Article In Brief
Neurologists are once again on high alert with another surge in coronavirus cases in full swing in the US and Europe. Here they discuss what is different this time and how their practice has changed amid the relentless pandemic.
One day early last spring when coronavirus had New York City in its grip, Steven Galetta, MD, FAAN, professor and chair of neurology at NYU Langone Health, dashed about to outpatient clinics with a colleague gathering up personal protective equipment (PPE) to take to front-line workers at the hospital.
“We had a tsunami and that was complicated by the fact that we really didn't know the manifestations of this illness or how best to treat it. We were worried because many of the patients were diabetic or immunocompromised,” Dr. Galetta recalled.
At the time, it was thought that COVID-19 was largely a respiratory disease but it soon became evident that the novel viral illness was more complex and had a worrisome inflammatory component that could affect organs throughout the body including the brain.
Now with New York City and other cities, towns and rural areas throughout the US and Europe under siege with the second wave of coronavirus, hospitals and health care workers are once again on high alert. Neurology Today spoke with neurologists about what is different this time and how their practice has changed amid the relentless pandemic.
Most of the doctors interviewed said they made a fairly smooth switch last spring to telemedicine for clinic visits, with some continuing with it more than others. Staff safety and morale remain top concerns, particularly as staff juggle young children at home along with their clinical and hospital duties.
“This time around we have much more knowledge about the neurologic manifestations of COVID and we have ample PPE,” Dr. Galetta said. The number of patients hospitalized with COVID-19 is down significantly from the peak in the spring, he said, though his staff remains busy with patients with the virus who developed neurologic complications.
The team at NYU, led by Jennifer Frontera, MD, published a paper in Neurology in October that found that 13.5 percent of (606 of 4,491) COVID patients hospitalized at NYU Langone hospitals between March 10 and May 20 had neurologic diagnoses, most commonly toxic/metabolic encephalopathy, seizure, stroke and hypoxic/ischemic injury.
On the outpatient side, patients have come back for face-to-face visits. Dr. Galetta said the volume of in-person clinic visits has nearly returned to the pre-pandemic level, with 20 percent of visits still being conducted virtually.
Justin C. McArthur, MBBS, MPH, FAAN, professor and director of neurology at Johns Hopkins University, said his staff is physically and mentally tired and some faculty are worried about their careers because their research was slowed or put on hold during the pandemic. But with vaccines on the horizon “we are seeing some light at the end of the tunnel.”
As of late November, his department was still doing about 50 percent of clinic visits virtually. After a learning curve for doctors and patients as they got used to the technology, “it is going extremely well. Patients and families love it, in general, and our neurologists generally love it,” said Dr. McArthur, president of the American Neurological Association. Virtual visits seem particularly well suited for epilepsy or migraine but not so much for neuromuscular disorders, he said.
“I think the big challenge is not being able to do a neurologic exam, but I am rapidly becoming more convinced that in many diseases a neurologic examination is superfluous,” he said. With migraine, “rarely does the neurologic examination yield anything.”
Dr. McArthur, a long proponent of telemedicine, said doctors have learned how to make the most of televisits by reviewing patient charts and test results ahead of time so that conversations with patients can be more specific and directed. Saying “I see you were in the hospital in the fall. Tell me about that,” may yield more information than a more general question such as “How you've been since the last time you were here?”
So far insurance reimbursement including from Medicare for televisits has been comparable to in-person visits, but that could change when the pandemic ends, Dr. McArthur said. Telemedicine also is proving a convenient way to bring together members of a patient's medical team for a consultation or to hold a faculty consensus conference on a patient case, he said.
Dr. McArthur said it is important for doctors to recognize that the pandemic has revealed a technology divide, where some patients have no access to a computer or Internet. They may also not feel comfortable with the telemedicine experience and so prefer to come to the office.
While it is too soon to say what long-term impacts the pandemic will have on patients' health, “being accessible (to patients) is more important than ever before,” he said.
David Lee Gordon, MD, FAHA, FAAN, professor and chair of neurology at the University of Oklahoma Health Sciences Center, said nursing turnover at the hospital concerns him as the pandemic wears on. Dr. Gordon said some nurses have left for better paying jobs in Texas or elsewhere and travelling nurses are filling slots. He said new or temporary personnel may not be as familiar with protocols or what needs to be done to meet quality metrics.
“When you have a stable nursing staff,” where nurses and doctors are used to working together, “things get done,” he said. He said it is particularly challenging when nurses who are not specially trained in stroke care are assigned temporarily to the stroke unit.
“Another challenge is to keep camaraderie going and the psychology of ‘team’ going,” when everyone is hunkered down and working hard, Dr. Gordon said. To keep people connected to each other and important issues of the day, his staff is invited to quarterly “cultural sharing” sessions on Zoom when someone presents on a topic of their choosing. The discussions have been varied, including one that focused on what it's like to be Black in America and another that delved into the finer points of Pakistani food.
“The idea is to get to know one another better and break down some of the walls of ignorance,” Dr. Gordon said.
Deborah Hall, MD, PhD, FAAN, professor of neurological sciences and section head of movement disorders at Rush University in Chicago, said challenges facing the staff and faculty are different with this surge. The first wave was marked by uncertainty over how best to treat the novel coronavirus and keeping people safe. Experience has helped, but Dr. Hall said the broad spread of COVID-19 in the community means that staff and faculty are vulnerable to becoming infected outside of work as well. Illinois is among the states with the highest COVID case count.
Five members of her staff or faculty have contracted COVID-19 from community spread. In addition, many of her staff and faculty have struggled with the demands of having children at home who have been quarantined or because child care or day care facilities closed abruptly due to COVID-infected staff. Last-minute changes mean patients must be switched to telemedicine encounters or rescheduled for 14 days later, Dr. Hall said, adding: “I try to be flexible in meeting the needs of staff and faculty, with much of the navigation of these almost daily issues by texts and calls at all hours.”
Dr. Hall said another challenge is keeping momentum on the 140 clinical or translational research projects in her department, some of which pretty much came to a halt last spring. The pace has picked up, with increasing pressure from sponsors who are making up from a slowdown in their clinical trials, she said.
Amid it all, Dr. Hall said she feels a sense of responsibility to help keep her staff safe and passes along official information to that effect, though she is careful not to issue her own edicts. She said that it is important to respect people's autonomy, but also remind staff and faculty that an infected section member puts the entire section and their patients at risk.
Dr. Hall said her colleagues have responded by choosing to have virtual family gatherings, cancel travel, or otherwise restrict outside interaction in an effort to keep everyone safe.
In Italy, Angelo Antonini, MD, PhD, professor of neurology and head of the movement disorders unit at Padua University, said his hospital spent the summer preparing for a second wave, including designating an area for COVID patients and establishing a treatment protocol consisting of steroids, heparin, and in some cases, remdesivir. He said the hospital also has a stock of antibody-rich plasma from donors.
“The mean duration of hospital stay is significantly shorter this time than the previous wave,” Dr. Antonini said in an email interview, though he said the COVID test positivity rate is now higher in the community, likely because the lockdown was not as extensive as it was in the spring.
“The decision was to limit the spread of COVID-19 but not to stop the country, so we have a relatively stable number of cases and live with that,” he said. “In other words, even if we fear the virus, we have somehow learned to accept it is there and we need to take precautions until there is a vaccine available.”
For a few neurologists, the pandemic led to a reconsideration of career plans. Alexander D. Rae-Grant, MD, FAAN, professor of neurology at the Cleveland Clinic, planned to move to New England in four to five years for a job in medical editing, a position he had started to do part time.
When coronavirus made it impossible to fly back and forth every other week, he decided to leave clinical practice after 38 years and go full time at DynaMed as deputy editor for neurology and psychiatry. He will keep a hand in teaching by running a journal club for medical students at Cleveland Clinic and Case Western University School of Medicine.
Dr. Rae-Grant said that while he misses interacting with patients and hospital colleagues, “change is healthy...It keeps you fresh and it keeps you learning.”
Heidi B. Schwarz, MD, FAAN, professor of clinical neurology at University of Rochester Medical Center, also accelerated long-term career plans amid the pandemic. She developed an autoimmune condition last spring that required high doses of steroids, which suddenly put her in a higher-risk category for COVID.
“I said, ‘Someone is giving me a message loud and clear to leave clinical practice,’” said Dr. Schwarz, a headache specialist in practice for 31 years. She said she found telemedicine to be challenging for her doctoring style.
“It's really hard for me not to see patients. It's a struggle not to be able to reach out in person,” she said.
Dr. Schwarz said it also was stressful to have colleagues become sick and even die from COVID. “I think all of us realized our vulnerabilities...whether we were saying it or not,” she said.
Dr. Schwarz now puts her energy into medical writing, consulting and journal reviews and is still teaching residents remotely, all pursuits that fill her desire to maintain a role in educating providers and patients. She said the switch also allows her to prioritize family and friends in a way she could not do while practicing.
Dr. Galetta, of NYU, said the pandemic has provided research opportunities and allowed residents to step up. His staff has published about 30 papers on COVID and 80 projects are in the works. Residents have taken the lead on authoring some of the key papers, including a survey of neurology faculty and staff on the psychosocial implications of the pandemic, which found high rates of increased fear, anxiety, and depression.
“This (the pandemic) has given our resident an opportunity for scholarly pursuit,” which may not have been so readily available during normal times, Dr. Galetta said.
As tough as the pandemic has been, “I think our attitude here has been to try to make lemonade out of lemons.”