Breathing 'Rheum' in COVID-19 Hotspots: New York City’s heart still beats ‘behind empty streets’
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Under normal circumstances, most New Yorkers thrive on being at the epicenter of civilization and culture. COVID-19 has raised the question of what happens when that civilization and culture is taken away. As residents hide out, many of them in cramped homes and studio apartments, health care workers from the biggest city in the world face challenges they have never had to face before.
As of June 18, 2020, New York City hit the grim milestone of 17,500 COVID-related fatalities, with more than 54,000 hospitalizations and 208,000 cases overall. Grace C. Wright, MD, PhD, president of the Association of Women in Rheumatology and consultant rheumatologist in New York City, sat down with Healio Rheumatology to tell some of the stories behind these numbers.
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Wright: The panic of possibly not being able to afford to keep my practice open was the first hurdle; that panic freezes and immobilizes you from finding a feasible solution. My advice to other rheumatologists in this position is to cut the panic and put logic back in place. This is a very stressful time, but we have to figure this out.
The next step is to manage the panic our patients experience about their health and do this without being able to really talk to them face to face. That was my situation. New York was not an initial zone for telehealth, so we did not have that infrastructure in place for our Medicare patients. Many other parts of the country had a much better toolkit for communicating with patients because telehealth was already in place. Not only did we have to figure out the technology, we had to teach patients how to use it and get them to trust this process. We were very unprepared for this.
Q. How did you get these communications up and running?
Wright: We had to figure out what tools we needed, what kind of internet access we had and what access our patients had. We needed to assess how tech savvy each patient was; some use communication technology every day, while others are much more reticent. Medicare relaxing the standards opened things up. For many patients, we use FaceTime, because this is something they use with their families every day, and, for others, we are able to use standard telehealth technology.
Q. Are you concerned about privacy issues with FaceTime and other non-secure technology?
Wright: At least we now have a way to call people, to see them, which is just so important. I agree that it is not ideal, but people are dealing with both physical and mental stresses from this pandemic. Just seeing their faces has been beneficial. You can tell a lot about how a patient is doing by watching their face as they talk. When the call goes through and your face pops up, they say, “I see you!” You are a trusting face, a source of accurate information. It is worth the tradeoff.
Q. What other impacts has this had on your professional life?
Wright: I would like to talk about two other aspects on the professional side. A big one is the lack of access to colleagues. Ordinarily, when a patient has a question that is better suited to another specialist, you can call them up or find them to talk. But everyone is busy, or everyone is at home, so when a patient has questions — even if they are outside of your field of expertise — you are it. You have to help this person. It puts another hat on your head. Things that used to be easy, like calling up a colleague, are not easy anymore.
Q. What is the other aspect on the professional side?
Wright: The rhinoceros in the room is the financial situation. Physicians are taking a hit just like professionals in other sectors. You need to figure out how to float financially, and how to make it all work. You need to figure out how to pay your staff. Essentially, it is a matter of creating a new business model from scratch, on the fly. You need to understand your margins, you need to figure out how to apply for assistance, how to get the money and how to do all of this through the proper channels. All of this is in addition, mind you, to the emotional strain of seeing scared patients in the middle of a pandemic. You have to survive and keep surviving.
Q. To that point, how difficult has it been to acquire personal protective equipment?
Wright: Impossible. Again, the things that used to be easy are not easy. We have been paying $5 a mask for N95s. Suddenly, there is a limit on the number of sanitizing wipes you can purchase. If you are not a regular customer for a particular vendor, they will tell you they are out of stock and do not know when they will get more. Also, the prices are outrageous. I just bought a plastic face shield for $10 that I know costs only 10 cents to make.
Q. In terms of other clinical matters, what about in-office infusions?
Wright: We try to do all of them on Monday and Tuesday, with social distancing measures throughout the offices. People need their infusions. Of course, some patients have well-controlled disease and can go for some time, but I know what a lot of my patients look like when they are forced to delay treatment or miss even one dose. Many will not do well if they go for months without their medication.
But, that said, our infusion volume has gone down by 50%, so we have to continually educate patients to let them know that a disease flare in this current situation is bad. We do not want them in the hospital. As this evolves, and patients are reassured of the many precautions we have instituted, they are now coming in for their treatments.
Q. Have you identified which patients are not coming in for infusions, and why?
Wright: The ones we are most worried about are the ones who have to take public transport. They are worried, as well. Although, I have to say, the New York City subways have not been this clean in decades. We have other patients who are sequestered in the Catskills, the Poconos, the Berkshires. How do you get them infused? We just have to maximize them on oral therapies and hope for the best. When patients want to cancel, we do everything we can to figure out how to make it work.
Q. With the recent push for prophylactic hydroxychloroquine for COVID-19, have you noticed drug shortages in your area? Have your patients?
Wright: Immediately. It started happening right after the first public announcement. Pharmacies were refusing to fill prescriptions or were giving patients just 14 days’ worth of the drug. That is negligence and puts their health at risk. Patients need 90 days of this drug, because you do not want them to keep coming back to the pharmacy and exposing themselves to possible infection.
Patients who have been stable on this drug for years are panicked. There is no data showing that this drug can prevent COVID. The irony is that, on the flip side, we have patients who have been refusing hydroxychloroquine for years and are now demanding it. So, it is a complex scenario.
Q. Shifting away from the clinic, can you talk about the mood on the streets in New York?
Wright: My commute from New Jersey used to take 90 minutes — now I can do it in less than 20. So, of course, that is a benefit for those of us who are still working. But the streets are empty; it is truly like a ghost town. The thing is, you have this knowledge that there are a lot of beating hearts behind these empty streets. You know New York is still there, it’s just wrapped up tight. It is eerie and peaceful at the same time.
Q. Other people have noted similar things, that there is this balance between fear and peace.
Wright: I am glad to still be working, because we have a lot of friends who had good jobs that they liked, but are no longer working. We feel fortunate that we have a house that allows us to work in separate spaces, because we know a lot of people who are in cramped apartments.
Q. People are making adjustments.
Wright: The other day, we were unable to place an order for lunch — such a simple thing. Every day, we would order pizza or Thai or Indian, but now most places are closed, so we had to look around the office to see what we had. There were some crackers from the day we had soup, and some chocolate leftover from Christmas, and a few bottles of water in a cabinet. OK, there’s lunch. As I said before, the things that used to be easy are not easy anymore.
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References:
New York City statistics
For more information:
Grace C. Wright, MD, PhD, can be reached at 345 East 37th Street, Suite 303C, New York, NY 10016; email: gcwright.md@gmail.com.
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