Perspectives

The slow-moving game of viral roulette is wearing on everyone. Eventually, we may all become fatigued and say, “well, let’s just take our chances,” the isolation being worse than the disease. I must say, however, the sight of the local funeral director loading lumber into his van at the hardware store last week made me snug up my mask a bit. We have had a surge of COVID-19 deaths in local nursing homes and I heard refrigerated space is tight. Who knows, though, maybe he just needed more shelf space in his garage.

The most exasperating thing is not knowing who has had the virus and who hasn’t, and what medicine might or might not work. My son, quartered in the sardine-tin bunks of an aircraft carrier has “it,” as do all his mates, is in total isolation except for fever checks once a day, and is having a tough time. His eagerness to receive our phone calls was sweet at first, but is now starting to worry me. Today, I received a letter from him, which I dutifully steam-microwaved for 5 minutes and am letting dry in the sun. He is asymptomatic by the way. This was not the case for one of my buddies in New York. He suffered through 10 days of shaking chills so bad he thought he had chipped his teeth, and weeks later he still has no sense of smell.

My practice has been completely disrupted, but we are open a couple of days a week. I have kept all my employees, doing busy things mostly. There will be long hours for everyone because of widely spaced appointments and a certain amount of friction with patients who miss appointments. My fellow is going to take a long trip in July. Who knows when he will have a month off again? I wonder where he plans to go.

We have rearranged the waiting room furniture, so everyone is 6 feet apart, though I am not confident this makes a difference. We all have masks, and use alcohol gel before and after patient encounters, and spritz all fixtures and handles with alcohol after encounters. I have a large exhaust fan in the lab that creates a negative pressure gradient in the office. Somehow, I don’t think it is quite the same as in the hospital.

One slick trick we’ve enacted is running an ozone generator in the office at night, which will kill all things on all surfaces and in the air. It also is probably eroding the insides of my computers, but hey, the insects and burglars hate it too.

We heard the fighter jets fly over today saluting the frontline health care workers, but did not go out and wave. We are taking care of skin cancers, and while my patients might have COVID, they do not have a fever or cough, and are not supposed to come in if they do. I feel a little guilt about this. Treating cancer is important, but we are not in the ICU or ED immersed in virus. That is who the jets are for.

My daughter, a high school senior, is taking the loss of graduation, prom, and pomp and circumstance quite well. I am relieved I don’t have to worry about the after-prom parties. She is gearing up for college, I just hope they allow classes to start.

The future is cloudy and uncertain, despite this beautiful spring day as I write this column. Surely the way we practice medicine is going to change, and for a long while. I am thinking of taking a part-time job out of town for a year or so, and my wife is considering closing her practice altogether. If we were a few years older, there is little doubt we would just move it down the line and retire.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. He has no disclosures. Write to him at [email protected].

The slow-moving game of viral roulette is wearing on everyone. Eventually, we may all become fatigued and say, “well, let’s just take our chances,” the isolation being worse than the disease. I must say, however, the sight of the local funeral director loading lumber into his van at the hardware store last week made me snug up my mask a bit. We have had a surge of COVID-19 deaths in local nursing homes and I heard refrigerated space is tight. Who knows, though, maybe he just needed more shelf space in his garage.

The most exasperating thing is not knowing who has had the virus and who hasn’t, and what medicine might or might not work. My son, quartered in the sardine-tin bunks of an aircraft carrier has “it,” as do all his mates, is in total isolation except for fever checks once a day, and is having a tough time. His eagerness to receive our phone calls was sweet at first, but is now starting to worry me. Today, I received a letter from him, which I dutifully steam-microwaved for 5 minutes and am letting dry in the sun. He is asymptomatic by the way. This was not the case for one of my buddies in New York. He suffered through 10 days of shaking chills so bad he thought he had chipped his teeth, and weeks later he still has no sense of smell.

My practice has been completely disrupted, but we are open a couple of days a week. I have kept all my employees, doing busy things mostly. There will be long hours for everyone because of widely spaced appointments and a certain amount of friction with patients who miss appointments. My fellow is going to take a long trip in July. Who knows when he will have a month off again? I wonder where he plans to go.

We have rearranged the waiting room furniture, so everyone is 6 feet apart, though I am not confident this makes a difference. We all have masks, and use alcohol gel before and after patient encounters, and spritz all fixtures and handles with alcohol after encounters. I have a large exhaust fan in the lab that creates a negative pressure gradient in the office. Somehow, I don’t think it is quite the same as in the hospital.

One slick trick we’ve enacted is running an ozone generator in the office at night, which will kill all things on all surfaces and in the air. It also is probably eroding the insides of my computers, but hey, the insects and burglars hate it too.

We heard the fighter jets fly over today saluting the frontline health care workers, but did not go out and wave. We are taking care of skin cancers, and while my patients might have COVID, they do not have a fever or cough, and are not supposed to come in if they do. I feel a little guilt about this. Treating cancer is important, but we are not in the ICU or ED immersed in virus. That is who the jets are for.

My daughter, a high school senior, is taking the loss of graduation, prom, and pomp and circumstance quite well. I am relieved I don’t have to worry about the after-prom parties. She is gearing up for college, I just hope they allow classes to start.

The future is cloudy and uncertain, despite this beautiful spring day as I write this column. Surely the way we practice medicine is going to change, and for a long while. I am thinking of taking a part-time job out of town for a year or so, and my wife is considering closing her practice altogether. If we were a few years older, there is little doubt we would just move it down the line and retire.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. He has no disclosures. Write to him at [email protected].

The slow-moving game of viral roulette is wearing on everyone. Eventually, we may all become fatigued and say, “well, let’s just take our chances,” the isolation being worse than the disease. I must say, however, the sight of the local funeral director loading lumber into his van at the hardware store last week made me snug up my mask a bit. We have had a surge of COVID-19 deaths in local nursing homes and I heard refrigerated space is tight. Who knows, though, maybe he just needed more shelf space in his garage.

The most exasperating thing is not knowing who has had the virus and who hasn’t, and what medicine might or might not work. My son, quartered in the sardine-tin bunks of an aircraft carrier has “it,” as do all his mates, is in total isolation except for fever checks once a day, and is having a tough time. His eagerness to receive our phone calls was sweet at first, but is now starting to worry me. Today, I received a letter from him, which I dutifully steam-microwaved for 5 minutes and am letting dry in the sun. He is asymptomatic by the way. This was not the case for one of my buddies in New York. He suffered through 10 days of shaking chills so bad he thought he had chipped his teeth, and weeks later he still has no sense of smell.

My practice has been completely disrupted, but we are open a couple of days a week. I have kept all my employees, doing busy things mostly. There will be long hours for everyone because of widely spaced appointments and a certain amount of friction with patients who miss appointments. My fellow is going to take a long trip in July. Who knows when he will have a month off again? I wonder where he plans to go.

We have rearranged the waiting room furniture, so everyone is 6 feet apart, though I am not confident this makes a difference. We all have masks, and use alcohol gel before and after patient encounters, and spritz all fixtures and handles with alcohol after encounters. I have a large exhaust fan in the lab that creates a negative pressure gradient in the office. Somehow, I don’t think it is quite the same as in the hospital.

One slick trick we’ve enacted is running an ozone generator in the office at night, which will kill all things on all surfaces and in the air. It also is probably eroding the insides of my computers, but hey, the insects and burglars hate it too.

We heard the fighter jets fly over today saluting the frontline health care workers, but did not go out and wave. We are taking care of skin cancers, and while my patients might have COVID, they do not have a fever or cough, and are not supposed to come in if they do. I feel a little guilt about this. Treating cancer is important, but we are not in the ICU or ED immersed in virus. That is who the jets are for.

My daughter, a high school senior, is taking the loss of graduation, prom, and pomp and circumstance quite well. I am relieved I don’t have to worry about the after-prom parties. She is gearing up for college, I just hope they allow classes to start.

The future is cloudy and uncertain, despite this beautiful spring day as I write this column. Surely the way we practice medicine is going to change, and for a long while. I am thinking of taking a part-time job out of town for a year or so, and my wife is considering closing her practice altogether. If we were a few years older, there is little doubt we would just move it down the line and retire.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. He has no disclosures. Write to him at [email protected].

While discussing the difficult decisions to be made if the SARS-CoV-2 pandemic outlasts emergency funds from the Paycheck Protection and Economic Injury Disaster loan programs in my last column, I suggested calculating your overhead – that is, the cost structure supporting the generation of revenue within your practice. Once you know your overhead, you can consider options for managing both costs and revenue during this critical period and beyond.

Kativ/iStockphoto

Based on the flood of questions I’ve received, it appears that many private practitioners do not know how to do those things. Those who do are prone to comparing their overhead figures with those of other offices or with some arbitrary national average. For example, an internist who has calculated his or her practice’s overhead at 65% is dismayed when a surgical colleague reports an overhead of only 35%. Or perhaps the internist reads that the “average” overhead for a practice of that size should never be more than, say, 50%.

First, it is essential to compare apples to apples. Medical practices have entirely different cost structures than do surgical practices. Within those categories, overheads can still vary widely. For example, a neurologist who spends most of the day doing consults in inpatient settings will have substantially different costs than does a dermatologist whose practice is almost entirely office based. Even within similar practices, what one office incorporates in its cost structure may be quite different than another. One may include performance bonuses, while another may factor in automobile allowances – or not. It is important to understand what you are comparing.

Once you have a firm understanding of your overhead, you must decide how to measure it. Typically, that is done as either a percentage (expenses divided by revenue) or as a straight dollar figure.

While everyone’s situation will be different, most accountants and practice consultants recommend looking at percentages. As I have written many times in the past, lower overhead cost, in dollars, doesn’t necessarily mean lower expenses. If your practice can generate more revenue by increasing your expenses, the higher revenue per dollar will result in a lower percentage.

For example, hypothetical Practice A generates $1,000,000 per year on costs of $500,000; Practice B generates $3,000,000 on costs of $1,000,000. Practice B has double the overhead costs of A; yet it brings in triple the revenue, generating more revenue per dollar spent, and making its overhead percentage lower (33% vs. 50%).

Of course, to manage your overhead percentage, you must look at both costs and revenue. Once again, everyone’s situation is different; but here are some general tips for managing costs:

• If you don’t have a budget, create one now, and measure your actual costs against it. Many private practices still operate without budgets, but you can’t manage what you don’t measure.
• Understand your costs. What drives them? What causes them to increase? Which ones are fixed, and which are variable?
• Get competitive bids on a regular basis for supplies, equipment, and outsourced services. Review your invoices monthly to ensure there is no “cost creep” – extra charges, or continued charges for discontinued items. One practice I worked with discovered that it was still making monthly lease payments on equipment that it had disposed of years before!

Equally important is managing revenue. To do this efficiently:

• Maximize documentation and coding. Other columnists and I have written extensively on this subject over the years.
• Ensure that your bookkeeping team challenges all claim denials, and follows up in a timely manner.
• Train your staff in effective patient collection techniques, and make sure they keep up on rule changes. If you haven’t started asking each patient for a credit card number, so that you can bill patient-owed portions after insurance payments come in, now would be a good time to start.
• Evaluate new ways of generating revenue; think outside the box.

Managing overhead requires conscious, consistent, and continuous oversight.

As I wrote in the May column, I sincerely hope that all of our practices will return to some semblance of normal in the coming months; but we cannot assume a best possible scenario. And even ideal scenarios suggest that overhead management will be more important than ever in future years.

As always, consult with your own attorney, accountant, and other business advisers before making any life-altering decisions.
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. He has no disclosures. Write to him at [email protected].

While discussing the difficult decisions to be made if the SARS-CoV-2 pandemic outlasts emergency funds from the Paycheck Protection and Economic Injury Disaster loan programs in my last column, I suggested calculating your overhead – that is, the cost structure supporting the generation of revenue within your practice. Once you know your overhead, you can consider options for managing both costs and revenue during this critical period and beyond.

Kativ/iStockphoto

Based on the flood of questions I’ve received, it appears that many private practitioners do not know how to do those things. Those who do are prone to comparing their overhead figures with those of other offices or with some arbitrary national average. For example, an internist who has calculated his or her practice’s overhead at 65% is dismayed when a surgical colleague reports an overhead of only 35%. Or perhaps the internist reads that the “average” overhead for a practice of that size should never be more than, say, 50%.

First, it is essential to compare apples to apples. Medical practices have entirely different cost structures than do surgical practices. Within those categories, overheads can still vary widely. For example, a neurologist who spends most of the day doing consults in inpatient settings will have substantially different costs than does a dermatologist whose practice is almost entirely office based. Even within similar practices, what one office incorporates in its cost structure may be quite different than another. One may include performance bonuses, while another may factor in automobile allowances – or not. It is important to understand what you are comparing.

Once you have a firm understanding of your overhead, you must decide how to measure it. Typically, that is done as either a percentage (expenses divided by revenue) or as a straight dollar figure.

While everyone’s situation will be different, most accountants and practice consultants recommend looking at percentages. As I have written many times in the past, lower overhead cost, in dollars, doesn’t necessarily mean lower expenses. If your practice can generate more revenue by increasing your expenses, the higher revenue per dollar will result in a lower percentage.

For example, hypothetical Practice A generates $1,000,000 per year on costs of $500,000; Practice B generates $3,000,000 on costs of $1,000,000. Practice B has double the overhead costs of A; yet it brings in triple the revenue, generating more revenue per dollar spent, and making its overhead percentage lower (33% vs. 50%).

Of course, to manage your overhead percentage, you must look at both costs and revenue. Once again, everyone’s situation is different; but here are some general tips for managing costs:

• If you don’t have a budget, create one now, and measure your actual costs against it. Many private practices still operate without budgets, but you can’t manage what you don’t measure.
• Understand your costs. What drives them? What causes them to increase? Which ones are fixed, and which are variable?
• Get competitive bids on a regular basis for supplies, equipment, and outsourced services. Review your invoices monthly to ensure there is no “cost creep” – extra charges, or continued charges for discontinued items. One practice I worked with discovered that it was still making monthly lease payments on equipment that it had disposed of years before!

Equally important is managing revenue. To do this efficiently:

• Maximize documentation and coding. Other columnists and I have written extensively on this subject over the years.
• Ensure that your bookkeeping team challenges all claim denials, and follows up in a timely manner.
• Train your staff in effective patient collection techniques, and make sure they keep up on rule changes. If you haven’t started asking each patient for a credit card number, so that you can bill patient-owed portions after insurance payments come in, now would be a good time to start.
• Evaluate new ways of generating revenue; think outside the box.

Managing overhead requires conscious, consistent, and continuous oversight.

As I wrote in the May column, I sincerely hope that all of our practices will return to some semblance of normal in the coming months; but we cannot assume a best possible scenario. And even ideal scenarios suggest that overhead management will be more important than ever in future years.

As always, consult with your own attorney, accountant, and other business advisers before making any life-altering decisions.
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. He has no disclosures. Write to him at [email protected].

While discussing the difficult decisions to be made if the SARS-CoV-2 pandemic outlasts emergency funds from the Paycheck Protection and Economic Injury Disaster loan programs in my last column, I suggested calculating your overhead – that is, the cost structure supporting the generation of revenue within your practice. Once you know your overhead, you can consider options for managing both costs and revenue during this critical period and beyond.

Kativ/iStockphoto

Based on the flood of questions I’ve received, it appears that many private practitioners do not know how to do those things. Those who do are prone to comparing their overhead figures with those of other offices or with some arbitrary national average. For example, an internist who has calculated his or her practice’s overhead at 65% is dismayed when a surgical colleague reports an overhead of only 35%. Or perhaps the internist reads that the “average” overhead for a practice of that size should never be more than, say, 50%.

First, it is essential to compare apples to apples. Medical practices have entirely different cost structures than do surgical practices. Within those categories, overheads can still vary widely. For example, a neurologist who spends most of the day doing consults in inpatient settings will have substantially different costs than does a dermatologist whose practice is almost entirely office based. Even within similar practices, what one office incorporates in its cost structure may be quite different than another. One may include performance bonuses, while another may factor in automobile allowances – or not. It is important to understand what you are comparing.

Once you have a firm understanding of your overhead, you must decide how to measure it. Typically, that is done as either a percentage (expenses divided by revenue) or as a straight dollar figure.

While everyone’s situation will be different, most accountants and practice consultants recommend looking at percentages. As I have written many times in the past, lower overhead cost, in dollars, doesn’t necessarily mean lower expenses. If your practice can generate more revenue by increasing your expenses, the higher revenue per dollar will result in a lower percentage.

For example, hypothetical Practice A generates $1,000,000 per year on costs of $500,000; Practice B generates $3,000,000 on costs of $1,000,000. Practice B has double the overhead costs of A; yet it brings in triple the revenue, generating more revenue per dollar spent, and making its overhead percentage lower (33% vs. 50%).

Of course, to manage your overhead percentage, you must look at both costs and revenue. Once again, everyone’s situation is different; but here are some general tips for managing costs:

• If you don’t have a budget, create one now, and measure your actual costs against it. Many private practices still operate without budgets, but you can’t manage what you don’t measure.
• Understand your costs. What drives them? What causes them to increase? Which ones are fixed, and which are variable?
• Get competitive bids on a regular basis for supplies, equipment, and outsourced services. Review your invoices monthly to ensure there is no “cost creep” – extra charges, or continued charges for discontinued items. One practice I worked with discovered that it was still making monthly lease payments on equipment that it had disposed of years before!

Equally important is managing revenue. To do this efficiently:

• Maximize documentation and coding. Other columnists and I have written extensively on this subject over the years.
• Ensure that your bookkeeping team challenges all claim denials, and follows up in a timely manner.
• Train your staff in effective patient collection techniques, and make sure they keep up on rule changes. If you haven’t started asking each patient for a credit card number, so that you can bill patient-owed portions after insurance payments come in, now would be a good time to start.
• Evaluate new ways of generating revenue; think outside the box.

Managing overhead requires conscious, consistent, and continuous oversight.

As I wrote in the May column, I sincerely hope that all of our practices will return to some semblance of normal in the coming months; but we cannot assume a best possible scenario. And even ideal scenarios suggest that overhead management will be more important than ever in future years.

As always, consult with your own attorney, accountant, and other business advisers before making any life-altering decisions.
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. He has no disclosures. Write to him at [email protected].

The prolonged and unique stresses imparted by the COVID-19 pandemic has many predicting a significant rise in mental health issues in the weeks, months, and years ahead.

To understand how health care workers can best get ahead of this emerging crisis within a crisis, Medscape Psychiatry editorial director Bret Stetka, MD, spoke with Sheila Rauch, PhD, who’s with the Department of Psychiatry and Behavioral Sciences at the Emory University, Atlanta. The director of Mental Health Research and Program Evaluation at the Atlanta VA Medical Center, Dr. Rauch has studied the effects of and best treatments for posttraumatic stress disorder (PTSD) and anxiety disorders over the past 20 years.
 

Are we going to see a PTSD or anxiety epidemic as a result of the pandemic?

First, I think it’s really important that we prepare for the worst but hope for the best. But I would expect that, given the high levels of stress, the impact on resources, and other factors, we are going to see a pretty significant mental health impact over time. This could be the new normal for a while. Some of that will be PTSD, but there will also be other things. I would suspect that the resulting increase in rates of depression, traumatic grief, and loss is probably going to be a significant issue for years to come.

What will the anxiety we see as a result of COVID-19 look like compared with that seen in past disasters, like 9/11?

Most disasters in recent history, like 9/11, are single incidents. Something horrible happened, it impacted people at different levels, and we were able to start putting the pieces back together right away. The prolonged nature of this pandemic makes it even more variable given that the impact is going to be extended over time.

We’re also going to see a lot more people with compound impact – people who’ve lost their jobs, loved ones, maybe even their homes. All of those financial and resource losses put people in a higher risk category for negative mental health outcomes.
 

Is this analogous to the prolonged trauma that can occur with military service during war?

There is some similarity there. Combat is kind of an overarching context in which people experience trauma and, much like this pandemic, may or may not have traumatic exposures during it.

We’re asking health care workers to actually be in a role similar to what we ask of our military: going into danger, sometimes even without proper protective equipment, in order to save the lives of others. That’s also something we need to be factoring in as we plan to support those people and their families.
 

This is an ongoing incident, but is there a time window we need to be particularly worried about for seeing spikes in anxiety and PTSD?

I think we’re going to see variability on that. PTSD is a disorder that’s related to a specific incident or a couple of incidents that are similar. It’s a memory that’s haunting you.

For instance, typically if you have a combat veteran who has PTSD, they’ve been exposed to the overarching context of combat but then they have specific memories that are stuck. If they don’t have PTSD about 3-6 months after those incidents happen, then we would expect that they will not develop it, or it’s much less common that they would.

Depression has a very different course. It’s more prolonged and tends to grow with time.
 

Are you already seeing increased symptoms in your patients?

We’re seeing more anxiety, a lot of frustration, and a lot of very strong feelings about the leadership decisions that are being made. This is pretty similar to what we see in combat veterans. They’ll often be unhappy with the leadership decisions that were made as they were being deployed.

We’re also seeing lots more anger, sadness, and isolation now. Especially over the past couple of weeks, we’ve seen a rise in things like people reaching out for help in our intakes because we’re still open and doing phone assessments and telehealth with veterans and the veterans program.
 

In terms of interventions for this, what should psychiatrists, psychologists, and other clinicians be thinking about?

Right now, the best thing that we can do as mental health providers for people affected by the trauma is provide crisis intervention for those saying they are a danger to themselves and others. That means providing coping strategies and support. It also means making sure people are taking breaks and taking care of themselves, taking that little bit of time off so that they can go back, fully recharged, to their jobs and really stay there.

As we move forward, it will be clearer whether people are going to naturally recover, which most people will. For those who are going to have ongoing problems with time, we need to be getting ready as a system and as a country for those long-term mental health issues that are going to be coming up. And when I say long-term, it means the next 1-3 months. We want to be providing preventive interventions, versions of prolonged exposure, and other things that have shown some help in preventing PTSD. Psychological first aid is helpful.

There’s also an app called COVID Coach that the National Center for PTSD has created. That features a lot of positive coping resources together in one source.

Then when we get to the middle of that point and beyond it, we need to be ready to provide those evidence-based interventions for PTSD, depression, panic disorder, and other issues that are going to come out of this current situation.

But we were already short-staffed as far as mental health resources in general across the country, and especially in rural areas. So that means finding ways to efficiently use what we have through potentially briefer versions of interventions, through primary care, mental health, and other staff.
 

In what ways can primary care providers help?

There are versions of prolonged exposure therapy for primary care. That’s one of my big areas of research – increasing access. That would be something that we need to be building, by training and embedding mental health providers in primary care settings so that they can help to accommodate the increased need for access that’s going to be showing up for the next, I would suspect, several years with the pandemic.

Is there evidence that a prior episode of PTSD or traumatic experience like combat influences a subsequent reaction to a trauma like this?

It depends on how they manage. Research suggests that veterans or other people who have experienced trauma and naturally recovered, or who have gotten good treatment and remitted from that issue, are probably at no higher risk. But people who have subsyndromal PTSD or depression, or who are still experiencing symptoms from a history of trauma exposure, are maybe at a higher risk of having problems over time.

Do you have any guidance for healthcare providers on how to approach the pandemic with their patients, and also on how they can look after their own mental health?

In talking to patients, make sure that they have what they need. Ask if they’ve thought through how they’re going to cope if things get harder for them.

For people who have preexisting mental health issues, I’m talking with them about whether things have gotten worse. If they’re at high risk for suicide, I’m checking in to make sure that they’ve got new plans and ways to connect with people to reduce isolation, keeping in mind the social distancing that we’re asked to engage in so that they can do that safely.

It’s important to check and see if they have had any losses, whether it’s a financial loss or a personal loss of people that they care about. Also have them think through ways to stay entertained, which tends to help manage their own anxiety.

Every coping strategy we outline for patients also applies to mental health professionals. However, you would add to it the real need to take time to recharge, to take breaks, time off. It can feel overwhelming and like you need to just keep going. But the more that you get stuck in that mode of overdoing it, the less effective you’re going to be in helping people and also the more likely that you’ll be at risk of perhaps being one of the people that needs help.

It’s also important to make sure you’re staying connected with family and friends virtually, in whatever ways you can safely do that with social distancing.
 

So take a break to watch some Netflix now and then?

Yes!
 

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

The prolonged and unique stresses imparted by the COVID-19 pandemic has many predicting a significant rise in mental health issues in the weeks, months, and years ahead.

To understand how health care workers can best get ahead of this emerging crisis within a crisis, Medscape Psychiatry editorial director Bret Stetka, MD, spoke with Sheila Rauch, PhD, who’s with the Department of Psychiatry and Behavioral Sciences at the Emory University, Atlanta. The director of Mental Health Research and Program Evaluation at the Atlanta VA Medical Center, Dr. Rauch has studied the effects of and best treatments for posttraumatic stress disorder (PTSD) and anxiety disorders over the past 20 years.
 

Are we going to see a PTSD or anxiety epidemic as a result of the pandemic?

First, I think it’s really important that we prepare for the worst but hope for the best. But I would expect that, given the high levels of stress, the impact on resources, and other factors, we are going to see a pretty significant mental health impact over time. This could be the new normal for a while. Some of that will be PTSD, but there will also be other things. I would suspect that the resulting increase in rates of depression, traumatic grief, and loss is probably going to be a significant issue for years to come.

What will the anxiety we see as a result of COVID-19 look like compared with that seen in past disasters, like 9/11?

Most disasters in recent history, like 9/11, are single incidents. Something horrible happened, it impacted people at different levels, and we were able to start putting the pieces back together right away. The prolonged nature of this pandemic makes it even more variable given that the impact is going to be extended over time.

We’re also going to see a lot more people with compound impact – people who’ve lost their jobs, loved ones, maybe even their homes. All of those financial and resource losses put people in a higher risk category for negative mental health outcomes.
 

Is this analogous to the prolonged trauma that can occur with military service during war?

There is some similarity there. Combat is kind of an overarching context in which people experience trauma and, much like this pandemic, may or may not have traumatic exposures during it.

We’re asking health care workers to actually be in a role similar to what we ask of our military: going into danger, sometimes even without proper protective equipment, in order to save the lives of others. That’s also something we need to be factoring in as we plan to support those people and their families.
 

This is an ongoing incident, but is there a time window we need to be particularly worried about for seeing spikes in anxiety and PTSD?

I think we’re going to see variability on that. PTSD is a disorder that’s related to a specific incident or a couple of incidents that are similar. It’s a memory that’s haunting you.

For instance, typically if you have a combat veteran who has PTSD, they’ve been exposed to the overarching context of combat but then they have specific memories that are stuck. If they don’t have PTSD about 3-6 months after those incidents happen, then we would expect that they will not develop it, or it’s much less common that they would.

Depression has a very different course. It’s more prolonged and tends to grow with time.
 

Are you already seeing increased symptoms in your patients?

We’re seeing more anxiety, a lot of frustration, and a lot of very strong feelings about the leadership decisions that are being made. This is pretty similar to what we see in combat veterans. They’ll often be unhappy with the leadership decisions that were made as they were being deployed.

We’re also seeing lots more anger, sadness, and isolation now. Especially over the past couple of weeks, we’ve seen a rise in things like people reaching out for help in our intakes because we’re still open and doing phone assessments and telehealth with veterans and the veterans program.
 

In terms of interventions for this, what should psychiatrists, psychologists, and other clinicians be thinking about?

Right now, the best thing that we can do as mental health providers for people affected by the trauma is provide crisis intervention for those saying they are a danger to themselves and others. That means providing coping strategies and support. It also means making sure people are taking breaks and taking care of themselves, taking that little bit of time off so that they can go back, fully recharged, to their jobs and really stay there.

As we move forward, it will be clearer whether people are going to naturally recover, which most people will. For those who are going to have ongoing problems with time, we need to be getting ready as a system and as a country for those long-term mental health issues that are going to be coming up. And when I say long-term, it means the next 1-3 months. We want to be providing preventive interventions, versions of prolonged exposure, and other things that have shown some help in preventing PTSD. Psychological first aid is helpful.

There’s also an app called COVID Coach that the National Center for PTSD has created. That features a lot of positive coping resources together in one source.

Then when we get to the middle of that point and beyond it, we need to be ready to provide those evidence-based interventions for PTSD, depression, panic disorder, and other issues that are going to come out of this current situation.

But we were already short-staffed as far as mental health resources in general across the country, and especially in rural areas. So that means finding ways to efficiently use what we have through potentially briefer versions of interventions, through primary care, mental health, and other staff.
 

In what ways can primary care providers help?

There are versions of prolonged exposure therapy for primary care. That’s one of my big areas of research – increasing access. That would be something that we need to be building, by training and embedding mental health providers in primary care settings so that they can help to accommodate the increased need for access that’s going to be showing up for the next, I would suspect, several years with the pandemic.

Is there evidence that a prior episode of PTSD or traumatic experience like combat influences a subsequent reaction to a trauma like this?

It depends on how they manage. Research suggests that veterans or other people who have experienced trauma and naturally recovered, or who have gotten good treatment and remitted from that issue, are probably at no higher risk. But people who have subsyndromal PTSD or depression, or who are still experiencing symptoms from a history of trauma exposure, are maybe at a higher risk of having problems over time.

Do you have any guidance for healthcare providers on how to approach the pandemic with their patients, and also on how they can look after their own mental health?

In talking to patients, make sure that they have what they need. Ask if they’ve thought through how they’re going to cope if things get harder for them.

For people who have preexisting mental health issues, I’m talking with them about whether things have gotten worse. If they’re at high risk for suicide, I’m checking in to make sure that they’ve got new plans and ways to connect with people to reduce isolation, keeping in mind the social distancing that we’re asked to engage in so that they can do that safely.

It’s important to check and see if they have had any losses, whether it’s a financial loss or a personal loss of people that they care about. Also have them think through ways to stay entertained, which tends to help manage their own anxiety.

Every coping strategy we outline for patients also applies to mental health professionals. However, you would add to it the real need to take time to recharge, to take breaks, time off. It can feel overwhelming and like you need to just keep going. But the more that you get stuck in that mode of overdoing it, the less effective you’re going to be in helping people and also the more likely that you’ll be at risk of perhaps being one of the people that needs help.

It’s also important to make sure you’re staying connected with family and friends virtually, in whatever ways you can safely do that with social distancing.
 

So take a break to watch some Netflix now and then?

Yes!
 

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

The prolonged and unique stresses imparted by the COVID-19 pandemic has many predicting a significant rise in mental health issues in the weeks, months, and years ahead.

To understand how health care workers can best get ahead of this emerging crisis within a crisis, Medscape Psychiatry editorial director Bret Stetka, MD, spoke with Sheila Rauch, PhD, who’s with the Department of Psychiatry and Behavioral Sciences at the Emory University, Atlanta. The director of Mental Health Research and Program Evaluation at the Atlanta VA Medical Center, Dr. Rauch has studied the effects of and best treatments for posttraumatic stress disorder (PTSD) and anxiety disorders over the past 20 years.
 

Are we going to see a PTSD or anxiety epidemic as a result of the pandemic?

First, I think it’s really important that we prepare for the worst but hope for the best. But I would expect that, given the high levels of stress, the impact on resources, and other factors, we are going to see a pretty significant mental health impact over time. This could be the new normal for a while. Some of that will be PTSD, but there will also be other things. I would suspect that the resulting increase in rates of depression, traumatic grief, and loss is probably going to be a significant issue for years to come.

What will the anxiety we see as a result of COVID-19 look like compared with that seen in past disasters, like 9/11?

Most disasters in recent history, like 9/11, are single incidents. Something horrible happened, it impacted people at different levels, and we were able to start putting the pieces back together right away. The prolonged nature of this pandemic makes it even more variable given that the impact is going to be extended over time.

We’re also going to see a lot more people with compound impact – people who’ve lost their jobs, loved ones, maybe even their homes. All of those financial and resource losses put people in a higher risk category for negative mental health outcomes.
 

Is this analogous to the prolonged trauma that can occur with military service during war?

There is some similarity there. Combat is kind of an overarching context in which people experience trauma and, much like this pandemic, may or may not have traumatic exposures during it.

We’re asking health care workers to actually be in a role similar to what we ask of our military: going into danger, sometimes even without proper protective equipment, in order to save the lives of others. That’s also something we need to be factoring in as we plan to support those people and their families.
 

This is an ongoing incident, but is there a time window we need to be particularly worried about for seeing spikes in anxiety and PTSD?

I think we’re going to see variability on that. PTSD is a disorder that’s related to a specific incident or a couple of incidents that are similar. It’s a memory that’s haunting you.

For instance, typically if you have a combat veteran who has PTSD, they’ve been exposed to the overarching context of combat but then they have specific memories that are stuck. If they don’t have PTSD about 3-6 months after those incidents happen, then we would expect that they will not develop it, or it’s much less common that they would.

Depression has a very different course. It’s more prolonged and tends to grow with time.
 

Are you already seeing increased symptoms in your patients?

We’re seeing more anxiety, a lot of frustration, and a lot of very strong feelings about the leadership decisions that are being made. This is pretty similar to what we see in combat veterans. They’ll often be unhappy with the leadership decisions that were made as they were being deployed.

We’re also seeing lots more anger, sadness, and isolation now. Especially over the past couple of weeks, we’ve seen a rise in things like people reaching out for help in our intakes because we’re still open and doing phone assessments and telehealth with veterans and the veterans program.
 

In terms of interventions for this, what should psychiatrists, psychologists, and other clinicians be thinking about?

Right now, the best thing that we can do as mental health providers for people affected by the trauma is provide crisis intervention for those saying they are a danger to themselves and others. That means providing coping strategies and support. It also means making sure people are taking breaks and taking care of themselves, taking that little bit of time off so that they can go back, fully recharged, to their jobs and really stay there.

As we move forward, it will be clearer whether people are going to naturally recover, which most people will. For those who are going to have ongoing problems with time, we need to be getting ready as a system and as a country for those long-term mental health issues that are going to be coming up. And when I say long-term, it means the next 1-3 months. We want to be providing preventive interventions, versions of prolonged exposure, and other things that have shown some help in preventing PTSD. Psychological first aid is helpful.

There’s also an app called COVID Coach that the National Center for PTSD has created. That features a lot of positive coping resources together in one source.

Then when we get to the middle of that point and beyond it, we need to be ready to provide those evidence-based interventions for PTSD, depression, panic disorder, and other issues that are going to come out of this current situation.

But we were already short-staffed as far as mental health resources in general across the country, and especially in rural areas. So that means finding ways to efficiently use what we have through potentially briefer versions of interventions, through primary care, mental health, and other staff.
 

In what ways can primary care providers help?

There are versions of prolonged exposure therapy for primary care. That’s one of my big areas of research – increasing access. That would be something that we need to be building, by training and embedding mental health providers in primary care settings so that they can help to accommodate the increased need for access that’s going to be showing up for the next, I would suspect, several years with the pandemic.

Is there evidence that a prior episode of PTSD or traumatic experience like combat influences a subsequent reaction to a trauma like this?

It depends on how they manage. Research suggests that veterans or other people who have experienced trauma and naturally recovered, or who have gotten good treatment and remitted from that issue, are probably at no higher risk. But people who have subsyndromal PTSD or depression, or who are still experiencing symptoms from a history of trauma exposure, are maybe at a higher risk of having problems over time.

Do you have any guidance for healthcare providers on how to approach the pandemic with their patients, and also on how they can look after their own mental health?

In talking to patients, make sure that they have what they need. Ask if they’ve thought through how they’re going to cope if things get harder for them.

For people who have preexisting mental health issues, I’m talking with them about whether things have gotten worse. If they’re at high risk for suicide, I’m checking in to make sure that they’ve got new plans and ways to connect with people to reduce isolation, keeping in mind the social distancing that we’re asked to engage in so that they can do that safely.

It’s important to check and see if they have had any losses, whether it’s a financial loss or a personal loss of people that they care about. Also have them think through ways to stay entertained, which tends to help manage their own anxiety.

Every coping strategy we outline for patients also applies to mental health professionals. However, you would add to it the real need to take time to recharge, to take breaks, time off. It can feel overwhelming and like you need to just keep going. But the more that you get stuck in that mode of overdoing it, the less effective you’re going to be in helping people and also the more likely that you’ll be at risk of perhaps being one of the people that needs help.

It’s also important to make sure you’re staying connected with family and friends virtually, in whatever ways you can safely do that with social distancing.
 

So take a break to watch some Netflix now and then?

Yes!
 

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

On Jan. 20, 2020, the first confirmed case of the 2019 novel coronavirus in the United States was admitted to Providence Regional Medical Center in Everett, Wash. Less than 3 months later, the COVID-19 pandemic has put enormous stress on the U.S. health care system, which is confronting acute resource shortage because of the surge of acute and critically ill patients, health care provider safety and burnout, and an ongoing need for managing vulnerable populations while minimizing the infection spread.

With the onset of these unprecedented challenges, telehealth has emerged as a powerful new resource for health care providers, hospitals, and health care systems across the country. This article offers a summary of government regulations that enabled telehealth expansion, and provides an overview of how two health care organizations, Providence St. Joseph Health and Sound Physicians, are employing telehealth services to combat the COVID-19 health care crisis.

The government response: Telehealth expansion

In response to the pandemic, the Centers for Medicare and Medicaid Services (CMS) have significantly increased access to telehealth services for Medicare and Medicaid beneficiaries. CMS swiftly put measures in place such as:

• Expanding telehealth beyond rural areas.
• Adding 80 services that can be provided in all settings, including patient homes
• Allowing providers to bill for telehealth visits at the same rate as in-person visits.

The U.S. Department of Health and Human Services also aided this effort by:

• Waiving requirements that physicians or other health care professionals must have licenses in the state in which they provide services, if they have an equivalent license from another state.
• Waving penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies, such as FaceTime or Skype

Without prior regulatory and reimbursement restrictions, telehealth rapidly became a powerful tool in helping to solve some of the problems brought about by the COVID-19 pandemic.

Providence Telehealth for COVID-19

Providence St. Joseph Health is a not-for-profit health care system operating 51 hospitals and 1,085 clinics across Alaska, California, Montana, New Mexico, Oregon, Texas, and Washington. Providence has developed an enterprise telemedicine network with more than 100 virtual programs. Several of these services – including Telestroke, Telepsychiatry, TeleICU, and Telehospitalist – have been scaled across several states as a clinical cloud. More than 400 telemedicine endpoints are deployed, such as robotic carts and fixed InTouch TVs. In fact, the first U.S. COVID-19 patient was treated at Providence Regional Medical Center in Everett, Wash., using the telemedical robot Vici from InTouch Health.

According to Todd Czartoski, MD, chief medical technology officer at Providence, “while telehealth has been around for many years, COVID-19 opened a lot of people’s eyes to the value of virtual care delivery.”

Providence’s telehealth response to COVID-19 has encompassed five main areas: COVID-19 home care, COVID-19 acute care, ambulatory virtual visits, behavioral health concierge (BHC) expansion, and additional support for outside partnerships.

COVID-19 Home Care

Providence rapidly deployed home monitoring for nearly 2,000 positive or presumptive COVID-19 patients. Those symptomatic, clinically stable patients are given a thermometer and a pulse oximeter, and are monitored from home by a central team of nurses and physicians using the Xealth and Twistle programs.

Providence is evaluating expansion of home monitoring to other diagnoses, including higher acuity conditions.

COVID-19 Acute Care

TeleTriage expedites the triage of suspected COVID-19 patients and reduces the use of personal protective equipment (PPE) by 50% per patient per day. To date, TeleTriage has resulted in the conservation of more than 90,000 PPE units.

TeleHospitalist services expanded from traditional night coverage to caring for patients in COVID-19 units around the clock. Currently, there are 25 telehospitalists who practice both in-person and virtual medicine.

TeleICU offers remote management of more than 180 ICU beds across 17 hospitals from two central command centers in Washington state and Alaska. The services include night-time intensivist and ICU nurse coverage, including medication and ventilator management, and family conferences. COVID-19 increased the demand for TeleICU, with anticipated expansion to more than 300 beds.

Core TeleSpecialty services include TeleStroke and TelePsychiatry across 135 remote sites.

Ambulatory Virtual Visits

Providence launched the COVID-19 hub microsite to help educate patients by providing accurate and timely information. A chatbot named Grace helps screen patients who are worried about COVID-19. Grace also suggests next steps, such as a video visit with a patient’s primary care provider or a visit using Express Care/Virtual team, a direct-to-consumer service available to patients within and outside of the health care system.

In less than 2 weeks, Providence enabled virtual visits for more than 7,000 outpatient providers, with more than 14,000 alternative visits now occurring daily. This has allowed primary and specialty providers to continue to manage their patient panels remotely. The number of Express Care/Virtual visits increased from 60 to more than 1,000 per day.

BHC Expansion

In the effort to improve care for its caregivers, Providence launched a behavioral health concierge (BHC) service that offers employees and their dependents virtual access to licensed mental health professionals. Over the last half of 2019, BHC provided more than 1,000 phone and virtual visits, depending on the individual preference of patients. Notably, 21% percent of users were physicians; 65% of users were seen the same day and 100% of users were seen within 48 hours.

COVID-19 increased demand for services that initially started in Seattle and rapidly expanded to Montana, Oregon, and California.

Outside Partnerships

Providence has established partnerships with outside facilities by providing services to 135 sites across eight states. COVID-19 accelerated the employment of new services, including TeleICU.
 

Telemedicine at Sound Physicians

Sound Physicians is a national physician-founded and -led organization that provides emergency medicine, critical care, hospital medicine, population health, and physician advisory services. Five years ago, Sound launched a telemedicine service line. I spoke with Brian Carpenter, MD, national medical director for TeleHospitalist Services at Sound, to learn about his experience implementing Telehospitalist programs across 22 hospitals and 22 skilled nursing facilities.

Prior to COVID-19, Sound offered a spectrum of telemedicine services including night-time telephonic cross coverage, as well as video-assisted admissions, transfers, and rapid responses. In 2019, Sound Telehospitalists received 88,000 connect requests, including 6,400 video-assisted new admissions and 82 rapid responses. Typically, one physician covers four to eight hospitals with back-up available for surges. The team uses a predictive model for staffing and developed an acuity-based algorithm to ensure that patients in distress are evaluated immediately, new stable admissions on average are seen within 12 minutes, and order clarifications are provided within 30 minutes.

The COVID-19 pandemic created an urgent demand for providers to support an overwhelmed health care system. Without the traditional barriers to implementation – such as lack of acceptance by medical staff, nurses and patients, strict state licensing and technology requirements, lack of reimbursement, and delays in hospital credentialing – Sound was able to develop a rapid implementation model for telemedicine services. Currently, four new hospitals are in the active implementation phase, with 40 more hospitals in the pipeline.

Implementing a telemedicine program at your hospital

In order to successfully launch a telemedicine program, Dr. Carpenter outlined the following critical implementation steps:

• In collaboration with local leadership, define the problem you are trying to solve, which helps inform the scope of the telemedicine practice and technology requirements (for example, night-time cross-coverage vs. full telemedicine service).
• Complete a discovery process (for example, existing workflow for patient admission and transfer) with the end-goal of developing a workflow and rules of engagement.
• Obtain hospital credentialing/privileges and EMR access.
• Train end-users, including physicians and nurse telepresenters.

Dr. Carpenter offered this advice to those considering a telemedicine program: “Telemedicine is not just about technology; a true telemedicine program encompasses change management, workflow development, end-user training, compliance, and mechanisms for continuous process improvement. We want to make things better for the physicians, nurses, and patients.”

Telehealth is offering support to health care providers on the front lines, patients in need of care, and health care systems managing the unprecedented surges in volume.
 

Dr. Farah is a hospitalist, physician adviser, and Lean Six Sigma Black Belt. She is a performance improvement consultant based in Corvallis, Ore., and a member of The Hospitalist’s editorial advisory board.

On Jan. 20, 2020, the first confirmed case of the 2019 novel coronavirus in the United States was admitted to Providence Regional Medical Center in Everett, Wash. Less than 3 months later, the COVID-19 pandemic has put enormous stress on the U.S. health care system, which is confronting acute resource shortage because of the surge of acute and critically ill patients, health care provider safety and burnout, and an ongoing need for managing vulnerable populations while minimizing the infection spread.

With the onset of these unprecedented challenges, telehealth has emerged as a powerful new resource for health care providers, hospitals, and health care systems across the country. This article offers a summary of government regulations that enabled telehealth expansion, and provides an overview of how two health care organizations, Providence St. Joseph Health and Sound Physicians, are employing telehealth services to combat the COVID-19 health care crisis.

The government response: Telehealth expansion

In response to the pandemic, the Centers for Medicare and Medicaid Services (CMS) have significantly increased access to telehealth services for Medicare and Medicaid beneficiaries. CMS swiftly put measures in place such as:

• Expanding telehealth beyond rural areas.
• Adding 80 services that can be provided in all settings, including patient homes
• Allowing providers to bill for telehealth visits at the same rate as in-person visits.

The U.S. Department of Health and Human Services also aided this effort by:

• Waiving requirements that physicians or other health care professionals must have licenses in the state in which they provide services, if they have an equivalent license from another state.
• Waving penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies, such as FaceTime or Skype

Without prior regulatory and reimbursement restrictions, telehealth rapidly became a powerful tool in helping to solve some of the problems brought about by the COVID-19 pandemic.

Providence Telehealth for COVID-19

Providence St. Joseph Health is a not-for-profit health care system operating 51 hospitals and 1,085 clinics across Alaska, California, Montana, New Mexico, Oregon, Texas, and Washington. Providence has developed an enterprise telemedicine network with more than 100 virtual programs. Several of these services – including Telestroke, Telepsychiatry, TeleICU, and Telehospitalist – have been scaled across several states as a clinical cloud. More than 400 telemedicine endpoints are deployed, such as robotic carts and fixed InTouch TVs. In fact, the first U.S. COVID-19 patient was treated at Providence Regional Medical Center in Everett, Wash., using the telemedical robot Vici from InTouch Health.

According to Todd Czartoski, MD, chief medical technology officer at Providence, “while telehealth has been around for many years, COVID-19 opened a lot of people’s eyes to the value of virtual care delivery.”

Providence’s telehealth response to COVID-19 has encompassed five main areas: COVID-19 home care, COVID-19 acute care, ambulatory virtual visits, behavioral health concierge (BHC) expansion, and additional support for outside partnerships.

COVID-19 Home Care

Providence rapidly deployed home monitoring for nearly 2,000 positive or presumptive COVID-19 patients. Those symptomatic, clinically stable patients are given a thermometer and a pulse oximeter, and are monitored from home by a central team of nurses and physicians using the Xealth and Twistle programs.

Providence is evaluating expansion of home monitoring to other diagnoses, including higher acuity conditions.

COVID-19 Acute Care

TeleTriage expedites the triage of suspected COVID-19 patients and reduces the use of personal protective equipment (PPE) by 50% per patient per day. To date, TeleTriage has resulted in the conservation of more than 90,000 PPE units.

TeleHospitalist services expanded from traditional night coverage to caring for patients in COVID-19 units around the clock. Currently, there are 25 telehospitalists who practice both in-person and virtual medicine.

TeleICU offers remote management of more than 180 ICU beds across 17 hospitals from two central command centers in Washington state and Alaska. The services include night-time intensivist and ICU nurse coverage, including medication and ventilator management, and family conferences. COVID-19 increased the demand for TeleICU, with anticipated expansion to more than 300 beds.

Core TeleSpecialty services include TeleStroke and TelePsychiatry across 135 remote sites.

Ambulatory Virtual Visits

Providence launched the COVID-19 hub microsite to help educate patients by providing accurate and timely information. A chatbot named Grace helps screen patients who are worried about COVID-19. Grace also suggests next steps, such as a video visit with a patient’s primary care provider or a visit using Express Care/Virtual team, a direct-to-consumer service available to patients within and outside of the health care system.

In less than 2 weeks, Providence enabled virtual visits for more than 7,000 outpatient providers, with more than 14,000 alternative visits now occurring daily. This has allowed primary and specialty providers to continue to manage their patient panels remotely. The number of Express Care/Virtual visits increased from 60 to more than 1,000 per day.

BHC Expansion

In the effort to improve care for its caregivers, Providence launched a behavioral health concierge (BHC) service that offers employees and their dependents virtual access to licensed mental health professionals. Over the last half of 2019, BHC provided more than 1,000 phone and virtual visits, depending on the individual preference of patients. Notably, 21% percent of users were physicians; 65% of users were seen the same day and 100% of users were seen within 48 hours.

COVID-19 increased demand for services that initially started in Seattle and rapidly expanded to Montana, Oregon, and California.

Outside Partnerships

Providence has established partnerships with outside facilities by providing services to 135 sites across eight states. COVID-19 accelerated the employment of new services, including TeleICU.
 

Telemedicine at Sound Physicians

Sound Physicians is a national physician-founded and -led organization that provides emergency medicine, critical care, hospital medicine, population health, and physician advisory services. Five years ago, Sound launched a telemedicine service line. I spoke with Brian Carpenter, MD, national medical director for TeleHospitalist Services at Sound, to learn about his experience implementing Telehospitalist programs across 22 hospitals and 22 skilled nursing facilities.

Prior to COVID-19, Sound offered a spectrum of telemedicine services including night-time telephonic cross coverage, as well as video-assisted admissions, transfers, and rapid responses. In 2019, Sound Telehospitalists received 88,000 connect requests, including 6,400 video-assisted new admissions and 82 rapid responses. Typically, one physician covers four to eight hospitals with back-up available for surges. The team uses a predictive model for staffing and developed an acuity-based algorithm to ensure that patients in distress are evaluated immediately, new stable admissions on average are seen within 12 minutes, and order clarifications are provided within 30 minutes.

The COVID-19 pandemic created an urgent demand for providers to support an overwhelmed health care system. Without the traditional barriers to implementation – such as lack of acceptance by medical staff, nurses and patients, strict state licensing and technology requirements, lack of reimbursement, and delays in hospital credentialing – Sound was able to develop a rapid implementation model for telemedicine services. Currently, four new hospitals are in the active implementation phase, with 40 more hospitals in the pipeline.

Implementing a telemedicine program at your hospital

In order to successfully launch a telemedicine program, Dr. Carpenter outlined the following critical implementation steps:

• In collaboration with local leadership, define the problem you are trying to solve, which helps inform the scope of the telemedicine practice and technology requirements (for example, night-time cross-coverage vs. full telemedicine service).
• Complete a discovery process (for example, existing workflow for patient admission and transfer) with the end-goal of developing a workflow and rules of engagement.
• Obtain hospital credentialing/privileges and EMR access.
• Train end-users, including physicians and nurse telepresenters.

Dr. Carpenter offered this advice to those considering a telemedicine program: “Telemedicine is not just about technology; a true telemedicine program encompasses change management, workflow development, end-user training, compliance, and mechanisms for continuous process improvement. We want to make things better for the physicians, nurses, and patients.”

Telehealth is offering support to health care providers on the front lines, patients in need of care, and health care systems managing the unprecedented surges in volume.
 

Dr. Farah is a hospitalist, physician adviser, and Lean Six Sigma Black Belt. She is a performance improvement consultant based in Corvallis, Ore., and a member of The Hospitalist’s editorial advisory board.

On Jan. 20, 2020, the first confirmed case of the 2019 novel coronavirus in the United States was admitted to Providence Regional Medical Center in Everett, Wash. Less than 3 months later, the COVID-19 pandemic has put enormous stress on the U.S. health care system, which is confronting acute resource shortage because of the surge of acute and critically ill patients, health care provider safety and burnout, and an ongoing need for managing vulnerable populations while minimizing the infection spread.

With the onset of these unprecedented challenges, telehealth has emerged as a powerful new resource for health care providers, hospitals, and health care systems across the country. This article offers a summary of government regulations that enabled telehealth expansion, and provides an overview of how two health care organizations, Providence St. Joseph Health and Sound Physicians, are employing telehealth services to combat the COVID-19 health care crisis.

The government response: Telehealth expansion

In response to the pandemic, the Centers for Medicare and Medicaid Services (CMS) have significantly increased access to telehealth services for Medicare and Medicaid beneficiaries. CMS swiftly put measures in place such as:

• Expanding telehealth beyond rural areas.
• Adding 80 services that can be provided in all settings, including patient homes
• Allowing providers to bill for telehealth visits at the same rate as in-person visits.

The U.S. Department of Health and Human Services also aided this effort by:

• Waiving requirements that physicians or other health care professionals must have licenses in the state in which they provide services, if they have an equivalent license from another state.
• Waving penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies, such as FaceTime or Skype

Without prior regulatory and reimbursement restrictions, telehealth rapidly became a powerful tool in helping to solve some of the problems brought about by the COVID-19 pandemic.

Providence Telehealth for COVID-19

Providence St. Joseph Health is a not-for-profit health care system operating 51 hospitals and 1,085 clinics across Alaska, California, Montana, New Mexico, Oregon, Texas, and Washington. Providence has developed an enterprise telemedicine network with more than 100 virtual programs. Several of these services – including Telestroke, Telepsychiatry, TeleICU, and Telehospitalist – have been scaled across several states as a clinical cloud. More than 400 telemedicine endpoints are deployed, such as robotic carts and fixed InTouch TVs. In fact, the first U.S. COVID-19 patient was treated at Providence Regional Medical Center in Everett, Wash., using the telemedical robot Vici from InTouch Health.

According to Todd Czartoski, MD, chief medical technology officer at Providence, “while telehealth has been around for many years, COVID-19 opened a lot of people’s eyes to the value of virtual care delivery.”

Providence’s telehealth response to COVID-19 has encompassed five main areas: COVID-19 home care, COVID-19 acute care, ambulatory virtual visits, behavioral health concierge (BHC) expansion, and additional support for outside partnerships.

COVID-19 Home Care

Providence rapidly deployed home monitoring for nearly 2,000 positive or presumptive COVID-19 patients. Those symptomatic, clinically stable patients are given a thermometer and a pulse oximeter, and are monitored from home by a central team of nurses and physicians using the Xealth and Twistle programs.

Providence is evaluating expansion of home monitoring to other diagnoses, including higher acuity conditions.

COVID-19 Acute Care

TeleTriage expedites the triage of suspected COVID-19 patients and reduces the use of personal protective equipment (PPE) by 50% per patient per day. To date, TeleTriage has resulted in the conservation of more than 90,000 PPE units.

TeleHospitalist services expanded from traditional night coverage to caring for patients in COVID-19 units around the clock. Currently, there are 25 telehospitalists who practice both in-person and virtual medicine.

TeleICU offers remote management of more than 180 ICU beds across 17 hospitals from two central command centers in Washington state and Alaska. The services include night-time intensivist and ICU nurse coverage, including medication and ventilator management, and family conferences. COVID-19 increased the demand for TeleICU, with anticipated expansion to more than 300 beds.

Core TeleSpecialty services include TeleStroke and TelePsychiatry across 135 remote sites.

Ambulatory Virtual Visits

Providence launched the COVID-19 hub microsite to help educate patients by providing accurate and timely information. A chatbot named Grace helps screen patients who are worried about COVID-19. Grace also suggests next steps, such as a video visit with a patient’s primary care provider or a visit using Express Care/Virtual team, a direct-to-consumer service available to patients within and outside of the health care system.

In less than 2 weeks, Providence enabled virtual visits for more than 7,000 outpatient providers, with more than 14,000 alternative visits now occurring daily. This has allowed primary and specialty providers to continue to manage their patient panels remotely. The number of Express Care/Virtual visits increased from 60 to more than 1,000 per day.

BHC Expansion

In the effort to improve care for its caregivers, Providence launched a behavioral health concierge (BHC) service that offers employees and their dependents virtual access to licensed mental health professionals. Over the last half of 2019, BHC provided more than 1,000 phone and virtual visits, depending on the individual preference of patients. Notably, 21% percent of users were physicians; 65% of users were seen the same day and 100% of users were seen within 48 hours.

COVID-19 increased demand for services that initially started in Seattle and rapidly expanded to Montana, Oregon, and California.

Outside Partnerships

Providence has established partnerships with outside facilities by providing services to 135 sites across eight states. COVID-19 accelerated the employment of new services, including TeleICU.
 

Telemedicine at Sound Physicians

Sound Physicians is a national physician-founded and -led organization that provides emergency medicine, critical care, hospital medicine, population health, and physician advisory services. Five years ago, Sound launched a telemedicine service line. I spoke with Brian Carpenter, MD, national medical director for TeleHospitalist Services at Sound, to learn about his experience implementing Telehospitalist programs across 22 hospitals and 22 skilled nursing facilities.

Prior to COVID-19, Sound offered a spectrum of telemedicine services including night-time telephonic cross coverage, as well as video-assisted admissions, transfers, and rapid responses. In 2019, Sound Telehospitalists received 88,000 connect requests, including 6,400 video-assisted new admissions and 82 rapid responses. Typically, one physician covers four to eight hospitals with back-up available for surges. The team uses a predictive model for staffing and developed an acuity-based algorithm to ensure that patients in distress are evaluated immediately, new stable admissions on average are seen within 12 minutes, and order clarifications are provided within 30 minutes.

The COVID-19 pandemic created an urgent demand for providers to support an overwhelmed health care system. Without the traditional barriers to implementation – such as lack of acceptance by medical staff, nurses and patients, strict state licensing and technology requirements, lack of reimbursement, and delays in hospital credentialing – Sound was able to develop a rapid implementation model for telemedicine services. Currently, four new hospitals are in the active implementation phase, with 40 more hospitals in the pipeline.

Implementing a telemedicine program at your hospital

In order to successfully launch a telemedicine program, Dr. Carpenter outlined the following critical implementation steps:

• In collaboration with local leadership, define the problem you are trying to solve, which helps inform the scope of the telemedicine practice and technology requirements (for example, night-time cross-coverage vs. full telemedicine service).
• Complete a discovery process (for example, existing workflow for patient admission and transfer) with the end-goal of developing a workflow and rules of engagement.
• Obtain hospital credentialing/privileges and EMR access.
• Train end-users, including physicians and nurse telepresenters.

Dr. Carpenter offered this advice to those considering a telemedicine program: “Telemedicine is not just about technology; a true telemedicine program encompasses change management, workflow development, end-user training, compliance, and mechanisms for continuous process improvement. We want to make things better for the physicians, nurses, and patients.”

Telehealth is offering support to health care providers on the front lines, patients in need of care, and health care systems managing the unprecedented surges in volume.
 

Dr. Farah is a hospitalist, physician adviser, and Lean Six Sigma Black Belt. She is a performance improvement consultant based in Corvallis, Ore., and a member of The Hospitalist’s editorial advisory board.

Recently, like in other major cities, Phoenix had a flyover by the Blue Angels to honor frontline health care workers. My kids and I watched it. While I think the gesture is nice, in my mind it brings up questions about whether the money for it could have been better spent elsewhere. But that’s not the point of my column.

Watching the whole thing, I couldn’t help but think about my role in the crisis. While I have friends on the front lines, I’m certainly not there. I’m probably as close to back line as you can be without being retired.

This is simply the nature of my practice. I’m primarily outpatient. Inpatient consults are few and far between in the era of the neuro-hospitalist. I still see patients, both by video and in person. If someone wants to come in and see me, I’ll be available if I’m able.

I see a lot of conditions, but no one is going to a neurologist to be evaluated for COVID-19. Nor should they. Even though there are reports of neurological complications of the disease, none of them are outpatient issues or presenting symptoms.

I was asked if I’d volunteer to practice inpatient general medicine in a pinch, and my answer to that would have to be no. This isn’t cowardice, as one person accused me of. I’ve been to the hospital and seen patients since this started.

I’m no more an internist than I am an electrician. Like other neurologists of my era, I did a 1-year general medicine internship. For me, that was in 1993. I haven’t practiced it since, nor have I kept up on it except as it crosses into neurology.

A lot has changed in the last 27 years in my field alone. For me to jump back into general medicine after that time would likely do more harm than good to the patients I would see.

So I sit in my office doing what I always have: Trying to provide the best care I can to those who do need my services as a neurologist.

I may not be on the front line in our current crisis, but for those who seek my help I’m still front and center for them. And I will be until I retire.
 

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

Recently, like in other major cities, Phoenix had a flyover by the Blue Angels to honor frontline health care workers. My kids and I watched it. While I think the gesture is nice, in my mind it brings up questions about whether the money for it could have been better spent elsewhere. But that’s not the point of my column.

Watching the whole thing, I couldn’t help but think about my role in the crisis. While I have friends on the front lines, I’m certainly not there. I’m probably as close to back line as you can be without being retired.

This is simply the nature of my practice. I’m primarily outpatient. Inpatient consults are few and far between in the era of the neuro-hospitalist. I still see patients, both by video and in person. If someone wants to come in and see me, I’ll be available if I’m able.

I see a lot of conditions, but no one is going to a neurologist to be evaluated for COVID-19. Nor should they. Even though there are reports of neurological complications of the disease, none of them are outpatient issues or presenting symptoms.

I was asked if I’d volunteer to practice inpatient general medicine in a pinch, and my answer to that would have to be no. This isn’t cowardice, as one person accused me of. I’ve been to the hospital and seen patients since this started.

I’m no more an internist than I am an electrician. Like other neurologists of my era, I did a 1-year general medicine internship. For me, that was in 1993. I haven’t practiced it since, nor have I kept up on it except as it crosses into neurology.

A lot has changed in the last 27 years in my field alone. For me to jump back into general medicine after that time would likely do more harm than good to the patients I would see.

So I sit in my office doing what I always have: Trying to provide the best care I can to those who do need my services as a neurologist.

I may not be on the front line in our current crisis, but for those who seek my help I’m still front and center for them. And I will be until I retire.
 

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

Recently, like in other major cities, Phoenix had a flyover by the Blue Angels to honor frontline health care workers. My kids and I watched it. While I think the gesture is nice, in my mind it brings up questions about whether the money for it could have been better spent elsewhere. But that’s not the point of my column.

Watching the whole thing, I couldn’t help but think about my role in the crisis. While I have friends on the front lines, I’m certainly not there. I’m probably as close to back line as you can be without being retired.

This is simply the nature of my practice. I’m primarily outpatient. Inpatient consults are few and far between in the era of the neuro-hospitalist. I still see patients, both by video and in person. If someone wants to come in and see me, I’ll be available if I’m able.

I see a lot of conditions, but no one is going to a neurologist to be evaluated for COVID-19. Nor should they. Even though there are reports of neurological complications of the disease, none of them are outpatient issues or presenting symptoms.

I was asked if I’d volunteer to practice inpatient general medicine in a pinch, and my answer to that would have to be no. This isn’t cowardice, as one person accused me of. I’ve been to the hospital and seen patients since this started.

I’m no more an internist than I am an electrician. Like other neurologists of my era, I did a 1-year general medicine internship. For me, that was in 1993. I haven’t practiced it since, nor have I kept up on it except as it crosses into neurology.

A lot has changed in the last 27 years in my field alone. For me to jump back into general medicine after that time would likely do more harm than good to the patients I would see.

So I sit in my office doing what I always have: Trying to provide the best care I can to those who do need my services as a neurologist.

I may not be on the front line in our current crisis, but for those who seek my help I’m still front and center for them. And I will be until I retire.
 

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

Yesterday during an office visit I was adjusting my mask when a patient suddenly said, “What if this is the new normal? What if we still have to wear masks years from now?”

An interesting thought. That might even be the case. I mean, the COVID-19 pandemic definitely has changed our world. On the other hand, there are far worse things to have to do.

Masks, to some extent, have already become a part of our society, I see more people out and about with them than without. Like lunchboxes, they’ve transitioned from utilitarian to fashion statements. I see Darth Vader, Batman, Hello Kitty, Pokemon, and many other characters on them.

Humans have, after all, adapted to wearing all kinds of things. At some point our ancestors discovered they could walk around outside more comfortably with a covering on their feet. Then they discovered that socks prevent chafing. Now shoes and socks are worn worldwide, available for many different purposes in varied colors, styles, and cultures.

Why should masks be any different? Just because they’re new doesn’t mean they’re bad.

Obviously, I’m exaggerating. I don’t want to wear a mask full time, either. They’re hot and uncomfortable and, for people with certain respiratory issues, impossible. I live in Phoenix and I definitely don’t want to go through one of our summers wearing a face mask.

But at the same time, while masks are no guarantee against viral spread, they certainly help reduce it. This makes me wonder when we’ll start to phase them out. The virus isn’t going anywhere, so the breaking point will be when there’s either an effective vaccine administered to most of the population, or enough people have had the virus that herd immunity takes effect.

Until then, I have no problem with wearing a mask and asking patients who can to please do so when they come in. I see a lot of people who are elderly and/or immune suppressed. I don’t want them to get sick. Or me. Or my family.

If wearing a mask through the Phoenix summer is a sacrifice that will lead to better health for all, it’s not a big one in the grand scheme of things.
 

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

Yesterday during an office visit I was adjusting my mask when a patient suddenly said, “What if this is the new normal? What if we still have to wear masks years from now?”

An interesting thought. That might even be the case. I mean, the COVID-19 pandemic definitely has changed our world. On the other hand, there are far worse things to have to do.

Masks, to some extent, have already become a part of our society, I see more people out and about with them than without. Like lunchboxes, they’ve transitioned from utilitarian to fashion statements. I see Darth Vader, Batman, Hello Kitty, Pokemon, and many other characters on them.

Humans have, after all, adapted to wearing all kinds of things. At some point our ancestors discovered they could walk around outside more comfortably with a covering on their feet. Then they discovered that socks prevent chafing. Now shoes and socks are worn worldwide, available for many different purposes in varied colors, styles, and cultures.

Why should masks be any different? Just because they’re new doesn’t mean they’re bad.

Obviously, I’m exaggerating. I don’t want to wear a mask full time, either. They’re hot and uncomfortable and, for people with certain respiratory issues, impossible. I live in Phoenix and I definitely don’t want to go through one of our summers wearing a face mask.

But at the same time, while masks are no guarantee against viral spread, they certainly help reduce it. This makes me wonder when we’ll start to phase them out. The virus isn’t going anywhere, so the breaking point will be when there’s either an effective vaccine administered to most of the population, or enough people have had the virus that herd immunity takes effect.

Until then, I have no problem with wearing a mask and asking patients who can to please do so when they come in. I see a lot of people who are elderly and/or immune suppressed. I don’t want them to get sick. Or me. Or my family.

If wearing a mask through the Phoenix summer is a sacrifice that will lead to better health for all, it’s not a big one in the grand scheme of things.
 

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

Yesterday during an office visit I was adjusting my mask when a patient suddenly said, “What if this is the new normal? What if we still have to wear masks years from now?”

An interesting thought. That might even be the case. I mean, the COVID-19 pandemic definitely has changed our world. On the other hand, there are far worse things to have to do.

Masks, to some extent, have already become a part of our society, I see more people out and about with them than without. Like lunchboxes, they’ve transitioned from utilitarian to fashion statements. I see Darth Vader, Batman, Hello Kitty, Pokemon, and many other characters on them.

Humans have, after all, adapted to wearing all kinds of things. At some point our ancestors discovered they could walk around outside more comfortably with a covering on their feet. Then they discovered that socks prevent chafing. Now shoes and socks are worn worldwide, available for many different purposes in varied colors, styles, and cultures.

Why should masks be any different? Just because they’re new doesn’t mean they’re bad.

Obviously, I’m exaggerating. I don’t want to wear a mask full time, either. They’re hot and uncomfortable and, for people with certain respiratory issues, impossible. I live in Phoenix and I definitely don’t want to go through one of our summers wearing a face mask.

But at the same time, while masks are no guarantee against viral spread, they certainly help reduce it. This makes me wonder when we’ll start to phase them out. The virus isn’t going anywhere, so the breaking point will be when there’s either an effective vaccine administered to most of the population, or enough people have had the virus that herd immunity takes effect.

Until then, I have no problem with wearing a mask and asking patients who can to please do so when they come in. I see a lot of people who are elderly and/or immune suppressed. I don’t want them to get sick. Or me. Or my family.

If wearing a mask through the Phoenix summer is a sacrifice that will lead to better health for all, it’s not a big one in the grand scheme of things.
 

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

The first installment of my new column was obsolete on arrival. It referred to walking abroad at midday, with no mention of masks and social distancing. The whole thing was so February 2020.

My last day in the office was in mid-March. Friday the 13th.

For a few weeks, I’ve been seeing patients remotely. I pitched telemedicine to an HMO about 30 years ago. I was hardly an innovator. Researchers had already shown the practical use of remote dermatology by then, using stored and forwarded images.

What I had in mind was visits by patients in nursing homes or too sick at home to come in. It always bothered me to see very aged and infirm patients brought to the office at great inconvenience and expense for what often turned out to be problems like xerosis or eczema that could have been managed quite well remotely.

The HMO never got back to me, though. There were too many hurdles, mostly bureaucratic rather than medical. Would insurance pay? What about consent? Malpractice? It has been interesting to watch the current crisis sweep away the inertia of such obstacles, including licensure considerations (seeing patients across state lines for cutaneous purposes). People get around to fixing the roof when it pours. Perhaps next time there will be tests, masks, respirators. Perhaps.

Seeing patients remotely has acquainted me with all the technical headaches everyone stuck at home talks and jokes about: Balky transmission (What did you say after, “and then the blood ...”?); patients who can’t figure out how to log on, or start the video, or unmute themselves, and on and on. Picture resolution is not great, as anyone knows from watching TV newscasters interview talking heads stuck in their homes.

I was never all that image-conscious, but my beard has grown fuller and my hair unkempter. Even though I sit at my desk, I do take care to keep my trousers on. Not taking any chances.

Everyone agonizes over what the “new normal” may be. Will people come back to doctors’ offices? Will practices survive economically if many patients don’t return to the office? Stay tuned. For a long time.

Mostly, though, remote visits seem to work. Helped if needed by additional, better-resolution emailed photos, it’s possible to make useful decisions, including which lesions can wait for in-person evaluation, until ...

... Until what? In an effort to keep this column up-to-the-nanosecond, I am writing it as many countries tentatively “open up.” Careful analysis of the knowledge behind this world-wide project shows ... not much. It seems to come down to some educated guesswork about what might work and what the risks might be, which leads to advice that differs widely from state to state and country to country. It’s as if people everywhere just decided that locking everyone down is a real drag, is financially ruinous, has a duration both uncertain and longer than most people and governments think they can handle, so let’s get out there and “be careful,” whatever that is said to mean.

And the risks? Well, more people will get sick and some will die. How many “extra” deaths are ethically acceptable? Thoughtful people are working on that. They’ll get back sometime to those who are still around.

I don’t blame anyone for our staggering ignorance about this terrifying new reality. But absorbing the ignorance in real time is not reassuring.

I have nothing but sympathy for those who are not emeritus, who have practices to sustain and families to feed. I didn’t ask to be born 73 years ago, and take no credit for having done so. So much of what happens to us depends on when and where we were born – two factors for which we deserve absolutely no credit – that it’s a wonder we take such pride in praising ourselves for what we think we accomplish. Having no better choice, we do the best we can.

Meantime, I am in a “high-risk” category. If I were obese, I could try to lose weight. But my risk factor is age, which tends not to decline. Risk-wise, there is just one way to exit my group.

So I don’t expect to get back to the office anytime soon. To paraphrase a comedian who shall remain nameless: I don’t want to live on in the hearts of men. I want to live on in my house.

Dr. Rockoff, who wrote the Dermatology News column “Under My Skin,” is now semiretired, after 40 years of practice in Brookline, Mass. He served on the clinical faculty at Tufts University, Boston, and taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available online. Write to him at [email protected].

The first installment of my new column was obsolete on arrival. It referred to walking abroad at midday, with no mention of masks and social distancing. The whole thing was so February 2020.

My last day in the office was in mid-March. Friday the 13th.

For a few weeks, I’ve been seeing patients remotely. I pitched telemedicine to an HMO about 30 years ago. I was hardly an innovator. Researchers had already shown the practical use of remote dermatology by then, using stored and forwarded images.

What I had in mind was visits by patients in nursing homes or too sick at home to come in. It always bothered me to see very aged and infirm patients brought to the office at great inconvenience and expense for what often turned out to be problems like xerosis or eczema that could have been managed quite well remotely.

The HMO never got back to me, though. There were too many hurdles, mostly bureaucratic rather than medical. Would insurance pay? What about consent? Malpractice? It has been interesting to watch the current crisis sweep away the inertia of such obstacles, including licensure considerations (seeing patients across state lines for cutaneous purposes). People get around to fixing the roof when it pours. Perhaps next time there will be tests, masks, respirators. Perhaps.

Seeing patients remotely has acquainted me with all the technical headaches everyone stuck at home talks and jokes about: Balky transmission (What did you say after, “and then the blood ...”?); patients who can’t figure out how to log on, or start the video, or unmute themselves, and on and on. Picture resolution is not great, as anyone knows from watching TV newscasters interview talking heads stuck in their homes.

I was never all that image-conscious, but my beard has grown fuller and my hair unkempter. Even though I sit at my desk, I do take care to keep my trousers on. Not taking any chances.

Everyone agonizes over what the “new normal” may be. Will people come back to doctors’ offices? Will practices survive economically if many patients don’t return to the office? Stay tuned. For a long time.

Mostly, though, remote visits seem to work. Helped if needed by additional, better-resolution emailed photos, it’s possible to make useful decisions, including which lesions can wait for in-person evaluation, until ...

... Until what? In an effort to keep this column up-to-the-nanosecond, I am writing it as many countries tentatively “open up.” Careful analysis of the knowledge behind this world-wide project shows ... not much. It seems to come down to some educated guesswork about what might work and what the risks might be, which leads to advice that differs widely from state to state and country to country. It’s as if people everywhere just decided that locking everyone down is a real drag, is financially ruinous, has a duration both uncertain and longer than most people and governments think they can handle, so let’s get out there and “be careful,” whatever that is said to mean.

And the risks? Well, more people will get sick and some will die. How many “extra” deaths are ethically acceptable? Thoughtful people are working on that. They’ll get back sometime to those who are still around.

I don’t blame anyone for our staggering ignorance about this terrifying new reality. But absorbing the ignorance in real time is not reassuring.

I have nothing but sympathy for those who are not emeritus, who have practices to sustain and families to feed. I didn’t ask to be born 73 years ago, and take no credit for having done so. So much of what happens to us depends on when and where we were born – two factors for which we deserve absolutely no credit – that it’s a wonder we take such pride in praising ourselves for what we think we accomplish. Having no better choice, we do the best we can.

Meantime, I am in a “high-risk” category. If I were obese, I could try to lose weight. But my risk factor is age, which tends not to decline. Risk-wise, there is just one way to exit my group.

So I don’t expect to get back to the office anytime soon. To paraphrase a comedian who shall remain nameless: I don’t want to live on in the hearts of men. I want to live on in my house.

Dr. Rockoff, who wrote the Dermatology News column “Under My Skin,” is now semiretired, after 40 years of practice in Brookline, Mass. He served on the clinical faculty at Tufts University, Boston, and taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available online. Write to him at [email protected].

The first installment of my new column was obsolete on arrival. It referred to walking abroad at midday, with no mention of masks and social distancing. The whole thing was so February 2020.

My last day in the office was in mid-March. Friday the 13th.

For a few weeks, I’ve been seeing patients remotely. I pitched telemedicine to an HMO about 30 years ago. I was hardly an innovator. Researchers had already shown the practical use of remote dermatology by then, using stored and forwarded images.

What I had in mind was visits by patients in nursing homes or too sick at home to come in. It always bothered me to see very aged and infirm patients brought to the office at great inconvenience and expense for what often turned out to be problems like xerosis or eczema that could have been managed quite well remotely.

The HMO never got back to me, though. There were too many hurdles, mostly bureaucratic rather than medical. Would insurance pay? What about consent? Malpractice? It has been interesting to watch the current crisis sweep away the inertia of such obstacles, including licensure considerations (seeing patients across state lines for cutaneous purposes). People get around to fixing the roof when it pours. Perhaps next time there will be tests, masks, respirators. Perhaps.

Seeing patients remotely has acquainted me with all the technical headaches everyone stuck at home talks and jokes about: Balky transmission (What did you say after, “and then the blood ...”?); patients who can’t figure out how to log on, or start the video, or unmute themselves, and on and on. Picture resolution is not great, as anyone knows from watching TV newscasters interview talking heads stuck in their homes.

I was never all that image-conscious, but my beard has grown fuller and my hair unkempter. Even though I sit at my desk, I do take care to keep my trousers on. Not taking any chances.

Everyone agonizes over what the “new normal” may be. Will people come back to doctors’ offices? Will practices survive economically if many patients don’t return to the office? Stay tuned. For a long time.

Mostly, though, remote visits seem to work. Helped if needed by additional, better-resolution emailed photos, it’s possible to make useful decisions, including which lesions can wait for in-person evaluation, until ...

... Until what? In an effort to keep this column up-to-the-nanosecond, I am writing it as many countries tentatively “open up.” Careful analysis of the knowledge behind this world-wide project shows ... not much. It seems to come down to some educated guesswork about what might work and what the risks might be, which leads to advice that differs widely from state to state and country to country. It’s as if people everywhere just decided that locking everyone down is a real drag, is financially ruinous, has a duration both uncertain and longer than most people and governments think they can handle, so let’s get out there and “be careful,” whatever that is said to mean.

And the risks? Well, more people will get sick and some will die. How many “extra” deaths are ethically acceptable? Thoughtful people are working on that. They’ll get back sometime to those who are still around.

I don’t blame anyone for our staggering ignorance about this terrifying new reality. But absorbing the ignorance in real time is not reassuring.

I have nothing but sympathy for those who are not emeritus, who have practices to sustain and families to feed. I didn’t ask to be born 73 years ago, and take no credit for having done so. So much of what happens to us depends on when and where we were born – two factors for which we deserve absolutely no credit – that it’s a wonder we take such pride in praising ourselves for what we think we accomplish. Having no better choice, we do the best we can.

Meantime, I am in a “high-risk” category. If I were obese, I could try to lose weight. But my risk factor is age, which tends not to decline. Risk-wise, there is just one way to exit my group.

So I don’t expect to get back to the office anytime soon. To paraphrase a comedian who shall remain nameless: I don’t want to live on in the hearts of men. I want to live on in my house.

Dr. Rockoff, who wrote the Dermatology News column “Under My Skin,” is now semiretired, after 40 years of practice in Brookline, Mass. He served on the clinical faculty at Tufts University, Boston, and taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available online. Write to him at [email protected].

A few months into the COVID-19 pandemic, social media’s role in the rapid spread of information is undeniable. From the beginning, Chinese ophthalmologist Li Wenliang, MD, first raised the alarm to his classmates through WeChat, a messaging and social media app. Since that time, individuals, groups, organizations, government agencies, and mass media outlets have used social media to share ideas and disseminate information. Individuals check in on loved ones and update others on their own safety. Networks of clinicians discuss patient presentations, new therapeutics, management strategies, and institutional protocols. Multiple organizations including the Federal Emergency Management Agency, the Centers for Disease Control and Prevention, and the World Health Organization use Facebook, Instagram, or Twitter accounts to provide updates on ongoing efforts and spread public health messaging.

Unfortunately, not all information is trustworthy. Social media outlets have been used to spread misinformation and conspiracy theories, and to promote false treatments. Google, YouTube, and Facebook are now actively trying to reduce the viral spread of misleading information and to block hoaxes. With the increasing amount of news and information consumed and disseminated via social media, clinicians need to critically appraise information presented on those platforms, and to be familiar with how to use them to disseminate informed, effective, and responsible information.
 

Appraisal of social media content

Traditional scholarly communication exists in many forms and includes observations, anecdotes, perspectives, case reports, and research. Each form involves differing levels of academic rigor and standards of evaluation. Electronic content and online resources pose a unique challenge because there is no standardized method for assessing impact and quality. Proposed scales for evaluation of online resources such as Medical Education Translational Resources: Impact and Quality (METRIQ),¹ Academic Life in Emergency Medicine Approved Instructional Resources (AliEM AIR) scoring system,² and the Social Media Index³ are promising and can be used to guide critical appraisal of social media content.

The same skepticism and critical thinking applied to traditional resources should be applied when evaluating online resources. The scales listed above include questions such as:

• How accurate is the data presented and conclusions drawn?
• Does the content reflect evidence-based medicine?
• Has the content undergone an editorial process?
• Who are the authors and what are their credentials?
• Are there potential biases or conflicts of interest present?
• Have references been cited?
• How does this content affect/change clinical practice?

While these proposed review metrics may not apply to all forms of social media content, clinicians should be discerning when consuming or disseminating online content.
 

Strategies for effective communication on social media

In addition to appraising social media content, clinicians also should be able to craft effective messages on social media to spread trustworthy content. The CDC offers guidelines and best practices for social media communication^4,5 and the WHO has created a framework for effective communications.⁶ Both organizations recognize social media as a powerful communication tool that has the potential to greatly impact public health efforts.

Some key principles highlighted from these sources include the following:

• Identify an audience and make messages relevant. Taking time to listen to key stakeholders within the target audience (individuals, health care providers, communities, policy-makers, organizations) allows for better understanding of baseline knowledge, attitudes, and beliefs that may drive concerns and ultimately helps to tailor the messaging.
• Make messages accessible. Certain social media platforms are more often utilized for specific target audiences. Verbiage used should take into account the health literacy of the audience. A friendly, professional, conversational tone encourages interaction and dialogue.
• Engage the audience by offering something actionable. Changing behavior is a daunting task that involves multiple steps. Encouraging behavioral changes initially at an individual level has the potential to influence community practices and policies.
• Communication should be timely. It should address current and urgent topics. Keep abreast of the situation as it evolves to ensure messaging stays relevant. Deliver consistent messaging and updates.
• Sources must be credible. It is important to be transparent about expertise and honest about what is known and unknown about the topic.
• Content should be understandable. In addition to using plain language, visual aids and real stories can be used to reinforce messages.

Use social media responsibly

Clinicians have a responsibility to use social media to disseminate credible content, refute misleading content, and create accurate content. When clinicians share health-related information via social media, it should be appraised skeptically and crafted responsibly because that message can have profound implications on public health. Mixed messaging that is contradictory, inconsistent, or unclear can lead to panic and confusion. By recognizing the important role of social media in access to information and as a tool for public health messaging and crisis communication, clinicians have an obligation to consider both the positive and negative impacts as messengers in that space.

Dr. Ren is a pediatric emergency medicine fellow at Children’s National Hospital, Washington. Dr. Simpson is a pediatric emergency medicine attending and medical director of emergency preparedness of Children’s National Hospital. They do not have any disclosures or conflicts of interest. Email Dr. Ren and Dr. Simpson at [email protected].

References

1. AEM Educ Train. 2019;3(4):387-92.

2. Ann Emerg Med. 2016;68(6):729-35.

3. Ann Emerg Med. 2018;72(6):696-702.

4. CDC Guide to Writing for Social Media.

5. The Health Communicator’s Social Media Toolkit.

6. WHO Strategic Communications Framework for effective communications.

A few months into the COVID-19 pandemic, social media’s role in the rapid spread of information is undeniable. From the beginning, Chinese ophthalmologist Li Wenliang, MD, first raised the alarm to his classmates through WeChat, a messaging and social media app. Since that time, individuals, groups, organizations, government agencies, and mass media outlets have used social media to share ideas and disseminate information. Individuals check in on loved ones and update others on their own safety. Networks of clinicians discuss patient presentations, new therapeutics, management strategies, and institutional protocols. Multiple organizations including the Federal Emergency Management Agency, the Centers for Disease Control and Prevention, and the World Health Organization use Facebook, Instagram, or Twitter accounts to provide updates on ongoing efforts and spread public health messaging.

Unfortunately, not all information is trustworthy. Social media outlets have been used to spread misinformation and conspiracy theories, and to promote false treatments. Google, YouTube, and Facebook are now actively trying to reduce the viral spread of misleading information and to block hoaxes. With the increasing amount of news and information consumed and disseminated via social media, clinicians need to critically appraise information presented on those platforms, and to be familiar with how to use them to disseminate informed, effective, and responsible information.
 

Appraisal of social media content

Traditional scholarly communication exists in many forms and includes observations, anecdotes, perspectives, case reports, and research. Each form involves differing levels of academic rigor and standards of evaluation. Electronic content and online resources pose a unique challenge because there is no standardized method for assessing impact and quality. Proposed scales for evaluation of online resources such as Medical Education Translational Resources: Impact and Quality (METRIQ),¹ Academic Life in Emergency Medicine Approved Instructional Resources (AliEM AIR) scoring system,² and the Social Media Index³ are promising and can be used to guide critical appraisal of social media content.

The same skepticism and critical thinking applied to traditional resources should be applied when evaluating online resources. The scales listed above include questions such as:

• How accurate is the data presented and conclusions drawn?
• Does the content reflect evidence-based medicine?
• Has the content undergone an editorial process?
• Who are the authors and what are their credentials?
• Are there potential biases or conflicts of interest present?
• Have references been cited?
• How does this content affect/change clinical practice?

While these proposed review metrics may not apply to all forms of social media content, clinicians should be discerning when consuming or disseminating online content.
 

Strategies for effective communication on social media

In addition to appraising social media content, clinicians also should be able to craft effective messages on social media to spread trustworthy content. The CDC offers guidelines and best practices for social media communication^4,5 and the WHO has created a framework for effective communications.⁶ Both organizations recognize social media as a powerful communication tool that has the potential to greatly impact public health efforts.

Some key principles highlighted from these sources include the following:

• Identify an audience and make messages relevant. Taking time to listen to key stakeholders within the target audience (individuals, health care providers, communities, policy-makers, organizations) allows for better understanding of baseline knowledge, attitudes, and beliefs that may drive concerns and ultimately helps to tailor the messaging.
• Make messages accessible. Certain social media platforms are more often utilized for specific target audiences. Verbiage used should take into account the health literacy of the audience. A friendly, professional, conversational tone encourages interaction and dialogue.
• Engage the audience by offering something actionable. Changing behavior is a daunting task that involves multiple steps. Encouraging behavioral changes initially at an individual level has the potential to influence community practices and policies.
• Communication should be timely. It should address current and urgent topics. Keep abreast of the situation as it evolves to ensure messaging stays relevant. Deliver consistent messaging and updates.
• Sources must be credible. It is important to be transparent about expertise and honest about what is known and unknown about the topic.
• Content should be understandable. In addition to using plain language, visual aids and real stories can be used to reinforce messages.

Use social media responsibly

Clinicians have a responsibility to use social media to disseminate credible content, refute misleading content, and create accurate content. When clinicians share health-related information via social media, it should be appraised skeptically and crafted responsibly because that message can have profound implications on public health. Mixed messaging that is contradictory, inconsistent, or unclear can lead to panic and confusion. By recognizing the important role of social media in access to information and as a tool for public health messaging and crisis communication, clinicians have an obligation to consider both the positive and negative impacts as messengers in that space.

Dr. Ren is a pediatric emergency medicine fellow at Children’s National Hospital, Washington. Dr. Simpson is a pediatric emergency medicine attending and medical director of emergency preparedness of Children’s National Hospital. They do not have any disclosures or conflicts of interest. Email Dr. Ren and Dr. Simpson at [email protected].

References

1. AEM Educ Train. 2019;3(4):387-92.

2. Ann Emerg Med. 2016;68(6):729-35.

3. Ann Emerg Med. 2018;72(6):696-702.

4. CDC Guide to Writing for Social Media.

5. The Health Communicator’s Social Media Toolkit.

6. WHO Strategic Communications Framework for effective communications.

A few months into the COVID-19 pandemic, social media’s role in the rapid spread of information is undeniable. From the beginning, Chinese ophthalmologist Li Wenliang, MD, first raised the alarm to his classmates through WeChat, a messaging and social media app. Since that time, individuals, groups, organizations, government agencies, and mass media outlets have used social media to share ideas and disseminate information. Individuals check in on loved ones and update others on their own safety. Networks of clinicians discuss patient presentations, new therapeutics, management strategies, and institutional protocols. Multiple organizations including the Federal Emergency Management Agency, the Centers for Disease Control and Prevention, and the World Health Organization use Facebook, Instagram, or Twitter accounts to provide updates on ongoing efforts and spread public health messaging.

Unfortunately, not all information is trustworthy. Social media outlets have been used to spread misinformation and conspiracy theories, and to promote false treatments. Google, YouTube, and Facebook are now actively trying to reduce the viral spread of misleading information and to block hoaxes. With the increasing amount of news and information consumed and disseminated via social media, clinicians need to critically appraise information presented on those platforms, and to be familiar with how to use them to disseminate informed, effective, and responsible information.
 

Appraisal of social media content

Traditional scholarly communication exists in many forms and includes observations, anecdotes, perspectives, case reports, and research. Each form involves differing levels of academic rigor and standards of evaluation. Electronic content and online resources pose a unique challenge because there is no standardized method for assessing impact and quality. Proposed scales for evaluation of online resources such as Medical Education Translational Resources: Impact and Quality (METRIQ),¹ Academic Life in Emergency Medicine Approved Instructional Resources (AliEM AIR) scoring system,² and the Social Media Index³ are promising and can be used to guide critical appraisal of social media content.

The same skepticism and critical thinking applied to traditional resources should be applied when evaluating online resources. The scales listed above include questions such as:

• How accurate is the data presented and conclusions drawn?
• Does the content reflect evidence-based medicine?
• Has the content undergone an editorial process?
• Who are the authors and what are their credentials?
• Are there potential biases or conflicts of interest present?
• Have references been cited?
• How does this content affect/change clinical practice?

While these proposed review metrics may not apply to all forms of social media content, clinicians should be discerning when consuming or disseminating online content.
 

Strategies for effective communication on social media

In addition to appraising social media content, clinicians also should be able to craft effective messages on social media to spread trustworthy content. The CDC offers guidelines and best practices for social media communication^4,5 and the WHO has created a framework for effective communications.⁶ Both organizations recognize social media as a powerful communication tool that has the potential to greatly impact public health efforts.

Some key principles highlighted from these sources include the following:

• Identify an audience and make messages relevant. Taking time to listen to key stakeholders within the target audience (individuals, health care providers, communities, policy-makers, organizations) allows for better understanding of baseline knowledge, attitudes, and beliefs that may drive concerns and ultimately helps to tailor the messaging.
• Make messages accessible. Certain social media platforms are more often utilized for specific target audiences. Verbiage used should take into account the health literacy of the audience. A friendly, professional, conversational tone encourages interaction and dialogue.
• Engage the audience by offering something actionable. Changing behavior is a daunting task that involves multiple steps. Encouraging behavioral changes initially at an individual level has the potential to influence community practices and policies.
• Communication should be timely. It should address current and urgent topics. Keep abreast of the situation as it evolves to ensure messaging stays relevant. Deliver consistent messaging and updates.
• Sources must be credible. It is important to be transparent about expertise and honest about what is known and unknown about the topic.
• Content should be understandable. In addition to using plain language, visual aids and real stories can be used to reinforce messages.

Use social media responsibly

Clinicians have a responsibility to use social media to disseminate credible content, refute misleading content, and create accurate content. When clinicians share health-related information via social media, it should be appraised skeptically and crafted responsibly because that message can have profound implications on public health. Mixed messaging that is contradictory, inconsistent, or unclear can lead to panic and confusion. By recognizing the important role of social media in access to information and as a tool for public health messaging and crisis communication, clinicians have an obligation to consider both the positive and negative impacts as messengers in that space.

Dr. Ren is a pediatric emergency medicine fellow at Children’s National Hospital, Washington. Dr. Simpson is a pediatric emergency medicine attending and medical director of emergency preparedness of Children’s National Hospital. They do not have any disclosures or conflicts of interest. Email Dr. Ren and Dr. Simpson at [email protected].

References

1. AEM Educ Train. 2019;3(4):387-92.

2. Ann Emerg Med. 2016;68(6):729-35.

3. Ann Emerg Med. 2018;72(6):696-702.

4. CDC Guide to Writing for Social Media.

5. The Health Communicator’s Social Media Toolkit.

6. WHO Strategic Communications Framework for effective communications.

In my home county of San Diego, school closure has meant some 800,000 children staying home.¹ Parents love and are committed to care for their children, but as these parents struggle with food insecurity and mass unemployment, local pediatricians are joining their national colleagues in worrying about rising rates of child abuse.

monkeybusinessimages/iStock/Getty Images

The cost of child abuse is real and lifelong. According to a policy statement from the American Academy of Pediatrics Council on Child Abuse and Neglect, a quarter of kids who suffer abusive head trauma die. Of the survivors, nearly 70% “have some degree of lasting neurological impairment.”⁵

Given the potentially disastrous consequences of child abuse, we must stay vigilant about child abuse. In our own profession, we must educate trainees and update experienced pediatricians about suspecting child abuse and reporting. For example, child abuse can be suspected and reported based on telemedicine interactions. The burden of proof for reporting child abuse is only “reasonable suspicion,” not “beyond a reasonable doubt.” In our communities, we must engage with local Child Welfare Services workers and educate them about sentinel injuries. And finally, in our practices, we must build families up with awareness, resources, and coping mechanisms to prevent abuse from happening in the first place.

Dr. Helen C. Wang, associate professor of pediatrics at the University of California, San Diego, talks to parents about managing stress early and often. She says, “I start counseling families at the prenatal visit. I do talk to families about what they liked to do before children. What brought you joy? What communities do you spend time with? And what have you been doing now?”

It can be hard to reconcile prior hobbies with the current recommendations of social distancing. “Now it’s more ‘Do FaceTime’ and ‘Do Zoom’ and spend more time with your extended family,” says Dr. Wang.

By caring for themselves, parents can better protect their children from mistreatment and injury. Healthychildren.org, the parent-facing website of the AAP, offers several tips for parenting in times of stress.

In this unusual time of COVID-19, it is more important than ever to provide parents with suggestions and strategies that will help them – and their children – survive this health crisis. By educating ourselves and our communities about child abuse, we as pediatricians can fulfill our mandate in keeping kids healthy and thriving.
 

Dr. Parekh is a pediatric resident at University of California, San Diego. She has no financial disclosures. Email Dr. Parekh at [email protected].

References

1. Early childhood age group in California. kidsdata.org.

2. U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (2020). Child Maltreatment 2018.

3. Hong Joe. “School closures lead to troubling drop in child abuse reports.” KPBS. 2020 Mar 27.

4. Pediatrics. 2013 Apr;131(4):701-7.

5. Pediatrics. 2020;145(4):e20200203.

In my home county of San Diego, school closure has meant some 800,000 children staying home.¹ Parents love and are committed to care for their children, but as these parents struggle with food insecurity and mass unemployment, local pediatricians are joining their national colleagues in worrying about rising rates of child abuse.

monkeybusinessimages/iStock/Getty Images

The cost of child abuse is real and lifelong. According to a policy statement from the American Academy of Pediatrics Council on Child Abuse and Neglect, a quarter of kids who suffer abusive head trauma die. Of the survivors, nearly 70% “have some degree of lasting neurological impairment.”⁵

Given the potentially disastrous consequences of child abuse, we must stay vigilant about child abuse. In our own profession, we must educate trainees and update experienced pediatricians about suspecting child abuse and reporting. For example, child abuse can be suspected and reported based on telemedicine interactions. The burden of proof for reporting child abuse is only “reasonable suspicion,” not “beyond a reasonable doubt.” In our communities, we must engage with local Child Welfare Services workers and educate them about sentinel injuries. And finally, in our practices, we must build families up with awareness, resources, and coping mechanisms to prevent abuse from happening in the first place.

Dr. Helen C. Wang, associate professor of pediatrics at the University of California, San Diego, talks to parents about managing stress early and often. She says, “I start counseling families at the prenatal visit. I do talk to families about what they liked to do before children. What brought you joy? What communities do you spend time with? And what have you been doing now?”

It can be hard to reconcile prior hobbies with the current recommendations of social distancing. “Now it’s more ‘Do FaceTime’ and ‘Do Zoom’ and spend more time with your extended family,” says Dr. Wang.

By caring for themselves, parents can better protect their children from mistreatment and injury. Healthychildren.org, the parent-facing website of the AAP, offers several tips for parenting in times of stress.

In this unusual time of COVID-19, it is more important than ever to provide parents with suggestions and strategies that will help them – and their children – survive this health crisis. By educating ourselves and our communities about child abuse, we as pediatricians can fulfill our mandate in keeping kids healthy and thriving.
 

Dr. Parekh is a pediatric resident at University of California, San Diego. She has no financial disclosures. Email Dr. Parekh at [email protected].

References

1. Early childhood age group in California. kidsdata.org.

2. U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (2020). Child Maltreatment 2018.

3. Hong Joe. “School closures lead to troubling drop in child abuse reports.” KPBS. 2020 Mar 27.

4. Pediatrics. 2013 Apr;131(4):701-7.

5. Pediatrics. 2020;145(4):e20200203.

In my home county of San Diego, school closure has meant some 800,000 children staying home.¹ Parents love and are committed to care for their children, but as these parents struggle with food insecurity and mass unemployment, local pediatricians are joining their national colleagues in worrying about rising rates of child abuse.

monkeybusinessimages/iStock/Getty Images

The cost of child abuse is real and lifelong. According to a policy statement from the American Academy of Pediatrics Council on Child Abuse and Neglect, a quarter of kids who suffer abusive head trauma die. Of the survivors, nearly 70% “have some degree of lasting neurological impairment.”⁵

Given the potentially disastrous consequences of child abuse, we must stay vigilant about child abuse. In our own profession, we must educate trainees and update experienced pediatricians about suspecting child abuse and reporting. For example, child abuse can be suspected and reported based on telemedicine interactions. The burden of proof for reporting child abuse is only “reasonable suspicion,” not “beyond a reasonable doubt.” In our communities, we must engage with local Child Welfare Services workers and educate them about sentinel injuries. And finally, in our practices, we must build families up with awareness, resources, and coping mechanisms to prevent abuse from happening in the first place.

Dr. Helen C. Wang, associate professor of pediatrics at the University of California, San Diego, talks to parents about managing stress early and often. She says, “I start counseling families at the prenatal visit. I do talk to families about what they liked to do before children. What brought you joy? What communities do you spend time with? And what have you been doing now?”

It can be hard to reconcile prior hobbies with the current recommendations of social distancing. “Now it’s more ‘Do FaceTime’ and ‘Do Zoom’ and spend more time with your extended family,” says Dr. Wang.

By caring for themselves, parents can better protect their children from mistreatment and injury. Healthychildren.org, the parent-facing website of the AAP, offers several tips for parenting in times of stress.

In this unusual time of COVID-19, it is more important than ever to provide parents with suggestions and strategies that will help them – and their children – survive this health crisis. By educating ourselves and our communities about child abuse, we as pediatricians can fulfill our mandate in keeping kids healthy and thriving.
 

Dr. Parekh is a pediatric resident at University of California, San Diego. She has no financial disclosures. Email Dr. Parekh at [email protected].

References

1. Early childhood age group in California. kidsdata.org.

2. U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (2020). Child Maltreatment 2018.

3. Hong Joe. “School closures lead to troubling drop in child abuse reports.” KPBS. 2020 Mar 27.

4. Pediatrics. 2013 Apr;131(4):701-7.

5. Pediatrics. 2020;145(4):e20200203.

A couple of weeks ago, I posted a silly picture of myself with one N95 mask and asked the folks on Twitter what else I might need. In a matter of a few days, I had filled out a form online for volunteering through the Society of Critical Care Medicine, been assigned to work at a hospital in New York City, and booked a hotel and flight.

Courtesy Arghavan Salles, MD

I was going to volunteer, although I wasn’t sure of exactly what I would be doing. I’m trained as a bariatric surgeon – not obviously suited for critical care, but arguably even less suited for medicine wards.

I undoubtedly would have been less prepared if I hadn’t sought guidance on what to bring with me and generally what to expect. Less than a day after seeking advice, two local women physicians donated N95s, face shields, gowns, bouffants, and coveralls to me. I also received a laminated photo of myself to attach to my gown in the mail from a stranger I met online.

Others suggested I bring goggles, chocolate, protein bars, hand sanitizer, powdered laundry detergent, and alcohol wipes. After running around all over town, I was able find everything but the wipes.

Just as others helped me achieve my goal of volunteering, I hope I can guide those who would like to do similar work by sharing details about my experience and other information I have collected about volunteering.

Below I answer some questions that those considering volunteering might have, including why I went, who I contacted to set this up, who paid for my flight, and what I observed in the hospital.
 

Motivation and logistics

I am currently serving in a nonclinical role at my institution. So when the pandemic hit the United States, I felt an immense amount of guilt for not being on the front lines caring for patients. I offered my services to local hospitals and registered for the California Health Corps. I live in northern California, which was the first part of the country to shelter in place. Since my home was actually relatively spared, my services weren’t needed.

As the weeks passed, I was slowly getting more and more fit, exercising in my house since there was little else I could do, and the guilt became a cloud gathering over my head.

I decided to volunteer in a place where demands for help were higher – New York. I tried very hard to sign up to volunteer through the state’s registry for health care volunteers, but was unable to do so. Coincidentally, around that same time, I saw on Twitter that Josh Mugele, MD, emergency medicine physician and program director of the emergency medicine residency at Northeast Georgia Medical Center in Gainesville, was on his way to New York. He shared the Society of Critical Care Medicine’s form for volunteering with me, and in less than 48 hours, I was assigned to a hospital in New York City. Five days later I was on a plane from San Francisco to my destination on the opposite side of the country. The airline paid for my flight.

This is not the only path to volunteering. Another volunteer, Sara Pauk, MD, ob.gyn. at the University of Washington, Seattle, found her volunteer role through contacting the New York City Health and Hospitals system directly. Other who have volunteered told me they had contacted specific hospitals or worked with agencies that were placing physicians.
 

PPE

Courtesy Arghavan Salles. MD

The Brooklyn hospital where I volunteered provided me with two sets of scrubs and two N95s. Gowns were variably available on our unit, and there was no eye protection. As a colleague of mine, Ben Daxon, MD, anesthesia and critical care physician at the Mayo Clinic in Rochester, Minn., had suggested, anyone volunteering in this context should bring personal protective equipment (PPE) – That includes gowns, bouffants/scrub caps, eye protection, masks, and scrubs.

The “COVID corner”

Once I arrived in New York, I did not feel particularly safe in my hotel, so I moved to another the next day. Then I had to sort out how to keep the whole room from being contaminated. I created a “COVID corner” right by the door where I kept almost everything that had been outside the door.

Every time I walked in the door, I immediately took off my shoes and left them in that corner. I could not find alcohol wipes, even after looking around in the city, so I relied on time to kill the virus, which I presumed was on everything that came from outside.

Courtesy Arghavan Salles, MD

Groceries stayed by the door for 48-72 hours if possible. After that, I would move them to the “clean” parts of the room. I wore the same outfit to and from the hospital everyday, putting it on right before I left and taking it off immediately after walking into the room (and then proceeding directly to the shower). Those clothes – “my COVID outfit” – lived in the COVID corner. Anything else I wore, including exercise clothes and underwear, got washed right after I wore it.

At the hospital, I would change into scrubs and leave my COVID outfit in a plastic bag inside my handbag. Note: I fully accepted that my handbag was now a COVID handbag. I kept a pair of clogs in the hospital for daily wear. Without alcohol wipes, my room did not feel clean. But I did start to become at peace with my system, even though it was inferior to the system I use in my own home.

Meal time

In addition to bringing snacks from home, I gathered some meal items at a grocery store during my first day in New York. These included water, yogurt, a few protein drinks, fruit, and some mini chocolate croissants. It’s a pandemic – chocolate is encouraged, right?

Neither any of the volunteers I knew nor I had access to a kitchen, so this was about the best I could do.

My first week I worked nights and ate sporadically. A couple of days I bought bagel sandwiches on the way back to the hotel in the morning. Other times, I would eat yogurt or a protein bar.

I had trouble sleeping, so I would wake up early and either do yoga in my room or go for a run in a nearby park. Usually I didn’t plan well enough to eat before I went into the hospital, so I would take yogurt, some fruit, and a croissant with me as I headed out. It was hard eating on the run with a mask on my face.

When I switched to working days, I actually ordered proper dinners from local Thai, Mexican, and Indian restaurants. I paid around $20 a meal.

One night I even had dinner with a coworker who was staying at a hotel close to mine – what a luxury! Prior to all this I had been sheltering in place alone for weeks, so in that sense, this experience was a delight. I interacted with other people, in person, every day!
 

My commute

My hotel was about 20 minutes from the hospital. Well-meaning folks informed me that Hertz had free car rentals and Uber had discounts for health care workers. When I investigated these options, I found that only employees of certain hospitals were eligible. As a volunteer, I was not eligible.

Courtesy Arghavan Salles, MD

I ultimately took Uber back and forth, and I was lucky that a few friends had sent me Uber gift cards to defray the costs. Most days, I paid about $20 each way, although 1 day there actually was “surge pricing.” The grand total for the trip was close to $800.

Many of the Uber drivers had put up plastic partitions – reminiscent of the plastic Dexter would use to contain his crime scenes – to increase their separation from their passengers. It was a bit eerie, but also somewhat welcome.
 

New normal

The actual work at the hospital in Brooklyn where I volunteered was different from usual practice in numerous ways. One of the things I immediately noticed was how difficult it was to get chest x-rays. After placing an emergent chest tube for a tension pneumothorax, it took about 6 hours to get a chest x-ray to assess placement.

Because code medications were needed much more frequently than normal times, these medications were kept in an open supply closet for ease of access. Many of the ventilators looked like they were from the 1970s. (They had been borrowed from the Federal Emergency Management Agency.)

What was most distinct about this work was the sheer volume of deaths and dying patients -- at least one death on our unit occurred every day I was there -- and the way families communicated with their loved ones. Countless times I held my phone over the faces of my unconscious patients to let their family profess their love and beg them to fight. While I have had to deliver bad news over the phone many times in my career, I have never had to intrude on families’ last conversations with their dying loved ones or witness that conversation occurring via a tiny screen.
 

Reentry

In many ways, I am lucky that I do not do clinical work in my hometown. So while other volunteers were figuring out how many more vacation days they would have to use, or whether they would have to take unpaid leave, and when and how they would get tested, all I had to do was prepare to go back home and quarantine myself for a couple of weeks.

I used up 2 weeks of vacation to volunteer in New York, but luckily, I could resume my normal work the day after I returned home.

Obviously, living in the pandemic is unique to anything we have ever experienced. Recognizing that, I recorded video diaries the whole time I was in New York. I laughed (like when I tried to fit all of my PPE on my tiny head), and I cried – several times. I suppose 1 day I may actually watch them and be reminded of what it was like to have been able to serve in this historic moment. Until then, they will remain locked up on the same phone that served as the only communication vehicle between my patients and their loved ones.

Dr. Salles is a bariatric surgeon and is currently a Scholar in Residence at Stanford (Calif.) University.

A couple of weeks ago, I posted a silly picture of myself with one N95 mask and asked the folks on Twitter what else I might need. In a matter of a few days, I had filled out a form online for volunteering through the Society of Critical Care Medicine, been assigned to work at a hospital in New York City, and booked a hotel and flight.

Courtesy Arghavan Salles, MD

I was going to volunteer, although I wasn’t sure of exactly what I would be doing. I’m trained as a bariatric surgeon – not obviously suited for critical care, but arguably even less suited for medicine wards.

I undoubtedly would have been less prepared if I hadn’t sought guidance on what to bring with me and generally what to expect. Less than a day after seeking advice, two local women physicians donated N95s, face shields, gowns, bouffants, and coveralls to me. I also received a laminated photo of myself to attach to my gown in the mail from a stranger I met online.

Others suggested I bring goggles, chocolate, protein bars, hand sanitizer, powdered laundry detergent, and alcohol wipes. After running around all over town, I was able find everything but the wipes.

Just as others helped me achieve my goal of volunteering, I hope I can guide those who would like to do similar work by sharing details about my experience and other information I have collected about volunteering.

Below I answer some questions that those considering volunteering might have, including why I went, who I contacted to set this up, who paid for my flight, and what I observed in the hospital.
 

Motivation and logistics

I am currently serving in a nonclinical role at my institution. So when the pandemic hit the United States, I felt an immense amount of guilt for not being on the front lines caring for patients. I offered my services to local hospitals and registered for the California Health Corps. I live in northern California, which was the first part of the country to shelter in place. Since my home was actually relatively spared, my services weren’t needed.

As the weeks passed, I was slowly getting more and more fit, exercising in my house since there was little else I could do, and the guilt became a cloud gathering over my head.

I decided to volunteer in a place where demands for help were higher – New York. I tried very hard to sign up to volunteer through the state’s registry for health care volunteers, but was unable to do so. Coincidentally, around that same time, I saw on Twitter that Josh Mugele, MD, emergency medicine physician and program director of the emergency medicine residency at Northeast Georgia Medical Center in Gainesville, was on his way to New York. He shared the Society of Critical Care Medicine’s form for volunteering with me, and in less than 48 hours, I was assigned to a hospital in New York City. Five days later I was on a plane from San Francisco to my destination on the opposite side of the country. The airline paid for my flight.

This is not the only path to volunteering. Another volunteer, Sara Pauk, MD, ob.gyn. at the University of Washington, Seattle, found her volunteer role through contacting the New York City Health and Hospitals system directly. Other who have volunteered told me they had contacted specific hospitals or worked with agencies that were placing physicians.
 

PPE

Courtesy Arghavan Salles. MD

The Brooklyn hospital where I volunteered provided me with two sets of scrubs and two N95s. Gowns were variably available on our unit, and there was no eye protection. As a colleague of mine, Ben Daxon, MD, anesthesia and critical care physician at the Mayo Clinic in Rochester, Minn., had suggested, anyone volunteering in this context should bring personal protective equipment (PPE) – That includes gowns, bouffants/scrub caps, eye protection, masks, and scrubs.

The “COVID corner”

Once I arrived in New York, I did not feel particularly safe in my hotel, so I moved to another the next day. Then I had to sort out how to keep the whole room from being contaminated. I created a “COVID corner” right by the door where I kept almost everything that had been outside the door.

Every time I walked in the door, I immediately took off my shoes and left them in that corner. I could not find alcohol wipes, even after looking around in the city, so I relied on time to kill the virus, which I presumed was on everything that came from outside.

Courtesy Arghavan Salles, MD

Groceries stayed by the door for 48-72 hours if possible. After that, I would move them to the “clean” parts of the room. I wore the same outfit to and from the hospital everyday, putting it on right before I left and taking it off immediately after walking into the room (and then proceeding directly to the shower). Those clothes – “my COVID outfit” – lived in the COVID corner. Anything else I wore, including exercise clothes and underwear, got washed right after I wore it.

At the hospital, I would change into scrubs and leave my COVID outfit in a plastic bag inside my handbag. Note: I fully accepted that my handbag was now a COVID handbag. I kept a pair of clogs in the hospital for daily wear. Without alcohol wipes, my room did not feel clean. But I did start to become at peace with my system, even though it was inferior to the system I use in my own home.

Meal time

In addition to bringing snacks from home, I gathered some meal items at a grocery store during my first day in New York. These included water, yogurt, a few protein drinks, fruit, and some mini chocolate croissants. It’s a pandemic – chocolate is encouraged, right?

Neither any of the volunteers I knew nor I had access to a kitchen, so this was about the best I could do.

My first week I worked nights and ate sporadically. A couple of days I bought bagel sandwiches on the way back to the hotel in the morning. Other times, I would eat yogurt or a protein bar.

I had trouble sleeping, so I would wake up early and either do yoga in my room or go for a run in a nearby park. Usually I didn’t plan well enough to eat before I went into the hospital, so I would take yogurt, some fruit, and a croissant with me as I headed out. It was hard eating on the run with a mask on my face.

When I switched to working days, I actually ordered proper dinners from local Thai, Mexican, and Indian restaurants. I paid around $20 a meal.

One night I even had dinner with a coworker who was staying at a hotel close to mine – what a luxury! Prior to all this I had been sheltering in place alone for weeks, so in that sense, this experience was a delight. I interacted with other people, in person, every day!
 

My commute

My hotel was about 20 minutes from the hospital. Well-meaning folks informed me that Hertz had free car rentals and Uber had discounts for health care workers. When I investigated these options, I found that only employees of certain hospitals were eligible. As a volunteer, I was not eligible.

Courtesy Arghavan Salles, MD

I ultimately took Uber back and forth, and I was lucky that a few friends had sent me Uber gift cards to defray the costs. Most days, I paid about $20 each way, although 1 day there actually was “surge pricing.” The grand total for the trip was close to $800.

Many of the Uber drivers had put up plastic partitions – reminiscent of the plastic Dexter would use to contain his crime scenes – to increase their separation from their passengers. It was a bit eerie, but also somewhat welcome.
 

New normal

The actual work at the hospital in Brooklyn where I volunteered was different from usual practice in numerous ways. One of the things I immediately noticed was how difficult it was to get chest x-rays. After placing an emergent chest tube for a tension pneumothorax, it took about 6 hours to get a chest x-ray to assess placement.

Because code medications were needed much more frequently than normal times, these medications were kept in an open supply closet for ease of access. Many of the ventilators looked like they were from the 1970s. (They had been borrowed from the Federal Emergency Management Agency.)

What was most distinct about this work was the sheer volume of deaths and dying patients -- at least one death on our unit occurred every day I was there -- and the way families communicated with their loved ones. Countless times I held my phone over the faces of my unconscious patients to let their family profess their love and beg them to fight. While I have had to deliver bad news over the phone many times in my career, I have never had to intrude on families’ last conversations with their dying loved ones or witness that conversation occurring via a tiny screen.
 

Reentry

In many ways, I am lucky that I do not do clinical work in my hometown. So while other volunteers were figuring out how many more vacation days they would have to use, or whether they would have to take unpaid leave, and when and how they would get tested, all I had to do was prepare to go back home and quarantine myself for a couple of weeks.

I used up 2 weeks of vacation to volunteer in New York, but luckily, I could resume my normal work the day after I returned home.

Obviously, living in the pandemic is unique to anything we have ever experienced. Recognizing that, I recorded video diaries the whole time I was in New York. I laughed (like when I tried to fit all of my PPE on my tiny head), and I cried – several times. I suppose 1 day I may actually watch them and be reminded of what it was like to have been able to serve in this historic moment. Until then, they will remain locked up on the same phone that served as the only communication vehicle between my patients and their loved ones.

Dr. Salles is a bariatric surgeon and is currently a Scholar in Residence at Stanford (Calif.) University.

A couple of weeks ago, I posted a silly picture of myself with one N95 mask and asked the folks on Twitter what else I might need. In a matter of a few days, I had filled out a form online for volunteering through the Society of Critical Care Medicine, been assigned to work at a hospital in New York City, and booked a hotel and flight.

Courtesy Arghavan Salles, MD

I was going to volunteer, although I wasn’t sure of exactly what I would be doing. I’m trained as a bariatric surgeon – not obviously suited for critical care, but arguably even less suited for medicine wards.

I undoubtedly would have been less prepared if I hadn’t sought guidance on what to bring with me and generally what to expect. Less than a day after seeking advice, two local women physicians donated N95s, face shields, gowns, bouffants, and coveralls to me. I also received a laminated photo of myself to attach to my gown in the mail from a stranger I met online.

Others suggested I bring goggles, chocolate, protein bars, hand sanitizer, powdered laundry detergent, and alcohol wipes. After running around all over town, I was able find everything but the wipes.

Just as others helped me achieve my goal of volunteering, I hope I can guide those who would like to do similar work by sharing details about my experience and other information I have collected about volunteering.

Below I answer some questions that those considering volunteering might have, including why I went, who I contacted to set this up, who paid for my flight, and what I observed in the hospital.
 

Motivation and logistics

I am currently serving in a nonclinical role at my institution. So when the pandemic hit the United States, I felt an immense amount of guilt for not being on the front lines caring for patients. I offered my services to local hospitals and registered for the California Health Corps. I live in northern California, which was the first part of the country to shelter in place. Since my home was actually relatively spared, my services weren’t needed.

As the weeks passed, I was slowly getting more and more fit, exercising in my house since there was little else I could do, and the guilt became a cloud gathering over my head.

I decided to volunteer in a place where demands for help were higher – New York. I tried very hard to sign up to volunteer through the state’s registry for health care volunteers, but was unable to do so. Coincidentally, around that same time, I saw on Twitter that Josh Mugele, MD, emergency medicine physician and program director of the emergency medicine residency at Northeast Georgia Medical Center in Gainesville, was on his way to New York. He shared the Society of Critical Care Medicine’s form for volunteering with me, and in less than 48 hours, I was assigned to a hospital in New York City. Five days later I was on a plane from San Francisco to my destination on the opposite side of the country. The airline paid for my flight.

This is not the only path to volunteering. Another volunteer, Sara Pauk, MD, ob.gyn. at the University of Washington, Seattle, found her volunteer role through contacting the New York City Health and Hospitals system directly. Other who have volunteered told me they had contacted specific hospitals or worked with agencies that were placing physicians.
 

PPE

Courtesy Arghavan Salles. MD

The Brooklyn hospital where I volunteered provided me with two sets of scrubs and two N95s. Gowns were variably available on our unit, and there was no eye protection. As a colleague of mine, Ben Daxon, MD, anesthesia and critical care physician at the Mayo Clinic in Rochester, Minn., had suggested, anyone volunteering in this context should bring personal protective equipment (PPE) – That includes gowns, bouffants/scrub caps, eye protection, masks, and scrubs.

The “COVID corner”

Once I arrived in New York, I did not feel particularly safe in my hotel, so I moved to another the next day. Then I had to sort out how to keep the whole room from being contaminated. I created a “COVID corner” right by the door where I kept almost everything that had been outside the door.

Every time I walked in the door, I immediately took off my shoes and left them in that corner. I could not find alcohol wipes, even after looking around in the city, so I relied on time to kill the virus, which I presumed was on everything that came from outside.

Courtesy Arghavan Salles, MD

Groceries stayed by the door for 48-72 hours if possible. After that, I would move them to the “clean” parts of the room. I wore the same outfit to and from the hospital everyday, putting it on right before I left and taking it off immediately after walking into the room (and then proceeding directly to the shower). Those clothes – “my COVID outfit” – lived in the COVID corner. Anything else I wore, including exercise clothes and underwear, got washed right after I wore it.

At the hospital, I would change into scrubs and leave my COVID outfit in a plastic bag inside my handbag. Note: I fully accepted that my handbag was now a COVID handbag. I kept a pair of clogs in the hospital for daily wear. Without alcohol wipes, my room did not feel clean. But I did start to become at peace with my system, even though it was inferior to the system I use in my own home.

Meal time

In addition to bringing snacks from home, I gathered some meal items at a grocery store during my first day in New York. These included water, yogurt, a few protein drinks, fruit, and some mini chocolate croissants. It’s a pandemic – chocolate is encouraged, right?

Neither any of the volunteers I knew nor I had access to a kitchen, so this was about the best I could do.

My first week I worked nights and ate sporadically. A couple of days I bought bagel sandwiches on the way back to the hotel in the morning. Other times, I would eat yogurt or a protein bar.

I had trouble sleeping, so I would wake up early and either do yoga in my room or go for a run in a nearby park. Usually I didn’t plan well enough to eat before I went into the hospital, so I would take yogurt, some fruit, and a croissant with me as I headed out. It was hard eating on the run with a mask on my face.

When I switched to working days, I actually ordered proper dinners from local Thai, Mexican, and Indian restaurants. I paid around $20 a meal.

One night I even had dinner with a coworker who was staying at a hotel close to mine – what a luxury! Prior to all this I had been sheltering in place alone for weeks, so in that sense, this experience was a delight. I interacted with other people, in person, every day!
 

My commute

My hotel was about 20 minutes from the hospital. Well-meaning folks informed me that Hertz had free car rentals and Uber had discounts for health care workers. When I investigated these options, I found that only employees of certain hospitals were eligible. As a volunteer, I was not eligible.

Courtesy Arghavan Salles, MD

I ultimately took Uber back and forth, and I was lucky that a few friends had sent me Uber gift cards to defray the costs. Most days, I paid about $20 each way, although 1 day there actually was “surge pricing.” The grand total for the trip was close to $800.

Many of the Uber drivers had put up plastic partitions – reminiscent of the plastic Dexter would use to contain his crime scenes – to increase their separation from their passengers. It was a bit eerie, but also somewhat welcome.
 

New normal

The actual work at the hospital in Brooklyn where I volunteered was different from usual practice in numerous ways. One of the things I immediately noticed was how difficult it was to get chest x-rays. After placing an emergent chest tube for a tension pneumothorax, it took about 6 hours to get a chest x-ray to assess placement.

Because code medications were needed much more frequently than normal times, these medications were kept in an open supply closet for ease of access. Many of the ventilators looked like they were from the 1970s. (They had been borrowed from the Federal Emergency Management Agency.)

What was most distinct about this work was the sheer volume of deaths and dying patients -- at least one death on our unit occurred every day I was there -- and the way families communicated with their loved ones. Countless times I held my phone over the faces of my unconscious patients to let their family profess their love and beg them to fight. While I have had to deliver bad news over the phone many times in my career, I have never had to intrude on families’ last conversations with their dying loved ones or witness that conversation occurring via a tiny screen.
 

Reentry

In many ways, I am lucky that I do not do clinical work in my hometown. So while other volunteers were figuring out how many more vacation days they would have to use, or whether they would have to take unpaid leave, and when and how they would get tested, all I had to do was prepare to go back home and quarantine myself for a couple of weeks.

I used up 2 weeks of vacation to volunteer in New York, but luckily, I could resume my normal work the day after I returned home.

Obviously, living in the pandemic is unique to anything we have ever experienced. Recognizing that, I recorded video diaries the whole time I was in New York. I laughed (like when I tried to fit all of my PPE on my tiny head), and I cried – several times. I suppose 1 day I may actually watch them and be reminded of what it was like to have been able to serve in this historic moment. Until then, they will remain locked up on the same phone that served as the only communication vehicle between my patients and their loved ones.

Dr. Salles is a bariatric surgeon and is currently a Scholar in Residence at Stanford (Calif.) University.