MY FIRST YEAR OF PRACTICE DURING A PANDEMIC Ryan R. Guinness, MD, MPH I had just become an attending and one of my first tasks was COVID-19. While I had studied historical pandemics and their epidemiological concepts during medical school and my public health degree, I was now living and practicing during one. It felt like unchartered territory. Though, as the pandemic advanced, familiar sentiments that I had experienced during the early days of residency began to emerge. It was as if I was an unblemished learner all over again. Just when I had thought my medical training was finally over, little did I know, that it was only the beginning. As the novel COVID-19 spread across the country, medical centers had to switch their healthcare delivery strategy overnight. The need for innovative measures to provide highquality patient care and manage its spread had become more imperative. I had never used video as a means to connect with a patient during any aspect of my medical training, yet within a few weeks into the pandemic, this was now the norm. I had my initial reservations. From the early days of medical training, I was taught the merit of the physical examination; auscultating the lungs or palpating the abdomen – the importance of ‘touch’ in making a clinical assessment. That same element of physical connection cannot happen in a virtual care model. Instead, I had to quickly adapt to this new kind of clinical encounter. This required learning on the fly, how to try to make the same clinical assessment using other objective measures, all this while trying to maintain some form of ‘webside manner’ with the patient. Part of this shift involved recognition that the scope of virtual practice has its limitations. A lot of objective data can certainly be gathered during virtual encounters – history of present illness, gross inspection, and/or data that patients can gather themselves with common devices (e.g., glucometers, home blood pressure monitors, thermometers, and weight scales). In contrast, it’s just as important to recognize that there are certain conditions not amenable to virtual care, including any new or significant emergency symptoms. New workplace safety standards had to be implemented. These included universal facemasks for all staff and physical distancing, which meant physicians could not be working so closely to one another. Creating staggered physician schedules (e.g., 50% home / virtual care, 50% in-office) helped to facilitate these kinds of standards. With most practices implementing a virtual-care-first strategy, inevitably some patients would need WWW.SFMMS.ORG
an in-person evaluation. Being able to navigate those patients into some form of ‘respiratory’ vs ‘non-respiratory’ status, with accommodating clinic workflows, allowed for lowered risk of exposure for clinic staff. Many more changes are on the horizon as we continue to endure this pandemic and begin flu season. As such, we need to keep adapting quickly. I find myself constantly learning and adjusting during this pandemic. Our knowledge of COVID-19 evolves on a weekly, if not daily basis. Articles surrounding COVID-19 continue to be published, as our understanding of the disease changes. Keeping up with the latest information can be daunting, all the while trying to do what is best for the patient in front of you, in-person or on a virtual platform, on any given day. Compounding these difficulties is a strong sense that the federal government and affiliated agencies, have not supplied the sort of clinical leadership that the moment demands. To fill that void, many of us have had to look to high-impact medical journals and academic institutions for guidance, while also relying on more informal networks to get the information and support we need. For instance, some medical centers have sought to provide regular updates through regularly-scheduled Town Halls or even virtual podcasts. Courage conquers. When others retreat from the lines of danger during a pandemic, healthcare providers run towards it. At the beginning of this experience, it meant taking care of patients despite not having enough Personal Protective Equipment to do the job safely. There was also constant worry that despite every precaution, we could bring the disease home to our loved ones. Of the many sad realities of this pandemic, most notable is that it has brought to the surface health inequities that have always existed. Black and Brown people are disproportionately affected by COVID-19, as they are by most other chronic conditions in medicine. The Black Lives Matter movement, reignited by the deaths of George Floyd and others at the hands of police brutality, have shed more light on systemic racism and its implications in many facets of our society, healthcare being one of them. “Put your oxygen mask on first” is a phrase we use to prepare for an impending flight emergency. In a similar realm, we can think about this concept when we describe the importance of self-care among physicians during the pandemic. At times, it can feel as though we’re fighting dual pandemics: COVID-19
NOVEMBER/DECEMBER 2020
SAN FRANCISCO MARIN MEDICINE
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