As a surgeon, my morning commute to work is much different these days. Casually listening to the morning news has been replaced by a preoccupation with one gnawing question: Is today the day I contract COVID-19? My inbox is filled with daily reminders from hospital administration about the judicious use of waning personal protective equipment and notification about rising COVID-19 cases within our hospital. This is interspersed with news articles expressing bewilderment why healthcare professionals are at higher risk than the general population. Certainly our greater exposure puts us at a higher risk, but it’s also true that the general population is in some respects better equipped than us. I’ve seen more people wearing N-95 masks in the streets of New Jersey than in the hospitals of New Jersey. All this has led to an environment of fear and anxiety within my workplace. Senior physicians, especially those with medical co-morbidities, are afraid to come to work. Others are bringing their own personal masks in from home.



Combined with this fear is guilt of contracting the disease. Do I already have COVID-19? Am I one of the asymptomatic cases? Am I giving this disease to my patients or my family? With the need for medical personnel, is it better for me to come to work even if I’m only mildly symptomatic? Am I letting everyone down by calling out sick? Emails about the lack of protective equipment are eerily quiet about the consequences of catching the disease. Guilt and fear are to some extent pervasive in medical practice. The fear of missing a diagnosis or the fear of instituting the wrong treatment, combined with the guilt of the resulting consequences, are strong motivators. These emotional inputs are tempered substantially by our training. In this pandemic, however, these emotional motivators have become all-consuming.



These emotions are also affecting the way we treat our patients. Despite the belief that physicians are objective arbiters of medical science, we all develop personal relationships with patients. The foundations of these connection are the principles of non-maleficence (“Do no harm”) and beneficence (“Do good”). But what do these look like in a time of social distancing? These heightened emotions and difficult questions, combined with the increased work load in such an unprecedented environment, require an effective coordinated policy response aimed at controlling the spread of the disease. Such a response can tamp down the emotional burden many doctors carry and limit the resulting burnout, ensuring patients receive the high quality care that they need during this pandemic.

Guilt and fear are to some extent pervasive in medical practice

Thankfully, hospital administration have begun to ramp up efforts to control the spread of the disease. Unfortunately, due to a lack of a coordinated pandemic plan in place, central responses have been haphazard, piecemeal, and, oftentimes, inadequate. For example, one of the hospitals in which I am employed cancelled elective operations only yesterday, while neighboring hospitals cancelled such operations weeks ago. Patients who have surgeries for elective hernias and hips occupy much needed inpatient hospital beds and take away highly experienced personnel. In the parlance of economics, there is an opportunity cost to continue doing business as usual. The cost here is time. Time is necessary to train physicians and nurses who are not used to treating critically ill patients. Time is necessary to learn about new coordinated policies aimed at controlling COVID-19. Time is necessary to save lives.



As a result of this central failure, people on the front lines have begun to take matters in their own hands. Healthcare workers are wearing surgical masks in lieu of the more effective N-95 mask. Groups of critical care physicians within the state have formed slack groups to discuss best practices and physicians are rescheduling their own clinic schedules without guidance from hospital administration. But these are makeshift solutions that are instituted by a select few. For example, I still see waiting rooms to non-urgent clinics filled with older patients, many with multiple co-morbidities. In these scenarios it is clear that doing no harm means not seeing your patients and having them stay at home, a situation that is anathema to the principles of medicine where treatment requires evaluation. Here, in non-urgent cases, the lack of an evaluation is the best treatment.



What is needed is a coordinated response from all relevant stakeholders: the federal government and state/local government, the private sector, hospital administration and front-line workers. The response should include using the powers in the Defense Production Act, signed by President Trump, to ramp up the production of personal protective equipment, ventilators, tests and testing centers. Drive-through testing centers should become the new norm throughout the country, especially in areas hardest hit by the epidemic. Funds should be allocated to train medical personnel, and even non-medical personnel, to man these centers.



At the level of hospitals, all elective operations and clinic visits should be cancelled. Physicians should be readily available to answer questions, whether it be via telephone or telemedicine, from worried and anxious patients. Regulations should be eased for such scenarios and reimbursements increased. Hospital wide training in caring for critically ill patients should be rapidly expanded and policies should be instituted about what to do when you yourself are sick. Most importantly, a hospital culture needs to be developed where our humanity and frailty are acknowledged. Too often, medical culture relies on the altruism of its employees to work hard, often to the point of mental and physical exhaustion. The culture shift I’m suggesting would provide us with the mental space necessary to leave work when sick guilt-free. It would also allow us to be able to keep an eye out for our fellow health care worker and tell them, “It’s OK to go home”.



Finally, any response should widely expand paid sick leave as well as offer more generous unemployment insurance. In addition, hazard pay should be offered to all the individuals who are taking an increased risk to ensure the safety of all Americans. I am not only referring here to healthcare workers, but to janitors, grocers, supermarket workers, public transit operators, cooks, police officers, and any other public facing occupation necessary to the functioning of our modern society.



These solutions may sound like a lot of work to do in little time. But as someone who lived in the New York City area during 9/11 and who worked in the intensive care unit during the Boston Marathon bombing, I’ve been repeatedly surprised by one thing. In both experiences, I’ve witnessed the ability of the American people to work together, to provide assistance when their neighbors need it, regardless of their political ideology, race, creed, or sexual orientation. We see this now in people offering to buy groceries for the elderly or pick up their prescriptions. Similar to those terrorist attacks, this disease strikes indiscriminately. However, unlike those attacks, we have the power to limit the casualties caused by this disease. I call on us to use this power and to continue this American tradition of working towards the common good in the face of tragic events. The surest way to get through the other side of this pandemic with the greatest amount of lives saved is to get through it together.

