What’s it like to be a doctor in the middle of the pandemic? I had a chance not long ago to talk with a New York surgeon about his experiences, on the condition that we would not use his name. Here’s a transcript of our conversation, edited for length and clarity. This is intended to be the first of a series.
Was there anything that particularly surprised you about Covid in the hospital?
New York doctor
Nobody had ever seen a situation where people could deteriorate as rapidly as they do. Patients can be really, really sick and not realize how sick they are.
The hospital systems were all so overwhelmed at the start, because there was this massive surge, that you couldn’t get admitted to a hospital if you weren’t actually having oxygenation problems. So if you had a fever and chills, but your oxygenation was O.K., and you went to your local E.R., since the first few weeks of Covid you are going to be discharged home.
But if you start then getting a little bit short of breath, do you have the wherewithal to get yourself back there quickly enough?
An example. A husband and wife. The wife’s brother and their son both got Covid and they went to a hospital in Westchester and had symptoms but were not short of breath and did not have hypoxia. So they were sent home.
The son was helping take care of the father. He was getting short of breath. But he didn’t want to go in the hospital because he wanted to make sure his father was O.K. By the time that he got himself to the E.R. finally, he was so short of breath. And his oxygenation was a level that we just don’t see people walking around. And three days later, he died of a cardiac arrest. And his father ended up on a ventilator and actually died today.
I was talking to an E.R. doc at a Westchester hospital. “Yeah,” he goes, “you just can’t believe how quickly people deteriorate, and it’s not right away. They get a little bit of fever and some muscle aches, and it’s five or six days later then all of a sudden, patients go from O.K. to not O.K., not in like a day, but in like an hour.”
How the virus spreads
What most surprised you about Covid outside of the hospital?
How much we still don’t know.
Initially, everybody thought, which is probably correct, that almost everybody gets infected by touching something and then touching their face somewhere.
But then there came this report out of Seattle about this choir practice where the whole choir got infected. Even though they were very close, they weren’t touching each other. So clearly in that situation, there is an ability to aerosolize virus.
There were a bunch of reports in the medical community about ENT (Ear, Nose, and Throat) surgeons in Italy and in Iran and in China, who were doing nasal procedures with endoscopes, where there was presumably a very high load of virus in the air at the time. People were getting super sick — they were getting this uber-dose of virus.
But the reality is, that type of situation, outside of a hospital environment or being a foot away from somebody yelling at a sports event, or singing, probably doesn’t happen very often.
And so the majority of it probably is what people thought that people transmit the way we think. But people don’t know that.
Another thing: In New Rochelle or Bronxville, Larchmont, in those communities, I’ve been asking around, nobody knows anybody who’s gotten sick in the last week, two weeks. It’s almost like it came. And then everybody kind of shut down.
That works on a small community basis. But how do you translate that? And how long does it take?
When I was in the hospital recently, the chief surgeon and the chief anesthesiologist were white men, and everybody else was black and brown women, all the nurses, everybody else who was working there. And I look at pictures of the New York City subways these days, then they’re packed with black and brown women. And I think there’s something to be said about that.
Well, I think the question is, is there a predisposition to being more ill among certain groups in society based on some genetic predisposition? Is there some aspect that makes somebody more likely to get really sick?
I don’t think we know the answer. I would imagine in your neighborhood, like my neighborhood, there aren’t many people who are 55 years old, who are obese diabetics.
Whereas you can go to parts of the city where it’s very, very commonplace. And you can say, O.K., there are much larger medical and demographic problems in minority groups. There are all kinds of aspects about access to space, access to food.
It may also be an aspect of those being the people (overweight, diabetics) who when they get really sick, aren’t able to fight it off as well.
When Covid hit the hospitals, the hospitals basically got converted to Covid hospitals, which means Covid is everywhere. And yet, despite the fact that there’s obviously been some doctors and nurses who have gotten very sick or died, proportionally, it’s a very small number. A lot of the really bad exposures, where people got really sick, happened when people didn’t really know it was here. I had three or four residents who had been working in an ICU get sick. They were feeling really bad, and were at home for a week, 10 days, two weeks. But I don’t know a lot of people in the last four weeks since.
People have really been a lot more careful in the hospitals.
And so how is that going to be different than sending people back to work? You’re going to have an environment where it’s going to be much lower risk than in a hospital.
So it seems to me at some point, you can say, O.K., we’re going to start with healthier people. We’re going to send them back to work for a couple of weeks. And we’re going to start with people, whatever, you can make whatever you want under 50, under 55, then you’re going to go up five years at a time.
And everyone’s going to wear a mask for whatever period of time until you’re certain that nobody’s getting sick. The hospitals have already done the experiment. You can’t be in a higher risk environment than a hospital. And yet most people haven’t gotten sick.
How many people didn’t get sick
That’s fascinating. Is anybody studying that?
None of the hospitals ever had enough testing to test all the health care workers. So you don’t know how many people ever had it. But you can test the backside of it and see how many people were exposed. How many people have antibodies.
It’s equally helpful to know how many people don’t have antibodies. How many health care workers who have been coming to work every day do not have antibodies, meaning for whatever reason, they never got sick from the virus, because of whatever precautions they were taking?
That hospital environment is so much more dangerous than anything they’re ever going to face on Wall Street or in any other job.
In our hospital, we could only start getting tested for the PCR test as a doctor, middle of last, not last week, the week before. So 10 days ago, if you had appropriate symptoms, you could get a nasal swab test.
Before that, if you had appropriate symptoms, go home. Come back when you haven’t been symptomatic for three days.
I’m sure when we look at all the data from the major New York hospitals, it’ll be really interesting. Word of mouth in our hospital: There have been very few doctors and nurses who have ended up really sick since people realized, O.K., this is what we all need to be doing. At that point, if you’re following precautions, the testing is less important.
The hardest part about New York is people don’t like to listen. That’s a big part of the difference between New York versus Seattle and even San Francisco. New Yorkers pride themselves on not having to listen. But doctors listen. Nurses listen, respiratory therapists listen, because they’re working in that environment. So we’ve already been the guinea pigs. And there were plenty of people nervous about being guinea pigs, but in the guinea pig environment, most of the guinea pigs did just fine.
But the tests aren’t very accurate, right?
When there is better validation of a few tests, and people know, O.K., this is 97% or 98%, accurate, whatever, we’ll get to that point.
But in the meantime, everybody just has to behave like we do at the hospital.
Nobody in a hospital is doing anything special: they wear a mask, wash their hands. And every patient that comes in, you assume they’re positive, even when they’re not.
So you treat everybody the same and then eventually if you treat everybody the same, then the mistake transmissions go down. And then eventually, at some point, we can treat everybody the same, a better way, without having to keep isolating and distancing.
Is there something specific that you notice in yourself, that has changed as far as how you act? How you work, how you think?
I think that everybody is just a little nicer. Whether it’s my kids, or colleagues professionally.
Anybody can get sick from this. It’s a great equalizer. Everybody has similar fears, uncertainties. We’re all equally at risk.
Somebody said that a few weeks ago. It was actually our local minister on Easter Sunday, his sermon was exactly that — how much he had noticed that, you know, even though people have masks on crossing the street, that people would take the extra second to stop and ask, “How are you doing? Is everything O.K.? Do you have everything you need?” you know, people being better humans in a lot of ways. The hope is that when this leaves that people remember that.
The hospital after Covid-19
What a terrific answer. Can you talk a little bit about long-lasting changes for the healthcare system for doctors?
The whole start was nobody had any idea what it was going to look like. Nobody had any idea how well social distancing was going to work. At the beginning, it was, how do we not overrun the healthcare system? For a little while, the ERs were overrun, and the hospitals came close, but they never got there.
Then all of a sudden, everybody staying home worked a lot quicker than people thought.
Then it became a matter of, O.K., what we’re doing is working. Now everything’s focused on, how do we get to the next phase of healthcare, where we know Covid is going to still be around? How do we reintegrate healthcare, knowing that there is going to be some Covid that we’re dealing with?
And then how do we get from there to hopefully a point where we’re not having a second bump?
Right now, so even though the hospital is still full of Covid the hospital focus is already on transition. Whereas six weeks ago, it was survival.
Every patient who comes in the hospital is going to get tested. Already now, if I have a patient who needs surgery, they get same-day COVID testing in a 90 minute turnaround test. Even if they’ve had a negative test last week, they get another one today to prove that they’re negative.
It’s more about keeping the hospital Covid and non- Covid. So you can have floors or areas of the hospital or maybe even whole hospitals. Montefiore may take one of their hospitals and say, “anything that’s Covid we’re shipping here. And we’re keeping this as a non- Covid hospital.”
That’s the next step that everyone’s focused on now.
There are still a lot of really, really sick patients. But everybody’s already realized that the faucet is mostly turned off. Not completely, but it’s much, much less now than it was. The problem areas now are areas that are harder to contain. Because they’re areas where you’ve got a greater population density, public transportation, you know.
Also people are starting to figure out better how to take care of these patients. They’re learning and because of the internet, there’s a lot of information sharing behind the scenes, say between pulmonologists and critical care doctors.
But the rest of medicine, either through patient fear, or not being able to do things that aren’t truly emergent — where did all those patients go? That is a huge problem. Because most people who need a hip replaced aren’t coming into a hospital for that surgery unless they’re pretty darn sure that they’re going to be safe. So there’s a lot still to work out.
How patients make decision to go back to the hospital
The “Total Hip Replacement” forum on Facebook is full of people saying “I didn’t get mine done. I’m going to be in a wheelchair by the time this happens.” We heard today about cancer patients who are not able or willing to get treatment. Let’s talk about returning to some kind of state where people who need a hip replacement or cancer treatment are going to be willing and able to go back to the hospital.
I think the psychological part of it for patients is going to be in some ways harder than it is for us.
I’m a neurosurgeon. So people who have to have surgery, a lot of those have to have surgery.
Now the ones who are elective can wait, and they’re waiting. The ones who are urgent — if they become really urgent, we can get them in for surgery now, otherwise they want to wait.
But the ones who have had to come in because of something urgent: I have not had anyone who has gotten sick as a result of coming in the hospital, with one exception of a patient who was in the hospital for weeks, and immunocompromised already from her cancer and in and out of the hospital.
You’re not putting a Covid patient in a room or on a floor with a non-Covid patient. And so, I think the patient’s psyche of that is going to lag behind the medical reality, which is that once the hospitals figure out how they’re segregating, that, it likely will be safe.
And so then it’s just a matter of how much time does the patient want to give that to be certain? And that’s going to depend on how urgent their condition is.
Look, I mean, if you’re a cancer patient, you need your chemotherapy.
Medicine learning how to be more efficient
We talked a little bit about the long-lasting changes through the healthcare system for doctors, patients and administration. Tell me more.
There’s a lot that people haven’t figured out.
So the concept where you would come in to see your orthopedist. There’s three docs having office hours, they’ve got a waiting room full of people who are at all at various stages of their paperwork being seen. That’s not going to happen for the foreseeable future.
So how do you set that up? How much is going to be screening appointments by video to determine whether you should have a face-to-face appointment? I mean, you can’t examine somebody over Zoom, but you can do a fair bit.
There’s going to be a lot more telemedicine initially, which some of which will be a good thing and some of which will probably stick. And then there’ll be a lot more organization to make certain that there’s more distancing between patients and every patient is going to be screened.
I think it’s going to completely change how we do medicine, at least for the foreseeable future. But then the question is, how long does that take? Is it ever going to come back to how it was? Should it? We need to improve health care as a result of this and not just strive to go back to how it was.
One of the things that’s always made Mayo Clinic so effective is that they do one-stop shopping. You go to the Mayo Clinic for a day and you see all five of your doctors, and it’s completely organized.
But in New York, you’ve got eight different doctors for your five different problems and their offices are apart. And sometimes they talk to each other, and other times they don’t. And the hospitals are going to have to figure out — even in a complicated medical environment like New York — how do you fix that?
When you have extreme conditions, you start realizing you have to do things differently.
I think that medicine is going to become more efficient as a result of it.
What do we do about the question of immunity? Whether if you have the antibodies, maybe the test reflects immunity, maybe it doesn’t — we don’t really know.
Nobody knows, obviously. I’ve had two antibody tests, one, the super rapid test, the other is the Elisa test, where they take your antibodies, and then they dilute it out to see how far out you still have antibodies, which gives you a theoretical view of how strong your antibodies are.
Both of those for me are negative, which I have to say I found incredibly hard to deal with at first.
Because I figured I’d kind of paid my dues and I should be positive. I’ve done my time. I’m mostly quarantining away from my kids. If I knew that I had already been infected, I wouldn’t worry about seeing my kids. Part of that is because if you look at other viruses, and particularly other coronaviruses, people don’t generally get the same coronavirus infection in the same season multiple times.
People have done research on people who get coronaviruses like the common cold and usually it’s kids — maybe they’ll get a coronavirus in the spring and get the same one in the fall.
When that happens, it’s usually kids but, but also with the common cold usually the second infection is much milder. Even when that happens, but that’s not happening back to back.
So based on what happens with other viruses, it’s pretty unlikely if you have a real antibody response — say we figure out a test, that’s able to say that somebody’s got a strong antibody response, with a high degree of sensitivity and specificity — the likelihood is that that person is going to be pretty darn safe.
How people return to work
That’s one of the interesting things because there are maybe 130 tests by now, of which many are not that accurate.
The FDA gave all these companies green lights initially, but they haven’t validated any of these tests enough to agree to say we really know. But I mean, that’s going to happen pretty quickly, because there’s so much riding on that.
I don’t feel like you have to have a negative antibody test or a positive antibody test to send somebody back to work. Now, what do you do with somebody who’s a 65-year-old overweight employee with emphysema? For that person, you know, yeah, that person, you would either want to have an antibody test, but probably there, if that person had Covid, they’d know it, and they would have known it.
All my friends who I thought were sick, every one of them who’s been tested has been antibody positive. Clinical diagnosis is better than a test for most of those people.
So for somebody like that, who’s has not been sick, and is unlikely to have been exposed without being sick — What do you do with that person? That’s a hard call. Because the way you get people back to work is you start with the people who are lowest risk, and even independent of their antibody status. Again, if people just are really careful about their hygiene, they’re pretty unlikely to get infected.
I’ve been in and out of ERs, ICUs, operating rooms with patients who are Covid positive, and I don’t have antibodies. And I’m not doing anything special beyond what anyone else in the hospital is doing.
The epidemiologists need to know, O.K., how much herd immunity is there? How many people were asymptomatic spreaders? What’s the true death rate? You know, what’s the true death rate in that patient? We just said a minute ago. So if you are a 65-year-old Caucasian guy who’s got a body mass index of 25, overweight, but not morbidly obese and you have no diabetes, if you get sick, what is your percentage of ending up in an ICU — at the end of all, this, all of that should be calculable.
And at that point, people have to make their decisions in their minds, because there’s always going to be risk, no matter what.
If we said, ‘Oh, well, we can’t reopen the economy, because it’s too dangerous.’ Nobody said that about hospitals. We didn’t have a choice. Again, I’m really looking forward to seeing what the hospital numbers are. Because I think once the first few weeks were gone, I think they’re going to be a lot lower than people think.
Is there any big question that we haven’t touched on?
What we’ve also learned as a whole is how unprepared we were, whether it’s the psyche of “it’s not going to happen here,” combined with a little bit of a weatherman phenomenon, but it’s the opposite right now.
If you’re a weatherman. If you over-call a snowstorm, you never get in trouble. Right? If you under-call a snowstorm, you’re in deep trouble, because everybody’s on the roadway, cars are crashing, kids are in buses overnight.
So at the start of this, nobody wanted to be on the wrong side of the curve, the short side of the curve. But despite that, when you think about it, nobody wanted to build up months in advance either.
Because if it turned out that it wasn’t really necessary, you know, what are we doing bringing 10,000 new ventilators into New York and turning the Javits Center into a hospital? We’ve largely been reactionary, and still are, even when you look at the testing. It’s still reactionary rather than “how do we actually take what we know and get a step ahead?”
That’s problematic. Hopefully, that will be one of the things that people learn, is that reactionary doesn’t do well, for the healthcare system. Because the healthcare system does a lot better when you anticipate rather than when you’re stuck reacting.
Doctors and a negative test for Covid
Wait, you said both of your tests were negative?
Early on, I thought I was sick. In fact, I was pretty sure I was sick, not classic Covid but what’s now known to be Covid symptoms.
I was petrified that I had either infected patients or that when a bunch of my friends got sick, could I have been the source. If you’re pretty sure as a physician, you’ve already been sick, kind of makes you a little bit bulletproof in the hospital. A lot of doctors I know at the hospital, maybe that’s what we have to do to stay sane. A lot of my colleagues are convinced that, that they’re positive, that they’re immune. But then all of a sudden, when you find out that you’re not immune, it’s tricky.
I was talking to a buddy the other day, who’s a vascular surgeon. They put in all the lines that their really sick patients needed in the ICU. Every patient they’re seeing is super high risk. He’s been doing that for the last few weeks.
And we were talking, we were trading notes a couple days ago. I’m like, “F–k, my antibody test is negative.” He’s like “mine too,” Probably only people with more exposure than him are the ER docs.
Think about it. In Singapore, supposedly, once they realized how transmission was happening
but in the hospitals, the only precautions that they had were gloves, surface and hand washing and masks. That’s it. And it’s supposedly none of their health care workers after like the first week got sick.
That blows my mind.
Yeah, but it’s also encouraging. Now that I’ve gotten my brain around it, the thought that all these friends of mine who have been in the hospital a ton don’t have antibodies — it’s also encouraging. Like it means you don’t have to be a superhuman to not get infected.