An Age/Old Dilemma? Pulling Senior Cardiologists From the Front During COVID-19
Some US hospitals have asked doctors over a certain age to work from home, but surge situations may mean all hands on deck.
Around the United States, hospital leaders either preparing for or already coping with an influx of patients with COVID-19 are facing a difficult dilemma: how do you protect your most senior—and most vulnerable—physicians from infection without losing their decades of knowledge and experience?
In many places, that means asking older cardiologists to work from home or otherwise away from the front lines to lessen their risk of contracting SARS-CoV-2 but still contribute to the fight.
Preliminary data from the Centers for Disease Control and Prevention (CDC) indicate that in the United States, COVID-19-related mortality increases with age—less than 1% in people ages 20 to 54; 3% to 11% in those ages 65 to 84; and 10% to 27% in the oldest Americans. More than half of intensive care unit admissions (53%) and 80% of deaths associated with the virus involved people 65 and older.
That’s relevant to workforce decisions because many clinicians are in the older age groups. In a recent viewpoint in JAMA, Peter Buerhaus, PhD, RN (Center for Interdisciplinary Health Workforce Studies, Montana State University College of Nursing, Boseman), and colleagues pointed out that in the US an estimated 22% of registered nurses employed in hospitals and 29% of physicians are 55 or older. The latest data from the Association of American Medical Colleges puts the percentage of physicians from all specialties who are 55 or older even higher, at 44.1%. That proportion topped 60% among physicians specializing in cardiovascular disease.
“These folks really have a lot of knowledge and experience that you can’t get in a younger person just a year or two into the workforce,” Buerhaus told TCTMD, adding that in the context of the ongoing pandemic, “we need to think very carefully about using these individuals. They’re qualitatively different from others.”
For that reason, it’s a good idea to protect this group of clinicians by having them do what they can from home, Buerhaus said. “It’s important to make sure that these older physicians, nurses, and others are there for the duration of this pandemic. We don’t know how long it will be, and being at home will reduce their risk of exposure. And secondly, they’re at higher risk of mortality should they become infected. So I think we need to keep that in mind.”
Taking a Step Back
Hospitals and cardiology practices across the US are handling the risks to their more senior physicians in different ways depending on their situation, according to L. Samuel Wann, MD (Ascension Healthcare, Milwaukee, WI), who is chair of the senior cardiovascular professionals section of the American College of Cardiology (ACC).
In smaller private practices, for instance, losing even one member of the team can place a big burden on the rest. On the other hand, it may be easier to allow a few members of the team to pull back in larger academic groups, where clinical duties are already separated.
Our older physicians came off service figuratively kicking and screaming. They did not want to come off service. Andrew Choi
One place where older physicians are among those being asked to reduce their time in the hospital is at the George Washington (GW) University School of Medicine and Health Sciences in Washington, DC.
Andrew Choi, MD, co-director of cardiac CT and MRI there, told TCTMD that near the beginning of March the faculty gathered to discuss how to prioritize safety and protect the most vulnerable physicians, nurses, and staff—ie, those who are pregnant, immunocompromised, or older than about 60 or 65. The decision was made to keep these groups off the front line.
Not everyone went willingly. “Our older physicians came off service figuratively kicking and screaming. They did not want to come off service,” Choi said. “I think bound by just an incredible duty to our patients they wanted to stay on service, and we basically forced them off.”
Richard Katz, MD, director of the division of cardiology at GW, who is in his early 70s, was one of the physicians asked to move into a different role during the COVID-19 crisis. He said there was uniform reluctance among the rest of the group to have him and one other physician treating patients in the hospital because of their age, adding that he received similar pressure from his family.
Katz said having older clinicians move away from in-person patient care is a good approach, although he acknowledged that “I have some natural desire to be in the mix of things because that’s what we’ve always done and committed to.”
It’s crucial, according to Choi, for these types of decisions to be made with contributions from everyone. “In our center, this was very collaborative, and all of us had input into what we thought the best approach would be for the group.” Though older physicians undoubtedly want to be on the front lines, he added, “this is a unique situation with COVID-19, and it took the collective will of our group to pull them off service.”
An Individualized Decision
This type of age-based approach is not universal across the country, however. Karen Stout, MD, who is heading up clinical cardiology care at the University of Washington Medical Center in Seattle, said she is putting the decision into the hands of her faculty. “I’m not doing it based on age,” she told TCTMD. “I’m actually letting people self-declare, because age alone doesn’t catch the risks.”
She pointed out that some faculty members, for example, may be immunocompromised, may be caring for someone at home who is immunocompromised, or may be pregnant. “I have had some faculty say, ‘Please don’t put me in with COVID patients unless you absolutely have to,’ and I’ve had others say, ‘You will look at me on paper and say that I shouldn’t be in there, but please put me in,’” Stout said. “So that’s been my approach: to individualize it and personalize it.”
Ajay Kirtane, MD, director of the cardiac catheterization laboratories at NewYork-Presbyterian/Columbia University Irving Medical Center in New York City, agreed that age alone will not necessarily capture everybody who has a heightened risk from COVID-19.
“Everybody has their own fears associated with it,” Kirtane told TCTMD, adding that administrators might not be aware of all of the factors placing specific employees at risk. “Age may be one characteristic that is somewhat obvious to talk about, but there may be other conditions on your team,” he explained. “Some of this requires individual conversations with team members. Sometimes people don’t want to disclose that they may have something that may put them at risk, because it may seem that they’re not trying to help but that’s not the case at all.” How to manage those perceptions among the rest of the team is an important issue, he said.
Wann, who said that at age 73 he had already been moving into part-time work before the COVID-19 situation exploded, also advocated a nuanced approach to determining who should be pulled back from the front lines. “I think we’re all pretty altruistic and pretty hardworking and willing to do the work, but you’ve also got to take care of yourself, and different people feel differently about that,” he said. “I don’t know that I’d want to make a blanket rule that you either should come in or you shouldn’t. I think it needs to be highly individualized based on what your needs are.”
There are plenty of roles to fill out of harm’s way, including performing phone triage, taking the lead on outpatient-based telehealth visits, reading diagnostic studies, and—for interventionalists—covering only cath lab call without rounding in the inpatient units.
Asked by his colleagues at Riverside University Health System Medical Center in Moreno Valley, CA, to work from home to lessen his risk, Rajagopal Krishnan, MD, transitioned into doing the bulk of the telemedicine and telephone visits, along with reading echocardiograms and ECGs. Administrative tasks take up about an hour out of each day, he told TCTMD.
The transition, he said, was not too difficult because many of these duties were already being done at home, with Krishnan often getting caught up with charting and reading tests at the end of his regular workday. Front office staff and nurses provide a lot of support from the hospital, he pointed out.
“I miss being in the field and with my colleagues, but other than that, the day is pretty busy,” Krishnan said, adding, “I think it is a very good approach.”
There’s a lot of divide-and-conquer strategy that is happening nationally, which is, I think, a responsible step to conserve the physician workforce. Purvi Parwani
Purvi Parwani, MD (Loma Linda University Health, CA), pointed out that there are important roles to be filled during the pandemic by her more senior colleagues and others who can’t, for now, see patients face-to-face. Chief among these are telehealth visits. “Our patients are anxious and they’re scared and they need us more than ever, and most of these visits are now converted into virtual televisits,” she told TCTMD. “These physicians who are staying at home can do all of that.”
Telehealth has been key to keeping cardiologists connected to their patients during the pandemic. Indeed, a report from MedAxiom, an ACC company, shows that within weeks, practices transitioned from using telemedicine for less than 5% of appointments to using it for more than 75%. That abrupt shift comes with growing pains, Parwani said, but the advantage of using more telemedicine is that “you’re still able to offer your services being at home without having that patient contact or being in the hospital,” where one might be exposed to the SARS-CoV-2 virus by either patients or coworkers.
“I think that’s where many practices are taking advantage, because someone has to do it so why not give it to the people who are staying at home?” Parwani said. “There’s a lot of divide-and-conquer strategy that is happening nationally, which is, I think, a responsible step to conserve the physician workforce. Because if we have everyone working in the hospital at the same time, there are chances that people may pick up this infection, and then if you have all the physicians out at the same time quarantined or affected by the disease, who’s going to be working at the front line?”
From Buerhaus’s perspective, older physicians also can continue being sources of invaluable knowledge for hospital administrators and fellow healthcare workers while remaining away from the hospital. Administrators and younger clinicians may benefit from conversations with older physicians and nurses who have been through prior disasters or public health emergencies in terms of making the best decisions on use of people and resources, he said. In addition, more senior clinicians can provide support to their younger colleagues who may be stressed in the context of a situation like the COVID-19 pandemic.
Moreover, taking advantage of the experience garnered over decades of medical practice can help overcome obstacles that pop up during an evolving situation. “I just know that, having been a former clinician, there’s little things that happen that you never really think about . . . so some of those folks, older physicians, could work with teams to walk through their preparations and really test the organization’s capabilities,” Buerhaus said.
As chief of cardiology, Katz said, there’s no shortage of things for him to do from home, with his workday regularly lasting late into the evening. He’s participating in virtual meetings and academic conferences, organizing short- and long-term schedules and managing workflow for his staff, and ramping up telemedicine capabilities, a process that has involved learning some new technology and working out obstacles for his patients. He’s also planning for the future, which will likely see an influx of patients returning to the clinic once COVID-19-related lockdowns are lifted.
No ‘Modern-Day Conscription’
Writing in Circulation this week, “three older and, we hope, wiser women cardiologists”—led by Annabelle Santos Volgman, MD (Rush University, Chicago, IL)—describe the conflict between wanting to help in a situation like this and the relief of remaining off the front lines, as well as the guilt that goes along with that struggle. But they also detail the ways in which they will continue to contribute to the effort.
“We will arm our warriors with ammunition, strategies, and courage to fight,” say Volgman, along with Sandra Lewis, MD (Oregon Health and Science University, Portland), and Nanette Kass Wenger, MD (Emory University, Atlanta, GA). “The contributions come in many forms: communication, education, advocacy, and emotional support for the soldiers. While our colleagues are occupied in battle, we are delving into the data, researching ways to help them fight better.”
Another debate that arises when assessing an age-based approach to managing the workforce during the pandemic is whether it’s fair to younger clinicians.
Asked about this issue, Kirtane noted that “it only takes one colleague with a bad outcome for the entire group, division, department to be devastated. So my sense of it is that’s why it has to be done really carefully and thoughtfully, and I do think that there may be certain people who are at extraordinarily high risk that’s obvious and objective to everybody and most people would not want that colleague to work. I’ve heard of and seen many colleagues who would step in front and not have those types of colleagues be exposed at all.”
On the other hand, he asked, should lower-risk individuals be preferentially put on in situations with the greatest likelihood of exposure? “I don’t think that that’s the way to proceed either,” Kirtane cautioned. One possible exception are people who have recovered from COVID-19 because they might be less susceptible to reinfection, he said. “But for a COVID-naive person, I think it does make sense to restrict the highest-risk individuals, and I think everybody would do that, but among the rest of them it’s a challenge. And I also think it’s important for leaders to be visible and for everybody to feel that there are contributions across the board.”
Choi acknowledged that even though people over age 65 have a higher risk there still is substantial risk of severe illness in younger age groups.
“Not to be controversial but I think we want to be cautious that we don’t view our COVID care like modern-day conscription, because younger physicians also care for elder family members and the youngest family members,” he said. “So we really want to be thoughtful across all age groups to be able to deliver care effectively to our patients.”
Speaking of his own colleagues, Wann said “the last thing on Earth they want me to do is come in and be exposed to coronavirus and then come in as a patient.”
Buerhaus raised a similar issue regarding older clinicians who have been around for decades and established strong relationships with many members of the staff. If a beloved leader falls ill and dies, that can take a toll on an organization, he said. “There’s a morale issue that I think hospitals should really be mindful of as a further reason for maybe using their older workforce slightly differently than what they normally would be doing.”
Ready to Jump Back In
But is the strategy of asking cardiologists over a certain age to work from home when they’re otherwise able to work feasible when a COVID-19 surge hits?
As Parwani pointed out, there are reports of physicians and nurses returning from retirement and semiretirement to help systems overburdened by COVID-19. In New York, one of the epicenters of COVID-19 activity, Governor Andrew Cuomo recently called for healthcare workers from around the country to volunteer to help out.
But even in New York City, there are ways to keep hospitals staffed sufficiently while still allowing older physicians—and other high-risk clinicians—to contribute while lessening their risk of exposure to the virus, according to Kirtane.
For nurses, respiratory therapists, and others most involved in the day-to-day care of COVID-19 patients, it’s really “all hands on deck,” he said. “Certainly physicians are called upon as part of that, but I don’t want to underrecognize the importance of so many of the people who are really on the front lines and getting more exposure than most physicians would be getting.”
When there is a need, obviously we’ll all be prepared to shoulder the burden. Rajagopal Krishnan
It’s possible even in a surge situation to let high-risk groups of physicians pull back from the front lines a bit, but it depends on the site. That approach might be easier in academic medical centers with a large number of doctors available than in smaller community hospitals, particularly in rural areas, Kirtane said.
“In a sense, it’s all hands on deck as a philosophy, but there are [situations] where you want to minimize folks’ exposure, and I think even within a surge it is possible to do that,” he said.
To Buerhaus, that choice would depend on local conditions, including the severity of the outbreak and the number of older physicians and nurses willing to come back in to help. “It will vary, and that’s why I think it’s really important for organizations today to be thinking: what is our older workforce composition? Who among them are the folks that we really, really want to lean on and see if they can help us?”
Thoughtful planning is required to sustain this type of effort in the midst of rising numbers of COVID-19 cases, according to Choi. For example, interventional cardiologists at his center have been staggering the way they cover the cath lab to minimize the risk of having multiple physicians sick at the same time. “The best term is, we can ‘hurry slowly’,” Choi said. “We know that it’s important to be on the front lines [and also] need to think of this not just for a short amount of time but really for the next several months.”
A surge of COVID-19 patients had not yet hit Stout’s center, allowing her team time to prepare. If case numbers start to balloon, any decisions about who can remain out of the thick of things will have to be reconsidered, she indicated, noting that her team is using projections that assume 30% of the workforce will be unable to work in the case of a deluge of patients. “If everything comes in and it’s hair afire like it is in New York, then everybody knows we’re all hands on deck,” she said. “But we actually have that articulated in the plan as well.”
Katz said contingencies in case of a surge include a list of physicians who could be called in as hospitalists or to cover the ICU. That list doesn’t include physicians over age 70, but that group might have to come in if the situation becomes serious enough. “I’m certainly willing to do so,” Katz said. “My family won’t be thrilled about it, but that’s just part of our job.”
Krishnan agreed: “When there is a need, obviously we’ll all be prepared to shoulder the burden.”