Eerily Quiet

Periodically I donate platelets, being CMV negative.  My previous donation occurred right before the coronavirus.  I delayed the followup a little, partly due to Passover which would keep me out of the post-donation snack canteen and partly because I wasn't feeling my best.  But achiness stabilized, diet resumed at baseline and I made the next donation.

Our regional donation center sits across the street from the Christiana campus of the Christiana Care Health System, the state's largest single employer.  Around the corner lies the regional megamall which predates the medical complex by quite a few years and across lies Delaware Park, a venerable racetrack with more recently added casino.  A smaller shopping center is also across the street and the main branch of the community college has a campus at the highway exit that people take to reach the medical complex.  Typically at 8AM, a lot of traffic accumulates, though not this time.  Surrounding hotels have been ordered closed by the Governor except for a few people involved in the nearby medical care.  The medical complex itself has active employees but also a lot of inactivated employees.  Retail has all but disappeared. At the racetrack, the horses need to be fed, the slot machines don't.  Our mini-metropolis looked virtually abandoned.

Inside the donor center, only modest adaptations were made.  Everyone, staff and donors, wore protective face coverings but social distancing is not realistic when nurses need to take blood pressures, measure hemoglobins, insert IV access and tend to machines.  The post-donation canteen still operated fairly normally. 

The number of donors seemed a little less than usual for an early midweek morning, maybe a little younger crowd now that these time slots are not currently prime work hours.  They are participating in an experiment to harvest post-convalescent Coronavirus plasma for transfusion to critically infected patients but it was not possible for a casual visitor to identify those donors.  Mostly business as usual, fewer people and a new video system to keep the donors from getting too disengaged while they bleed out. 

I leave my cell phone in the car during donations.  When I returned, I opened email to find a note from a friend who departed for NY a few months ago to take a job as radiologist.  I just assumed as a center of coronavirus pandemic he would be inundated with chest images to report.  He noted that it really did not play out that way.  There were coronavirus related images but not excessive.  Offsetting that was a drastic decline in other imaging as most non-urgent care has gone into hibernation.  Financially, that's a net loss for his department and a reduction in assignments for him personally. 

Coronavirus has stressed medical capacity at its peak, though more selectively than I would have imagined.  Those working can be overworked but everyone else lives amid suspended activities.

Suspending Burnout

As I read comments from active physicians immersed in Coronavirus care, Burnout has virtually disappeared from the conversation.  Physical exhaustion occurs and there are skirmishes with the management, though less so.  People have found meaning in what they do.  The EHR with its irritations has become secondary.  Hierarchies seem to have flattened.  Meetings have been cancelled.  In some settings those pesky middlemen have been furloughed.

It would be interesting to administer those Maslach Burnout Inventory profiles to see if a change of focus changes the score.  Viktor Frankl's belief that finding life's meaning as the ultimate satisfaction may express itself that way.

Pink Slips

As people and institutions adapt to coronavirus disruptions, hospitals cannot be displaced as essential points of care.  Yet not everyone within a hospital building or network really contributes to immediate care or to planning essential for restoring normalcy.  A report came to my inbox announcing layoffs at a number of regional centers, with the one from which I retired appearing at the top of the list.  There may be no greater demonstration of institutional values than selecting who plays and who warms the bench.  The ICU people and the hospitalists have to stay.  I presume residents do as well, though electives other than Infectious Disease or Radiology may need to be reconsidered.  My own position as endocrinologist would be useful to surgeons, hospital teams and the like, though maybe expendable to bill payers as the hospital has plodded along in my absence without replacement.  Since residents are now needed both for labor and education, I would expect the director of the residency program who herds this collection of cats to remain on payroll.

How badly do we need dieticians?  Well, diabetes and heart disease patients occupy beds as they did before.  Sanitation crew?  We have the same amount of floor space.  Those people who maintain statistics to report Meaningful Use?  We could have argued whether this blight on medicine should even exist.  As office encounters give way to remote visits, the folks who take weights and blood pressure might be expendable, though they often take the intake history as well and may be the only people on site who know how to troubleshoot the malevolent EHR when it impedes medical care.  And there is always a layer of management that impedes medical care.  They should be more recognizable in that capacity.  Nobody wants to impede medical care right now.  Layoffs for them, though not permanent.  It is a chance to really think about the value of what the many contributors do.  Whether it adds to the learning curve of how to best provide medical care to the public without padding the bill with non-contributory payroll remains to be seen.

Resident Reappears

Some residents are just more memorable than others.  There is a barely definable bell of knowledge, insight, and social grace that lumps most into this big ball.  A progression from novice to experienced occurs, the certificates get signed and onward they move to their next destination.  A few remain colleagues, some fill military or visa obligations, a few appear in print later on.

An article by a former resident, one of the most unique, came my way.  Nicest fellow, the type you would do anything to help advance.  And it took quite a lot.  He did not finish our program but transferred to a different specialty which now puts him face to face with the difficulties of the corona pandemic.  I remember most how appreciative he was of any assistance he received from faculty and other residents.  He remains appreciative for the people who assist him at the front lines of coronavirus.

There is no better gratification than learning that a former resident has been trained in the best way possible. 

Changing the Medical Conversation

Dealing with Covid-19 has been a stress on medical providers.  Retirees like me are dormant, and maybe even regret not being in the fray.  It has changed the conversation of medicine for the better, though.  We'll start with Provider.  The Flexner Report, not yet fully of Blessed Memory, purged practitioners of lesser training and instituted licensing and credentialing.  Physicians often resent parity with other practitioners for understandable reasons.  But with stresses on caring for high volumes of sick patients, a willingness to work and threshold of skill rises in importance.  Doctors get the most attention but good medical care also depends on nurses, technicians, housekeepers with their disinfectants and secretaries to direct patients to the right place and assure their appointments.  They are at personal risk and often have young families.  In a crisis we are all providers with a much flattened hierarchy.

As a reader of social media, medical and otherwise, the conversation in the charting rooms and doctors' lounges no longer focuses on the devaluation of physicians.  Those reviled dysfunctional EHR's have not gone away.  Eventually somebody will get back to our metrics and RBVU's.  But for now we are focused on good outcomes for patients.  Not just the doctors but the managers.  We are all rowing our canoes in the right direction.  Professional antagonism, even animosity sometimes, no longer appears in the physician restricted or public postings.  As we watch TV, we wish there was a Gong to get the President off the podium so we can hear from the learned doctor instead.  People have better priorities from this health stressor, both in public and in private.

Like most calamities other than the extinction of the dinosaurs, Covid-19 will one day pass from the forefront to fond anecdotes and ultimately to the history books.  It remains to be determined if the professional nobility of thought and expression will remain.  But for now we can admire those doing their best to mitigate our crisis and take comfort in knowing that our loftiest doctors can rise in stature above all others.

Not on Weekly Schedule

Every Sunday I outline my weekly schedule on a white board.  If it's a day ending in zero other than Shabbos, Sermo gets a notation in green marker, though not this week.  I'm just no longer interested. 

It's not the first social media that I've abandoned.  There was a great site called classmates.com, great only if free, that predated Facebook.  I reconnected with a lot of the old crowd that way, dumped en mass when a fee was added.  I used to chat with the 40-somethings every morning and some Jewish group chat in the evening.  Screeches from Abdul were worthy of mass use of the Ignore option but enough participants preferred to engage him and the site no longer was attractive.  Physicians Online introduced me to cyberspace.  They had a physicians chat or posting room.  It did not take long for it to appear as a talk radio echo chamber.  As Physicians Online became Medscape, they made a business decision to abolish the service rather than police it.

Sermo once served as a daily destination, a place to make virtual friends.  It took longer for the echo chamber to take over, but it eventually did.  My sign-in dwindled from daily to dates that end in zero but until now remained on schedule.  The new format did not help, hard to navigate, more international posters with concerns different from American physicians, and most importantly, lacking the sharp analytical minds.  Just not on this week's weekly planning.  Not interesting and really not interactive, which could take the mundane on more intriguing directions.  But they still do not charge a fee.  I'd have been gone long ago if they did.

Inundated by Covid-19

Last time I got in on the ground floor of a new disease, AIDS, I completely missed the boat.  I saw early AIDS as a VA hospitalist, not so much as an endocrinologist, so I never really learned its management except as related to adapting endocrine drugs.

Ebola, West Nile, SARS all passed me by professionally.

Now we have a new infection, a serious one, that dominates the news.  It is far rarer than things that I really see like diabetes, hypothyroidism, opioid OD's and respiratory infections of mostly non covid-19 pathogens.  Since nobody's really an expert, most of all the President and VP, it is another chance to enter on the ground floor of a new disease.  Too many distractions for me to become more than a novice at this one too.  But at least I should be able to master the classification of the respiratory viruses and get a better grasp of epidemiology this time.