Simranjit Singh, MD, Assistant Professor of Clinical Medicine, Indiana University School of Medicine
Q: How are you involved in the COVID response?
A: I am a frontline provider as a hospitalist at a tertiary care center providing care to COVID patients, and the Accountable Care Team Lead for the orthopedics-trauma-neurosurgery unit. As a lead physician, I offer clinical services pertaining to perioperative inpatient medicine care and leadership/administrative role of supervising and coordinating various disciplines including but not limited to nursing staff, social workers, case managers, physical/occupational therapists, and clinical managers, towards keeping daily patient care and unit operations effective. Therefore, along with providing care to the general COVID patient population, I am also involved in providing care to COVID patients in a perioperative setting. Currently, with the cancellation of the majority of elective surgeries, most of the care is channeled towards emergent surgeries. Emergent surgeries in the setting of COVID invariably pose a greater challenge from the standpoint of inpatient care, complications, disposition, etc.
Q: What novel methods have you had to implement in caring for patients during this time?
A: MDRs [Multidisciplinary rounds] are a vital tool in modern-day inpatient/hospitalist medicine practice. As an accountable care team lead, I am involved in supervising multidisciplinary rounds involving various disciplines like nursing staff, physical/occupational therapists, social workers, case managers, etc. Due to current COVID pandemic situation, in-house absence of many vital staff members (case managers, social workers, clinical managers) has posed a major challenge towards the efficient functioning of MDRs.
To bridge the gap and to keep MDRs effective, as a team, we have implemented utilization of WebEx call conference software to bring together clinical staff and providers. We have also utilized audio/video calling approach to connect patients and patient families to non-in-house clinical staff like social workers and case managers. Additionally, we provided personal room phones to patients under isolation. The list of patient’s room phones is made available to providers in a PDF format. Patients under isolation are provided updates over the phone [unless in-person presence of provider is deemed necessary] by primary and specialist services. This does not include the daily rounding visit by the primary team, which is provided as usual including thorough in-person evaluation. This strategy has effectively decreased the requirement of PPE and exposure to the coronavirus.
In coordination with case managers and social workers, we have implemented in-house models to triage patients early on based on anticipated disposition, to effectively minimize the length of stay, early discharge planning, and isolating discharge barriers in a timely fashion. These in-house models for triaging are designed specifically to COVID patient population.
Q: How has COVID effected your working relationships? How has communication and collaboration for patient care been affected?
A: Most surgeries and inpatient procedures are requiring COVID rule out, thus, increasing the waiting period with a possible impact on outcomes and associated complications. Most of the consultant services are not seeing COVID positive patients in person. They are offering services virtually/phone interviews and a chart review. This has further increased the burden of clinical responsibilities on primary [hospitalist] teams.
Due to visitor policies in place, no visitors are allowed. This requires more phone calls to patient's families regarding updates, therefore, it has further increased the daily work burden. It is even more challenging to engage family members over the phone in regards to sensitive discussions like goals of care and hospice care. As typically these discussions involve multiple team members/providers and family members. Arranging these conversations remotely is challenging both logistically and emotionally to patients and their families. This has led to extra responsibility for hospitalist physicians to bridge the gap.
Q: What advice would you like to give to SGIM members to encourage them in their efforts to contribute to the response?
A: These are unprecedented and difficult times. But at the same time, these challenging times are an opportunity to be creative and courageous. This is the time to unleash the best within us..
Nicole Lurie, MD, MSPH, Strategic Advisor to the CEO, Coalition for Epidemic Preparedness Innovations (CEPI)
Q: How are you involved in the COVID response?
A: When I left government, I decided to take the things I had learned to help make my country, and the world a better place. I’m working intensively with the Coalition for Epidemic Preparedness Innovations, a new international NGO dedicated to making vaccines for potentially epidemic diseases. I am now leading their incident management team for COVID vaccine development, which is an amazing opportunity to impact global health and the global ecosystem for epidemic emergencies. I am co-authoring a the background chapter on the R&D ecosystem for the Global Preparedness Monitoring Board, an international body set up to monitor implementation of pandemic-related recommendations, which is also now playing a key role in the COVID response. Domestically, I am co-chairing a webinar series that NAM and APHA are sponsoring on COVID. As dialysis patients are particularly vulnerable in disasters, I’ve also been working with the American Society of Nephrology on disaster preparedness in general, and now on COVID-related issues, and I have been advising members of Congress and their staffs on the response and related legislation. Finally, I serve on the Steering Committee for the DC Mayor’s ReOpening Council.
Q: How important is organizing international cooperation when leading the incident management team for COVID, and what are some of the advantages of organizing an international response?
A: International cooperation is critical because we need to ensure the best minds in the world are working together on the challenges of getting to a vaccine, manufacturing it at scale, and making it available, all the way down to the last mile, in a globally fair way, around the world. A huge goal is to ensure that vaccine doesn’t just go to rich countries-- from an equity perspective, a global health security perspective and because vaccinating front line workers around the world is key to economic recovery.
Q: What advice would you like to give to SGIM members to encourage them in their efforts to contribute to the response?
A: There are so many ways to contribute-whether in direct care, in clinical research (which is very badly needed), in putting in place plans and systems in your institutions, or in your community, whether with public health agencies or, as I am doing, on re-opening advisory committees. The behavioral health needs of individuals and communities are huge, and SGIM members have always been at the front line of innovation there. Finally, COVID is also going to fundamentally change the way we deliver care, including via tele-health. SGIM needs to help drive this system redesign; our patients depend on us to do that. If you’re not already involved, please start now.
Noble Maleque, MD, Assistant Professor of Medicine at Emory University
Q: How are you involved in the COVID response?
A: As a hospitalist I have been involved in the direct care of patients under investigation for COVID-19 as well as those who have tested positive. I have experienced taking care of patients both as a direct care frontline physician as well as a supervising attending physician for our medical housestaff. I have been involved in discussions as to how to implement tele-health consults in a responsible way. As an associate program director for residents, I have witnessed the amazing response of our residency leadership, chief residents, and administrative staff as they reconfigure deployment of residents, manage the changing landscape of patient care, and keep the needs and well-being of our trainees at the forefront while facing uncertainty in terms of best practices and service needs related to the COVID-19 crisis. As an advisor and mentor to medical students, I spend time connecting with them (virtually) as they process how this crisis has affected them and how it impacts their learning now and their career in the future.
Q: How has your day-to-day work changed since responding to COVID?
A: Like many others in healthcare, COVID-19 has permeated almost all facets of my life both in and out of work. In the clinical environment, the anxiety and stress surrounding management of COVID-19 patients as well as overwhelming diligence for one’s own personal safety feels overwhelming and has been exhausting. The same type of work feels more tiring and draining. I have been fortunate to feel supported with adequate personal protective equipment yet can feel the strain from my fellow health care workers as well as other hospital staff especially during the first few weeks when guidelines for best practices were evolving and there was confusion and uncertainty about how best to care for patients and ourselves with limited testing and limited interventions. Like many others, choosing how to best protect ourselves and those at home have led to changing normal routines that one takes for granted. From isolating myself at home including sleeping in a different bedroom for past month to multiple changes of clothing to/from work and a lot of showering, there is a constant reminder of how COVID is affecting my life.
Seeing how patients have to deal with their illness in isolation without the comfort of family or friends at bedside is often times heartbreaking. I spend more time now on the phone with family members offering updates and reassurances as to how their loved ones are doing. I miss spending time with patients getting to know them better as people but I find myself self-conscious about my proximity to them and the time spent in rooms. I know I have not been as thorough during routine daily physical exams as I should be. Yet I have daily reminders about the value and importance of the therapeutic touch. I will share a story of a middle aged African American man who was admitted with suspicion of COVID 19. He seemed like someone who didn’t let things get to him. This was early on during the COVID crisis. When he was informed that he indeed tested positive for the COVID virus he was stoic initially. As we talked more, he shared his fears for himself, for his family, and for his children. He had a young child at home the same age as mine and I found myself consoling him knowing that he could easily be me. It was only a five minute interaction in his hospital room but he was crying by the end. His tears were not as I thought related to fear but due to gratitude. He told me that I had made him feel like a regular person just by touching his hand and shoulder. In that way, I didn’t change what I would normally have been doing but it was a reminder to me about how special and privileged we are to help people when they are most vulnerable.
Q: What advice would you like to give to SGIM members to encourage them in their efforts to contribute to the response?
A: I hope members of SGIM know that I and many others are inspired by what they have been doing to contribute to this COVID19 crisis. I am proud to be part of an organization where so many have been continuing to work as advocates for our patients in the realm of health policy. I appreciate all the general internists especially in the ambulatory setting who have made many sacrifices including dealing with reduced patient encounters and quickly developing tele-health capabilities. These efforts on the outpatient side have made our work on the inpatient side much more manageable. For those involved in hospital medicine, I encourage them to remember how impactful we can be for our patients but also to each other and all the people we interact with in the hospital. For those involved with teaching, I have found it very challenging to maintain a productive learning environment. I think having honest conversations with your learners as they experience how this crisis affects them can be very helpful. In many ways, this crisis has flattened the typical hierarchy found in medicine as we are all facing this crisis together and learning about it and how we respond to a crisis together. I know that many people are being deployed and recruited to working outside of their usual comfort zone to care for the COVID19 patients. There are many resources that have been made available to help in that transition but the COVID response could not be possible without their efforts and I am proud to be their colleague.
Christopher O’Donnell, MD, Associate Professor of Medicine, Emory University School of Medicine
Q: How are you involved in the COVID response?
A: I am a hospitalist and have been taking care of the Person of Interests (PUIs) who are sick enough to need medical treatment and observation on the medical wards.
Q: How has your day-to-day work changed since responding to COVID?
A: There have been many changes to the day to day activities for myself and our hospitalist teams. PUIs are currently the plurality of the cases we see as our institution is limiting outpatient clinics and elective surgeries to minimize exposures and conserve protective personal equipment (PPE). As a result, our individual census is lower however we are finding that a COVID positive patient does stay in the hospital longer than an average patient with multiple co-morbidities. We need to coordinate follow up as well as coordinate with nursing homes and outside providers especially if they have comorbidities that need to be addressed. Additionally, our daily multidisciplinary rounds have been limited to a call in as opposed to a group meeting to enforce social distancing. Lastly, I have noticed that overall the floors have taken on a more somber tone as nurses, physicians, and ancillary staff are keeping their distancing from others with the jokes and casual interaction being much less. This is also true between the physicians in our group. A lot of the hospitalists in our group have children and loved ones that they are personally struggling with how to best protect them knowing that we are seeing COVID patients. Some of my colleagues are staying in hotels or in guest houses, or spare bedrooms when they are on service. Almost everyone is taking showers once they get home. For me, I am taking a shower at work before I leave, leaving my scrubs at work and changing into driving clothes and then leaving them in the car and showering immediately when I get home before I see my family. I am trying to minimize any work exposures for them.
Q: What advice would you like to give to SGIM members to encourage them in their efforts to contribute to the response?
A: I would advise everyone to stay positive and practice the social distancing to flatten the curve. I have seen a lot of healthcare providers feeling depressed, anxious, or angry regarding the situation that we are put in. I would definitely seek help if you feel that these are strongly affecting you. I would also have them reach out to their government representatives to make sure that your institutions receive enough PPE given the lack of preparation that was done nationally early on.
Karen DeSalvo, MD, MPH, MSc, SGIM Past President and Chief Health Officer at Google
Q: How are you involved in the COVID response?
A: At Google, we are focused on seeing that Search and YouTube provided authoritative information for people and this work has never been more important than in this historic global pandemic. We literally have billions of people depending on Google products to get through a normal day and the pandemic is one of the top topics people are looking for globally. My team is made up of physicians, pharmacists and public health experts who provide strategic guidance, knowledge and feedback to our products like Search and YouTube to ensure that users are getting authoritative information on COVID-19. For example, when people look up COVID-19 on Search, they are taken to a page that offers official information on symptoms, links to local public health authorities and more. On YouTube, we are providing community focused information such as our newly launched content for doctors. We are also providing services for the public health community. Last week we launched mobility reports, a tool that gathers insights on how communities have reacted to social distancing measures. We did this because we heard from public health officials that the same type of aggregated, anonymized data that we use for features on Google Maps could be helpful as they make critical decisions to combat COVID-19. These reports provide the community with insights into what has changed in response to work from home, shelter in place, and other policies aimed at flattening the curve of this pandemic.
Q: How has your day-to-day work changed since responding to COVID?
A: I was about 90 days into my role as Chief Health Officer at Google Health when I was pulled into Google’s company-wide COVID-19 response efforts. My “noogler” days - that’s what we call new Google employees - ended abruptly and I shifted into crisis response mode grounded in my experiences following Hurricane Katrina and Ebola. It has been a tremendous learning experience to be part of crisis response in the private sector.
Q: As SGIM President, what advice would you like to give to SGIM members to encourage them in their efforts to contribute to the response?
A: First, thank you. Your efforts are heroic, historic and appreciated by the community. Second, be kind to yourself and others - remember this is not a sprint. We have many months ahead of us. Third, consider whether COVID-19 could be an “accelerant use case” for projects that already mattered to you in your clinical, research, educational or policy work. Some of us may pivot focus, but for others, the pandemic may help accelerate getting work pushed ahead such as in telehealth, equity, or social.
Dan Hunt, MD, Director of the Emory Division of Hospital Medicine
Q: How are you involved in the COVID response?
A: I serve as the Director of the Emory Division of Hospital Medicine. We have more than 200 physicians and 40 advanced practice providers caring for patients in ten different hospitals in Atlanta. My role in responding to COVID-19 is primarily to support and to help make decisions with our outstanding leadership team that includes site directors who are managing hospitalist groups ranging from 14 to 47 clinicians. Our groups are on the frontline caring for many patients with COVID-19, preparing for the anticipated surge of patients that is expected later this month, learning every day, and adapting our systems to provide the best possible care. My major responsibilities in the COVID response at this point are communicating with our leadership team in daily huddles, communicating upward to system leadership to be sure we’re coordinating effort, and recognizing the efforts of our leaders and individual clinicians. I’ll be on the frontline when I return to the teaching service in May and before May as our clinical demands increase.
Q: How has your day-to-day work changed since responding to COVID?
A: In many ways, my day-to-day is quieter than usual. I’m working primarily in my office (with the door closed…which is unusual for me) but our administrative team and the other occupants on this typically busy floor are for the most part working remotely. I’m not someone who does well sitting in an office all day and I believe leadership is about personal connections, but I’ve had to curtail my informal and even scheduled visits with our teams. We’re doing a lot of Zoom meetings, Zoom interviews, and conference calls. Frankly, I hate these modes for interaction, but it’s the best we can do under social distancing conditions.
Although we’re still working on budgets, recruitment, research projects, and faculty development our focus is on COVID-19. Normally at this time of year, my calendar would be jammed with one-on-one career conferences for our individual faculty. Always a highlight of my year and we’ll delay these until social distancing is lifted. We’re also putting a number of major initiatives on hold for now and that’s disappointing but we’ll re-energize these when the crisis passes.
Q: How has your leadership been tested in organizing 250 clinicians during such a hectic and uncertain time?
A: As I mentioned before, we have an outstanding leadership team and much of the leadership of the division is being done by the team. Organization for our clinicians is primarily at the hospital level and this is better managed by site leaders who are intimately aware of their individual hospital systems and nuances. So it’s important for me to stay out of the way and to intercede or contribute only when it’s beneficial. And it’s even more important for me to make sure the efforts of our leaders and our teams are recognized.
It’s also important not to “command-and-control” at this point even though the leadership experts might identify the current state as a crisis that requires this approach. Trust in the decision-making of others is key to effectively addressing the uncertainty of the current situation and to sustaining an effective response over an extended period of time.
I think there’s a leadership temptation to communicate with the team too much during times of crisis. Email seems like an easy way to communicate but I’m sure all of our In Boxes have been jammed with COVID-19 communications to the point of distraction. And I’ve made a conscious decision not to add to the cacophony unless it’s absolutely essential.
We’re all dealing with our own anxieties about COVID-19 and it’s been important for me to try to remain calm in the midst of the storm. I’m also beginning to think ahead about our emergence from this crisis and how we’ll manage to get back on track, although the uncertainty we’re facing over the next few months makes it difficult to accurately envision that future.
Q: What advice would you like to give to SGIM members to encourage them in their efforts to contribute to the response?
A: Continue taking great care of patients. We’re seeing an inpatient census that’s about 60-70% of normal right now and we’re worried about all the patients who don’t have COVID-19 but are scared to come to the hospital. They need our help.
We should continue to share our experiences and share what we’re learning. Being able to share approaches with other division leaders around the country has been invaluable in shaping our approach.
And take time to celebrate the victories, even if they’re small. I’m trying to reach out to at least 2-3 colleagues each day by text or email to let them know what a great job they did or simply to let friends around the country know I’m thinking of them.