Frontliners

Q: How are you involved in the COVID response?
A: Overall, I’ve worked in the hospital caring for patients with COVID. In response to what I saw on the wards, and my own perceived failing of one patient in particular, I started a qualitative research project to investigate unintended consequences of health system, personal, and local government policies. Finally, given the racial/ethnic disparities in COVID-19 cases, hospitalizations, and deaths, I co-founded an interdisciplinary social justice consortium to suggest policy to address the long-standing structural inequities and systemic racism that have led to long standing health disparities that have been exacerbated by COVID .

Q: You currently work as an academic hospitalist at Montefiore Medical Center and a Professor at the Albert Einstein College of Medicine. You were not scheduled to see patients until August, yet in March you volunteered to return to the hospital at the start of the pandemic and in the most populous city in the U.S. What drove you to volunteer despite the fear and unknowns surrounding the novel virus ?
A: My hospitalist colleagues at the where I see patients (Weiler hospital) started a Whatsapp chat. We talked about what was going on, shared resources related to COVID-19, etc. In those chats I could feel the fear. My colleagues started getting sick and I emailed the director of the service and gave him my availability to pick up shifts for sick colleagues.

Q: You volunteered again in May to treat COVID-19 patients. How were patient care and safety protocols for hospitalists adjusted in that time?
A: In May, they needed help covering weekend coverage, and I chipped in again. This time was so much easier. In March we were truly building the plane as we flew it. Our Division Chief, Dr. Will Southern, met with us regularly, at the peak making himself available for nightly group calls. We were sure that some patients were dying suddenly from massive pulmonary emboli, among other things, but we couldn’t get autopsies to prove it. We all tried to share information and even had extra calls with the teams coming on service to share updates, all in the hope of trying to save lives. COVID in March was worse than anything I had imagined. When I returned in May, the difference was amazing. For one, I wasn’t scared anymore. The advances in our understanding of the disease process and the outcomes of research we had pioneered in our hospitals created so much more guidance. we were trying so hard to help people in the beginning, and we felt helpless when the overhead announcements for code after code seemed endless. By May we had a much better handle on what to do, could more reliably anticipate patients going into cytokine storm, intubate people earlier, prone patients, etc. My mind is blown by the advances we all made in five weeks.

Q: After your time in the hospital with COVID-19 patients, you began qualitative research on policies and patient care. Can you explain your research a bit more?
A: On my first day caring for patients with COVID-19 in March, I discharged a woman home. I was so happy she had survived, and I was happy to explain things to her in Spanish. The next day, I found out she sleeps in a room with five people. I realized that by sending her home to “isolate” I sent her home to infect her family. I was devastated. That experience motivated me to invite one of my subspecialty colleagues, Dr. Irene Blanco (a rheumatologist who was redeployed to the medicine wards) and a primary care colleague, Dr. Shani Scott, to design an open-ended qualitative survey. This survey is an in-depth inquiry into people’s perspectives on policies with unintended consequences, policies that worked, and lessons learned. We are focused on policies at the health system, local government, and personal decision-making levels. You can participate in the survey here: https://www.surveymonkey.com/r/V5BLKSP.

Another experience in March led me to co-found an interdisciplinary social justice collaborative. One day I was already gowned up and had donned my PPE. One of the food service workers was on the floor and I asked her if she could just give the trays to the few patients who were COVID negative on the floor, and leave the trays outside the other rooms; I would then distribute the trays and then see my own patients with COVID. It so happened that the other half of the patients on the floor were much younger than mine. I went into room after room and met young, Black and Brown men - all sick, all on oxygen. My heart broke. When I was done I had to duck into the stairwell and cry it out. I was already working with members of SGIM’s Health Equity Commission to work to address health disparities. I had to contribute to progress toward health equity. I knew we needed to capitalize on this narrow window of political will to change the structural factors and systemic racism that drive and perpetuate health disparities. Then George Floyd was murdered, and the protest began anew. An attorney friend and I convened a group of physicians, attorneys, scientists, teachers, public health and policy experts, a historian, an economist a sociologist, and a cost-effectiveness researcher, and are working in our spare time to create policy to suggest to the Governor of New York.

Q: What did your research conclude, and how have you used your findings to promote better policy for future waves of the virus?
A: Data analysis is still underway, but preliminary findings include lessons learned on positive and negative consequences of suggested policies. Lessons learned include the need for home pulse oximetry monitoring, follow-up care to monitor for symptoms and need to return to ED, creative ways to help patients manage their chronic disease so they do not need to leave their homes (for example, for prescription refills). When facing an unknown disease use the most protective PPE first and then if the science proves it is not airborne de-escalate to surgical masks. Not the other way around.

All policies affect health. For example, cutting down the number of subway trains or busses that ran when some people started working from home may have seemed cost effective at the time, but in reality it led to essential workers standing on crowded platforms and bus stops and causing unnecessary spread of disease in predominantly minority communities. We need better palliative care preparedness. People are going to die in pandemics and we need to be ready to care for dying patients and prevent needless suffering as well as needless exposure to healthcare workers during multiple futile codes. Drive through testing sites were short-sighted. Calling healthcare workers heroes made it harder for some to ask for help when they needed it, and had other unintended negative consequences that should be balanced in the next wave.

Anticipate issues like depression, anxiety, and PTSD in both the community and front-line workers. Find a routine and support system now if possible that make you feel better. Anticipate shortages for the second wave and be proactive in protecting essential workers, advocate for paid sick leave (inequities exist within hospital systems even, in addition to general society). Make a plan now for where to send people who need to isolate after hospital discharge.

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 encourage people to find ways to get involved in local politics. Never before had I really paid attention to local politics, or even who my Congressperson was. Now I do. Everyone is very busy with different levels of interest and expertise in the topic. For those who are so inclined, I would suggest encouraging your patients to vote. Contributing to efforts to get patients registered to vote. Underserved areas will remain underserved if politicians (of either party) don’t feel the need to respond to voters in the area- which they definitely will not feel if people don’t vote. Or sit on health system committees to lend your perspective as a person who directly cared for patients, and help improve the system in general, and the response for the anticipated second wave. Our voices matter. Please take the time to fill out our survey: https://www.surveymonkey.com/r/V5BLKSP. Thank you!

Q: How are you involved in the COVID response?
A: We were involved in the COVID-19 response by providing direct medical care in outpatient and inpatient setting. Additionally, as a healthcare executive I was involved in risk assessment, screening process and project management of dealing with COVID-19 pandemic aboard a vessel and in the office premises in Athens, Singapore, Philippines, Romania, Ukraine, Korea, China, Shanghai. We developed a Business Continuity Management Plan to prepare, respond, and recover from various types of operational threats and to reduce the potential impact of a pandemic event. Following the COVID19 2020 Pandemic we established new procedures in order to comply with all measures required by WHO (World Health Organization), Greek Public Authorities and the National Organisation of Public Health. With sense of accountability towards employees and partners, we took all necessary precautions to preserve public health and employees’ health and wellbeing.

Q: Your focus is in cancer immunology and immunotherapy. How has COVID effected your ability to conduct research and provide quality care for cancer patients? Has telehealth played a role??
A: The COVID-19 pandemic has disrupted the spectrum of cancer care, including delaying diagnoses and treatment and halting clinical trials.

First, although the data remain limited, patients with cancer appear to be more vulnerable to worse outcomes from the infection. Second, diagnosis may be delayed as screening programs and diagnostic services have been decreased, and patients have been more reluctant to present to healthcare services. Third, treatment pathways (surgeries, radiation treatment) have been altered to minimize potential exposure of patients with cancer to COVID-19. Fourth, certain aspects of ongoing care have been deprioritized to enable health systems to respond to the COVID-19 pandemic, which has resulted in patients’ receiving suboptimal care. Fifth, many clinical trials have been suspended and has jeopardized longer-term therapy development.

In response, as healthcare professionals we acted quickly to mitigate the repercussions of COVID-19 on the provision of cancer care by updating guidance for medical staff and patients. In terms of cancer immunity research, the long-term impact on therapy is hard to evaluate, but many trials are on hold, from practice-changing to novel agents. New drugs will not be offered to patients for many months to come. The research effort across the community, academics, government and industry, is halted. Due to my experience as a medical provider in shipping, telehealth the last four years has been my daily routine. Additionally, due to the shipping company’s structure, with offices in seven different countries, working remotely is our day-to-day practice, therefore, we were ready to implement fully teleworking and telehealth. Telehealth can be used as a strategy of continuity of care, to the extent possible, for chronic, or routine care that might otherwise be delayed. Telehealth visits can help determine when it is reasonable to defer an in-person service.

During the Greek Lockdown (from March 11th to May 4th) all medical visits were held through telehealth first and then with an in-person meeting. Even staff meetings were conducted through zoom instead of the usual morning gathering, in order to maintain social distancing.

Q: You completed your medical training in both Greece and the United States. How does the field of internal medicine differ between the two nations, and why do you think the United States has failed to contain the virus?
A: Internal Medicine in Greece is more primary care oriented. We are the patient’s first point of care and contact. We also manage many diseases that in the US, specialists would take care of. In the US, internal medicine physicians, nowadays, choose a hospitalist or primary care pathway, and sometimes they may act as revolving doors to a patient’s care. In Greece, we take a traditional approach, the one that existed many years ago in the US. We care for the patient as primary care providers, when in need of hospitalization and after discharge from the hospital, we continue to follow-up his care.

On the other hand, technology, structures and amenities, subspecialists and R&D in medicine, are way better in the US, helping both healthcare providers and patients to achieve the best care possible.

Q: What advice would you like to give to SGIM members to encourage them in their efforts to contribute to the response?
A: Providing care to others during the COVID-19 pandemic can lead to stress, anxiety, fear, and other strong emotions. Health workers are facing unprecedented circumstances and pressure during the coronavirus (COVID-19) outbreak. We lost patients, colleagues, friends, even family members to the COVID-19 battle. Showing resilience, compassion, empathy and support is our daily routine, but it takes a toll on our personal relationships and mental health. My advice would be to take regular breaks from the COVID-19 frenzy, reconnecting with friends, family and ourselves. We need to stay strong to help the community.

Q: How are you involved in the COVID response?
A: As a leader in our health care system as the Chief of the UCSF Division of General Internal Medicine for UCSF Health - and as a GIM clinician and educator. 

Q: California is now leading the nation in positive COVID-19 cases, however San Francisco county accounts for only 5500 of the 432,000 confirmed cases. What are the major factors keeping San Francisco numbers so low compared to southern California?
A: It seems that in the San Francisco Bay Area we were both smart and lucky. We instituted shelter in place earlier than most through local government edict and with the support of many of the prominent tech companies (it turns out that even one week earlier of SIP seems to have made a significant difference in cases and deaths when one compares Southern California with San Francisco), and we have a highly educated population living for the most part in lower density settings along with other factors intrinsic to San Francisco. The Bay Area experience also underscores the importance of strong, proactive, engaged, and evidence-based leadership who believe in science and rely on epidemiological data to make decisions. Who knew that would matter!!

Q: How has COVID tested your leadership as Chief of General Internal Medicine at UCSF?
A: It has been a challenging time for all of us in so many ways. I was approached by UCSF Health leadership at the very outset of the pandemic and asked if the Division of General Internal Medicine (DGIM) would take responsibility for standing up and leading the ambulatory response to the crisis: Respiratory Symptom Clinics (RSCs). At the time, like our colleagues across the country, we were expecting and preparing for a large surge of patients to overwhelm our ambulatory practices and the ED. Literally overnight, we transformed the urgent care clinic we run into an RSC and created a second one in clinic space that had recently been vacated. So operationally, we were gearing up to prepare for the surge while continuing to care for our large cohort of multimorbid primary care patients and trying to maintain our high standards for our educational and research programs. This put tremendous strain on DGIM faculty, staff, and trainees—many of whom were also confronting their own personal challenges of kids now home from school, staff with new financial challenges, and so on. Maintaining DGIM’s sense of purpose and mission, attending to the personal and professional challenges for many faculty and staff, and overseeing increasingly complex finances, all while doing our part to respond to the crisis was both challenging and exhilarating. I am beyond proud of how our entire division responded.

Q: As the Associate Vice Provost for UCSF Faculty Mentoring Program, how has COVID effected mentoring programs, and how have mentoring practices been adjusted for the current medical environment?
A: This is an interesting question. I have long spoken about the importance of distance and virtual mentoring as part of a robust mentoring program. But there is not much empirical evidence on best practices for virtual mentoring. This has allowed us to think more deeply about how to support faculty development and mentoring in an environment in which face-to-face meetings are not possible. I think we have learned that like many other aspects of this new Zoom world, that we can have satisfying mentoring relationships by Zoom, just like we can conduct other meetings and even care for patients in this way. Just not exclusively – and not forever.

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 that SGIM and its members can contribute, but perhaps the most important is for us to individually and collectively help lead the response to the crushing and immoral disparities that are evident in who is being most impacted by COVID. It has been said that there are two pandemics taking place in this country: structural racism and COVID-19. But of course, these crises are inextricably linked, and I am so proud of SGIM for speaking up for social justice and acting against structural racism and health care disparities.

Q: How are you involved in the COVID response?
A: One of my current major areas of focus is working with chairs, chiefs, GME, and other leaders to adjust and refine our medical surge staffing plans based on changing conditions and on anticipated future needs. I work with medical directors from the other hospitals in our system to address COVID-19 census management and load leveling issues. I communicate regularly with our medical staff, housestaff, and executive team regarding updated protocols and changes in our current situation. I relay questions, concerns, and updates to our hospital Incident Command meetings as our Medical Staff Supervisor, and round regularly in our ED, ICU’s, and med-surg units to identify questions and concerns and to share information. I have been volunteering on a team that performs community screening for COVID-19 for residents of assisted living and skilled nursing facilities and continue to see patients in clinic. 

Q: We are currently seeing a severe rise in cases in Washington state. How is your institution learning from hospitals and medical centers in former hot spots to better handle the current surge?
A: We are using a variety of resources to learn from others’ experiences, including:
a. Society of Critical Care Medicine
   i. Webinars - https://covid19.sccm.org/webcast/
   ii. Rapid resource center - https://www.sccm.org/COVID19RapidResources/Home
b. CHEST
   i. COVID-19: Advice From the Front Lines webinar series
c. CDC/IDSA COVID Clinician Calls
   i. https://www.idsociety.org/Podcasts/
d. Project ECHO COVID-19 Clinical rounds –
   i. https://echo.unm.edu/covid-19/sessions/hhs-aspr-clinical-rounds

Many of us have also leveraged our informal networks of colleagues and peers, including participating in large WhatsApp discussion groups.

Q: Institutional departments have a habit of working independently from one another. How has COVID-19 altered communication and collaboration between departments at the University of Washington Medical Center to ensure the best patient care and safety protocols are followed?
A: Effective communication, efficient, high-quality, decision making, and good situational awareness are critical to a successful organization response to a challenge such as the emergence of COVID-19. Many of our most important questions are being addressed by new work groups of multiple department chairs, service chiefs, medical directors, GME, and administrative leaders. These groups have been meeting regularly at the University of Washington Medical Center and across our UW Medicine enterprise to address issues such as medical staff surge planning, surgical services recovery efforts, and our procedural infection control practices. In early March we developed an intranet site, which was subsequently made publicly available, to provide ready access to our current patient care protocols and guidelines. Since mid-March our Associate Dean for Faculty Affairs has facilitated weekly or bi-weekly virtual town halls in which our chief medical officer and hospital medical directors, chief nursing officers, infection prevention medical directors, and our Assistant Dean for Well-Being address question from faculty and staff on infection prevention, safety protocols, and other topics of general interest.

Q: What advice would you like to give to SGIM members to encourage them in their efforts to contribute to the response?
A: SGIM members have an abundance of skills, knowledge, and passion needed to meaningfully contribute to our patients, our organizations, and our communities during the COVID-19 response. Please be as generous as possible with your time and talents while taking enough time to promote and preserve your personal and family well-being during this uniquely challenging time.

Q: How are you involved in the COVID response?
A: My major contribution to the Yale New Haven Hospital COVID response was as a part of the Hospital Incident Command System (HICS). In this role, I was accountable for the planning and implementation of a strategy to care for admitted COVID-19 patients. At our peak census in April of 450 COVID-19 patients, we had 27 dedicated medical/surgical units for COVID care, a dedicated obstetrics COVID-19 unit, and were using a converted medical/surgical floor, PACU, and OR spaces as ICUs for our COVID-19 patients. Currently, we are running with 3 COVID units and a converted medical/surgical unit that now functions as an ICU. 

Q: What has the response been at Yale New Haven Hospital, and how have you as the Director of Bed Resources at YNHH and your department had to adjust to COVID?
A: COVID-19 created an unprecedented challenge to our hospital, health system, and State of Connecticut. The standard pathways of providing inpatient care had to be rewritten from scratch in a short period of time. Through coordination with our health system and other facilities across the State, a level of collaboration and mutual aid was clear at all levels. In my Director, Bed Resources role, I was asked to coordinate the inpatient resources for non-ICU care across all of Yale New Haven Health, a 7-campus health system in Connecticut and Rhode Island. In New Haven, business as usual ceased and this was a critically important decision that allowed us to navigate our peak COVID-19 census, which was 450 admitted patients.

Q: On June 17^th, New Haven began its Phase 2 opening. It is likely a rise in cases will occur as the county opens more and more. What have you and your division learned and implemented since March so that it will be better equipped to handle a new spike in cases?
A:We quickly realized that there is no playbook for this kind of a disease when it comes to capacity management. We viewed this as a learning experience in addition to disaster response. Through copious notes and a process of cross-checking each step as we went along during our initial COVID-19 response, we feel more prepared for an additional spike. We are also updating our institutional Capacity Surge Plan to incorporate lessons learned in anticipation of a difficult influenza season. The areas focus in our inpatient medicine resources and our emergency department as these are the clinical areas most impacted by COVID-19 thus far.

Q: What advice would you like to give to SGIM members to encourage them in their efforts to contribute to the response?
A: I was clinically active during the peak, seeing inpatients that were admitted to a converted ambulatory infusion center and adults admitted to an overflow unit in the children's hospital. I can say that the sense of collaboration and shared goals was palpable at every level. Any sense of the tribalism we sometimes encounter was gone. Everyone was willing to help everyone else. This is what makes our profession special. This forms the basis for my advice: You're not alone. Whatever you need, clinical advice on a patient, or how to manage a major change in clinical workflow, or perhaps even a few minutes of quiet during a terrible shift - just ask. Someone will be there for you because we're all in this together. And, of course, if someone asks you, be there for them. As I tell my colleagues and residents, we are all in the same canoe and it only works if we paddle in the same direction.

Q: How are you involved in the COVID response?
A: At times, I feel like I have been relegated to head cheerleader! I have a very capable group of faculty who were here when Hurricane Ike devastated Galveston in 2008. At the time, there was talk of shutting down the hospital and the medical school and moving operations to Austin. The faculty who took care our patients then are now in leadership roles throughout the School of Medicine and health system. These hurricane veterans know their jobs and responsibilities. My job is to get out of the way and just ask “how can I help?” I do sit in on the operational and strategic meetings and advocate for my faculty. I am trying to strike a balance between standing up extra inpatient teams while maintaining our outpatient clinic responsibilities. Reducing outpatient access due to physical distancing needs leads to greater inpatient admissions down the road, thus burdening the inpatient teams that need to focus on COVID patients.

Q: When did you transition into your new role as Division Chief?
A: Prior to being named Division Chief of General Medicine at the University of Texas Medical Branch at Galveston, I was at the University of Texas MD Anderson Cancer Center in Houston for 15 years. I started at UTMB on Monday, February 3rd of 2020. At that time, COVID19 was just beginning to reach our shores in the United States. Many of believed it would be like SARS or MERS but reports out of Italy during the first few weeks of February really changed our perceptions. We all slowly came to the realization that COVID19 was going to be history changing event.

Q: You are both the leading figure in your team and a high-risk person for COVID. Because you are unable to work directly with COVID patients, how have you had to adapt your leadership?
A: One of my leadership principles is that in order to lead the team, you must be part of the team. In my previous position, I worked in all the different service lines we offered, from the Perioperative Medicine program to the Suspicion of Cancer Clinic. Being at the bedside allowed me to experience the daily frustrations of my faculty and respond as a leader. I also insisted that weekend call and backup call was a shared responsibility, so it was divided equally amongst all of us, including me. I plan to do the same with my new team at Galveston.

When we started planning our inpatient surge teams in March, I expected to do my part as an Attending. We had placed higher- risk faculty members on “non COVID” teams and sought out volunteers for the COVID Surge teams and COVID Diagnosis Clinic. With the data showing that I am at higher risk for severe COVID complications, my new team effectively mutinied against me (Galveston has a rich history of pirate lore) and kept me off the COVID teams. This surreptitious act of changing the schedule showed that they had embraced me as one of their own and felt the need to protect me. For that, I am extremely grateful and blessed.

From a leadership perspective, I am learning a whole new organization that is facing a crisis in unprecedented times. What was supposed to be a leisurely six-month long learning and listening tour turned into a crisis response position role requiring me to make rapid decisions without full insight into the history or strengths of my team or the institution. My faculty know how to respond in a crisis. My job is to ask what they need from an institutional response perspective and do my best to see that they get it.

At the same time, the team and greater institution is trying to get an idea of who I am as a leader. I was able to pull off several small group “Say hi to Sahai” meetings in February, but then we went into lockdown in March. I sent my team an email in April of 2020 when we thought the tsunami was going to hit Texas summarizing my feelings and hoping to lift their spirits. I subsequently shared the email on LinkedIn. It has since gotten over 30 thousand views. You can read it here. The tsunami is hitting us three months later than expected, but my thoughts remain the same.

Q: What advice would you like to give to SGIM members to encourage them in their efforts to contribute to the response?
A: It now sounds trite, but Mr. Rogers said it the best, “look for the helpers”.  I am blessed to have faculty and team who have embraced the crisis to do what we do best, take care of patients.  As General Internists, our role should be helping the helpers by supporting them in whatever way we can if we are not on the frontline.  If we are at the bedside, we must continually remind each other about selfcare and burnout prevention. Don’t “doomscroll” on social media at night before going to bed. Advocate for sound science and public health measures in your neighborhoods and communities.  Be the source for evidence-based medical measures and teach the nuance of medicine to our fellow citizens.  Don’t be afraid to call out politicians or pundits in your communities sprouting conspiracy theories or questionable medical advice. Explain the science as best we can.  Don’t be afraid to say, “we don’t know yet; based on what we know, this is our best guess.”  We will get through this together.

Q: How are you involved in the COVID response?
A: I am the Associate Vice Chair for Ambulatory Practices in the Department of Medicine as well as the Clinical Director for one of our academic General Internal Medicine practices. Early on in the COVID pandemic, I partnered with several other institutional ambulatory leaders, (including SGIM member Stephen Sisson, MD), to form the Johns Hopkins Ambulatory Incident Command team. 

Our group worked to rapidly set up an infrastructure to facilitate COVID testing of patients, and developed drive through testing tents at six hospital and ambulatory locations.  We have performed over 25,000 tests since inception. As part of this effort, we also developed testing guidelines for practitioners in conjunction with our Infection Control team.

We also realized that many patients did not have a primary provider who could triage their COVID symptoms, so we established the COVID Ambulatory Response Team (CART). This is staffed by nurses and re-deployed physicians to facilitate COVID testing for individuals without primary care as well as for follow-up post-COVID diagnosis or post-hospital discharge if necessary.  This became a central resource for the care of many of our Latino patients. We worked closely with our inpatient colleagues as well as care management teams to ensure patients were transitioned from the hospital after a COVID diagnosis and had adequate follow-up with the CART.

Our team partnered with the Maryland Health Department to assist in nursing home COVID testing and screening, sending teams into the facilities for onsite evaluation in an effort to reduce further spread in facilities.

Along with fellow SGIM member Bimal Ashar, MD, we established the Employee Covid Call Center (ECCC) to handle the Johns Hopkins Health System employees’ concerns about possible COVID symptoms or exposures and have had upwards of 10,000 incoming calls. We developed screening and triage guidelines for COVID testing as well as return to work guidance. With rapid testing available, we were able to identify those who needed to be home, as well as those who could quickly and safely return to work. 

At an institutional and departmental level, I have worked on our plans for delivering team-based care throughout this crisis.  Soon after the start, we dramatically increased our capacity for telemedicine. Now that we are increasing our in-person visits, I am working with divisions to continue the team based approach in both the clinic and telemedicine space.  I also continue to see clinic patients in person and via telehealth. 

Q: Because there are so many unknowns surrounding COVID-19, how does the fluctuating research effect your ability to create clinical guidelines?
A: As we created the guidelines for screening, testing, return to work, returning to clinic of COVID+ patients, etc., we partnered with our hospital infection control and infectious disease experts daily. We tried to align with CDC guidance but often had to make decisions based on the local supply of testing kits, reagents, and PPE. We were fortunate enough to have a robust infrastructure, and our supply chain as well as lab support was fantastic. We relied on the expertise of our infectious disease colleagues to monitor early reports on the disease to inform our decisions, but we also listened to feedback from frontline providers who were seeing the disease in real time to give us a sense of presenting symptoms. Early on in the response we had to frequently change the guidelines to address new evidence and local issues. Although the pace of change has slowed, we are still making adjustments.

Realizing other academic institutions were going through a similar process, I have worked to share Johns Hopkins guidelines through the AAMC Covid-19 Clinical Guidance Repository that is accessible for clinicians.

Q: As more states loosen restrictions and non-COVID related medical care returns, what do you anticipate the new “normal” looking like for ambulatory care?
A: I think this is an evolving process. Given the importance of physical distancing, minimizing extended exposure to crowded areas, and aggressive cleaning protocols that are necessary to ensure a safe environment for our patients and staff, the clinic workflow will dramatically change. Clinic visits will be streamlined to avoid busy waiting rooms and multiple stops. Hopefully, this will translate into a more efficient and patient friendly visit. Additionally, telemedicine has now been embraced and we should continue to build on this success. Telemedicine can help reduce the number of in person visits needed, but we should expand the services we can offer with telemedicine, for example in monitoring for heart failure, diabetes, etc. It can be used for more frequent “check ins” for patients with multiple comorbidities. We should look to simplify our telemedicine platforms to ensure that our disadvantaged patients may also benefit from these programs.

Q: What advice would you like to give to SGIM members to encourage them in their efforts to contribute to the response?
A: I have been fortunate enough to work with colleagues from across my health system during this challenge and value that experience. I have realized the importance of bringing the “generalist’s view” to the problem solving table. There is still a lot in front of us, and much to be done, and we need to be “all in”.

Q: How are you involved in the COVID response?
A: I have been involved on several fronts to combat the COVID-19 pandemic in Louisiana. One example is epidemic modeling of the COVID-19 pandemic curve. My Team and I (Ochsner Center for Outcomes and Health Services Research) worked with Louisiana Department of Health to create epidemic models for select hospital regions to predict ICU/mechanical ventilation needs. We provided the same information on a daily basis for hospitals in the Greater New Orleans area which was hardest hit by the pandemic.

I am also part of the Louisiana COVID-19 Health Equity Task Force. Specifically, the Health Disparities Task Force subcommittee which is tasked with reviewing the Louisiana Crisis Standard of Care, strategies to address medical mistrust and provider bias, and evidence-based practices to improve health equity.

My team has also created and is maintaining a comprehensive research database for all patients tested for COVID-19. 29 studies (combination of observational studies and clinical trials) are currently utilizing the database.

In the midst of all this, I am continuing precepting in the ambulatory clinic to assist residents with rapidly transitioning to Telemedicine virtual video and audio visits.

Q: In congruency with data collected across the country, your most recent study at Ochsner Health Center for Outcomes and Health Services Research in Louisiana found that, “black race was associated with approximately twice the odds of hospital admission as white race”. Why is the black race so disproportionally effected by COVID-19?
A: The problem is multi-factorial.

Community testing was not widely available and only patients with symptoms (including fever) could be tested. A higher proportion of black patients had Medicaid, lived in low-income neighborhood and were tested in the ED instead of clinic or urgent care. A higher proportion of black patients appeared to be sicker at presentation. The trends occurred in a community with a large African American population and whose economy is heavily dependent on the tourist/service industry. Minorities are disproportionately represented in service industry jobs in the Greater New Orleans area. Service industry jobs are occupied by the working poor who likely are not eligible for Medicaid and if their employer offers insurance, they are likely not able to afford premiums and co-pay. Under these circumstances people are more likely to delay care and/or seek care in the ED. Most of the essential worker jobs (like grocery store workers) did not have the luxury of working from home, making social distancing more difficult. Additionally, low income, minority neighborhoods tend to have dense housing with duplex and quadruplex housing units. Minorities often live in multigenerational homes – which likely includes an essential worker, again making social distancing impractical. Minorities have higher rates of obesity, diabetes and hypertension – conditions which may increase the risk of poor outcomes.

Q: Are you concerned about a spike in COVID-19 cases in the weeks following mass protests, and is there concern that protest-related COVID-19 cases will continue to disproportionally effect African Americans?
A: We are still in the middle of a pandemic and public health officials were anticipating a second rise in the number of cases prior to the mass protests. As such, we must continue social distancing, wearing face masks in public and maintaining a distance of 6 feet between each other. That is very difficult to achieve in a large crowd; so, we must constantly remind the public of these recommended measures to make sure they practice their rights while maintaining their health.

Q: What advice would you like to give to SGIM members to encourage them in their efforts to contribute to the response?
A: Everyone has a role to play. Everyone’s contributions are essential no matter how big or small you may perceive your efforts to be. Stay strong and stay well.

To read Dr. Price-Haywood’s latest article, visit here.

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..

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.

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.

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.

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.

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.