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COVID-19 Update: April 11, 2020, Discussion with Knowledgeable JRC Doctors

04/22/2020 03:50:50 PM


JRC is working to help our members stay connected during the COVID-19 pandemic and its ever-changing implications for our community. Our working group of staff and lay leaders continues talking on a daily basis with health professionals. JRC's board president Elliot Frolichstein-Appel recently had an opportunity to chat with Rhonda Stein and Ed Smolevitz, two married doctors who are long-time JRC members. An edited transcript of that conversation is below.


Elliot: Thank you for sharing your experience with the JRC community. How is COVID-19 affecting your everyday work?


Ed: Both of us work in general internal medicine with NorthShore University Health System, with a heavy tendency in both of our practices toward geriatrics.

I do a lot of nursing home work – roughly 20% of the patients I see, but 40% of the patient visits I do. Before COVD-19, my typical day would be 60% office visits and 40% nursing home visits. Of the patients see in nursing homes, many of them are there on a temporary basis. We call these “skilled” patients because they are in a skilled nursing facility recovering after a hospitalization before they can continue to get better at home. The other group in nursing homes is what we call “custodial” patients, and they are there for the rest of their lives due to chronic conditions, many associated with aging.


Rhonda: I see a lot fewer nursing home patients than Ed does. He's at nursing homes a lot. Most of our colleagues don't do nursing home rounds at all, so Ed picks many of those up, either temporarily during their nursing home stay for “skilled” patients, or becoming their primary doctor for those who become “custodial”. I'll do rounds for my own patients in a nursing home. Only about 10-15% of my patients are nursing home patients. I think we both have a lot of JRC members of many ages as patients.


Ed: One thing that is new to us under COVID is that we are both doing a lot of follow-up phone calls for people who have had COVID tests through NorthShore, who are not necessarily our own patients. If they're positive for the virus, we talk them through precautions they need to take to protect those around them and to take care of themselves, as well as how to know when they need to go to the hospital. If their COVID test is negative, we talk through what else may have caused the symptoms that led to them being tested, and how to protect themselves from COVID.


Rhonda: Under COVID, like other doctors, we are trying hard not to bring anyone into office for routine visits. Instead we're doing phone conversations or video chats. It's harder to do that if our patients need some sort of test, like if we need to check their blood pressure and they don't have a blood pressure machine at home. In those cases we may need to bring them in for a quick visit to check vitals or run other tests. General wellness checks are much better suited to phone or telemedicine. But overall visits are down, as our patients are aware that they should avoid even doctor's offices if they can these days. For example, in a typical recent week I saw 4 or 5 patients in the office instead of a typical 40-50, plus about 20 telemedicine visits. So my face to face visits are down by 90%, and my total number is down by about 50%.


Ed: Last week, I saw about 20 appointments, of which only 1 came in, and the others were all telemedicine. I did 8 nursing home visits in person and 15 by telemedicine.


Elliot: We've all heard about the deadly outbreaks at nursing homes. How have those nursing home visits changed for you, Ed?


Ed: The experience of nursing home visits are now very different, and frankly a little worrisome because most everyone there is old or frail, and nobody knows who might be infected. I can't pull up a chair and hold my patient's hand while talking like I used to. I can still talk to nursing home patients, but now it's from 6 feet away in mask and gloves and a gown, and I do many fewer physical exams.


The whole staff is anxious. Not every nursing home has the same training, equipment or infrastructure as the hospitals. I am nervous both about whether I might be bringing any virus in inadvertently, and worried about catching it myself if I'm going in without the full PPE. If a patient has a cough or fever, the regular nursing staff at the nursing home is still caring for them, but they are also worried for the same reasons I am.


We both know several health care workers and others who have gotten infected and have since recovered. However, we really don't have a good way to predict which of the people who have been infected will have more severe or less severe symptoms. And despite the widespread hope that if you recover from this virus you will have gained immunity from it, it is still much too early in the research community's knowledge of this disease to be confident that that will be the case. So we see, even when there is a story in the news of an ICU doctor returning to work after recovering from an infection, that doctor is still wearing a mask like everyone else when he goes back to work.



Rhonda: NorthShore has done around 12,000 COVID-19 tests so far, and the positive rate only is only about 20%. A lot of the symptoms that prompt folks to get tested turn out to be flu and allergies. You can never know without testing if somebody who exhibits coughing or sneezing, or even some stomach complaints, is infected. You have to assume they are infected with COVID because it is so infectious until proven otherwise. A month ago, if a nursing home patient had a fever, it most likely meant they had a urinary tract infection, or pneumonia, or flu. Today, because this new virus is so infectious, there is a much higher chance it is COVID.


Elliot: You both have a lot of older patients, many of whom live in senior housing even if it's not a nursing home. How are they weathering the current situation?



All the facilities – nursing homes and senior housing – are on full lockdown. There is no more communal dining, no activities, no exercise classes, and no visitors. So it can get really lonely for these people. For example, I have one patient who is 87 years old with some dementia and lives with her daughter, who is an MRI tech at a hospital. The mom is not going to her day program and not seeing her buddies, so the isolation is very disruptive when the daughter goes to work all day. The change in routine is particularly hard for patients with dementia. Some of our more functional elderly patients have smart phones and internet access, so they are not quite as isolated. But the isolation is very hard for those with dementia and for those who have other trouble connecting.


We are also seeing patients and their families trying to avoid hospitals for other reasons. I have a patient who is 97 years old who may have a kidney stone. I'm working with her and her family to try to manage her pain at home, but she and her kids are adamantly opposed to bringing her into a hospital, because they are convinced she will get COVID. They don't realize that hospitals and urgent care facilities are separated to direct anyone with any respiratory issue into one building or office and still have other facilities available for other patients. If my patient needs to come into the hospital to treat her kidney stone, she can still get that treatment at a hospital that is not full of COVID patients. The virus caution is important, but it shouldn't go so far as to make a vulnerable patient avoid needed treatment.



Elliot: What suggestions do you have for those of us who are older and at risk, or who worry about our older relatives?


Rhonda: Really just stay in touch with your loved ones. The phone can be great at relieving isolation. Make sure you or your loved ones have food, medications, and a working phone or other device to be in touch. Family members can also show up and wave outside their window, but don't go in. Senior homes and hospitals all have no visitors unless the resident or patient is in hospice care, in which case they are usually limited to one visitor. If a relative is delivering groceries, for a senior who lives independently, it should be just one person doing deliveries, hopefully a relative who does not have to go out to work or shop on a regular basis so they are not exposed to lots of people before they come in. If your relative lives in a professionally-managed senior property, for the most part, you have to leave the groceries at the front desk and the staff will bring it upstairs.


Ed: One tricky detail that is a common concern is that many seniors rely on personal caregivers who are not professionally trained. These caregivers may be older themselves or have their own underlying health conditions, and they typically don't have paid sick time, so if they get sick themselves, they may feel like they need to keep working to support their own families. They may also not have great health insurance themselves. I also worry that some caregivers may work a few days a week in one building, and then a few more in another, which can be a dangerous way for them to transfer infections between two communities of vulnerable people.


Rhonda: That's true. If the caregiver essentially lives with your senior 24/7, it may be okay, but if they are going home to their family, and they have relatives who are going off to jobs, that is a concern. If you can swing it, the best solution may be to become your parent's caregiver yourself, at least through the end of this period. Not everyone can do that, though, and it's unclear if these buildings will let you in to serve as your own parent's caregiver. I had one 87 year old patient, and her daughter wanted to take mom to the hospital because she couldn't care for her herself. I asked about the regular caregiver, and it turned out the caregiver had been out sick, almost certainly with COVID, but was now recovered. In this case, the caregiver was more likely to now be immune, so she hopefully wouldn't get sick again and also would be at a much lower risk of spreading the infection.


Elliot: We have heard some anecdotal stories about some seniors not quite understanding the restrictions. My own mom insisted she had to go to the bank to deposit a check, so I had to walk her through setting up online banking and assure her she could do that from her apartment.


Rhonda: By and large, our older patients are getting the point. We did a Zoom seder that included our daughter-in-law's grandparents, who are elderly, and they report that they and their neighbors are being diligent about staying in their apartments.


Elliot: What else should we know?


Rhonda: I think we have both been impressed by how the whole NorthShore system has stepped up in this crisis. We think NorthShore is being quite nicely patient-focused and community-focused through this.


Ed: Many of our colleagues have volunteered to help staff the COVID floors in hospitals within the NorthShore system because, like many hospitals around the country, we need more doctors working with this large new patient population than just our regular ICU staff. We are both of ages that put us in a higher risk category, so we are doing mostly non face-to-face care. However, there is plenty of work for doctors to do outside of COVID care, so if we can focus on that and on keeping our patients out of the hospitals unless they absolutely need to go in, we feel useful in helping keep the rest of our health care system functioning.


Elliot: Thanks both for all you do! We hope to see you (virtually) around JRC, and we really appreciate your insight.

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