Cardiology News

Because of stark racial disparities in COVID-19 infection and mortality, the pandemic is being called a “sentinel” and “bellwether” event that should push the United States to finally come to grips with disparities in health care.

When it comes to COVID-19, the pattern is “irrefutable”: Blacks in the United States are being infected with SARS-CoV-2 and are dying of COVID-19 at higher rates than whites, Clyde W. Yancy, MD, Northwestern University, Chicago, wrote in a viewpoint article published online April 15 in JAMA.

According to one recent survey, he noted, the infection rate is threefold higher and the death rate is sixfold higher in predominantly black counties in the United States relative to predominantly white counties.

A sixfold increase in the rate of death for blacks due to a now ubiquitous virus should be deemed “unconscionable” and a moment of “ethical reckoning,” Dr. Yancy wrote.

“Why is this uniquely important to me? I am an academic cardiologist; I study health care disparities; and I am a black man,” he wrote.

The COVID-19 pandemic may be the “bellwether” event that the United States has needed to fully address disparities in health care, Dr. Yancy said.

“Public health is complicated and social reengineering is complex, but change of this magnitude does not happen without a new resolve,” he concluded. “The U.S. has needed a trigger to fully address health care disparities; COVID-19 may be that bellwether event. Certainly, within the broad and powerful economic and legislative engines of the U.S., there is room to definitively address a scourge even worse than COVID-19: health care disparities. It only takes will. It is time to end the refrain.”

The question is, he asks, will the nation finally “think differently, and, as has been done in response to other major diseases, declare that a civil society will no longer accept disproportionate suffering?”

Keith C. Ferdinand, MD, Tulane University, New Orleans, doesn’t think so.

In a related editorial published online April 17 in the Journal of the American College of Cardiology, he points out that the 1985 Heckler Report, from the Department of Health and Human Services, documented higher racial/ethnic mortality rates and the need to correct them. This was followed in 2002 by a report from the Institute of Medicine called Unequal Treatment that also underscored health disparities.

Despite some progress, the goal of reducing and eventually eliminating racial/ethnic disparities has not been realized, Dr. Ferdinand said. “I think baked into the consciousness of the American psyche is that there are some people who have and some who have not,” he said in an interview.

“To some extent, some societies at some point become immune. We would not like to think that America, with its sense of egalitarianism, would get to that point, but maybe we have,” said Dr. Ferdinand.
 

A ‘sentinel event’

He points out that black people are not genetically or biologically predisposed to COVID-19 but are socially prone to coronavirus exposure and are more likely to have comorbid conditions, such as hypertension, diabetes, obesity, and heart disease, that fuel complications.

The “tragic” higher COVID-19 mortality among African Americans and other racial/ethnic minorities confirms “inadequate” efforts on the part of society to eliminate disparities in cardiovascular disease (CVD) and is a “sentinel event,” Dr. Ferdinand wrote.

A sentinel event, as defined by the Joint Commission, is an unexpected occurrence that leads to death or serious physical or psychological injury or the risk thereof, he explained.

“Conventionally identified sentinel events, such as unintended retention of foreign objects and fall-related events, are used to evaluate quality in hospital care. Similarly, disparate [African American] COVID-19 mortality reflects long-standing, unacceptable U.S. racial/ethnic and socioeconomic CVD inequities and unmasks system failures and unacceptable care to be caught and mitigated,” Dr. Ferdinand concluded.

Dr. Yancy and Dr. Ferdinand have disclosed no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

Because of stark racial disparities in COVID-19 infection and mortality, the pandemic is being called a “sentinel” and “bellwether” event that should push the United States to finally come to grips with disparities in health care.

When it comes to COVID-19, the pattern is “irrefutable”: Blacks in the United States are being infected with SARS-CoV-2 and are dying of COVID-19 at higher rates than whites, Clyde W. Yancy, MD, Northwestern University, Chicago, wrote in a viewpoint article published online April 15 in JAMA.

According to one recent survey, he noted, the infection rate is threefold higher and the death rate is sixfold higher in predominantly black counties in the United States relative to predominantly white counties.

A sixfold increase in the rate of death for blacks due to a now ubiquitous virus should be deemed “unconscionable” and a moment of “ethical reckoning,” Dr. Yancy wrote.

“Why is this uniquely important to me? I am an academic cardiologist; I study health care disparities; and I am a black man,” he wrote.

The COVID-19 pandemic may be the “bellwether” event that the United States has needed to fully address disparities in health care, Dr. Yancy said.

“Public health is complicated and social reengineering is complex, but change of this magnitude does not happen without a new resolve,” he concluded. “The U.S. has needed a trigger to fully address health care disparities; COVID-19 may be that bellwether event. Certainly, within the broad and powerful economic and legislative engines of the U.S., there is room to definitively address a scourge even worse than COVID-19: health care disparities. It only takes will. It is time to end the refrain.”

The question is, he asks, will the nation finally “think differently, and, as has been done in response to other major diseases, declare that a civil society will no longer accept disproportionate suffering?”

Keith C. Ferdinand, MD, Tulane University, New Orleans, doesn’t think so.

In a related editorial published online April 17 in the Journal of the American College of Cardiology, he points out that the 1985 Heckler Report, from the Department of Health and Human Services, documented higher racial/ethnic mortality rates and the need to correct them. This was followed in 2002 by a report from the Institute of Medicine called Unequal Treatment that also underscored health disparities.

Despite some progress, the goal of reducing and eventually eliminating racial/ethnic disparities has not been realized, Dr. Ferdinand said. “I think baked into the consciousness of the American psyche is that there are some people who have and some who have not,” he said in an interview.

“To some extent, some societies at some point become immune. We would not like to think that America, with its sense of egalitarianism, would get to that point, but maybe we have,” said Dr. Ferdinand.
 

A ‘sentinel event’

He points out that black people are not genetically or biologically predisposed to COVID-19 but are socially prone to coronavirus exposure and are more likely to have comorbid conditions, such as hypertension, diabetes, obesity, and heart disease, that fuel complications.

The “tragic” higher COVID-19 mortality among African Americans and other racial/ethnic minorities confirms “inadequate” efforts on the part of society to eliminate disparities in cardiovascular disease (CVD) and is a “sentinel event,” Dr. Ferdinand wrote.

A sentinel event, as defined by the Joint Commission, is an unexpected occurrence that leads to death or serious physical or psychological injury or the risk thereof, he explained.

“Conventionally identified sentinel events, such as unintended retention of foreign objects and fall-related events, are used to evaluate quality in hospital care. Similarly, disparate [African American] COVID-19 mortality reflects long-standing, unacceptable U.S. racial/ethnic and socioeconomic CVD inequities and unmasks system failures and unacceptable care to be caught and mitigated,” Dr. Ferdinand concluded.

Dr. Yancy and Dr. Ferdinand have disclosed no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

Because of stark racial disparities in COVID-19 infection and mortality, the pandemic is being called a “sentinel” and “bellwether” event that should push the United States to finally come to grips with disparities in health care.

When it comes to COVID-19, the pattern is “irrefutable”: Blacks in the United States are being infected with SARS-CoV-2 and are dying of COVID-19 at higher rates than whites, Clyde W. Yancy, MD, Northwestern University, Chicago, wrote in a viewpoint article published online April 15 in JAMA.

According to one recent survey, he noted, the infection rate is threefold higher and the death rate is sixfold higher in predominantly black counties in the United States relative to predominantly white counties.

A sixfold increase in the rate of death for blacks due to a now ubiquitous virus should be deemed “unconscionable” and a moment of “ethical reckoning,” Dr. Yancy wrote.

“Why is this uniquely important to me? I am an academic cardiologist; I study health care disparities; and I am a black man,” he wrote.

The COVID-19 pandemic may be the “bellwether” event that the United States has needed to fully address disparities in health care, Dr. Yancy said.

“Public health is complicated and social reengineering is complex, but change of this magnitude does not happen without a new resolve,” he concluded. “The U.S. has needed a trigger to fully address health care disparities; COVID-19 may be that bellwether event. Certainly, within the broad and powerful economic and legislative engines of the U.S., there is room to definitively address a scourge even worse than COVID-19: health care disparities. It only takes will. It is time to end the refrain.”

The question is, he asks, will the nation finally “think differently, and, as has been done in response to other major diseases, declare that a civil society will no longer accept disproportionate suffering?”

Keith C. Ferdinand, MD, Tulane University, New Orleans, doesn’t think so.

In a related editorial published online April 17 in the Journal of the American College of Cardiology, he points out that the 1985 Heckler Report, from the Department of Health and Human Services, documented higher racial/ethnic mortality rates and the need to correct them. This was followed in 2002 by a report from the Institute of Medicine called Unequal Treatment that also underscored health disparities.

Despite some progress, the goal of reducing and eventually eliminating racial/ethnic disparities has not been realized, Dr. Ferdinand said. “I think baked into the consciousness of the American psyche is that there are some people who have and some who have not,” he said in an interview.

“To some extent, some societies at some point become immune. We would not like to think that America, with its sense of egalitarianism, would get to that point, but maybe we have,” said Dr. Ferdinand.
 

A ‘sentinel event’

He points out that black people are not genetically or biologically predisposed to COVID-19 but are socially prone to coronavirus exposure and are more likely to have comorbid conditions, such as hypertension, diabetes, obesity, and heart disease, that fuel complications.

The “tragic” higher COVID-19 mortality among African Americans and other racial/ethnic minorities confirms “inadequate” efforts on the part of society to eliminate disparities in cardiovascular disease (CVD) and is a “sentinel event,” Dr. Ferdinand wrote.

A sentinel event, as defined by the Joint Commission, is an unexpected occurrence that leads to death or serious physical or psychological injury or the risk thereof, he explained.

“Conventionally identified sentinel events, such as unintended retention of foreign objects and fall-related events, are used to evaluate quality in hospital care. Similarly, disparate [African American] COVID-19 mortality reflects long-standing, unacceptable U.S. racial/ethnic and socioeconomic CVD inequities and unmasks system failures and unacceptable care to be caught and mitigated,” Dr. Ferdinand concluded.

Dr. Yancy and Dr. Ferdinand have disclosed no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

A consensus statement from the American College of Cardiology (ACC), the American College of Emergency Physicians (ACEP), and the Society for Cardiovascular Angiography & Interventions (SCAI) outlines recommendations for a systematic approach for the care of patients with an acute myocardial infarction (AMI) during the COVID-19 pandemic.

The statement was published in the Journal of the American College of Cardiology.

During the COVID-19 pandemic, percutaneous coronary intervention (PCI) remains the standard of care for patients with ST-segment elevation MI (STEMI) at PCI-capable hospitals when it can be provided in a timely fashion in a dedicated cardiac catheterization laboratory with an expert care team wearing personal protection equipment (PPE), the writing group advised.

“A fibrinolysis-based strategy may be entertained at non-PCI capable referral hospitals or in specific situations where primary PCI cannot be executed or is not deemed the best option,” they said.

SCAI President Ehtisham Mahmud, MD, of the University of California, San Diego, and the writing group also said that clinicians should recognize that cardiovascular manifestations of COVID-19 are “complex” in patients presenting with AMI, myocarditis simulating a STEMI, stress cardiomyopathy, nonischemic cardiomyopathy, coronary spasm, or nonspecific myocardial injury.

A “broad differential diagnosis for ST elevations (including COVID-associated myocarditis) should be considered in the ED prior to choosing a reperfusion strategy,” they advised.

In the absence of hemodynamic instability or ongoing ischemic symptoms, non-STEMI patients with known or suspected COVID-19 are best managed with an initial medical stabilization strategy, the group said.

They also said it is “imperative that health care workers use appropriate PPE for all invasive procedures during this pandemic” and that new rapid COVID-19 testing be “expeditiously” disseminated to all hospitals that manage patients with AMI.

Major challenges are that the prevalence of the COVID-19 in the United States remains unknown and there is the risk for asymptomatic spread.

The writing group said it’s “critical” to “inform the public that we can minimize exposure to the coronavirus so they can continue to call the Emergency Medical System (EMS) for acute ischemic heart disease symptoms and therefore get the appropriate level of cardiac care that their presentation warrants.”

This research had no commercial funding. Dr. Mahmud reported receiving clinical trial research support from Corindus, Abbott Vascular, and CSI; consulting with Medtronic; and consulting and equity with Abiomed. A complete list of author disclosures is included with the original article.

A version of this article originally appeared on Medscape.com.

A consensus statement from the American College of Cardiology (ACC), the American College of Emergency Physicians (ACEP), and the Society for Cardiovascular Angiography & Interventions (SCAI) outlines recommendations for a systematic approach for the care of patients with an acute myocardial infarction (AMI) during the COVID-19 pandemic.

The statement was published in the Journal of the American College of Cardiology.

During the COVID-19 pandemic, percutaneous coronary intervention (PCI) remains the standard of care for patients with ST-segment elevation MI (STEMI) at PCI-capable hospitals when it can be provided in a timely fashion in a dedicated cardiac catheterization laboratory with an expert care team wearing personal protection equipment (PPE), the writing group advised.

“A fibrinolysis-based strategy may be entertained at non-PCI capable referral hospitals or in specific situations where primary PCI cannot be executed or is not deemed the best option,” they said.

SCAI President Ehtisham Mahmud, MD, of the University of California, San Diego, and the writing group also said that clinicians should recognize that cardiovascular manifestations of COVID-19 are “complex” in patients presenting with AMI, myocarditis simulating a STEMI, stress cardiomyopathy, nonischemic cardiomyopathy, coronary spasm, or nonspecific myocardial injury.

A “broad differential diagnosis for ST elevations (including COVID-associated myocarditis) should be considered in the ED prior to choosing a reperfusion strategy,” they advised.

In the absence of hemodynamic instability or ongoing ischemic symptoms, non-STEMI patients with known or suspected COVID-19 are best managed with an initial medical stabilization strategy, the group said.

They also said it is “imperative that health care workers use appropriate PPE for all invasive procedures during this pandemic” and that new rapid COVID-19 testing be “expeditiously” disseminated to all hospitals that manage patients with AMI.

Major challenges are that the prevalence of the COVID-19 in the United States remains unknown and there is the risk for asymptomatic spread.

The writing group said it’s “critical” to “inform the public that we can minimize exposure to the coronavirus so they can continue to call the Emergency Medical System (EMS) for acute ischemic heart disease symptoms and therefore get the appropriate level of cardiac care that their presentation warrants.”

This research had no commercial funding. Dr. Mahmud reported receiving clinical trial research support from Corindus, Abbott Vascular, and CSI; consulting with Medtronic; and consulting and equity with Abiomed. A complete list of author disclosures is included with the original article.

A version of this article originally appeared on Medscape.com.

A consensus statement from the American College of Cardiology (ACC), the American College of Emergency Physicians (ACEP), and the Society for Cardiovascular Angiography & Interventions (SCAI) outlines recommendations for a systematic approach for the care of patients with an acute myocardial infarction (AMI) during the COVID-19 pandemic.

The statement was published in the Journal of the American College of Cardiology.

During the COVID-19 pandemic, percutaneous coronary intervention (PCI) remains the standard of care for patients with ST-segment elevation MI (STEMI) at PCI-capable hospitals when it can be provided in a timely fashion in a dedicated cardiac catheterization laboratory with an expert care team wearing personal protection equipment (PPE), the writing group advised.

“A fibrinolysis-based strategy may be entertained at non-PCI capable referral hospitals or in specific situations where primary PCI cannot be executed or is not deemed the best option,” they said.

SCAI President Ehtisham Mahmud, MD, of the University of California, San Diego, and the writing group also said that clinicians should recognize that cardiovascular manifestations of COVID-19 are “complex” in patients presenting with AMI, myocarditis simulating a STEMI, stress cardiomyopathy, nonischemic cardiomyopathy, coronary spasm, or nonspecific myocardial injury.

A “broad differential diagnosis for ST elevations (including COVID-associated myocarditis) should be considered in the ED prior to choosing a reperfusion strategy,” they advised.

In the absence of hemodynamic instability or ongoing ischemic symptoms, non-STEMI patients with known or suspected COVID-19 are best managed with an initial medical stabilization strategy, the group said.

They also said it is “imperative that health care workers use appropriate PPE for all invasive procedures during this pandemic” and that new rapid COVID-19 testing be “expeditiously” disseminated to all hospitals that manage patients with AMI.

Major challenges are that the prevalence of the COVID-19 in the United States remains unknown and there is the risk for asymptomatic spread.

The writing group said it’s “critical” to “inform the public that we can minimize exposure to the coronavirus so they can continue to call the Emergency Medical System (EMS) for acute ischemic heart disease symptoms and therefore get the appropriate level of cardiac care that their presentation warrants.”

This research had no commercial funding. Dr. Mahmud reported receiving clinical trial research support from Corindus, Abbott Vascular, and CSI; consulting with Medtronic; and consulting and equity with Abiomed. A complete list of author disclosures is included with the original article.

A version of this article originally appeared on Medscape.com.

A new advocacy organization is launching on April 28 to give “every physician” a voice in decisions that affect their professional lives. But this group doesn’t intend to use the top-down approach to decision making seen in many medical societies.

Paul Teirstein, MD, chief of cardiology for Scripps Clinic in La Jolla, Calif., and founder of the new organization United Physicians, said in an interviewit is a nonprofit group that will operate through online participation.

He said the intention is to use online voting and discussions among physicians across specialties to advocate for more and better legislation on pressing issues for their profession and, as noted on the group’s website, “protect the physician-patient relationship.”

Projects would need the support of a two-thirds majority of United Physicians’ members to proceed with any proposals. Meetings will be held publicly online, Dr. Teirstein explained.

There is a need for a broad-based organization that will respond to the voice of practicing physicians rather than dictate legislative priorities from management ranks, he said.

Dr. Teirstein said he learned how challenging it is to bring physicians together on issues in 2014 in his battles against changes in maintenance of certification rules. The result of his efforts was the National Board of Physicians and Surgeons (NBPAS), set up to provide a means of certification different from the one offered by the American Board of Internal Medicine.

Dr. Teirstein has argued that the approach of ABIM unfairly burdened physicians with a stepped-up schedule of testing and relied on an outdated approach to the practice of medicine.

Physicians busy with their practices feel they lack a unified voice in contesting the growing administrative burden and unproductive federal and state policies, Dr. Teirstein said.

He cited the limited enrollment in the largest physician groups as evidence of how disenfranchised many clinicians feel. There are about 1 million professional active physicians in the United States, according to the nonprofit Kaiser Family Foundation. Yet, even the largest physician group, the American Medical Association, has about 250,000 members, according to its 2018 annual report

“Clearly, most physicians believe they have little voice when it comes to health care decisions,” Dr. Teirstein said. “Our physician associations are governed from the top down. The leaders set the agenda. There may be delegates, but does leadership really listen to the delegates? Do the delegates really listen to the physician community?”

On its website, AMA describes itself as “physicians’ powerful ally in patient care” that works with more than 190 state and specialty medical societies. In recent months, James L. Madara, MD, the group’s chief executive officer, has urged governors to remove obstacles for physicians who want to fill workforce gaps in COVID-19 hot spots, among other actions.

In its annual report, the AMA, which declined to comment for this article, said its membership rose by 3.4% in 2018, double the growth rate of the previous year, thanks to a membership drive.

“The campaign celebrates the powerful work of our physician members and showcases how their individual efforts – along with the AMA – are moving medicine forward,” wrote Dr. Madara and other organization leaders in the report.

What Dr. Teirstein proposes is an inversion of the structure used by other medical societies, in which he says leaders and delegates dictate priorities.

United Physicians will use meetings and votes held by members online to decide which projects to pursue. Fees would be kept nominal, likely about $10 a year, depending on the number of members. Fees would be subject to change on the basis of expenses. The AMA has a sliding fee schedule that tops out with annual dues for physicians in regular practice of $420.

“There are no delegates, no representatives, and no board of directors. We want every physician to join and every physician to vote on every issue,” Dr. Teirstein said.

He stressed that he sees United Physicians as being complementary to the AMA.

“We do not compete with other organizations. Ideally, other organizations will use the platform,” Dr. Teirstein said. “If the AMA is considering a new policy, it can use the United Physicians platform to measure physician support. For example, through online discussions, petitions, and voting, it might learn a proposed policy needs a few tweaks to be accepted by most physicians.”

No compensation

Dr. Teirstein is among physician leaders who in recent years have sought to rally their colleagues to fight back against growing administrative burdens.

In a 2015 article in JAMA that was written with Medscape’s editor in chief, Eric Topol, MD, Dr. Teirstein criticized the ABIM’s drive to have physicians complete tests every 2 years and participate in continuous certification instead of recertifying once a decade, as had been the practice.

Dr. Teirstein formed the NBPAS as an alternative path for certification, with Dr. Topol serving on the board for that organization. Dr. Topol also will serve as a member of the advisory board for Teirstein’s United Physicians.

Dr. Topol wrote an article that appeared in the New Yorker last August that argued for physicians to move beyond the confines of medical societies and seek a path for broad-based activism. He said he intended to challenge medical societies, which, for all the good they do, can sometimes lose focus on that core relationship in favor of the bottom line.

Dr. Topol said in an interview that his colleague’s new project is a “good idea for a democratized platform at a time when physician solidarity is needed more than ever.”

Dr. Teirstein plans to run United Physicians on a volunteer basis. This builds on the approach he has used for NBPAS. He and the directors of the NBPAS will receive no compensation, he said, as was confirmed by the NBPAS.

In contrast, Dr. Madara made about $2.5 million in total compensation for 2018, according to the organization’s Internal Revenue Service filing. Physicians who served as trustees and officials for the AMA that year received annual compensation that ranged from around $60,000 to $291,980, depending on their duties.

“Having volunteer leadership mitigates conflict of interest. It also ensures leadership has a ‘day job’ that keeps them in touch with issues impacting practicing physicians,” Dr. Teirstein said

Start-up costs for United Physicians will be supported by NBPAS, but it will function as a completely independent organization, he added.

In introducing the group, Dr. Teirstein outlined suggestions for proposals it might pursue. These include making hospitals secure adequate supplies of personal protective equipment ahead of health crises such as the COVID-19 pandemic.

His outline also includes suggestions for issues that likely will persist beyond the response to the pandemic.

Dr. Teirstein proposed a project for persuading insurance companies to provide online calendar appointments for peer-to-peer patient preauthorization. Failure of the insurer’s representative to attend would trigger approval of authorization under this proposal. He also suggested a lobbying effort for specific reimbursement for peer-to-peer, patient preauthorization phone calls.

Dr. Teirstein said he hopes most of the proposals will come from physicians who join United Physicians. Still, it is unclear whether United Physicians will succeed. An initial challenge could be in sorting through a barrage of competing ideas submitted to United Physicians.

But Dr. Teirstein appears hopeful about the changes for this experiment in online advocacy. He intends for United Physicians to be a pathway for clinicians to translate their complaints about policies into calls for action, with only a short investment of their time.

“Most of us have wonderful, engrossing jobs. It’s hard to beat helping a patient, and most of us get to do it every day,” Dr. .Teirstein said. “Will we take the 30 seconds required to sign up and become a United Physicians member? Will we spend a little time each week reviewing the issues and voting? I think it’s an experiment worth watching.”

A version of this article originally appeared on Medscape.com.

A new advocacy organization is launching on April 28 to give “every physician” a voice in decisions that affect their professional lives. But this group doesn’t intend to use the top-down approach to decision making seen in many medical societies.

Paul Teirstein, MD, chief of cardiology for Scripps Clinic in La Jolla, Calif., and founder of the new organization United Physicians, said in an interviewit is a nonprofit group that will operate through online participation.

He said the intention is to use online voting and discussions among physicians across specialties to advocate for more and better legislation on pressing issues for their profession and, as noted on the group’s website, “protect the physician-patient relationship.”

Projects would need the support of a two-thirds majority of United Physicians’ members to proceed with any proposals. Meetings will be held publicly online, Dr. Teirstein explained.

There is a need for a broad-based organization that will respond to the voice of practicing physicians rather than dictate legislative priorities from management ranks, he said.

Dr. Teirstein said he learned how challenging it is to bring physicians together on issues in 2014 in his battles against changes in maintenance of certification rules. The result of his efforts was the National Board of Physicians and Surgeons (NBPAS), set up to provide a means of certification different from the one offered by the American Board of Internal Medicine.

Dr. Teirstein has argued that the approach of ABIM unfairly burdened physicians with a stepped-up schedule of testing and relied on an outdated approach to the practice of medicine.

Physicians busy with their practices feel they lack a unified voice in contesting the growing administrative burden and unproductive federal and state policies, Dr. Teirstein said.

He cited the limited enrollment in the largest physician groups as evidence of how disenfranchised many clinicians feel. There are about 1 million professional active physicians in the United States, according to the nonprofit Kaiser Family Foundation. Yet, even the largest physician group, the American Medical Association, has about 250,000 members, according to its 2018 annual report

“Clearly, most physicians believe they have little voice when it comes to health care decisions,” Dr. Teirstein said. “Our physician associations are governed from the top down. The leaders set the agenda. There may be delegates, but does leadership really listen to the delegates? Do the delegates really listen to the physician community?”

On its website, AMA describes itself as “physicians’ powerful ally in patient care” that works with more than 190 state and specialty medical societies. In recent months, James L. Madara, MD, the group’s chief executive officer, has urged governors to remove obstacles for physicians who want to fill workforce gaps in COVID-19 hot spots, among other actions.

In its annual report, the AMA, which declined to comment for this article, said its membership rose by 3.4% in 2018, double the growth rate of the previous year, thanks to a membership drive.

“The campaign celebrates the powerful work of our physician members and showcases how their individual efforts – along with the AMA – are moving medicine forward,” wrote Dr. Madara and other organization leaders in the report.

What Dr. Teirstein proposes is an inversion of the structure used by other medical societies, in which he says leaders and delegates dictate priorities.

United Physicians will use meetings and votes held by members online to decide which projects to pursue. Fees would be kept nominal, likely about $10 a year, depending on the number of members. Fees would be subject to change on the basis of expenses. The AMA has a sliding fee schedule that tops out with annual dues for physicians in regular practice of $420.

“There are no delegates, no representatives, and no board of directors. We want every physician to join and every physician to vote on every issue,” Dr. Teirstein said.

He stressed that he sees United Physicians as being complementary to the AMA.

“We do not compete with other organizations. Ideally, other organizations will use the platform,” Dr. Teirstein said. “If the AMA is considering a new policy, it can use the United Physicians platform to measure physician support. For example, through online discussions, petitions, and voting, it might learn a proposed policy needs a few tweaks to be accepted by most physicians.”

No compensation

Dr. Teirstein is among physician leaders who in recent years have sought to rally their colleagues to fight back against growing administrative burdens.

In a 2015 article in JAMA that was written with Medscape’s editor in chief, Eric Topol, MD, Dr. Teirstein criticized the ABIM’s drive to have physicians complete tests every 2 years and participate in continuous certification instead of recertifying once a decade, as had been the practice.

Dr. Teirstein formed the NBPAS as an alternative path for certification, with Dr. Topol serving on the board for that organization. Dr. Topol also will serve as a member of the advisory board for Teirstein’s United Physicians.

Dr. Topol wrote an article that appeared in the New Yorker last August that argued for physicians to move beyond the confines of medical societies and seek a path for broad-based activism. He said he intended to challenge medical societies, which, for all the good they do, can sometimes lose focus on that core relationship in favor of the bottom line.

Dr. Topol said in an interview that his colleague’s new project is a “good idea for a democratized platform at a time when physician solidarity is needed more than ever.”

Dr. Teirstein plans to run United Physicians on a volunteer basis. This builds on the approach he has used for NBPAS. He and the directors of the NBPAS will receive no compensation, he said, as was confirmed by the NBPAS.

In contrast, Dr. Madara made about $2.5 million in total compensation for 2018, according to the organization’s Internal Revenue Service filing. Physicians who served as trustees and officials for the AMA that year received annual compensation that ranged from around $60,000 to $291,980, depending on their duties.

“Having volunteer leadership mitigates conflict of interest. It also ensures leadership has a ‘day job’ that keeps them in touch with issues impacting practicing physicians,” Dr. Teirstein said

Start-up costs for United Physicians will be supported by NBPAS, but it will function as a completely independent organization, he added.

In introducing the group, Dr. Teirstein outlined suggestions for proposals it might pursue. These include making hospitals secure adequate supplies of personal protective equipment ahead of health crises such as the COVID-19 pandemic.

His outline also includes suggestions for issues that likely will persist beyond the response to the pandemic.

Dr. Teirstein proposed a project for persuading insurance companies to provide online calendar appointments for peer-to-peer patient preauthorization. Failure of the insurer’s representative to attend would trigger approval of authorization under this proposal. He also suggested a lobbying effort for specific reimbursement for peer-to-peer, patient preauthorization phone calls.

Dr. Teirstein said he hopes most of the proposals will come from physicians who join United Physicians. Still, it is unclear whether United Physicians will succeed. An initial challenge could be in sorting through a barrage of competing ideas submitted to United Physicians.

But Dr. Teirstein appears hopeful about the changes for this experiment in online advocacy. He intends for United Physicians to be a pathway for clinicians to translate their complaints about policies into calls for action, with only a short investment of their time.

“Most of us have wonderful, engrossing jobs. It’s hard to beat helping a patient, and most of us get to do it every day,” Dr. .Teirstein said. “Will we take the 30 seconds required to sign up and become a United Physicians member? Will we spend a little time each week reviewing the issues and voting? I think it’s an experiment worth watching.”

A version of this article originally appeared on Medscape.com.

A new advocacy organization is launching on April 28 to give “every physician” a voice in decisions that affect their professional lives. But this group doesn’t intend to use the top-down approach to decision making seen in many medical societies.

Paul Teirstein, MD, chief of cardiology for Scripps Clinic in La Jolla, Calif., and founder of the new organization United Physicians, said in an interviewit is a nonprofit group that will operate through online participation.

He said the intention is to use online voting and discussions among physicians across specialties to advocate for more and better legislation on pressing issues for their profession and, as noted on the group’s website, “protect the physician-patient relationship.”

Projects would need the support of a two-thirds majority of United Physicians’ members to proceed with any proposals. Meetings will be held publicly online, Dr. Teirstein explained.

There is a need for a broad-based organization that will respond to the voice of practicing physicians rather than dictate legislative priorities from management ranks, he said.

Dr. Teirstein said he learned how challenging it is to bring physicians together on issues in 2014 in his battles against changes in maintenance of certification rules. The result of his efforts was the National Board of Physicians and Surgeons (NBPAS), set up to provide a means of certification different from the one offered by the American Board of Internal Medicine.

Dr. Teirstein has argued that the approach of ABIM unfairly burdened physicians with a stepped-up schedule of testing and relied on an outdated approach to the practice of medicine.

Physicians busy with their practices feel they lack a unified voice in contesting the growing administrative burden and unproductive federal and state policies, Dr. Teirstein said.

He cited the limited enrollment in the largest physician groups as evidence of how disenfranchised many clinicians feel. There are about 1 million professional active physicians in the United States, according to the nonprofit Kaiser Family Foundation. Yet, even the largest physician group, the American Medical Association, has about 250,000 members, according to its 2018 annual report

“Clearly, most physicians believe they have little voice when it comes to health care decisions,” Dr. Teirstein said. “Our physician associations are governed from the top down. The leaders set the agenda. There may be delegates, but does leadership really listen to the delegates? Do the delegates really listen to the physician community?”

On its website, AMA describes itself as “physicians’ powerful ally in patient care” that works with more than 190 state and specialty medical societies. In recent months, James L. Madara, MD, the group’s chief executive officer, has urged governors to remove obstacles for physicians who want to fill workforce gaps in COVID-19 hot spots, among other actions.

In its annual report, the AMA, which declined to comment for this article, said its membership rose by 3.4% in 2018, double the growth rate of the previous year, thanks to a membership drive.

“The campaign celebrates the powerful work of our physician members and showcases how their individual efforts – along with the AMA – are moving medicine forward,” wrote Dr. Madara and other organization leaders in the report.

What Dr. Teirstein proposes is an inversion of the structure used by other medical societies, in which he says leaders and delegates dictate priorities.

United Physicians will use meetings and votes held by members online to decide which projects to pursue. Fees would be kept nominal, likely about $10 a year, depending on the number of members. Fees would be subject to change on the basis of expenses. The AMA has a sliding fee schedule that tops out with annual dues for physicians in regular practice of $420.

“There are no delegates, no representatives, and no board of directors. We want every physician to join and every physician to vote on every issue,” Dr. Teirstein said.

He stressed that he sees United Physicians as being complementary to the AMA.

“We do not compete with other organizations. Ideally, other organizations will use the platform,” Dr. Teirstein said. “If the AMA is considering a new policy, it can use the United Physicians platform to measure physician support. For example, through online discussions, petitions, and voting, it might learn a proposed policy needs a few tweaks to be accepted by most physicians.”

No compensation

Dr. Teirstein is among physician leaders who in recent years have sought to rally their colleagues to fight back against growing administrative burdens.

In a 2015 article in JAMA that was written with Medscape’s editor in chief, Eric Topol, MD, Dr. Teirstein criticized the ABIM’s drive to have physicians complete tests every 2 years and participate in continuous certification instead of recertifying once a decade, as had been the practice.

Dr. Teirstein formed the NBPAS as an alternative path for certification, with Dr. Topol serving on the board for that organization. Dr. Topol also will serve as a member of the advisory board for Teirstein’s United Physicians.

Dr. Topol wrote an article that appeared in the New Yorker last August that argued for physicians to move beyond the confines of medical societies and seek a path for broad-based activism. He said he intended to challenge medical societies, which, for all the good they do, can sometimes lose focus on that core relationship in favor of the bottom line.

Dr. Topol said in an interview that his colleague’s new project is a “good idea for a democratized platform at a time when physician solidarity is needed more than ever.”

Dr. Teirstein plans to run United Physicians on a volunteer basis. This builds on the approach he has used for NBPAS. He and the directors of the NBPAS will receive no compensation, he said, as was confirmed by the NBPAS.

In contrast, Dr. Madara made about $2.5 million in total compensation for 2018, according to the organization’s Internal Revenue Service filing. Physicians who served as trustees and officials for the AMA that year received annual compensation that ranged from around $60,000 to $291,980, depending on their duties.

“Having volunteer leadership mitigates conflict of interest. It also ensures leadership has a ‘day job’ that keeps them in touch with issues impacting practicing physicians,” Dr. Teirstein said

Start-up costs for United Physicians will be supported by NBPAS, but it will function as a completely independent organization, he added.

In introducing the group, Dr. Teirstein outlined suggestions for proposals it might pursue. These include making hospitals secure adequate supplies of personal protective equipment ahead of health crises such as the COVID-19 pandemic.

His outline also includes suggestions for issues that likely will persist beyond the response to the pandemic.

Dr. Teirstein proposed a project for persuading insurance companies to provide online calendar appointments for peer-to-peer patient preauthorization. Failure of the insurer’s representative to attend would trigger approval of authorization under this proposal. He also suggested a lobbying effort for specific reimbursement for peer-to-peer, patient preauthorization phone calls.

Dr. Teirstein said he hopes most of the proposals will come from physicians who join United Physicians. Still, it is unclear whether United Physicians will succeed. An initial challenge could be in sorting through a barrage of competing ideas submitted to United Physicians.

But Dr. Teirstein appears hopeful about the changes for this experiment in online advocacy. He intends for United Physicians to be a pathway for clinicians to translate their complaints about policies into calls for action, with only a short investment of their time.

“Most of us have wonderful, engrossing jobs. It’s hard to beat helping a patient, and most of us get to do it every day,” Dr. .Teirstein said. “Will we take the 30 seconds required to sign up and become a United Physicians member? Will we spend a little time each week reviewing the issues and voting? I think it’s an experiment worth watching.”

A version of this article originally appeared on Medscape.com.

The Centers for Medicare & Medicaid Services will suspend its Medicare advance payment program for clinicians and is reevaluating how much to pay to hospitals going forward through particular COVID-19 relief initiatives. CMS announced the changes on April 26. Physicians and others who use the accelerated and advance Medicare payments program repay these advances, and they are typically given 1 year or less to repay the funding.

CMS said in a news release it will not accept new applications for the advanced Medicare payment, and it will be reevaluating all pending and new applications “in light of historical direct payments made available through the Department of Health & Human Services’ (HHS) Provider Relief Fund.”

The advance Medicare payment program predates COVID-19, although it previously was used on a much smaller scale. In the past 5 years, CMS approved about 100 total requests for advanced Medicare payment, with most being tied to natural disasters such as hurricanes.

CMS said it has approved, since March, more than 21,000 applications for advanced Medicare payment, totaling $59.6 billion, for hospitals and other organizations that bill its Part A program. In addition, CMS approved almost 24,000 applications for its Part B program, advancing $40.4 billion for physicians, other clinicians, and medical equipment suppliers.

CMS noted that Congress also has provided $175 billion in aid for the medical community that clinicians and medical organizations would not need to repay. The Coronavirus Aid, Relief, and Economic Security (CARES) Act enacted in March included $100 billion, and the Paycheck Protection Program and Health Care Enhancement Act, enacted March 24, includes another $75 billion.

A version of this article was originally published on Medscape.com.

The Centers for Medicare & Medicaid Services will suspend its Medicare advance payment program for clinicians and is reevaluating how much to pay to hospitals going forward through particular COVID-19 relief initiatives. CMS announced the changes on April 26. Physicians and others who use the accelerated and advance Medicare payments program repay these advances, and they are typically given 1 year or less to repay the funding.

CMS said in a news release it will not accept new applications for the advanced Medicare payment, and it will be reevaluating all pending and new applications “in light of historical direct payments made available through the Department of Health & Human Services’ (HHS) Provider Relief Fund.”

The advance Medicare payment program predates COVID-19, although it previously was used on a much smaller scale. In the past 5 years, CMS approved about 100 total requests for advanced Medicare payment, with most being tied to natural disasters such as hurricanes.

CMS said it has approved, since March, more than 21,000 applications for advanced Medicare payment, totaling $59.6 billion, for hospitals and other organizations that bill its Part A program. In addition, CMS approved almost 24,000 applications for its Part B program, advancing $40.4 billion for physicians, other clinicians, and medical equipment suppliers.

CMS noted that Congress also has provided $175 billion in aid for the medical community that clinicians and medical organizations would not need to repay. The Coronavirus Aid, Relief, and Economic Security (CARES) Act enacted in March included $100 billion, and the Paycheck Protection Program and Health Care Enhancement Act, enacted March 24, includes another $75 billion.

A version of this article was originally published on Medscape.com.

The Centers for Medicare & Medicaid Services will suspend its Medicare advance payment program for clinicians and is reevaluating how much to pay to hospitals going forward through particular COVID-19 relief initiatives. CMS announced the changes on April 26. Physicians and others who use the accelerated and advance Medicare payments program repay these advances, and they are typically given 1 year or less to repay the funding.

CMS said in a news release it will not accept new applications for the advanced Medicare payment, and it will be reevaluating all pending and new applications “in light of historical direct payments made available through the Department of Health & Human Services’ (HHS) Provider Relief Fund.”

The advance Medicare payment program predates COVID-19, although it previously was used on a much smaller scale. In the past 5 years, CMS approved about 100 total requests for advanced Medicare payment, with most being tied to natural disasters such as hurricanes.

CMS said it has approved, since March, more than 21,000 applications for advanced Medicare payment, totaling $59.6 billion, for hospitals and other organizations that bill its Part A program. In addition, CMS approved almost 24,000 applications for its Part B program, advancing $40.4 billion for physicians, other clinicians, and medical equipment suppliers.

CMS noted that Congress also has provided $175 billion in aid for the medical community that clinicians and medical organizations would not need to repay. The Coronavirus Aid, Relief, and Economic Security (CARES) Act enacted in March included $100 billion, and the Paycheck Protection Program and Health Care Enhancement Act, enacted March 24, includes another $75 billion.

A version of this article was originally published on Medscape.com.

Like you, I’m not sure when this weird Twilight Zone world of coronavirus will end. Even when it does, its effects will be with us for a long time to come.

But in some ways, they may be for the better. Hopefully some of these changes will stick. Like every new situation, I try to take away something of value from it.

As pithy as it sounds, I used to obsess (sort of) over the daily mail delivery. My secretary would check it mid-afternoon, and if it wasn’t there either she or I would run down again before we left. If it still wasn’t there I’d swing by the box when I came in early the next morning. On Saturdays, I’d sometimes drive in just to get the mail.

There certainly are things that come in that are important: payments, bills, medical records, legal cases to review ... but realistically a lot of mail is junk. Office-supply catalogs, CME or pharmaceutical ads, credit card promotions, and so on.

Now? I just don’t care. If I go several days without seeing patients at the office, the mail is at the back of my mind. It’s in a locked box and isn’t going anywhere. Why worry about it? Next time I’m there I can deal with it. It’s not worth thinking about, it’s just the mail. It’s not worth a special trip.

Sleep is another thing. For years my internal alarm has had me up around 4:00 a.m. (I don’t even bother to set one on my phone), and I get up and go in to get started on the day.

Now? I don’t think I’ve ever slept this much. If I have to go to my office, I’m much less rushed. Many days I don’t even have to do that. I walk down to my home office, call up my charts and the day’s video appointment schedule, and we’re off. Granted, once things return to speed, this will probably be back to normal.

My kids are all home from college, so I have the extra time at home to enjoy them and our dogs. My wife, an oncology infusion nurse, doesn’t get home until 6:00 each night, so for now I’ve become a stay-at-home dad. This is actually something I’ve always liked (in high school, I was voted “most likely to to be a house husband”). So I do the laundry and am in charge of dinner each night. I’m enjoying the last, as I get to pick things out, go through recipes, and cook. I won’t say I’m a great cook, but I’m learning and having fun. As strange as it sounds, being a house husband has always been something I wanted to do, so I’m appreciating the opportunity while it lasts.

I think all of us have come to accept this strange pause button that’s been pushed, and I’ll try to learn what I can from it and take that with me as I move forward.

Dr. Block has a solo neurology practice in Scottsdale, Ariz. He has no relevant disclosures.

Like you, I’m not sure when this weird Twilight Zone world of coronavirus will end. Even when it does, its effects will be with us for a long time to come.

But in some ways, they may be for the better. Hopefully some of these changes will stick. Like every new situation, I try to take away something of value from it.

As pithy as it sounds, I used to obsess (sort of) over the daily mail delivery. My secretary would check it mid-afternoon, and if it wasn’t there either she or I would run down again before we left. If it still wasn’t there I’d swing by the box when I came in early the next morning. On Saturdays, I’d sometimes drive in just to get the mail.

There certainly are things that come in that are important: payments, bills, medical records, legal cases to review ... but realistically a lot of mail is junk. Office-supply catalogs, CME or pharmaceutical ads, credit card promotions, and so on.

Now? I just don’t care. If I go several days without seeing patients at the office, the mail is at the back of my mind. It’s in a locked box and isn’t going anywhere. Why worry about it? Next time I’m there I can deal with it. It’s not worth thinking about, it’s just the mail. It’s not worth a special trip.

Sleep is another thing. For years my internal alarm has had me up around 4:00 a.m. (I don’t even bother to set one on my phone), and I get up and go in to get started on the day.

Now? I don’t think I’ve ever slept this much. If I have to go to my office, I’m much less rushed. Many days I don’t even have to do that. I walk down to my home office, call up my charts and the day’s video appointment schedule, and we’re off. Granted, once things return to speed, this will probably be back to normal.

My kids are all home from college, so I have the extra time at home to enjoy them and our dogs. My wife, an oncology infusion nurse, doesn’t get home until 6:00 each night, so for now I’ve become a stay-at-home dad. This is actually something I’ve always liked (in high school, I was voted “most likely to to be a house husband”). So I do the laundry and am in charge of dinner each night. I’m enjoying the last, as I get to pick things out, go through recipes, and cook. I won’t say I’m a great cook, but I’m learning and having fun. As strange as it sounds, being a house husband has always been something I wanted to do, so I’m appreciating the opportunity while it lasts.

I think all of us have come to accept this strange pause button that’s been pushed, and I’ll try to learn what I can from it and take that with me as I move forward.

Dr. Block has a solo neurology practice in Scottsdale, Ariz. He has no relevant disclosures.

Like you, I’m not sure when this weird Twilight Zone world of coronavirus will end. Even when it does, its effects will be with us for a long time to come.

But in some ways, they may be for the better. Hopefully some of these changes will stick. Like every new situation, I try to take away something of value from it.

As pithy as it sounds, I used to obsess (sort of) over the daily mail delivery. My secretary would check it mid-afternoon, and if it wasn’t there either she or I would run down again before we left. If it still wasn’t there I’d swing by the box when I came in early the next morning. On Saturdays, I’d sometimes drive in just to get the mail.

There certainly are things that come in that are important: payments, bills, medical records, legal cases to review ... but realistically a lot of mail is junk. Office-supply catalogs, CME or pharmaceutical ads, credit card promotions, and so on.

Now? I just don’t care. If I go several days without seeing patients at the office, the mail is at the back of my mind. It’s in a locked box and isn’t going anywhere. Why worry about it? Next time I’m there I can deal with it. It’s not worth thinking about, it’s just the mail. It’s not worth a special trip.

Sleep is another thing. For years my internal alarm has had me up around 4:00 a.m. (I don’t even bother to set one on my phone), and I get up and go in to get started on the day.

Now? I don’t think I’ve ever slept this much. If I have to go to my office, I’m much less rushed. Many days I don’t even have to do that. I walk down to my home office, call up my charts and the day’s video appointment schedule, and we’re off. Granted, once things return to speed, this will probably be back to normal.

My kids are all home from college, so I have the extra time at home to enjoy them and our dogs. My wife, an oncology infusion nurse, doesn’t get home until 6:00 each night, so for now I’ve become a stay-at-home dad. This is actually something I’ve always liked (in high school, I was voted “most likely to to be a house husband”). So I do the laundry and am in charge of dinner each night. I’m enjoying the last, as I get to pick things out, go through recipes, and cook. I won’t say I’m a great cook, but I’m learning and having fun. As strange as it sounds, being a house husband has always been something I wanted to do, so I’m appreciating the opportunity while it lasts.

I think all of us have come to accept this strange pause button that’s been pushed, and I’ll try to learn what I can from it and take that with me as I move forward.

Dr. Block has a solo neurology practice in Scottsdale, Ariz. He has no relevant disclosures.

Concerns about potential risks about the use of spironolactone for acne during the COVID-19 pandemic were raised on social media last month, but spironolactone and other androgen blockers might actually protect against the virus, according to a report in the Journal of the American Academy of Dermatology.

The virus needs androgens to infect cells, and uses androgen-dependent transmembrane protease serine 2 to prime viral protein spikes to anchor onto ACE2 receptors. Without that step, the virus can’t enter cells. Androgens are the only known activator in humans, so androgen blockers like spironolactone probably short-circuit the process, said the report’s lead author Carlos Wambier, MD, PhD, of the department of dermatology at Brown University, Providence, R.I (J Am Acad Dermatol. 2020 Apr 10. doi: 10.1016/j.jaad.2020.04.032).

The lack of androgens could be a possible explanation as to why mortality is so rare among children with COVID-19, and why fatalities among men are higher than among women with COVID-19, he said in an interview.

There are a lot of androgen blocker candidates, but he said spironolactone – a mainstay of acne treatment – might well be the best for the pandemic because of its concomitant lung and heart benefits.

The message counters a post on Instagram in March from a New York City dermatologist in private practice, Ellen Marmur, MD, that raised a question about spironolactone. Concerned about the situation in New York, she reviewed the literature and found a 2005 study that reported that macrophages drawn from 10 heart failure patients had increased ACE2 activity and increased messenger RNA expression after the subjects had been on spironolactone 25 mg per day for a month.

In an interview, Adam Friedman, MD, professor and interim chair of dermatology at George Washington University, Washington, said he’s been addressing concerns about spironolactone in educational webinars because of it.

He tells his audience that “you can’t make any claims” for COVID-19 based on the 2005 study. It was a small clinical study in heart failure patients and only assessed ACE2 expression on macrophages, not respiratory, cardiac, or mesangial cells, which are the relevant locations for viral invasion and damage. In fact, there are studies showing that spironolactone reduced ACE2 in renal mesangial cells. Also of note, spironolactone has been used with no indication of virus risk since the 1950s, he pointed out. The American Academy of Dermatology has not said to stop spironolactone.

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Concerns about potential risks about the use of spironolactone for acne during the COVID-19 pandemic were raised on social media last month, but spironolactone and other androgen blockers might actually protect against the virus, according to a report in the Journal of the American Academy of Dermatology.

The virus needs androgens to infect cells, and uses androgen-dependent transmembrane protease serine 2 to prime viral protein spikes to anchor onto ACE2 receptors. Without that step, the virus can’t enter cells. Androgens are the only known activator in humans, so androgen blockers like spironolactone probably short-circuit the process, said the report’s lead author Carlos Wambier, MD, PhD, of the department of dermatology at Brown University, Providence, R.I (J Am Acad Dermatol. 2020 Apr 10. doi: 10.1016/j.jaad.2020.04.032).

The lack of androgens could be a possible explanation as to why mortality is so rare among children with COVID-19, and why fatalities among men are higher than among women with COVID-19, he said in an interview.

There are a lot of androgen blocker candidates, but he said spironolactone – a mainstay of acne treatment – might well be the best for the pandemic because of its concomitant lung and heart benefits.

The message counters a post on Instagram in March from a New York City dermatologist in private practice, Ellen Marmur, MD, that raised a question about spironolactone. Concerned about the situation in New York, she reviewed the literature and found a 2005 study that reported that macrophages drawn from 10 heart failure patients had increased ACE2 activity and increased messenger RNA expression after the subjects had been on spironolactone 25 mg per day for a month.

In an interview, Adam Friedman, MD, professor and interim chair of dermatology at George Washington University, Washington, said he’s been addressing concerns about spironolactone in educational webinars because of it.

He tells his audience that “you can’t make any claims” for COVID-19 based on the 2005 study. It was a small clinical study in heart failure patients and only assessed ACE2 expression on macrophages, not respiratory, cardiac, or mesangial cells, which are the relevant locations for viral invasion and damage. In fact, there are studies showing that spironolactone reduced ACE2 in renal mesangial cells. Also of note, spironolactone has been used with no indication of virus risk since the 1950s, he pointed out. The American Academy of Dermatology has not said to stop spironolactone.

[email protected]

Concerns about potential risks about the use of spironolactone for acne during the COVID-19 pandemic were raised on social media last month, but spironolactone and other androgen blockers might actually protect against the virus, according to a report in the Journal of the American Academy of Dermatology.

The virus needs androgens to infect cells, and uses androgen-dependent transmembrane protease serine 2 to prime viral protein spikes to anchor onto ACE2 receptors. Without that step, the virus can’t enter cells. Androgens are the only known activator in humans, so androgen blockers like spironolactone probably short-circuit the process, said the report’s lead author Carlos Wambier, MD, PhD, of the department of dermatology at Brown University, Providence, R.I (J Am Acad Dermatol. 2020 Apr 10. doi: 10.1016/j.jaad.2020.04.032).

The lack of androgens could be a possible explanation as to why mortality is so rare among children with COVID-19, and why fatalities among men are higher than among women with COVID-19, he said in an interview.

There are a lot of androgen blocker candidates, but he said spironolactone – a mainstay of acne treatment – might well be the best for the pandemic because of its concomitant lung and heart benefits.

The message counters a post on Instagram in March from a New York City dermatologist in private practice, Ellen Marmur, MD, that raised a question about spironolactone. Concerned about the situation in New York, she reviewed the literature and found a 2005 study that reported that macrophages drawn from 10 heart failure patients had increased ACE2 activity and increased messenger RNA expression after the subjects had been on spironolactone 25 mg per day for a month.

In an interview, Adam Friedman, MD, professor and interim chair of dermatology at George Washington University, Washington, said he’s been addressing concerns about spironolactone in educational webinars because of it.

He tells his audience that “you can’t make any claims” for COVID-19 based on the 2005 study. It was a small clinical study in heart failure patients and only assessed ACE2 expression on macrophages, not respiratory, cardiac, or mesangial cells, which are the relevant locations for viral invasion and damage. In fact, there are studies showing that spironolactone reduced ACE2 in renal mesangial cells. Also of note, spironolactone has been used with no indication of virus risk since the 1950s, he pointed out. The American Academy of Dermatology has not said to stop spironolactone.

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The nonmetropolitan, largely rural, areas of the United States have fewer ICU beds than do urban areas, but their populations may be at higher risk for COVID-19 complications, according to the Kaiser Family Foundation.

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The nonmetropolitan, largely rural, areas of the United States have fewer ICU beds than do urban areas, but their populations may be at higher risk for COVID-19 complications, according to the Kaiser Family Foundation.

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The nonmetropolitan, largely rural, areas of the United States have fewer ICU beds than do urban areas, but their populations may be at higher risk for COVID-19 complications, according to the Kaiser Family Foundation.

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Older adults with COVID-19, the illness caused by the coronavirus, have several “atypical” symptoms, complicating efforts to ensure they get timely and appropriate treatment, according to physicians.

COVID-19 is typically signaled by three symptoms: a fever, an insistent cough, and shortness of breath. But older adults – the age group most at risk of severe complications or death from this condition – may have none of these characteristics.

Instead, seniors may seem “off” – not acting like themselves – early on after being infected by the coronavirus. They may sleep more than usual or stop eating. They may seem unusually apathetic or confused, losing orientation to their surroundings. They may become dizzy and fall. Sometimes, seniors stop speaking or simply collapse.

“With a lot of conditions, older adults don’t present in a typical way, and we’re seeing that with COVID-19 as well,” said Camille Vaughan, MD, section chief of geriatrics and gerontology at Emory University, Atlanta.

The reason has to do with how older bodies respond to illness and infection.

At advanced ages, “someone’s immune response may be blunted and their ability to regulate temperature may be altered,” said Dr. Joseph Ouslander, a professor of geriatric medicine at Florida Atlantic University in Boca Raton.

“Underlying chronic illnesses can mask or interfere with signs of infection,” he said. “Some older people, whether from age-related changes or previous neurologic issues such as a stroke, may have altered cough reflexes. Others with cognitive impairment may not be able to communicate their symptoms.”

Recognizing danger signs is important: If early signs of COVID-19 are missed, seniors may deteriorate before getting needed care. And people may go in and out of their homes without adequate protective measures, risking the spread of infection.

Quratulain Syed, MD, an Atlanta geriatrician, describes a man in his 80s whom she treated in mid-March. Over a period of days, this patient, who had heart disease, diabetes and moderate cognitive impairment, stopped walking and became incontinent and profoundly lethargic. But he didn’t have a fever or a cough. His only respiratory symptom: sneezing off and on.

The man’s elderly spouse called 911 twice. Both times, paramedics checked his vital signs and declared he was OK. After another worried call from the overwhelmed spouse, Dr. Syed insisted the patient be taken to the hospital, where he tested positive for COVID-19.

“I was quite concerned about the paramedics and health aides who’d been in the house and who hadn’t used PPE [personal protective equipment],” Dr. Syed said.

Dr. Sam Torbati, medical director of the emergency department at Cedars-Sinai Medical Center, Los Angeles, describes treating seniors who initially appear to be trauma patients but are found to have COVID-19.

“They get weak and dehydrated,” he said, “and when they stand to walk, they collapse and injure themselves badly.”

Dr. Torbati has seen older adults who are profoundly disoriented and unable to speak and who appear at first to have suffered strokes.

“When we test them, we discover that what’s producing these changes is a central nervous system effect of coronavirus,” he said.

Laura Perry, MD, of the University of California, San Francisco, saw a patient like this several weeks ago. The woman, in her 80s, had what seemed to be a cold before becoming very confused. In the hospital, she couldn’t identify where she was or stay awake during an examination. Dr. Perry diagnosed hypoactive delirium, an altered mental state in which people become inactive and drowsy. The patient tested positive for coronavirus and is still in the ICU.

Anthony Perry, MD, of the department of geriatric medicine at Rush University Medical Center in Chicago, tells of an 81-year-old woman with nausea, vomiting, and diarrhea who tested positive for COVID-19 in the emergency room. After receiving intravenous fluids, oxygen, and medication for her intestinal upset, she returned home after 2 days and is doing well.

Another 80-year-old Rush patient with similar symptoms – nausea and vomiting, but no cough, fever, or shortness of breath – is in intensive care after getting a positive COVID-19 test and due to be put on a ventilator. The difference? This patient is frail with “a lot of cardiovascular disease,” Dr. Perry said. Other than that, it’s not yet clear why some older patients do well while others do not.

So far, reports of cases like these have been anecdotal. But a few physicians are trying to gather more systematic information.

In Switzerland, Sylvain Nguyen, MD, a geriatrician at the University of Lausanne Hospital Center, put together a list of typical and atypical symptoms in older COVID-19 patients for a paper to be published in the Revue Médicale Suisse. Included on the atypical list are changes in a patient’s usual status, delirium, falls, fatigue, lethargy, low blood pressure, painful swallowing, fainting, diarrhea, nausea, vomiting, abdominal pain, and the loss of smell and taste.

Data come from hospitals and nursing homes in Switzerland, Italy, and France, Dr. Nguyen said in an email.

On the front lines, physicians need to make sure they carefully assess an older patient’s symptoms.

“While we have to have a high suspicion of COVID-19 because it’s so dangerous in the older population, there are many other things to consider,” said Kathleen Unroe, MD, a geriatrician at Indiana University, Indianapolis.

Seniors may also do poorly because their routines have changed. In nursing homes and most assisted living centers, activities have stopped and “residents are going to get weaker and more deconditioned because they’re not walking to and from the dining hall,” she said.

At home, isolated seniors may not be getting as much help with medication management or other essential needs from family members who are keeping their distance, other experts suggested. Or they may have become apathetic or depressed.

“I’d want to know ‘What’s the potential this person has had an exposure [to the coronavirus], especially in the last 2 weeks?’ ” said Dr. Vaughan of Emory. “Do they have home health personnel coming in? Have they gotten together with other family members? Are chronic conditions being controlled? Is there another diagnosis that seems more likely?”

“Someone may be just having a bad day. But if they’re not themselves for a couple of days, absolutely reach out to a primary care doctor or a local health system hotline to see if they meet the threshold for [coronavirus] testing,” Dr. Vaughan advised. “Be persistent. If you get a ‘no’ the first time and things aren’t improving, call back and ask again.”

Kaiser Health News (khn.org) is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

Older adults with COVID-19, the illness caused by the coronavirus, have several “atypical” symptoms, complicating efforts to ensure they get timely and appropriate treatment, according to physicians.

COVID-19 is typically signaled by three symptoms: a fever, an insistent cough, and shortness of breath. But older adults – the age group most at risk of severe complications or death from this condition – may have none of these characteristics.

Instead, seniors may seem “off” – not acting like themselves – early on after being infected by the coronavirus. They may sleep more than usual or stop eating. They may seem unusually apathetic or confused, losing orientation to their surroundings. They may become dizzy and fall. Sometimes, seniors stop speaking or simply collapse.

“With a lot of conditions, older adults don’t present in a typical way, and we’re seeing that with COVID-19 as well,” said Camille Vaughan, MD, section chief of geriatrics and gerontology at Emory University, Atlanta.

The reason has to do with how older bodies respond to illness and infection.

At advanced ages, “someone’s immune response may be blunted and their ability to regulate temperature may be altered,” said Dr. Joseph Ouslander, a professor of geriatric medicine at Florida Atlantic University in Boca Raton.

“Underlying chronic illnesses can mask or interfere with signs of infection,” he said. “Some older people, whether from age-related changes or previous neurologic issues such as a stroke, may have altered cough reflexes. Others with cognitive impairment may not be able to communicate their symptoms.”

Recognizing danger signs is important: If early signs of COVID-19 are missed, seniors may deteriorate before getting needed care. And people may go in and out of their homes without adequate protective measures, risking the spread of infection.

Quratulain Syed, MD, an Atlanta geriatrician, describes a man in his 80s whom she treated in mid-March. Over a period of days, this patient, who had heart disease, diabetes and moderate cognitive impairment, stopped walking and became incontinent and profoundly lethargic. But he didn’t have a fever or a cough. His only respiratory symptom: sneezing off and on.

The man’s elderly spouse called 911 twice. Both times, paramedics checked his vital signs and declared he was OK. After another worried call from the overwhelmed spouse, Dr. Syed insisted the patient be taken to the hospital, where he tested positive for COVID-19.

“I was quite concerned about the paramedics and health aides who’d been in the house and who hadn’t used PPE [personal protective equipment],” Dr. Syed said.

Dr. Sam Torbati, medical director of the emergency department at Cedars-Sinai Medical Center, Los Angeles, describes treating seniors who initially appear to be trauma patients but are found to have COVID-19.

“They get weak and dehydrated,” he said, “and when they stand to walk, they collapse and injure themselves badly.”

Dr. Torbati has seen older adults who are profoundly disoriented and unable to speak and who appear at first to have suffered strokes.

“When we test them, we discover that what’s producing these changes is a central nervous system effect of coronavirus,” he said.

Laura Perry, MD, of the University of California, San Francisco, saw a patient like this several weeks ago. The woman, in her 80s, had what seemed to be a cold before becoming very confused. In the hospital, she couldn’t identify where she was or stay awake during an examination. Dr. Perry diagnosed hypoactive delirium, an altered mental state in which people become inactive and drowsy. The patient tested positive for coronavirus and is still in the ICU.

Anthony Perry, MD, of the department of geriatric medicine at Rush University Medical Center in Chicago, tells of an 81-year-old woman with nausea, vomiting, and diarrhea who tested positive for COVID-19 in the emergency room. After receiving intravenous fluids, oxygen, and medication for her intestinal upset, she returned home after 2 days and is doing well.

Another 80-year-old Rush patient with similar symptoms – nausea and vomiting, but no cough, fever, or shortness of breath – is in intensive care after getting a positive COVID-19 test and due to be put on a ventilator. The difference? This patient is frail with “a lot of cardiovascular disease,” Dr. Perry said. Other than that, it’s not yet clear why some older patients do well while others do not.

So far, reports of cases like these have been anecdotal. But a few physicians are trying to gather more systematic information.

In Switzerland, Sylvain Nguyen, MD, a geriatrician at the University of Lausanne Hospital Center, put together a list of typical and atypical symptoms in older COVID-19 patients for a paper to be published in the Revue Médicale Suisse. Included on the atypical list are changes in a patient’s usual status, delirium, falls, fatigue, lethargy, low blood pressure, painful swallowing, fainting, diarrhea, nausea, vomiting, abdominal pain, and the loss of smell and taste.

Data come from hospitals and nursing homes in Switzerland, Italy, and France, Dr. Nguyen said in an email.

On the front lines, physicians need to make sure they carefully assess an older patient’s symptoms.

“While we have to have a high suspicion of COVID-19 because it’s so dangerous in the older population, there are many other things to consider,” said Kathleen Unroe, MD, a geriatrician at Indiana University, Indianapolis.

Seniors may also do poorly because their routines have changed. In nursing homes and most assisted living centers, activities have stopped and “residents are going to get weaker and more deconditioned because they’re not walking to and from the dining hall,” she said.

At home, isolated seniors may not be getting as much help with medication management or other essential needs from family members who are keeping their distance, other experts suggested. Or they may have become apathetic or depressed.

“I’d want to know ‘What’s the potential this person has had an exposure [to the coronavirus], especially in the last 2 weeks?’ ” said Dr. Vaughan of Emory. “Do they have home health personnel coming in? Have they gotten together with other family members? Are chronic conditions being controlled? Is there another diagnosis that seems more likely?”

“Someone may be just having a bad day. But if they’re not themselves for a couple of days, absolutely reach out to a primary care doctor or a local health system hotline to see if they meet the threshold for [coronavirus] testing,” Dr. Vaughan advised. “Be persistent. If you get a ‘no’ the first time and things aren’t improving, call back and ask again.”

Kaiser Health News (khn.org) is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

Older adults with COVID-19, the illness caused by the coronavirus, have several “atypical” symptoms, complicating efforts to ensure they get timely and appropriate treatment, according to physicians.

COVID-19 is typically signaled by three symptoms: a fever, an insistent cough, and shortness of breath. But older adults – the age group most at risk of severe complications or death from this condition – may have none of these characteristics.

Instead, seniors may seem “off” – not acting like themselves – early on after being infected by the coronavirus. They may sleep more than usual or stop eating. They may seem unusually apathetic or confused, losing orientation to their surroundings. They may become dizzy and fall. Sometimes, seniors stop speaking or simply collapse.

“With a lot of conditions, older adults don’t present in a typical way, and we’re seeing that with COVID-19 as well,” said Camille Vaughan, MD, section chief of geriatrics and gerontology at Emory University, Atlanta.

The reason has to do with how older bodies respond to illness and infection.

At advanced ages, “someone’s immune response may be blunted and their ability to regulate temperature may be altered,” said Dr. Joseph Ouslander, a professor of geriatric medicine at Florida Atlantic University in Boca Raton.

“Underlying chronic illnesses can mask or interfere with signs of infection,” he said. “Some older people, whether from age-related changes or previous neurologic issues such as a stroke, may have altered cough reflexes. Others with cognitive impairment may not be able to communicate their symptoms.”

Recognizing danger signs is important: If early signs of COVID-19 are missed, seniors may deteriorate before getting needed care. And people may go in and out of their homes without adequate protective measures, risking the spread of infection.

Quratulain Syed, MD, an Atlanta geriatrician, describes a man in his 80s whom she treated in mid-March. Over a period of days, this patient, who had heart disease, diabetes and moderate cognitive impairment, stopped walking and became incontinent and profoundly lethargic. But he didn’t have a fever or a cough. His only respiratory symptom: sneezing off and on.

The man’s elderly spouse called 911 twice. Both times, paramedics checked his vital signs and declared he was OK. After another worried call from the overwhelmed spouse, Dr. Syed insisted the patient be taken to the hospital, where he tested positive for COVID-19.

“I was quite concerned about the paramedics and health aides who’d been in the house and who hadn’t used PPE [personal protective equipment],” Dr. Syed said.

Dr. Sam Torbati, medical director of the emergency department at Cedars-Sinai Medical Center, Los Angeles, describes treating seniors who initially appear to be trauma patients but are found to have COVID-19.

“They get weak and dehydrated,” he said, “and when they stand to walk, they collapse and injure themselves badly.”

Dr. Torbati has seen older adults who are profoundly disoriented and unable to speak and who appear at first to have suffered strokes.

“When we test them, we discover that what’s producing these changes is a central nervous system effect of coronavirus,” he said.

Laura Perry, MD, of the University of California, San Francisco, saw a patient like this several weeks ago. The woman, in her 80s, had what seemed to be a cold before becoming very confused. In the hospital, she couldn’t identify where she was or stay awake during an examination. Dr. Perry diagnosed hypoactive delirium, an altered mental state in which people become inactive and drowsy. The patient tested positive for coronavirus and is still in the ICU.

Anthony Perry, MD, of the department of geriatric medicine at Rush University Medical Center in Chicago, tells of an 81-year-old woman with nausea, vomiting, and diarrhea who tested positive for COVID-19 in the emergency room. After receiving intravenous fluids, oxygen, and medication for her intestinal upset, she returned home after 2 days and is doing well.

Another 80-year-old Rush patient with similar symptoms – nausea and vomiting, but no cough, fever, or shortness of breath – is in intensive care after getting a positive COVID-19 test and due to be put on a ventilator. The difference? This patient is frail with “a lot of cardiovascular disease,” Dr. Perry said. Other than that, it’s not yet clear why some older patients do well while others do not.

So far, reports of cases like these have been anecdotal. But a few physicians are trying to gather more systematic information.

In Switzerland, Sylvain Nguyen, MD, a geriatrician at the University of Lausanne Hospital Center, put together a list of typical and atypical symptoms in older COVID-19 patients for a paper to be published in the Revue Médicale Suisse. Included on the atypical list are changes in a patient’s usual status, delirium, falls, fatigue, lethargy, low blood pressure, painful swallowing, fainting, diarrhea, nausea, vomiting, abdominal pain, and the loss of smell and taste.

Data come from hospitals and nursing homes in Switzerland, Italy, and France, Dr. Nguyen said in an email.

On the front lines, physicians need to make sure they carefully assess an older patient’s symptoms.

“While we have to have a high suspicion of COVID-19 because it’s so dangerous in the older population, there are many other things to consider,” said Kathleen Unroe, MD, a geriatrician at Indiana University, Indianapolis.

Seniors may also do poorly because their routines have changed. In nursing homes and most assisted living centers, activities have stopped and “residents are going to get weaker and more deconditioned because they’re not walking to and from the dining hall,” she said.

At home, isolated seniors may not be getting as much help with medication management or other essential needs from family members who are keeping their distance, other experts suggested. Or they may have become apathetic or depressed.

“I’d want to know ‘What’s the potential this person has had an exposure [to the coronavirus], especially in the last 2 weeks?’ ” said Dr. Vaughan of Emory. “Do they have home health personnel coming in? Have they gotten together with other family members? Are chronic conditions being controlled? Is there another diagnosis that seems more likely?”

“Someone may be just having a bad day. But if they’re not themselves for a couple of days, absolutely reach out to a primary care doctor or a local health system hotline to see if they meet the threshold for [coronavirus] testing,” Dr. Vaughan advised. “Be persistent. If you get a ‘no’ the first time and things aren’t improving, call back and ask again.”

Kaiser Health News (khn.org) is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

A study from China showed that the presence of SARS-CoV-2 lasts significantly longer in stool samples from COVID-19 patients than in respiratory and serum samples.

CDC/John Hierholzer, MD

However, the virus also persists longer with higher loads and later peaks in the respiratory tissue of patients with severe disease than in those with mild disease, according to an analysis of 96 consecutively admitted patients with laboratory confirmed SARS-CoV-2 infection.

The retrospective study cohort data were collected from Jan. 19 to March 20 at a designated hospital for patients with COVID-19 in Zhejiang province. Among the patients, 22 had mild disease, and 74 had severe disease, according to the researchers.

Infection was confirmed in all patients by testing sputum and saliva samples. Viral RNA was detected in the stool of 59% of the patients and in the serum of 41% of patients. Only one of the patients had a positive urine sample. The median duration of virus in stool (22 days) was significantly longer than in respiratory (18 days; P = .002) and serum samples (16 days; P < .001).

In addition, the median duration of virus in the respiratory samples of patients with severe disease (21 days) was significantly longer than in patients with mild disease (14 days; P = .04).

“In the mild group, the viral loads peaked in respiratory samples in the second week from disease onset, whereas viral load continued to be high during the third week in the severe group,” the authors stated.

Virus duration was also longer in patients older than 60 years and in men.

The longer duration of SARS-CoV-2 in stool samples highlights the need to strengthen the management of stool samples in the prevention and control of the epidemic, especially for patients in the later stages of the disease, the authors advised.

“Compared with patients with mild disease, those with severe disease showed longer duration of SARS-CoV-2 in respiratory samples, higher viral load, and a later shedding peak. These findings suggest that reducing viral loads through clinical means and strengthening management during each stage of severe disease should help to prevent the spread of the virus,” the researchers concluded.

The study was funded by the China National Mega-Projects for Infectious Diseases and the National Natural Science Foundation of China. The authors reported they had no disclosures.

[email protected]

SOURCE: Zheng S et al. BMJ. 2020;369:m1443.

A study from China showed that the presence of SARS-CoV-2 lasts significantly longer in stool samples from COVID-19 patients than in respiratory and serum samples.

CDC/John Hierholzer, MD

However, the virus also persists longer with higher loads and later peaks in the respiratory tissue of patients with severe disease than in those with mild disease, according to an analysis of 96 consecutively admitted patients with laboratory confirmed SARS-CoV-2 infection.

The retrospective study cohort data were collected from Jan. 19 to March 20 at a designated hospital for patients with COVID-19 in Zhejiang province. Among the patients, 22 had mild disease, and 74 had severe disease, according to the researchers.

Infection was confirmed in all patients by testing sputum and saliva samples. Viral RNA was detected in the stool of 59% of the patients and in the serum of 41% of patients. Only one of the patients had a positive urine sample. The median duration of virus in stool (22 days) was significantly longer than in respiratory (18 days; P = .002) and serum samples (16 days; P < .001).

In addition, the median duration of virus in the respiratory samples of patients with severe disease (21 days) was significantly longer than in patients with mild disease (14 days; P = .04).

“In the mild group, the viral loads peaked in respiratory samples in the second week from disease onset, whereas viral load continued to be high during the third week in the severe group,” the authors stated.

Virus duration was also longer in patients older than 60 years and in men.

The longer duration of SARS-CoV-2 in stool samples highlights the need to strengthen the management of stool samples in the prevention and control of the epidemic, especially for patients in the later stages of the disease, the authors advised.

“Compared with patients with mild disease, those with severe disease showed longer duration of SARS-CoV-2 in respiratory samples, higher viral load, and a later shedding peak. These findings suggest that reducing viral loads through clinical means and strengthening management during each stage of severe disease should help to prevent the spread of the virus,” the researchers concluded.

The study was funded by the China National Mega-Projects for Infectious Diseases and the National Natural Science Foundation of China. The authors reported they had no disclosures.

[email protected]

SOURCE: Zheng S et al. BMJ. 2020;369:m1443.

A study from China showed that the presence of SARS-CoV-2 lasts significantly longer in stool samples from COVID-19 patients than in respiratory and serum samples.

CDC/John Hierholzer, MD

However, the virus also persists longer with higher loads and later peaks in the respiratory tissue of patients with severe disease than in those with mild disease, according to an analysis of 96 consecutively admitted patients with laboratory confirmed SARS-CoV-2 infection.

The retrospective study cohort data were collected from Jan. 19 to March 20 at a designated hospital for patients with COVID-19 in Zhejiang province. Among the patients, 22 had mild disease, and 74 had severe disease, according to the researchers.

Infection was confirmed in all patients by testing sputum and saliva samples. Viral RNA was detected in the stool of 59% of the patients and in the serum of 41% of patients. Only one of the patients had a positive urine sample. The median duration of virus in stool (22 days) was significantly longer than in respiratory (18 days; P = .002) and serum samples (16 days; P < .001).

In addition, the median duration of virus in the respiratory samples of patients with severe disease (21 days) was significantly longer than in patients with mild disease (14 days; P = .04).

“In the mild group, the viral loads peaked in respiratory samples in the second week from disease onset, whereas viral load continued to be high during the third week in the severe group,” the authors stated.

Virus duration was also longer in patients older than 60 years and in men.

The longer duration of SARS-CoV-2 in stool samples highlights the need to strengthen the management of stool samples in the prevention and control of the epidemic, especially for patients in the later stages of the disease, the authors advised.

“Compared with patients with mild disease, those with severe disease showed longer duration of SARS-CoV-2 in respiratory samples, higher viral load, and a later shedding peak. These findings suggest that reducing viral loads through clinical means and strengthening management during each stage of severe disease should help to prevent the spread of the virus,” the researchers concluded.

The study was funded by the China National Mega-Projects for Infectious Diseases and the National Natural Science Foundation of China. The authors reported they had no disclosures.

[email protected]

SOURCE: Zheng S et al. BMJ. 2020;369:m1443.

The first time that the Rev. Michael Mercier, BCC (a board-certified chaplain), provided spiritual care for a patient hospitalized with COVID-19 in March, he found himself engaged in a bit of soul-searching. Even though he donned a mask, gloves, and gown, he could get no closer than the hospital room doorway to interact with the patient because of infection-control measures.

Bill Murphy/Lifespan

“It went against all my natural instincts and my experience as a chaplain,” said Rev. Mercier, who serves as director of spiritual care for Rhode Island Hospital, Hasbro Children’s Hospital, Miriam Hospital, and Newport Hospital, which are operated by Lifespan, Rhode Island’s largest health system. “The first instinct is to be physically present in the room with the person who’s dying, to have the family gathered around the bedside.”

Prior to standing in the doorway that day, he’d been on the phone with family members, “just listening to their fear and their anxiety that they could not be with their loved one when their loved one was dying,” he said. “I validated their feelings. I also urged them to work with me and the nurse to bring a phone into the room, hold it to the patient’s ear, and they were able to say their goodbyes and how much they loved the person.”

The patient was a devout Roman Catholic, he added, and the family requested that the Prayer of Commendation and the Apostolic Pardon be performed. Rev. Mercier arranged for a Catholic priest to carry out this request. “The nurse told the patient what was going on, and the priest offered the prayers and the rituals from the doorway,” Rev. Mercier said. “It was a surreal experience. For me, it was almost entirely phone based, and it was mostly with the family because the patient couldn’t talk too much.”

To add to the sense of detachment in a situation like that, doctors, nurses, and chaplains caring for COVID-19 patients are wearing masks and face shields, and sometimes the sickest patients are intubated, which can complicate efforts to communicate. “I’m surprised at how we find the mask as somewhat of a barrier,” said Carolanne B. Hauck, BCC, director of chaplaincy care & education and volunteer services at Lancaster (Pa.) General Hospital, which is part of the Penn Medicine system. “By that I mean, often for us, sitting at the bedside and really being able to see someone’s face and have them see our face – with our masks, that’s just not happening. We’re also having briefer visits when we’re visiting with COVID patients.”

COVID-19 may have quarantined some traditional ways of providing spiritual care, but hospital chaplains are relying on technology more than ever in their efforts to meet the needs of patients and their families, including the use of iPads, FaceTime, and video conferencing programs like Zoom and BlueJeans.

“We’ve used Zoom to talk with family members that live out of state,” Rev. Mercier said. “Most of the time, I get an invitation to join a Zoom meeting, but now I need to become proficient in utilizing Zoom to set up those end-of-life family meetings. There’s a lot of learning on the fly, how to use these technologies in a way that’s helpful for everybody. That’s the biggest thing I’m learning: Connection is connection during this time of high stress and anxiety, and we just have to get creative.”

Courtesy Rabbi Neal J. Loevinger

Hospital chaplains may be using smartphones and other gadgets to communicate with patients and their families more than they did in the pre-COVID-19 world, but their basic job has not changed, said Rabbi Neal J. Loevinger, BCC, director of spiritual care services at Vassar Brothers Medical Center in Poughkeepsie, N.Y., part of a seven-hospital system operated by Nuvance Health. “We offer the hope of a caring presence,” said Rabbi Loevinger, who is also a member of the board of directors for Neshama: Association of Jewish Chaplains. “If someone is in a hole, our job is to climb down into the hole with them and say, ‘We’re going to get out of this hole together.’ We can’t promise that someone’s going to get better. We can’t promise that everything’s going to be all right. What we can promise is that we will not abandon you. We can promise that there will be someone accompanying you in any way we can through this crisis.”

Ms. Hauck remembered a phone conversation with the granddaughter of a patient hospitalized with COVID-19 who was nearing the end of her life. The granddaughter told her a story about how her grandmother and her best friend made a pact with each other that, when one was dying, the other would come to her side and pray the Rosary with her. “The granddaughter got tearful and said, ‘That can’t happen now,’ ” said Ms. Hauck, who oversees a staff of 9 chaplains and 10 per diem chaplains. “I made a promise that I would do my best to be at the bedside and pray the Rosary with her grandmother.”

The nurses were aware of the request, and about a day later, Ms. Hauck received a call at 1 a.m., indicating that the patient was close to dying. She drove to Lancaster General, put on her personal protective equipment, made it to the patient’s bedside, and began to pray the Rosary with her, with a nurse in the room. “The nurse said to me, ‘Carolanne, all of her stats are going up,’ and the patient actually became a little more alert,” she recalled. “We talked a little bit, and I asked, ‘Would you like to pray the Rosary now?’ She shook her head yes, and said, ‘Hail Mary, full of grace ...’ and those were the last words that she spoke. I finished the prayers for her, and then she died. It was very meaningful knowing that I could honor that wish for her, but more importantly, that I could do that for the family, who otherwise would have been at her side saying the Rosary with her. We have a recognition of how hard it is to leave someone at the hospital and not be at their bedside.”

Hospital chaplains are also supporting interdisciplinary teams of physicians, nurses, and other staff, as they navigate the provision of care in the wake of a pandemic. “They are under a great deal of stress – not only from being at work but with all the role changes that have happened in their home life,” Ms. Wetsch-Johnson said. “Some of them now are being the teacher at home and having to care for children. They have a lot that they come in with. My job is to help them so that they can go do their job. Regularly what I do is check in with the units and ask, ‘How are you doing today? What’s going on for you?’ Because people need to know that someone’s there to be with them and walk with them and listen to them.”

Courtesy Mary Wetsch-Johnson

On any given day, it’s not uncommon for hospital staff members to spontaneously pull aside chaplains to vent, pray, or just to talk. “They process their own fears and anxieties about working in this kind of environment,” Rev. Mercier said. “They’re scared for themselves. They think, ‘Could I get the virus? Could I spread the virus to my family?’ Or, they may express the care and concern they have for their patients. Oftentimes, it’s a mixture of both. Those spontaneous conversations are often the most powerful.”

Ms. Hauck noted that some nurses and clinicians at Lancaster General Hospital “are doing work they may have not done before,” she said. “Some of them are experiencing death for the first time, so we help them to navigate that. One of the best things we can do is hear the anxiety they have or the sadness they have when a patient dies. Also, maybe the frustration that they couldn’t do more in some cases and helping them to see that sometimes their best is good enough.”

She recalled one younger patient with COVID-19 who fell seriously ill. “It was really affecting a lot of people on the unit because of the patient’s age,” she said. “When we saw that the patient was getting better and would be discharged, there was such a sense of relief. I’m not sure that patient will ever understand how that helped us. It was comforting to us to know that people are getting better. It is something we celebrate.”

As chaplains adjust to their “new normal,” carving out time for self-care is key. Ms. Hauck and her staff periodically meet on Zoom with a psychotherapist “who understands what we do, asks us really good questions, and reminds us to take care of ourselves,” she said. “Personally, I’m making sure I get my exercise in, I pack a healthy lunch. We do check in with each other. Part of our handoff at every shift provides for an opportunity to debrief about how your day was.”

Rev. Mercier’s self check-in includes deep-breathing meditation and reciting certain prayers throughout the day. “The deep breathing helps me center and refocus with my body, while the prayers remind me of my connection to the Divine,” he said. “It also reminds me that in the midst of the fear and the anxiety, I fear for myself. It’s hard not to be concerned that I could be infected. I have a family at home and could spread this to them. The prayer practices are a reminder to me that it’s okay to feel those fears and anxieties. Sometimes the spiritual practice helps me find that place of acceptance. That enables me to keep moving forward.”

Ms. Wetsch-Johnson described the sense of upendedness caused by the COVID-19 pandemic as a “ripple in the water that’s going to have long-lasting effects on the delivery of health care. People are taking the time to listen to one another. I’ve seen people in all departments be more compassionate with one another. I’ve seen managers go out of their way to make sure their staff are deeply cared for. I think that will have a ripple effect. That’s my hope, that we will continue to be more compassionate, more loving, and more understanding.”

Rabbi Loevinger hopes that even the most reticent physicians remember that chaplains serve as their advocate, too, especially during times of crisis. “This has been a time of unprecedented ethical wrestling in our hospitals, where there’s been a real concern that doctors, nurses, and respiratory therapists are going to be faced with morally distressing situations regarding insufficient PPE, or insufficient ventilator or dialysis machine supply to support everybody that needs to be supported,” he said. “Chaplains are a key part of the process of making ethical decisions, but also supporting physicians who are in distress over [being in] situations they never had imagined. Physicians don’t like to talk about the fact that a lot of the decisions they make are really heartbreaking. But if chaplains understand anything, it’s that being brokenhearted is part of the human condition, and that we can be part of the answer for keeping physicians morally and spiritually grounded in their work. We always invite that conversation.”

For Rev. Mercier, serving in a time of crisis reminds him of the importance of providing care as a team, “not just for patients and families, but for one another,” he said. “One of the lessons we can learn is, how can we build that connection with one another, to support and care for one another? How can we make sure that no one feels alone while working in the hospital?”

He draws inspiration from a saying credited to St. John of the Cross, which reads, “I saw the river through which every soul must pass, and the name of that river is suffering. I saw the boat that carries each soul across that river, and the name of that boat is love.”

“It’s that image that’s sticking with me, not just for myself as a chaplain but for all of my colleagues in the hospital,” said Rev. Mercier, who also pastors Tabernacle Baptist Church in Hope, R.I. “We’re in that river with the patients right now, suffering, and we’re doing our best to help them get to the other side – whatever the other side may look like.”

[email protected]

Correction, 4/30/20: An earlier version of the caption for the photo with Mary Wetsch-Johnson misstated the location. The photo was taken outside St. Elizabeth Hospital in Enumclaw, Wash.

The first time that the Rev. Michael Mercier, BCC (a board-certified chaplain), provided spiritual care for a patient hospitalized with COVID-19 in March, he found himself engaged in a bit of soul-searching. Even though he donned a mask, gloves, and gown, he could get no closer than the hospital room doorway to interact with the patient because of infection-control measures.

Bill Murphy/Lifespan

“It went against all my natural instincts and my experience as a chaplain,” said Rev. Mercier, who serves as director of spiritual care for Rhode Island Hospital, Hasbro Children’s Hospital, Miriam Hospital, and Newport Hospital, which are operated by Lifespan, Rhode Island’s largest health system. “The first instinct is to be physically present in the room with the person who’s dying, to have the family gathered around the bedside.”

Prior to standing in the doorway that day, he’d been on the phone with family members, “just listening to their fear and their anxiety that they could not be with their loved one when their loved one was dying,” he said. “I validated their feelings. I also urged them to work with me and the nurse to bring a phone into the room, hold it to the patient’s ear, and they were able to say their goodbyes and how much they loved the person.”

The patient was a devout Roman Catholic, he added, and the family requested that the Prayer of Commendation and the Apostolic Pardon be performed. Rev. Mercier arranged for a Catholic priest to carry out this request. “The nurse told the patient what was going on, and the priest offered the prayers and the rituals from the doorway,” Rev. Mercier said. “It was a surreal experience. For me, it was almost entirely phone based, and it was mostly with the family because the patient couldn’t talk too much.”

To add to the sense of detachment in a situation like that, doctors, nurses, and chaplains caring for COVID-19 patients are wearing masks and face shields, and sometimes the sickest patients are intubated, which can complicate efforts to communicate. “I’m surprised at how we find the mask as somewhat of a barrier,” said Carolanne B. Hauck, BCC, director of chaplaincy care & education and volunteer services at Lancaster (Pa.) General Hospital, which is part of the Penn Medicine system. “By that I mean, often for us, sitting at the bedside and really being able to see someone’s face and have them see our face – with our masks, that’s just not happening. We’re also having briefer visits when we’re visiting with COVID patients.”

COVID-19 may have quarantined some traditional ways of providing spiritual care, but hospital chaplains are relying on technology more than ever in their efforts to meet the needs of patients and their families, including the use of iPads, FaceTime, and video conferencing programs like Zoom and BlueJeans.

“We’ve used Zoom to talk with family members that live out of state,” Rev. Mercier said. “Most of the time, I get an invitation to join a Zoom meeting, but now I need to become proficient in utilizing Zoom to set up those end-of-life family meetings. There’s a lot of learning on the fly, how to use these technologies in a way that’s helpful for everybody. That’s the biggest thing I’m learning: Connection is connection during this time of high stress and anxiety, and we just have to get creative.”

Courtesy Rabbi Neal J. Loevinger

Hospital chaplains may be using smartphones and other gadgets to communicate with patients and their families more than they did in the pre-COVID-19 world, but their basic job has not changed, said Rabbi Neal J. Loevinger, BCC, director of spiritual care services at Vassar Brothers Medical Center in Poughkeepsie, N.Y., part of a seven-hospital system operated by Nuvance Health. “We offer the hope of a caring presence,” said Rabbi Loevinger, who is also a member of the board of directors for Neshama: Association of Jewish Chaplains. “If someone is in a hole, our job is to climb down into the hole with them and say, ‘We’re going to get out of this hole together.’ We can’t promise that someone’s going to get better. We can’t promise that everything’s going to be all right. What we can promise is that we will not abandon you. We can promise that there will be someone accompanying you in any way we can through this crisis.”

Ms. Hauck remembered a phone conversation with the granddaughter of a patient hospitalized with COVID-19 who was nearing the end of her life. The granddaughter told her a story about how her grandmother and her best friend made a pact with each other that, when one was dying, the other would come to her side and pray the Rosary with her. “The granddaughter got tearful and said, ‘That can’t happen now,’ ” said Ms. Hauck, who oversees a staff of 9 chaplains and 10 per diem chaplains. “I made a promise that I would do my best to be at the bedside and pray the Rosary with her grandmother.”

The nurses were aware of the request, and about a day later, Ms. Hauck received a call at 1 a.m., indicating that the patient was close to dying. She drove to Lancaster General, put on her personal protective equipment, made it to the patient’s bedside, and began to pray the Rosary with her, with a nurse in the room. “The nurse said to me, ‘Carolanne, all of her stats are going up,’ and the patient actually became a little more alert,” she recalled. “We talked a little bit, and I asked, ‘Would you like to pray the Rosary now?’ She shook her head yes, and said, ‘Hail Mary, full of grace ...’ and those were the last words that she spoke. I finished the prayers for her, and then she died. It was very meaningful knowing that I could honor that wish for her, but more importantly, that I could do that for the family, who otherwise would have been at her side saying the Rosary with her. We have a recognition of how hard it is to leave someone at the hospital and not be at their bedside.”

Hospital chaplains are also supporting interdisciplinary teams of physicians, nurses, and other staff, as they navigate the provision of care in the wake of a pandemic. “They are under a great deal of stress – not only from being at work but with all the role changes that have happened in their home life,” Ms. Wetsch-Johnson said. “Some of them now are being the teacher at home and having to care for children. They have a lot that they come in with. My job is to help them so that they can go do their job. Regularly what I do is check in with the units and ask, ‘How are you doing today? What’s going on for you?’ Because people need to know that someone’s there to be with them and walk with them and listen to them.”

Courtesy Mary Wetsch-Johnson

On any given day, it’s not uncommon for hospital staff members to spontaneously pull aside chaplains to vent, pray, or just to talk. “They process their own fears and anxieties about working in this kind of environment,” Rev. Mercier said. “They’re scared for themselves. They think, ‘Could I get the virus? Could I spread the virus to my family?’ Or, they may express the care and concern they have for their patients. Oftentimes, it’s a mixture of both. Those spontaneous conversations are often the most powerful.”

Ms. Hauck noted that some nurses and clinicians at Lancaster General Hospital “are doing work they may have not done before,” she said. “Some of them are experiencing death for the first time, so we help them to navigate that. One of the best things we can do is hear the anxiety they have or the sadness they have when a patient dies. Also, maybe the frustration that they couldn’t do more in some cases and helping them to see that sometimes their best is good enough.”

She recalled one younger patient with COVID-19 who fell seriously ill. “It was really affecting a lot of people on the unit because of the patient’s age,” she said. “When we saw that the patient was getting better and would be discharged, there was such a sense of relief. I’m not sure that patient will ever understand how that helped us. It was comforting to us to know that people are getting better. It is something we celebrate.”

As chaplains adjust to their “new normal,” carving out time for self-care is key. Ms. Hauck and her staff periodically meet on Zoom with a psychotherapist “who understands what we do, asks us really good questions, and reminds us to take care of ourselves,” she said. “Personally, I’m making sure I get my exercise in, I pack a healthy lunch. We do check in with each other. Part of our handoff at every shift provides for an opportunity to debrief about how your day was.”

Rev. Mercier’s self check-in includes deep-breathing meditation and reciting certain prayers throughout the day. “The deep breathing helps me center and refocus with my body, while the prayers remind me of my connection to the Divine,” he said. “It also reminds me that in the midst of the fear and the anxiety, I fear for myself. It’s hard not to be concerned that I could be infected. I have a family at home and could spread this to them. The prayer practices are a reminder to me that it’s okay to feel those fears and anxieties. Sometimes the spiritual practice helps me find that place of acceptance. That enables me to keep moving forward.”

Ms. Wetsch-Johnson described the sense of upendedness caused by the COVID-19 pandemic as a “ripple in the water that’s going to have long-lasting effects on the delivery of health care. People are taking the time to listen to one another. I’ve seen people in all departments be more compassionate with one another. I’ve seen managers go out of their way to make sure their staff are deeply cared for. I think that will have a ripple effect. That’s my hope, that we will continue to be more compassionate, more loving, and more understanding.”

Rabbi Loevinger hopes that even the most reticent physicians remember that chaplains serve as their advocate, too, especially during times of crisis. “This has been a time of unprecedented ethical wrestling in our hospitals, where there’s been a real concern that doctors, nurses, and respiratory therapists are going to be faced with morally distressing situations regarding insufficient PPE, or insufficient ventilator or dialysis machine supply to support everybody that needs to be supported,” he said. “Chaplains are a key part of the process of making ethical decisions, but also supporting physicians who are in distress over [being in] situations they never had imagined. Physicians don’t like to talk about the fact that a lot of the decisions they make are really heartbreaking. But if chaplains understand anything, it’s that being brokenhearted is part of the human condition, and that we can be part of the answer for keeping physicians morally and spiritually grounded in their work. We always invite that conversation.”

For Rev. Mercier, serving in a time of crisis reminds him of the importance of providing care as a team, “not just for patients and families, but for one another,” he said. “One of the lessons we can learn is, how can we build that connection with one another, to support and care for one another? How can we make sure that no one feels alone while working in the hospital?”

He draws inspiration from a saying credited to St. John of the Cross, which reads, “I saw the river through which every soul must pass, and the name of that river is suffering. I saw the boat that carries each soul across that river, and the name of that boat is love.”

“It’s that image that’s sticking with me, not just for myself as a chaplain but for all of my colleagues in the hospital,” said Rev. Mercier, who also pastors Tabernacle Baptist Church in Hope, R.I. “We’re in that river with the patients right now, suffering, and we’re doing our best to help them get to the other side – whatever the other side may look like.”

[email protected]

Correction, 4/30/20: An earlier version of the caption for the photo with Mary Wetsch-Johnson misstated the location. The photo was taken outside St. Elizabeth Hospital in Enumclaw, Wash.

The first time that the Rev. Michael Mercier, BCC (a board-certified chaplain), provided spiritual care for a patient hospitalized with COVID-19 in March, he found himself engaged in a bit of soul-searching. Even though he donned a mask, gloves, and gown, he could get no closer than the hospital room doorway to interact with the patient because of infection-control measures.

Bill Murphy/Lifespan

“It went against all my natural instincts and my experience as a chaplain,” said Rev. Mercier, who serves as director of spiritual care for Rhode Island Hospital, Hasbro Children’s Hospital, Miriam Hospital, and Newport Hospital, which are operated by Lifespan, Rhode Island’s largest health system. “The first instinct is to be physically present in the room with the person who’s dying, to have the family gathered around the bedside.”

Prior to standing in the doorway that day, he’d been on the phone with family members, “just listening to their fear and their anxiety that they could not be with their loved one when their loved one was dying,” he said. “I validated their feelings. I also urged them to work with me and the nurse to bring a phone into the room, hold it to the patient’s ear, and they were able to say their goodbyes and how much they loved the person.”

The patient was a devout Roman Catholic, he added, and the family requested that the Prayer of Commendation and the Apostolic Pardon be performed. Rev. Mercier arranged for a Catholic priest to carry out this request. “The nurse told the patient what was going on, and the priest offered the prayers and the rituals from the doorway,” Rev. Mercier said. “It was a surreal experience. For me, it was almost entirely phone based, and it was mostly with the family because the patient couldn’t talk too much.”

To add to the sense of detachment in a situation like that, doctors, nurses, and chaplains caring for COVID-19 patients are wearing masks and face shields, and sometimes the sickest patients are intubated, which can complicate efforts to communicate. “I’m surprised at how we find the mask as somewhat of a barrier,” said Carolanne B. Hauck, BCC, director of chaplaincy care & education and volunteer services at Lancaster (Pa.) General Hospital, which is part of the Penn Medicine system. “By that I mean, often for us, sitting at the bedside and really being able to see someone’s face and have them see our face – with our masks, that’s just not happening. We’re also having briefer visits when we’re visiting with COVID patients.”

COVID-19 may have quarantined some traditional ways of providing spiritual care, but hospital chaplains are relying on technology more than ever in their efforts to meet the needs of patients and their families, including the use of iPads, FaceTime, and video conferencing programs like Zoom and BlueJeans.

“We’ve used Zoom to talk with family members that live out of state,” Rev. Mercier said. “Most of the time, I get an invitation to join a Zoom meeting, but now I need to become proficient in utilizing Zoom to set up those end-of-life family meetings. There’s a lot of learning on the fly, how to use these technologies in a way that’s helpful for everybody. That’s the biggest thing I’m learning: Connection is connection during this time of high stress and anxiety, and we just have to get creative.”

Courtesy Rabbi Neal J. Loevinger

Hospital chaplains may be using smartphones and other gadgets to communicate with patients and their families more than they did in the pre-COVID-19 world, but their basic job has not changed, said Rabbi Neal J. Loevinger, BCC, director of spiritual care services at Vassar Brothers Medical Center in Poughkeepsie, N.Y., part of a seven-hospital system operated by Nuvance Health. “We offer the hope of a caring presence,” said Rabbi Loevinger, who is also a member of the board of directors for Neshama: Association of Jewish Chaplains. “If someone is in a hole, our job is to climb down into the hole with them and say, ‘We’re going to get out of this hole together.’ We can’t promise that someone’s going to get better. We can’t promise that everything’s going to be all right. What we can promise is that we will not abandon you. We can promise that there will be someone accompanying you in any way we can through this crisis.”

Ms. Hauck remembered a phone conversation with the granddaughter of a patient hospitalized with COVID-19 who was nearing the end of her life. The granddaughter told her a story about how her grandmother and her best friend made a pact with each other that, when one was dying, the other would come to her side and pray the Rosary with her. “The granddaughter got tearful and said, ‘That can’t happen now,’ ” said Ms. Hauck, who oversees a staff of 9 chaplains and 10 per diem chaplains. “I made a promise that I would do my best to be at the bedside and pray the Rosary with her grandmother.”

The nurses were aware of the request, and about a day later, Ms. Hauck received a call at 1 a.m., indicating that the patient was close to dying. She drove to Lancaster General, put on her personal protective equipment, made it to the patient’s bedside, and began to pray the Rosary with her, with a nurse in the room. “The nurse said to me, ‘Carolanne, all of her stats are going up,’ and the patient actually became a little more alert,” she recalled. “We talked a little bit, and I asked, ‘Would you like to pray the Rosary now?’ She shook her head yes, and said, ‘Hail Mary, full of grace ...’ and those were the last words that she spoke. I finished the prayers for her, and then she died. It was very meaningful knowing that I could honor that wish for her, but more importantly, that I could do that for the family, who otherwise would have been at her side saying the Rosary with her. We have a recognition of how hard it is to leave someone at the hospital and not be at their bedside.”

Hospital chaplains are also supporting interdisciplinary teams of physicians, nurses, and other staff, as they navigate the provision of care in the wake of a pandemic. “They are under a great deal of stress – not only from being at work but with all the role changes that have happened in their home life,” Ms. Wetsch-Johnson said. “Some of them now are being the teacher at home and having to care for children. They have a lot that they come in with. My job is to help them so that they can go do their job. Regularly what I do is check in with the units and ask, ‘How are you doing today? What’s going on for you?’ Because people need to know that someone’s there to be with them and walk with them and listen to them.”

Courtesy Mary Wetsch-Johnson

On any given day, it’s not uncommon for hospital staff members to spontaneously pull aside chaplains to vent, pray, or just to talk. “They process their own fears and anxieties about working in this kind of environment,” Rev. Mercier said. “They’re scared for themselves. They think, ‘Could I get the virus? Could I spread the virus to my family?’ Or, they may express the care and concern they have for their patients. Oftentimes, it’s a mixture of both. Those spontaneous conversations are often the most powerful.”

Ms. Hauck noted that some nurses and clinicians at Lancaster General Hospital “are doing work they may have not done before,” she said. “Some of them are experiencing death for the first time, so we help them to navigate that. One of the best things we can do is hear the anxiety they have or the sadness they have when a patient dies. Also, maybe the frustration that they couldn’t do more in some cases and helping them to see that sometimes their best is good enough.”

She recalled one younger patient with COVID-19 who fell seriously ill. “It was really affecting a lot of people on the unit because of the patient’s age,” she said. “When we saw that the patient was getting better and would be discharged, there was such a sense of relief. I’m not sure that patient will ever understand how that helped us. It was comforting to us to know that people are getting better. It is something we celebrate.”

As chaplains adjust to their “new normal,” carving out time for self-care is key. Ms. Hauck and her staff periodically meet on Zoom with a psychotherapist “who understands what we do, asks us really good questions, and reminds us to take care of ourselves,” she said. “Personally, I’m making sure I get my exercise in, I pack a healthy lunch. We do check in with each other. Part of our handoff at every shift provides for an opportunity to debrief about how your day was.”

Rev. Mercier’s self check-in includes deep-breathing meditation and reciting certain prayers throughout the day. “The deep breathing helps me center and refocus with my body, while the prayers remind me of my connection to the Divine,” he said. “It also reminds me that in the midst of the fear and the anxiety, I fear for myself. It’s hard not to be concerned that I could be infected. I have a family at home and could spread this to them. The prayer practices are a reminder to me that it’s okay to feel those fears and anxieties. Sometimes the spiritual practice helps me find that place of acceptance. That enables me to keep moving forward.”

Ms. Wetsch-Johnson described the sense of upendedness caused by the COVID-19 pandemic as a “ripple in the water that’s going to have long-lasting effects on the delivery of health care. People are taking the time to listen to one another. I’ve seen people in all departments be more compassionate with one another. I’ve seen managers go out of their way to make sure their staff are deeply cared for. I think that will have a ripple effect. That’s my hope, that we will continue to be more compassionate, more loving, and more understanding.”

Rabbi Loevinger hopes that even the most reticent physicians remember that chaplains serve as their advocate, too, especially during times of crisis. “This has been a time of unprecedented ethical wrestling in our hospitals, where there’s been a real concern that doctors, nurses, and respiratory therapists are going to be faced with morally distressing situations regarding insufficient PPE, or insufficient ventilator or dialysis machine supply to support everybody that needs to be supported,” he said. “Chaplains are a key part of the process of making ethical decisions, but also supporting physicians who are in distress over [being in] situations they never had imagined. Physicians don’t like to talk about the fact that a lot of the decisions they make are really heartbreaking. But if chaplains understand anything, it’s that being brokenhearted is part of the human condition, and that we can be part of the answer for keeping physicians morally and spiritually grounded in their work. We always invite that conversation.”

For Rev. Mercier, serving in a time of crisis reminds him of the importance of providing care as a team, “not just for patients and families, but for one another,” he said. “One of the lessons we can learn is, how can we build that connection with one another, to support and care for one another? How can we make sure that no one feels alone while working in the hospital?”

He draws inspiration from a saying credited to St. John of the Cross, which reads, “I saw the river through which every soul must pass, and the name of that river is suffering. I saw the boat that carries each soul across that river, and the name of that boat is love.”

“It’s that image that’s sticking with me, not just for myself as a chaplain but for all of my colleagues in the hospital,” said Rev. Mercier, who also pastors Tabernacle Baptist Church in Hope, R.I. “We’re in that river with the patients right now, suffering, and we’re doing our best to help them get to the other side – whatever the other side may look like.”

[email protected]

Correction, 4/30/20: An earlier version of the caption for the photo with Mary Wetsch-Johnson misstated the location. The photo was taken outside St. Elizabeth Hospital in Enumclaw, Wash.