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Frontliners

SGIM is honoring our members at the front lines of COVID-19 with our new member highlight series, "Frontliners". Are you or anyone you know at the front lines of COVID-19? Contact us with the subject “Frontliners” to have your story told.

Cristina Gonzalez, MD, Academic Hospitalist at Montefiore Medical Center and Professor at the Albert Einstein College of Medicine

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!

Chrysoula Liakou, MD, PhD, Attending Physician in Internal Medicine at Athens Medical Practice

Mitchell Feldman, MD, MPhil, Chief of Internal Medicine at University of California San Francisco

Tom Staiger, MD, Medical Director, University of Washington Medical Center, Professor of Medicine, University of Washington School of Medicine

Robert Fogerty, MD, MPH, Director of Bed Resources at Yale-New Haven Hospital

Sunil Sahai, MD, Division Chief of General Medicine at the University of Texas Medical Branch at Galveston

Kimberly Peairs, MD, Associate Vice Chair of Ambulatory Medicine at Johns Hopkins University

Eboni Price-Haywood, MD, MPH, FACP, Director at Center for Outcomes and Health Services Research, Ochsner Health

Simranjit Singh, MD, Assistant Professor of Clinical Medicine, Indiana University School of Medicine

Nicole Lurie, MD, MSPH, Strategic Advisor to the CEO, Coalition for Epidemic Preparedness Innovations (CEPI)

Noble Maleque, MD, Assistant Professor of Medicine at Emory University

Christopher O’Donnell, MD, Associate Professor of Medicine, Emory University School of Medicine

Karen DeSalvo, MD, MPH, MSc, SGIM Past President and Chief Health Officer at Google

 

Dan Hunt, MD, Director of the Emory Division of Hospital Medicine