It is not OK for physicians’ anxieties to harm their patients [PODCAST]

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“It is OK to be scared, but it is not OK to let our own anxieties harm our patients. As we tackle the numerous crises created by the COVID-19 pandemic, let’s acknowledge our fear and draw on the logic and clinical reasoning that we have spent years cultivating. We can be scared and scientific, anxious, but courageous. Let’s not create two causalities from one disease, the patient who dies from coronavirus and the patient who dies waiting for surgery because they could have had coronavirus.”

Sami El-Dalati is an infectious disease physician.

He shares his story and discusses his KevinMD article, “It is OK to be scared, but it is not OK to let our own anxieties harm our patients.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Sami El-Dalati. He’s an infectious disease physician, and he wrote the KevinMD article “It is OK to be scared, but it is not OK to let our own anxieties harm our patients.” Sami, welcome to the show.

Sami El-Dalati: Oh, thank you for having me.

Kevin Pho: So we’ll get into the article in a little bit, but first off, tell me your story and your journey to where you are today.

Sami El-Dalati: Yeah, so I grew up outside of Cleveland, Ohio, and I did my medical school at Ohio State, and then betrayed a lot of people in Ohio and went to Michigan to do my residency and fellowship. I did my fellowship in infectious diseases, and there I sort of developed an interest in endocarditis and opioid use disorder. Then my last four months of fellowship were really impacted pretty significantly by the COVID pandemic, as most people’s training and work lives and personal lives have been.

The article sort of arose from that, because what we found was that a number of commonly utilized tests and procedures were being delayed or canceled, postponed, and so patients really just couldn’t get the same access to care, even for potentially life-threatening indications.

Kevin Pho: All right, so tell me more in detail. How has the pandemic specifically affected the last few months of your fellowship training?

Sami El-Dalati: Yeah, so first of all, I ended up getting sick very early on in the pandemic, and my testing was negative, but I never found another clear source. I missed a couple of weeks, actually, while I had symptoms. Then for the first two months, we were practicing in southeast Michigan, which was pretty hard hit, and so really all of our consult service was refocused to seeing and evaluating COVID patients.

The hospital really was at much lower capacity than normal in some respects, because all of our routine elective surgeries were delayed. So there was a good two-month period where we really just focused on COVID, and that was probably the biggest impact. But then when we would have patients who came in for non-COVID-related problems, it could be very difficult to get them the same quality of care that we would typically administer in the past, whether it was bronchoscopies, endoscopies, colonoscopies, or surgical procedures. It was very difficult to try and facilitate that for patients during the pandemic.

Kevin Pho: Sure. That segues into the article that you wrote, “It is OK to be scared, but it is not OK to let our own anxieties harm our patients.” Can you walk my audience through that article and describe some of the reasons why you decided to write it?

Sami El-Dalati: Yeah, so it started out as a particularly challenging week with respect to this topic. I was working at our veterans hospital, and we had a couple of patients that came in with sort of undifferentiated pulmonary processes. They were hypoxic, short of breath, and a couple had low-grade fevers. This was early April, really the height of the pandemic, and so people really jumped on this being COVID as the most likely explanation for their symptoms.

But the patients had multiple negative tests, and while we know that the tests are not perfectly sensitive, some of these patients had three or four negative tests. The differential for these presentations was quite broad. Some of these patients were immunocompromised, and so there were a number of other things that could be going on. We had a very difficult time getting some of our pulmonary colleagues to consider bronchoscopy, which in most situations would have happened quite quickly. Actually, one of the patients we ended up diagnosing with pneumocystis pneumonia several days after they were admitted, and they got better with treatment for that.

So that was sort of how the article started in my mind: just having these phone conversations multiple times a day with multiple providers, trying to get these procedures for patients, and really unsuccessfully for the most part. We ended up just getting a sputum sample for that individual. So that was sort of how it started.

We saw it play out even after that with patients who needed surgical procedures. I had a patient who had endocarditis and was tested just as part of his routine admission to the hospital. He was found to be persistently positive for COVID, completely asymptomatic, and he continued to shed the virus. His PCR was positive for several weeks after he came in. Likely, we felt he was not infectious, but we couldn’t convince anyone to actually do surgery on him for his endocarditis. Fortunately, he was relatively stable, but it was very frustrating to feel like the best course of action for this patient was being put on hold.

I think a lot of that stemmed from providers’ concerns about acquiring the infection themselves, and I think certainly that’s understandable. Everybody was sacrificing themselves, potentially, to take care of these patients. But at the same time, in some of these situations, we have patients with multiple negative tests. Fortunately, our hospital had a sufficient supply of PPE, so there was never an example of people having to do procedures without appropriate PPE.

And so it really got back to the idea of: Why are we not doing this procedure? Is it really because there’s any evidence behind it? Is there science behind it? Or is it more our own internal discomfort, our own fears, that are driving that? That was kind of the heart of what I was trying to get at with the piece.

Kevin Pho: So from an infectious disease standpoint, what are some of the factors that can determine whether a procedure can be done now versus put off until later?

Sami El-Dalati: Right. Well, obviously the urgency of the procedure is probably the most important thing. If the procedure is felt to be emergent and the patient’s life is threatened, then generally we would recommend going ahead and doing that procedure anyway and taking the appropriate precautions in terms of personal protective equipment, sterilizing the operating room, and so forth.

It becomes a little less clear if the procedure is in sort of that elective to semi-elective pattern. In those cases, we would prefer to have the patient have a negative test. Our policy: We would screen people prior to the procedure, and if it was negative, we’d go ahead. If the patients had a positive test, in order to clear them, generally we would do two negative tests 24 hours apart. That would be the way to take them off precautions and really go ahead with the procedures.

I think what’s been challenging is that patients shed virus, as we’ve seen, for several weeks, and even up to months, and the clinical significance of that is somewhat unclear. This virus has only been around since late 2019, so we don’t have great literature about how these patients do when they have procedures. So it becomes challenging, because you can’t point to the literature when you’re telling a surgeon, “We think it’s OK to do this.” We’re just saying this is based on our personal experience. I can’t point to some concrete evidence, and that can be a challenge.

So that was sort of our general approach. If it’s emergent, you go ahead and do it. If it’s not urgent, let’s try to make sure that the patient is negative. And then it sort of becomes a case-by-case basis for patients who are positive, figuring out what the indications are.

Kevin Pho: Now, you wrote your article back in April, and we’re speaking now in mid-July. Has anything changed in the intervening three months?

Sami El-Dalati: Well, in Michigan, where I’ve been practicing, we saw a fairly steep decline in our number of new cases, and so by late May, early June, much of the state had opened back up. The hospital had opened back up, and so a lot of our routine procedures were happening again. But there was a good six- to eight-week period where standard procedures were really not available.

So by the time I finished fellowship at the end of June, we were mostly back to standard operating practice, and we were testing all of our patients upon admission to the hospital for COVID, just to make sure, regardless of their symptoms. But at the time that I finished fellowship, I believe we only had seven inpatients with COVID at that point. So the first wave had started to recede when I was finishing up.

Kevin Pho: So let’s take a step back. As I mentioned, we are talking mid-July, and the pandemic has certainly spread, especially in the South and the West. From an infectious disease standpoint, can you comment on what’s going on now and perhaps give an assessment of what you think is going to happen in the next one to two months?

Sami El-Dalati: Yeah, I mean, I think the trends we’re seeing nationally are pretty concerning: a rising number of cases in Texas, Florida, and Arizona. Quite honestly, without more aggressive infection control measures and quarantine measures, I don’t think there’s a reason to think that is going to change too dramatically, as long as we continue to have states that are open.

I think the only thing that’s changed is that we have more testing capacity now than we did back in March, and so we’re able to identify new cases. But remdesivir is really our best treatment, and it’s very limited in terms of its supply and who we can get it to. So for the next one to two months, I anticipate that we’re going to continue to see the same sort of surge of cases, and probably start to cycle back to some states that had had a wave and recovered, which may start to see cases increase, unfortunately.

There is some promising literature. There’s a study in the New England Journal that came out this week about a vaccine. It’s a 45-patient study, a phase 2 trial that’s been approved for phase 3 trials, and the vaccine appeared to boost. All the patients ended up developing an antibody response to COVID. Whether that confers immunity is somewhat up in the air still, but at least we’re making progress. I think the big thing that will change the outlook for all this is if we can get a vaccine.

Kevin Pho: We’re talking to Sami El-Dalati. He’s an infectious disease physician, and he wrote the KevinMD article “It is OK to be scared, but it is not OK to let our own anxieties harm our patients.” Sami, if you could share with my audience something that you’ve been passionate about or something that you’ve been curious about over the last few months.

Sami El-Dalati: Yeah, so as I mentioned earlier, one of my big passions is endocarditis care, specifically multidisciplinary care of the disease. It’s an infectious disease that affects heart valves and is managed usually by a number of medical specialists: infectious disease, cardiac surgery, cardiology, and neurology. But often the care of those patients is very fragmented, and it can lead to poor outcomes for those individuals.

There’s some literature in Europe that multidisciplinary conferences, similar to tumor boards, that present and discuss these patients can lead to improved outcomes, and so that’s actually been adopted by most European academic medical centers. But it hasn’t really caught on in the United States, and so one of my projects as a fellow was to help start something like that at the University of Michigan. We were able to see a significant improvement in our mortality outcomes when we implemented this group. So multidisciplinary care of patients, that kind of cooperation among specialties, is something that I’m a big believer in, especially as it comes to endocarditis.

And then the other intersection of that is opioid use disorder. I think before the COVID pandemic hit, the opioid epidemic was probably one of the biggest health crises affecting our country and our population. A lot of our patients do have underlying opioid use disorder, and there’s still a lot of stigma associated with it when it comes to getting them access to medication-assisted treatment as well as surgery for their endocarditis.

So our group incorporates addiction treatment into the care of the endocarditis patients, and that’s something that I feel pretty strongly about. You really have to treat both diseases. If you don’t treat the underlying addiction, then treating the endocarditis is really just prolonging the inevitable, and they’ll relapse and have recurrent episodes. So trying to tackle both problems is something that I care a lot about.

Kevin Pho: And my final question, as it relates to the pandemic: What’s the number one tip that you can share with your non-infectious disease colleagues who may be listening to this podcast?

Sami El-Dalati: Yeah, I mean, for my colleagues, I would encourage them to this virus, but to remember that we are in the unique and privileged position of taking care of patients who really need our help, whether they have COVID or not, and to try and work on understanding those anxieties and fears and where they come from, to allow us to take better care of our patients and be better providers for them. I think that’s part of our responsibility as physicians and other health care providers: to do that work to understand ourselves, so we can be better for them.

Kevin Pho: Sami, thank you so much for sharing your time and insight, and thank you for being on the show.

Sami El-Dalati: Yeah, thank you for having me. I really appreciate this opportunity.

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