Life in the time of COVID

A few days ago I held the COVID-19 “pager” for my hospital. I couldn’t keep up. For every call I answered, 3 more showed up. In my 21 years as a physician there have been quick emergencies during which I couldn’t keep up with calls. But nothing close to this.

As our hospital, which serves over a million people in Vermont and surrounding states, gets reads for COVID-19 to hit hard, I’ve worked incredible hard, and been inspired every day. The way our hospital and our entire health network works has been entirely changed. Whole hospital floors retooled. Thousands of elective surgeries cancelled. Buildings commandeered. Entire clinical processes and teams fully made a new over and again.

I direct our ethics program, and a cascade of questions have kept me busy. If we run out of hospital beds or PPE or mechanical ventilator, how should we apportion them wisely? Should we resuscitate someone with COVID-19 even if it could infect their caregivers and the next patients those caregivers see? Should we save the lives of children over older adults? Is it ethical to consider disability in resource allocation schemes?

Even as we address hard ethical and scientific questions, one of the biggest challenges of the COVID-19 epidemic has been getting trustable information out to the general public. Questions abound, from should I stay home (yes), to should I get tested (not if you are stable), to should I take hydroxychloroquine (probably not) . Oh, yeah, and is the grocery store totally safe? (No, but nowhere is).

Here is one example of a PSA put out through the magic of our hardworking communications team. I hope you like it. More to follow, and today I’m going to try my first Facebook live Q&A about the novel coronavirus to see if that is helpful.

When the best medicine means asking parents to leave the room

I struggled to get the burly 20-year-old construction worker to talk about his fatigue.

Was he sleeping okay? “Yep.”

How was his mood? “Fine.”

At this point the patient’s mother, sitting in the chair beside him, broke in. “What he’s trying to say,” the mother said, giving the patient a playful punch to the deltoid, “is that he …”

After that, the patient’s mother talked more than he did. She provided articulate descriptions of her son’s symptoms, occasionally interrupting him to do so.

“He hasn’t told you this,” the mother said at one point, “but on weekends he drinks a lot with his friends and … well … I wonder if that relates to what’s going on?”

I had wondered the same thing. Also, I needed to get the patient’s mother out of the room.

For more on how to support young adult autonomy and self-advocacy, check out my new article at the Washington Post.

Did you know hospitals hire "secret shoppers" to understand the patient experience of care?

A nurse walked in with a loaded syringe. “Can you lift your gown?” she asked.

The woman on the gurney held the scratchy emergency room blanket closer to her chin. “What’s in the syringe?” she asked.

The nurse frowned. “Don’t you want the medicine your doctor ordered?”

The woman took a deep breath and kept asking questions. She had more than just self-interest on the line.

She was a “secret shopper,” a consultant pretending to be a patient in order to evaluate the quality and culture of care in a hospital.

TO learn more, check out my article at The New York Times.

How professionalism grades hurt medical student professionalism

I love the profusion of new ways to teach and assess professionalism in medical school. It’s a huge advance from the days when people like me could still get in.

Yet, there are sharks in those waters. My friend and med ed collaborator Dr. Roshini Pinto-Powell of Dartmouth’s Geisel School of Medicine and I describe one of those sharks: numerical professionalism grades.

It starts with good intentions: we create a grading rubric on the thought that we should take professionalism AT LEAST as seriously as other topics in medical school. And the easiest way to grade is on a Likert scale.

Yet, we argue, boiling down something as complicated as professionalism into a simple, arguably meaningless professionalism grade is perilous. One reason why is that it imposes external incentives on a complex task, a combination known to sap students’ internal motivation.

That means we might begin with the intention of highlighting the importance of medical student professionalism, and end by undermining it.

Fortunately, there are better ways forward.

To read more, check out our full text publication at the Journal of General Internal Medicine, here.

How we honor a new organ donor

The double doors of the surgical intensive care unit opened into a hallway crowded with dozens of hospital employees. A hospital bed emerged, and we all fell silent.

Most beds roll out of the I.C.U. briskly, en route to radiology or an operating room, whirring with the beeps and blinks of monitors and the quick conversation of busy nurses.

This bed was different. It moved at a stately pace, and the team that accompanied it was changed as well. Nurses steered, but there was no chitchat this time. A tall anesthesiologist learned over the head of the bed to squeeze a bag valve oxygen mask with clocklike regularity.

People in street clothes trailed close behind the bed, unsure of where to look. These were the parents of the young woman in the bed, the one we had all come to honor.

This was an “honor walk” for a dying patient about to donate her organs to others.

To learn more, check out my new article at The New York Times.

A harder death for people with intellectual disabilities

Several weeks after my patient was admitted to the intensive care unit for pneumonia and other problems, a clear plastic tube sprouted up from the mechanical ventilator, onto his pillow and down into his trachea. He showed few signs of improvement. In fact, the weeks on his back in an I.C.U. bed were making my 59-year-old patient more and more debilitated.

Still worse, a law meant to protect him was probably making him suffer more.

When the prognosis looks this bad, clinicians typically ask the patient what kind of care they want. Should we push for a miracle or focus on comfort? When patients cannot speak for themselves, we ask the same questions of a loved one or a legal guardian. This helps us avoid giving unwanted care that isn’t likely to heal the patient.

This patient was different. Because he was born with a severe intellectual disability, the law made it much harder for him to avoid unwanted care.

To learn more, including what happened, read my new post here at The New York Times.

Let Opioid Users Inject in Hospitals

It is a new world in health care as America grapples with an epidemic of opioid drug abuse. The Centers for Disease Control and Prevention reported that opioid overdoses killed over 28,000 people nationwide in 2014, more than ever before.

From heart-valve infections to drug overdoses, the casualties of this epidemic wash up in our hospitals. It has changed my hospital service significantly. Almost every day, we try to save a young person dying from infectious complications of injection drug use.

Addicted patients usually bond with their providers over the shared goal of healing. Yet these interactions, which often bridge divides of class, culture and personal psychology, can break down. When addicted patients inject drugs in the hospital, doctors and nurses can find themselves cast in the role of disciplinarians, even jailers.

Confining patients to their rooms, restricting their activities and posting guards is expensive. It may also compromise a patient’s well-being: Ambivalent providers may visit less often, educate patients less avidly and spend less time devising the best treatments.

The worst effect of confining addicted patients in the hospital may be the damage to the patient-provider bond. 

To read more, including my proposal to let opioid users inject in the hospital, check out my new op-ed at The New York Times. 

Also, check out my new 8-minute radio spot about the topic at for Word of Mouth by Virginia Prescott at NHPR. It was also a trip to appear on Sirius XM's widely-syndicated Michael Smerconish show, although a recording has not been archived. The controversy the post created was nicely covered in Concord's Union Leader.