andre Sofair:     At our hospital, everybody is to wear a mask, healthcare providers, when they come into the hospital and wear it throughout the day. Those are typically surgical masks, the N95 masks are reserved really for people that are taking care of COVID-positive patients, or patients that are being evaluated for the possibility of COVID. We have a very strict visitor restriction policy at our hospital where visitors are only allowed to visit if people are dying or on hospice.

Dr. William Chavey:     And we’ve had the same, and we also see this in the ambulatory setting. We’re not allowing people to accompany patients when they are physically seen in the office unless it’s a young child or someone needing assistance in a wheelchair. Something of that sort.

Joe Elia:     Okay.

Dr. Andre Sofair:     I can say, Joe, just to add to that, it has made the stay for the patients very difficult, as you can imagine. They’re communicating with family and loved ones over the telephone. Physicians are doing the same, and it’s also very difficult to the family because of the fact that they don’t have the daily updates in person with their loved ones in the hospital, so it’s made the care of patients very challenging, I would say.

Joe Elia:     So, questions for the both of you. What do you fear will happen as a result of COVID-19.

Dr. William Chavey:     I think right now here is a great deal of uncertainty and health systems, private medical offices and clinicians about what the future holds, and I think one thing that is clear as we emerge is that the post-pandemic world will not resemble the pre-COVID world, and I think…and if it is I think that’s a shame. I think we need…I think one fear or concern I would have is that we pretend all of this is going to go away and things are going to operate the way they used to, and I hope and think that’s probably not going to be the case, but none of us really know, and I think we’ve had to realize that we’re not in control. None of us really know what that post-pandemic world is going to look like. There are health systems that are beginning to lay off staff and faculty and are cutting salaries. There’s concern that we will never have the same volume of patients, or in the same nature that we had before, and I think a lot of people are struggling to figure out what their role is going to be in this post-pandemic world.

Dr. Andre Sofair:     Yeah, I would agree with what Rusty said. I think there are too many unknowns at this point, in terms of how long it will last, what kind of immunity, and what kind of herd immunity, if any, we’ll have. What kind of vaccines, if any, will be available, and whether or not they’re effective in terms of preventing [spread in] the population, so I think there are a lot of unknowns.

But I do think that there will be some changes in the way medicine is practiced. I think that there will probably be more telemedicine than there was before. I think that our rounding procedures will probably be different. I think that our use of personal protective equipment will be different. I think that our attending of medical conferences, whether locally, nationally, or internationally will be different. I think there will be a lot of reliance on communication that is at a distance, as opposed to in-person. I do also share the question and concern about what will happen with out-patient practices because a lot of out-patient practices now have had to close because of lack of patients, and will they be able to reopen in the future because of staff having been laid off and maybe going to other types of work, so I think it’s still very unknown, but those are the changes that, at least, I see in the future.

Dr. William Chavey:     So, Joe, in response to what Andre said there was a…there’s a policy arm of the American Academy of Family Physicians, the Graham Center, and they published data that by June 60,000 family medicine offices would be either closed or would significantly cut back, and this would impact 800,000 employees of these offices, so this could be an existential threat to private practice in that regard, and as Andre said, will they come back online, will they be able to? If they don’t what will happen with the patients who have been going to those practices and can the hospital-based practices, absorb those patients when all of this is said and done.

Joe Elia:     It must be different to prepare yourself for the clinical day in these times. Is there something that…has your routine changed as you get up in the morning and you’re about to go in? Do you recall something that a favorite professor of medicine told you as a young resident, or is there anything different about it?

Dr. Andre Sofair:     I would say for me the major change is how I have led my life at home, so for instance for the past month I’ve been living in the basement and on a different floor from my family, and I’m eating my meals separately. I’m always, or at least try to be, six feet away, and the most notable thing for me is where I have my clothes, how I put them on in the morning, and then when I come back home how I take them off and how I try to make myself as clean as possible so I don’t run the risk of bringing anything home to my family, so that’s been a major change for me.

Dr. William Chavey:     I guess one report from the ambulatory setting yesterday, I think my first four patients were all done in different ways, and we have…we’re doing some drive-by or drive-thru testing so we’re seeing some patients. We walk out to the car…we put our personal protective equipment on and go to the car, and we’ll do sampling there, check blood pressures, do what we need to do with them in the car, and one of my patients was done via that approach. We have divided the clinic into two halves, one clean side, if you will, and one where patients who might have some sort of infectious symptoms come, and so I had to go on one side to see one of the other patients. Another patient was just via phone call and another patient was telemedicine, and so instead of getting into a groove I’m seeing patients in all of these different manners and having to adjust, and take off one coat and put on another coat and go into one office where I have a computer to do the telemedicine, and you don’t…the comfort level that you had, that you developed over the years gets lost because you’re in very unusual situations.

Joe Elia:     Yeah. What advice would you give to a young clinician just starting out in the middle of all of this?

Dr. Andre Sofair:     When I was in medical school, I went to medical school in the Bronx at Albert Einstein, and that was the very beginning of the HIV epidemic, and so people were very unsure about how it was transmitted, what you had to wear to go into the room, and I think that there are a lot of analogies to the way that we responded then and the way that we respond now. And I really think that medicine is still a wonderful profession, whether you’re starting now where there’s a lot of insecurity about where we’ll be in the future, but I think that the calling is still the same. We’re there to collaborate with one another, to do our best together, to take care of suffering patients and families that are afraid, and so I still think it’s a very exciting time to be in medicine, and it’s interesting that some of the house officers that are on our unit said that they’ve spoken with some of their young colleagues who are not in medicine now and wish that they were.

Dr. William Chavey:     I think if you buy someone a gift you can either buy them something you would like or you can buy something they would like, and certainly the latter would be the preferred. Medicine is still, at its core, a vocation of service. And I think the advice I would give is, don’t go into it with your own perspective, your own sense of what it ought to be. If this has taught us anything it’s that we have to be flexible, and if you’re going to be giving the gift of service to a patient it has to be what they need in that environment, and that environment may change, and you may have to put aside your own sense of how you might want to do it in order to be prepared to serve.

Dr. Andre Sofair:     You know, the one thing that has struck me about…at least at our hospital, the way things have gone, and it’s been very comforting to me, is just the preparation on the part of the medical school and also of the hospital. Our hospital had a lot of foresight and started the preparations a couple of weeks before we started seeing our first cases, and we’ve been going at this now for about six weeks, and we have daily calls with our chief of our department of medicine and lots of leaders in the department to brainstorm, to get information out. Nursing has the same thing. The hospital leadership has the same thing, and I think that that planning processes has given people a lot of comfort and has allowed us not only to take care of each other but also to take the best care that we can of our patients. We have teams of physicians and researchers that are working on protocols to make sure that we’re delivering the best medicine that we can, given the lack of evidence.

We have teams that are working on recycling the PPE to make sure that we have adequate PPE that’s safe for us to use, and all of that gets disseminated on a daily basis out to the hospital and to the workers, and so I think that it has been the best situation possible given the circumstances.

The other thing that I just wanted to say — that has really touched me — is the bravery of all of the staff. We have residents that are in pathology, that are in psychiatry, that are in dermatology, that are in neurology that have volunteered to help out on the medical service to take care of patients, and we’ve had attending physicians from all of those levels that have also pitched in to help out. The anesthesiologists have been very helpful, for instance, in our ICUs to helping out the critical care attendings that have been strapped because of all of the patients that have needed care, and there’s been just an extraordinary amount of collaboration between the physician staff, the nursing staff. And the nursing staff have also stepped up. We have nurses that have not worked in an ICU for years that are now working in an intensive care unit, taking care of very sick patients, COVID-positive patients and non-COVID positive patients just to pitch in, so that has been the greatest memory and experience that I’ve had through this whole epidemic.

Joe Elia:     I want to thank you, Dr. William Chavey and Dr. Andre Sofair, for spending time with us today and sharing the wisdom of your experience with COVID-19.

Dr. Andre Sofair:     Thank you, Joe.

Dr. William Chavey:     Thank you, Joe. Thanks, Andre.

Dr. Andre Sofair:     Thanks, Rusty.

Joe Elia:     That was our 263rd episode. All of the previous episodes are searchable and available free at podcasts.jwatch.org. We come to you from the NEJM group. The executive producer is Kristin Kelly. I’m Joe Elia. Thanks for listening.