COVID-19 – Page 4 – The Early Career Voice

Diversity, Equity, & Inclusion Are Not Just Buzzwords— Practical Steps for People Who Teach

July 2, 2020July 2, 2020 Elizabeth Knight, PhD, DNP

Those of us who work in science, healthcare, and academia often find ourselves teaching others, whether or not we set out to be educators. Residents teach medical students. Nurses precept new nurses. Graduate students teach undergraduates. And faculty roles for researchers and clinicians also include teaching loads. Yet for many of us, our training did not include any grounding in how to teach. We might not have brought the same theoretical rigor and deep expertise to our teaching that we have to our other roles. Now, as we are teaching in a world of rapid change and increased awareness around structural racism, we must approach equity in our educational practices with intention, but some among us may not feel prepared and we are already overwhelmed. We are already adapting to enormous change related to COVID-19, and the intellectual energy required to reexamine another entire part of your professional life can feel paralyzing. It can feel like an impossible task that there will never be time for.

Despite these barriers, I strongly believe that you can start (or carry on) right now, no matter where you or your institution are in the struggle for antiracism. Here are some immediate suggestions to make your practice as an educator explicitly equity-focused and antiracist, for folks who teach in all kinds of contexts (these topics work for self-education, too):

No matter what format you teach in, there are some basic practices you can adopt to establish a “floor” for equity and inclusion.

Can you pronounce the name of everyone in your group? Do you know what they prefer to be called and what pronouns they use? Some teachers inadvertently avoid calling on students because they haven’t bothered to learn these things and don’t want to make a mistake. Don’t be that teacher.
How much time does every person (including you) speak? Is anyone taking up more space than they need? Now, the era of video calls, some platforms can actually show you how much time each individual speaks for, and this can be eye-opening. I encourage you to actually measure and observe this at least once. It can be surprising to see how some groups are consistently dominating conversation at the expense of others.
Have you adopted principles of Universal Design for Learning in your teaching? If not, now is a good time to start. UDL is a set of principles that improves the experience for all learners by focusing on accessibility and flexibility and assuming diversity.
Are you yourself familiar with concepts of antiracism? Have you examined your own privilege, bias, and ignorance? Are you learning?

For those who teach in a classroom or seminar format, Dr. Valerie Lewis has shared some more tips:

Include an equity-focused reading with every topic (e.g., if you are teaching about asthma, include an article about disparities related to race and social determinants of health).
Message that equity isn’t a specialty; every field should address it as part of ongoing professional practice.
Create a dedicated class session for equity, and if possible do two— one at the beginning to frame the ideas for learning, and one towards the end to integrate the content you’ve covered with broader ideas around equity. This can help to lay the groundwork for ongoing reflective professional practice.
Audit your syllabus: can you include AT LEAST one scholar of color every week? You might have go-to reading lists that you’ve inherited or developed, but if your list doesn’t measure up, you can change it. Go to PubMed or google scholar. Look at professional societies. Ask colleagues. Crowd-source on twitter. This is a key way to amplify voices— remember that citations are academic currency.
Don’t be afraid to make mistakes. Be open with students that you are doing this intentionally and why, and take feedback.

This is not a checklist or an exhaustive resource for inclusivity. But I hope that if you are floundering as you try to figure out how to teach with a focus on equity and inclusion, that you’ve got a good first foothold. Let’s keep the conversation going— I’d love to hear more ideas. Hit me up on twitter @TheKnightNurse and let me know what you are doing.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

How My Hospitalization During COVID Changed Me as a Physician

June 18, 2020June 18, 2020 Alyssa Vermeulen, DO, FAAP

Takatsubo Cardiomyopathy, known as “broken heart syndrome,” is a form of heart disease that occurs following a traumatic or stressful event; people may present after the death of a loved one or other tragic accident. Thanks to COVID-19 we are currently in a time of great stress. The stress response of a global pandemic is something that we will see the effects of long after the treatment and vaccine are developed. There are many new reports and articles focusing on the stress related to COVID-19, tips to help combat that stress and guide wellness, and even some hospitals setting up wellness teams and meetings in the hospital to support the staff.

Early on we saw the stress associated with staying home— stress of the unknown and the lack of human contact, as well as stress with going to the hospital for any illness. Many saw a decrease in typical ER consults and patients who wanted to come to the outpatient clinics for fear of the disease, many were furloughed or lost their jobs. Patients admitted for COVID and non-COVID alike have experienced a different kind of stress: on top of the typical stress of hospitalization, there are often no visitors or family allowed at their side.

Visitor restrictions have left patients and parents facing already stressful admissions, with less support from family and/or caretakers. While hospital staff have adapted and learned unique ways like video chat and providing more frequent updates to families to bridge this isolation, it is still a difficult and stressful process.

I experienced being a patient during COVID-19 when I delivered my first baby this May, followed by what any pediatrician, including myself, would consider a minor/routine readmission for my daughter a few days after birth. We were admitted at the hospital where I work, so it was more familiar to me, and my husband was allowed to visit us during the birth (but not my daughter’s admission). While there was no lack of empathy or care from the staff, this was still a very stressful time for me without the physical presence and support of my family and friends being allowed in the hospital with us. I cannot imagine how much more stressful this would have been for someone who does not work in a hospital, had never been in a hospital, or was not allowed any family members present.

One positive thing that came out of this stress for me was a new appreciation and respect for my patients and their parents. Despite being able to FaceTime family, I was surrounded by new faces and a new experience; it was a scary and isolating few days. I realized that something I always felt was routine or minor as the treating physician, didn’t seem that way when I was laying in the hospital bed myself or hovering over my newborn’s crib. I realized that I can use this experience to better myself as a clinician and that what may be routine or minor for me the physician, may be that patient or parent’s worst day.

The way healthcare workers have gone above and beyond to try to engage and support those in the hospital is to be applauded and respected, and I think the lessons learned during this time will go a long way into life after COVID-19. We need to continue to find ways to incorporate family and friends who cannot physically be present, and reduce some of the stress and isolation that admission to the hospital carries.

COVID-19 doesn’t discriminate based on age, race, gender, occupation, identity, or even infection status; it affects everyone whether you have the virus or not. The physical effects of stress may not always be as obvious as something like Takatsubo Cardiomyopathy, but they are nonetheless important to recognize and treat. We as physicians should continue to take the time to respect and assess the mental health of not only ourselves, but all of those around us, and engage the full person into our care while adapting to new and uncomfortable situations.

Pandemics Juxtaposed

June 16, 2020June 16, 2020 Sherry-Ann Brown, MD, PhD

Many of you are wondering about what I as a leader in various ways am thinking about the racial pandemic, juxtaposed with the coronavirus pandemic.

In the coronavirus pandemic, I had been starting my emails with something like, “I hope you have been able to stay well during these unprecedented times”.

This morning, I started to write an email to a group of people.

At first, I typed, “I hope you are well”.

Then I deleted that and started over.

And then wrote, “I hope you are sorting through these multiply tumultuous times.”

I deleted that too and skipped that intro altogether, and instead decided to share it with you all.

Let me tell you why. You should already be able to figure this out, but let me walk you through it.

Here it is.

Plainly and simply.

I hope you are NOT well.

I hope you are not OK with seeing what is going on in the world around you. I hope you are not OK with the global ignorance we have as people. I hope you’re not OK with the complacency with which we live our lives.

I hope you are NOT well.

I hope that your heart has been breaking inside due to centuries and decades of injustice.

I hope your well-being has been ruffled knowing that all are NOT well.

That all is NOT well.

We all agreed that as a society the goal is to be well.

However, the goal we should desire is for all to be well.

We cannot be true to ourselves until we honestly recognize that all are not well until the futures of our black men, women, boys, girls, and babies in this country and around the world are well.

Until then, how can you be well?

Together, in community, how can we be well?

We can be well when we start to admit that we are not.

We can be well when we commit to open dialogue and truthful conversation about race.

We can be well when we recognize our ineptitude as a society at understanding and addressing what ails us.

We can be well when it finally legitimately rings true that all men, women, boys, girls, and babies in the United States are indeed understood, recognized, perceived, and treated as equal.

Virtual #QCOR20 and the future of cardiology academic meetings

June 12, 2020June 12, 2020 Aaysha Cader, MD, MRCP

Much like many recent academic cardiology meetings, the American Heart Association (AHA)’s Quality of Care & Outcomes Research 2020 (#QCOR20) meeting took place virtually as well, owing to limitations posed by the COVID-19 pandemic. Having attended AHA Scientific Sessions 2019 as an international delegate, this was both my first time attending QCOR as well as my first virtual QCOR. There was a wide range of content encompassing cardiovascular outcomes research, abstract presentations, plenary sessions and also an online interactive early career session via zoom.

So, as I logged into HeartHub (https://www.hearthubs.org/qcor ) for the sessions, in the comfort of my pajamas in a time zone a dozen hours apart, I found that the platform was rather unique, convenient and user-friendly. Talks were pre-recorded in good quality, but what really stood about the #QCOR20 format was the chat function that ran simultaneously with the ongoing talks. Completely flattening all medical hierarchies, this allowed for extensive, insightful and interactive discussions in an informal manner between speakers and attendees, irrespective of where they stood in the totem pole of medicine. This also served to obviate some of the conventional barriers of Q&A sessions at large meetings, allowing for more questions as well as the active engagement of more junior delegates.

Additionally, Virtual QCOR registration came with on-demand access to recorded lectures as well as other available conference materials including handouts for until three months after sessions, allowing one to catch up on sessions that might have been missed.

This was particularly useful, because, that very weekend SCAI also hosted their annual scientific sessions virtually. In a parallel world, I wouldn’t have dreamed of testing my efficiency with two parallel meetings. But the effort to attending both was significantly less than usual, including financially, involved no flights, commutes or time off work, and conveniently, I could switch between windows to “pop in” to the sessions of my interest at either meeting.

Despite some of these conveniences, I found myself missing the buzz of in-person meetings: the anticipation of results of late-breaking clinical trials, discussions of live cases, interaction and camaraderie of meeting colleagues face to face from the around the world, seeing new technology in the exhibit calls and especially, coming to think of it, the downtime off work and the absolute joy of travel.

Basically, the nerd, the wanderlust, and the human in me didn’t quite agree entirely with this virtual format. But that’s personal. And while we can agree that the science and education will certainly find its way to clinicians, many of the other goals and expectations of such annual academic conferences hinges on in-person meetings. These include small-group practical education, meeting and networking with peers, sharing of experiences, and potential collaborations borne thereof, none of which can be effectively achieved by a virtual meeting. From the perspective of scientific associations, building agendas, policy-making, professional skills development, and interactions with industry are all far better achieved with face-to-face interactions.

With restrictions to air travel, dwindling economies, social distancing measures and the varying commitments of the global medical community facing different phases of the pandemic in their respective countries, there has been much discussion on the future of medical conferences. Given the current climate, delegates (especially international) may re-evaluate priorities, with considerations of finances and if in-person presence was in fact, absolutely necessary.

And as many more international cardiology meetings are successfully converted into virtual events, and many more physicians adapt to this convenient method of education, it begs the question if this indeed will be the default arrangement for the foreseeable future? Further, into the future, academic societies ought to consider the possibility of combining the best of both worlds, so to speak, with a “hybrid” format, offering the in-person meeting as well as the virtual format, thus giving delegates who might prefer it, the option of attending sessions live from the comfort of their homes.

Also, while large global meetings with thousands of delegates might survive the pandemic and transition into hybrid conferences, what of the smaller meetings? Some of these are dedicated to niche specialties for smaller audiences, offering opportunities for hands-on learning and more intimate networking with experts and mentors. Only time will tell if such smaller meetings will indeed prevail.

Virtual meetings may have sufficiently filled the void of medical education and academic discourse that occurred as a result of cancellations of in-person conferences. Part of this void has also been filled by increased interactions between peers on social media platforms, particularly twitter, with renewed importance of the role of social media ambassadors. In more ways than one, virtual meetings may even have brought the world closer, with many of us logging in at the same time from different time zones. But let’s be real: We can dissect a trial on twitter all we like, but it will never be the same as the standing room only attendance at late-breaking clinical trial sessions. Also, let us seriously spare a thought for the principal investigator presenting his/her pioneering research to a computer screen: that is nowhere near the real thing.

The impact of COVID-19 on the course of major professional meetings has been huge. While Science will always find a way to reach us, meetings are so much more than just science. The whole world is adapting to a new normal and it will be interesting to see how this pans out for the medical community.

Battling the Pandemic of misinformation

June 9, 2020June 9, 2020 Noora Alhajri, MD, MPH

The Myth

The global disruption caused by the coronavirus disease (COVID-19) has resulted in conspiracy theories and misinformation about the scale of the pandemic and the origin, diagnosis, treatment, and prognosis of the disease. Falsified information including international disinformation has been spread through various social media platforms such as Twitter, Instagram, Youtube, and WhatsApp. In some countries such as India, Bangladesh, Ethiopia, journalists have been arrested for allegedly spreading fake news about the pandemic.

Misinformation has been propagated by prominent public figures, celebrities, and politicians, while, several religious groups have claimed that their faith will protect them from the virus. Some claim that the virus is a bio-weapon, accidentally or purposely leaked from laboratories, a population control stratagem, the result of a spy operation, or linked to 5G network.

On Jan 30th, several news channels reported about the increasing spread in the conspiracy theories and false health advice in relation to COVID-19. Notable examples at the time include:

“ Bill Gates is behind the COVID-19 pandemic”

“ COVID-19 can be cured by ingesting Clorox”

“ Coronavirus can be prevented by anti-corona sprays”

“ Gargle with an antiseptic and warm water such as vinegar, salt, or lemon for every day to clear your airways”.

On February 2nd, the World Health Organization (WHO) described a “massive infodemic” of incorrect information about the virus, which makes the work of public health practitioners even more difficult and poses risk to global health.

Misinformation is among the most critical issues confronting our frontline heroes. The issue of fake medicines and treatment has become all of the more pervasive in the age of COVID-19. This urges the governments to recognize this serious issue and calls for the development of a unified national and international response and action plan that include comprehensive legal framework, robust reporting systems, and strong national regulatory mechanisms linked to the global regulatory network as well as greater pharmacovigilance capacity

Busting the Myth

The pandemic has created ideal situations for criminals to exploit people’s fears of contracting the disease by advertising falsified information regarding treatments and vaccines, promoting fake tests, and spreading dangerous rumors about potential cures. In some countries, several people have died from drinking toxic alcohol after coronavirus cure rumor. The World Health Organization (WHO) and the US Food & Drug Administration (FDA), has warned against other mythical cures for COVID-19 and confirmed that, to date, there is no specific treatment recommended to treat the SARS-CoV-2 viral infection.

Several countries around the world are struggling with infectious disease and fragile health systems, and the increased spread of false information on fake cures could put these systems under huge pressures and make the situation for physicians and public health practitioners a lot harder than what it already is.

“ COVID-19 is on the rise in Africa, and we are already facing shortages of critical protective equipment and plethora of misinformation,” says Thembeka Gwagwa, ICN’s second Vice-President, and a nurse from South Africa. : Lack of access to care will mean many people will seek cheap, fake medicines which will have devastating consequences”.

Our role as citizens and healthcare professionals

Researchers at Massachusetts Institute of Technology have shown that videos and posts that trigger an emotional response are shared more and are most likely to influence the public.

As citizens, we have the most important role in curbing misinformation. Social media platforms are a source of immense power that can influence the public and promote awareness about fake cures and false news. Since out-of-context images are a major source of misinformation, citizens can learn to use reverse search image tools such as RevEye and TinEye to locate their origin and verify the truthfulness of these images. Videos can sometimes be misleading and present an even higher level of complexity, however, tools like InVid have begun to make a difference. In general, we should always be vigilant and verify the accuracy of information by looking up a reliable source before we spread the information.

As healthcare professionals, our role is to educate the public on safety concerns related to the use of fake medical products and dispel false rumors about potential cures. Our role is to promote health literacy to support properly informed preventative measures and discourage self-diagnosis and self-prescribing. Although healthcare professionals are under severe pressure during this pandemic, however, the work of educating and informing patients and their families should not be seen as an additional burden but rather as part of safeguarding the health of the community and the public.

Furthermore, there are several campaigns that aim to raise the awareness of fake medicines where victims get to voice their own stories with fake medicines. These campaigns are now a warning of an ever-growing “infodemic” alongside the SARS-CoV-2 pandemic.

Lastly, our fight against COVID-19, future pandemics, and falsified medical information emphasis the urgent need to strengthen the health system, promote health literacy and citizens’ sense of awareness and responsibility, educate healthcare professionals, and better support the ones we have. If we are to be prepared for the next health crisis, and without any doubts, there will be one, we need to better support and invest in our public health and health workforce sector.

References:

https://news.harvard.edu/gazette/story/2020/05/social-media-used-to-spread-create-covid-19-falsehoods/
Rochwerg, Bram MD^1,2; Parke, Rachael PhD^3,4; Murthy, Srinivas MD⁵; Fernando, Shannon M. MD⁶; Leigh, Jeanna Parsons PhD⁷; Marshall, John MD⁸; Adhikari, Neill K. J. MD^8,9; Fiest, Kirsten PhD^10–12; Fowler, Rob MD^8,9; Lamontagne, François MD^13,14; Sevransky, Jonathan E. MD¹⁵Misinformation During the Coronavirus Disease 2019 Outbreak: How Knowledge Emerges From Noise, Critical Care Explorations: April 2020 – Volume 2 – Issue 4 – p e0098 doi: 10.1097/CCE.0000000000000098
Cuan-Baltazar, J. Y., Muñoz-Perez, M. J., Robledo-Vega, C., Pérez-Zepeda, M. F., & Soto-Vega, E. (2020). Misinformation of COVID-19 on the Internet: Infodemiology Study. JMIR public health and surveillance, 6(2), e18444. https://doi.org/10.2196/18444
Li HO, Bailey A, Huynh D, et al. YouTube as a source of information on COVID-19: a pandemic of misinformation?.BMJ Global Health 2020;5:e002604
Citizens’ use of social media in government, perceived transparency, and trust in government. Public Perform Manag Rev.2016; 39: 430-453
Nicole M. Krause, Isabelle Freiling, Becca Beets & Dominique Brossard(2020) Fact-checking as risk communication: the multi-layered risk of misinformation in times of COVID-19, Journal of Risk Research, DOI: 1080/13669877.2020.1756385

Mastering the Art Of A Virtual Interview

June 8, 2020June 8, 2020 Barinder Hansra, MD

The COVID-19 pandemic has created an entirely new (and robust) world of online platforms. All across the globe classrooms, meetings, conferences, and social get-togethers have become virtual. Companies such as Zoom (Zoom Video Communications, San Jose, California), WebEx (Cisco WebEx, Milpitas, California), and BlueJeans (BlueJeans Network, Mountain View, California) have allowed us to maintain social distancing while maintaining the ability to round as teams, attending meetings, and even conduct interviews. However, for many trainees, interviewing for residency and fellowships is challenging on the best of days but needing to conduct an interview online has its unique set of problems. This past year, as a chief cardiology fellow, I was able to interview a number of candidates. Some did a fantastic job while others struggled. Here are a few tips to help this interview season be even more successful.

Practice makes perfect: One of the great features of Zoom (and others) is the ability to record video calls, making it an incredible tool for interview preparation. You can optimize a lot of in your interview by seeing how the lighting is affecting the way you appear on screen, are you fidgeting too much, and how is the video/audio quality. I would recommend having a few mock sessions with friends, family, and even a mentor to get feedback. It is key trainees get enough practice before the real deal.
Get rid of distractions: In face-to-face meetings, distractions are shared by the interviewer and candidate – we are often able to laugh at them together. However, if your dog or child runs into the room when you interview it’s a lot harder to laugh. Even small things such as text messages, emails, or noises from the outside of your own home can be a distraction that may be hard to recover from.
Maintaining eye contact: This may be one of the trickiest parts of an online interview. If you look at the person you are talking to then the camera doesn’t capture your eye contact. If you look into the camera, then you don’t get to see the body language or facial reactions of the interviewers. I recommend the second option – look into the camera when speaking. You can look down at the screen to get cues about how the interview is going when the interviewer is speaking.
Double-check the date and time zone: Since we are not traveling for an in-person interview, it is important to make sure you have the correct date and time. If you are interviewing with a program in another time zone you do not want to be late because you did not take the time difference into account. This will be especially important for those interviewing on the different coasts, or if interviewing in a state such as Arizona that does not have daylight savings.
Don’t be afraid to ask questions: Training programs have had to adjust during the COVID pandemic so don’t be shy to ask what steps institutions have taken and what is their plan for going back to “normal.” You may have specific goals you want to accomplish during your training – share this on the interview to see if the program will be able to help you fulfill your goals. Remember to ask the most important questions on the interview day that will better inform you about the program, you can always follow up with an email if more questions come to mind.

Interviewing is a challenging skill to perfect however, with preparation and keeping a few of the above-mentioned tips in mind, you can set yourself up for success. You’ll feel more confident and relaxed during your virtual interview by taking these tips into account, and hopefully match at your top program.

Image website addresses:

Panel with female interviewer: https://www.forbes.com/sites/zackfriedman/2018/12/05/most-common-interview-questions/#508966cc8e3c
Online interview image: https://www.wayup.com/guide/community/ey-245237-sponsored-video-virtual-interview-guide-expert/

What will training look like in the post-pandemic era?

May 26, 2020May 26, 2020 Adham Karim, MD

I remember my first week of internship very clearly – I was a part of my first code blue as a physician. Later that week, I had to have a goals of care discussion with a patient who had been in the hospital for 3 weeks (longer than I had been a doctor at that point). These were new experiences that I was eager for, but I was fortunate to have my routine that maintained a sense of normalcy for me, very much like naptime to my toddler. I was diligent in pre-rounding and seeing all my patients before my attending showed up, and would have formed a plan for their care before 8 AM.

Once the COVID-19 pandemic was in full swing here in the US, a lot of these things that were part of my routine as an intern suddenly went to the wayside. At my institution, interns were instructed not to pre-round on patients such as to minimize contact and potential infection transmission. Family meetings could only be conducted via telephone, or in some cases, video conference. Code blues were no longer a mad dash to the patient’s room, but rather, different hospital wards had different teams, such that a provider taking care of COVID+ patients does not go to a code blue for non-COVID patients and vice versa.

Rounding on these revamped inpatient teams has been…interesting to say the least. I can’t tell you the amount of times I or an attending will ask the patient a question about the patient and the response is “I don’t know, I haven’t seen them.” It’s great that interns are more comfortable admitting they don’t know something rather than lie about it, but at the same time, I can’t help but feel a sense of lack of ownership on their behalf.

Everybody will tell you that intern year sucks, and it’s rough, and they would hate to go back and do it again. But many people will also admit that they are impressed with how much they have learned and managed to push themselves beyond their perceived level of comfort during that time frame. I didn’t particularly enjoy coming to the hospital early each day I was on an inpatient service just to see my patients and review their charts, or going to the patient’s room for the umpteenth time in a day, but there have been a number of times where something meaningful was gleaned, and my ability to think critically and manage patients independently grew a little that day.

The thing that bothers me the most about these precautions is the huge change to goals of care discussions and family meetings. The logic behind it – minimizing spread of infection and exposures – makes sense and I agree with it completely. But it’s hard to develop good rapport with an individual only over the phone, and similarly, it’s difficult to comfort another human being digitally. There’s something about the physical presence of another person, the eye contact, and even the slightest gestures, that can help make the worst day of someone’s life a little less painful.

It’s quite fortunate that these protocol changes came more than halfway through the academic year, when interns at least have a handle on what things to look out for and have developed their own sense of alarm from glancing at the chart. I can’t imagine starting intern year where I only physically interact with “my” patients during rounds with my attending, or via telephone, unless there is some kind of emergency.

On the other hand, this is accelerating our embrace of telemedicine on the outpatient side, which is good for both patients and providers in many cases, and from my anecdotal experience, has resulted in a lot fewer “no-shows.” Interns are afforded more sleep, and arguably learning to pay more attention to vital signs changes and lab value changes – or at least they’re getting a better sense of when they should actually get up and go see the patient (sometimes at the urging of their senior 😊). This could simply be an inevitable step in the evolution of medical education that was accelerated by the pandemic, but I can’t say I feel that all these changes should be here to stay.

Whether it was fumbling through morning rounds and trying to formulate a new plan based on overnight events, or developing my emotional intelligence and flexing that empathy muscle, these were formative experiences for me during my intern year that have significantly contributed to my development as a clinician. These could just be the ramblings of a dinosaur, much akin to the older physicians talking about their paper charts, fibrinolytics and 48 hour calls, but I do hope some of these changes can be undone soon, for the sake of our trainees as well as our patients and their families.

The COVID-19 Pandemic: A Master Class in Health Inequity

May 22, 2020May 22, 2020 Anika Hines, PhD, MPH

In my course, Social and Economic Determinants of Health Disparities, we spend the semester discussing the complex web of factors rooted in social and economic policies that propagate disparities in health. These include education, employment, housing, broader neighborhood structures and, of course, healthcare. We also contextualize individual and interpersonal health behaviors within those structures. When news of the virus really gained steam in mainstream media, one of my students commented that this was an “inverse disparity”—that predominantly rich, white people who’d vacationed in far-off places were affected. I assured him that as data by race and ethnicity surfaced, we would find minorities bearing the brunt of the burden. Unfortunately, as data began to roll in state-by-state, my prediction was accurate. Further, I knew that this was bigger than who was or wasn’t wearing a mask in public, or of the disproportionate number of minorities with pre-existing conditions that may place them at higher risk. It is about a system that consistently favors the physical, mental, emotional, and financial health of certain sects of the population over others.

When the novel coronavirus came to the US public’s attention just months ago, very few of us expected that our lives would change as much as it has in subsequent months. There were so many uncertainties with this unique virus—its transmission, incubation period, symptoms, and appropriate treatment—that we were left whirling in unpreparedness. US culture, built on the foundational value of individual freedom, found itself at odds with the need to protect a more social interest: stopping the spread.

Our best defensive effort was to stay away from each other, or social distancing—a solution (with all of its benefits) that is fundamentally steeped in privilege. It didn’t account for an invisible, operational background of millions of people who occupy the less educated, often undervalued workforce who, ironically, have come to be regarded as “essential”. There are people who must travel on crowded buses to work elbow-to-elbow in order to feed us, sanitize spaces that we might encounter, and help maintain a semblance of normalcy. While some of those workers may view their efforts as an act of service, there is undoubtedly some life or death decision-making happening. On the one hand, they face the risk of exposure to a potentially deadly virus. On the other hand, they face the equally compelling risk of not being paid if they choose not to show up to work, or if they fall ill. For many, there is really no choice at all: the financial strain posed by the latter and its negative effects on their families is non-negotiable. So, they put themselves in harm’s way, hoping against hope that they won’t contract the virus and/or bring it home to their loved ones.

Although we’re “in this together,” we have left many of the most vulnerable to fend for themselves. They live in food deserts and now have even fewer options at their disposal than before, as those with disposable income and time stocked up on supplies. They are disconnected from accurate, timely information, which is even more important as we learn new lessons about the virus daily. For some, their experience with this pandemic can best be described as “inconvenienced,” while others don the armor of homemade masks to preserve their (and our) lives.

My students are learning the same lessons many are starting to awaken to: when systems fail, the marginalized become more marginalized. The pandemic operationalizes the very definition of “disparities” that we discussed during the first lecture. We are all seeing that “differences rooted in social disadvantages that further expose individuals to additional disadvantage” mean that those who are the least equipped with the resources to withstand a pandemic are placed at higher risk of exposure, unable to effectively employ best-practices for protection against an unpredictable virus. The novel coronavirus has set the stage for a master class in health inequity and demands that we pay attention to the socially and racially stratified patterns emerging from the COVID-19 pandemic. Luckily, experts have provided a game plan for helping the most vulnerable. Hopefully, this experience will build our empathy towards the overlooked among us as we tackle health inequity together.

Class is in session.

COVID -19 and the clotting conundrum

May 19, 2020May 19, 2020 Aaysha Cader, MD, MRCP

Initially known as a predominantly respiratory disease, there is currently no doubt that COVID-19 is increasingly emerging as a prothrombotic condition. Observational studies, as well as published and anecdotal case reports have highlighted the thrombotic manifestations of COVID-19, with particular emphasis on the strong association between D-dimer levels and poor prognosis.^1,2 While the COVID-19 clotting narrative has been dominated by venous thromboembolism (VTE) and pulmonary embolism (PE),^3-5 macro-thrombosis of the coronary⁶ and cerebral circulations⁷ have also been reported, as have the prevalence of microthrombi arising from endotheliitis in other sites.⁸

The pathophysiology

Some authors have described this SARS-CoV-2 induced hypercoagulability as ‘thromboinflammation’, an interplay between inflammation and coagulability leading to sepsis-induced-coagulopathy (SIC) and disseminated intravascular coagulopathy in severe COVID-19 cases.⁹ The pathophysiology is still incompletely understood but may be largely explained by the three components of Virchow’s triad:

Endothelial dysfunction: SARS-CoV-2 virus enters the host using the angiotensin converting enzyme 2 (ACE2) receptor, which is widely expressed not only in the alveolar epithelium of the lungs but also vascular endothelial cells, which traverse multiple organs.⁸ Varga, et al. reported this concept of COVID-19 ‘endotheliitis’ in their paper, explaining how endothelial dysfunction, which is a principal determinant of microvascular dysfunction, shifts the vascular equilibrium towards vasoconstriction, organ ischaemia, inflammation, tissue oedema, and a procoagulant state, leading to clinical sequalae in different vascular beds.⁸ Complement-mediated endothelial injury leading to hypercoagulability has also been suggested.¹⁰

Hypercoagulability: SARS-CoV-2-induced hypercoagulability has also been attributed as a consequence of the ‘cytokine storm’ that precipitates the onset of a systemic inflammatory response syndrome, resulting in the activation of the coagulation cascade.^11,12However, whether the coagulation cascade is directly activated by the virus or whether this is the result of local or systemic inflammation is not completely understood.¹²

Stasis: Critically ill hospitalized patients, irrespective of pathophysiology are prone to vascular stasis as a result of immobilization.¹³

Currently available data: predominantly observational studies

In some of the earliest data emerging from Wuhan, Tang, et al. reported significantly higher markers of coagulation, especially prothrombin time, D-dimers and FDP levels, among non-survivors compared to survivors of SARS-COV2 novel coronavirus pneumonia (NCP), suggesting a common coagulation activation in these patients.¹

Subsequently, Zhou, et al., reported that D-dimer levels, along with high-sensitivity cardiac troponin I and IL-6 were clearly elevated in non-survivors compared with .¹⁴This was highlighted in one of the earliest CCC-ACC webinars on COVID-19 in March 2020, by Professor Cao, who drew emphasis on their data where D-Dimer >1μg/mL was an independent risk factor for in-hospital death, with an odds ratio of 18.42 (p=0.0033).^14,15

In another single centre study among 81 severe NCP patients from Wuhan, Ciu, et al., observed that D-dimer levels >1.5 μg/mL had a sensitivity of 85% and specificity of 88.5% for detecting VTE events.³ In an observational study of 343 eligible patients by Zhang, et al., the optimum cutoff value of D-dimer level on admission to predict in-hospital mortality was 2.0 µg/ml with a sensitivity of 92.3% and a specificity of 83.3%.¹⁶

With a shift in the epicenter of the pandemic, data from Europe highlighted the prevalence of both arterial and venous thrombotic manifestations among hospitalized COVID-19 patients, many of whom received at least standard doses of thromboprophylaxis.^5,13

Most recent data from an observational cohort of 2,773 hospitalized COVID-19 patients in New York, showed that in-hospital mortality was 22.5% with anticoagulation and 22.8% without anticoagulation (median survival, 14 days vs 21 days).¹⁷ Confounded by the immortal time bias, among others, these data underscore the pressing need for well-designed RCT’s to answer this burgeoning therapeutic dilemma.

Antithrombotic therapy: What is the guidance?

As physicians learn more about this clotting conundrum, there is an increasing need for evidence-based guidance in treatment protocols, especially pertaining to anticoagulation dosing and the role of D-dimers in deciding on optimum therapeutics.

International consensus-based recommendations published by Bikdeli, et al. in the Journal of American College of Cardiology on 15^th April 2020 recommend risk stratification for hospitalized COVID-19 patients for VTE prophylaxis, with high index of suspicion.¹¹ They further state that, as elevated D-dimer levels are a common finding in patients with COVID-19, it does not currently warrant routine investigation for acute VTE in absence of clinical manifestations or supporting information. For outpatients with mild COVID-19, increased mobility is encouraged with recommendations against the indiscriminate use of VTE prophylaxis, unless stratified as elevated-risk VTE.

The majority of panel members considered prophylactic anticoagulation to be reasonable for hospitalized patients of moderate to severe COVID-19 without DIC, acknowledging that there is insufficient data to consider therapeutic or intermediate dose anticoagulation; the optimal dosing however, remains unknown.¹¹ Furthermore, extended prophylaxis, with low-molecular weight heparin or direct oral anticoagulants for up to 45 days after hospital discharge, was considered reasonable for patients with low-bleeding-risk patients and elevated VTE (i.e. reduced mobility, comorbidities and, according to some members, elevated D-dimer more than twice the upper normal ).¹¹

A Dutch consensus published shortly after on the 23^rd April 2020, also recommends prophylactic anticoagulation for all hospitalized patients, irrespective of risk scores.¹²Imaging for VTE and therapeutic anticoagulation recommendations are largely guided by admission D-dimer levels and their progressive increase, based on serial testing during hospital stay, in addition to clinical suspicion. A lower threshold for imaging has been recommended if D-dimer levels increase progressively (>2,000-4,000 μg/L), particularly in presence of clinically-relevant hypercoagulability. However, in contrast to the consensus document published in JACC, the Dutch guidance recommends that, where imaging is not feasible, therapeutic-dose LMWH without imaging may be considered if D-dimer levels increase progressively (>2,000-4,000 μg/L), in settings suggestive of clinically relevant hypercoagulability and acceptable bleeding risk.¹²

The need for RCT’s

Even as we scramble to clarify the pathophysiology, the urgency to establish evidence-based standard of care in terms of anticoagulation has never been greater. Dosing is a matter of hot debate (prophylactic versus intermediate versus therapeutic), especially considering the risk of bleeding that can arise from indiscriminate anticoagulation.

Furthermore, while we have data that underscores increased coagulation activity (D-dimers in particular) as a potential risk marker of poor prognosis, D-dimers remain non-specific and there is insufficient evidence as to whether they can be used to guide decision-making on optimum anticoagulation doses among patients with COVID-19.

The existing evidence on thrombotic complications and their treatment has been primarily derived from non-randomized, relatively small and retrospective analyses. Such observational studies have been hypothesis generating at best, and in the absence of robust evidence, randomized clinical trials are imperative to address this critical gap in knowledge in an area of clinical equipoise. And there are quite a few to watch out for, as evidenced by a quick search in Clinicaltrials.gov, some of which are already recruiting.

RCT’s of therapeutic vs prophylactic anticoagulation:

Preventing COVID-19-associated Thrombosis, Coagulopathy and Mortality With Low- and High-dose Anticoagulation: a Randomized, Open-label Clinical Trial (COVID-HEP) [https://clinicaltrials.gov/ct2/show/NCT04345848]

Currently recruiting at University Hospital, Geneva, this trial randomizes 200 hospitalized adults with severe COVID-19 to therapeutic anticoagulation versus thromboprophylaxis during hospital stay. The primary endpoint is a composite outcome of arterial or venous thrombosis, DIC and all-cause mortality at 30 days.

A Randomized Trial of Anticoagulation Strategies in COVID-19 [https://clinicaltrials.gov/ct2/show/NCT04359277]

This open label RCT of hospitalized COVID-19 positive patients with a D-dimer >500 ng/ml is currently recruiting at NYU Langone Health (estimated enrolment of 1000 patients). Patients will be randomized to higher-dose versus lower-dose (e.g. prophylactic-dose) anticoagulation in 1:1 ratio. Primary endpoints include incidences of cardiac arrest, DVT, PE, MI, arterial thromboembolism or hemodynamic shock at 21 days and all-cause mortality at 1 year.

A Randomized, Open-Label Trial of Therapeutic Anticoagulation in COVID-19 Patients With an Elevated D-Dimer [https://clinicaltrials.gov/ct2/show/NCT04377997]

This randomized, open-label trial sponsored by Massachusetts General Hospital (MGH) commencing recruitment mid-May, will randomize 300 participants with elevated D-dimer > 1500 ng/ml to therapeutic versus standard of care anticoagulation in a 1:1 ratio, based on MGH COVID-19 Treatment Guidance. Designed to evaluate the efficacy and safety of anticoagulation, primary outcome measures include the composite efficacy endpoint of death, cardiac arrest, symptomatic DVT, PE, arterial thromboembolism, MI, or hemodynamic shock at 12 weeks, as well as a major bleeding event at 12 weeks.

Enoxaparin for Thromboprophylaxis in Hospitalized COVID-19 Patients: Comparison of 40 mg o.d. Versus 40 mg b.i.d. A Randomized Clinical Trial (X-COVID 19)[https://clinicaltrials.gov/ct2/show/NCT04366960]

This open-label multi-centre RCT will recruit 2712 hospitalized COVID-19 patients in Milan, Italy, randomized to subcutaneous enoxaparin 40 mg daily versus twice daily within 12 hours after hospitalization, to assess the primary outcome measure of venous thromboembolism detected by imaging at 30 days.

RCT of intermediate vs prophylactic dose anticoagulation:

Intermediate or Prophylactic-Dose Anticoagulation for Venous or Arterial Thromboembolismin Severe COVID-19: A Cluster Based Randomized Selection Trial (IMPROVE-COVID) [https://clinicaltrials.gov/ct2/show/NCT04367831]

A cluster-randomized trial of 100 participants, IMPROVE-COVID, sponsored by Columbia University will compare the efficacy of intermediate versus prophylactic doses of anticoagulation in critically ill patients with COVID-19. The primary outcome measure is the composite of being alive and without clinically-relevant venous or arterial thrombotic events at discharge from ICU or at 30 days (if ICU duration ≥30 days).

Even months later, COVID-19 continues to baffle clinicians. But what has been crystal clear right from the outset is that there is no alternative to evidence-based practice, and it stands true in the face of this clotting conundrum as well.

Image from Shutterstock

References

Tang N, Li D, Wang X, Sun Z. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. J Thromb Haemost. 2020;18(4):844-847.
Zhang L, Yan X, Fan Q, Liu H, Liu X, Liu Z, et al. D-dimer levels on admission to predict in-hospital mortality in patients with Covid-19. J Thromb Haemost. 2020 Apr 19. doi: 10.1111/jth.14859.
Cui S, Chen S, Li X, Liu S, Wang F: Prevalence of venous thromboembolism in patients with severe novel coronavirus pneumonia.. J Thromb Haemost. 2020 Apr 9. doi: 10.1111/jth.14830
Poissy J, Goutay J, Caplan M, Parmentier E, Duburcq T, Lassalle F, et al. Pulmonary Embolism in COVID-19 Patients: Awareness of an Increased Prevalence. Circulation. 2020 Apr 24. doi: 10.1161/CIRCULATIONAHA.120.047430.
Lodigiani C, Iapichino G, Carenzo L, Cecconi M Ferrazzi P, Sebastian T, et al., on behalf of the Humanitas COVID-19 Task Force. Venous and arterial thromboembolic complications in COVID-19 patients admitted to an academic hospital in Milan, Italy. Thromb Res. 2020; 191: 9–14.
Dominguez-Erquicia P, Dobarro D, Raposeiras-Roubín S, Bastos-Fernandez G, Iñiguez-Romo A. Multivessel coronary thrombosis in a patient with COVID-19 pneumonia, European Heart Journal, , ehaa393, https://doi.org/10.1093/eurheartj/ehaa393
Oxley TJ, Mocco J, Majidi S, Kellner CP, Shoirah H, Singh IP, et al. Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young. N Engl J Med. 2020 Apr 28.
Varga Z, Flammer AJ, Steiger P, Haberecker M, Andermatt R, Zinkernagel AS, et al. Endothelial cell infection and endotheliitis in COVID-19. Lancet. 2020 May 2;395(10234):1417-1418
Connors JM, Levy JH. Thromboinflammation and the hypercoagulability of COVID-19. J Thromb Haemost. 2020 Apr 17. doi: 10.1111/jth.14849.
Magro C, Mulvey JJ, Berlin D, Nuovo G, Salvatore S, Harp J, Baxter-Stoltzfus A, et al. Complement associated microvascular injury and thrombosis in the pathogenesis of severe COVID-19 infection: a report of five cases [published online ahead of print, 2020 Apr 15]. Transl Res. 2020;S1931-5244(20)30070-0. doi:10.1016/j.trsl.2020.04.007
Bikdeli B, Madhavan MV, Jimenez D, Chuich T, Dreyfus I, Driggin E, et al. COVID-19 and Thrombotic or Thromboembolic Disease: Implications for Prevention, Antithrombotic Therapy, and Follow-up. J Am Coll Cardiol. 2020 Apr 15:S0735-1097(20)35008-7
Oudkerk M, Büller HR, Kuijpers D, van Es N, Oudkerk SF, McLoud TC, et al. Diagnosis, Prevention, and Treatment of Thromboembolic Complications in COVID-19: Report of the National Institute for Public Health of the Netherlands. Radiology. 2020 Apr 23:201629.
Klok FA, Kruip MJHA, van der Meer NJM, Arbous MS, Gommers DAMPJ, Kant KM, et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res. 2020 Apr 10. pii: S0049-3848(20)30120-1. doi: 10.1016/j.thromres.2020.04.013.
Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al.Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020 Mar 28;395(10229):1054-1062.
https://www.youtube.com/watch?v=CjEhV68GcD8&feature=youtu.be
Zhang L, Yan X, Fan Q, Liu H, Liu X, Liu Z, Zhang Z. D-dimer levels on admission to predict in-hospital mortality in patients with Covid-19. J Thromb Haemost. 2020 Apr 19. doi: 10.1111/jth.14859. [Epub ahead of print]
Paranjpe I, Fuster V, Lala A, Russak A, Glicksberg BS, Levin MA, et al. Association of Treatment Dose Anticoagulation with In-Hospital Survival Among Hospitalized Patients with COVID-19 [published online ahead of print, 2020 May 6]. J Am Coll Cardiol. 2020;doi:10.1016/j.jacc.2020.05.001

Wellness Amid a Pandemic

May 14, 2020May 14, 2020 Nasrien E. Ibrahim, MD

I think about wellness often and the unique aspects of being a physician that make preserving our wellbeing even more important. Of course, this COVID-19 pandemic has tested all of us and the things we turn to for wellness and our escape from medicine, may not be available to us right now. After work dinner and drinks, early morning group fitness classes, and young professional networking events have been replaced by Netlfix© and dine-in, home workouts, and Zoom “wine” downs. We all had to dig down deep inside to find new venues for wellness and if we were lucky, our institutions provided resources to help us during this crazy time. What this pandemic taught me was that there are things I still needed to work on to build my resilience even further- and I am totally okay with that. Working on ourselves to better ourselves should be a continuous goal- everyone has room for improvement.

As a single woman living in the city, my nights and weekends were always filled with social events. I felt very isolated and realized how much of my free time was being occupied by my friends and the events I attended as part of my wellness routines. I miss my morning classes at bootcamp and will never complain again when my alarm wakes me up at 4:25am to get to class- whenever that may be. Some of the things that have helped me are FaceTime and Houseparty dates with friends and family, walking outside on the few sunny days Boston has graced us with, trying to eat healthy when I can, in-home workouts which I am not a fan of to be completely honest, but most important, was being vulnerable with friends, family, colleagues, and even patients who asked how I was doing during our virtual visits. I met with a Wellness Coach provided through my institution and the lightbulb moment for me was when he reminded me to be kind to myself. I remember seeing posts all over social media about how we should be building businesses, getting in shape, writing grants, or checking off any other number of “goals” because we have “so much time” and feeling bad, but I got over that. In the middle of this crisis, all our lives have been disrupted, some much more so than others, and we are all doing the absolute best we can. I remind myself to be grateful and I started writing specific things down that I am grateful for each day.

May is Mental Health Awareness Month and as physicians, we shy away from talking about such things. It may be that we are supposed to be superheroes who are invincible, or it may be that if we did seek help and received a diagnosis we would have to declare it on some medical state licensing applications, or we may just be afraid. Mental health is one of the many aspects of overall wellbeing and there are many ways to reach out for help for those who need it. COVID-19 has had many casualties and we must guard our mental health during this pandemic. Find what works for you and do it. Reach out when you need to and remember that it is totally okay to not be okay. Protect your mind, body, and soul as these are key aspects of our overall wellbeing. I feel optimistic about our future. When we come out on the other side of this let us take all the lessons we learned and remember to never take things such as human contact for granted again.

Stay safe and stay healthy.