Tagged Doctors

To ‘Keep The Lights On,’ Doctors And Hospitals Ask For Advance Medicare Payments

Darrin Menard, a family physician in Lafayette, Louisiana, has spent the past month easing patients’ anxieties about the coronavirus that has killed 10 people in his parish so far.

But Menard has his own fears: How will his medical practice survive the pandemic?

His office typically sees 70 patients a day, but now it handles half that amount and many of those appointments are done over the phone or computer. He said revenue in the practice has dropped by 40% — which makes it challenging to pay a mortgage, staff salaries, malpractice insurance, utilities, electronic health records costs and other expenses.

To help stay afloat, Menard is one of thousands of doctors, hospitals and other health providers reaching out for a lifeline made available in the series of federal relief measures to counteract the effects of the viral outbreak.

He applied last week for a three-month advance on his Medicare billings, which he hopes will bring in about $120,000 or more to cushion the strain. He’s also applying for the Small Business Administration’s Paycheck Protection loans to help cover costs of meeting payroll.

“We are quite thankful for the help so I can keep the lights on in the office for us to be available for our patients,” Menard said.

The Centers for Medicare & Medicaid Services announced in late March that it would implement for the first time a national accelerated Medicare payments program to help ease the financial strain for health providers. Thursday, officials said they had disbursed $51 billion to hospitals, doctors and other care providers.

“Healthcare providers are making massive financial sacrifices to care for the influx of coronavirus patients,” CMS Administrator Seema Verma said in a statement.

“Many are rightly complying with federal recommendations to delay non-essential elective surgeries to preserve capacity and personal protective equipment. They shouldn’t be penalized for doing the right thing. Amid a public health storm of unprecedented fury, these payments are helping providers and suppliers ― so critical to defeating this terrible virus — stay afloat.”

The federal help has inspired private insurers such as UnitedHealth Group and several Blue Cross Blue Shield plans to offer advanced payments and other financial support.

CMS in April has received more than 25,000 requests from providers and suppliers for expedited payments and has approved more than 17,000 requests. Before the pandemic, CMS had approved about 100 requests for advanced payments in the past five years, mostly for natural disasters such as hurricanes and tornadoes.

Most physicians can get an advance on three months of their Medicare reimbursements, and hospitals can get up to six months. Hospitals will generally have up to one year from the date the accelerated payment was made to repay the balance. Doctors will have up to seven months to complete repayments.

To put all this $51 billion in financial aid in perspective, traditional Medicare in 2018 paid $403 billion to health care providers.

Coronavirus patients are overwhelming hospitals in cities including New York, New Orleans and Detroit. But as other health systems brace for similar spikes, they are also seeing sharp drop-offs in regular doctor visits, emergency room arrivals, and the lucrative surgeries and medical procedures that are vital to their bottom lines.

The advanced Medicare payments are just part of the hundreds of billions of dollars the federal government is providing doctors, hospitals and other health providers.

Congress also set up a separate $100 billion program for hospitals and other health providers with coronavirus-related expenses.

The Trump administration Tuesday said it will begin distributing the first $30 billion from this fund to hospitals this week. The money will go to all hospitals based on their Medicare fee-for-service revenue.

Lobbying groups representing safety-net hospitals slammed the decision because they get a lower share of their revenue from Medicare than some other hospitals do. And safety-net hospitals have a higher percentage of patients who are uninsured or covered by Medicaid, the state-federal health insurance program for low-income people.

It also upset hospitals in New York, the epicenter of the U.S. epidemic, because they were getting no more funding than hospitals little affected by the outbreak.

Verma said the administration’s top priority was getting the funding to hospitals as quickly as possible. She said children’s hospitals, nursing homes, pediatricians and other health care providers that receive much of their revenue from Medicaid and other sources will be given priority when the second round of funding is distributed.

Other federal steps to help providers include Medicare for the first time paying for telemedicine treatments at the same rate as in-person visits. Previously, those fees paid less than half of what in-person visits paid.

Congress has also suspended a 2% Medicare reimbursement cut and bumped up Medicare fees by 20% for treating COVID-19 patients. The Trump administration said it is also paying hospitals Medicare rates for uninsured COVID-19 patients.

The billions in advanced Medicare payments are seen as one of the quickest ways to get funds to struggling hospitals and doctors.

“It’s money we will desperately need,” said Patrick McCabe, senior vice president of finance at Yale New Haven Health, the largest health system in Connecticut. It is counting on more than $450 million in advanced Medicare payments to get through the pandemic — at least for the next couple of months.

The health system, which runs a $5 billion annual budget, could lose more than $600 million as a result of the added expenses of preparing and dealing with COVID-19 and the drop-off in other revenue, he said. Such a loss — without any federal assistance — would more than wipe out the health system’s ability to upgrade equipment and keep up with rising expenses, he added.

McCabe said determining whether the federal relief will be enough depends on how long the pandemic lasts.

Shelly Schlenker, senior vice president of public policy and advocacy for CommonSpirit Health, a Chicago-based Catholic health system with 137 hospitals, said she expects all these facilities will apply for advanced Medicare payments.

“Hospitals are in urgent need of assistance to meet the demands of the pandemic,” she said. “It’s an unprecedented time.”

Even with all the government help, industry analysts say, the economic fallout from COVID-19, the disease caused by the coronavirus, will rock the health industry, which communities often count on to fuel their economies.

The average large hospital will see about a 51% decline in revenue as a result of the pandemic, said Christopher Kerns, vice president at the Advisory Board Co., a consulting firm.

While some patients who postpone procedures will return, Kern said, hospital systems shouldn’t expect a quick recovery. “Health systems are going to try to capture as much pent-up demand as possible, but there are big challenges with that,” he said.

Before the crisis, a quarter of U.S. rural hospitals were at high risk of closing, according to a report this month from consulting firm Guidehouse. These 354 hospitals span 40 states, though most are in the Southeast and central states.

“It was already troubling that the economic outlook for rural hospitals deteriorated during the longest period of uninterrupted economic growth our country has ever experienced,” said Dave Mosley, a Guidehouse partner. “A major crisis like the COVID-19 pandemic or any significant economic downturn is likely to make the situation even more dire.”

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‘It’s Like Walking Into Chernobyl,’ One Doctor Says Of Her Emergency Room

At one New York City hospital, a doctor’s used mask tore as she performed CPR on her infected patient.

In Seattle, a nurse compares walking into her intensive care unit to bathing in COVID-19.

And in St. Louis, a nurse slips her used N95 mask into a paper bag at the end of her shift and prays it’s disinfected properly.

These are scenes playing out in hospitals across the country, based on interviews with over a dozen residents, doctors and nurses who go into work every day feeling unprotected from the disease they’re supposed to treat.

Nearly a month into the declared pandemic, some health care workers say they’re exhausted and burning out from the stress of treating a stream of critically ill patients in an increasingly overstretched health care system. Many are questioning how long they can risk their own health. Some are falling sick themselves, and even dying. In many hospitals, the pandemic has transformed emergency rooms and upended protocols and precautions that workers previously took for granted.

“It’s like walking into Chernobyl without any gear,” said Jacklyn, an ER doctor at a New York City hospital who asked to go by her middle name for fear of being fired over speaking out.

At her hospital, 90% of patients have COVID-19, but health care workers get only one N95 mask every five days.

“We’re constantly breathing in everything that’s aerosolized because of all of the procedures that we’re doing,” the New York City doctor said.

Coronavirus can spread easily through droplets during close interactions such as coughing and talking. It can also stay on some surfaces for days. During certain procedures, the virus becomes aerosolized and can linger in a room for longer periods. In such cases, health care workers are directed to take “airborne precautions” and wear N95 masks or another kind of respirator.

She said she’s baffled by how unprepared the government and hospitals are for this moment.

The day Jacklyn shows up to the hospital and there are no N95 masks, she said, she’ll refuse to work.

“I’m not on a suicide mission here. I’m not going to do anything that puts my life at risk. What is my daughter going to do without me? What would my husband do without me?” she said.

With a nationwide shortage of protective equipment, many hospitals are limiting how often nurses and doctors can get new masks and devising ways to stretch supplies.

“Whoever is disinfecting these masks, are they trained to do this? Is someone supervising? Where are they doing it and how?” wondered Sophia Rago, an ER nurse based in St. Louis, about her hospital’s policy.

Rago said she gets only one surgical mask and one N95 mask for three shifts in a row. Afterward, she places her gear in a brown paper bag and writes her name on it.

“You give it to somebody and they are supposed to be disinfecting it between your shifts,” she said. “Do I trust that? No! It can be disheartening to have that feeling of uncertainty that you are not going to be protected.”

Much of the anxiety felt by front-line health care workers stems from the ever-shifting federal guidance that in some cases later turned out to be wrong.

For example, in the early days of the pandemic, the Centers for Disease Control and Prevention had narrow criteria for screening suspected coronavirus cases, which was later broadened as the virus spread in the U.S.

The CDC still recommends, in cases where N95s aren’t readily available, that a simple surgical mask will suffice for health care workers unless they’re doing procedures that cause aerosol spray from the patients, such as intubating someone. It was only last week that the agency changed its guidelines and told all Americans to cover their faces with masks or cloth when in public.

Health care workers are distrustful of recommendations that, many said, appear to err on the side of less than what they require for protection. They point to the CDC’s recommendation to use a bandana or scarf as a last resort if masks run out.

“I don’t care what the CDC guidelines say. If your nurses feel uncomfortable in a certain area, you should give them what they need,” said Ramona Moll, a nurse who works at UC Davis Medical Center in Sacramento, California.

Moll said she contracted COVID-19 in mid-March after treating a patient suspected of having contracted the coronavirus. She believes the exposure happened when the older patient with dementia became combative and tried to bite her. At the time, Moll was wearing a surgical mask, goggles, gloves and a gown, but no N95 mask. Her gear was in line with CDC guidelines.

“The hospitals need to take responsibility for the fact that they did not take care of their nurses. They did not have N95s available,” she said.

Her hospital disputes her account. Spokesperson Edwin Garcia said there were no COVID-19 patients at the hospital at the time and that it has “dedicated, full-time teams that are committed to infection prevention and keeping our employees safe.”

Grueling Shifts, Stress And Bruised Faces

The lack of protective gear is one piece of a mosaic of stress that comes with caring for COVID-19 patients.

There are the 12- and 13-hour shifts in uncomfortable masks, the many unknowns of the disease and difficulties screening for it, the fear of getting infected or accidentally infecting another patient and the sadness of watching people die alone.

At an underresourced community hospital in Los Angeles, a nurse practitioner, Marie, has a plastic bag in her car in which she stashes her used N95s for the day her hospital may run out.

“I’ll spend the majority of my shift trying not to have a panic attack and then come home and fear going back to work,” she said. “If this goes on for weeks and weeks and things only get worse, I just don’t know how I’m going to be able to handle it.”

She asked to use her middle name because her hospital has warned employees not to speak publicly; some workers have been reprimanded for critical social media posts.

Marie has lost 3 pounds in a week. Once she puts her mask on during a shift, she won’t take it off and, thus, avoids eating. The bridge of her nose is cut open from wearing it on her face for hours at a time. The lack of preparation has her considering leaving nursing after the pandemic passes.

“I have dedicated my life to treating other people,” she said. “And yet when I’m in need, I’m not provided with what I need. It’s like an abusive relationship.”

Health care workers across the country and the globe are sharing selfies of their bruised faces from wearing N95 masks.

“It is a long six hours to be in all that gear,” said Amanda Adams, a travel nurse who works at an ER in the New York City suburbs. “I try to put aside my emotions and cheer up the patients. Meanwhile, I am thinking, which one is going to give it to me and am I going to get sick?”

Once Infected, Who Takes Care Of The Health Care Worker?

Already, front-line workers are falling ill and feeling they have to choose whether to risk their lives to save others.

At least 40 U.S. health care workers in the U.S. have died of COVID-19, according to Medscape. Some of them were young and early in their careers.

“That also increases the fear. That it’s hitting young people,” said Dr. Roy Akarakian, an ER resident at Henry Ford Hospital in Detroit. “I’m worried and afraid about the overall situation. This is something we’ve never seen before.”

Akarakian has already survived the virus — one of more than 730 employees of the Henry Ford Health System who have tested postive since tracking began on March 12.

In Seattle, Edward, an ICU nurse, said he developed flu-like symptoms and shortness of breath last month, after treating COVID-19 patients. He decided to stay at home out of caution, while he waited for his test results. Seven days passed before he learned he was positive.

“It was just really hard and nerve-wracking,” said Edward who works at Swedish Medical Center, and is using only his first name because he’s afraid of losing his job for speaking publicly.

While in isolation and recovering, he was required to use his own vacation and sick time. After learning he had COVID-19, he said, his employer “tried to pin those results on something outside the hospital” — probably, Edward said, because the hospital provides fully paid emergency administrative leave only if you can prove you caught it on the job.

“I did not feel supported at all,” he said. “Their main concern was trying to explain away my positive results as community-acquired.”

In a statement, Swedish said “it’s grateful for our caregivers’ unwavering commitment to our patients and the selflessness they bring to work every day to ensure our patients and community are safe.”

Tiffany Moss, a hospital spokesperson, also noted Swedish provides 80 hours of full-paid emergency time off for workers affected by COVID-19 — no matter where they were exposed to the virus — but only after infected employees exhaust vacation and sick time.

When Edward got the green light to go back to work, his co-workers seemed afraid to be near him.

“When I would tell people, they would physically back away from me, they would question whether I should be at work,” he said. “It was hard to go home at night and deal with those emotions.”

This story is part of a partnership that includes NPR and Kaiser Health News.

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‘Baby, I Can’t Breathe’: America’s First ER Doctor To Die In Heat Of COVID-19 Battle

At about 5 a.m. on March 19, a New York City ER physician named Frank Gabrin texted a friend about his concerns over the lack of medical supplies at hospitals.

“It’s busy ― everyone wants a COVID test that I do not have to give them,” he wrote in the message to Eddy Soffer. “So they are angry and disappointed.”

Worse, though, was the limited availability of personal protective equipment (PPE) — the masks and gloves that help keep health care workers from getting sick and spreading the virus to others. Gabrin said he had no choice but to don the same mask for several shifts, against Food and Drug Administration guidelines.

“Don’t have any PPE that has not been used,” he wrote. “No N95 masks ― my own goggles — my own face shield,” he added, referring to the N95 respirators considered among the best lines of defense.

Frank Gabrin’s messages to Eddy Soffer.(Courtesy of Eddy Soffer)

Less than two weeks later, Gabrin became the first ER doctor in the U.S. known to have died as a result of the COVID-19 pandemic, according to the American College of Emergency Physicians.

He is one of numerous medical workers across the U.S. who have succumbed to the virus, from doctors and nurses to paramedics and hospital food service employees. The Guardian and Kaiser Health News are launching a new project, “Lost on the Frontline,” to track them and tell their stories.

New York City-area hospitals have been particularly hard-hit. of all U.S. cases have occurred in New York state. At a hospital in the borough of Queens, patients have reportedly died while waiting for a bed, and a temporary trailer morgue was set up outside. Physicians at another hospital system created a GoFundMe drive because they had insufficient masks and gowns.

Gabrin knew the stakes of his job. “Inside the emergency, the angel of death is in the room,” he wrote in his 2013 book, “Back From Burnout.” “The pressure is intense, yet there is a calm, a peace, like being in the eye of the storm.”

His own resilience was hard-won after several close brushes with mortality, and his marriage to a special man only seven months prior to the COVID-19 spike in New York. But circumstances around the coronavirus unsettled him. “I have to admit,” he posted on Facebook, “I am having some anxiety.”

‘He Showed Me The Light’

Toothy and energetic, Gabrin, 60, was adored by colleagues at hospitals in Ohio, New York and elsewhere. He was loud. He always arrived at work bearing food to share. He was “a ray of sunshine,” said physician assistant Lois-Ann Welsh, and possessed the “emotional intelligence” that differentiated a great doctor from merely a good one.

“I don’t hold any fancy titles and I am not the director of anything,” Gabrin explained in his book. “But I can say that I have spent the last quarter of a century at the bedside of America’s sick, injured, intoxicated, impaired and disenfranchised.”

Born in Pennsylvania, Gabrin was a physician by calling, and his mother had photographs of him as a child tending to neighborhood dogs. His commitment to his profession was strengthened by his own illness. During his first year as an attending physician, he was diagnosed with testicular cancer. He survived, but it returned when he was 38. Both testicles were eventually removed ― he called it “the mutilating surgery.” Even so, he resolved to offer others the second chance that he himself received twice.

This, and an incident when a man tried to kill Gabrin at his ER, choking him so that he “started turning purple in the face,” helped lead to Gabrin’s unique professional philosophy. He described it in his book, explaining how medics can overcome burnout and feel greater compassion for their patients.

A huge shift in his life came a few years ago, when at a nightclub he met Arnold Vargas, a Peruvian who had lived in the U.S. for a decade.

Arnold Vargas and Frank Gabrin. ‘I saw [Gabrin] the happiest with Angel,’ says Eddy Soffer.(Courtesy of Arnold Vargas)

“I saw [Gabrin] the happiest with Angel,” said Eddy Soffer, using Vargas’ middle name, as Gabrin did. “All his fear dissipated and he became his true self.”

“I think it gave me a second chance,” said Vargas, now 28. “He showed me the light — how beautiful my life can be.” He had been miserable, in a rut, yet Gabrin pushed him to train in massage therapy and to apply for U.S. citizenship. There was an age difference, but to Vargas, who felt enriched by Gabrin and his experiences, it was irrelevant. “I was always thinking, ‘I just want to make you happy,’ and he did the same for me.”

They married in August 2019 at City Hall in New York.

‘It’s Not Going To Be This Way Forever’

When infections in New York surged in March, Gabrin posted a picture of ambulances crowding a hospital bay on Facebook. “I was thinking, ‘Oh my God, this is the moment Armageddon happens,’” said Debra Vasalech Lyons, another old friend. “He said, ‘No, it’s still manageable, but it’s not going to be this way forever.’”

In fact, St. John’s Episcopal in Queens, one of two hospitals where Gabrin worked at the time, was among local facilities “dealing with challenges around PPE,” said New York City Council member Donovan Richards. The hospital says it has always had enough equipment for staff.

Richards linked difficult conditions there to historical discrimination and underresourcing in the largely African American and Hispanic district. “When America gets a cold, black and brown communities get pneumonia,” Richards said. “But in this instance, we are getting death sentences.”

The other hospital at which Gabrin was employed, East Orange General in New Jersey, served a majority African American community, and also had a devoted staff that before the virus had struggled to maintain care standards.

In conversations with his husband and friends in mid- and late March, including in text messages shared with The Guardian, Gabrin said he had to reuse his PPE because he did not receive replacements. He told Lyons that he was attempting to wash an N95 mask to make it last several shifts, and that the only gloves available were too small for his hands and ripped.

When America gets a cold, black and brown communities get pneumonia. But in this instance, we are getting death sentences.

Donovan Richards, New York City Council member

Lyons mailed him gloves in the correct size from Florida, where she lives, and ordered 4 gallons of hand sanitizer for him. On Facebook, Gabrin wrote about concocting his own sanitizer from vodka and aloe vera plants.

The heads of the two emergency rooms where Gabrin worked both said they had sufficient supplies of protective equipment.

“I know for one thing he wasn’t speaking about a lack of PPE at St. John’s,” said Dr. Teddy Lee, the ER chairman there.

“If for a second I thought that was our problem at East Orange, I would tell you otherwise,” said ER chairman Dr. Alvaro Alban.

On March 25, when Gabrin arrived home, “he said, ‘Baby, something bad happened tonight,’” Vargas recalled. A coronavirus patient with whom Gabrin formed a deep connection had passed away. Gabrin took a shower and cried, then he and Vargas offered a prayer for the person’s soul.

Frank Gabrin’s messages to Debra Vasalech Lyons.(Courtesy of Debra Vasalech Lyons)

The next morning, a Thursday, they both had symptoms and self-quarantined. “It was me using the same mask for four days in a row that infected me,” he texted Lyons. Through the weekend, their cases seemed mild. Gabrin coughed and had joint aches but didn’t have significant respiratory issues. On Monday, though, Gabrin was in greater pain and spent the day in bed.

At around 10 a.m. on Tuesday, he woke Vargas and said, “Baby, I can’t breathe, help me.”

He was gasping for air in great, hoarse breaths, but could not get enough oxygen. Vargas called Lyons and 911. But by the time paramedics arrived, Gabrin was on the edge of death, or had already gone. His face had turned purple.

Frank “passed away in my arms,” Vargas said. “He was looking into my eyes.”

Vargas himself eventually recovered. On Tuesday, two weeks after his death, Gabrin will be buried at Maple Grove Cemetery in Queens.

Owing to the need for physical distancing, Vargas was told, only 10 mourners will be allowed.

The headstone, Vargas expects, will bear a middle name that Gabrin adopted through his decades-old interest in Kabbalah, the Jewish mystical tradition. That name, Pinchas, now seems poignant.

It comes from a biblical figure who halted a plague.

This story is part of Lost On The Frontline, a project from The Guardian and Kaiser Health News that aims to document the life of every healthcare worker in America who dies from COVID-19 during the pandemic. We’ll be sharing more about the project soon, but if you have a colleague or loved one we should include, please email covidtips@kff.org.

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Nursing Homes Have Thousands Of Ventilators That Hospitals Desperately Need

As the number of COVID-19 patients climbs and health officials hunt for ventilators to treat them, nursing homes across the United States have a cache ― about 8,200 of the lifesaving machines, according to data from the Centers for Medicare & Medicaid Services.

Most of the machines are in use, often by people who’ve suffered a brain injury or stroke. Some of those residents are in a vegetative state and have remained on a ventilator for years.

State officials are working to consolidate ventilators where they are most urgently needed. But so far, the supply in nursing homes has not drawn the same attention.

Or course, commandeering those units would set up a monumental ethical dilemma: Do you remove life support for a long-term nursing care patient in order to give a COVID-19 patient a better chance of survival?

The highest number of machines, about 2,300, is in California, where the state has created designated nursing home units for people on life support, officially called subacute units but known pejoratively by some doctors as “vent farms.” New York has the second most, 1,822, according to state officials.

Already, one nursing home on Long Island has lent a nearby hospital 11 ventilators that were not being used, leaving just five for its residents.

“The hospital came to us last week and asked, ‘Do you have any ventilators?’” the nursing home assistant administrator said on the condition of anonymity because he was not authorized to speak to the news media.

“We left ourselves with the bare minimum,” he said. In all, three hospitals reached out to the nursing home for ventilators ― it had to say no to the other two.

New York Gov. Andrew Cuomo has announced an executive order that ventilators not in use by hospitals be redeployed to ICUs. And he’s calling in the New York National Guard to facilitate the order. “We know where every ventilator is,” Cuomo said Sunday.

Nursing home ventilators are not included in his order, but they are included in the state’s tally of the machines.

Dr. Michael Kalafer, a pulmonologist and the medical director at two San Diego subacute units, said he can’t imagine taking one of his patients off a ventilator because it’s needed for someone else.

“I severely doubt we’ll take [a hypothetical] Mrs. Smith off a ventilator because she’s 80 and has been on it for a few years and has not gotten better,” Kalafer said.

But these are precisely the decisions bioethicists are being asked to weigh in on as the country confronts the crush of COVID-19 patients overwhelming the health care system.

And in some cases, states have already decided to give people who are severely brain-injured a lower priority when it comes to access to ventilators. Disability advocates oppose such guidelines and filed complaints with the Department of Health and Human Services last month, according to ProPublica. And although states and health associations can draw up recommendations, they are not legally binding.

“From an ethical point of view, for people who are not conscious, if it’s a matter of removing people from a [ventilator] who are not going to recover, I think it’s a hard decision, but one that in an emergency has to be made,” said Ronald Bayer, a professor of sociomedical sciences at the Mailman School of Public Health at Columbia University.

Bayer has been a member of the World Health Organization and in 2011 served on an ethics subcommittee that advised the Centers for Disease Control and Prevention on the allocation of ventilators in the event of a severe pandemic.

He and several other ethicists said these decisions should not be made at the bedside but by triage committees or people in supervisory roles. And the guidelines ought to be uniform and transparent. That’s why the CDC, the state of New York and medical associations like the American College of Chest Physicians have drafted ethical recommendations for deciding how to ration lifesaving equipment like ventilators in the event of a pandemic.

The California Department of Public Health in 2008 released guidelines to follow during a health care surge: They don’t specifically address ventilator allocation, but rather resources in general. Doctors should consider the likelihood of survival and change in the quality of life as opposed to the ability to pay or the perception of a person’s worth when there are not enough medical resources to treat everyone in need.

When the New York State Task Force on Life and the Law updated its ventilator allocation guidelines in 2015, it considered the question of withdrawing ventilators from nursing home residents, or chronic ventilator patients, to save the lives of those who grow critically ill during a pandemic.

“Are we comfortable sacrificing this group in exchange for saving more lives?” asked Stuart Sherman, the executive director of the task force at the time.

That question drew much debate, but the group ultimately decided that “chronic” vent patients should not be included in the pool when considering how to allocate ventilators during a pandemic. The task force does recommend prioritizing ventilator therapy based on who is likely to survive using a SOFA ― Sequential Organ Failure Assessment ― score.

Cuomo, whose daily televised news conferences have made “ventilators” a household word, is not making decisions based on those guidelines. The task force report is not a binding policy document, according to a spokesperson from the governor’s office.

In the U.S., there are about 62,000 “full-featured ventilators,” the kind needed to treat the most severe cases of COVID-19. An additional 10,000 to 20,000 ventilators are in the government’s National Strategic Stockpile, and 98,000 basic models, the kind often in nursing homes, exist that could be used in a crisis.

In the simplest terms, ventilators push oxygen into the lungs. The machines in ICUs are more powerful and have better monitoring systems than those in a nursing home.

Kalafer’s patients need ventilators to do the work for respiratory muscles. He said they could be used in a pinch during the pandemic. But the real issue is finding enough staff trained to operate and monitor the machines.

Meanwhile, a group of bioethicists, physicians and public health experts are recommending that in a shortage, health care workers could disconnect people from ventilators who have little or no chance of recovery to put them in service of those who do.

The recommendation is the first of six listed in an article published in the New England Journal of Medicine last month.

It did not consider the people who’ve been on vents long term.

“Honestly, before you emailed me, I thought about those patients but never thought about the actual number and how important that might be,” said Dr. James Phillips, one of the paper’s authors and chief of disaster and operational medicine at George Washington University Hospital.

“For patients who have devastating neurological injury and are deemed to never recover and who require ventilation for the rest of their lives, I think it’s an ethical conversation to have with those families to determine if it’s a more appropriate use of resources,” Phillips said.

One ventilator can save multiple lives. The average time a person sick with COVID-19 who needed a ventilator was 11 days, according to an NEJM article that looked at critically ill patients in the Seattle region. Using that number, eight people could potentially be saved over three months.

It is an especially complex moral dilemma when considering the withdrawal of treatment from someone who has lived several years on a ventilator, said Govind Persad, an assistant professor at the University of Denver Sturm College of Law and one of the authors of the NEJM paper.

Persad offered a hypothetical scenario.

“A 78-year-old grandmother has been on ventilator support for 5 years in a subacute facility and is expected to remain on it for the foreseeable future. Covid-19 has reached a senior apartment complex nearby, and doctors are looking everywhere for more ventilators,” Persad wrote.

“They think one more ventilator would give them a chance of saving another 78-year-old grandmother in the senior apartments who is growing worse with viral pneumonia, and, once she is off the ventilator, to save some of her neighbors, who are not yet sick but who they expect to be sick in a few weeks.”

Who gets the ventilator?

Persad suggested it should go to the grandmother in the senior apartments because she is likely to need less time on the ventilator, enabling the ventilator to be used to save her neighbors later.

As he put it: “We save her in order to save more lives, not because of quality-of-life judgments.”

The real-life decision is more problematic and heart-wrenching.

Nancy Curcio’s daughter Maria, who was born with a disabling form of cerebral palsy, was on a ventilator as an adult in San Diego for about three months in 2004. She was eventually weaned off the machine but lived the remainder of her life in a nursing home with a breathing and feeding tube, unable to walk or talk. She died in 2017 at age 57.

“I would be very upset if a doctor said I have to take her ventilator away for someone to live,” Curcio said. “But I can understand in triage this is what a doctor has to do. Would I like it? No. I would want to run away with the ventilator.”

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Dispatch From A Country Doctor: Seeing Patients Differently In The Time Of Coronavirus

Patients would often stop by River Bend Family Medicine just to gab with staff at the front desk or bring baked goods to Dr. Matt Hahn.

“I’m a simple country doctor,” said Hahn, who has practiced in Hancock, Maryland, for 20 years ― the past decade at his River Bend office. “Our waiting room is like a social network in and of itself.” Hahn is also a candidate for West Virginia’s 2nd Congressional District though he has backed away from campaigning because of the coronavirus threat.

His waiting room is now closed for the same reason. But Hahn’s practice in this small town — pinned hard up against the borders with West Virginia and Pennsylvania, about 100 miles northwest of Washington, D.C. ― is not.

Patients who need an in-office appointment call when they get to the parking lot and wait there instead. A staff member escorts them in, opening all the doors, telling patients not to touch anything. Those who are ill use one specific entrance, which leads them upstairs where they are met by staff who follow strict infection-control measures. The rest, such as those coming in with a wound or a diabetes checkup, are treated downstairs.

Still, Hahn now sees most of his patients in telehealth appointments, linked to their computers or smartphones. He can do a lot over video and phone, he said. Some things present more of a challenge, though. With rashes, for example, “people are angling their bodies to show a body part to their camera,” said Hahn. “We’ve had some fun with that.”

Humor remains important during this coronavirus crisis. But, jokes aside, Hahn isn’t taking any of it lightly. As of April 6, 37 coronavirus cases were confirmed in Washington County, which encompasses Hancock, and the governor of Maryland on March 30 issued a statewide stay-at-home order.

On March 17, the Trump administration used emergency powers to expand Medicare payments for telemedicine so that more doctors, hospitals and clinics could be paid for such services. While the expansion applies only to Medicare, Hahn said other insurers moved quickly to do the same. Previously, telemedicine coverage was generally limited to people in remote or underserved areas. Even though it’s at least 30 minutes from the nearest hospital, Hancock is not considered remote.

“It’s something we really wanted to do — we didn’t want to shut our doors,” said Hahn, who trained at George Washington University School of Medicine, in Washington, D.C.

Across the country, practices large and small, like River Bend, are enlisting the help of such technological innovations. In addition to the changes to Medicare reimbursement rules, the administration has loosened privacy enforcement for medical providers making “good faith” efforts to use non-public video services: Facebook Messenger is OK, for example, but Facebook Live is not.

Still, online visits are not perfect.

For one thing, internet service can be spotty, Hahn and nurse practitioner Lora Cole said. Another concern: The new rules required the use of both audio and video in consults with patients. But on March 30, the Centers for Medicare & Medicaid Services took an additional step of further loosening telehealth restrictions to allow providers to conduct the telehealth exams for beneficiaries who have audio phones only.

Another concern is that some patients are not that familiar with computers or smartphones, making telehealth consults more challenging, according to Hahn. And a number of them don’t have access to the internet.

For those who do, the staff tries to help them download apps, go to websites, adjust their cameras or turn on the audio.

“The first few days were frustrating. We spent much of the day trying to get people to paste an address into the right line and put in a nine-digit code,” said Hahn.

Part of the problem was they were trying to use a wide variety of different websites or apps. Once they narrowed the choices, the process got easier. Hahn settled on using Google Duo on his phone, while Cole and the other nurses use the web service GoToMeeting in their virtual exam room.

“We give them the code. They click join. It’s a couple of steps that are very quick and easy,” said Cole.

Those who struggle aren’t having problems with the programs themselves, she said, but with maneuvering their smartphone or computer. She and the nurses in the office walk them through it when they can.

“We take a big deep breath,” said Cole. “With some of our patients, we have actually asked them to find someone ― a family member — who can help them.”

The visits themselves work out just fine, even if they are missing a certain, well, human element, both say.

“It has been very hard on my heart,” said Cole, who said her patients know she loves elephants, often bring her presents to add to her collection of pictures, figurines and other tchotchkes. “I miss my patients. I miss being able to see them and give them a hug.”

Clinically, it has limitations, as well.

“I can’t see the entire body. I can’t do a physical exam,” said Hahn. “But, this is a wonderful thing to have right now. Until we have some break in this situation, we want to keep people home. This gives us the opportunity to take care of patients and keep patients safe and staff safe. Under these circumstances, I am not complaining.”

Someday, Hahn and Cole hope things return to normal, whenever that will be.

And what will things look like at River Bend when it’s all over? Will they still rely heavily on video visits? It hasn’t come up yet.

“We just don’t have time to think or even discuss what the future may hold,” said Cole. “We’re just totally focused on what we have to do that day. Personally, I want it to go back. I want to see my patients again.”

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After COVID-19: Doctors Ponder Best Advice As Patients Recover From Coronavirus

When David Vega fell ill with the novel coronavirus in mid-March, fever, chills and nausea left the 27-year-old Indiana medical student curled up in bed for days.

After a test confirmed he had COVID-19, the disease caused by the coronavirus, his doctor advised Vega to isolate himself at home for an additional week. The week passed, and Vega improved. His doctor cleared him to get back to his regular routines without additional testing after he had gone three days without symptoms.

But getting an all-clear from his medical provider has not completely assuaged Vega’s fears. How can he be sure he no longer carries the virus? Is it safe for him to be with others? One of his roommates decided to move out, he said, and still acts cautiously around him.

“Even after the quarantine was over and I felt recovered,” he said in a message, “I felt paranoid and very [conscious] of the fact that I had COVID-19.”

As with so many other aspects of this novel coronavirus, determining when a patient has recovered is still fraught with uncertainties. Although federal officials have issued general guidelines, information about the disease is limited. Physicians said they can’t offer seemingly recovered patients who aren’t retested any guarantees about whether they will be able to transmit the virus.

“I feel that the public is kind of like my 91-year-old mom,” said Dr. Gary LeRoy, president of the American Academy of Family Physicians. The public is “asking these questions, and we as clinicians don’t have the answers like we’re used to.”

This predicament highlights how scientists still lack a complete picture of how COVID-19 is transmitted, doctors said. Generating more data on such mysteries as how much of the virus a person emits at different stages of infection could give doctors a clearer sense of a patient’s risk of sickening others.

The federal Centers for Disease Control and Prevention says doctors can verify whether a patient is healthy enough to leave home isolation in two ways. One method requires patients to test negative from samples taken at least 24 hours apart.

But the nationwide shortage of tests has made it difficult for doctors to vet patients in recovery with an exam, a fact the guidelines acknowledged. Several states including Minnesota have restricted testing to certain populations, such as hospitalized patients and health care workers.

“It’s still kind of an Easter egg hunt for the availability of testing materials and test kits to do COVID-19 tests,” said LeRoy.

The second method allows patients to come out of isolation at least seven days after symptoms begin or after being diagnosed and three days after they are symptom-free.

This option “will prevent most, but may not prevent all instances of secondary spread,” according to the CDC’s website. “The risk of transmission after recovery is likely very substantially less than that during illness.”

The agency declined a request for an interview.

Its recommendation gives state authorities and doctors the flexibility to amend their approach based on their circumstances.

“The guidelines are guidelines,” said Dr. Kathryn Edwards, a professor of pediatrics at Vanderbilt University who specializes in infectious diseases. “But they’re not the Ten Commandments.”

One vital piece of the recovery puzzle several doctors mentioned is figuring out when and how long people with COVID-19 are able to transmit the virus — particularly those who don’t develop symptoms at all.

David Vega, a medical student in Indianapolis who has recuperated from a COVID-19 infection, worries about how safe it is to be around others now, such as when he goes running or grocery shopping. “I think it’s still something in the back of my mind,” he says.(Courtesy of David Vega)

The number of asymptomatic patients could be sizable. CDC director Dr. Robert Redfield said in an interview with NPR that as many as 25% of those who test positive for the virus do not develop symptoms. And patients who eventually develop symptoms may be spreading the virus up to 48 hours before they start feeling ill, he added.

Early research has suggested that patients who have recovered from COVID-19 may also continue to spread the virus.

Even Vega, now symptom-free, said he hesitates to get close to others when he goes on a run or picks up groceries.

“I think it’s still something in the back of my mind,” he said. “I think that it’ll get better with time.”

The need to prevent transmission must be balanced against the benefit of the person returning to their daily life, said Edwards, especially if they are working in an essential industry like health care.

“We’re always between a rock and a hard place,” she said.

Other factors help determine when a patient is ready to leave isolation. A provider may choose to leave a person in home isolation longer if they work with a high-risk population, like the elderly, or if they have a spouse with preexisting conditions, said LeRoy.

Ultimately, medical providers will likely tailor their advice to the patient’s lifestyle, said Dr. Marcus Plescia, chief medical officer of the Association of State and Territorial Health Officials.

“These are difficult questions that would likely be dealt with on a case-by-case basis,” he said.

People worried about getting the virus from someone who has recovered or doesn’t have symptoms can reduce their risk by practicing social distancing and good hygiene, such as frequent hand-washing, said Plescia.

Despite the uncertainty, Plescia said, it is important not to ostracize those who have recovered. He is concerned they could become stigmatized.

“In the back of everyone’s mind, whether they want to acknowledge it or not, people are going to be fearful about something they don’t know,” said LeRoy.

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Must-Reads Of The Week From Brianna Labuskes

Hello! It is once again Friday, which means I’m going to attempt to do my very best to give you a snapshot of some (read: a fraction) of the best stories from the week amid a flood of them.

But first! Take yourself on this journey about how the most well-known coronavirus image (that gray blob with stone-like texture and red crowns and colored flecks) was made. Sometimes when the government is creating informational illustrations it focuses on the vector or the symptoms, but for this coronavirus the CDC’s Alissa Eckert and Dan Higgins went with what’s called a “beauty shot.” It’s a very cool read!

All right, here we go:

The confirmed number of confirmed cases globally ticked past a million this week in a grim milestone that experts still say represents only a percentage of the actual cases out there. The U.S. had recorded over 250,000 cases as of press time, with more than 6,500 deaths.

President Donald Trump invoked his wartime powers to help manufacturers secure supplies needed to make ventilators and protective face masks, but is it too little, too late? New York Gov. Andrew Cuomo, whose state has become the epicenter of the nation’s outbreak, said on Thursday it will use up all available ventilators in less than a week. Meanwhile, FEMA said that most of the ventilators Trump promised to obtain won’t be ready until June.

Governors are distraught over their inability to obtain the needed supplies, likening the process of requesting the equipment to eBay auctions. “You now literally will have a company call you up and say, ‘Well, California just outbid you,’” Cuomo said.

Another roadblock is that 2,000 of the ventilators in the national stockpile are unusable because of a lapse in a contract that left a monthslong gap, during which the machines weren’t being properly maintained.

In the meantime, General Motors has shrugged off Trump’s attacks on the company (he said GM and its chief executive were dragging their feet on the project) and are moving full-throttle ahead at producing the needed equipment. “Every ventilator is a life,” said one GM exec.

With so much focus on ventilators, doctors are being advised on how to ration care and being told that they’ll be supported in their decisions not to perform futile intubations.

One quick note on that front: New York lawmakers are moving on legislation that would grant sweeping civil- and criminal-liability protections to hospitals and health care workers dealing with coronavirus patients.

And even though there’s a ton of attention on ventilators, the survival rate of any patient who requires one is only 20% — meaning that even without a shortage, they can only help a fraction of patients.

In other important news on the preparedness front:


Trump warned Americans this week that “hard days” lie ahead and that people should be braced for a “bad two weeks,” with the White House projecting that the death toll could be somewhere between 100,000 to 240,000. For what it’s worth, disease forecasters were mystified over where the task force got those numbers, mostly because we don’t yet know enough about the virus.

(What helped change Trump’s mind, considering he’d previously mused that the country could return to normal in time to fill the pews on Easter? Polling numbers.)

To help states deal with the crisis, CMS relaxed safety rules for hospitals, giving them unprecedented flexibility. The changes include what counts as a hospital bed, how closely certain medical professionals need to be supervised and what kinds of health care can be delivered at home.

The administration decided not to follow suit after a handful of states reopened their exchanges, though Trump seemed to hint that the possibility was still on the table “as a matter of fairness.” Also, to note, if people have lost their insurance because of their jobs, that counts as a qualifying event and they have 60 days to enroll in the federal exchanges, regardless of what Trump does with a special session.

And although Drs. Anthony Fauci and Deborah Birx, along with Vice President Mike Pence, have emerged as the leading voices of the administration’s pandemic response, Trump’s son-in-law Jared Kushner has taken charge behind the scenes. Critics say its adding confusion to an already chaotic situation.

And reports continue to emerge that the Trump administration was cutting pandemic detection positions in China just months before the outbreak.

In other news on the administration:


House Speaker Nancy Pelosi will be creating a special committee to oversee the implementation of the $2.2 trillion stimulus package and any other coronavirus legislation coming down the pike. “Where there’s money there’s also frequently mischief,” Pelosi said, in perhaps one of my favorite quotes of the week. Meanwhile, House Democrats may be raring to get started on a fourth stimulus package, but Republicans are pumping the brakes. At the very least, they say, they want to see how the current stimulus package plays out.

The news came the same day as it was reported that 6.6 million Americans filed for unemployment benefits. That eye-popping number blows past all previous records. And experts say it represents only a sliver of the economic devastation the virus is wreaking on the country. There are many affected Americans who remain uncounted — some have lost jobs or income and did not initially qualify for benefits, and others, encountering state unemployment offices that were overwhelmed by the deluge of claimants, were unsuccessful in filing.

In other news about Congress and the economic damage from the outbreak:


The Democratic National Convention, expected to draw as many as 50,000 visitors, was postponed from July to August in one of the largest disruptions to the 2020 elections so far. On the other hand, Wisconsin is going ahead with its primary on Tuesday, which is causing mixed reactions … including apoplectic rage.

More stories on elections:


Much focus this week was on serology tests that serve the dual purpose of finding Americans who can safely return to some normalcy and helping researchers find treatments for COVID-19. Experts are fairly unified on the fact that to get the country back into operation, we need a way to identify those who are now immune to the disease. And using plasma collected from recovered patients is a century-old practice (which, to be clear, has had mixed results in past diseases).

Beyond studies on actually treating the coronavirus illness (a small study out this week showed a much-touted malaria drug combo had positive results), doctors are also trying to figure out how to treat the phenomenon known as “cytokine storm,” in which the body’s own immune system attacks its organs. This is thought to be the cause of some of the severe cases seen in younger patients.

On a side note, the Food and Drug Administration on Sunday issued an emergency-use authorization for hydroxychloroquine and chloroquine, despite scant evidence that they work against COVID-19.


With Florida (and three other states who had been hesitating) finally caving into pressure to issue the stay-at-home order, the vast majority of Americans are now huddled at home. The good news is that the extreme measures seem to be working in California, which was an earlier disciple of flattening the curve.

Google, meanwhile, is offering the government a report on “mobility data” to help states recognize where social-distancing measures are failing, with a specific focus on how foot traffic has increased or declined to six categories of destinations: homes; workplaces; retail and recreation establishments; parks; grocery stores and pharmacies; and transit stations.

Although things might seem a bit grim right now because of these measures, a look at data from the 1918 flu pandemic shows cities that locked down emerged from the crisis stronger economically than those that didn’t. One caveat, though: Because working-age people were harder hit by the 1918 flu (and the coronavirus strikes worse among older generations), any comparisons might not hold.


So, onto some of the stories I find most fascinating … aka the science behind all of this.


I’m going to cut this off here, or else this will no longer be able to be called the Breeze. If you want a more comprehensive roundup, please check out the Morning Briefings from the week, which are chock-full of more stories than you could ever finish reading. Including ones on workers’ protests and the supply chain; the gun store debate; how jails are “ticking time bombs;” autocrats’ power grab; snapshots from a New York in crisis; health disparities; and a call to arms for medical workers that doesn’t guarantee coverage of potential hospital bills.

Please have a safe and restful weekend, if possible!

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More Than 5,000 Surgery Centers Can Now Serve As Makeshift Hospitals During COVID-19 Crisis

The Trump administration cleared the way Monday to immediately use outpatient surgery centers, inpatient rehabilitation hospitals, hotels and even dormitories as makeshift hospitals, health care centers or quarantine sites during the coronavirus crisis.

The Centers for Medicare & Medicaid Services announced it is temporarily waiving a range of rules, thereby allowing doctors to care for more patients.

Hospitals and health systems overwhelmed with COVID-19 patients will be able to transfer people with other medical needs to the nation’s 5,000 outpatient surgery centers, about half of which are affiliated with hospitals. This will give the country thousands of additional hospital beds and operating rooms, some of which have ventilators or anesthesia gas machines that could be repurposed as ventilators.

Outpatient surgery centers will be allowed to treat patients with other critical needs — such as serious injuries, cancer or heart attacks — unrelated to COVID-19, allowing hospitals to conserve scarce resources and reduce the risk of infection to these patients.

Until now, federal regulations allowed outpatient surgery centers to care for patients for a maximum of 24 hours.

“Transferring uninfected patients will help hospital staffs to focus on the most critical COVID-19 patients, maintain infection control protocols, and conserve personal protective equipment,” the agency said in a statement.

Many outpatient surgery centers had closed after being told to halt elective procedures. A coalition of anesthesiologists in recent weeks called for them to stop performing nonessential surgery and assist hospitals.

The waivers “will allow hospitals to save more lives” by performing “surgeries and procedures that can’t wait until the pandemic is over,” said Bill Prentice, CEO the Ambulatory Surgery Center Association, an industry group.

Before the CMS announcement, the California Ambulatory Surgery Association had expressed its willingness to help.

The outpatient centers “want to be part of the solution as the entire healthcare industry must rise to meet this enormous challenge,” said Michelle George, president of the California Ambulatory Surgery Association, in a statement issued Monday morning. “We have valuable resources to lend to this crisis — whether it is staff, space, equipment, supplies or other capabilities. ASCs are coordinating with the public health teams on local and regional levels to identify how their facilities can be utilized most effectively on a case by case basis.”

Advocates who have pushed for surgery centers to assist hospitals praised the move.

“This is a great step in fighting this pandemic,” said Dr. Adam Schlifke, an anesthesiologist and clinical assistant professor at Stanford University in California.

“We recognize that it’s going to be hard,” Schlifke said. “It’s extremely complicated, but we are here to support all the surgery centers that will need to convert as a result of this order.”

The waivers will allow hospitals to hire local physicians and health care providers to address potential surges; transfer critical equipment, including telemedicine equipment, to doctors’ offices; and provide meals and child care for their health care workers.

Hospitals will be able to triage sick patients at community locations, then send them to the most appropriate facility, according to CMS.

“Front-line health care providers need to be able to focus on patient care in the most flexible and innovative ways possible,” said CMS Administrator Seema Verma. “This unprecedented temporary relaxation in regulation will help the health care system deal with patient surges by giving it tools and support to create nontraditional care sites and staff them quickly.”

Even with additional facilities, hospitals and health care systems could run out of staff, especially as health providers become sick with COVID-19. Although surgery centers typically employ their own nurses, they tend to share surgeons with local hospitals.

More than a dozen states and health care associations had requested waivers. The CMS move means that other states will no longer need to apply for waivers.

Texas had taken the lead in recent days, even before the new announcement, by permitting hospitals to use off-site facilities. Texas Gov. Greg Abbott last week signaled his interest in using outpatient surgery centers to expand care by ordering them to tell the state how many ventilators they possess.

Among other sweeping changes:

  • Ambulances will be allowed to transport patients to outpatient surgery centers, community mental health centers, federally qualified health centers, physician’s offices, urgent care facilities and any locations furnishing dialysis services when a dedicated kidney failure treatment center isn’t available. Hospitals will be able to charge for services provided outside their four walls and emergency departments can use telehealth services to evaluate sick people.
  • Physician-owned hospitals can temporarily increase their number of licensed beds, operating rooms and procedure rooms, according to CMS.
  • Instead of going to crowded emergency rooms, patients could go to off-site locations to be evaluated by emergency health care providers using telemedicine. That change will help preserve space in the emergency room for those who need it most. CMS will allow health providers to treat more patients via apps or telephone and bill at the same rate as in-person visits.
  • Physician assistants and nurse practitioners will be allowed to order tests and medications that may have previously required a physician’s order, as long as state law allows it. Also, certified registered nurse anesthetists will no longer have to work under the supervision of a doctor, freeing up physicians to focus more on patients and less on supervising.
  • To reduce the need for patients with health problems unrelated to COVID-19 to go to a doctor’s office or hospital, doctors will be allowed to monitor patients remotely with devices that can measure a patient’s oxygen saturation levels using pulse oximetry.

Health care experts have been suggesting the administration offer such waivers for weeks. The country has “got to muster all reasonable facilities and personnel,” said Arthur Caplan, a bioethics professor at NYU Langone Medical Center. “The best way to ration is to avoid it by stretching resources and sharing.”

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Already Taxed Health Care Workers Not ‘Immune’ From Layoffs And Less Pay

Just three weeks ago, Dr. Kathryn Davis worried about the coronavirus, but not about how it might affect her group of five OB-GYNs who practice at a suburban hospital outside Boston.

“In medicine we think we’re relatively immune from the economy,” Davis said. “People are always going to get sick; people are always going to need doctors.”

Then, two weeks ago, she watched her practice revenue drop 50% almost overnight after Massachusetts officials told doctors and hospitals to stop performing elective tests and procedures. For Davis, that meant no more non-urgent gynecological visits and screenings.

Late last week, as Davis and her partners absorbed the stunning turn of events, they devised a stopgap plan. The 35 nurses, medical assistants and secretaries they employ would have two options: move from full-time to part-time status or start collecting unemployment. Doctors in the practice would take a substantial pay cut. Davis said she’s hearing from colleagues who may have to permanently close their offices if the focus on crisis-level care continues for months.

“It’s shocking,” she said. “Everyone has been blindsided.”

Atrius Health, the largest independent physician group in Massachusetts, said patient volume is down 75% since mid-March. It is temporarily closing offices, placing many nonclinical employees on furlough and withholding pay for those who remain. The average withholding is 20%, and the company pledges that pay withheld will be returned. The lowest-paid workers, those earning up to $55,000, are exempt.

“What we’re trying to do is piece together a solution to get through the crisis and keep employed as many people as we can,” said Dr. Steven Strongwater, Atrius Health’s CEO.

Atrius cares for 745,000 patients in clinics that often include primary care, specialists, radiology and a pharmacy under one roof.

Strongwater said physician groups must be included when the federal government distributes $100 billion to hospitals from the $2 trillion stimulus package.

It’s not clear if that money will stop the tide of layoffs and lost pay at hospitals as well as in doctor’s offices. A Harvard Medical School physician group will suspend retirement contributions starting April 1.

Beth Israel Lahey Health, the second-largest hospital network in Massachusetts, announced executive pay cuts Monday.

“The suspension of elective procedures and decline in visits to our primary care practices and urgent care centers have resulted in financial challenges,” wrote CEO Dr. Kevin Tabb in an email to employees. Tabb said he would take a 50% salary cut. Other executives and hospital presidents in the system will forgo 20% of their salaries for the next three months.

“Although executive leadership compensation is being reduced, we will never compromise on doing the things that are essential to protect your safety and the safety of our patients,” Tabb told staff.

Dallas-based Steward Health Care has told hospital employees in Massachusetts and eight other states where it operates to expect furloughs focused on nonclinical staff. In a statement, Steward Health Care said it prepared for the pandemic but is experiencing a “seismic financial shock.”

“Elective surgeries are the cornerstone of our hospital system’s operating model — and the negative impact due to the cancellations of these procedures cannot be overstated. In addition, patients are understandably cautious and choosing to defer any nonemergency treatments or routine visits until this crisis has passed.”

Dr. Kaarkuzhali Babu Krishnamurthy, an assistant professor of neurology at Harvard Medical School who studies medical ethics, said employers need to think more carefully about the ethics of asking doctors and nurses to live on less when many are working longer hours and putting the health of their families at risk.

“At a time when health care systems are calling on doctors and nurses to do more, this is not the time to be making it more difficult to do that,” said Krishnamurthy.

There’s talk of redeploying laid-off health care workers to new COVID-19 units opening in shuttered hospitals or to patient overflow sites. Tim Foley, executive vice president for the largest health care union in Massachusetts, 1199SEIU, is promoting the development of a staff registry.

“It is more important, now more than ever, to explore all options to maintain the level of urgent care needed across the state and we look forward to working with all stakeholders to do just that,” Foley said in an email.

This story is part of a partnership that includes WBUR, NPR and Kaiser Health News.

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The Nation’s 5,000 Outpatient Surgery Centers Could Help With The COVID-19 Overflow

As the number of COVID-19 cases continues to rise, a group of anesthesiologists wants to convert America’s surgery centers into critical care units for infected patients.

Many of the country’s more than 5,000 outpatient surgery centers have closed or sharply cut back on the number of elective procedures they perform, to comply with requests from government agencies and professional societies. But those surgery centers have space and staff, as well as anesthesia machines that could be repurposed into ventilators — all of which could be especially crucial in hard-hit areas like New York.

“Half of the surgery centers in New York are not doing anything,” said Adam Schlifke, an anesthesiologist and clinical assistant professor at Stanford University in California, who is leading the push for the centers to help. “All these anesthesiologists and nurses who are sitting on the sidelines, they want to help. They don’t know how to help. There’s nowhere for them to help. What if they could work in the surgery centers?”

Opening such outpatient centers nationwide to coronavirus patients would nearly double the number of facilities nationwide, up from the country’s fewer than 6,200 hospitals. But turning day facilities into places for 24/7 care worries some anesthesiologists. There are questions about staffing, regulations and payment. They also fear that using surgery centers as critical care units would do more harm than good if the centers aren’t properly equipped to handle severe cases of COVID-19.

“Even if we lifted the regulatory restrictions, surgery centers are licensed to do a certain thing,” said Dr. Steven Dalbec, a private practice anesthesiologist in Columbia, Missouri, who once ran a surgery center in Arizona. “If we could say, ‘OK, we’re going to lift all those restrictions and let you take care of critically ill patients,’ it’s not something that could happen overnight.”

Still, that’s exactly why Schlifke argues that it’s important to start now, especially in parts of the country with fewer cases. His group has created a blueprint that outlines the steps needed for surgery centers to convert.

In the coming days, Schlifke said, he and the approximately 75 members of the CovidVent coalition of anesthesiologists he’s helping organize will call for a federal executive order to enable the conversion of surgery centers and hospital operating rooms into COVID-19 care sites to help save lives.

The order is needed, he said, because he recognizes that providers want to get paid. The idea is so new, he said, there’s no reimbursement plan in place for surgery centers that agree to treat COVID-19 patients.

What’s most troubling, Schlifke said, is the number of anesthesiologists who cannot help with the pandemic because their center is either closed or they are busy with elective surgeries that aren’t necessary. It’s a frustrating dilemma.

“They want to work,” Schlifke said.

The CovidVent group also wants to make sure surgery centers follow Centers for Medicare & Medicaid Services recommendations that call for them to end nonessential elective surgeries to keep front-line medical providers safe amid shortages of protective supplies such as masks. Many of those surgery centers are in states like New York, California and Washington where hospitals can’t keep up with the demand.

“An important question for hospitals and health systems that continue to perform elective and nonessential surgeries is, ‘Why?’” said Dr. Greg Martin, president-elect of the Society of Critical Care Medicine, which represents intensive care doctors. “How do they justify the risk to the otherwise healthy individuals, justify the risk to the health care provider workforce who may be imminently needed elsewhere, and justify the unnecessary consumption of health care resources such as masks, gloves and gowns?”

But William Prentice, CEO of the Ambulatory Surgery Center Association, an industry group, argued that some surgeries remain necessary. “We’re pushing things off that can be pushed off,” he said.

Meanwhile, in Washington, D.C., Vice President Mike Pence has already come out in support of the use of anesthesiology equipment as ventilators.

Anesthesia machines used in the operating room can be repurposed as mechanical ventilators, Martin said. “But they function differently and do not have all the same settings as ICU ventilators, so employing them in COVID-19 care requires education or oversight from those who are expert in using them.”

Dalbec also supports converting anesthesia machines into ventilators. He now works at Boone Hospital Center in Columbia, Missouri, which he said is prepared to do that if needed. As of Friday, he said, the 230-bed hospital hasn’t treated a confirmed COVID-19 patient.

But creating new intensive care units is challenging, according to both Dalbec and Martin.

Dalbec, who ran a surgery center in Tucson, Arizona, for 10 years, worries a lot of surgery centers don’t have the training, skills or supplies to care for critically ill patients.

“Time is of the essence,” Dalbec said. “And so that would make the care for these patients considerably challenging.”

An ICU has sophisticated equipment, such as bedside machines to monitor a patient’s heart rate and mechanical ventilators to help them breathe, Martin said. Ventilators need to be hooked up to oxygen and gas lines, which supply patients with the appropriate mix of air.

Only a few areas of the hospital have the equipment and gas hookups to provide ventilator care to critically ill patients, Martin said. These include the operating room, emergency department and units used for post-anesthesia care. To convert an ordinary hospital unit to an ICU, Martin said, “You would literally need to tear down the wall and run the piping in.”

Hospitals are already looking to use operating rooms for intensive care, Martin said.

“Using OR space, equipment and staff to care for sick COVID-19 patients is the right thing to do,” Martin said. “This is one approach that most health systems are already considering and using.”

Many outpatient operating rooms at surgery centers already have the required gas and oxygen hookups, Martin said. “Some will have fully configured operating rooms with ventilators,” he said. “It would be one way to expand ICU-level patient care space.”

But they are unlikely to stock all the medications used in an ICU.

Another challenge, he said, would be that staff from most surgery centers may be pulled into hospitals — anesthesiologists, nurses and nurse anesthetists — and surgery centers would not have all the pharmacists, respiratory therapists and other staff.

Intensive care units are staffed by specially trained doctors, nurses and respiratory therapists, who set up ventilators and closely monitor patients’ breathing, Martin said. “The hardest thing to change is the staffing,” he said. “We only have a certain number of doctors, nurses and respiratory therapists.”

CovidVent is working with several telemedicine groups that could help treat patients in areas where the staff lacks the expertise, Schlifke said.

Outpatient surgery centers would need to receive a waiver from federal regulators to keep patients overnight or perform medical care they don’t currently perform, Prentice said.

Prentice said he’s optimistic that the Centers for Medicare & Medicaid Services will make an announcement about such waivers in coming days.

“Once we get that flexibility, we can find the best way to help,” Prentice said. “Decisions about how to best to use ambulatory surgery centers need to be made in conjunction with hospitals at the local level.”

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California Health Industry Public Health States

Para luchar contra el coronavirus, médicos y enfermeras retirados vuelven a trabajar

Laura Benson se retiró de la enfermería en 2018, pero hace pocos días volvió a presentarse a trabajar en New Rochelle, Nueva York, donde se registró uno de los primeros grupos de casos de COVID-19.

“Las enfermeras somos entregadas”, dijo. “Si no hay suficiente gente, simplemente te presentas”.

Con más de 40,000 casos confirmados, Nueva York es ahora el epicentro del brote de coronavirus en el país: casi la mitad de los más de 92,900 casos en todo el país hasta el viernes 27 de marzo al mediodía.

Anticipándose a una grave escasez de personal médico para tratar el flujo de pacientes enfermos, el gobernador Andrew Cuomo y otros funcionarios hicieron un llamado para que médicos, enfermeras y otros profesionales de salud retirados desempolvaran sus guardapolvos y regresaran al trabajo.

Para el jueves 26, habían respondido 52,000 personas.

Funcionarios de otros estados, incluidos California, Colorado e Illinois, han hecho pedidos similares para que los profesionales de salud retirados den un paso adelante.

En el condado de Westchester, en Nueva York -que incluye New Rochelle y otras ciudades al norte de la ciudad de Nueva York- su ejecutivo, George Latimer, dijo que cerca de 90 enfermeras retiradas y un puñado de médicos respondieron después que publicara un mensaje en la página de Facebook del condado en busca de ayuda.

No hay un plan definitivo para desplegar con los voluntarios médicos, explicó Latimer. Pueden ser necesarios para atender a pacientes por fuera del coronavirus, o para ayudar al personal del Westchester County Center, que ahora funciona como un hospital temporal.

Laura Benson(Courtesy of Laura Benson)

Benson, de 60 años, trabaja para el Departamento de Salud del condado. Enfermera practicante con especialidad en oncología, pasó 20 años en el Albert Einstein Cancer Center en el Bronx. Se retiró de un trabajo en una compañía de dispositivos médicos, donde trabajó con pacientes con tumores cerebrales. También enseña a estudiantes de enfermería en un colegio comunitario.

En su primer día como voluntaria jubilada, Benson llamó por teléfono a pacientes que habían sido examinados recientemente para detectar el nuevo coronavirus para explicarles las pautas que deberían seguir para protegerse a sí mismos y a los demás.

Si hay una necesidad, dijo, está “absolutamente” dispuesta a trabajar directamente con pacientes que tengan COVID-19.

“Pienso en la persona en esa cama de hospital”, dijo. “Me gustaría que alguien la cuide”.

Benson no está particularmente preocupada por el virus, ya que trabajó durante la crisis del sida y trató a los pacientes incluso antes que la gente entendiera qué era esa enfermedad. “Sigues las pautas y te proteges”, explicó.

El mejor papel para muchos profesionales médicos retirados puede ser ayudar detrás de escena, dijeron expertos, liberando a colegas más jóvenes para que puedan centrarse en la atención directa del paciente.

Una razón para esto: la edad.

“Mi única preocupación es que muchas de estas personas retiradas estén en grupos de alto riesgo” con mayor probabilidad de verse gravemente afectados por COVID-19, dijo el doctor Arthur Fougner, presidente de la Sociedad Médica del Estado de Nueva York.

Otra preocupación es si los jubilados están actualizados con sus conocimientos médicos.

“Si han estado sin trabajar por más de dos o tres años, debes preocuparte que estén al día”, dijo el doctor Janis Orlowski, director de atención médica de la Asociación de Colegios Médicos Americanos.

Además, las licencias estatales de los proveedores de atención médica pueden haber caducado si han estado retirados por unos años. Renovarlas puede llevar mucho tiempo.

Aun así, “si alguien todavía tiene su licencia y está dispuesto a regresar, deberíamos recibirlo”, dijo Orlowski.

Michele Pedicone es una de esas profesionales. La terapeuta de atención respiratoria dejó su trabajo en Seattle el año pasado para dirigir el área de educación clínica en el departamento de educación de terapia respiratoria de la Universidad Médica SUNY Upstate en Syracuse, Nueva York.

Con sus clases ahora en su mayoría en línea y las prácticas de los estudiantes, suspendidas, tiene tiempo para volver a la atención clínica. Pedicone contactó a dos hospitales cercanos para ver si podían usar sus servicios y espera trabajar tres o cuatro días a la semana.

“Sinceramente, no sé lo que me están pagando; el dinero no es un problema “, dijo Pedicone, de 54 años.” Es lo correcto”.

Los terapeutas respiratorios, los médicos de cuidados críticos y las enfermeras capacitadas en la operación de ventiladores que ayudan a los pacientes hospitalizados a respirar se encuentran entre los especialistas que se espera que comiencen a escasear a medida que la pandemia de coronavirus empeora en Nueva York y en otros lugares, según un análisis de la Sociedad de Medicina de Cuidados Críticos.

La expansión de la oferta de trabajadores de cuidados intensivos será clave para manejar la pandemia de coronavirus, dijo Ashish Jha, director del Instituto de Salud Global de Harvard, en una sesión informativa la semana del 23 sobre asuntos de la fuerza laboral de atención médica patrocinados por el Commonwealth Fund.

Una opción que los encargados de formular políticas han discutido es que los estados podrían permitir, por ejemplo, que los profesionales médicos que se retiraron en los últimos cinco años con licencias vigentes obtengan una licencia automática de tres o seis meses sin tener que hacer muchos trámites, dijo Jha.

Mientras tanto, los sistemas de atención médica están desarrollando sus propias estrategias.

Northwell Health posee y opera 19 hospitales en la ciudad de Nueva York, el condado de Westchester y Long Island. La semana del 23, el sistema de salud ha tenido más de 700 pacientes con COVID-19, en comparación con solo 40 pacientes la semana anterior, según Terry Lynam, vicepresidente senior del sistema de salud.

Northwell ha estado planeando cómo fortalecer al personal desde enero, contó Judy Howard, vicepresidenta de adquisición que supervisa la contratación de personal. Desarrollaron una lista de 200 enfermeras jubiladas a las que se ha contactado para evaluar su interés en regresar al trabajo remunerado de alguna manera. Hasta ahora, 28 han firmado, dijo Howard.

En este momento, están pidiendo a las enfermeras jubiladas que trabajen en el centro de llamadas del sistema de salud y compartan las responsabilidades para capacitar a las nuevas enfermeras. Algunas trabajan en atención directa al paciente. Otra posibilidad es que colaboren en las instalaciones que Northwell ha establecido para cuidar a los hijos de los miembros del personal durante la pandemia de coronavirus.

“Si alguien realmente quiere trabajar cuatro horas a la semana o le gustaría trabajar 10 horas a la semana, trabajaremos con ellos para satisfacer sus necesidades”, dijo Howard.

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Must-Reads Of The Week From Brianna Labuskes

Hello! We have once again reached Friday, and I’ll do my best to give you a snapshot of the biggest health news from the week. But, first, I must dispel some bad advice that I’ve seen: Everyone wants to see your pet on those video conferences! Don’t hide them away in this time of need! Show us the doggos, the cats, and the … whatever this is. (A porcupine, I think?) Also make sure you’re following DogsOfKFF on Twitter for some of the best content on that social media platform.

All right, onto the news.

As predicted, the United States has surpassed China in the number of confirmed coronavirus cases, with nearly 93,000 to China’s nearly 82,000, as of 1 p.m. ET Friday. According to Johns Hopkins’ tracker, we also have surpassed 1,300 recorded deaths. (Worldwide, we’re at more than 566,000 and over 25,000 deaths.) Meanwhile, all that data comes with an asterisk in that most experts believe there are far more cases going unrecorded either because of testing flaws or overwhelmed state health departments that can’t keep up. Either way, not exactly something we want to be first in.

Meanwhile, the House came back to Washington to approve the $2.2 trillion stimulus package the Senate managed to send through this week (more on that in a second), despite concerns over lawmakers’ safety. There had been (dim but existent) hope earlier in the week that the House might be able to pass the legislation by unanimous consent. But that seemed too easy to be true, and it was. Concerns that a voice vote would be derailed by objections from a libertarian Kentucky lawmaker went unrealized, and the House passed the legislation Friday afternoon. The bill now goes to President Donald Trump, who is expected to sign it.

So what exactly is in that legislation?

— Direct payments of $1,200 to millions of Americans, including those earning up to $75,000, and an additional $500 per child

— $100 billion for grants to hospitals, public and nonprofit health organizations and Medicare and Medicaid suppliers, including a 20% bump in Medicare payments for treating patients with the virus

— $221 billion in a variety of tax benefits for businesses, including allowing businesses to defer payroll taxes, which finance Medicare and Social Security, for the rest of the year

— More than $25 billion in new money for food assistance programs, like SNAP

— Expanded jobless aid, providing an additional 13 weeks and a four-month enhancement of benefits, and extending the payments for the first time to freelancers and gig workers

— $377 billion in federally guaranteed loans to small businesses and the establishment of a $500 billion government lending program for distressed companies

— Millions in aid for states to begin offering early voting or voting by mail

— A rule that blocks foreclosures and evictions during the crisis on properties where the federal government backs the mortgage

— The suspension of federal student loan payments for six months and waives the interest

Predictably, some sectors (like cruise ships) were unhappy with being left out, but for once some people were pleased — for example, the hospital industry, which got the $100 billion it asked for.

For those of you, like me, who love a good tick-tock, here are a few inside looks at how Senate leaders and White House advisers struck a quick, expansive deal in a Washington that typically seems incapable of compromise.

The New York Times: As Coronavirus Spread, Largest Stimulus in History United a Polarized Senate

Politico: Inside the 10 Days to Rescue the Economy

The Washington Post: The Dealmaker’s Dealmaker: Mnuchin Steps In as Trump’s Negotiator, but President’s Doubts Linger With Economy in Crisis

The urgency of the legislation was underscored by an astronomical jump in jobless claims this week. Nearly 3.3. million Americans applied for benefits, up from 200,000 during pre-outbreak days. The “widespread carnage,” as one economist put it, is expected to get worse. While the stimulus package is expected to help mitigate some of the devastation, many have said it should be looked at as just the beginning.

It seemed strangely appropriate this week that the health law turned 10 amid a pandemic — the legislation’s journey to here has been anything but smooth, why should this anniversary be? But one ripple effect of the pandemic and economic fallout might actually be a boost to the health law, which is likely to serve as a crucial safety net for many Americans who possibly lost their employer-sponsored coverage in the past few weeks. States have already started reopening their marketplaces, and the federal government is being urged to follow suit.


Trump chafed this week at the drastic measures states are putting in place to try to curb the outbreak, raising eyebrows when he said he’d like to see church pews full by Easter. Public health experts have warned that lifting the social-distancing measures would result in a surge of cases that slam an already stretched-thin hospital system. But for Trump, who has tied his reputation to the well-being of the stock market, the economic toll seems too much. (The rhetoric also started a truly bizarre push from conservatives for older Americans to sacrifice themselves for the good of the country.)

The president’s most recent proposal to kick-start parts of the country is identifying places by risk level and applying strategies to match. But experts, like Dr. Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, warn that even “cool spots” that aren’t seeing many cases might be in for a surge coming down the pike.

Meanwhile, Gov. Andrew Cuomo has said that New York’s experience presages America’s future. But some say that’s not necessarily accurate. Leading specialists say that while it is likely that devastation similar to New York’s will emerge in other places, there’s hope that in lower-density areas, where there are fewer factors like mass transit to exacerbate the spread, the outcome might be different.

Realistically, though, Americans will need to eventually think about returning to normalcy. Are there exit strategies from this complete lockdown that would work effectively? Here’s the problem: All the experts say success relies on extreme, aggressive and widespread testing to isolate the sick before they can give it to anyone. This has not exactly been America’s strong suit in recent weeks.


There are two storylines that have taken hold to demonstrate how much this pandemic will strain the hospital system, the first being the lack of ventilators available. States and hospitals have been pleading with the federal government to invoke war powers to jump-start the manufacturing process on the equipment. This comes as doctors are being forced to split ventilators between patients (a risky practice), planning to make the tough ethical decisions to ration care, creating policies to not resuscitate, searching for alternative treatments despite the dangers they might pose, and being warned that morgues are reaching capacity.

But Trump, who had been set to announce a partnership with GM to produce up to 80,000 ventilators, balked this week at the $1 billion price tag that came with it. “I don’t believe you need 40,000 or 30,000 ventilators,” he said, in a reference to New York, where Gov. Andrew Cuomo has appealed for federal help in obtaining them. “You go into major hospitals sometimes, and they’ll have two ventilators. And now all of a sudden they’re saying, ‘Can we order 30,000 ventilators?’”

The second notable thread throughout the country is a lack of personal protective equipment for health care workers on the front lines of the epidemic. There might be a long medical tradition of accepting elevated risk in the middle of a crisis, but many health care workers are frustrated that they’re being put in that position. Some are resorting to using hand-sewn masks, which do little to protect them and trash bags for surgical gowns. But others are drawing a line in the sand.

Meanwhile, something that might get missed with everyone’s attention directed at the coasts: Atlanta’s mayor is warning that its hospitals are at capacity.


Gilead, whose antiviral drug is getting a lot of buzz, was granted orphan drug status for the treatment because there are fewer than 200,000 cases of COVID-19 in the States right now. The designation would have granted Gilead lucrative perks, like the ability to keep generic competitors from the marketplace. But the news was meant with rage-filled incredulity from, uh, pretty much everyone, and so the company rescinded the request. As one expert said: “I think it’s embarrassing to take something that’s potentially the most widespread disease in the history of the pharmaceutical industry and claim it’s a rare disease.”

Meanwhile, an antimalarial drug is getting tons of attention after Trump touted it as a possible game changer. But a new, more carefully constructed study that finds it did little to help patients in China shows why people shouldn’t be looking for a quick, miracle cure. Researchers say this doesn’t disprove that the drug works but is a good check on expectations, especially when people are trying to self-medicate with the drug — resulting in shortages for those who need it for other illnesses and fatal consequences for others.

On the good-news front (there is some!), Moderna said there could be a vaccine ready for the fall for health care workers under emergency use authorization, ahead of the wider release that’s not expected to come for about a year.

And another treatment that some scientists are hopeful about is the practice of injecting recovered patients’ blood into new patients. The strategy is at least a century old but has scattershot results. “It’s not exactly a shot in the dark, but it’s not tried and true,” says one scientist. Still, in this era, people are willing to try what they can.


And here are some other interesting stories to get you through the weekend.

Federal Response:

Politico: Trump Team Failed to Follow NSC’s Pandemic Playbook

Politico: Those Who Intentionally Spread Coronavirus Could Be Charged As Terrorists

The New York Times: As Coronavirus Surveillance Escalates, Personal Privacy Plummets

2020 Elections:

The New York Times: Joe Biden, Struggling for Visibility, Faults Trump’s Response to Coronavirus

The New York Times: Is All of 2020 Postponed?

From The States:

Stateline: One Governor’s Actions Highlight the Strengths — and Shortcomings — of State-Led Interventions

The New York Times: Governors Tell Outsiders From ‘Hot Zone’ to Stay Away as Virus Divides States

NBC News: Entire Senior Home in New Jersey, 94 People, Presumed to Have Coronavirus

Science And Innovation:

The New York Times: The Virus Can Be Stopped, But Only With Harsh Steps, Experts Say

The New York Times: Warmer Weather May Slow, But Not Halt Coronavirus

The Washington Post: What Research on Coronavirus Structure Can Tell Us About How to Kill It

The Washington Post: The Science of Why Coronavirus Is So Hard to Stop

Reuters: Smokers Likely to Be More at Risk From Coronavirus: EU Agency

Public Health:

ProPublica: Domestic Violence and Child Abuse Will Rise During Quarantines. So Will Neglect of At-Risk People, Social Workers Say.

NBC News: Anti-Abortion Groups Seek Halt to Abortions During Coronavirus Pandemic

Politico: New York’s Health Care Workforce Braces for Influx of Retirees, Inexperienced Staffers


That’s it from me! Have a safe and healthy weekend!

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Global Health Watch

Help Wanted: Retired Doctors And Nurses Don Scrubs Again In Coronavirus Fight

Laura Benson retired from nursing in 2018, but this week she reported for work again in New Rochelle, New York, where the first cluster of COVID-19 cases occurred a few short weeks ago.

“Nurses are used to giving of themselves,” she said. “If there’s not enough people, you just do it.”

With more than 39,000 confirmed cases, New York is now the epicenter in the U.S. of the novel coronavirus outbreak, accounting for almost half of the more than 85,500 cases nationwide as of late Thursday evening. Anticipating a severe shortage of medical personnel to treat the influx of sick patients, Gov. Andrew Cuomo and other officials put out a call for retired doctors, nurses and other medical professionals to dust off their scrubs and return to work. By Thursday, 52,000 people had responded.

Officials in other states, including California, Colorado and Illinois, have issued similar pleas for retired medical professionals to step forward.

In New York’s Westchester County, which includes New Rochelle and other towns north of New York City, County Executive George Latimer said about 90 retired nurses and a handful of doctors responded after he posted a message on the county’s Facebook page about a week ago seeking help.

There’s no definite plan for deploying the medical volunteers, Latimer said. They may be needed to replace personnel sidelined by the coronavirus or to help staff the Westchester County Center being repurposed as a temporary hospital.

Benson, 60, is working for the county health department. A nurse practitioner with a specialty in oncology, she spent 20 years at the Albert Einstein Cancer Center in the Bronx. She eventually retired from a job at a medical device company, where she worked with patients who have brain tumors. She also teaches nursing students at a community college.

Nurses are used to giving of themselves. If there’s not enough people, you just do it.

Laura Benson

(Photo courtesy of Laura Benson)

On her first day as a retiree volunteer, Benson phoned patients who had recently been tested for the novel coronavirus to talk them through the guidelines they should follow to protect themselves and others.

If there’s a need, she said, she is “absolutely” willing to work directly with patients who have COVID-19, the illness caused by the coronavirus.

“I think about the person laying in that bed,” she said. “I’d want someone to take care of them.”

Benson is not particularly worried about the virus, having worked through the AIDS crisis, treating patients before people understood what that disease was. “You follow the guidelines and protect yourself,” she explained.

The best role for many retired medical professionals may be to fill in behind the scenes, said experts, freeing up younger colleagues to focus on direct patient care.

One reason for this: age.

“My only concern is that many of these retired folks fall into high-risk groups” more likely to be seriously affected by COVID-19, said Dr. Arthur Fougner, president of the Medical Society of the State of New York, a professional group for physicians.

Another concern is whether retirees are up-to-date in their medical knowledge.

“If they’re out for more than two to three years, you have to worry about them being current,” said Dr. Janis Orlowski, chief health care officer for the Association of American Medical Colleges, which represents the academic medical community.

In addition, health care providers’ state licenses may have lapsed if they’ve been retired for more than a few years. Renewing them can be time-consuming.

Still, “if someone still has their licensing and is willing to come back, we should grab that,” Orlowski said.

Michele Pedicone is one such professional. The respiratory care therapist left her job in Seattle last year to head up clinical education at SUNY Upstate Medical University’s respiratory therapy education department in Syracuse, New York. With her classes now mostly happening online and student clinical placements on hold, she has time to step back into clinical care. She contacted two nearby hospitals to see if they could use her services and expects to work three or four days a week.

“I honestly don’t know what they’re paying me; the money isn’t an issue,” said Pedicone, 54. “It’s the right thing to do.”

Respiratory therapists, critical care physicians and nurses trained in operating ventilators that help hospitalized patients breathe are among the specialists expected to be in severely short supply as the coronavirus pandemic worsens in New York and elsewhere, according to an analysis by the Society of Critical Care Medicine.

Expanding the supply of intensive care workers will be key to managing the coronavirus pandemic, said Ashish Jha, director of the Harvard Global Health Institute, at a briefing this week on health care workforce issues sponsored by the Commonwealth Fund.

I honestly don’t know what they’re paying me, the money isn’t an issue. It’s the right thing to do.

Michele Pedicone

One option policymakers have discussed is that states could allow, for example, medical professionals who retired in the past five years with licenses in good standing to get an automatic three- or six-month license without having to do a lot of paperwork, Jha said.

In the meantime, health care systems are developing their own strategies. Northwell Health owns and operates 19 hospitals in New York City, Westchester County and Long Island. This week, the health system has more than 700 patients with COVID-19, compared with just 40 patients last week, according to Terry Lynam, a senior vice president at the health system.

Northwell has been planning how to beef up staff since January, said Judy Howard, vice president of talent acquisition at the health system who oversees hiring, except for physician leadership. They developed a list of 200 retired nurses whom they’ve been contacting to gauge their interest in returning to paid work in some capacity. So far, 28 have signed on, Howard said.

At this time, they’re asking retired nurses to work at the health system’s call center and share responsibilities for training new nurse employees. Some are working in direct patient care. Another possibility is for retired nurses to staff facilities that Northwell has put in place to care for staff members’ children during the coronavirus pandemic.

“Whether someone really wants to work four hours a week or would like to work 10 hours a week, we’ll work with them to meet their needs,” Howard said.

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Health Industry Public Health States

Physicians Fear For Their Families As They Battle Coronavirus With Too Little Armor

Dr. Jessica Kiss’ twin girls cry most mornings when she goes to work. They’re 9, old enough to know she could catch the coronavirus from her patients and get so sick she could die.

Kiss shares that fear, and worries at least as much about bringing the virus home to her family — especially since she depends on a mask more than a week old to protect her.

“I have four small children. I’m always thinking of them,” said the 37-year-old California family physician, who has one daughter with asthma. “But there really is no choice. I took an oath as a doctor to do the right thing.”

Kiss’ concerns are mirrored by dozens of physician parents from around the nation in an impassioned letter to Congress begging that the remainder of the relevant personal protective equipment be released from the Strategic National Stockpile, a federal cache of medical supplies, for those on the front lines. They join a growing chorus of American health care workers who say they’re battling the virus with far too little armor as shortages force them to reuse personal protective equipment, known as PPE, or rely on homemade substitutes. Sometimes they must even go without protection altogether.

“We are physically bringing home bacteria and viruses,” said Dr. Hala Sabry, an emergency medicine physician outside Los Angeles who founded the Physician Moms Group on Facebook, which has more than 70,000 members. “We need PPE, and we need it now. We actually needed it yesterday.”

The danger is clear. A March 21 editorial in The Lancet said 3,300 health care workers were infected with the COVID-19 virus in China as of early March. At least 22 died by the end of February.

The virus has also stricken health care workers in the United States. On March 14, the American College of Emergency Physicians announced that two members — one in Washington state and another in New Jersey — were in critical condition with COVID-19.

At the private practice outside Los Angeles where Kiss works, three patients have had confirmed cases of COVID-19 since the pandemic began. Tests are pending on 10 others, she said, and they suspect at least 50 more potential cases based on symptoms.

Ideally, Kiss said, she’d use a fresh, tight-fitting N95 respirator mask each time she examined a patient. But she has had just one mask since March 16, when she got a box of five for her practice from a physician friend. Someone left a box of them on the friend’s porch, she said.

When she encounters a patient with symptoms resembling COVID-19, Kiss said, she wears a face shield over her mask, wiping it down with medical-grade wipes between treating patients.

As soon as she gets home from work, she said, she jumps straight into the shower and then launders her scrubs. She knows it could be devastating if she infects her family, even though children generally experience milder symptoms than adults. According to the Centers for Disease Control and Prevention, her daughter’s asthma may put the girl at greater risk of a severe form of the disease.

Dr. Niran Al-Agba of Bremerton, Washington, said she worries “every single day” about bringing the COVID-19 virus home to her family.

“I’ve been hugging them a lot,” the 45-year-old pediatrician said in a phone interview, as she cuddled one of her four children on her lap. “It’s the hardest part of what we’re doing. I could lose my husband. I could lose myself. I could lose my children.”

Al-Agba said she first realized she’d need N95 masks and gowns after hearing about a COVID-19 death about 30 miles away in Kirkland last month. She asked her distributor to order them, but they were sold out. In early March, she found one N95 mask among painting gear in a storage facility. She figured she could reuse the mask if she sprayed it down with a little isopropyl alcohol and also protected herself with gloves, goggles and a jacket instead of a gown. So that’s what she did, visiting symptomatic patients in their cars to reduce the risk of spreading the virus in her office and the need for more protective equipment for other staffers.

Recently, she began getting donations of such equipment. Someone left two boxes of N95s on her doorstep. Three retired dentists dropped off supplies. Patients brought her dozens of homemade masks. Al-Agba plans to make these supplies last, so she’s continuing to examine patients in cars.

In the March 19 letter to Congress, about 50 other physicians described similar experiences and fears for their families, with their names excluded to protect them from possible retaliation from employers. Several described having few or no masks or gowns. Two said their health centers stopped testing for COVID-19 because there is not enough protective gear to keep workers safe. One described buying N95 masks from the Home Depot to distribute to colleagues; another spoke of buying safety glasses from a local construction site.

“Healthcare workers around the country continue to risk exposure — some requiring quarantine and others falling ill,” said the letter. “With emergency rooms and hospitals running at and even over capacity, and as the crisis expands, so does the risk to our healthcare workers. And with a shortage of PPE, that risk is even greater.”

Besides asking the government to release the entire stockpile of masks and other protective equipment — some of which has already been sent to states — the doctors requested it be replenished with newly manufactured equipment that is steered to health care workers before retail stores.

They called on the U.S. Government Accountability Office to investigate the distribution of stockpile supplies and recommended ways to ensure they are distributed as efficiently as possible. They said the current system, which requires requests from local, state and territorial authorities, “may create delays that could cause significant harm to the health and welfare of the general public.”

At this point, Sabry said, the federal government should not be keeping any part of the stockpile for a rainy day.

“It’s pouring in the United States right now,” she said. “What are they waiting for? How bad does it have to get?”

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Think Like a Doctor: The Boy With Nighttime Fevers Solved!

Photo

Credit Andreas Samuelsson

On Thursday we asked Well readers to take on the case of a 7-year-old boy who’d been having fevers and drenching sweats nightly for over a month. More than 300 of you wrote in, and although 20 of you came up with the right diagnosis, only three of you figured out both the diagnosis and the test needed to confirm it.

The correct diagnosis is…

Coccidioidomycosis, or valley fever.

The diagnosis was made based on a lymph node biopsy.

The first reader to suggest this diagnosis and the test was Dr. Malkhaz Jalagonia, an internist from Zugdidi, in the Republic of Georgia. He says he’s never seen a case like this, but he’s fascinated by zebras and so recognized the disease immediately. Well done, Dr. Jalagonia!

One of the reasons I chose this case was that, although this diagnosis is rare in life, it was the most frequently suggested diagnosis in my last column – the one about the middle-aged man with a cough for over a year. I thought it would be fun to show what valley fever really looks like. Hope you did too.

The Diagnosis

Coccidioidomycosis is a lung infection usually caused by inhaling the spores of a tiny fungus called coccidioides. This organism grows as a mold, a few inches below the surface of the soil in deserts in parts of the southwestern United States, Mexico and other countries of Central America.

In dry conditions, the fungus becomes fragile and is easily broken up into tiny single-celled spores that can be sent airborne with even the slightest disturbance. And once these single cells are aloft they can remain suspended there for prolonged periods of time.

Infection is usually acquired by inhaling the spores. Once lodged in the lung, the organism begins to reproduce almost immediately. The time course between exposure and disease depends on the inhaled dose and the patient’s immune system.

Symptoms, or No Symptoms

Disease severity varies considerably. Nearly half of those who breathe in these spores have no symptoms, or symptoms are so mild they never visit the doctor’s office.

More severe infection usually takes the form of a slowly progressive pneumonia known as coccidioidomycosis, or valley fever. This illness is characterized by a cough, fevers, chest pain, fatigue and sometimes joint pain. Indeed, because of the prominent joint pain, in some cases — though not this one — the disease is also known as desert rheumatism.

Rashes are also seen in many patients. Those who get a rash seem to have a more benign course of illness. The thinking is that the skin symptoms are the result of an aggressive immune response in the host to the pathogen.

Symptoms can last for months, and in many cases they resolve without treatment. But in some cases they get worse.

Hard to Diagnose

Those who seek medical attention are often not diagnosed — or not diagnosed quickly — because the symptoms of valley fever are not very specific, and few of the tests that doctors usually order have features that are unusual enough to suggest the diagnosis.

Chest X-rays are often normal. Blood tests may be normal as well, though some patients, like this child, have an unusually high number of a type of white blood cell known as eosinophils. These cells are usually seen in allergic responses or with infections due to parasites.

The most important clue to the possibility of this infection is travel to one of the areas where the fungus lives. In the United States, valley fever is endemic primarily in Arizona and southern California, as well as parts of southern New Mexico and West Texas. Indeed, the name valley fever is a shorter and more general term for an earlier name, San Joaquin Valley fever, because it was so common in that part of California.

A Dramatic Rise

There has been a significant increase in the number of cases of coccidioidomycosis in the past 15 years, with nearly 10 times as many in areas where the fungus is found. Development in areas where the fungus is endemic is thought to be the primary cause. Better diagnostic testing may also play a role.

While this infection may cause only a minor illness in many, there are some – like this child – for whom the disease can spread beyond the lungs into the rest of the body. Disseminated coccidioidomycosis is usually seen in those with some problem with the immune system – an underlying disorder such as H.I.V., for example, or because someone is taking immune suppressing medications such as prednisone.

Once out of the lungs, the bugs can go anywhere in the body, though they seem to prefer joints, skin or bones. Those with disseminated disease have to be treated for a long time – often up to a year, or occasionally for life.

How the Diagnosis Was Made

The little boy had been sick for nearly a month, and his parents were getting quite worried. He was pale, thin and really, really tired.

With their pediatrician’s encouragement, they had gone on a long planned, much anticipated vacation to the mountains of Colorado. But the child wasn’t getting better, and so his mother took him to yet another doctor – this one in a walk-in clinic.

The results of some simple blood tests done at that visit worried the doctor, who suggested that the boy be taken to a hematologist, a specialist in diseases and cancers of the blood.

Now the parents were terrified. The mother faxed copies of the lab results to her brother, a researcher in immunology. He wasn’t a physician but showed the results to friends who were. They agreed with the doctor at the walk-in clinic: The boy needed to be seen by a hematologist.

A Series of Specialists

The next morning the family headed home to Minneapolis. They took the boy to his regular pediatrician, who sent them to a hematologist. It wasn’t cancer, that specialist told them. Maybe some kind of severe food allergy, he suggested, and referred them to a gastroenterologist.

Not a GI thing, that specialist told them, and he referred the now nearly frantic family to an infectious disease specialist and a rheumatologist.

Nearly 10 days after getting the alarming blood test results, the couple and their child found themselves in the office of Dr. Bazak Sharon, a specialist in infectious diseases in adults and children at the University of Minnesota Masonic Children’s Hospital. After introducing himself, Dr. Sharon settled down to get a detailed history of the boy and the family.

A Desert Visit, but Other Possibilities

When Dr. Sharon heard that the family had spent a week at a ranch in the desert of Arizona, he immediately thought of coccidioidomycosis. The fungus isn’t found in Minnesota or Colorado – which is probably why other doctors hadn’t considered it. But it is all over the part of Arizona where they’d visited.

Still, there were other possibilities that had to be ruled out, including some types of cancer. After Dr. Sharon examined the boy, he sent the family to the lab for a chest X-ray and some blood tests.

The results of those tests were concerning. The child was getting worse. Dr. Sharon wasn’t going to be back in clinic for a week, and he was certain the child needed to be seen and diagnosed well before then. He called a friend and colleague who was taking care of patients in the hospital, Dr. Abraham Jacob, and asked if he would admit the child and coordinate the needed diagnostic workup for the boy.

First Some Answers, Then More Questions

Once in the hospital, the child had a chest CT scan. The results were frightening. The lymph nodes that surround the trachea, the tube that carries inspired air to the lungs, were hugely enlarged. They were so big that the trachea was almost completely blocked. The opening at one point was just two millimeters wide – basically the dimensions of a cocktail straw. Any worsening of his disease might cause the tube to close completely, making breathing impossible.

A pediatric surgeon was brought in immediately. The enlarged lymph nodes had to be removed. First in order to protect the child’s airways. And second because those nodes would reveal what the little boy had.

But trying to do surgery on a 7-year-old boy’s neck was complicated. Although the surgeon could easily feel the enlarged gland in his neck, it was close to many vital blood vessels, nerves and organs. The child had to lie perfectly still, and with most children that could only be guaranteed if they were under anesthesia.

Risky Surgery

When the anesthesiologist saw the CT scan, the doctors’ concern grew. They could put the child to sleep, but if anything went wrong during surgery and they had to put a tube down his throat into his lungs, they weren’t sure it would be able to fit.

The trachea was so small, there was no guarantee they could get the tube into place. In order to do this safely, they said they needed to use a technique known as ECMO, or extracorporeal membrane oxygenation – basically a machine that allows them to oxygenate blood without sending it to the lungs.

Rather than subject the child to this risky procedure, Dr. Jacob and the surgeon decided to just take a piece of the lymph node out in order to make the diagnosis. Treatment of whatever the boy had would bring the size of the lymph node down.

Don’t Make a Move

When the boy was brought to the procedure room, the surgeon explained that he was going to put numbing medicine all around the bump in the boy’s neck and take out a piece of it. The child listened calmly and agreed.

He wasn’t to move at all, the surgeon explained. The child nodded solemnly. He understood. The boy was remarkably mature and so brave throughout the entire process of anesthetizing the region that the surgeon thought he might be able to continue and get the entire node out.

He paused in his surgery and consulted the parents. Would they allow him to try this? Their son was doing so well he was sure he could get it. They agreed, and the surgeon returned to his task. The lymph node came out without difficulty.

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It was sent to the lab and the answer came back almost immediately. The swollen tissue was filled with the tiny coccidioides. You can see a picture of these little critters here.

A Year of Medicine

The boy was started on an intravenous medicine for fungal infections. Then after a week it was changed to one he could take by mouth.

Because the infection had spread beyond the lungs, the child will have to take this medication for a year. After starting the medication, the child began to look a little better. Slowly he was less tired. Slowly he started to eat the way he used to.

It was a long road to the diagnosis, and an even longer road to cure, but at least they were on the right one.

A Perfect Storm?

The mother called the ranch in Arizona where they stayed to let them know what had happened.
The owner told them that their son was not the only person visiting then who got sick. At least one other guest, there at the same time, had come down with the disease.

Apparently the conditions for spread were perfect. Their stay had started off with some rain, followed by heat and some brisk wind. The moisture helped the fungus grow; the heat dried it out so that it could become easily airborne and inhaled when lifted by the wind.

Although the family has loved their visits to this ranch – this was their second year – the child’s mother tells me that she’s not sure she’ll be going back, at least for a couple of years. Most people exposed to valley fever become immune forever, but because her little boy was so very sick, she’s planning to wait a while before they return.

Think Like a Doctor: The Boy With Nighttime Fevers

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The challenge: A healthy 7-year-old boy suddenly starts having fevers and night sweats. Can you figure out why?

Every month, the Diagnosis column of The New York Times Magazine asks Well readers to sift through a difficult medical case and solve a diagnostic riddle. This month we present the case of a boy who has fevers topping 102 degrees every night for over a month. His parents sought help from nearly a dozen doctors in two states before a diagnosis was made.

Below I’ve given you the information that was available to the doctors who figured out the cause of the boy’s fevers. It’s up to you to use this information to put his story together for yourself.

As usual, the first person to crack the case gets a copy of my book, “Every Patient Tells a Story,” and, of course, that fabulous feeling you get when you solve a really tough puzzle.

The Patient’s Story

“I think you need to take him back home.” Her brother’s voice was calm, but she could hear an undertone of anxiety even over the poor cellphone reception that was all she could get from rural Colorado. “He needs to see a hematologist. It could be a virus, but it could also be something else.” He didn’t say it, but she knew what he was thinking: cancer.

Her son, just 7 years old and always a little delicate, had been sick for nearly a month. He was fine during the day, but every night he’d spike a fever of 102 or 103.

Even before they’d come to the mountains for a much needed vacation, she’d taken him to see his pediatrician at home in Minneapolis several times. At each visit, the doctor or one of his partners had looked the boy over closely, and each time he’d seemed fine.

It was probably viral, she was told, time after time. But he seemed to be having one viral infection after another.

A Vacation Cut Short

The day before they left for Colorado, the boy’s father took him to the doctor’s office one more time.

Maybe it wasn’t viral, the pediatrician acknowledged, and prescribed a “Z-pak” — a five-day course of azithromycin. Don’t cancel the trip, the doctor reassured him. He’ll get better.

But he hadn’t. While on vacation, his mother took him to a walk-in clinic, where they’d checked his blood. A worried looking doctor told her that he didn’t know what was wrong with her boy. He should probably see a cancer specialist.

Now she was really worried. There weren’t any specialists anywhere near the bucolic town where they were staying. That’s when she’d sent the test results to her brother, a researcher in immunology. He wasn’t a doctor, but he passed the results to friends who were, and they were worried, too.

Thin and Pale

The family headed home right away, but the 4th of July was coming. They couldn’t get in to see a hematologist until Tuesday.

By now the boy was starting to look sick. He was pale and had dark circles under his eyes. Small for his age — consistently in the fifth percentile for height and weight — he now looked even smaller, thinner. He was a quiet child, always had been. Thoughtful and comfortable in the company of adults, as so many only children are. Even now he never complained.

Nothing hurt. He was simply tired. His fevers started coming a little earlier, peaking a little higher. His mother noticed a cough and wheezing sometimes. Always a picky eater, with these intermittent fevers, very few foods seemed appealing. She tried to hide the terror she felt when he seemed to be fading as she watched.

A Long Line of Specialists

The hematologist examined the boy and sent off more blood. Definitely not cancer, he said. He suggested seeing a gastroenterologist.

The gastroenterologist got an M.R.I. of the child’s digestive system. Nothing there. He noticed the boy’s wheezing and gave him an inhaler, then referred mother and child to a rheumatologist and an infectious disease specialist.

It seemed to the parents that this had to be an infection, but the earliest they could get in to see the infectious disease doctor was the following week. For the boy’s mother, the delay now seemed intolerable.

It had been five weeks since the fevers first started. In that time, the boy had lost nearly 10 pounds. They’d seen eight doctors in two states. They’d all been very nice, thorough, thoughtful, but had no answers.

By the weekend she was desperate. The boy needed to be in the hospital. Couldn’t they see how sick he was? She couldn’t wait for the specialist. She took him to the emergency room of the big university hospital.

The E.R. doctors, like all the doctors they’d seen so far, were kind and thoughtful, and so gentle with her delicate son. But like all the other doctors, they had no answers. They prescribed another inhaler for the boy’s wheezing, since the first hadn’t helped. They also urged her to see the infectious disease specialist. His appointment was just a couple of days away.

TB or not TB?

The boy was sitting quietly between his parents watching a video on his tablet when Dr. Bazak Sharon and the infectious disease fellow he was training entered the exam room. Dr. Sharon’s first thought was that the child looked as if he had tuberculosis.

He’d seen a lot of TB in this clinic, but it was usually among immigrant families who had traveled to Minneapolis from countries where the disease was common. Like this boy, kids with TB were usually thin, sickly looking, pale and quiet. But based on what his fellow told him, the child had no exposures that would put him at risk for this disease. He’d only been out of the country once – to Canada. He’d visited the beaches of South Carolina and the deserts of Arizona, and most recently the mountains of Colorado. But TB was rare in all these locales.

Dr. Sharon introduced himself to the child, who looked up immediately and smiled. How do you feel, he asked the boy? His temperature had been recorded at 103 degrees. I feel good, he’d answered pleasantly. Does anything hurt? No.

His heart was beating rapidly – nearly 140 beats per minute, but that was probably due to the fever. There were several enlarged lymph nodes in the child’s neck and his groin, though none under his arms. Otherwise his exam was unremarkable.

Getting Worse

Dr. Sharon had reviewed the blood tests that had already been done but wanted to see if anything had changed. And given that the only localized complaint was cough and wheezing, he wanted to get another chest X-ray.

Reviewing those studies that night, Dr. Sharon saw that the boy was slowly getting worse. He saw patients at that clinic only once a week and was reluctant to wait that long before having him seen again. He thought they needed an answer much sooner than that.

You can see the note from Dr. Sharon and his fellow here.

Dr. Sharon’s Note

The note from the patient’s visit to the hospital.

To the Hospital

Dr. Sharon called the family the next morning. He’d reached out to one of his friends and colleagues, Dr. Abraham Jacob, who could see them. They should go to the University of Minnesota Medical Center Fairview, where Dr. Jacob would orchestrate a thorough workup. That would be the fastest way to get an answer.

Based on the assessment by Dr. Jacob and his resident and the recommendations from Dr. Sharon, the team reached out to specialists in hematology-oncology and in rheumatology. And since his chest X-ray was abnormal and he had enlarged lymph nodes, they wanted to get a CT scan as well.

You can see the note from Dr. Jacob and his resident here.

Dr. Jacob’s Notes

Here are the notes from the pediatrics department.

Breathing Through a Straw

It was the results of the CT scan that really got things moving. It was the middle of the day when the resident was paged by the radiologist. The pictures showed that the lymph nodes in the boy’s chest were so swollen that they were pressing on the trachea – the breathing tube – so that it was almost completely cut off. Essentially he was breathing through the equivalent of a cocktail straw.

Any additional swelling could cut off the boy’s breath completely. You can see an image from the CT scan here.

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This CT scan shows the patient’s chest. In a child of this age, the trachea is normally eight to 12 millimeters wide. Much of the gray tissue surrounding the trachea and esophagus is swollen lymph nodes.

This CT scan shows the patient’s chest. In a child of this age, the trachea is normally eight to 12 millimeters wide. Much of the gray tissue surrounding the trachea and esophagus is swollen lymph nodes.Credit

A normal trachea in a child this age is four to six times the size seen in the scan. The image added even more pressure to make a diagnosis and treat the child before he got sicker.

Solving the Mystery

A diagnosis was made within the next 24 hours. Can you figure out what the boy had, and how the diagnosis was made?

The first person to offer the correct answers to these two questions will get a copy of my book and that sense of triumph that comes from nailing the right diagnosis when it really matters.

Rules and Regulations: Post your questions and diagnosis in the comments section below. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.

Just a Regular Doctor

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Credit iStock

“What’s your specialty?” That’s the question people always ask, as soon as they learn that you are a doctor.

My specialty? This question continually flummoxes me. This is the moment that I experience a brief surge of envy toward my cardiology and dermatology colleagues who have simple one-word answers to this question that any lay person can understand.

But what do internists say? What is our specialty?

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Danielle Ofri, M.D.

Danielle Ofri, M.D.Credit Joon Park

I sometimes say, “general internal medicine.” But that’s a mouthful. Plus many people have no idea what general internal medicine actually means.

I usually end up saying that I’m just a regular doctor, but it always feels deflating to have to add that “just.”

The American College of Physicians, the professional group for internal medicine, started an ad campaign several years ago to address the confusion. They came up with the slogan of internists as “doctors for adults,” wanting us to credibly sound like specialists, people with more training than the old-fashioned G.P.s. But it just didn’t catch on. I don’t fault the A.C.P. or its Madison Avenue colleagues who came up with this lusterless campaign; there’s just not a lot of pithy material to work with.

Internists, along with the others in the primary care field — family physicians, pediatricians, gynecologists — make up the bulwark of the medical system, though nothing we do or say or represent is especially snappy. No one is rushing to make an edgy cable TV series about adjusting blood pressure medications or treating constipation.

But the need is surely there. Anyone who’s tried to get an appointment with his or her doctor already knows about the primary-care crunch. The Affordable Care Act has highlighted the need for more primary care doctors, with the shortage only likely to grow more acute with a growing and aging population.

In most other countries, the vast majority of physicians are primary care doctors, in recognition that they deliver the vast majority of health care. It is only in the United States that the free market for higher-paid fields results in the number of specialists actually surpassing that of primary care doctors.

We all know the stats — primary care doctors get paid less than specialists, have more administrative headaches, more paperwork, and are generally viewed as lower on the totem pole. Reputation always has it that the smartest medical students go into the specialties; the generalist fields get everyone else who couldn’t make up their mind or who didn’t want to compete in the big leagues.

Dr. Wayne Riley, the president of the American College of Physicians, strongly disputes this characterization. He notes the wisdom acquired by physicians who are required to take both the long view and the wider view of medicine. “I proudly tell people that my specialty is internal medicine.” And if people are still confused, he humorously describes an internist as, “Like television’s Dr. House, but without the bad manners or ethical issues.”

The stereotype of specialists handling the more complex and intellectually challenging cases makes many generalists fume. Generalists observe that specialists get the “simplicity” of handling very narrow slivers of medicine. It’s much easier to be an expert when you only have a handful of diseases to worry about. And any issue that a specialist doesn’t want to deal with can be permissibly kicked back to the generalist.

The generalist, however, gets no dispensation. Every issue that the patient raises must be addressed. Every symptom from any organ has to be acknowledged. Plus, every medication prescribed by every specialist must be accounted for. Every competing interest between the many medical cooks in today’s fragmented health care environment must be integrated.

A recent study regarding patients with diabetes illustrates this reality. In a review of more than 4,500 patients with diabetes, 80 percent of visits to specialists involved only one diagnosis. However, only 45 percent of visits to generalists involved a single diagnosis. Of patients with four or more diagnoses, 90 percent fell to the generalists.

Specialists also get the added ease of pre-screening. A patient referred to a gastroenterologist is generally known to have a GI issue. A patient sent to a cardiologist has some type of heart condition. But the patient who walks into a generalist’s office will often just report pain somewhere in the middle of the body. The generalist has to figure out if the source of the pain is cardiac or pulmonary or gastric or muscular or inflammatory or infectious or hematologic or autoimmune or psychosomatic — a tall order that is somehow considered less intellectually rigorous, and less worthy of reimbursement, than specialty care.

To me, primary care and specialty care are equally demanding. They perhaps represent different types of intellectual challenges, but there’s no reason for one to be thought of as more worthy of respect (or pay).

Primary care doctors, the generalists, won’t be likely to achieve parity in pay or respect until the economics of American medicine changes drastically to reflect more realistically the needs of our patients. Right now, the system values procedures far more than talking to the patient, and so generalists — who do far fewer procedures — continue to rank at the bottom.

But generalists can take heart in the fact that they are what people usually have in mind when they say that they need a doctor. So now when people ask what my specialty is, I say that I’m just a regular doctor. Though I try to remember to leave out the “just.”


Danielle Ofri’s newest book is What Doctors Feel: How Emotions Affect the Practice of Medicine. She is a physician at Bellevue Hospital and an associate professor of medicine at the New York University School of Medicine, as well as editor in chief of the Bellevue Literary Review. She spoke on Deconstructing Our Perception of Perfection at TEDMED.

Food, a Place to Sleep and Other Basic Patient Needs

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Credit Earl Wilson/The New York Times

“Doc,” my patient said, his voice a mix of amusement and irritation. “I ain’t got food to eat or a place to sleep. Took me two hours and three buses to get here. And you’re tellin’ me about some numbers?”

He had a point. Though, in my defense, these numbers — his cholesterol and blood pressure — were important ones.

As I tried to persuade him of their relevance, I thought of another number, his ZIP code — or lack of one, since he lived on the street — and how that was a far more important factor for how long he might live than his cholesterol.

What’s remarkable about our conversation isn’t that it happened, but that it doesn’t happen enough. Many of my patients are not forthcoming about their challenges, and when I probe, I’m often surprised by how many struggle with basic needs like housing, food and transportation.

I recently discussed starting insulin with a patient to control his diabetes. He hesitated — his concern not the syringes needed to inject it, but rather not having a refrigerator to store it. Another patient recently called to cancel her appointment. She was moving into a new apartment — again. Her son’s asthma had flared up, and she thought the mold and cockroaches in their current home were making it worse.

These situations highlight what we’ve known for decades: that patients’ social and economic circumstances powerfully influence their health and well-being. But until recently there’s been relatively little effort to systematically address these factors.

The Center for Medicare and Medicaid Innovation, a government organization established by the Affordable Care Act to test new ways to deliver and pay for health care, is trying to change that. It recently announced a pilot program to help health systems close gaps between medical care and social services in their communities. The program, known as Accountable Health Communities, will invest $157 million over five years to study whether helping patients with social needs in five key areas — housing, food, utilities, transportation and interpersonal safety — can improve health and reduce medical costs.

“Clearly we’re not the first to understand that social factors are important,” said Dr. Darshak Sanghavi, the innovation center’s director of preventive and population health care models. “But these efforts have been fragmented. They haven’t been studied in a way that can be nationally scaled.” As the world’s largest purchaser of health care services, the Centers for Medicare and Medicaid Services can help address that, he said.

The Accountable Health Communities program will award grants to 44 organizations around the country to build partnerships among state Medicaid agencies, health systems and community service providers to identify which strategies are most effective for linking patients to the services they need.

There’s good evidence that dedicated attention to social support can improve health and cut costs. Research suggests nutrition assistance for low-income women and children reduces the risk of low birth weight, infant mortality and developmental problems — at a cost that’s more than fully offset by lower Medicaid spending. Other work suggests providing elderly patients with home-delivered meals can help them live independently and prevent expensive nursing home stays. Research also shows that providing housing for low-income and homeless people can substantially reduce medical costs. A housing initiative in Oregon, for example, decreased Medicaid spending by 55 percent for the newly housed; a study of a similar program in Los Angeles found that every $1 spent on housing led to $6 saved on medical costs.

And local efforts around the country can serve as models for change.

Hennepin Health in Minnesota, for example, is an organization that serves low-income patients, and emerged as a partnership between local social service, public health and medical leaders. These groups share data and funding to ensure patients have access to services like housing, utilities, job training and behavioral and substance abuse counseling. The program’s efforts have lowered emergency department use, reduced the need for hospitalizations, improved chronic disease care — and saved money. Other innovative organizations, like the Camden Coalition in New Jersey and Health Leads in several metropolitan areas, have likewise recognized the challenges vulnerable patients face outside the hospital, and tackled them in inspiring ways.

But we haven’t yet done enough to collect, examine and scale these insights. There’s been no concerted national effort to ease the social problems that drive poor health, and consequently, little financial incentive for medical practitioners to collaborate with social service providers. Until now.

“I think what’s most important is the signal we’re sending,” Dr. Sanghavi said of the Accountable Health Communities initiative. “We recognize that hundreds, potentially thousands, of communities have these needs. We can’t meet them all right now. But this sends a broader signal to other innovators out there — be they private, public or philanthropic: Social determinants are important. We want to learn from their efforts. We want to spark that flame.”

Dhruv Khullar, M.D., M.P.P., is a resident physician at Massachusetts General Hospital and Harvard Medical School. Follow him on Twitter: @DhruvKhullar.

Doctors Should Listen to Patient Instincts

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When a patient complains that he or she doesn’t feel well, doctors should pay attention.

That’s the finding of a new study that suggests that how patients say they feel may be a better predictor of health than objective measures like a blood test. The study, published in Psychoneuroendocrinology, used data from 1,500 people who took part in the Texas City Stress and Health Study, which tracked the stress and health levels of people living near Houston.

The survey included self-assessments from a 36-item questionnaire as well as blood samples, which were analyzed for markers of inflammation and the activity of latent herpes viruses. (The viruses were benign and not the type associated with sexually transmitted disease or cold sores.) Inflammation and viral activity are general markers of immune system health, but they don’t typically cause any obvious symptoms or show up in traditional blood tests.

The study found that when people said they felt poorly, they had high virus and inflammation levels. People who reported feeling well had low virus and inflammation levels.

“I think the take-home message is that self-reported health matters,” said Christopher P. Fagundes, an assistant psychology professor at Rice University and a co-author of the study. “Physicians should pay close to attention to their patients. There are likely biological mechanisms underlying why they feel their health is poor.”

The Doctor-Patient Relationship Is Alive and Well

It’s 2:20 p.m. and Ms. M. is precisely on time for her appointment. She’s brought her hand-printed list of questions, her sack of medications that need renewal, her mordant observations about her newest home attendant, and a box of chocolates that she will press upon me no matter how hard I protest. At 89, her medical conditions don’t have easy cures and the setbacks from aging are often implacable. Yet we always manage to find something optimistic to work on, even if modest in scope.

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Danielle Ofri, M.D.

Danielle Ofri, M.D.Credit Joon Park

Ms. M. requires the assistance of her daughter to make the hour-plus trip by public transportation. Over the 10 years we’ve worked together, I’ve periodically suggested she might consider a clinic closer to home to avoid the arduous travel. She sniffs sharply at the affront and then barrels into the meat of our visit.

It’s been a rocky decade for medicine — the Affordable Care Act, the migration to electronic medical records, record-breaking medication prices, and the shift from traditional doctor-run practices to mammoth corporate-run organizations have left us all reeling. Physician anger at overwhelming administrative demands and patient frustration at the impossibility of navigating the system have frayed the fortitude of everyone.

Medicine is unquestionably harder than it was 10 years ago. Many more doctors I know talk about quitting (an option that is not equally available to patients). However, there’s been no mass exodus of doctors. We doctors grumble loudly — often with good cause — but we aren’t quitting in droves, mainly because of patients like Ms. M.

A new study by the Physicians Foundation of more than 1,500 patients found that more than 90 percent of patients were satisfied with their relationship with their primary care doctor. They felt that their doctors were respectful of them, listened well, explained well, and had a good understanding of their medical history.

On the surface, this seems to contradict the dyspeptic view of medicine we hear about in the media. But it actually reflects the larger truth that most patient rancor is directed not toward the doctor but to the bureaucratic aspects of medicine — the cost, the hassle, the opaqueness. On the whole, patients are happy with the medical care they receive from their primary care doctors — once they’ve slogged through the seven circles of pre-authorization purgatory to get there.

The same is true for doctors. What doctors hate most is everything that surrounds medicine, but not medicine itself. Peel away the administrative migraines and most doctors relish the practice of medicine.

It’s heartening to see that the doctor-patient relationship is surviving this latest round of upheaval. For primary care doctors in particular, whose daily work life has been pummeled with exceptional relentlessness, this latest survey is immensely validating.

So maybe it’s not surprising that it can feel as if morale is both exceptionally high and exceptionally low at the same time. Just this month, a new set of requirements was piled on to our clinic’s electronic medical record system, and a dreary sigh of resignation echoed from one doctor to the next. With all the computerized busywork that a medical visit requires these days, there’s hardly time to call in our patients from the waiting room.

On the other hand, when we welcome our new students and interns — July is the starting month of the medical calendar — the enthusiasm for primary care is fervent. We all have patients, like Ms. M., who bring joy and fulfillment no matter how much inanity we have to lumber though in the electronic medical records system.

Nothing comes close to the experience of making another human being feel better, even a tiny bit. After months of trial and error, Ms. M. and I finally worked out a schedule of her diuretic pill such that she could go for a midday stroll without having to scramble for a nonexistent public bathroom. This isn’t the sort of high-tech medical wizardry that grabs headlines or stock prices, but it allows a formerly housebound patient to now keep tabs on her Brooklyn neighborhood.

The awe of discovering the human body, the honor of being trusted to give advice, the gratification of helping someone through a difficult illness, the intellectual stimulation of continually learning — these things never grow old.

And word seems to be getting out — applications to medical school are at an all-time high, and new medical schools are opening to meet the demand. (By comparison, law school applications continue to decline and business school applications remain flat.)

When I close the door to the exam room and it’s just the patient and me, with all the bureaucracy safely barricaded outside, the power of human connection becomes palpable. I can’t always solve my patients’ issues, but the opportunity to try cannot be underestimated.

We doctors shouldn’t be afraid to speak up about what’s wrong with medicine — and there is plenty that is wrong. But we also shouldn’t be afraid to speak up about what’s right. While the logistics of practicing medicine may feel like an ever-tightening thumbscrew, the doctor-patient relationship is alive and well, and the prognosis is excellent.

Danielle Ofri’s newest book is “What Doctors Feel: How Emotions Affect the Practice of Medicine.” She is a physician at Bellevue Hospital and an associate professor of medicine at N.Y.U. School of Medicine, as well as editor in chief of the Bellevue Literary Review. She spoke on Deconstructing Perfection at TEDMED.

Think Like a Doctor: A Cough That Won’t Stop

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Credit Andreas Samuelsson

The Challenge: A 43-year-old man starts to cough every time he takes a deep breath. Can you help him figure out why?

Every month, the Diagnosis column of The New York Times Magazine asks Well readers to try their hand at solving a medical mystery. Below you will find the story of a healthy middle-aged man who starts coughing and just can’t stop. He can’t exercise. He can’t laugh. Sometimes he can’t even talk without interrupting himself with deep, awful-sounding hacks.

Below I provide much of the information available to the doctors who examined him. It took 18 months before a doctor figured out what was wrong. Can you do it any faster? The first reader to offer the correct diagnosis will receive a signed copy of my book, “Every Patient Tells a Story,” and the satisfaction of solving a real-life case.

An Emergency 18 Months in the Making

“You should probably have that checked out in the E.R.,” the nurse suggested to the middle-aged man on the other end of the phone. “And sooner rather than later.” In the next few days? he asked. In the next few hours, the nurse replied.

The 43-year-old man hung up the phone more surprised than worried. He had been dealing with an annoying and persistent cough for a year and a half and none of the doctors or nurses he’d seen in that time seemed to think it was a big deal. Until now – since he started coughing up blood.

He called his wife to tell her what the nurse suggested. After work he was going to drive himself to the emergency room at the veterans’ hospital in downtown Denver. He could hear the relief in her voice when she asked if he wanted her to come with him. No, she had enough on her hands looking after their four children. He’d let her know what they said.

An Abnormal X-ray

In the E.R., the man’s complaint got him seen right away. His chest X-ray was normal, they told him. (The X-ray is shown here)

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Credit

But when they came back into his cubby wearing masks over their noses and mouths he suspected that the CT scan was not. The scan had shown some kind of hole in his lungs, the E.R. doctor told him. That’s why he was coughing up blood. One of the diseases that can cause those kinds of cavities was tuberculosis. Had he ever been exposed to TB? Not that he knew of. (The CT scan images are shown here.)

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Credit

Because TB was such a dangerous disease – and extremely contagious — they would have to find out if he had it. If he did, he would certainly need to be treated. And to make sure he didn’t infect anyone while he was being tested, he needed to be in a specialized room – a room where the air he breathed wouldn’t be breathed by anyone else. None of the hospital’s negative pressure rooms were available so they were going to transfer him to Presbyterian/St. Luke’s Medical Center, the big regional hospital just a couple of miles away. They had an available room and would be able to care for him.

You can read the patient’s history and physical from the E.R. here:

Admission Notes

The patient’s notes from the hospital.

The Patient’s Long Story

Dr. Karen Schmitz was the second-year resident assigned to care for the new guy sent over to be tested for TB. She could see the patient sitting up in bed talking on the phone as she secured the mask over her nose and mouth and entered the double-door room that would prevent any air-borne infectives from spreading. As she entered, the patient looked at her, smiled a warm smile, and held up a finger as if to say, “I’ll be with you in a minute.” As he finished up his phone call, the doctor looked at him carefully. He was a robust guy – youthful and healthy looking. He certainly didn’t look like any of the people she’d cared for with active TB. When he hung up, he apologized and the doctor introduced herself. She pulled up a chair and settled in. She knew from what she’d read in the chart that it was going to be a long story.

The bloody cough was pretty new, he told her. It started two weeks earlier. But the cough itself had been around for 18 months. He’d caught it a couple of summers ago, and it just never went away. At first he thought it was bronchitis – he’d had that a lot when he was a kid — but when it lasted for more than a couple of weeks, he went to see his primary care doctor. He’d never had a fever or any other sign of being sick. He had some runny nose and itchy eye symptoms that started weeks before the cough and so he and his doctors thought it was allergies. Or asthma. His doctor prescribed an antihistamine and later an inhaler. They fixed his runny nose, and eased up the chest tightness, but the hacking never slowed down.

He went to an ear, nose and throat specialist who scoped his nose and throat. Completely normal. He had a chest X-ray – also normal.

He saw a pulmonologist who, hearing that he had a little heartburn, started him on a powerful antacid medication. That pill completely fixed the heartburn but didn’t touch the cough.

That first year he’d seen three doctors in a half-dozen appointments, and had a scope, a chest X-ray and a slew of blood tests and still no one could tell him why he was coughing or how to make it stop. So he figured he’d just have to learn to live with it.

Not that he wanted that. Every time he took a deep breath he would cough. In the middle of telling a good story he’d have to stop to cough. Whenever he laughed, he coughed. Dozens of times a day, he coughed. He even had to give up exercising. Any time he exerted himself, even just a little, the cough would kick in with a shocking fierceness. Recently he’d tried riding his bike and just 15 minutes in he had to stop. Even though he was taking it easy, as soon as he started to breathe just a little harder than usual, he nearly keeled over. He had to get off his bike. He was doubled over with the ferocious hacking. Sweat and tears poured down his cheeks. He could hear the rasping sound of his breath between the deep jagged coughs. He wondered if he could even make it home. That was the last time he tried to exert himself. And that had been weeks earlier.

You can see the pulmonologist’s notes here:

Pulmonary Consult Note

The notes from the lung specialist.

The Doctor’s Visit

But eventually, he started to cough up blood. That happened the morning after he’d had another terrible blast of coughing. He’d gone with his wife and four children to Vail for Thanksgiving. As he was packing the car to come home he started coughing and felt as if it would never stop, as if he’d never be able to breathe again. But he recovered, until the next morning when he started to cough up blood. It scared him. And terrified his wife. When it didn’t get better after a couple of weeks, he’d decided to call the hospital, and the nurse on the phone sent him to the E.R.

Now, talking to Dr. Schmitz, he told her he never smoked and rarely drank. And even though it was legal, he never smoked pot either. He had been an officer in the Air Force and now was a real estate agent. He had spent a few months in Kuwait and another few in Saudi Arabia, but that was in the 1990s. He’d traveled a bit – mostly out west, but nothing recent. He took medicine for high cholesterol, the antihistamine and the antacid medicine, but that was it. His exam was unremarkable. Dr. Schmitz listened hard through her stethoscope as she placed it on his chest where she knew the hole in his lung was, but heard nothing abnormal.

She didn’t start him on antibiotics, because she didn’t yet know what she was treating, she told him. Tuberculosis seemed unlikely so she was going to test him for other infections as well. To make sure the team didn’t miss anything, they consulted an infectious diseases specialist and a pulmonologist.

You can see their notes here.

Infectious Disease Consult

Notes from the infectious disease specialist.

Dr. Schmitz checked on her patient throughout the day. He was always on the phone, his computer open, hard at work. So far they were doing nothing for the guy – just watching and waiting for answers. When the TB test came back negative, Dr. Schmitz thought he might very well be the healthiest patient in the entire hospital. Was she right? The patient got his diagnosis the very next day.

Solve the Mystery

What do you think is making this patient cough?

Post your answers in the comment section. I’ll tell you the answer tomorrow.

At the End of Life, What Would Doctors Do?

Photo

Credit Stuart Bradford

Americans have long been chided as the only people on earth who believe death is optional. But the quip is losing its premise. A recent profusion of personal narratives, best-selling books and social entrepreneurs’ projects suggest that, as a culture, we are finally starting to come to terms with our mortality. Nationally, the Conversation Project is engaging people to discuss their wishes for end-of-life care. Death Cafes and Death Over Dinner events are popping up across the country, reflecting an appetite for exploring these matters. So too, the Dinner Party and the Kitchen Widow are using meals as a communal space to explore life after loss.

Admittedly, contemplating mortality is not (yet) a national strong suit. That’s why these cultural stirrings are so significant. At a minimum, our heightened awareness and willingness to talk about illness, dying, caregiving and grieving will lead to much better end-of-life care. However, the impact on American culture needn’t stop there. Like individuals who grow wiser with age, collectively, in turning toward death, we stand to learn a lot about living.

Doctors can be valuable guides in this process. In matters of illness, people are fascinated by the question, what would doctors do? Consider the social phenomenon of Dr. Ken Murray’s online essay, “How Doctors Die.” Dr. Murray wrote that doctors he knew tended to die differently than most people, often eschewing the same late-stage treatments they prescribed for patients. The article went viral, being read by millions, and reprinted in multiple languages in magazines, newspapers and websites across the globe.

Dr. Murray’s observation even engendered studies of doctors’ preferences for care near the end of life. So far, results are mixed. In a Stanford study, 88 percent of responding physicians said they would avoid invasive procedures and life-prolonging machines. But a newly released comparative study of Medicare recipients, as well as a longitudinal study and separate analysis of Medicare data published in January, suggest that the actual differences between end-of-life treatments that doctors and nondoctors receive are slight. Perhaps like nearly everyone else, when life is fleeting, physicians find it difficult to follow their previous wishes to avoid aggressive life-prolonging treatments.

For what it’s worth, the terminally ill colleagues I’ve known, including those I’ve been privileged to care for, have usually been willing to use medical treatments aplenty as long as life was worth living, and took great pains to avoid medicalizing their waning days. In any event, the public’s interest in the medical treatments that doctors choose must not be allowed to reinforce our culture’s tendency to see dying solely through medical lenses. More to the point is the question, how do dying doctors live?

What dying doctors do with their time and limited energy, and what they say, are deeply personal, sometimes raw and often tender. Like everyone else, doctors experience pain and suffering – yet many speak of a deepening moment-to-moment sense of life and connection to the people who matter most.

Listen to a few.

Dr. Jane Poulson lost her sight to diabetes while still in medical school. After years of successful internal medicine practice, Dr. Poulson developed inflammatory breast cancer and knew it would claim her life. Writing in the Canadian Medical Journal she said:

In a paradoxical way, I think I can say that I feel more alive now than ever before in my life … When you presume to have infinity before you the value of each person, each relationship, all knowledge you possess is diluted.

I have found my Holy Grail: it is surrounding myself with my dear friends and family and enjoying sharing my fragile and precious time with them as I have never done before. I wonder wistfully why it took a disaster of such proportions before I could see so clearly what was truly important and uniquely mine.

About a year after being given a diagnosis of incurable esophageal cancer, Dr. Bill Bartholome, a pediatrician and ethicist at the University of Kansas, wrote:

I like the person I am now more than I have ever liked myself before. There is a kind of spontaneity and joyfulness in my life that I had rarely known before. I am free of the tyranny of all the things that need to get done. I realize now more than ever before that I exist in a ‘web’ of relationships that support and nourish me, that clinging to each other here ‘against the dark beyond’ is what makes us human … I have come to know more about what it means to receive and give love unconditionally.

Dr. Bartholome referred to this period before his death as “a gift.”

It has given me the opportunity of tying up the ‘loose ends’ that all our lives have. I have been provided the opportunity of reconnecting with those who have taught me, who have shared their lives with me, who have ‘touched’ my life. I have been able … to apologize for past wrongs, to seek forgiveness for past failings.

A healthy defiance is often palpable within the personal decisions of doctors who are living in the growing shadow of death. My friends Herbert Mauer and Lisa Mills, long-married oncologists, boldly renewed their vows before a crowd of family and friends during the months Herb was dying of cancer. In “When Breath Becomes Air,” the neurosurgeon Dr. Paul Kalanithi relates the decision he and his wife, the internist Dr. Lucy Kalanithi, made to have a child, while knowing full well that he was unlikely to see their daughter grow up. Such affirmations of couplehood in the face of death are not denial; but rather insubordination, eyes-wide-open commitments to living fully despite the force majeure.

Gratitude also commonly emerges in the experiences of dying clinicians. In one of our last email exchanges, my friend, the clinical psychologist Peter Rodis, wrote:

The shock of knowing I’ll die has passed. And the sorrow of it comes only at moments. Mostly, deep underneath, there is quiet, joyous anticipation and curiosity; gratitude for the days that remain; love all around. I am fortunate.

The neurologist Dr. Oliver Sacks concluded his essay “My Own Life” in exaltation.

Above all, I have been a sentient being, a thinking animal, on this beautiful planet, and that in itself has been an enormous privilege and adventure.

These experiences are like dabs of paint on an Impressionist’s canvas. Taking in this contemporary ars morendi we can appreciate how dying and well-being can coexist. For all the sadness and suffering that dying entails, our human potential for love, gratitude and joy persists.

How fitting would it be for a corrective to the medicalization of dying to come from the medical profession itself? The general public’s interest in what doctors do can teach all of us about living fully for whatever time we each have.

Ira Byock, a palliative care physician, is founder and chief medical officer of the Providence Institute for Human Caring in Torrance, Calif. His books include “Dying Well” and “The Best Care Possible.”

When Doctors Have Conflicts of Interest

My mother-in-law is an impressive woman.

At the age of 77, she still maintains a garden the size of my entire backyard, on the three acres of land she and my father-in-law, now 81, share in rural western Pennsylvania.

She does not tolerate stasis, and anytime my father-in-law collapses into his plaid armchair in front of the television, she appears on the scene within a minute or two, barks at him that there will be plenty of time to rest when they’re in the old age home, grabs the remote control, and turns the television off while simultaneously giving him another task to perform.

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Mikkael Sekeres, M.D.

Mikkael Sekeres, M.D.Credit

She has kept old age at bay through constant activity, sheer strength of will, and a splash of denial.

Her hip must have been bothering her for some time, then, before she let me and my wife in on her problem. At our insistence, she told one of her doctors, who sent her for X-rays and reviewed them with her, in his office, with my wife at her side.

“Ouch,” her doctor said, pointing at the image of her hip where her femur was scraping against the acetabulum of her pelvis, bone-on-bone. “That looks like it hurts.”

“Well, I do a few chores around the house in the morning and rest on the couch with a heating pad, and then I’m all right,” she told him.

My wife interjected. “Just so you understand, by ‘a few chores,’ she means that she plants five flats of flowers.”

Her doctor’s eyes widened. Recognizing that she is the type of person who would have to decide for herself when she was ready for surgery, he recommended she let the rest of us know when that time occurred. Earlier this summer, she decided it was time.

She met with the orthopedist who would perform her surgery, and the two quickly bonded. As it turned out, his wife is also a gardener, and like my father-in-law, he collects classic cars. He discussed the surgery he intended to perform, her likely recovery period, and then paused.

“Now, I have to tell you that the artificial hip I’m going to use is one that I had a hand in inventing, and although I will receive no royalties for implanting this hip in you, I do have a conflict of interest, and want to make sure you’re O.K. with that.”

I sit on our institution’s conflict of interest committee and this scenario, while not falling into the majority of doctor-patient interactions, is becoming increasingly common.

There are a number of different types of potential conflicts that can arise.

Like my mother-in-law’s surgeon, a doctor may invent a technology, or develop a drug, and receive payments every time that technology or drug is used – though, as my mother-in-law’s doctor told her, no royalties are received if the device is used at our institution. Still, you might wonder if his using that artificial hip influences other doctors who want to emulate him to use the same device, from which he would receive royalties.

Or, a doctor may provide advice to a company, for which she receives an honorarium, and conducts research (such as being an investigator on a clinical trial) using that company’s product. Will the payment she received influence her interpretation of the clinical trial results, in favor of the investigational drug? Or did she make the trial better because of the advice she provided?

What if, instead, the drug for which she provided advice is already commercially available. How much is her likelihood of prescribing this medication – what we call a conflict of commitment – influenced by her having been given an honorarium by the manufacturer for her advice about this or another drug made by the same company?

We know already that doctors are influenced in their prescribing patterns even by tchotchkes like pens or free lunches. One recent study of almost 280,000 physicians who received over 63,000 payments, most of which were in the form of free meals worth under $20, showed that these doctors were more likely to prescribe the blood pressure, cholesterol or antidepressant medication promoted as part of that meal than other medications in the same class of drugs. Are these incentives really enough to encroach on our sworn obligation to do what’s best for our patients, irrespective of outside influences? Perhaps, and that’s the reason many hospitals ban them.

In both scenarios the doctor should, at the very least, have to disclose the conflict to patients, either on a website, where patients could easily view it, or by informing them directly, as my mother-in-law’s doctor did to her.

More importantly, what do patients think of these conflicts? Back in the comfort of our family room, following her appointment, I asked my mother-in-law that very question.

“Oh, I was glad he told me.” I prodded her to go on, as she shifted in her chair, trying to get comfortable. “It made me trust him more. He must be an expert if he helped invent the hip. And of course I want him using the one he invented, he knows it better than anyone!”

It turns out, she’s not alone. In a study of over 600 surgical patients, about 80 percent felt it was both ethical and either did not influence, or actually benefited their health care, if their surgeons were consultants for surgical device companies.

It’s complicated. Certainly, the relationships doctors have with drug or device manufacturers drive innovation, and help make those products better for patients. But can we ever be sure these relationships aren’t influencing the purity of our practice of medicine, even a little?

Dr. Mikkael Sekeres is director of the leukemia program at the Cleveland Clinic. Follow him on Twitter @MikkaelSekeres.

Pelvic Exams May Not Prolong Life, a Task Force Says

Photo

Credit Stuart Bradford

Many women dread the indignity of the annual pelvic exam, in which they are poked and prodded with their feet in stirrups.

Now an influential government task force says there isn’t evidence that routine pelvic exams are necessary or prolong a woman’s life. Some experts think they may even do more harm than good.

And although some 60 million pelvic exams are done each year, the practice hasn’t been studied much. The United States Preventive Services Task Force, a panel of experts in preventative and primary care, declared today that the current evidence is “insufficient” to assess the balance of benefits and harms of the pelvic exam. The task force performed an exhaustive search of the medical literature published over the past 60 years and located only eight studies looking at the diagnostic accuracy of pelvic exams for just four medical conditions.

“We can’t make a recommendation one way or the other at this time,” said Dr. Maureen Phipps, the chairwoman of obstetrics and gynecology at Brown University’s Warren Alpert Medical School and a member of the task force. “We need more evidence.”

The finding refers only to the practice of routine pelvic exams for healthy women, and does not apply to women who are pregnant or those with existing conditions or symptoms that need to be evaluated.

“This is not a recommendation against doing the exam,” Dr. Phipps emphasized. “This is a recommendation to call for more research to figure out the benefits and harms associated with screening pelvic exams. That’s the big message here.”

This is the first time the Preventive Services Task Force has turned its attention to pelvic examinations, which can include a visual exam of external genitalia, an internal exam using a speculum, manual palpation to check the shape and size of the uterus, ovaries and fallopian tubes, and the simultaneous palpation of the rectum and vagina using lubricated gloves.

The recommendations about pelvic exams do not change current guidelines for cervical cancer screening, in which cells are collected from the surface of the cervix and vagina. The screening test is recommended every three years for women ages 21 to 29 and every five years for ages 30 to 65.

Pelvic exams have been subjected to quite a bit of scrutiny in recent years, possibly because of turf battles between physicians and reimbursement battles with insurers. The exams can be both time-consuming and expensive, in part because doctors are advised to have a chaperone present during the exam.

In 2014, the American College of Physicians told doctors to stop performing routine pelvic exams as part of a physical, saying there is no evidence they are useful and much evidence to suggest they can provoke fear, anxiety and pain in women, especially those who have suffered sexual abuse or other trauma.

The American Academy of Family Physicians endorsed that recommendation. But the American College of Obstetricians and Gynecologists (ACOG) continues to recommend an annual pelvic examination for women 21 and older, while acknowledging a dearth of data. Its Well-Woman Task Force, which was convened in 2015, recommended annual external exams but said internal speculum and bimanual exams for women without specific complaints or symptoms should be “a shared, informed decision between the patient and provider.”

“No woman should ever be coerced into having an exam, and that discussion should take place in a nonexam room environment, while the woman is fully dressed and sitting at equal level with the provider at a round table, without a desk between them,” said Dr. Barbara S. Levy, vice president for health policy at ACOG.

But Dr. Levy says that the exams should not be scrapped because trials – which would be difficult to design and fund — have not been carried out.

“I think there’s tremendous value in the laying on of hands,” Dr. Levy said. “Touch has a lot to do with establishing trust, and there are many things I can pick up on during a pelvic exam because I’m skilled and trained.”

She may pick up on the fact that a woman is experiencing abuse or domestic violence, or discover that a woman may benefit from interventions to strengthen muscles to prevent urinary incontinence down the line, she said, adding, “This is the art of medicine.”

Most obstetrician-gynecologists do routine pelvic exams, as do many other physicians, and the majority of preventive care visits between 2008 and 2010 included one, according to the task force’s report.

Health care providers say they can pick up on myriad gynecologic conditions during a pelvic exam, including cancers of the cervix, vagina, vulva, ovaries and endometrium, sexually transmitted diseases, genital warts and genital herpes, uterine fibroids, ovarian cysts and more.

But the task force found no studies that assessed how effective the exams are for reducing death and disease. So for example, although a pelvic exam might be useful in detecting ovarian cancer, the disease is relatively rare, so exams often result in false-positives that can lead to unnecessary surgery, the report said.

In four ovarian cancer screening studies with over 26,000 screened patients, more than 96 percent of the positive test results were false positives, meaning there was no real disease and many patients had unnecessary follow-up procedures.

But Dr. Levy said the call for more research is impractical. Exams are part of preventive care that is tricky to evaluate or assess, she said, and such studies are unlikely to get funded. “Looking for evidence-based answers to centuries-old processes and procedures doesn’t always make sense,” she said.

Reading Novels at Medical School

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Credit Getty Images

Sitting in a classroom at Georgetown Medical School usually reserved for committee meetings, we begin by reading an Emily Dickinson poem about the isolating power of sadness:

I measure every Grief I meet
With narrow, probing, eyes –
I wonder if It weighs like Mine –
Or has an Easier size.

It’s a strange sight: me, a surgical resident, reading poetry to 30 medical students late on a Tuesday night. Some of us are in scrubs, others in jeans; there are no white coats. Over the past four years, as the leader of the group, this has become my routine.

The students are here after long days in class and on the wards because they have discovered that medical education is changing them in ways that are unsettling. I remember that uneasiness well. My own medical education began with anatomy lab. The first day with the cadaver was unnerving, but after the first week the radio was blaring as we methodically dissected the anonymous body before us.

Two years later, on my first clinical rotation, I discovered that it does not take long to acclimate to the cries of patients as I hurried past their rooms, eager not to fall behind in a setting where work must be done quickly and efficiently. This practiced detachment feels necessary, a form of emotional and physical self-preservation. But with little time to slow down, ignoring our own thoughts and feelings quickly hardens into a habit.

During my first year in medical school, I found myself gravitating toward my old comfort zone — literature. As an English major, I had grown accustomed to the company of books and was feeling their absence now that “Don Quixote” had been displaced by Netter’s “Atlas of Human Anatomy.” I could look to Netter for concrete answers, but I needed Cervantes to help me formulate questions I had trouble pinning down, like why it was so easy to ignore the dead (and later, living) bodies around me? Illustrated cross-sections of the brain did little to illuminate the workings of my own mind. I needed time and space for introspection. The solution came in the form of a book club that later became an official course.

At Georgetown, the goal of our new literature and medicine track is to foster habits of reflection over four years of medical school. On the surface, the assigned books have nothing to do with medicine. We read no patient narratives, doctors’ memoirs or stories about disease.

Today’s topic is Haruki Murakami’s novel “Colorless Tsukuru Tazaki and His Years of Pilgrimage,” which tells the story of a depressed middle-aged Tokyoite’s attempt to retrace his past in order to understand how his life became so empty. We talk about the main character’s colorless perception of the world, and why his mind feels so inaccessible to us.

I receive an email from a student later that evening. He, an aspiring psychiatrist, tells me the story of a much-admired college mentor. “I heard last week that he committed suicide. I am still crushed,” he writes. “He was diagnosed with depression but seemed to be doing great.” If he so misjudged his teacher’s state of mind, he worries, how will he make it as a psychiatrist?

Earlier this year, we placed the ethics of animal testing under the magnifying glass of Karen Joy Fowler’s “We Are All Completely Beside Ourselves.” The novel is narrated by a woman whose “sibling,” we later discover, is a chimpanzee who was raised with her as part of a human-chimp experiment. We used the book to think through real-life examples like the Silver Spring Monkeys — a series of gruesome primate experiments that both galvanized American animal-rights groups and led to breakthrough scientific discoveries.

A third-year student talked about the three years he spent working with rhesus macaques. Research from his lab led to breakthrough discoveries about memory and behavior and contributed to therapies such as deep brain stimulation. “Doesn’t that answer the ethical questions?” he asked.

Another student talked about studies that she worked on for several years before starting medical school. “Have you heard of professional testers?” she asked the room. “People whose only source of income is volunteering for different studies, mostly college kids and immigrants? Shouldn’t we be talking about human research also?” For me, the discussion proved transformative. I walked into that class firmly supporting animal research and walked away still supporting research but no longer eating meat.

Our busy jobs on the hospital wards require precision and efficiency, but in literature class we can slow down and explore human lives and thoughts in a different, more complex way. The class is an anatomy lab of the mind. We examine cultural conventions and conflicting perspectives, and reflect on our own preconceived notions about life and work. Reading attentively and well, we hope, will become a sustaining part of our daily lives and practice.

As I’m walking out of the classroom at the end of the evening, a third-year student approaches me to tell me he’s been thinking more deeply about his experience of being an unrelated organ donor to his step-uncle, a man he barely knew. “It’s been on my mind since we read Ishiguro’s ‘Never Let Me Go’ last month,” he says. “I want to write about it. I don’t even know how I feel about it, and I need to figure it out.”

Daniel Marchalik, M.D., is a urologist in Washington and heads the literature and medicine track at the Georgetown University School of Medicine.