Machiavelli famously said to the prince: "It is better to be both loved and feared but if you can only be one, be feared". I've been wondering what Machiavelli would...
It is mid-April and physicians and hospitals are already planning on how and when to re-institute normal operations, like flowers poking through snow after a cold winter. But it is pretty clear that the normal operations of the future will not be like the normal operations of the past. I’m using this post to speculate on how things may be different.
Hand sanitizer will become the new tabletop condiment
If you go to a breakfast restaurant, you’ll find pitchers of syrup and honey on the tables. At lunch and dinner, there will be bottles of ketchup, mustard, and hot sauce on the tables. In the future, look for bottles of hand sanitizer on your restaurant tables.
Obstetricians will be busy in January 2021
“Blizzard baby booms” are a debated phenomenon that lie somewhere between urban myth and obstetric reality. I am a member of the baby boom generation, a surge in babies born after soldiers returned to the U.S. after World War II and the Korean War. That baby boom was a reality but whether there is a mini-boom of babies born 9 months after hurricanes and blizzards keep people indoors for a period of time is more uncertain. A blizzard or hurricane keeps people cooped up together for just a few days but COVID-19 keeps couples isolating at home with little to do for weeks. Will the social isolation of March and April result in a lot of babies in December and January?
Infectious disease physicians will be hospital medical directors
In a war, Majors are promoted to Colonels and Colonels are promoted to Generals by demonstrated success in battle. Similarly, hospitals select their medical directors based on administrative success in leading individual hospital programs. Throughout the world, hospitals are having their COVID-19 response led by epidemiologists and infectious disease specialists. Those who successfully steer their hospital through the infection control and financial perils of the pandemic will find themselves in line for promotion to hospital leadership positions.
Surgical masks won’t just be for surgeons any longer
Wearing a surgical mask does help prevent one from becoming infected with respiratory viruses when an infected person coughs or sneezes in your face. But when everyone wears a mask, there are two other important infection control effects. First, if the person wearing the mask is unknowingly infected with a respiratory virus, it helps prevent that masked person from coughing or sneezing on others. Second, when a person is wearing a mask, it reduces the chance that the person will touch their nose, mouth, or eyes with hands that could have picked up respiratory viruses from fomites such as a door handle, shopping cart, or elevator button that harbored viruses. In the future, people may likely feel more safe when those around them are wearing masks and that may be doubly so for their doctors and nurses wearing masks. Look for future masks emblazed with people’s favorite NFL team, alma mater, or beer maker.
A COVID-19 PCR test will become a routine admission order
When most patients get admitted to the hospital through the emergency department, they get “routine admission labs” – generally a CBC and chemistry panel. Look for a COVID-19 test to be added to that list of routine tests. Right now, there is near-paranoia by many physicians that their patients will have asymptomatic and potentially contagious COVID-19 to the point that they will not do procedures unless their asymptomatic patients have a negative COVID-19 PCR test. Even then, many demand that they be allowed to wear an N-95 mask for patients with a negative test because of the theoretic possibility that the test is a false negative.
Public health nurses will have job security
Countries that have been successful in controlling the COVID-19 outbreak have had very strong case isolation and contact identification. This takes manpower – primarily public health nurses that can go out in the community to interview patients and do testing of contacts. Public health departments are often underfunded and understaffed. There will be increased demand for public health nurses for the foreseeable future.
Don’t expect your hospital to replace the old MRI machine
Although many U.S. hospitals have their ICUs full of COVID-19 patients, their overall medical/surgical census is generally low. That is because elective surgical procedures have all been postponed. Not only are surgeries not being done but neither are non-emergent diagnostic tests such as MRIs, CT scans, cardiac non-invasive tests, and pulmonary function tests. Hospitals don’t make much money off of medical admissions and depend on those surgeries and diagnostic tests to show a positive financial margin at the end of the year. Currently, hospitals are burning through their reserves (“days cash on hand”) with all of these surgeries and procedures not being done. With days cash on hand depleted, hospitals will be postponing large expenditures over the next couple of years.
The handshake will be a custom of the past
When a patient is infected with COVID-19, their hand becomes a fomite that can transmit the virus to everyone that they touch. Overnight, the handshake has changed from a greeting of politeness to a gesture of threat. Look for the handshake to disappear as an American social convention.
Telemedicine will come of age
Until March 2020, telemedicine was relegated to a few specific circumstances and primarily used in rural, sparsely populated areas of the nation. With the federal government relaxing rules for telemedicine, physicians all over the country are realizing that a lot of routine outpatient care can be done by telemedicine. Medical practices are adopting video telemedicine platforms through their electronic medical record or through separate commercial video applications. I have found that video telemedicine works very well for many of my patients, for both new and return visits. For patients who lack transportation or who live long distances from the office, the convenience of a video visit is a game-changer.
Anti-vaccine proponents will finally be quiet
One of the reasons that anti-vaxxers have flourished is that enough other people get vaccines so that devastating diseases such as polio, measles, and hepatitis B are uncommon enough that herd immunity protects the anti-vaxxers. If there were no influenza vaccines, then even influenza could periodically be as threatening as COVID-19. The current pandemic is a reminder of just how deadly infectious diseases can be and how much they can disrupt the economic structure of a community. An effective vaccine against COVID-19 will hopefully silence the anti-vaxxers since COVID-19 is unlikely to otherwise go away – it will just periodically die back and flare up as long as there are immunologically susceptible people for it to affect. The older the anti-vaxxers get, the more likely they are to become critically ill and die should they become infected and this will hopefully motivate them to forget their conspiracy theories and get a COVID shot.
It will be safe to go outside when your doctor has a beard
All of a sudden, most doctors and nurses in the United States became clean-shaven. That was because they needed to get fit-tested for N-95 face masks and a couple of years ago, OSHA made a rule that men with beards could not undergo fit-testing. Because I normally see patients in the hospital in airborne isolation (for example, those who are suspected of having tuberculosis), I have had an annual N-95 fit test for many years. And each year, I always passed my fit test, even though I had a beard. When OSHA came out with their rule, I was no longer permitted to wear an N-95 mask and had to switch to a PAPR hood but with PAPRs in short supply nationwide, men who provide inpatient healthcare had to shave and be fit tested. Just like robins are the first sign of spring, doctors with beards will be the first sign that the hospitals are no longer full of COVID-19 patients.
April 16, 2020