More silver linings of the COVID pandemic: Uplifting effects continue

Abstract

The phrase “silver lining,” is generally understood to mean the “bright side” that proverbially accompanies the darkest trouble. Arising from the oft‐quoted lines from Milton's “Comus,” the silver lining is the ‘light of the moon shining from behind the cloud.’ Having born witness to pandemic life for almost 2 years, emergency medicine physicians are yearning for a silver lining now more than ever. In late 2020, we wrote the article, “The Silver Linings of Covid 19: Uplifting Effects of the Pandemic,” hoping to offer the medical profession a few unexpected positive consequences that resulted from the pandemic. Those included: (1) the rapid development of telemedicine, (2) more time for family and self, (3) progressive use of personal protective equipment (PPE), (4) respect for front‐line providers, (5) intensified goals of care conversations and advance care planning, (6) attention on physician mental health and disclosure policies, and (7) improved management of COVID hypoxia. Now 1 year later, while we are recovering from the Omicron surge and still without a clear end in our fight against COVID, we would like to acknowledge additional silver linings as we continue grieving the devastating losses. SILVER LINING #8 INNOVATIVE REMOTE WORK PRACTICES AND “VIRTUAL” EMERGENCY MEDICINE Emergency medicine has exploded with virtual possibilities. The pandemic has demonstrated that telemedicine is a reliable channel for reaching patients and viewed favorably by both providers and patients. 1 , 2 Remote work from a virtual platform has provided a release from the pressure cooker setting of emergency medicine and offered career extending flexibility for many academic physicians. With much work being done from home, or even an interesting travel destination, virtual medicine has offered many clinicians both increased wellbeing and productivity. In a commentary article for the NEJM Catalyst, Hollander and Sharma wrote, “the future of emergency medicine will include a 'virtual ED' where emergency clinicians will provide remote care in a lower cost setting.” The article discussed moving emergency care from the traditional four walls of the emergency department (ED) and advocated continuing the framework put in place early in the pandemic that directs patients to the location best tailored for their needs while keeping in mind scare resources. 3 , 4 SILVER LINING #9 EXPANDING OUTPATIENT INFUSION SERVICES AND HOME‐BASED CHRONIC DISEASE MANAGEMENT The pandemic has forced hospital and health systems to be creative with health care delivery methods while keeping in mind scarce human and infrastructure resources. The ED is highly utilized by patients with chronic diseases and COVID‐19 grants have funded pilot programs to help keep chronically ill patients out of hospitals. For example, University of Michigan Health started the “hospital at home” program, which allows patients with serious illnesses to receive home‐based treatments and monitoring by trained health care providers. Through utilization of advanced technology including hand‐held tablets and collaborating with visiting nurses, home infusion pharmacies, and ambulance services, 5 programs like these are intended to reduce inpatient numbers and ED boarding for the chronically ill who require frequent hospitalizations and are high ED utilizers. The larger movement in medicine to expand outpatient services and implement care at home has also increased access to infusion centers. Pre‐COVID, many patients receiving short‐term intravenous (IV) treatments such as IV antibiotics, would require a resource intensive overnight observation hospital admission. With limitations in oral treatments but more availability of infusion treatments for COVID including the monoclonal antibody cocktails (casirivimab‐imdevimab [Regen‐COV]) and Bamlanivimab‐Etesevimab, hospitals and health systems have expanded “infusion” centers to accommodate this treatment modality without requiring a hospital admission. Veteran and military health systems have been pioneers in this effort, efficiently setting up more infusion centers at their facilities so stable patients with positive COVID tests can be quickly discharged from the ED's and followed up at infusion centers the next day. SILVER LINING #10 AN INSIGHTFUL PERSPECTIVE ON THE UNVACCINATED We physicians know we are expected to be there for all patients, vaccinated or not, intoxicated or not, compliant with medications or not. However, even prior to the pandemic, many physicians felt an acute ignominy toward those who were refusing to get vaccinated. During the pandemic when vaccinations in some communities slumped, there has been an outcry within our profession on social media and in our departments that includes feelings of anger, disappointment, indignity, and grief. However, as the pandemic wages on, we physicians are learning to accept COVID as a pervasive chronic disease, similar to other chronic preventable diseases, such as diabetes, hypertension, HIV/AIDS, and coronary artery disease. We recognize that our feelings of anger and indignity toward the unvaccinated are changing more to those of resigned acceptance. Although we are unhappy that our patients are noncompliant with vaccines, we are learning to accept their unwise choices in the same way we do when patients are noncompliant with medications, diets, exercise, or abstinence from drugs or alcohol. This grudging acceptance may relieve a tiny bit of the distress we are experiencing. SILVER LINING #11 INNOVATIVE RESIDENCY RECRUITMENT PRACTICES The pandemic has forced residency programs to move recruitment efforts to virtual platforms. Depending on the competitiveness of the specialty, fourth‐year medical students participate in 11 to 12 residency interviews on average. 6 Despite drawbacks, the ability of students to utilize virtual residency interviews without enduring the prohibitive travel costs and rigor of the “residency interview trail” is definitely a silver lining. This has made the playing field fairer to students who do not have the financial resources to jet around the country visiting numerous sites. Additionally, residency leadership has instituted more time and cost‐saving strategies in recruitment activities, such as organized video tours of clinics and departments as well as online zoom “town hall” discussions; all that can be done from the comfort of one's own home. This has freed up medical students to have more time for study and residency leadership more time for teaching and clinical activities. SILVER LINING #12 VALIDATING “CALL‐OUTS” AND EXPANDING BACKUP COVERAGE In many specialties, physicians have long bragged on social media about the personal injuries or illnesses they have “endured” and still showed up to work. This practice, while common, is not safe for patients. An unwell provider is not fit to care for a sick patient. In emergency medicine, we have suffered the terrible loss of physicians who have worked while they were ill, leading to worse outcomes, including suicide and death, as well as long‐lasting mental health maladies. More recently, after a COVID diagnosis is made in a practicing physician, the mandatory quarantine period allows a break from the job so energy can be focused on healing. This has further catalyzed a culture change away from the pre‐COVID practice of bullying physicians to report for work despite significant illness. CONCLUSIONS The pandemic is not over, but we are far from where we started. We are more open minded about work place culture and using mainstream technologies to reach our patients and our colleagues in more efficient and less resource intensive ways. Silver linings will continue to arise in medicine as we develop innovations to deliver quality patient care with our increasingly scarce assets and personnel.