COVID-19 Update: Newswise Live Expert Panel
Newswise Live Expert Panel discussion of unique angles to the COVID-19 pandemic and the effects on all aspects of daily life around the world.
Experts from institutions including American Society of Anesthesiologists, Mayo Clinic, and University of Rochester will participate in an expert panel covering a wide variety of topics, with questions prepared by Newswise editors and submissions from media attendees.
Topics: Healthcare After COVID: what's changing about the healthcare system to adapt, what areas are under strain, the mental health of healthcare workforce, closures and job losses, adoption of telehealth and how to safely restore routine healthcare services
Who:
- Mary Dale Peterson M.D., MSHCA, FACHE, FASA - President - American Society of Anesthesiologists. Peterson can discuss the guidelines to resume surgery, safety for patients and healthcare workers.
- Susan McDaniel, PhD - Professor of Families & Health in the Departments of Psychiatry and Family Medicine - University of Rochester. McDaniel can discuss mental health issues as it relates to the pandemic and the strain on healthcare workers and their families.
- Joseph A. Dearani, MD, – President – The Society of Thoracic Surgeons. Dearani can discuss changes in health care delivery, potential consequences of delayed care, preparations for the second wave, and managing the physical and emotional wellbeing of those on the front lines.
- Professor Gilberto Montibeller - Professor of Management Science at Loughborough University (UK) & Senior Research Fellow at CREATE, University of Southern California.
- Eunice Wang, MD - Chief of Leukemia and Director of Infusion Services, Roswell Park Comprehensive Cancer Center.Wang can discuss how to safely continue oncology care, measures centers are taking as they return to more in-person encounters, and the expanded role for virtual visits.
- Dr. Robert Bonar - Gordon A. Friesen Professor of Healthcare Administration, Director of Master of Health Administration Program - George Washington University.
When: May 21, 2020, 2PM EDT
Where: Newswise Live event space on Zoom - https://newswiselive.zoom.us/j/7459578068
Registration for media, as well as colleagues from participating Newswise member institutions
This live event will also be recorded and transcribed for use by media and communicators after it is concluded.
Thom Canalichio: Welcome to this Newswise Live expert panel. We have with us today several experts to talk about the topic of how the Covid pandemic has changed healthcare. I want to make a few quick announcements for media who are on today’s call, we want you to be able to use any quotes from today’s panellists for your coverage, so please do feel free to use anything that’s part of today’s panel. You are also more than welcome to reach out and follow up with any of today’s panellists to set up some other kind of interview and further follow up that you'd like to do and we’ll be providing after today’s event, a video as well as a transcript and we also invite media to ask your questions in order to make the panel and all of the panellists responses useful for you and your coverage, we want to hear your questions. So please chat those to us. There's a little chat bubble at the bottom of the Zoom program where you can chat, we will then invite you if you'd like, to ask your question yourself on video and audio. If you don’t want to do that or can't for whatever reason, just let me know and I will ask those questions on your behalf.
We’re going to get started right away with questions, I just want to introduce all of our panellists briefly to make sure that we identify all of them. So, can we have first with us Mary Dale Peterson, she is president of the American Society of Anaesthesiologists. We also have Susan McDaniel, she is professor of families and health in the department of psychiatry and family medicine at the University of Rochester and her participation today was made possible by the American Psychological Association of which Dr. McDaniel is a former president.
We also have Dr. Joseph Dearani. Dr. Dearani is the president of the society of thoracic surgeons and he's also chair of cardiovascular surgery at the Mayo clinic. We have Gilberto Montibeller. Gillberto is professor of management science at Loughborough University in the UK and he's also a senior research fellow at CREATE, part of the university of Southern California. His participation today was made possible through the society for risk analysis.
We also have Dr. Eunice Wang. Dr. Wang is at Roswell Park Cancer institute. She's the chief of leukaemia and the director of infusion services at Rosewell Park Comprehensive Cancer Centre. And we also have Dr. Robert Bonar, Dr. Bonar is at George Washington University, he’s the Gordon A. Friesen professor of healthcare administration and he's also director of the masters of health administration program at GW. Thank you to all the panellists for joining today. I want to start with Dr. Bonar as a healthcare administrator and a former hospital CEO, share your perspective about leadership from policy makers and healthcare administrators could have been better in this crisis. What lessons have been learnt through these missteps?
Dr. Robert Bonar: Well I think that saying it could have been better at the policy level might be an understatement, that’s just my personal opinion, but I think that one of the things that has really bubbled up throughout this whole process is the importance of coordination between government agencies and healthcare providers, both regionally and in the states and on a national basis I think that this crisis has brought forward the importance of crystal clear communication and coordination, especially as it related to protecting our healthcare services providers and offering the best advice to patients. I think that that’s going to have to change and is in the process of changing, also I think that we may even see differences in accreditation requirements from the joint commission on healthcare accreditation in terms of how it impacts the preparation of hospitals and big health systems with similar incidents.
Thom Canalichio: How would you say or what would you say has been the biggest impact of the pandemic on the functioning of our healthcare system?
Dr. Robert Bonar: Well from the standpoint of someone who worked for 40 years in hospital administration, it seems to me that if I were still in that world, I would be worried about how I could prepare better my organisation or organisations for the aftermath of this situation. How do we better equip our healthcare providers who are rushing in and taking risks every day, taking care of patients, they’ve shown that – how can we better prepare and working with our public health departments as well as government to have adequate PPE to protect them. Those are the things that I would be worried about, especially since we’re reopening and there is concern as you all know about potential future outbreaks.
Thom Canalichio: thank you Dr. Bonar, I want to go directly to someone treating patients, performing surgeries, Dr. Dearani there at Mayo Clinic, in your area of cardio thoracic surgery this so in often involves emergency situations. So tell us a little bit more about how your kind of surgery has not necessarily been halted and how that compares to other so called elective surgeries and what are some of the strategies being done in order to accommodate surgeries that are absolutely necessary to keep them as safe as possible during this time?
Dr. Dearani: Well thanks Thom, so yeah in all of the surgical specialities there are grades of urgency for surgery and cardiac surgery is probably on the extreme of very few operations are really elective, it’s just degrees of how soon they should be done. Cardiac surgery never really came to a halt through the pandemic, it came down to very slow paces and emergency cases coming through the emergency room that typically go right to the operating room things like aortic dissection, really acute emergencies that are very time sensitive, those continued on. There are also sort of the heart attack family of patients that cannot be treated in a Cath lab and need urgent or emergent surgery. Those continued and those really were the ones that sort of kept on going through the early phase of the pandemic and then we had a chance to really sort of understand what the implications were going to be with this and then we started prioritising the other kinds of cases, and there are clearly some kinds of cases that should not wait too long, and most of those – without getting into very specific lesions, are those that have obstructive lesions in the heart. Those are cases where there's an incidence of sudden death. Aneurisms that could rupture, those kinds of cases are the ones that we end up prioritising and doing sooner whereas other lesions, you have the ability to wait a number of weeks or even a number of months.
And so, now we’re back in this sort of reactivation phase where those kinds of cases are being reintroduced and surgical programs around the country are sort of ramping back up again. I will say there have been patients that have died that were delayed because of surgery in the world of cardio thoracic surgery. And then there's the cancer patients where there's some ability to delay a bit, but not too long otherwise you run the risk of cancer perhaps spreading. So, it is a specialty that has been difficult to delay too many patients for too long.
Thom Canalichio: Thank you Dr. Dearani, and you mentioned cancer patients, I want to turn next to Dr. Wang at Roswell Park, Dr. Wang with routine surgery and elective procedures being on hold, Dr. Dearani pointing out some of the ways that emergency surgeries like heart surgery are still being done. Tell us more about how that’s impacted cancer patients? What's been the impact there and how are you continuing to deliver care to the cancer patients that can't afford to postpone treatment?
Dr. Wang: Yes, that’s an excellent question, as Dr. Dearani mentioned, cancer is not elective. Cancer can't wait. It’s incredibly scary to have a life-threatening diagnosis or be told a life-threatening diagnosis like cancer and also have the fears associated with the Covid pandemic layered on top of that. We don’t feel at our centre that cancer is elective, the cancer patients that I treat, which are perhaps the ones with the most aggressive medical cancer, acute leukaemia are individuals whose lifespan is measured in weeks or even a few months. So delaying therapy until the outbreak improves is not an option for those individuals. For many individuals delaying or putting off radiation, surgery, chemotherapy is going to allow the cancer 100% to progress.
So, our cancer centre as the Mayo Clinic also as well, has continued to prioritise delivery of cancer care throughout the pandemic’s ups and downs. We’ve remained fully operational throughout. I have continued to see patients and administer active chemotherapy with the knowledge that if I stopped my patients would not be able to see the end of that. We don’t know how long this is going to last, this is not a 2 or a 4 or a 6-week delay, we’re talking this could be going on for months. I tell my patients that it’s not a 100% that you will get Covid, it is a 100% that if we don’t give you your treatment, you may not be here to get to the end of the pandemic, to see improvement.
Out centre has done an outstanding job in my opinion of protecting patients, we are aware of the fears and anxiety associated with coming into a hospital. We have converted those patients that maybe didn't necessarily have urgent needs or weren’t getting chemotherapy actively and maybe getting surveillance therapy to virtual visits. We have also dedicated staff to screening patients before they enter the hospital, at the time of their entry and then symptom wise throughout their hospital stay. We are testing all patients prior to admissions and cancer surgeries to ensure –
Thom Canalichio: Thank you Dr. Wang, I want to go also to Dr. Peterson for the perspective from the American Society of Anaesthesiologists, the healthcare workers who are members of your association are experiencing two dramatic ends of the spectrum here. They're either frontline workers under a lot of strain and a lot of stress, or they may be from other kinds of clinics or other hospitals that are on hold. Maybe they're furloughed, maybe they're even unemployed. What can you tell us about how they are dealing with that or how they're being redeployed to help fight the Covid crisis?
Dr. Peterson: Sure Thom, so it is a tale of two cities and I would say that our anaesthesiologists we have a group that are full time and trained in doing critical care medicine, been working really hard in those – especially those Covid critical care units but all anaesthesiologists get training in critical care medicine and we provided extra boot camp resources to get them back up to speed, so a lot of anaesthesiologists when elective surgeries were cancelled, were redeployed to critical care units in some of the really hard hit areas like New York and Boston and we actually converted operating rooms and used our anaesthesia gas machine ventilators as ICU ventilators to supplement the ICU ventilators. So, they also organised themselves into intubation teams in many of the hospitals where you could have the most experienced people that could go in and offload some of that work for other colleagues, either in the emergency room or critical care unit. So, either with invasive lines or intubation or proning or helping with the ventilator management. Now we’ve got a lot that we’re furloughed because of all the elective surgeries going away and a lot of people were anxious to get elective surgery back up when it’s safe to do so and a lot of communities they're getting to that point or have already started.
Thom Canalichio: Great thank you and I want to now take it to Dr. McDaniel to talk about the mental health of the healthcare workforce. What's your opinion about how they are faring and what struggles are they facing that may be unique, but also may be in common with what the public in large are experiencing during this crisis?
Dr. McDaniel: So, you could hear me in the presentations to my colleagues that there are a lot of psychological issues involved being a physician or a healthcare professional, whether it’s having to be flexible about converting ventilators or prioritising surgeries, wishing that you could take care of people sooner. I think there are a lot of pressures on healthcare professionals right now. Fears about their own health, as we haven’t had enough PPE. Fears about becoming positive themselves or taking the illness to family members. I know about residents who are sleeping in their basements and not talking to their family members to try to make sure that they don’t pass it on. There are a lot of issues. There are also some studies starting to come out, some scientist in London studied what happened in Wuhan, showing that anxiety is about 23% of that workforce and depression in about 22%. So that’s early analysis, systematic review in a journal, Brain, behaviour and immunity. So, sleep disturbance is also an issue. One of the things that I thought most important in that study was that it showed that increase social support resulted in fewer symptoms of the kind that I just talked about, and in Rochester we had to convert – we have psychologists in eight clinical departments. In surgery, in orthopaedics, in medicine, ObGyn medicine, paediatric etc. and we’ve been able to pivot our roles to providing a stronger support system through weekly or bi-weekly Zoom chats for physicians. A different one for residents, another one for managers, another one for staff and those have been appreciated, having different people on the Zoom chat, sharing what they're experiences were. We also have things like newsletters and we invite all the health professionals to contribute poems or limericks or music or anything that they would like – we call it a breath of fresh air, and we send that out two times a week and try to feature their particular ways of coping in a positive way. We have employee chat lines where employees can call and triage whatever it is that’s their concern and we also have behavioural health partners which is psychotherapy in mental health services for any employee in the medical centre, so we have an easy way to connect people hopefully early in time when they become distressed. So that it doesn't turn out to be something that is long lasting.
Thom Canalichio: Great, thank you Dr. McDaniel’s. All of our panellists so far have given us a really good overview of where we are and what's happening. I want to turn toward what the future may look like of reopening and how people’s behaviour may change as well as what some of the healthcare systems might do differently and first I would like to bring in now Dr. Montibeller from USC and Loughborough university – Gillberto if you could explain for us what are some of the risk assessment and behavioural factors that go into how people perceive the danger of a health crisis and make health decisions. How is that unique and are there other types of threat that compare well to health or is health such a unique challenge that it makes us think and behave about it in very specific ways.
Dr. Gillberto: Thanks Thom and good evening to everybody from London. That’s a great question and my point is actually that there are a lot of parallels between health threats and security threats, like terrorism. And one thing we know about these kind of threats is that the perceived risk is very high. Both because there is dreadful, the fear of dreadful consequences, but also because of the unknown caused by an emerging disease and so not only you have actual risks but also perceived risks that play a role and while you can manage actual risks, we have to just try to also manage those passive risks, and I think this also brings tough – I mean we could see from panel speakers here that it brings very tough trade-offs to those that are responsible for the healthcare because you have to take into account – for example Dr. McDaniel’s was talking about psychologists providing support, but the real situation that is well beyond the one we experience with chronic diseases and I think – an understanding of risk management and how people decide under this kind of pandemic scenario is really important and is something that risk analysis can really help.
Thom Canalichio: Thank you Gilberto, if any of the media in today’s meeting have questions, please do chat those to us and we’ll give the opportunity to ask your question. I want to go back to Dr. Dearani, as far as meeting with patients and performing surgery, doing tele medicine is becoming more and more a routine part of that process. A lot of people I think may have some misunderstandings about how telemedicine can be incorporated into something like appointments with your surgeon or preparing for a surgery. Can you walk us through a little bit what that looks like and what some of those changes are that maybe beneficial long term, even after this crisis has concluded, to streamline this process and make it more safe for patients coming into the hospital?
Dr. Dearani: Thanks, so telemedicine I think has been one of the wonderful eye-opening new approaches to healthcare and telemedicine will be here for good once this pandemic is behind us. It will be much more applicable in some situations than others and in surgery actually it’s worked really quite well. I mean at least for cardio thoracic surgery, the vast majority of the decision making is based on imaging studies that patients get and all of that imaging can be revealed remotely and you can have a face to face discussion on a computer or facetime or virtually, however –whatever options you have and you can discuss all these things and explain the imaging and make the decision to do surgery before you actually even see the patient in the majority of circumstances. There are always some situations where it may not be clear and you have to correlate the symptoms of the patient and how they're doing with the imaging, but most of the time you can recommend an operation based on the imaging alone. So you can have a lot of interaction and connection with the patient before you actually physically see them and the time that you see them could be the day before surgery or even the morning of surgery, depending upon the system that you work in and you can sort of tidy up loose ends at that point, but this will reduce the number of interactions and face to face contacts with not just a surgeon but the other people that would need to be in the equation along the way. Secretaries and other staff members that need to check them in waiting rooms and all of that.
So, I think it’s going to be something that will be a very helpful adjunct for all aspects of the medical and surgical specialties moving forward.
Thom Canalichio: Thank you Dr. Dearani. Dr. Wang what can you tell us about some of the policies and procedures being done now at Rosewell Park that might be good and beneficial changes long term and similar ways that you're strategizing bringing cancer patients in for all kinds of different therapies in a way that protects them and your staff.
Dr. Wang: Yeah thank you that’s an important question, what can we learn from this experience and how can we move forward. One of the things that I think and I agree with Dr. Dearani is that telemedicine is here to stay. By doing virtual visits we’ve been able to extend outreach particularly to those individuals that live at quite a distance. If you look at the healthcare system in the US, a number of individuals don’t live – the majority of people don’t live within driving distance per se of a large city.so having the ability to connect with them virtually has allowed us to extend our care to those individuals who otherwise would not have access to the sub speciality cancer care that we can provide. Certainly, it also allows us to connect on a regular basis and communicate with individuals who are survivors. Cancer survivors require a lot of feedback and a lot of communication. So, for example over the last few weeks I have done virtual visits with individuals from Canada and New York city as well as South Carolina and Texas through this new methodology which I wouldn’t have been able to do otherwise.
The other thing that we see changing is our awareness and our attention to infectious disease control and prevention and I think that that realisation that we play an important role in protecting and guaranteeing the safety of our patients and our staff I think will go a long way and will be long lasting after this has really been over.
Thom Canalichio: Great yes thank you Dr. Wang. I want to go over to one of our media in attendance, we have Roser Prose a freelancer writing for Texas hospitals magazine and I would love to have you go ahead and ask your question to Dr. Bonar directly. I just want to find you in our system here – your sound is now enabled, go ahead with your question.
Roser Prose: Yes, I’d like to ask Dr. Bonar and anybody else who wants to respond. Do you think that funding for emergency preparedness will finally be increased by the government as a result of the pandemic or will it continue to be the red haired step child that a lot of people know it to be in the past?
Dr. Bonar: Well you know, if it isn’t increased, I have a hard time understanding what it would take to cause it to be increased. I have had some concerns in the recent past with hospitals, the ascertain that hospitals should have had all of the armamentarium lined up in their supply chain management to provide healthcare workers with all the PPE as they needed – as an example. Even the number of ventilators that they needed. So I do believe, not only will hospitals be more aware of and concerned about that and pay attention to that, but I do not think that hospitals and health systems are going to be financially capable of marshalling all that and that it’s going to have to be a state and/or federal support effort to do that and that by the way is also going to demand and require much more efficient supply chain management for hospitals and health system in the event that we have flare ups in the future and that sort of thing. So my answer to you would be a hopeful yes but I think its most likely incumbent on all of us, to keep an eye on that and require that so that we don’t have problems with healthcare providers having to wear a single mask for a whole week and things of this nature.
Thom Canalichio: Thank you Dr. Bonar, Dr Peterson, you have something to add to this?
Dr. Peterson: Yes Thom, so I think for many years now we have actually had some problems with our supply chain and this is only brought to light to the average public person, how severe it can be and I’d just like to point out that we have been struggling with drug shortages for many years, ASA has led some work in this and we know that 80% of raw drug comes from China, that there's been a lot of consolidation in the pharmaceutical industry where one hurricane Maria can wipe out a plant or a plant goes down because of quality issues. So we’ve had shortages of really lifesaving medications even before this pandemic – including drugs, even before the pandemic earlier this year we had none of our prefilled syringes for epinephrine in our crash carts and we’re actually having to make kits up where you're having to draw up and dilute drugs at the time of a code. So, I'm really hoping that this, the silver lining will bring to light that we need to have a better strategy in ensuring an appropriate drug supply. PPE supply. General equipment supplies in the US and really, it’s a worldwide problem but it goes way beyond just PPE.
Thom Canalichio: Thank you Dr. Peterson, we have a question from Deb Wood from Nurse Zone for Dr. McDaniel. Deb would you like to go ahead and ask your question?
Deb Wood: Yes, thank you very much. I'm working on a story about respiratory therapists having mental health issues during the Covid crisis and this is a profession that deals with death quite a bit, taking people off ventilators. What is the risk, why have the risks increased during Covid and what can they do to protect their mental health?
Dr. McDaniel: I do think this is a really important problem. Actually, there are a variety of problems, mental health risks for people at different stages and different disciplines that are dealing with Covid but certainly respiratory therapists are particularly at risk and around when difficult decisions have to be made. Family members are often not present and it’s a very difficult situation. I had an email from some people at our hospital about talking to respiratory therapists just today. I think that what people can do is – across the board are some basic things that are just hard to do if you're a health professional in a crisis which is to develop a routine. To communicate with your colleagues. To be supportive. To give people grace. Crisis doesn’t always bring out the best in people, and to really think about self-care, to try to sleep. There's a lot of sleep disturbance related to mental health issues with this crisis. To try to exercise the things that we all know, that they really do predict better mental health outcomes. So, I think that having somebody for the respiratory therapist to talk to, to debrief, coming off service can really be a help. We’ve also paired people, especially people that might be at risk, to have somebody check in with them once or twice a day, just to hear how they're doing. There are a variety of things like that. You asked earlier Thom about how our healthcare professionals and the general public are the same. Certainly, the difficulty is much stronger for health professionals but the things I'm mentioning are things that everyone can do to maintain their mental health in a period of so much uncertainty.
Thom Canalichio: Thank you Dr. McDaniel. I want to go next to Gilberto again and ask – how have you seen that this crisis has exposed some flaws in the healthcare system and what kind of policy changes or other types of factors such as Medicare for all and proposals about that are economic considerations, regional considerations or even the insurance industry. What has been exposed that may be flaws in those parts of the system and what road moving forward would you see areas for improvement as a lesson from this crisis?
Dr. Gilberto: Thanks Thom, I would like to link up this question with a previous issue that was about funding. Are we going to have more funding for pandemic preparation and preparedness? Well if you look at the e 9/11 consequences, one major consequence was actually a huge increase for countries preparedness and this simply happened in all the countries that had terrorist attacks such as Britain, France, Germany. So, all the expected funds increased – that’s my prediction, it’s just a prediction, but then the question – I’ll go to you question is – what can we do with this extra funding and one thing that I’d like to pick up is professor Bonar mentioned coordination. I think if you have extra funding you need to make sure that the system is well coordinated enough so that the funding is properly and efficiently used. So that’s one issue. The second one is about health capabilities. So the health capabilities of the current system, the American system, the Western European system is mainly focused on chronic diseases and I think we could learn from the mediatory on how to be prepared against infectious diseases. Pandemics, endemics and everything that capability planning can provide us. So that’s the second issue.
The third issue that was also mentioned by many of the speakers is the lack of PPE, the protective equipment. It’s not just a matter of having it but also of being there and then I think reconsidering very long supply chains and that’s an operations management problem, is really critical. So, if you have a supply chain that is so long, its produced so far away, it could be very efficient, however if you need it right now, you might not have it. And I think this would call for a more strategic take on these supply chains of PPE’s and other critical medical equipment. Thank you.
Thom Canalichio: Thankyou Gillberto, I want to share a question among a couple of our panellists briefly here, for Dr. Wang and Dr. Dearani both seeing patients themselves as practitioners and Dr. McDaniel in your experience speaking with healthcare practitioners, how would all of you – each of you say that the relationship between patients, nurses and doctors has changed as a result of this crisis and do we see challenges and maybe a drop in engagement or how these new ways of interacting are being adopted. Things like bed side manner in those cases and touch being part of practicing medicine. What's your experience with that and your thoughts on that question? Dr. Wang to start with.
Dr. Wang: Thanks Thom that’s a great question. I think that that’s an important aspect of medicine that really is under recognised. I mean I did not go into clinical medicine and haematology, oncology specifically to talk to people on WebEx’s and do virtual telemedicine 24x7. The desire that every medical school applicant can tell you is to interact with patients and to feel that direct connection that you're helping individuals, you're improving their lives in some ways. Although I do appreciate the technology and the convenience of the virtual visit platform, what I miss is the personal interactions. I feel that it works best for those patients that I already have an established relationship with and I have seen over and over again and I can easily re-establish that through even a poor telephone or video connection. For new patients however and for patients getting active chemo and for those how have symptoms, it is lacking. I can't shake the persons hand I can't interact with them, they don’t get to know me, we don’t get to form that bond or that commonality if I'm meeting them for the first time over the internet and for patients that have acute symptoms, for example they have chest pain, their arm hurts, they're having trouble breathing, it’s very inadequate because I can't make an assessment about whether they're having a seasonal allergy or whether they're having cardiac pain. Not necessarily without an exam and without further evaluation.
For my patients – the leukaemia patients, a lot of the treatment is based on their lab work and whether their blood counts are going up and down and whether they're neutropenic and immono compromised. So certainly, there are aspects that are not able to be re-established and lastly your question about the team work, I feel that during this crisis, we have all risen to the challenge. I feel like patients and doctors and respiratory techs and psychiatrists and even down to the people that clean and sterilise and change the linens in my exam rooms, we feel in a way a common purpose that we are continuing to provide care and somewhat it’s a little weird because there's been a lot of recognition of healthcare providers and front line workers and flyovers and donations and so forth and some of us feel a little bit guilty because we’re just doing what we’re trained to do.
Thom Canalichio: thank you Dr. Wang, Dr. Dearani, what's been your perspective on that and what things have been challenges in the relationship with patients and what efforts are you seeing to bridge even in these virtual types of connections?
Dr. Dearani: First I agree with everything that Dr. Wang said, I would say there are some differences between surgical specialities and the medical specialties. For example in surgery we sort of are used to things that are a little closer to crisis management when you're in the operating room, we interface with technology and when things malfunction it does require people to rally together, have coordinated efforts, sort of at least in the operating theatre and so I think we probably had a little bit of a head start because that sort of part of how we work I think that the pandemic has really tested our physical and our emotional well-being and our communication skills because it adds pressure to the situation. I think it’s brought the medical specialties and the surgical specialties much closer together because we have to rely for example on the ID people to let us know if the screening process is satisfactory, is it okay for somebody to go to the OR? How many people are going to be at risk etc. so, I think that it’s brought us all closer together. I will say that the physical connection while on the surface may not seem as important to surgeons, it actually is quite important to surgeons because I think when somebody is having surgery the anxiety and tension that’s present is quite high from the patients and families standpoint and so to minimise the personal connection and really not even be able to do a handshake and to have to do things with the physical distance in the equation, I think depersonalises it a bit at a time when there is exceptional tension and anxiety. I think that the patients and the families understand the circumstances and the hope is that at some point we’ll get back to it being closer to what it was. Probably not exactly identical to what it was, but I have to say on the whole, the medical profession has been on the stage with this pandemic and I think all of the specialties and every level of healthcare workers, particularly the nurses and the respiratory therapists and the people that are at the bedside minute by minute, they’ve stepped up. I think through the eyes of the world, I think the medical profession has performed really quite well under very untoward circumstances and personally I feel proud to be part of a profession that the higher the pressure the better the performance.
Thom Canalichio: Well said Dr. Dearani, Dr. McDaniel, in your work with physicians and other healthcare professionals trying to coach them and counsel them, what are you employing to help them make connections with their patients in light of the kind of challenges that Dr. Dearani and Dr. Wang described.
Dr. McDaniel: First I want to really agree about people rising to the challenge. Its inspiring what has happened – against a lot of difficulty in our fragmented healthcare system which has also been revealed, but in spite of that whether in medical specialties or surgical specialties it’s very impressive how people have functioned. One of the things I do beside telehealth with my own patients is I run a communication coaching program for our physicians. Mostly our physician faculty. We have other people with the [inaudible 41:19] we’re really focused on communication and as was said earlier during a crisis – communication can be wonderful and also can be too simple or too complicated for patients to understand and - - and other members of my team to Zoom in as a communication coach and easily watch the interaction and provide some feedback to the physician after the fact and then produce by saying hello to the patients first and they usually are very pleased that the Medical Centre is doing something about this. Then I turn off my video so then I'm less of a presence and try to help physicians make sure that they're clear, allow time for the patient to be able to express their questions and their concerns and their emotion, increase the empathic statements of the physicians and mostly provide the physicians with support and my feedback to them. So, in usual times, we go into the OR, and try to use various evidence-based ways of improving team communication in the OR as well as in medical visits. But in this situation, we're primarily focused on Zoom.
Thom Canalichio: Thank you, Dr. McDaniel. Dr. Peterson, you have something you'd like to add on this topic.
Mary Dale Peterson: Sure. I was just going to follow up with what statement that Dr. Dearani made and there were a number of anaesthesiologists who left the comfort of their homes in Florida or the Midwest and volunteered to go to New York and work in the Covid ICU’s and significant risk to themselves, and potentially their families and having to quarantine going back to their homes. But I think that really focuses on why physicians and other health care workers went into their respective professions. And it's basically when there is a call for a volunteer, like there is a call in the middle of the night that you got to come in to the OR or whatever. It's like, here I am. And it was that call to action that I think actually salvaged a lot of the hospitals that were in the hardest hit areas that didn't have the staffing for it. So, just like we have a voluntary military, I think we have almost a Reserve Corps and medicine that’s willing to step up.
Thom Canalichio: Dr. Wang, you'd like to add something?
Dr. Wang: In your discussion you asked what could possibly – I'm sorry, can you hear me?
Thom Canalichio: We can.
Dr. Wang: Yeah, so in thinking a little bit more about your questions about what could have come out of this long term that could be a benefit in relation to your question about interacting with patients. I just wanted to mention that one thing that COVID pandemic has allowed us to do is allowed us to address the issue of end of life care and goals of care. Because we don't have good treatments and we are talking about putting people on and off ventilators, it is brought to the forefront that having discussions about DNR, do not intubate, Do Not Resuscitate really need to be done with patients at any stage whether they be young or old.
The other thing I'd like to highlight is the medical research and the advances that we've made in providing care. The pandemic has forced us as a cancer centre to prioritize our clinical trials, to streamline our regulatory paperwork and to embark upon new clinical trials in record speed to try to address the issues and I feel like just like cancer prompted a huge amount of medical research in the 1970s. This pandemic might lead to advances in Immunology and infectious control in genomics that might last for years to come.
Thom Canalichio: Great. Thank you so much. Going to Dr. Bonar, a couple of the key things that are part of implementing safer procedures at hospitals during and through the pandemic as well as potentially after it, is wearing masks and other kinds of PPE. We've seen a lot of protests, we've seen public freak outs caught on cell phone video shared on social media – people objecting to these face masks, when they are such a key part of making healthcare environment safe. And yet we're seeing messages in the media, on social media that contradict these things or object to them. What are your thoughts about that and how can we convince the public to accept the correct research that masks do, in fact reduce the exposure and risk of infection?
Robert Bonar: Thanks. Thanks very much, Thom. I have strong feelings about this, even though I'm not a physician or nurse, my doctorates in healthcare administration and policy nonetheless – I worked for 40 years in the hospital and I had a difficult time understanding why the initial advice that was being given was for the general public: Don't wear masks, you're wasting your time; just wash your hands and stop touching your face. And I have to tell you, I find myself retreating down the aisles at the grocery store frequently when I see someone coming at me without a mask. I think that we need to coach leadership to display the proper behaviour, even if you don't think it's something that you would want to do personally. I think there's more than a little evidence that masks do make a difference. I got a couple of articles from journals I just read yesterday, written by physicians who confirmed the same thing. So, I think it needs to be – my personal opinion is it needs to be something that's modelled at the highest levels of government. We could hear that perhaps from Dr. Fauci and from others because, you know, when everyone wears a mask, everyone is a little bit safer. Is it the panacea? Of course not. But it is helpful. So, I think we need to have that at the highest level and see that in leaders. That's my opinion.
Thom Canalichio: Thank you so much, Dr. Bonar. Gilberto Dr. Montibeller, what possible long-term benefits do you see as a transformation in response to this pandemic and what are some of the things that our health care workers are doing that you think can be beneficial long term?
Dr. Gilberto: Yeah, one thing that I really like to see is that everybody wears a mask when they have a flu, like in Asia. I think its really good practice and I always thought so even before the pandemic. Coming back to your question here, and I should say that I'm not a magical person. You know, I have a PhD in Management Science, but we really appreciate all the treatment into, you know, super efforts that are all over the world, all the medical people have put on, on saving lives, and how many people died from the contact with the disease here in Britain, for instance. And I think it's just a pity that the protective equipment was not there. And indeed, there are some studies that the National Health System started decreasing the requirements for protective equipment because they didn't have it. So, it became – it was very strict initially like Ebola level protective. And then in the end it was just a simple mask that could be rewashed and reused. So that is really scary. I think in the long term, I would like to see something that is similar to counterterrorism analysis in which we use more intelligently the resources available, building up capabilities – health capabilities are different than counterterrorism capabilities because some of them are easy to turn into protection if there is a pandemic, but the supply chains can be quite long. So I’d like to have a more well-informed evidence-based analysis of resources in deployment in better aligned systems as well because the more decentralized the system, the harder it is to actually deploy the resources not only effectively and efficiently, but also take into account that there are scenarios where you might need over supplies of, for example, protective equipment.
Thom Canalichio: Thank you, Gilberto. I want to go next to Alice Benjamin of NBC for Los Angeles. Alice, you have a question that I think multiple of the panellists may like to address. Please go ahead.
Alice Benjamin: Yes. Hi, thank you for having this zoom meeting. I really appreciate it. One of the questions that I have is with the growing need and demand for healthcare services to a variety of people, what are your thoughts on expanding the scope of practice for nurse practitioners and other mid-level providers to help meet the demands of the community?
Thom Canalichio: Great. Thank you, Dr. Bonar, perhaps as a former hospital CEO – that might be a good one for you to begin with. And we'd love to have any other panellists respond with this.
Robert Bonar: Sure. Thanks, Thom. I'll kick it off and hope others will come in on it.
When I was in administrative practice, we were constantly working as best we could to try to help our professional’s practice of what we said practice at the top of their license. And in addition to that, I think one of the things that we may also have learnt from the COVID-19 pandemic is, perhaps we need to be a little more flexible in some of our policies and procedures around credentialing and privileging in our hospitals that allow physicians and others to move from hospital to hospital more fluidly rather than running into some very well-intentioned and necessary credentialing issues, but perhaps not the best thing during the middle of a crisis pandemic. So, in response to the question, I would like to see that as one of the areas that we look at nationally in terms of allowing those professionals to do a little bit more than perhaps we have in the past and still keeping it safe.
Thom Canalichio: Thank you, Dr. Bonar. Dr. Peterson, do you have something you'd like to add to this?
Mary Dale Peterson: Sure. I mean, I think we all appreciate the nurse practitioners, PAs in the anaesthesia world is certified registered nurse anaesthetist and anaesthesiologist assistance that really can extend. What we do either in the operating rooms or in the surgical care units - Our position is that we still want to have physician oversight and physician-led care so that, that 12 to 15 years of training can really help provide the safest care for patients so that we're working really as a team-based care in this particular crisis because half of our workforce including the nurse, anaesthetists, and anaesthesiologist were actually furloughed, while the other half were working really, really hard in the ICUs and so we didn't really have a shortage. Now as we come back up right back up, if hospitals are trying to ramp up too quickly before they have sort of, gone through the peak of patients in their ICUs, that could be your problem as you're trying to start up elective surgeries again. Then you might have, some workforce issues, but that's not in our recommendations nor is in the federal recommendations and most state recommendations that you would be at a stable or lowering level of patients in the hospital before you would start elective surgery.
Thom Canalichio: Dr. McDaniel, you are in contact with various levels and different positions throughout the healthcare system there at Rochester. What's your thought on nurse practitioners and really fully utilizing the full breadth and depth of their knowledge and skills?
Dr. McDaniel: Thank you, Thom. One of my other jobs is that I'm Vice Chair of the Department of Family Medicine. And I'm acutely aware - I was at a meeting yesterday that would usually be in Washington about trying to advocate for more funds for Workforce Development in primary care – the place where patients are tested, where chronic illnesses are often managed, where referrals to the medical and surgical specialties happen, and it is underfunded in this country relative to any other country. In our clinic and in New York NP’s are able to practice independently and our NPs – we have NPs who have their own panels, their own patients in the clinic. They collaborate closely with physicians. The physicians usually see the more complex patient or triage to the physicians but the NP’s carry a lot of the load. We also have an NP residency to teach NP graduates how to function in this way at the top of their scope of practice. And they really perform very valuable functions in primary care.
Thom Canalichio: Thank you, Dr. McDaniel. Alice, and thank you for your question. Gilberto, pandemics being a unique threat, you've advocated already today, I think for better preparedness for this kind of protracted and long-term crisis rather than a short one-time event like a natural disaster. What are some of those policies, training and other procedures that you think need to be factored into all of that? What behavioural science and other science inform some of those things, and I want to get Dr. Bonar to weigh in on this as well.
Gilberto Montibeller: Thanks, Thom. So most of the behavioural science that we have in decision making, even though decision making is focused on kind of, say regular decisions, not decisions under such extreme scenario – so where you find interesting, behavioural findings is actually where you have people thinking about, for example, accidents, threats and things like that. And I think we have to have a better understanding also in relation to health threats themselves because the knowledge that we have, the behavioural science that we know and that we have mostly is not focused on health threats and they might be different. So, there is a question mark here – to which extent health threats, for example, are different than terrorist threats. One thing is that terrorists are intelligent, and vitals are just very opportunistic. So, in this sense, maybe the reactions that people might have actually are different against terrorists and in health threats. If you build up your protections, terrorists are aware and do not attack. If you build up your protections in the same way with health, the virus might not attack. But again, it's not an intelligent entity. So, I think all of these parallels are just to open questions in science and I think there is a lot that we can learn from security threats and counterterrorism analysis.
Thom Canalichio: Dr. Bonar, what kind of coordination and other public health preparedness do you see as a real dramatic and clear need at this point that you hope our healthcare system starts to move in that direction?
Robert Bonar: Well, thank you, Thom. I actually think that’s acute care services delivery leaders and public health departments, but I would hope should better see and understand how they need each other, and thus do more planning together and break down silos. There are assets and resources in public health that could be very helpful to our healthcare systems and in hospitals in responding to a situation like this. And I also think that, as has been previously mentioned, there should be no doubt right now that we have under invested in public health. I would assert for the last few decades, I think this might be an opportunity for those leading our major health care systems and those leading our public health systems to collaborate more effectively so that this kind of disjointed response where everyone's working very hard but it's not working very well, would be less inclined to happen again.
Thom Canalichio: Okay, I want to conclude with some questions about testing, testing being a really, really critical element to resuming more normal health care practices, but also protecting the special kinds of cases that some of our doctors with us today have to deal with. So, first to Dr. Dearani, how important is testing in the process of bringing in someone for heart surgery, for example? And how are you seeing that implemented? What do you see that may need to be done better?
Dr. Dearani: Well, thank you, Thom. This has been a wonderful session. Screening and testing is absolutely, I think probably the most important thing right now, not just for the patients but also for the healthcare workers. I mean, you need to know who is carrying the virus and who can wait and who can't, so that you know how many people are really going to be at risk. You know, we listen to our ID colleagues, our screening protocol here has been constantly evolving. Now, it's a combination of the nasal swab and serum testing. It’s right up until the day of surgery and I think that at some point in time a vaccination will become available. So, you need to know what you're dealing with and screening is probably front and centre moving forward, particularly with patients that are going to have surgery and large numbers of people are going to be exposed during the course of their hospital stay. And then physical distancing and PPE are the other two things that we need to be strict about, then we need to honour the rules if we want to keep this from getting out of hand moving forward.
Thom Canalichio: Thank you, Dr. Wang. What are your thoughts about testing and screening and how has that impacted your ability to keep your cancer centre as safe as possible? How are you measuring that and following the success with that?
Dr. Wang: Thanks. I appreciate the opportunity to further emphasize how important screening and testing is to just our perception of how safe we are, and how actually safe we are and how we're going to move forward past this crisis. We at our centre have instituted drive by testing for certain patient populations – about 72 hours prior to elective surgeries, procedures, dermatological procedures, even dental check-ups. Patients are requested to come through and get that nasal swab from the safety of their own car. We also are routinely testing all of our both planned and unplanned inpatient admissions. And we are recommending that staff members with high probability contacts also get tested. I think that in order to understand the prevalence of the disease in our community, I feel that antibody testing is very valuable. There's discussions about development of a herd immunity, or those patients who might have been exposed but have the antibodies now, identifies individuals that might be able to donate convalescent plasma to help individuals that are actively ill. It is a key component to us moving forward. We have a very aggressive screening protocol. And I think that that's important for the safety and well-being and the anxiety level and stress levels as was pointed out by my colleague from University of Rochester, of both staff and patients as we move forward through this crisis over the next several weeks to months.
Thom Canalichio: To Dr. Peterson, and I want to add one element to this question. Alice Benjamin from NBC for Los Angeles added to this question, Serial Testing – testing people repeatedly to ensure that they haven't been exposed since their previous test. What are your thoughts about that, if you could respond to that in the context of the question about testing in general?
Mary Dale Peterson: Well, I was just going to add that testing is not perfect. And so, I think it's a safety procedure when people come in for elective surgery and you have the time to test. But then you're asking people to self-quarantine until the time of their surgery. But we even know with the best PCR machines that it can miss testing for a variety of reasons, either the time that people were coming down with illness or, you know, how the sample was obtained versus the limits of the machines. And so, our recommendation is that still the staff be very vigilant in practicing all the other infection control measures, PPE, etc. The question of how often you should test I think that is up for debate. It's a challenge because I don't think we have enough testing supplies to test everybody on a daily basis or weekly basis, even a lot of places including the areas I live in, in South Texas, it’s hard enough. There are send outs, to get tasks even for the ones where you really need it, even for patients that are sick, it's challenging. So, we're not there yet in doing it, and then there is the false negative tests that we have to worry about. So, it's I think it's still an evolving question.
Thom Canalichio: Thank you, Dr. Peterson. Dr. McDaniel, what can you tell us about gestures of public support for the healthcare workers? Are those effective signs on the roadways and cheering at night? Do those things help? What other kinds of gestures from the public may help and what can you tell us about how the mental health of mental healthcare workers impacts their ability to successfully deliver good care? Sorry, your audio is not on. Go ahead, Dr. McDaniel.
Dr. McDaniel: Thanks, Thom. I definitely want to answer those questions. But if I could just say one thing about testing, which is – I was on the phone with a colleague from Germany yesterday. I think he lives in Munich and he said that they can be tested anytime they want. All you have to do as dial 6114 or something and somebody comes to your house and tests you. So, I think they have supplies that we don't have, that's for sure. But testing is very important to the mental health of health professionals and our screening as well. I was screened, I'd probably everybody was as I walked into the clinic this morning, and our primary care patients fill out depression and anxiety screens as well when they come in so that we can act early in terms of the mental health issues that are going on right now for professionals and patients.
I think that the signs are heart-warming to people. You know, I was interested -- feeling guilty that I'm like, I'm a physician, this is what I do. But on the other hand, I think it has to be important to see the support of the public – [inaudible 01:05:53] the street in Rochester had put together thanking all of these different kinds of essential workers, and it was very sweet. So, I think it’s important [inaudible] and make the testing better. So, I think there's a lot of things that we can advocate as citizens to help our health care professionals in addition to just saying a clear thank you.
Thom Canalichio: Thank you, Dr. McDaniel. Dr. Bonar, one final question for you. What are some of the positive transformations that you've seen possible out of this pandemic and some of the procedures and practices that might change healthcare for the better moving forward?
Robert Bonar: Well, aside from the technical managerial aspects in supply chain management, coordination and so forth – one of the things that I've seen and this has already been touched upon by Dr. Dearani and others, is that I would certainly hope and I believe we see that the public would have a much more positive point of view of healthcare, healthcare service delivery and health care providers. That's been mentioned a couple times. I don't think we can mention it too many times. I mean when the public sees doctors and nurses and allied health care professionals and others rushing in at their own peril to take care of sick people and they see what's happened, I hope they support and better support our healthcare system, our healthcare supply chain, and may even be willing to accept additional taxes to support better public health infrastructure. I think I see that we'll see in the next year what happens.
Thom Canalichio: Thank you, Dr. Bonar. To Dr. Montibeller for one final question for you. A lot of this has been the subtext being reopening the economy at large, in particular reopening health care and hospitals, to back to a more normal pre-pandemic state of things – what are your thoughts about reopening and with the public having been doing social distancing in many places for such a period of time and then having these high perceived risks? If we were to begin to “reopen”, will it take some time for the public to start to behave more normally? And does that mean it would be okay to try reopening sooner than later? Or does your knowledge and data suggest something different as a policy?
Gilberto Montibeller: Yes. So, the perceived risk, the high perceived risk that you mentioned Thom is likely to stay high for a while. I think also – I am not a medical doctor, but we should remind ourselves that this is a new emerging disease. There is no effective treatment, there is no vaccine. And, therefore, I think a precautionary principle makes sense. You asked one question before to Professor Bonar that I would like to mention as well if you don't mind – I think for me the biggest learning out of this pandemic, two actually. One is the importance of correct problem framing because one of the major reasons that some Asian countries got it right and some Western countries got wrong because the Asian countries framed problem as if it was a SARS outbreak and the Western countries framed the problem as if it were a simple regular influence outbreak. So that's one side. The other learning point I think is the importance of strong sound leadership. And I think the best example is Germany and Britain. These are similar countries, similar levels of wealth, similar distribution of age. And perhaps Britain is a bit more unequal. But you can see the difference in number of cases and number of deaths in Britain and Germany this is really due to a strong clever leadership in Germany in I'm sorry to say but weekly, the [inaudible 01:10:28] mess in Britain. For me, that's the most important learning point.
Thom Canalichio: Thank you very much, Gilberto. With that, we will draw to a close a few final notes for our attendees for media here. You're welcome to use quotes from today's panel in your coverage, you're also welcome to reach out and schedule any kind of follow-up interview or additional questions that you may have for any of today's panellists. If you registered for today's event, we will be sending you later on today an email when the video and the transcript are available of today's event. And you'll also be able to find all of the contact information on our release posted on the Newswise website for how to get in touch with today's panellists.
I want to also make mention of some upcoming events that we have planned. Next week we are going to be doing a panel with several panellists from the College of American Pathologists. That's on the 28th from 2 to 3pm, partnering with the College of American Pathologists to talk about testing and dig into that issue more. We also have planned on June 4th, education after the pandemic – talking about higher education as well as elementary K through 12 of how we've adapted to teaching in this environment with doing social distancing and what will be the impact long term to education. We also plan on June 11th to have a panel all about mental health. We expect to have other panellists from the APA as well as other members to talk about various aspects of mental health both for the public as well as for our healthcare workers. And we're also planning another one on the economy with emphasis on reopening pro sports as well as other kinds of businesses that involve maybe gatherings of people in the economy more at large. That's scheduled for June 18th. If you're interested in any of those, you can find more information about those on our website. We'll be sending out more invitations as those events get finalized and all the panellists confirmed. Meanwhile, I want to thank all of our panellists here today – Dr. Peterson, Dr. Bonar, Dr. Wang, Dr. Dearani and Dr. McDaniel as well and Dr. Montibeller and a special thanks to our contacts who helped to facilitate this from the American Society of anaesthesiologists – George Washington University, Roswell Park Cancer Centre, the Mayo Clinic and the Society for thoracic surgeons and the American Psychological Association and also the Society for risk analysis. Thank you very much to all the panellists. Thank you to media for attending. And with that, we will close. Thank you all very much. Stay safe, stay healthy and good luck.
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