A Mayo Clinic expert panel discusses barriers that patients have faced throughout the COVID-19 pandemic, and presents scenarios reflecting the importance of ongoing care. They also share ideal safety measures adopted by health care institutions.
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Welcome to Mayo Clinic Cove in 19 expert insights and strategies. The following activity is supported in part by an independent medical education grant from Pfizer Inc and is in accordance with a C CMI guidelines. Hello, everyone, and welcome to this episode off health care during the Cover 19 Pandemic. I'm your moderator. Davion allowed more to come about me in a little bit, but I'd like to welcome my Panelists. We have a very esteemed panel here with Dr Clyne, who is in Women's Health. Dr Ben Doc, who is a neurosurgeon, and Dr Beckett Sob, who is a gastro intestinal cancer specialist. This video cast is part of Our Cove in 19 Expert Insight and Strategies put out by the Mayo Clinic and I am Devyani Law. I am the course director off the Cove in 19, Expert Inside and Strategies Siri's I'm, a professor and consultant in the department of Otolaryngology at Mayo Clinic in Arizona, and I also served as the associate dean for the Mayo Clinic School of Continuous Professional Development and also um, Service advisor off Education at Mayo Clinic in Arizona. As part of my duties to my institution, I have served in creating educational content for health care providers, organizations and administrators dealing with the pandemic as part off that Siri's. We're also creating some patient focused material and discussions that are relevant to everyone, including specialists and doctors, that you see on the panel. And today I hope that our esteemed Panelists will discuss some of the barriers that have challenged our patients to the pandemic. And also, I hope they will be able to share some of the experiences with their patients that reflects the importance of ongoing care. And I also hope that you will be able to share with our listeners some of the safety practices and some off the technological solutions that have adopted to caring for your patients during the pandemic. So none of the Panelists have any conflicts of interest or disclosures. This educational activity is supported in part by an independent medical grant that was provided by Pfizer. Incorporated are preparations today and all the presentations with the SYRIZA Cove in 19 are in accordance with the A. C. C. M E guidelines, and that means that if you are a health care provider, you can visit our website ce dot mayo dot e D u slash Kobe expert and claim the relevant AM a Category one credit. Our first Panelists that I'd like to introduce is Doctor Canio's back Isa. He is a professor of medicine at, and he's a consultant in medical oncology in the division of hematology oncology and has a specialty interest in gastrointestinal cancers. He wears many leadership roles hats at the Mayo Clinic. And I like for Dr Back Isa to give his own introduction as Thio Why he went into medicine, What makes him passionate about healthcare, And how has his family dealt with seeking health care during the pandemic, you know? Thank you. Well, you know, my, uh, my interest in in medicine, believe it or not, actually started at a quite quite a young age. Um, in fact, you know, while visiting my family in Beirut in my early thirties, I found a little a little drawing book that I used Thio, you know, used to draw things and write little poems, kids, poems. And I actually saw autobiography that I had when I was 10 years old. And in it, I actually you know what I was talking about, Uh, my trajectory into into medicine and going to the American University of Beirut, which I actually were ended up going for medical school. So I think that interest comes also from heavy presence in medicine and the family from a lot off off my fathers uncles on both sides heavily invested into medicine. And so the curiosity about medicine ended up being or coming from quite a young age. Uh, so I grew up in, in, in in an environment that what that was conclusive. But, you know, in terms off a choice for oncology, Uh, that that came about, you know, as I was building my journey through medical school and then ultimately through residency, and I found the natural attraction to the humane aspect off oncology that that is certainly unrivaled. I mean, all all medicine is very humane. But in oncology, I felt that extreme closeness to patients who are suffering and dying, um, in quite a different way. Also, given my background and pharmacology and my interest in drug development oncology, hematology, oncology offered the closest you can get thio cutting edge research, drug therapies and others. So So a lot of this, you know, came together and and let let my path into where I'm at right now. You know, in terms of how my family, you know, have been dealing with with with Covic 19, as they live far away. They are in Lebanon where you know there's not a single country that's immune to this awful disease. And, you know, they're both older and they've bean a twist. My parents have bean relatively, uh, staying put at home, I think, has affected them quite a bit, both mentally and and and and and physically. A zit does for most. Most of our patients unfortunately, um, and has certainly affected their capacity to travel, to visit family eso in a way isolated, isolated them. So it's It's been a tough time for the family, of course, in a tough time for for all of us, because it has limited interactions as well. Well, thank you so much for sharing such a human perspective. Um, Thio, why you you join the field of medicine and how it means not just, uh to be dealing with a pandemic as a doctor, but as a human being, as a family member and sharing experiences. And I have to say that I grew up in India, and I have had two aunts. I come from a very large family on my mother's side. Two aunts that came down with Cove in one of them, uh, fairly elderly after she was hospitalized for a fractured femur and thanks. You know, heavens, because they are both okay, So I thank you for sharing back. I'd like to next introduced Professor Bernard Ben. Doc. Doctor, Ben Doc is a professor of neurosurgery in the Mayo Clinic College of Medicine. And he actually holds joint appointments in radiology as well as my department, orderly technology and head neck surgery. And we work closely together in managing patients that have tumors of the skull base, which is at the junction of the brain with the recipe head. Um, he is an extremely innovative person. And since I have worked with him so closely, I would say that the reason he's here is because of what he has done. And I welcome him to share some of those fabulous things that he's working on endeavors, and, uh, he's been working on my clinic. I will say that prior to inviting both Doctor a kiss off and Dr Ben Dog. I did not know that they both had Lebanese heritage, so we'll talk a little bit about diversity later on. But we have to excuse that part. So a doctor, Ben. Doc, if you don't mind telling us about what drives you, why you're in medicine, How your family here in the states and Lebanon are dealing with the pandemic and in terms of health care. Well, if you've seen that movie, my eyes, a big factory, Greek wedding, Uh, most Lebanese believe the whole world is somehow related to us. So way could all be finishing, you know? So, uh, but, um, so Thank you, Dr. Well, for the this, uh, invitation and, uh, you know, just briefly, you know, you know, I'm passionate. I have been I am passionate about, um, moving the story of our feet, our collective fields together, forward from where I think we've been in the in the and what I call traditional surgery era. Let's say additional health care to precision surgery, precision medicine, and and that involves many things, including, um, augmented reality. Virtual reality. Three D visualization, uh, design of new devices, uh, intra operative advanced images. I've been honored to work with you on that. So those are the kind of things that drive me and, um and but on the in terms of co vid covert has been, uh um, it's very interesting. You know, when I when I when Covert first hit, It was like when I first moved to Phoenix five years ago, I was most worried about my kids, but, uh, turns out the kids can adapt better than adults. And it's amazing to see how the kids have adapted. And, uh, on my end and Karen's and my wife, you know, we've we've made the best of it and and But it has been challenging. I think the, uh, the social challenges of not being able to see friends not be able to visit, not be able to go toe doctor laws, lovely dinner parties. Those things all carry a toll on us, and I think that's that's been a big hit My father just had covet. So, uh, 10 days ago, two weeks ago he was hey had some emphasis. He had the G version. Apparently, there's a G I on set and and got diagnosed with co vid daily fevers. Eventually hospitalized at a government hospital in Lebanon, where the I don't mean to embarrass Lebanon, but the in this particular hospital, which is in my dad's hometown. The floor beds are the floor rooms are six patients. A room I see you is to patients a room that's eso because of maybe because of me a little bit in other connections, he got the ice. You bet. I hate to say I feel embarrassed to even say that eso uh, most of the government hospitals Excuse me That the private hospitals are not admitting covet very limited Ice Cube s. So I feel very fortunate to be a male clinic. Very fortunate to be have. The resource is we have here. We can complain, of course, about things not being perfect. United States, they never are. But certainly I've gained a perspective on how lucky we are to be in this somewhat rich and well resourced environment. And so I've become even more passionate about trying to help improve systems. You know, I visited Kuwait once. It's part of a consulting team and they lacked for no money, but yet they're neurosurgery. Hospital was very poorly running because they didn't have the right systems in place. And so I'm very pleased and honored and lucky to be at male clinic where we have assistant. I was just telling a student earlier today that if I was a musician, I'd be in a band. Maybe I have my 10 minute solo, you know, But I'd like to be in a band because I enjoy the teamwork I enjoy working with Dr Lal. I enjoy working with the tautology team and those areas at the cross borders, things that we could do really well at Male clinic. So that's that's my story in the show. Thank you. Thank you so much for sharing. How harrowing to be here far away from your father and knowing very well that the organization and the teamwork that really matters to your family is probably not as great as what is available to us in this. Yeah, Thank you. Luckily, luckily, he is doing okay. He went home, but it could have ended very poorly. So thank you for your kind words. Thank you. And our third Panelists is someone that I'm really honored to introduce. Dr Joel Flynn, who is an n b a. M. P Asian actually is an associate professor of medicine and the College of Medicine, and is Thean Terim, chair in the division of women's Health, Internal Medicine and, uh, have come to know her duty. A work on diversity She is, ah, diversity leader at Mayo Clinic in Arizona. That is, several interests in terms of student outreach community clinics. Onda. A lot of research related to breast health, menopause, education, LGBT healthcare, education, etcetera. She is also a passionate educator. Helps out a Mayo Clinic with several educational ventures, but there's a lot more to her that she's kept quiet about in her introductory slides. So Dr Klink, if you don't mind sharing what drives you what your passions are regarding medicine, patience and love for you to share some experiences that you've had with yourself and the family member about the impact of the pandemic. Of course. Thank you so much for inviting me. I'm truly flattered and honored to be on a panel with these impressive colleagues of mine. I think maybe one thing that makes me stand out from the rest is that I'm the only native Finnish in represented on this panel was actually born in the same hospital in downtown Phoenix that I had both of my kids at and have stayed here and did my training here at Mayo Clinic, Arizona. Um, the the thing that that drew me to medicine, I think becomes clear, is you look through the slide, the kind of work that I'm doing. It really had to do with advocacy, and I realized the importance of advocacy. Um, through my parents examples, um, in their careers, my mother was a therapist for sex crime victims or sexual assault victims. And my dad was, ah, detective on homicide and sex crime Detective and I saw them bring to their careers a passion for really helping people out. And so that's what an informed my decision to go into medicine. It seemed like such a beautiful way to advocate for people you know, both within the exam room but outside of the exam room, which is really one of the reasons I got my masters in public health. Um, it's definitely come in handy when we think about the the intersections of a global pandemic and primary care and women's health in general. I fortunately have stayed healthy, as has my immediate family from co vid. Um, but I do have lots of patients and lots of colleagues that haven't, you know, lots of my friends I went to medical school with that are at the front lines in the I C. U. And in the hospital working long hours. Um, and so again, going back to that desire to be an advocate. I take that role very seriously, and when I'm talking to patients and friends and neighbors trying to really, you know, preach the gospel about those good public health strategy so that we can reduce the spread in our communities in our clinic. So I think that was all the questions that you asked. Thank you again. Um, I said, You know, I am. I don't know how many of you watch America's got talent, but for some reason, America's got talent Had all four American judges were born outside of the United States. So thank you for being the one person from Phoenix had no idea. So that's great. Um, and I think that just reflects on our organization that where we come from is not as important as what we do today. So fabulous. So without much to do. I put together some thoughts and thank you for, you know, reviewing these. And I thought we could have a broad conversation starting and sort of progressing organically through some of the, um, factors in health care that have been severely upended, upended care as usual. And so what are your experiences and how the pandemic effective? Uh, the care off patients, ongoing new patients. And And then I hope that Dr Cling, you can talk a little bit about preventative health care. Because Dr Ben, Doc and Dr Back I saw, but both mostly on the other end of specialty care, surgical and nonsurgical. And using examples, if you could tell us about how how proactive care has been helpful, how you and your practices or mail as an organization has adopted practices that has that have delivered healthcare safely, that could be potentially adopted at other organizations. Um, and so maybe I could start first with Dr Ben Doc. Dr. Ben. Doc. I was telling the other Panelists before you join that, I'm gonna ask you a question. That might someone put you on the spot? Not gonna be a tough question. And I'm just gonna ask you since March, Have you been to a doctor yourself? Uh, interestingly, I have on the reason is not like you would think I had the opposite effect of So I had ignored going toe a primary. You know what I used to in Chicago? I moved here in 2015. I used to go see a primary doctor every year, even though I didn't need much. Just a, you know, oil change, 10,000 mile checkup. And but when I came here, I kind of got so engrossed in my work that I but one of things a pandemic, I think has, uh, reminded me, and I think of this I'm on a personal level, but also a global level if you look and I'm no expert on epidemiology or the the medical manifestations of the virus, but just as an observation, perhaps almost at the lay level as a neurosurgeon, is that a risk factor reduction eyes is absolutely critical. You know, if you look at health care in North America and you look at how disadvantaged communities have been hit harder than others and and and the the risk factors that are more prevalent in those communities where they were talking about diabetes, etcetera. And so I I've and I've become simultaneously, I've become more passionate about the concept of wellness and self care. And I actually I never sit down with a man Tina, with That's the first topic I always bring up. What are you doing about wellness? And because without wellness, the rest of that matter and and and I don't want to turn this answer dark. But in my career, so far, I've lost about 5 to 6 colleagues my age to sudden death and s o I I bring it up with all trainees. And again, I'm not an expert on there. I don't have deep knowledge into their health care, but they all seemed to me to have risk factors and and both, whether it's stress, etcetera and other things. But so I'm sorry. That's a long answer to your question. But I think the pandemic has made me introspective about the world, about our about our health care, both individually, my learner. You know, when I remember, the first case I did was a giant meningioma when Cove it hit. And I actually asked my learners to stay out of the case because at that point, it was like a tsunami hitting. We didn't know. How do we protect our learners? So I told my learners the fellows not to go to the case because we still didn't know the exact Now we know much more, of course. But on DSO the wellness well being and wellness of our learners is perhaps our most important thing we can give them guidance on. And so I don't know if I answer your question, but that's sort of been what's on my mind, you know? Thank you. And as always, I continue to be impressed. But the fact that you actually have time, which I know you're dying when you had a PSA Kudos to you. I think you're leading by example. And the way you eloquently at, you know, describe risk reduction is fabulous. So I'd like to jump to Dr Cling next to take on from there because you deal with the primary care setting essentially for women. Um, and perhaps, you know, talk about how depend Emmick affected your ability to take care off your patients, whether they were established or the other folks that wanted to establish there with you, um, and share any personal anecdotes that you have. Uh, yeah, it's it's certainly impacted things. Um, and like Dr Ben, Doc was saying at the beginning, we weren't quite sure what to Dio. And so what that meant is that our full calendars, um, you know, got restructured. Many patients got canceled. Um, we weren't set up at the beginning of March to do video visits on DSO. Had to figure out some other way to reach out to our patients who really needed us, and so did phone visits and kind of learned as we went. It was incredibly impressive and such an honor. Thio lead the team in women's health as we were telling them to do medicine such a different way than they learned calling their patients, figuring out how to do it from home. Um, and thankfully, we were able to figure that out together. And, you know, I can think about many times where I reached out to a patient, and certainly a phone visit is not ideal, especially for like, a preventative visit. But you could just hear their fear in their voice and to have that opportunity for us to talk to them and answer their questions about Covic about their risk factors was such a big thing. Um, and it was really nice to work for an institution that did everything to help facilitate that. So we could continue finding ways to care for our patients and rapidly went to being able to do video visits rapidly went to creating infrastructure in our clinic. That was safe. So for those patients that truly needed to come in face to face that we could see them and care for them safely and has, you know, throughout really been able to support us in doing that Eso You know, there was a lot of times that were tough, both for us and our patients. Um, but on this end of things, looking back, we realized that it, you know, taught us the things that were truly important and has given us this really beautiful opportunity to re evaluate how we practice and where we practice. And we've taken those opportunities. Thio look at models like teleworking for our are working mom physicians and, you know, video visits for our patients that are working and need to walk into the O. R to do their surgery, but maybe need to talk to us about their, you know, preventative care, their mammogram. So, um, it's been a roller coaster, but I think on the this end of it, um, there's a lot of positives. Thank you. Well, in my practice, a zoo, uh, TNT specializing in Sinus and school based pathology. I can say that, uh, the impact of the pandemic was quick. We pivoted and and we were able thio come through with some safety protocols. But I do. Still, I am seeing now patients that are presenting, whether it's cancer or non cancer patients that are coming to us in more advanced stages. And that is truly heartbreaking because thes folks thought that they were protecting the health by not seeking care during the pandemic. And I don't think that strategy has served us well in that. So I'd like to ask Dr Back Isa about cancer care during the pandemic on DWhite, would you say to our patients, Do you think that you know, you're right on one of the biggest tragedies off this pandemic is delaying diagnosis and and and folks delaying their preventive measures which we know are you know, they're only opportunity for potential curative surgery. There's also an aspect to for quality off life, also that's being compromised by delaying getting attention. Even a few months can make a big difference. Um, and I do understand the discovery were all we were all in that in that period between at least March and may even trickling into June, we are all really short off answers. We were trying hard to understand the behavior of this disease which came, you know, came like a tsunami on us trying to understand you know how to protect our patients. Most importantly, how to protect you know, our colleagues as well. Because, you know, uh, even 23 colleagues down or quarantine can affect the whole the whole system. Also, we were stretched for resource is so there were certainly these were tough times. And, you know, although we do understand a little bit more the behavior of the disease and have things a little bit better control than we've implemented a lot of great measures, you know? In fact, uh, you know, I I dropped wearing scrubs. You know, it's an oncologist. I don't want scrubs way adopted the scrubs because ultimately, you know, way had to ensure that that we don't take back the virus back home, etcetera. And, you know, two months ago, I was thinking, you know, I come toe work, uh, to probably the safest place I could come toe. We take every measure possible to protect our patients and our staff. We assume that, you know, everyone is a Triscuit, and we want to ensure that, uh, no care is interrupted. And so we take every measure possible to protect our patients, protect everyone from transmission. I mean, we live in an environment that essentially ensures when when I kept when we come toe work our mayo clinic to ensure that you know everyone is safe from from the virus and so, you know, went back to normal. You know, dress code may address code with the suit and the tie and just, you know, thinking that not only I'm safe in this environment because off the protective measures, my patients are very safe. But also, when I get back home, my family is also very safe because again, everyone is masking up. We're putting glasses on proper distancing, proper cleaning uh, proper screening. Everything is done in a way that is actually very protective. Now, going back to the to the question off. You know what? What have what have we done with our cancer patients? No, other than the fact that I remain concerned that we're going to see a lot more patients over the next few months trickling into the next year that would be presenting leader with their diagnosis. Oh, are even even beyond that. You know, we had mostly uninterrupted care for most of our patients. You know, As you know, a lot of our patients undergo chemotherapy. Um, and then chemotherapy is, for some part off a curative regimen for others, part of a palliative regimen. And, you know, holding chemotherapy can have tragic consequences at the same at the same token. And so we had to essentially continue through and muscle this through through the early phases of the pandemic, ensuring that essentially our patients have uninterrupted care. I'm proud to say that we have not had for most patients any interrupted care. We're able to continue Aziz normal as possible in terms of a administering our chemotherapy. We had to be a little bit more creative in terms of how we do it. Eso thinking about for some patients how to de intensify treatment. So moving from an intensive toe, less intense treatment, spacing out when possible. Treatment to minimize, you know, having patients to come to frequently if they don't need to, um, ensuring that rather than having patients be seen all the time face to face. When we felt that we could replace a face to face visit by a video visit, Ah, and to Dr Clings Point is that you know, it took it took a little bit to get to the video visit. We had to start with phone visits, but we we clump all these into virtual visits. You know, we had to implement measures where you know, to ensure that if patients didn't need to be on campus being seen face to face, we were able to see him o r meet with them virtually. We also for some patients who were just having routine follow ups, we had to consider delaying, delaying their, uh, you know, delaying their their their visits by a month or two just to accommodate. So we have to. We had to be quite creative. And I I'm proud to say that at least, you know, in our division, um, we feel that we have not compromised the care of our patients. If anything, you know, we've we've implemented every measure possible to ensure that the continuing to your care doesn't stop. And the safety of our patients, you know, continues to be first. Thank you. And I both at you and Dr Feign mentioned telemedicine. And it's interesting to me that you come from, you know, you come from a very specialized aspect of care, doctor back Assad and Dr Cling, you come on the front lines of, you know, preventative as well as curative treatments. Can you describe the experience that you've had in terms of patient care Whether you're able to establish that relationship with patients? Um, what has been the experience of your patients with regard to tell you medicine and Dr Ben Doc, I know that you are surgeon, um, and, uh, wow. Yes, I do know that you're a surgeon, but what has been your experience with folks? Uh, think folks over a video visit and what has been the reaction of your patients and whoever wants to jump in first. Please, go ahead. I mean, I'm happy just to quickly take this through just to continue through the discussion. You know, uh, I will say that that for a lot of our patients that there was actually a pleasure for them and for me to be able to see actually, the full face unmasked until the visits. You know, these facial expressions say a lot Say a lot from the patient's side, but say a lot also from the physician side when delivering good news or bad news, it's very important for the patient to be able to see with official expression and to understand, you know, where we're going with this. So part of this was was, was a little bit more personal, although it was it was through a video at the same time. You know, I think on I'll just summarize it. I think we learned so much about virtual visits that post covet, and there will be post covet post covert. Uh, you know, we will implement a lot of these measures because I think they do bring a level of quality tow our patient care that we were kind of scared off before Cove It so that was That was a moment. And I think, you know, a lot of tragedies bring some benefits to them. If there's any benefit to this, um, is that now we know, you know, especially that we care for a lot of patients who travel distances. We know that we can do it. We can do it well, we can do it safely. And we can benefit our patients tremendously by cutting down on the visits, the risk of being here or even you know, that the inconvenience off traveling hours when we can do this through through a video visit. Eso Would you like me to comment after law, please? Please. And I know Dr Claim has also been very involved with telehealth. But just briefly, I think it's been a big game changer for us in neurosurgery. I think our patients have been very pleased. My favorite stories. I saw a patient with leg pain from a disc. They're back was on his boat, and, uh, somewhere on a beautiful lake. I thought it was a zoom. Background says. That's a beautiful zoom back. I know that's actually riel. I could see the mountains behind him, and he was just delighted to be with his wife on their boat, which is where he likes to hang out. So in a way, you know, we talked about Male Clinic in 2030 bringing digital health to patients, bringing the health to the patient rather than having the patient come to us, and I think the the pandemic accelerated that. So I've been very pleased. You do get the occasional patient who still wants to be seen in person, not because it's a better care, but because they have this ingrained psychology around. The idea of seeing a doctor in person and there's nothing wrong with that on. Do you have to be sensitive to that that there are some people prefer that? But I do think it's enhanced our ability to deliver high level, uh, destination care bye meeting the patient before they leave their home, so that when they do come, they're lined up to get all the things they need, and it's not. It's much more organized and and then for their follow up care, I think it makes it just very efficient for them. Uh, just you know, when we when we book a half hour appointment with me or you, Doctor. Well, for us, it's just maybe 2030 minutes. But for the patients, a whole day, they have to take the day off work. They have to get in their car. They have toe dr find a parking spot, come to your clinic. Uh, sometimes if we're running behind in surgery, hopefully that it doesn't happen very often, But if it does happen, it's an additional nuisance. And so I think this is really enhanced our ability to engage in. And I think it's just the beginning. Well, Dr Law, as you know, you and I are engaged in virtual reality, uh, research where perhaps one day we'll have a beautiful clinic room with a view of Paris. You know, perhaps, or we could meet with the patient and they can pick their environment, you know, sort of speak. And, uh but we could actually walk them through their brain or through their Sinuses so you can actually walk them through their Sinuses to show them what you're doing in a way that you maybe couldn't do in person in a very scalable way. And by creating a virtual environment, not just of the patient and you, but of your tools. Your surgeries, your, uh, educational platforms that you can share with your patient, I think, really is a game changer. So it's been It's been really good for us, and I think it's just the beginning. I actually just a final anecdote is I started, uh, just to help our practice get back on its feet in terms of adjusting to the pandemic, doing some Saturday clinic. And I hate to even bring that up because I know that, uh, you know, we all worked so hard, and we all need to have that Saturday morning to be with our families and so on. But there may be a way to also adjust to the needs of our practice in terms of people having different schedules so that if somebody works a Saturday morning, maybe they get a weekday off. Perhaps, and that is attractive to some people for various reasons. But also one other dimension of that that's surprising. I think it's worth bringing up in this panel is that when I met with patients with complex problems on a Saturday, all of a sudden their families around the country were logging into the zoom. So I got to meet the people that matter to them. When it's a weekday, they're coming to see you on your time or my time. Their daughter or son or wife may be working, but when they see you on it, let's say in the evening or on a Saturday morning, Um, they, um all of a sudden I was getting this greater buy in because their family, who maybe in India or in Eastern Europe, were also logging in because they could, because it was a weekend and so and also it's finally the international. So I met with somebody from China the other day, so I think it was. I remember it was late here. I got locked in at the end of my day, which was the beginning of his day. And so by through the digital platforms were able to engage our international patients in a way that was, you know, used to require a $5000 business class ticket just to meet, meet us, whereas now we could meet them first, and then we could be more strategic about when they should come. If they should come, how they should come on. Who else do they need? What do they need when they come? And so I think that's all very important. Sorry for the long answer. Now, that's great, Doctor claim. Yeah, I agree with most of everything that was already said, Um, I think maybe a different perspective that I've had the opportunity to see is, um, me and fellow family medicine Doctor supervised the clinic at ST Vincent de Paul with the second year medical students, and that clinic has been completely virtual since the end of March on bond. What we've seen is that the, um, amount of patients that are actually coming for those visits so the no show rates have decreased significantly for the same reasons that we've been talking about. Just that ease of being able thio log in from wherever, Um, I've seen so many patients on a construction site or in their closet at their office or in their car, where they're able to take a 10 minute break and join and ask those really important medical questions that they wouldn't have have been able thio without access, um, to a video visit or without access to a a fantastic free clinic like ST Vincent de Paul. But it looks like it's, you know, help facilitate care for, um, you know, people internationally, people on their yachts and also people that are on the construction site that maybe wouldn't have been able to come in otherwise. It's always, you know, Dr Clean, you bring in such a diverse and intelligent perspective. And shortly before he started the panel you were talking about, some of your older patients and early stage of the pandemic were, well, fearful, leaving their homes and especially coming to the hospital as we were still learning on the fly. I was certainly true for some of my older patients to um and tell you how, uh, it has been that bridge. But I would say that by and large, most of my patients who were more worried are now coming back to the clinic. And if they had elective surgery scheduled which they pushed out, they are willing to reschedule. I will agree with all of you if there is a silver lining on this pandemic is the ability to take care of patients with telehealth, which has not always been the case to you to regulatory barriers more than technological barriers. Um, and thanks to the pandemic, I hope that this temporary measure that allows us Thio see patients in other local states countries, uh, we will be able to certainly continue this going forward because the blend, especially in surgical practices like yours, Bernard and mind it's important to the examined person care and like yourself, Doctor Back Isa, I think Dr. Clean you mentioned it to I mean, if I were having surgery, I'd like to see the face of my surgeon. So one thing that I always do is now on this. Sounds bizarre. I have a face to face. But since I instrument in the nose, I have to wear an N 95 all sorts of things for aerosol generated procedures. Patients have tested ahead of time. But I always wear that P. B because I know that if I fall ill, then the health of my patients, my family members, is that state too. So where that But then that means my patients don't see my face. So I will at least have one visit on three video s so that you know we can see each other. Family members could join in and they can gauge the personality of the surgeon. Or, you know, the emotional aspect of it that gets blunted with masking etcetera. It's been quite the blessing, Um, so from the same point off surgery, Dr Ben Doc, I mean the operating room, especially for some of the procedures that you do through the nose, etcetera, that sometimes we do together. I mean, it is a new area that is considered to be a high risk aerosol generating procedures, and and the first few cases out of China in the medical community will also reportedly from spread during a case done by new surgery through the nose. And so, early on in the pandemic. I remember we had a patient that needed urgent surgery, and we were running around looking for an N 95 we've come a long way since then. We have lots of protocols, and I wonder if you could share some of the safety protocols in terms of how we optimize care for our patients. Yes, So I've been so impressed with, you know, one of things that may or excels at many things but one thing you realize when you're when you're young and medical school, you think that you want to be a great doctor. You think of it as a Superman act or a superhero act superwoman act. But But, as I said earlier, my reference to the band, What you realize is that your performance and your safety is dependent on a lot of things were happening in the background and male excels. It systems of care. And it was so impressive to watch how male quickly adapted to the new realities on the ground. The institute protocols secure everything we needed for safety both for ourselves, our colleagues and our patients. So it starts with simple things. You know what we hear from the 500 everyday social distancing that we eso, first of all, is protecting staff. And so that's, um, very important, even the way we sit in the cafeteria wearing of masks at all times a bail clinic washing of hands. If another good thing that came out of the pandemic is American hospitals. I've been trying to get people to wash hands for 100 years, surprise since the Spanish flu, and now almost now I think finally people are. I'm not talking about male. I'm talking about all hospitals. All right? Now people are gonna wash their hands. And actually, the new I watch will measure how long you're washing your hands for. It's gonna electrocute you if you don't wash your hands long enough. So that's a new feature on the new I watch. But, um, so that's that's in terms of the individual safety. The other is that taking temperatures daily and people I think I've become more conscientious used to be in the old days before the pandemic. If you had a cold, especially if you're you know, some people have this. You just tough it out. You came to work, and now people are being smart. So the other thing about telehealth is it a lot? It's and tele not just health, but also it affects all three of our shoes were doing tell a research until education teleconferencing is it allowed people to continue their mission even when they may have. Let's say they're quarantining, they can still do things from home, so it's opened up a whole new way to re think about how we run our lives But in terms of going now, drilling down to the O. R. A Z you know R O. R is, we've really we do about 10 minute briefings in every case. And there are a lot of criteria that the anesthesia put in place so that people have to be covert tested in advance of surgery in a very defined time time point are detailed checklist that the staff go through to keep people safe. We limit the number of people who come see the patient. That has been actually been a nuisance emotional burden. Actually, the pandemic Probably The biggest I notice is when people have surgery, especially serious surgery, they wanna have their loved one or significant other or a family member with them. And that's, I think, been the biggest emotional burden for our patients. Uh, but, you know, knock on wood. We've been very lucky, perhaps, but we've had a tremendous safety in neurosurgery on an E M t R surgical specialties and and thankfully it's because we we do put such great emphasis on systems of care. It's not so much about Dr Lal and Dr Brenda being very good surgeons. We try to be the best we can, but it's much more about following the same rules every time and having a system in place. So when Dr Lal learned from her colleagues in at Stanford and in Asia that E. N t nasal procedures were higher risk than average surgery because of the aerosol, we quickly, uh uh instituted with Dr Wells. Help and her colleagues help protocols to add additional measures of protection in the surgery. Whether it's the way we intubate three negative pressure rooms as well or quickly rigged, essentially on bond, put in tow, put into place very quickly. So I think it's, uh, you know, goes back to the male model that was, I believe will mail coat three interest of the patient Come first, I'm paraphrasing. But when you when you think of it that way on a daily basis, what it's safest for the patients and and the flip side of the male model is also what's best for each other. We have to look out for each other at mail, and so if we look out for each other, we look out for the patient, you quickly get to the solutions. Thank you so much. for again putting those points across. And I will say that, um, it was fascinating how quickly we were able to come up with systems, he said. On the Surgical Practices Committee, I serve on the Outpatients Practices Committee. Doctor back. I saw a view on the Cancer center committee doctor claim you sit on several internal medicine committees, and but I think that at the end, what I realized is we put the patient at the center and patient care at the center, and we worked away from their thio instituting protocols, whether it's testing prior to coming to surgery or insurgent subspecialties, Um, and I have to say that sometimes I sit down with that patients and and some of them are actually cancer patients that have bad disease that require follow up so they require follow up multiple times, and some of them have undergone testing in the teens. And it's almost like a proud badge. And I say I feel so bad that you have to undergo this and they say to me, I know it keeps us all safe. It keeps me safe and it keeps the person sitting next to me in the lobby safe. So our patients have just been fabulous. And it's just been amazing to see every, um, every male clinic worker, actually, in terms of social personal responsibility stepping up, but also to see services that perhaps were in the background, like engineering that came around and rig rooms to negative pressure rooms put in HEPA filters where necessary enhanced cleaning procedures are supply chain. I am just blessed to be part of an organization where we truly never came to the point where we had to ration care because we did not have enough protected with. Yes, we have. We still have to be very careful about how much pp we used. But would they kept us going? So as you said that it's a family that works together, But at the heart of that intent, you know, everyone is just focus on effective, safe patient. Can't doctor back. I saw you take care of some of the sickest patients in the hospital. You mentioned that you you know, chemotherapy drives immune systems down, etcetera. Um, what are the safety measures that you undertake with these patients in terms of counseling, etcetera? Because I know some patients just worried about going through treatment of any sort during the pandemic because they're worried about losing the immune systems on becoming susceptible to the virus. Yeah, and And it's when we when we talk about treatment, we talk about the checks and balances. I mean, even even before the pandemic it was It was the same. Although the pandemic added another dimension to the discussion, I think I think we we in our, you know, line off work. We're always talking about the benefits of treatment, which is the risks and the ratio and why we tell it one way or the other. You know, one can give multiple examples, so I'll give two brief examples about some some of the discussions and and why it's important to have them with patients at any time. But even more so now, eso assume patient goes through through their surgical treatment and, uh, and you know, they're cure their cure from surgeries at 50%. And we know that chemotherapy adds 25% to the cure, which is huge. So we have that discussion. I mean, this is this is, ah, a case where we would think that depriving chemotherapy or depriving the patient from chemo. Active chemotherapy would would be detrimental, essentially to the likelihood of survival and with chemotherapy or with treatment after surgery. Time is of the essence. We have some leeway, and we try to take advantage off of the leeway to the stretch. But to a certain point, the patient will need to be treated. So we have this discussion patients that are in the more advanced stages. Oftentimes our treatments are palliative, and they do prolong survival. But the quality off life component off the treatments is equally important. Meaning they do cut down on the symptoms on the pains. Um, you know, on overall improving, improving well being of the patient. Um and so we have these discussions now, some of the things we we have bean implementing a little bit more aggressively off course. In addition to all the safety measures we all are doing around our patients being, you know, be careful, you know, mask up, keep distanced. Um, unfortunately, you know, our patients end up being a little bit more isolated because they're, you know, the treatment is not a snapshot in time, but continues unfortunately, that that is something that has bean one of the biggest tragedies, in addition to a lot of other things in this, um, but take just these basic measures. Thea Other thing is when when faced with regiments save with our treatment regiments that we consider more aggressive. You know, we were based on data, of course. You know, we for the longest time being at work advocating for what we call the intensification strategy is meaning You start strong and very quickly within 2 to 3 months based on data, of course, but but also in common sense, you know, go down toe the minimum required to maintain the level of response. And that's in the more advanced settings. So these the intensification strategies allow patients to be less sick on that chemotherapy less likely to have to visit the hospital or to the ER, and so cuts down somewhat on the risk off Getting infected also measures to Bush. They're they're white counts. Uh, especially with a more aggressive regiments, you know, to be implemented a little bit more reflexively, uh, have become an important aspect of what what we do. So educating our patients and educating them about the risks ensuring that the discussion continues to focus on the balance of quality versus quantity, risk and benefit all these things that you know which were always important but you know, have have anything but become overemphasized. There's also the factor that although, although the risks outside the clinic are relatively, you know what they are for the average patient, uh, in the clinic, you know, I you know, ah, high level of assurance to the patients that, you know, their safety is well preserved when they actually come to us, when they come through our door steps, all the measures that we're taking to ensure that they don't get exposed, they don't get the risks that they may be privy. Privy to it in the outside, you know, are very important because that actually brings down the level of anxiety. Oftentimes I hear from patients, you know, they're concerned, uh, that they want to avoid to visit the yard if they have a severe symptoms. So we certainly, you know, have the discussion and understanding that actually, the ER at Mayo Clinic, um is relatively quite a safe place, and the risks are incredibly dismal. And delaying care is actually more concerning so again, you know, spending more time, educating patients, reassuring them and then ensuring that everyone is doing the right thing around them. And I can see over the last few months quite a bit of shift of the patient from with our patients, you know, feeling now much more comfortable, to come back and and feel comfortable with being treated and feel comfortable to present to the R and feel comfortable with with going back at it became on. And so I think you know, all these measures have Bean have bean ultimately and reassuring to our patients. And I see us going back to normality, although I should again reemphasize. My biggest concern remains that those are the patients that are sick. They will come to us. They are because they feel sick. My biggest concern is those patients who do not feel sick, who have a polyp that may transform into cancer or have risk factors. Or they need a mammogram or they need ah, sit low. You know, low CT scan for the preventive measure for lung cancer or a P s, a test or prostate test. Those patients are actually because they feel healthy. They many of them are avoiding coming, not to me. But they come to Dr Klink, for example, and they're avoiding that now because they're scared. They're concerned. Unfortunately, if we don't start bringing that awareness of our community that it is safe and it's almost safer for them to come and get those screening measures done. Those print inventive measures done because it's safer on the long run. We catch their cancer earlier with almost no risk from Cove it in our clinics. Um, I think I think that's the message that needs to be emphasized and over emphasized our community. You made such great points, Doctor McKay Saban. I personally can attest to some heartbreaking stories about some patients that were worried about coming in, um, to seek care for a nosebleed and eventually or, you know, other, um, concerns. And by the time they presented, um, to me, it was not in a state where we could offer a reasonable chance of cure and and that indeed has been one of the most heartbreaking aspect off my career, especially and and I wanted to talk dr thinking about some of the points that you mentioned. But I am so happy that you mentioned preventative aspects to care because we cannot assume that we're in health if you're not getting health care. And so, Dr Clean, I'd like for you to take this opportunity to speak out to our patients about preventative care. Whether it's, you know, mammograms. Is doctor back isa mentioned or other aspects off meeting with their physicians in in a timely fashion? Well, I think really to echo his points into emphasize that we have created a safe space so that we can continue that critically important preventative care. Um and so we encourage our patients to come and get their mammograms and do their colonoscopies, um, and continue to find ways to practice those other healthy lifestyle habits that even Dr Ben Doc was talking about. You know, wellness is critical and one of the things that we've been seeing, um really over and over is just how negatively from even a mood or anxiety perspective cove. It has impacted our patients on dso addressing that directly and figuring out how to find ways. Um, to help patients, um s O that depression anxiety does not impact their health or stand in the way of them getting that preventative care. And perhaps that's one of the nice things about the video option is sometimes me just setting up a you know, 10 minute video with a patient where I can reassure him. Hey, I went and had my mammogram. My mom came and did her colonoscopy. This is a, you know, a safe place. Let's get this set up for you Can can do so much for your patients. So thank you. Because I think you shared some very important points. That is, we're encouraging our own family members. A busy surgeon like Dr Ben Doc found time finally to take care of his health. And I have been to my primary care physician, and I have some follow ups and slaps on on the wrist Dio December again. But I did. I did mine by video so I could avoid getting weighed in, which was probably not the right way to do it. But yes, yeah, I know it's important for our own wellness and Dr Ben Docks Point. I was one of this folks with the psychological disposition to request an in person visit, see oh, position in person so each to their own. But thank you. I mean, we're encouraging our family members a T least of the United States, where they are good protocols and most health care centers and and certainly at Mayo Clinic. I think when you talked about a safe place, I do feel very safe coming in here and at the last account. And I scrolled through the report on our incident command center, which is the organization that is helping us deal with the pandemic. Uh, the number off cove. It, uh, the transmission of cove it between workers at Mayo Clinic or between a patient toe healthcare worker or health care worker to a patient has has not occurred. And so that speaks volumes about safety protocols. Also talked about what about the disease. And so whatever we're doing uh, Malcolm, what seems to work? Andi, I think that the downsides of not seeking medical care Attn. This stage of the pandemic, um, is significant in comparison to the risk of just coming and contracting. Kobe is likely not to happen. So any final talks about how to get the pandemic. If I may, I just like to make a shout out to a group that we unintentionally may have not mentioned tonight this'll evening. And that's our male nurses. Um and they have been truly phenomenal. I I had to visit a patient of covert unit the other day, and I felt like I was entering a top secret military facility with multiple layers of nursing screening and not in a very gentle way, guiding a naive or Dr Ben Doc through the various protocols for how to put, you know, do the extra. We're all putting on masks and gloves, but this is even additional layer of safety that they guided me through, which was pretty phenomenal. And disorders also acknowledged the bravery of our nurses, who really at the front line back in March in February when we were all trying to figure out what was going on. And I know one of my prior nurses, for example, who was working out patient orthopedics as she her uncle was a famous orthopedic surgeon. She sent me a note saying that she was volunteering toe work in a nice you a covert. I see you on DSO. I would just wanna the spirit of nursing at Mayo Clinic, and I've worked at many I've worked at several health care systems, and I've visited others. And, uh, there's nothing quite like our mayo nursing cultures, so I just wanted to give them a shadow. Absolutely. I mean, you know, if you want something done in an organization, I think nursing is three way to go. And not just in the i c U, but in maintaining outpatient practices. And the Kobe Tet covert testing tense calling patients delivering vaccination. Um, which brings us to the last point off Kobe. 19 vaccinations, which might be coming soon. And flu vaccinations. Um, Dr Cling, you seem to be the obvious a Panelist to direct this question to, but also Dr Paul Kizza about, you know, vaccinations in the setting of immune suppression or vaccination at all for thes two conditions. Dr. Link Start. And then I'll talk about the the compromise patient, please. Yeah, uh, everybody should go get their flu shots. We have ah, for our male patients and drive through flu shot clinic, which will hopefully be, are set up for the cove it vaccine once that's available to but, um yep, everybody, my whole family has already gotten theirs, and I'm encouraging on my patients. I you know, I second that for our immuno compromised patients. We do have, you know, special protocols for when they get their flu shots. Essentially, every single one of our patients has to get their flu shot and ultimately, hopefully, the covert vaccine and any other vaccine that is essentially indicated for their age group or for the risk factors, Um and, you know, although again came with that, we can affect the immune system. We do know. And there are number of studies that to suggest that those patients do form the required immune responses similar to the general population as long as we time them correctly and we have these protocols in place, um, so and I think that our patients are at higher risk if if they get the flu, if they're not vaccinated against the floor, there are at high risk not to catch the flu, but to get complications from the flu on serious complications, including, you know, potential for for death. So I think I think it is a must for every one of our patients to be up to date with their vaccinations and again, like I said, you know, the concern regarding the potential immune compromise is minor. Azi long as again, we follow the protocol. And of course, we do here. So all our patients, uh, well, will be will be referred for vaccination, um, for flu and others as well. So thank you. It is 6. 14. And I know that all of you have taken time away from your families and I'm getting your shorts etcetera. And Dr Fling, your kids are extremely well behaved. I was hoping that they would come in and bombing in you and your virtual background as you're at home while your husband goes and works a shift somewhere. Eso I It just goes to show how devoted uh, you guys are my colleagues at the man clinic. Um, in terms of your passion towards not just patients, but as you know, this is going to be a patient facing presentation, um, and patients who are not even our patients yet, but just, uh, advocating for them. Thio pay attention to the health care during the pandemic. So I am truly gratified to be a colleague. And, um, I would like for you to say your vice, if you have any special words of advice tips. Something in Lebanese. English. Venetia, let's go for it. I just like to say thank you, Doctor lol, for this fabulous opportunity to connect. And one of the greatest things about being a Mayo clinic is working with some amazing people. So really pleased to be with all of you tonight. So thank you so much. I agree. Yeah. Thank you so much. Yeah, I would just say the doctor playing you have least three Phoenicians. Mhm. Love it. Okay. Have a great evening, everyone. Thank you.