A number of politically tinged narratives have
divided physicians during the pandemic. It would be unfortunate if politics
obscured the major problem brought into stark relief by the pandemic: a system
that marginalizes physicians and strips them of agency.
In practices big and small, hospital-employed
or private practice, nursing homes or hospitals, there are serious issues
raising their heads for doctors and their patients.
No masks for you
When I walked into my office Thursday, March 12th, I assembled the office staff for the first time to talk about COVID. The prior weekend had been awash with scenes of mayhem in Italy, and I had come away with the dawning realization that my wishful thinking on the virus from Wuhan skipping us was dead wrong. The US focus had been on travel from China and other Far East hotspots. There was no such limitation on travel from Europe. The virus had clearly seeded Italy and possibly other parts of Europe heavily, and now the US was faced with the very real possibility that there was significant community spread that had occurred from travelers from Europe and Italy over the last month. I had assumed that seeing no cases in our hospitals and ICUs by early March meant the virus had been contained in China. That was clearly not the case.
Our testing apparatus had also largely been limited in the US to symptomatic patients who had been to high-risk countries. If Europe was seeded, this meant we had not been screening nearly enough people. When I heard the first few cases pop up in my county, it was clear the jig was up. It was pandemic panic mode time. There was a chance that there were thousands of cases in the community we didn’t know about and that we were weeks away from the die-off happening in hospitals in China and Italy. So what I told the staff the morning of March 12th was that we needed to start acting now as if there was significant spread of COVID in the community. This meant canceling clinic visits for all but urgent patients, wearing masks, trying to buy masks, attention to hand hygiene, cleaning rooms between patients, screening everyone for flu-like symptoms before coming to the office, and moving to a skeleton staff in the office. I left the office that day wearing a mask as I headed to the ER.
We have seen and heard about the classic symptoms of
COVID-19 at UCSF Medical Center, where I work as a cardiologist. Patients keep
coming in with pulmonary distress, pneumonia, and ultimately, Acute Respiratory
Distress Syndrome (ARDS) – the life-and-death situation that requires
However, I’m beginning to learn about other symptoms that some
doctors are noticing. There are numerous reports of other complications, especially
in advanced disease.
Elevation in D-Dimer, (a biomarker of coagulation system activation) has been associated with dramatically increased risk of death from COVID-19. This has led some to speculate that empiric treatment with anticoagulants might improve outcomes in these critically ill patients. Indeed, there was this recent publication of a retrospective analysis of anticoagulation with heparin or low molecular weight heparin showing an association with improved outcomes in COVID-19 patients in China.
One harsh Chicago winter, I remember calling a patient to cancel his appointment because we had deemed it too risky for patients to come in for routine visits—a major snowstorm made us rethink all non-essential appointments. Mr. Z was scheduled for his 3-month follow-up for an aggressive brain lymphoma that was diagnosed the prior year, during which he endured several rounds of intense chemotherapy. His discontent in hearing that his appointment was canceled was palpable; he confessed that he was very much looking forward to the visit so that he could greet the nurses, front-desk staff, and ask me how I was doing. My carefully crafted script explaining that his visit was “non-essential” and “postponable” fell on deaf ears. I was unprepared to hear Mr. Z question: if this is his care, shouldn’t he be the one to decide what’s essential and what’s not?
This is a question we are all grappling with in the face of the COVID-19 pandemic. The healthcare industry is struggling to decide how to handle patient visits to doctor’s offices, hospitals, and imaging centers, among others. Elective surgeries are being canceled and advocates are arguing that non-essential outpatient and ER visits should be stopped. Ideas are flying left and right on how best to triage patients in need. Everyone has an opinion, including those who ironically consider themselves non-opinionated.
an oncologist, these various views, sentiments, tweets, and posts give me
pause. I understand the rationale to minimize patients’ exposure and thus prevent
transmission. However, reconsidering what we should deem “essential” has made
me reflect broadly on our method of providing care. Suddenly, physicians are
becoming less concerned about (and constrained by) guidelines and requirements.
Learning how to practice “essential oncology” may leave lasting changes in our
Practices cannot survive the COVID-19 cash flow crisis
By JEFF LIVINGSTON, MD
Will doctors be able to keep their practices open during the worst pandemic in our lifetime? Our country needs every available doctor in the country to fight the challenges of Covid-19. Doctors working in independent practices face an immediate cash flow crisis threatening their ability to continue services.
The CARES Act was signed into law on Friday, March 27, 2020. The law offers much-needed help to the acute needs of hospitals and the medical supply chain. This aid will facilitate the production of critical supplies such as ventilators and PPE. The law failed to consider the needs of the doctors who will run the ventilators and wear the masks.
Cash flow crisis
Private-practice physician groups experienced an unprecedented reduction in in-office visits as they moved to provide a safe and secure environment for patients and staff. In compliance with CDC guidelines, practices suspended preventative care, nonurgent visits, nonemergent surgery, and office procedures.
These necessary practice changes help keep patients safe and slow the spread of Covid-19. The unintended consequence is an unreported and unrecognized cash flow crisis threatening the viability of physician practices.
By CHITRA CHHABRA KOHLI MD, AJAY KOHLI MD, and VINAY KOHLI MD, MBA
With a doubling time of cases estimated between 3 days within the U.S. and about 6 days globally (at the time of this writing) COVID-19 is demonstrating its terrifying virulence as it spreads across the world.
What’s perhaps equally terrifying, if not more, is the absence of a known cure or treatment plan for COVID-19. While there has been a lot of attention focused on Hydroxychloroquine and Azithromycin, there has been debate on the scientific validity of these treatment options, either as therapy or as prophylaxis. The impact of a solution certainly has far reaching potential, the scope of the challenge is overwhelmingly large. The editor-in-chief of Science recently wrote that the efforts to find a cure are not just ”fixing a plane while it’s flying — it’s fixing a plane that’s flying while its blueprints are still being drawn.”
There is a promising therapy that may help us weather the COVID-19 storm and, perhaps, flatten the curve. It’s based around science that defines immunology and has already been used in many different diseases, going as far back as the 1918 flu pandemic. This potential treatment is convalescent plasma therapy — using antibodies from patients who have recovered from COVID-19 and then transfusing them into patients who are currently mounting an immune response against the rapidly rising viral loads of COVID-19.
Occasionally, you get handed a question you know little about, but it’s clear you need to know more. Like most of us these days, I was chatting with my colleagues about the novel coronavirus. It goes by several names: SARS-CoV-2, 2019-nCoV or COVID-19 but I’ll just call it COVID. Declared a pandemic on March 12, 2020 by the World Health Organization (WHO), COVID is diagnosed by laboratory test – PCR. The early PCR test used in Wuhan was apparently low sensitivity (30-60%), lengthy to run (days), and in short supply. As CT scanning was relatively available, it became an importantdiagnostic tool for suspected COVID cases in Wuhan.
The prospect of scanning thousands of contagious patients was daunting, with many radiologists arguing back and forth about its appropriateness. As the pandemic has evolved, we now have better and faster PCR tests and most radiologists do not believe that CT scanning has a role for diagnosis of COVID, but rather should be reserved for its complications. Part of the reason is the concern of transmission of COVID to other patients or healthcare workers via the radiology department.
But then someone asked: “After you have scanned a patient for COVID, how long will the room be down?” And nobody really could answer – I certainly couldn’t. A recent white paper put forth by radiology leaders suggested anywhere from 30 minutes to three hours. A general review of infection control information for the radiologist and radiologic technologist can be found in Radiographics.
So, let’s go down the rabbit hole of infection control in the radiology department. While I’m a radiologist, and will speak about radiology-specific concerns, the fundamental rationale behind it is applicable to other ancillary treatment rooms in the hospital or outpatient arena, provided the appropriate specifics about THAT environment is obtained from references held by the CDC.
I got asked the other day to comment for Wired on the role of AI in Covid-19 detection, in particular for use with CT scanning. Since I didn’t know exactly what resources they had on the ground in China, I could only make some generic vaguely negative statements. I thought it would be worthwhile to expand on those ideas here, so I am writing two blog posts on the topic, on CT scanning for Covid-19, and on using AI on those CT scans.
As background, the pro-AI argument goes like this:
CT screening detects 97% of Covid-19, viral PCR only detects 70%!
A radiologist takes 5-10 minutes to read a CT chest scan. AI can do it in a second or two.
If you use CT for screening, there will be so many studies that radiologists will be overwhelmed.
In this first post, I will explain why CT, with or without AI, is not worthwhile for Covid-19 screening and diagnosis, and why that 97% sensitivity report is unfounded and unbelievable.
Next post, I will address the use of AI for this task specifically.
It took a 125 nanometer virus only a few weeks to move American healthcare from the twentieth to the twenty-first century.
This had nothing to do with science or technology and only to a small degree was it due to public interest or demand, which had both been present for decades. It happened this month for one simple reason: Medicare and Medicaid started paying for managing patient care without a face to face encounter.
Surprise! In the regular service industries, businesses either charge for their services or give certain services away for free to build customer loyalty. In healthcare, up until this month, any unreimbursed care or free advice was provided on top of the doctors’ already productivity driven work schedules.
By HOWARD LUKS MD, JOEL TOPF MD, FACP, ETHAN WEISS MD, CARRIE DIULUS MD, NANCY YEN SHIPLEY MD, ERIC LEVI MBBS, FRACS, BRYAN VARTABEDIAN MD
“EVERYTHING WE DO BEFORE A PANDEMIC WILL SEEM ALARMIST. EVERYTHING WE DO AFTER WILL SEEM INADEQUATE”
Last updated 3/18/2020.
Why are we writing this?
The COVID-19 pandemic has reached a point where containment is no longer possible. The COVID-19 threat is real, and rapidly getting worse. Many of you are very nervous, some are unsure of the validity of the information you are reading. As physician leaders, we felt it was important to craft a resource you can rely on as being scientifically accurate and one which contains as much actionable information and guidance as possible.
Accurate, actionable information during an epidemic can save lives. Physicians are on the front line of this epidemic. Not only are we treating the sick, but we are also cringing at the misinformation spread through both traditional broadcast and social media. Evidence matters. Unfortunately, evidence is often slow, methodical, and boring and has a tough time against clicky headlines and exaggeration. We believe that an accurate representation of the current COVID-19 pandemic followed by a set of actionable steps you, your loved ones, politicians and local officials can utilize is of paramount importance and ultimately could save tens of thousands of lives.
COVID-19 isn’t just the flu?
COVID-19 has been described by some as “just a cold”, or just like the common flu. COVID-19 is not the common flu. COVID-19 is an order of magnitude worse than the flu. The fatality rate is approximately 10 times worse than the flu.
The flu spreads from September through April in the US, and June through August in the Southern Hemisphere. Yes, it does cause severe illness in many, but it does so over a longer time course. Time is a variable that is working against us during this COVID-19 outbreak. COVID-19 victims will be presenting to a hospital in need of critical care at a rate that is far higher than occurs with the flu.
In addition, these patients will be requiring hospital treatment over the course of a few weeks rather than the 3-4 months of a typical flu season. The healthcare system in the USA is not ready to handle tens of thousands or hundreds of thousands of people over a short time frame. In Italy, the healthcare system buckled under the strain and the healthcare teams are now forced to make horrible life and death decisions.
As the globe faces a novel, highly transmissible,
lethal virus, I am most struck by a medicine cabinet that is embarrassingly
empty for doctors in this battle. This
means much of the debate centers on mitigation of spread of the virus. Tempers flare over discussions on travel
bans, social distancing, and self quarantines, yet the inescapable fact remains
that the medical community can do little more than support the varying
fractions of patients who progress from mild to severe and life threatening
disease. This isn’t meant to minimize the
massive efforts brought to bear to keep patients alive by health care workers
but those massive efforts to support failing organs in the severely ill are in
large part because we lack any effective therapy to combat the virus. It is akin to taking care of patients with
bacterial infections in an era before antibiotics, or HIV/AIDS in an era before
It should be a familiar feeling for at least
one of the leading physicians charged with managing the current crisis – Dr.
Anthony Fauci. Dr. Fauci started as an
immunologist at the NIH in the 1960s and quickly made breakthroughs in
previously fatal diseases marked by an overactive immune response. Strange reports of a new disease that was
sweeping through the gay community in the early 1980’s caused him to shift
focus to join the great battle against the AIDS epidemic.
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