Illustration by Justin Vaughan
About this time last year, we were in the process of shutting down life as the COVID-19 pandemic was in the initial stages of its surge across America. There were 114 reported cases overall in Virginia in late March, 15 of them across metro Richmond. Since then, the novel coronavirus has resulted in more than 10,000 deaths in Virginia, along with almost 600,000 COVID cases in the commonwealth, according to the Virginia Department of Health. Indirectly, the pandemic has wreaked havoc on everyone’s lives, impacting the economy and employment, upending education, triggering an epidemic of mental health crises and fraying nerves and relationships.
Common-sense measures including masking up and social distancing have helped mitigate the toll, and the advent of vaccines, with three currently approved for use in the United States, seems to indicate that a return to more normal life may be in offing late this year. As of mid-March, more than 1 million Virginians had received a first dose of vaccine, and more than 600,000 had received the second vaccine shot. It’s a start, but there’s a long way to go, considering the state population of some 6.7 million.
As we begin to see some meaningful progress in containing the coronavirus, it’s time for some reflection. In Richmond, health care professionals foresee permanent changes in how they do their jobs and in how health care is delivered in the United States. As part of the Top Docs survey, we asked respondents for comments concerning their perceptions on the future of how they practice medicine, and on health care in general post-pandemic. We contacted several providers who participated in the survey, as well as others in the metro Richmond medical community who are teaching some of the next generation of healers. Here’s a sampling of their insights.
Back to Basics and Reinvention
Many local health care providers noted the financial pressures of increased costs for safety gear and equipment, the time and money lost to shutdowns and social distancing requirements, and smaller numbers of patients, with many leery of medical treatment during a pandemic.
“The legacy will be that we sacrificed our business and focused on all our safety,” says Dr. J. Mark Shreve of Pediatric Associates of Richmond. “The reason why we all became doctors has really come to light.” The financial impact of the pandemic has been brutal for many practitioners, especially those in private practices, with additional expenses in protective gear and a reduced stream of patients to keep everyone safe, Shreve notes. As with many practices, Shreve engaged in telehealth visits, but pediatrics is more of a hands-on field. The doors needed to open and stay that way, and Shreve notes that his practice made that happen. “I can’t tell you how proud I am that people rallied,’’ he says. “It’s amazing how people understood the gravity and did the best they could.”
It’s also been a time of change.
The crisis was an inspiration for innovation to Dr. Aaron Hartman of Family Associates of Chesterfield. Hartman says he was primed to deal with a pandemic, having served eight years in the military on active duty and in reserve, training for disaster scenarios ranging from dealing with nuclear incidents to biowarfare. “My mindset has always been that this is going to happen eventually,” he says. The practice members’ goal was to keep people out of the hospital, and to do that, they had to keep their doors open and do so safely, to protect the health of patients, providers and staff. “It’s kind of what we train for our entire lives,” Hartman says.
They pivoted early on to telehealth visits and also kept seeing patients in their office.
Hartman also has been heavily involved in creating an educational resource center online in order to keep patients informed and educated on their options and to dispel disinformation. His wife, Becky, is the practice’s office manager and has overseen the creation of online courses, including one on long COVID, in which some patients take weeks or longer to recover, that attracted more than 100 participants. “People want answers,” Hartman says.
Hartman’s social media sessions have included one in January 2020 that dealt with COVID-19 as it was emerging from China, in response to patient questions. “As a practitioner, you’re at the tip of the spear, listening to people that you are taking care of,” he says. He also produced posts on the benefits of masks, science-based information on possible use of vitamin C and zinc in treating coronavirus, and exploring treatments such as hydroxychloroquine, which has proved ineffective. He says most people don’t have access to scientific data, nor the training to properly assess it. He says he can help to educate people and encourage and enable them to make good decisions.
Dr. Salmaan Khawaja (Photo by Jay Paul)
Long COVID and Other Lingering Maladies
Even as some protective measures are eased, some health impacts will continue.
The pandemic has been associated with an array of woes for children, with increases in kids attempting suicide, drug ingestions and child abuse, says Dr. Matthew Schefft, an assistant professor in pediatrics with the Children’s Hospital of Richmond at VCU. He says there has been a lot of effort locally in working to boost services, “but it’s just been an overwhelming problem.”
The pandemic’s aftermath also includes a number of people with long COVID who must contend with a bewildering array of seemingly unrelated symptoms. Many experience various cognitive symptoms, along with emotional distress and respiratory complaints, says Salmaan Khawaja, a licensed clinical psychologist and neuropsychologist with the Bon Secours Neurology Clinic. There will be a continuing need for support in dealing with long COVID.
There are also overall societal impacts stemming from COVID-19-related stress, anxiety and depression. Khawaja notes an uptick in pseudo-dementia, more suicides, increases in drug overdoses and substance abuse issues, and more people who are dealing with marital problems. “We’ll be feeling the effects of this a long time,” he says.
He’s working with health care providers who are dealing with psychological trauma from providing care during the pandemic. Suicides and critical care errors are concerns. Working COVID ICUs is especially stressful. “It’s basically a war zone in a civilian world,” Khawaja says.
To help, he’s started a support group for providers dealing with psychological trauma that has drawn participants across 13 states.
On the upside, the time at home, social distancing and masking has helped keep kids out of the hospital. It’s also led to a decline in asthma, bronchitis, pneumonia and other respiratory diseases, Schefft says. There were few cases of regular flu this winter, Schefft noted. The respiratory illnesses that were being seen were generally less severe. “It’s all social distancing and masking,” he says.
The U.S. Centers for Disease Control and Prevention in March reported that only one child has died from flu in the current influenza season, compared with 195 pediatric deaths from flu in 2019-2021. The Virginia Department of Health registered six deaths in children to age 17 in the previous flu season.
Schefft says a rebound may be likely, but he says it may be mitigated by longer-term culture changes, such as greater acceptance of mask wearing. He’s less confident of that occurring in the general population, but he is hopeful that health care providers will mask up more often when providing care than was usual pre-pandemic.
Other Silver Linings
The pandemic also has shined a light on the importance of patient-centric care, says Dr. David Cifu, associate dean for innovation and system integration for the VCU School of Medicine. This entails listening to the patient — what they want, when, where and how they want it — and accounting for the individual nature of health care. “Patient-driven health management [is] not only what patients want and deserve, but our best long-term defense against COVID-19, dementia, cardiovascular disease, cancer, mental illness and diabetes mellitus,” he says.
Cifu also contends that the pandemic has brought public attention to the fault lines in America’s health care system, the poor health of too many of its citizens and the limits of high-tech approaches in addressing the deficiencies. Many of the people at greatest risk for dying or being hospitalized for COVID-19, including the poor and people of color, have been underserved when it comes to patient-centric practices.
Hartman agress that the pandemic has made people more aware of the systemic problems in American health care, but he says that it is unlikely to change the system. He notes that more doctors are specialists than are in general practice, serving on the front line of dealing with patients, and that the payment structure to reimburse doctors doesn’t sufficiently reimburse doctors for their time to allow for comprehensive assessments.
A key lesson learned in the pandemic has been the need for flexibility, along with teamwork and collaboration, says Dr. Ron Clark, the CEO of VCU Health Hospitals and Clinics. The breakdown in the supply chain nationally was a critical failure. “The pandemic caught us with our pants down,” Clark says. “It’s taught us to be a little more flexible in warehousing and delivery.”
Dr. Gregory Hale of Tuckahoe Orthopaedics says he hopes that the nation is now willing to invest again in preparedness, in order to be ready when the inevitable occurs — another pandemic. “The legacy of the pandemic will be that it caused a lot of pain, suffering, sadness and death, and illustrated how unequipped our country was to handle such a crisis,” he says. “This will hopefully raise our level of awareness.”
“We’ll be feeling the effects of this a long time.” —Psychologist Salmaan Khawaja
Shreve expects a lasting, positive impact in that people have received an education and are more aware of how viruses spread, are more attuned to hand washing and mask wearing. “That’s the silver lining in all this, [learning] how not to get sick.”
The pandemic has also inspired a new generation to become health care providers.
Applications to medical schools nationally are up 20% since the pandemic began, notes Dr. Peter Buckley, dean of the VCU School of Medicine and the VCU Health System’s executive vice president for medical affairs. The applicants have been inspired by the science, and by watching the impact health care providers have on the community. “It’s staggering, the pandemic effect,” he says.
He says the current crop of medical-school residents are akin to what Tom Brokaw called The Greatest Generation, people who came of age during the Great Depression and World War II. Like that generation, the health care workers now are facing down remarkable challenges as they train in a pandemic. They will be the greatest generation of doctors ever, Buckley says, and they will play a crucial role in America’s rebounding from the pandemic. “The current crop of doctors are going to be spectacular,” he says.
Buckley also notes that his system never furloughed or laid off workers and that it turned a positive financial margin during the pandemic. The coronavirus response also led to boosts in funding and donations and research. COVID-19-related research such as studies involving treatment of the coronavirus with remdesivir proved popular, drawing an abundance of eager volunteers for the trials. The antiviral was later approved for use in treating COVID-19.
Buckley says the pandemic also enhanced coordination and joint actions among Richmond’s health care systems — VCU, Bon Secours and HCA.
Khawaja is encouraged by the unprecedented sharing of resources and equipment and cooperation of local health care systems. He’s also upbeat concerning the prospects of how the medical community overall will adapt to changes in the coronavirus and to pandemics to come. “We are learning every day,” he says. “Our approach has been evolving, even as COVID has been evolving. We will improve how we deal with this over time.”
