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Ramping up Tele-GeriPal in a Pandemic: Claire Ankuda, Chris Woodrell, Ashwin Kotwal, & Lynn Flint



As Ashwin Kotwal and Lynn Flint note in the introduction to their Annals of Internal Medicine essay, one year ago people were outraged at the thought of a physician using video to deliver bad news to a seriously ill man in the ICU.  And look at where we are today.  Video and telephone consults at home, in the ICU, and in the ED are common, accepted, and normal.  What a difference a year makes.

This week, in addition to Ashwin and Lynn, we talk with Claire Ankuda and Chris Woodrell from Mt Sinai in NYC about their experience with telephone and video palliative care.  Claire and Chris recently published a terrific NEJM Catalyst piece about their remarkable ramp up of a telephone based palliative care consult service.   Take a look at the figure depicting time trends of health system confirmed/suspected COVID19 cases in their health system and the dramatic rise in tele-palliative care consults.  Their service peaked at 50 consults per day, and as they note, that is likely an undercount.  About half of the consults were in the ED.

Ashwin and Lynn talk about the nuts and bolts of of how to prepare and conduct video and telephone based serious illness discussions with patients, as described in their Annals essay.  Eric and I talk briefly about our experience conducting palliative care consults remotely with patients at New York Presbyterian Columbia, described in our recent JAGS paper.

And (bonus!) you get to sing along to "Call Me Maybe."  

-@AlexSmithMD



  


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TRANSCRIPT

Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And, Alex, we have lots of people with us today.

Alex: We got lots of people, we're going to start off with Claire Ankuda, who's assistant professor in the department of geriatrics and palliative medicine at Mount Sinai. Welcome to the GeriPal podcast, Claire.

Claire: Thanks, it's great to be here.

Alex: We have Chris Woodrell, who's assistant professor in the same department at Mount Sinai, and also has an appointment at the J&J Peters Medical Center in the Bronx. Welcome to the GeriPal Podcast, Chris.

Chris: Thanks so much. Glad to be here.

Eric: And, for those who can't see, Chris' background is the Seinfeld apartment. So, on YouTube, you can check it out.

Alex: And Claire, is that London?

Eric: Central Park?

Claire: It is the reservoir in Central Park. We're looking at the west side. Mount Sinai's on the east side and there's a great running look around the reservoir.

Alex: And you just put your laptop right there.

Claire: I'm just out here in Central Park.

Lynn: I like how the two New Yorkers choose New York virtual backgrounds. We don't travel far.

Claire: We definitely don't travel far.

Eric: Who else is with us, Alex?

Alex: And we have Lynn Flint, who's a regular on this podcast as a host and a guest. She's Associate Professor in the UCSF Division of Geriatrics. Welcome back, Lynn.

Lynn: Thank you.

Alex: And Ashwin, is this your first time on the podcast?

Ashwin: It's my first time. I'm really excited.

Alex: All right. Ashwin Kotwal is Assistant Professor in the UCFS Division of Geriatrics. Welcome to the GeriPal podcast.

Ashwin: Thanks for having me.

Eric: I am super excited because Chris and Claire have authored and article of New England Journal of Medicine Catalyst on Telephonic Support Line in New York that they created. And then Lynn and Ashwin, they authored an article in Annals of Internal Medicine on Key Considerations in Having Goals of Care Conversations or Serious Illness Communication over Video or Telephone. But, before we get into that, we always start off with a song request. Claire, we're going to turn to you on this one. Do you have a song for Alex?

Claire: Yeah. So, on theme with our 24/7 palliative care tele-support line, I'd like to request the Carly Rae Jepsen song, Call Me Maybe.

Alex: So, I was afraid because I remember, at the National Palliative Care Research Center Annual Retreat, Claire, I think, made me sing... what was it?

Claire: Taylor Swift, Blank Spaces. [laughter]

Alex: So, I knew I was going to get something like this. And, true to form, I get Carly Rae Jepsen. And I thought that you were just torturing me when I first heard this request and it was only days later that Eric and I realized, oh, there actually is a connection with the podcast theme.

Eric: I actually showed Alex the Sesame Street Cookie Monster version of this song, which I greatly prefer.

Claire: Oh, I don't know that one.

Alex: That song does not link to the theme of the podcast...the Cookie Monster song [laughter]. Okay, here we go. Let's see what happens here.

Alex: (singing) I threw a wish in a well. Don't ask me I'll never tell. I looked at you as it fell and now you're in my way. I'd trade my soul for a wish, pennies and dimes for a kiss. I wasn't looking for this, but now you're in my way. Your star was holding, ripped jeans, skin was showing. Hot night, wind was blowing. Where you think you're going, baby? Hey, I just met you and this is crazy, but here's my number, so call me maybe. It's hard to look right at you, baby, but here's my number, so call me maybe.

Eric: Just to let everybody know, the Cookie Monster lyric was, "me got a wish on my mind, it's the chocolate chip kind. Me look at you, me tell, you have a snicker doodle."

Lynn: You took a little artistic license there, Alex. [laughter]

Alex: I did? Well, I'm not a rock band. [laughter]

Lynn: I know.

Alex: I usually look up acoustic covers of these songs and then try to do my best.

Lynn: Yeah.

Eric: So, let's turn first to Claire and Chris. So, you guys developed this great thing. We'll have a link to the New England Journal of Medicine Catalyst paper. Tell us the timeline; why did you start thinking about putting together a palliative care support line and how soon were you able to get it up and running?

Chris: So, I think it was Monday, March 23rd. Things were starting to ramp up in New York City. Clair and I got a text message from Emily Chai, who's the senior author on the paper with us. It was 8:20 in the morning and she said, "Can you be on an 8:30 call?" We said, yes! So, we got on the call and she said, "I'm going to ask one of our administrators to procure an iPhone for you with its own number and we'd like you to create a 24 hour phone line." And that was the guidance that we started with and Claire and I got into a Zoom room together.

Claire: We didn't leave it for the next many weeks.

Chris: Yeah, we pretty much hung out in the room together almost constantly while we developed it.

Claire: Yeah, and I think a lot of the story of why we wrote this paper, it's not supposed to be a story of how to do this perfectly, it's more how we figured this out, every day, realizing there was a new problem we hadn't solved and we were behind the eight ball. The program, we call it Patch 24, which is an acronym for palliative care support line, and it changed every three days. And the first week in particular, I love the song Call Me Maybe baseline, but this, we were trying to get business in the emergency room, and so I started going to these 8 PM emergency room huddles in the ambulance bay and I don't think they've ever had a palliative care doctor there at 8 PM in the EDN, and it was like giving out this number like, "Just call us! We'll figure it out. This is crazy, but just call us."

Claire: And I think we just learned so much from the process and it felt like our whole city was changing every three days. So, it was an ever shifting thing.

Eric: And when you first created this, what was the hope for this support line? What were you trying to do?

Chris: We also have to keep in mind that we have a large palliative care program in our health system, in most of the hospitals and so those teams had already been growing their capacity inside the hospitals. This line was meant to augment the work that they were doing and also provide coverage that goes across the entire day and, also, to reach the hospitals where palliative care has a relatively smaller footprint compared to some of the larger hospitals.

Chris: In addition, one of the things that we very early decided as to really focus our efforts in the emergency department because that's where a lot of our sickest patients were showing up, already very sick at that point in the pandemic, needing serious conversations, needing support for family that couldn't be at the bedside of the family member, and a lot of distress all at once in very large volumes.

Claire: Although, to start, we actually thought we would be doing a coaching line. That was our idea; we'll get people from the hospital who just need some advice on how to have these conversations, maybe how to address symptoms, and that was not at all what we ended up doing because we didn't realize what the problems were at first.

Eric: You started on March 23rd, and by the 26th, you started getting calls. Were those initial calls the, "hey, let's support the ED physicians," or were those actual palliative care consults?

Chris: It was both and, to be honest, it was a little confusing at first. People were like, "am I calling a hotline? Am I calling a consult?" We had to do a little bit of working through how we were going to educate folks and we really wanted to make sure that we did not send the people consulting us on a wild goose chase trying to figure out the right number to call. So, if that did happen, we wanted to make sure to make the connection ourselves to whoever was going to be doing the work.

Chris: It was a mix. It was people who just needed advice. It was people who needed us to make a call for them. It was people who were dealing with severe dyspnea and needed coaching on symptom management.

Alex: And can you tell us what are the typically goals of care-type call that you might get from the ED and how that would go?

Claire: Yeah. So, our work in the ED shifted a lot because initially, again, we were there trying to drum up business and, by the end of the first week, we started to see more calls and then the call line went silent and we realized the problem was, at that point, our emergency rooms were really hitting the peak of the surge. And the physicians were totally swamped, providing life saving care for patients, to where patients would come in and there might be multiple patients at once who were looking like they needed to be intubated and they did not have time to have the conversations with the kind of time those conversations take.

Claire: So, our calls really shifted to being a lot from the ED where rapid response questions of patients who would likely need intubation in the next hour, usually not minutes, but usually hours, or calls from the physicians in the ICU or on the floors of similar patients who were acutely decompensating; they really needed help talking to families then, but were also tied up with other patients in a crisis situation.

Alex: You have terrific visual display of quantitative information in your article. The figure you included that shows the overall number of COVID cases, the number of calls, which rose and peaked around 50-ish a day, and then the proportion of those calls that were COVID. Tremendous amount of information in that figure. Kudos to you for that terrific figure. Thank you.

Chris: Well, if you look at the figure, I think it's the third or fourth day from the left, it's the first time you see the lighter blue ED cases, and that was the day Claire said, where the line went quiet from the ER and they weren't calling us anymore. And we realized they don't have time. And so Claire went in person that day. That first bar of ED cases, that's Claire, physically, on a Saturday afternoon, in the emergency department.

Claire: Chris normally likes to mention that I rode my bike in. It's his favorite part of this story.

Alex: That's awesome. Awesome that you went in the midst of the pandemic and the crisis at the peak moment and were there on a Saturday, and that you rode your bike.

Claire: Thanks. Well, I think the lesson learned was that the call line was a great tool to directly do palliative care work but, as a health system tool, it was also a great tool to figure out where needs were and target those precious in-person resources, where in-person resources had to exist. The ED, during these shifts, there was just no time to make a call. So, the call line helped us figure that problem out, which was a really interesting health system blessing for us.

Eric: That's interesting.

Chris: I will also add, one of our goals early one was, once we realized what people needed in terms of us making calls, we really wanted to be responsive, timely. When someone called us, we wanted to address the issue almost immediately and so that was really a focus of how it evolved. How can we continue to do that? We want to be on the phone with the family within 15 minutes, let's say.

Eric: And it's interesting; you're doing a couple consults for the first couple days. Claire goes in on Saturday. You get almost 10 consults. The next day's a little slower. Then you jump to 15, then you jump to over 30 consults and then, a week later, you're doing 50 consults a day!

Claire: And, to be clear, that's a under count because the count in the paper is the number of notes we wrote. We were pulled into far more cases and in far more calls where we were just curb siding and not writing notes.

Alex: Wow.

Eric: So far, it starts off with just you two doing these consults. I can imagine at over 50 documented consults a day, that would be pretty hard to do just by two people.

Chris: For sure. One of the things, thinking back, that I think was a good move was Emily brought in-

Claire: Emily Chai, she's the head of our clinical services.

Chris: Yeah, she enlisted Helen Fernandez and Elizabeth Linenburger, who are our two fellowship directors of the GeriPal and Pal programs. So, because they were two of the first attendings on it, they could immediately begin figuring out how we can incorp-... because it was attending only at first. They thought, how are we going to start incorporating our fellows because we have quite a few fellows.

Chris: And so, after we put an attending physician in the Sinai ED, we had three or four other EDs to put someone in, so that's where fellows started going. That's where you really start to see the ED cases go up and there were fellows stationed in the ED doing precepting with different attendings.

Claire: Yeah, and this was our always being behind the eight ball is volume grew really rapidly and so it was first, we started with two attendings, then week two, we made it a little rotation with four attendings a week rotating through the calls, taking calls during the day, taking calls during the night, or being in the ED in person. Then we added in back up callers and, because of that, we needed med students to triage the calls because we wanted the calls to go directly to an attending, so we had, at all times, a primary attending, a fellow, backup attendings on the call line, and med students manning this operating system online, patching the calls through. So, those were the things we did to keep up with the calls.

Alex: And, at some point, you even recruited outside clinicians from outside the Mt. Sinai system. Is that right?

Claire: Yeah. I'd say they volunteered and found us more than we recruited them...they were extremely generous. I think the first two groups, we had some wonderful individuals; Meaghann Weaver, who's one of my research colleagues, but she's actually pediatrician, pediatric palliative care physician, who volunteered. And then we had a whole team from Pittsburgh who also volunteered and other scattered alumni from around the country.

Alex: That's terrific. I noted that you focused on a one-time consultative model for the most part.

Chris: Yeah.

Alex: Could you talk to us about that decision not to provide longitudinal services and, if you didn't provide it, was there an on-site palliative care team that would pick up some of these folks?

Chris: We started with that intent, that this was going to a similar model to an inpatient consult team and we have a list and we follow it, et cetera. Once the volume started picking up and the staff started turning over between shifts, that just wasn't feasible and, again, I mentioned the issue of confusion with the in-person consult teams. That became an issue; we were stepping on each other's toes. A couple times it was like, they called the consult team, too. We're both working on the same case.

Chris: So, we very quickly learned we need to be very, very clear to all the people staffing the line, please don't promise longitudinal follow up. We even put it in our note template, "this is a one-time call. Please call back." There were cases where we, ourselves, would try to do more than just one call but, to follow someone across days wasn't feasible. So, those were cases that needed referral to inpatient teams and the one site that did not have an inpatient team staff department, we actually had a physician, who was deployed with a fellow and was in-person there.

Claire: And, actually, with one exception, too; you may have read in the news, there was multiple unusual facilities set up in New York City for care of people with COVID, including a tent. Technically running partnership with Mt. Sinai but right in Central Park, near where my background photo is, that our pal care department was staffing pal care needs for the tent, but they didn't have anyone in person, so Patch line was the pal care team for the tent. So, for those patients, we were very aware if it was a tent patient because they didn't have on-site pal care.

Eric: I also opened it up to Twitter to ask some questions for you guys and Brianna Morgan brought up a really great point: what about incorporating other interprofessional team members like APNs, nurses, social workers, chaplains. Was there a role in this at all for them? How did you guys think about that?

Claire: That is a great point and I think, again, lesson learned; there are some ways that we incorporated IDT and brought our staff outside of what we describe in the paper. Later on in the line, we had nurse practitioners helping staff patch. Not at first, but later. Our chaplain team actually took on all the bereavement work for patients seen by patch who died and, in the emergency room, that's one of the few places in the hospital where there's really active 24/7 social work. So, in the emergency rooms, we'd often partner with the on-site social workers.

Claire: However, our own team palliative care social work and chaplains as part of our regular team; we doubled our inpatient services as well, so they went from being spread thin to being spread extremely thin so, unfortunately, between the staffing needs and logistics, they weren't looped in simultaneously with Patch calls.

Chris: They would always make themselves available to us, but we were in addition to the structure that already existed within IDT and the hospitals. And the other thing is, some members of our team were doing work that they wouldn't normally be doing. Our massage therapist was holding the triage pager at one of the hospitals at one point, as was the yoga therapist. So, we certainly missed having a full IDT for each case for sure and, when there was something we could ask them to help us with, we definitely would and we tried to leverage our relationships with people in other disciplines and other departments wherever we could, like the social workers.

Eric: I also feel like, for a lot of palliative care teams, we went from maybe a couple telemedicine calls, if any, that we were doing to... really going from zero to 100 in a very short timeframe, learning how to do this. I want to turn both to Lynn and Ashwin. Lynn has been doing telemedicine calls in nursing homes for palliative care. Ashwin has been doing this as far as his outpatient palliative care clinic that he runs at the San Francisco VA. And you guys just published a great paper in annals of Internal Medicine about the key things that we should be thinking about when we're having these types of conversations on video or telephone. Based on your experience and this paper, Lynn and Ashwin, what are the key things that we should be thinking about when we're having these conversations virtually?

Ashwin: I think that's a great questions. Hearing about some of these stories, Claire and Chris, that you're bringing up, the conversations that you're having with patients and family members who were coming into the emergency departments in distress and needed urgent medical decisions to be made, those conversations can be hard to have in person and there's so many important decisions that have to be made so quickly and now we're having these conversations over video or the telephone, even with these hospital visitor restrictions, protection precautions.

Ashwin: And so, I think Lynn and I really wanted to share strategies that we've learned so that we can still preserve human connection, warmth, and I think many of the conversations that you have in person, the conversations that you have over video or telephone based, they have the same principles; careful preparation, building trust, having clear goals, being really mindful of emotion, so I think those same principles kind of hold.

Alex: Another question by Ben Thompson; you talk about building trust and rapport. Ben asks: how is the process of building rapport any different when you're not meeting patients and families face to face?

Lynn: It's a great question because it seems, on the face of it, that it would be the same, but it's not. Ashwin and I have been talking about writing something about this before the pandemic, actually, because we found that we were both really learning a lot from doing video visits in our different environments. And I will say in my nursing home work, of doing that through a research study, and I would have three visits with the patients and I spent every single first visit almost entirely on getting to know the person and rapport building and it was about developing trust. It was also about getting that person who was a frail nursing home patient used to using this interface. Even to simply trust the fact that this was going to work and that we could have a human connection takes time with some people who are not as accustomed to it.

Lynn: So, I think there is something to just the idea to having a chat for a few minutes to say, this is okay, this is a real person on the other end. It's not just some TV show or something like that.

Alex: And you had a great hook to the beginning of your article. Do you want to share that story with our listeners?

Lynn: Sure, happy to. So, I think it was almost exactly a year before the pandemic started, interestingly, a man had advanced COPD, was in an ICU. I saw a video of this, it looked like an iPad on a device with wheels, was rolled into the ICU room, and you see the doctor's face on the iPad and you hear a little bit of what he says. He's breaking bad news that the lung condition is not going to get better and you hear something about morphine and then the clip ends and the man died the next day. And the family was really dissatisfied with the encounter and released the video to the press, and if you just google "robot doctor bad news," you get a ton of articles about this very story.

Lynn: And so, we thought it was really fascinating that, almost to the date, that was published about a year before the pandemic happened and, suddenly, everybody's having this experience.

Ashwin: Yeah, and I think one of the things that came out of that story, for us, was this really marked feeling of abandonment that the patients and family members experience. And even the reaction afterward in the press, people were talking about how you should never deliver serious illness news over telephone or video. That's outside of the standard of care for medicine and, now, this is happening all over the place.

Ashwin: And I think what we realized was there's this perception that there's a huge risk that clinicians will feel like they're making their patients or family members feel abandoned and we really wanted to encourage people to have these conversations regardless of the mode of communication.

Alex: We'd love to hear from your experiences, because you've all done these telephone and video calls now, what are some key pointers, lessons learned, practical tips for our listeners who might be engaging in these serious illness conversations via phone or video? So, maybe we'll go around; we'll start with you, Ashwin. We'll go to Lynn and then Claire and then Chris. Ashwin, take it away.

Ashwin: I want to go back a little bit to the building trust and rapport. I think that's so important and I think even small gestures can go a long way. I spoke with a few colleagues who, one of their common practices was, if they saw pictures in the background of the room, they would ask the patient or family member, "I see some pictures in the background. Can you tell me a little bit about that?" Encouraging people to tell stories, learning about life prior to the COVID pandemic, just to get to know people a little bit more.

Ashwin: I think the more that you can show people that you care, that you're making an effort, that you really want to build a relationship, that can help get around some of the awkwardness that inevitably comes up in some of the video conversations. Who hasn't had a conversation on Zoom where, suddenly, you're looking at someone's forehead or you're looking at someone's chin? And so, I think people are more likely to be understanding of some of that awkwardness if they see that you care and you're making an effort.

Alex: Mm-hmm (affirmative). Lynn?

Lynn: Yeah, I think that was a good segue to what I was going to say; this is something I talk about all the time, even when I'm teaching about in-person serious illness communication. I think transparency and authenticity is so important. It's nice to see everybody nodding. So, calling out the awkwardness and saying, "this is not how we normally do this. I may say things I don't normally say it, I might have to restate things."

Lynn: I even wrote a tweet about this in response to our article where, just last week, we were Zooming into a conference room where there were a couple family members and a resident and we Zoomed in to create social distance and one of the family members started crying and the resident's iPhone was propped up on the tissue box in the room. And so, she grabbed the tissue box and then the phone fell on the table and I was looking at the ceiling and I feel like the palliative care team's key role is really helping to respond in those moments of emotion and so, I was able to make a small joke and also respond to the motion because it was just a very awkward moment for the phone to fall down.

Lynn: So, I think bringing that transparency and authenticity and I think, going along with that, trying to prevent those moments by being really careful about how you set up the physical environment of your call. Family members shouldn't be driving their car, for example. Family members shouldn't widely distribute a link to a Zoom meeting so that you have, suddenly, 20 people calling in. Stuff like that. Really trying to be mindful of the logistical details can help, too.

Alex: Terrific. Claire?

Claire: Yeah, I don't know if this is a piece of advice or just a slightly different perspective, but allowing for the possibility of these technologies to improve communication, actually. I'm thinking about, in particular, most of our calls through Patch were on the phone, but one thing that we'd often do, especially if a patient was maybe about to be intubated or looking like time was very short in the emergency room, was to facilitate a Zoom call with family. And I can think of several times when these calls turned into the most joyous event of 10 family members from around the country, around the world, multiple times, too, were showing the babies and were showing the dogs to each other and were spending time at bedside in a way that I can't have imagined ever thinking of facilitating in the emergency room in normal times.

Claire: One call in particular, we just left the Zoom set up with a patient who was in his last minutes of life and there were children in Japan and in the States and there were puppies and babies and it was so wonderful-

Alex: That's amazing.

Claire: It was such a beautiful family presence at bedside that technology can create these things. So, I think being creative about how to use this differently than maybe we normally do.

Alex: It's terrific point. Chris?

Chris: Everything that you guys have said really resonates with me, especially, Lynn, what you said about transparency. I found myself on these calls on our line; usually early on in the conversation when I introduce myself and what palliative care is, I would usually add something right there about: I want to let you know, I'm not present in the hospital. I'm being asked by your family member's team to make sure that you get a call, that we check in, we give you updates, I have been in contact with them. Really important, for me, in terms of developing our relationship on the call.

Chris: And then the other thing is not to undermine that, is that when they invariably ask, what does my family member look like, we would tell everyone coming on, I think it was bolded in our instruction summary, always ask the team to talk to you about what the patient looks like. Are they awake? Are they confused? Are they sleepy? Are they whatever? Are they at the window? Are they still in the ER? Because they will ask and you want to be able to answer that question.

Eric: I got a question for all of you. A bunch of us have also been doing these consultations with New York Presbyterian and Columbia and, just to plug it, Journal American Geriatric Society just published a letter to the editor about our experiences spanning these state and institutional borders to get volunteers. Online, we'll have a link to that.

Eric: But I think one of the issues is, some of the volunteers, you zoom, some like me and Alex just use telephone. Do we need video? Is it helpful? It sounds like, Lynn and Ashwin, you're using a lot of Zoom, Chris and Claire, you're using a lot of telephone. How do you think about that?

Chris: We planned to use, actually, it sounds like the same as the robot doctor.

Claire: We wanted to do the robo doctor. [laughter]

Chris: We needed someone on the other end. And now people, I think, are figuring that out. They have different people in the hospital who can facilitate that but, in the beginning, when this was all happening, that just wasn't feasible. So, we just ended up on the phone all the time. And then, also, how do you get the family members to get the right software or app or whatever? They have to have a smartphone. That's a big problem. So, for our purposes, just going back to the telephone was the best we could do in the moment. You lose the video image.

Ashwin: I think what I found is that, when you have video, you have a little bit more ability to pick up some of those non-verbal cues that you rely on so heavily when we're having in-person meetings. So, I agree with Chris; you've got to use the technology that's available, particularly the technologies that are most accessible. But if you're limited to telephone, I think it just means you have to be much more intentional about thinking about emotion and responding to it.

Lynn: Yeah, using Zoom helped us, just logistically, we had some international family members with one case and that seemed like the most straight-forward way to get them all in the same room, so to speak.

Claire: Right. We would do similar with interpreters, too; when it gets to be multiple children and an interpreter, the Zoom phone line, even without video, is our solution. And, thinking about your question, too, I think one thing we learned that I haven't heard talked a lot about is there's a lot of talk, especially in communicating with patients of how this can be a very cold medium and it can be hard to connect. I think one thing we found from the Patch line, especially working the overnights, was the degree of intimacy of this work, in particular because you're getting a call at 2 AM, at 3 AM, like the dog is sleeping beside me, I'm in my home getting a call from a very distressed physician, I'm talking with them. It feels very intimate, not maybe because the technology, but just because you're operating from within your space and then, oftentime, I'd be calling families and there might be the baby's in the background, the kids are bursting in because they want to watch another TV show.

Claire: In some ways, that could be a barrier. At other times, it felt like an opening to a much more human interaction that I felt far more personally affected at times, I think, because I was in my own space and this blurring of work and life that I think was very new.

Lynn: Actually, I was going to ask you earlier if you found any ways to take care of yourselves because you probably continued to be incredibly busy and wanted to hear a little bit about that.

Claire: Yeah. I'm far less so and, actually, one of my favorite phone calls was one that I think we mentioned in the paper, of a hospitalist who called and started telling this story of the patient and then just started weeping before she got through the problem and was like, "This is my first year out, I'm just so overwhelmed. I don't know what to do. She's dying." We talked about it, we talked about it, and then my dog started having this weird coughing attack and she was like, "Is that a dog?" And we both started laughing and it was this very human, wonderful, meaningful connection with a colleague that was facilitated through this and I think we all talked about these interactions. We had a daily logistical huddle, technically, to go over the numbers every day; 9 AM and 9 PM. We recently stopped. We are no longer meeting twice a day, but I think those huddles were a great time to tell stories, to share, to vent and we formed tremendous camaraderie with each other and with our colleagues through this work.

Eric: Is the phone number still active? Are you guys still doing this?

Chris: It is active. It's much quieter.

Alex: I'm glad to hear.

Eric: It also looks like you peaked around a little less than 2,500 COVID patients in the Sinai network. Do you know where you are right now?

Claire: We just got an email about it.

Chris: I want to say it's 400 in the system, 100 in the ...

Eric: Significantly less.

Claire: Huge difference.

Chris: What's interesting is, now, the volume is way down. The complexity is way up, though, because now we have the chronic critical illness situations and a lot of these cases that we're getting now are much better addressed by the interdisciplinary inpatient teams and they have the capacity to do so now.

Eric: Yeah, that's what we also noticed with the New York Presbyterian model is that, initially, we were staffing consults in the ED and that quickly changed as the surge passed to the longitudinal needs of chronically critically ill patients, where a one time palliative care consultations just does not work for these individuals.

Claire: Yep.

Chris: One thing I wanted to go back to is that, I think something Lynn said made me think of this, it's just that what was so different about doing this work in this time is that there is this shared experiences that you're having with the people you're on the phone with that's sort of an unspoken thing. And, usually, the way that it came out in the calls I found, and maybe the rest of you had similar experiences, was when we would break terrible news to them. Nothing good was coming out of this in terms of a plan and then, at the end of the call, they would thank us and tell us to be safe. And I, at first, had [inaudible 00:41:21] comfort with that, and then they quickly said, no, you need to respond earnestly to that and say thank you and that that means a lot.

Claire: And I think, in terms of well being through this, I keep coming back to the camaraderie with each other and also with the physicians on the line and the physicians in the ED in particular, everyone in the ED. I remember one of the shifts, I was leaving and said goodbye to one of the attendings and he said, "We will never forget this," and it was just so sincere. I've never felt so appreciated for the work that we were doing and for being there and being with them and partnering with them in this, and the camaraderie was amazing.

Claire: There was one night where it was a terrible shift and I think I saw 15 patients and everyone, it felt like, was dying when I saw them, and these conversations are obviously very hard and there was one patient I saw, who I was just helping go with the ED attending to comfort a mother whose son had just died, and really just be there for bereavement support, along with other members of the team. And it was just one of these days where it didn't feel like we were doing enough in the face of this horrible thing that was happening and there's a security guard who would watch me speak with this family member.

Claire: I kept walking back and forth between them because I was going to different sections of the emergency room, and he pulled me over and he said, "you're doing a really good job." And it meant the world to me, just that he was watching and it meant so much, and I think that's, frankly, the way that we all treated each other for weeks and it was such a different mode of generosity that we had that we pulled each other through, and I mean everyone.

Eric: I want to thank all of you for, A, doing what you're doing and being on this podcast. It means a lot to me and our listeners certainly enjoy hearing everything that you're doing.

Alex: Do we have time for a lightning round? Give them a quick lightning round!

Eric: Quick lightning round? Okay, we got to do it fast. That means you got to give a quick song afterwards.

Alex: Quick song afterward.

Eric: Okay, Twitter questions. So, first one is: What's the biggest obstacle in preventing more widespread use of tele-palliative care?

Claire: Used to be payment.

Lynn: Right.

Chris: And technology.

Lynn: Technology. I think, also, widely available wifi.

Eric: Are there questions that you would want answered by all patients before a potential palliative care tele-health encounter?

Chris: A healthcare proxy.

Eric: Healthcare proxy.

Claire: Yeah, healthcare proxy. Who the decision maker is.

Eric: Great. With the recent crisis, seeing your hospital officials, palliative care doctors have been hyper focused on consulting with patients' last few days of life. How do we not get pigeonholed into that narrow scope of view?

Claire: When there's a pandemic, we have to go where the need is.

Claire: Outside a pandemic, we can start working on our marketing and making sure we're seeing people more broadly.

Chris: Now we're focused more on the longitudinal chronic critical illness and demonstrating our strength in that regard.

Eric: You're doing these consults, Michael Sigmund says, "Is it safe or responsible to prescribe medications to a patient I've never examined?"

Chris: We did not.

Claire: We can coach.

Eric: Coach. Make recommendations.

Ashwin: And I think, in certain situations, it makes sense, especially when you know people have really serious illnesses and really need those medications soon.

Alex: And you do that more in your longitudinal practice, right, Ashwin?

Ashwin: Yeah. Outpatient clinic, this is pretty common, especially with people not being able to be seen in person or people in rural settings.

Eric: All right, last question. This one's for Alex. Alex, we just did a podcast and this is crazy, but would you mind giving us a little bit more of Call Me Maybe?

Claire: I can't believe someone Tweeted that! [laughter]

Alex: (singing) Your star was holding, ripped jeans, skin was showing. Hot night, wind was blowing. Where you think you're going, baby? Hey, I just met you and this is crazy, but here's my number, so call my maybe. It's hard to look right at you, baby, but here's my number, so call me maybe.

Eric: You cookie showing, me hunger growing... [laughter]

Lynn: Alex, you need to know, there's going to be another season of American Idol starting soon. Just putting that out there.

Eric: Well, Claire and Chris, but thank you for joining us today. Ashwin and Lynn, thank you, too. It's been great having everybody. Big thank you to all our listeners and Archstone Foundation for your continued support.

Alex: Thanks, everyone.


NOTE: Claire Ankuda and Chris Woodrell would like to state "the views expressed here are our own and do not represent those of our employers"

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