Cheryl K. Lee, MD

Health care’s modern-day version of the Greek chorus is growing louder and more persistent. My colleagues and I have long been among them.

In news conferences, journal articles, and podcasts, this chorus is pleading with the public to pay attention to its message: SARs-CoV-2 is not done with us. Omicron can kill; it can infect the vaccinated.

We have found, like everyone else, that Omicron runs on its rules; with Delta, two vaccine shots were able to lower the positivity rate. With Omicron, two shots have not been enough.

The WHO used the word “surprise” in its November announcement that Omicron was a variant of “concern.”

So did Trevor Bedford, a computational biologist and infectious disease scientist at the Fred Hutchinson Cancer Center in Seattle, who said that Omicron “took me and everyone by surprise.”¹ Speaking on KevinMD’s podcast, he told his host that with the degree of immunity in the global population, he was expecting subsequent evolving strains to have minor, subtle genetic mutations, akin to how flu varies from year to year. What was a surprise was the giant leap in evolution that occurred with Omicron, which contains 36 mutations in the spike protein and approximately 50 mutations in total. Because of these mutations, the original two-shot mRNA COVID vaccines becomes only 40% effective against symptomatic disease after several months (thankfully a booster shot increases this to ~80%).² But the decreased vaccine protection without a booster, along with relaxation of mitigation measures, brought us to where we are now.

In Chicago, we knew the Omicron variant would move quickly, considering how it moved through South Africa and the United Kingdom. What we didn’t anticipate was that in one week’s time, our hospital would need to add another 100 dedicated COVID ICU beds. Nor did we anticipate the extent that Omicron would affect staffing levels in the same amount of time.

At our hospital, we have eliminated elective surgeries that require a hospital stay, which includes surgeries for cancer. One of my colleagues, Ryan Merkow, MD, a surgical oncologist, remarked recently he had to cancel half of his scheduled surgeries because of a lack of hospital space.³

Dispelling Myths

What is concerning about this current wave is how many unvaccinated are hospitalized. Because Omicron is so infectious and because of lower vaccination rates in younger adults and children, we have a younger group of adults and children admitted with COVID, who had been uninfected by previous surges.

A major myth that makes health care workers so frustrated is the tale that Omicron is milder. Unvaccinated people infected with this variant are seriously ill and are dying. Despite its “mild” label, once a patient is hospitalized, Omicron can be just as severe as its predecessors.⁴ For many, getting vaccinated is the difference between staying at home with some symptoms and being in the ICU.

As of January 10, according to the CDC, although 88% of people over the age of 65 are vaccinated, only 37.5% have gotten boosters which are key to restoring protection against Omicron. And among children, only 54% between 12- and 17-years-old are fully vaccinated, and a mere 17% of children aged 5 to 11 have gotten both of their shots.

Remember the conversations regarding natural immunity? Omicron has muffled that conversation. Those who have been infected with SARS-Co-V2 before can still get infected and very ill with Omicron. So now is the time to get vaccinated.

Transmissibility

We knew SARS-CoV-2 could spread 1 of 2 ways: large virus-carrying droplets that enter through the nose, mouth, and eyes, as well as miniscule airborne droplets of virus that float in the air and travel further than 6 feet. However, prior to Omicron, transmission of these smaller droplets via the air was not as frequent. But with Omicron, while it still travels by larger respiratory droplets, it appears to have more airborne spread.

In late December, The Lancet Regional Health published results of research conducted one month earlier at a designated quarantine hotel in Hong Kong.⁵ The index case was housed in the room across a hallway from the second case, who developed their case 8 days into quarantine. Testing showed the Omicron variant in both cases. Environmental testing of the walls and ceiling suggested airborne spread of the virus in places unreachable by large respiratory droplets.

Now with Omicron, people need to wear high-filtering masks that fit tight against the face, such as a N95, KN-95, or KF-94 if possible. And when removing the mask to eat and drink, one should be in well-ventilated areas, away from others.

People should avoid getting Omicron, regardless of vaccination status. This variant is so infectious that, compared to the Delta variant, people are twice as likely to infect others that live with them. And infecting others leads to a chain of transmission that can close schools, take over hospital beds, and disable or kill the most vulnerable in our communities.

Public and private behavior, and public policy

In July, months before that WHO announced Omicron’s existence, Rella and colleagues reported in Scientific Reports on the outcome of a new model designed to show how a vaccine-resistant strain could rapidly transmit through a highly vaccinated population if transmission mitigation interventions are dropped too soon.⁶

The authors wrote that the success of a vaccine-resistant strain making inroads into a population depends on the obvious – it finds populations with a low rate of vaccination. What is not so obvious, the authors wrote, is that a vaccine-resistant virus does its worst when transmission is not well controlled in a highly vaccinated population. What can prevent a surge like this are social behaviors and public policy that decrease the chain of transmission of SARS-CoV-2, such as vaccination, masking, and testing.

It is people’s behavior, and ineffective public policy, that are so frustrating to us. The WHO’s secretary general warned against relying solely on vaccines in December. “Vaccines alone will not get any country out of this crisis.”

Omicron takes a new mindset. What we were doing before is not protecting now. Unchecked spread is overwhelming our health care systems and putting the vulnerable in our population at risk. The ramification of this unchecked spread reaches everywhere – into the economy, our educational system, and our nation’s mental health.

When the pandemic started, the policies to control its spread rested on local government and public agencies; we all would have been better served had there been a unified, national response to an infectious threat that does not obey municipal or state boundaries.

 The universal sentiment among health care workers is frustration with local and state governments that are either dictating policy that can harm the public we are trying to protect.

As of September, at least 23 state legislatures have passed laws changing a governor’s executive power reach. Many have taken it away. Others are fighting in the courts over mask mandates.

As for when the pandemic will subside, that appears to be up to the public and public policy makers. They will determine how long this will last and how many will die or be disabled before its end.

Health care’s modern-day version of the Greek chorus is growing louder and more persistent. My colleagues and I have long been among them.

In news conferences, journal articles, and podcasts, this chorus is pleading with the public to pay attention to its message: SARs-CoV-2 is not done with us. Omicron can kill; it can infect the vaccinated.

We have found, like everyone else, that Omicron runs on its rules; with Delta, two vaccine shots were able to lower the positivity rate. With Omicron, two shots have not been enough.

The WHO used the word “surprise” in its November announcement that Omicron was a variant of “concern.”

So did Trevor Bedford, a computational biologist and infectious disease scientist at the Fred Hutchinson Cancer Center in Seattle, who said that Omicron “took me and everyone by surprise.”¹ Speaking on KevinMD’s podcast, he told his host that with the degree of immunity in the global population, he was expecting subsequent evolving strains to have minor, subtle genetic mutations, akin to how flu varies from year to year. What was a surprise was the giant leap in evolution that occurred with Omicron, which contains 36 mutations in the spike protein and approximately 50 mutations in total. Because of these mutations, the original two-shot mRNA COVID vaccines becomes only 40% effective against symptomatic disease after several months (thankfully a booster shot increases this to ~80%).² But the decreased vaccine protection without a booster, along with relaxation of mitigation measures, brought us to where we are now.

In Chicago, we knew the Omicron variant would move quickly, considering how it moved through South Africa and the United Kingdom. What we didn’t anticipate was that in one week’s time, our hospital would need to add another 100 dedicated COVID ICU beds. Nor did we anticipate the extent that Omicron would affect staffing levels in the same amount of time.

At our hospital, we have eliminated elective surgeries that require a hospital stay, which includes surgeries for cancer. One of my colleagues, Ryan Merkow, MD, a surgical oncologist, remarked recently he had to cancel half of his scheduled surgeries because of a lack of hospital space.³

Dispelling Myths

What is concerning about this current wave is how many unvaccinated are hospitalized. Because Omicron is so infectious and because of lower vaccination rates in younger adults and children, we have a younger group of adults and children admitted with COVID, who had been uninfected by previous surges.

A major myth that makes health care workers so frustrated is the tale that Omicron is milder. Unvaccinated people infected with this variant are seriously ill and are dying. Despite its “mild” label, once a patient is hospitalized, Omicron can be just as severe as its predecessors.⁴ For many, getting vaccinated is the difference between staying at home with some symptoms and being in the ICU.

As of January 10, according to the CDC, although 88% of people over the age of 65 are vaccinated, only 37.5% have gotten boosters which are key to restoring protection against Omicron. And among children, only 54% between 12- and 17-years-old are fully vaccinated, and a mere 17% of children aged 5 to 11 have gotten both of their shots.

Remember the conversations regarding natural immunity? Omicron has muffled that conversation. Those who have been infected with SARS-Co-V2 before can still get infected and very ill with Omicron. So now is the time to get vaccinated.

Transmissibility

We knew SARS-CoV-2 could spread 1 of 2 ways: large virus-carrying droplets that enter through the nose, mouth, and eyes, as well as miniscule airborne droplets of virus that float in the air and travel further than 6 feet. However, prior to Omicron, transmission of these smaller droplets via the air was not as frequent. But with Omicron, while it still travels by larger respiratory droplets, it appears to have more airborne spread.

In late December, The Lancet Regional Health published results of research conducted one month earlier at a designated quarantine hotel in Hong Kong.⁵ The index case was housed in the room across a hallway from the second case, who developed their case 8 days into quarantine. Testing showed the Omicron variant in both cases. Environmental testing of the walls and ceiling suggested airborne spread of the virus in places unreachable by large respiratory droplets.

Now with Omicron, people need to wear high-filtering masks that fit tight against the face, such as a N95, KN-95, or KF-94 if possible. And when removing the mask to eat and drink, one should be in well-ventilated areas, away from others.

People should avoid getting Omicron, regardless of vaccination status. This variant is so infectious that, compared to the Delta variant, people are twice as likely to infect others that live with them. And infecting others leads to a chain of transmission that can close schools, take over hospital beds, and disable or kill the most vulnerable in our communities.

Public and private behavior, and public policy

In July, months before that WHO announced Omicron’s existence, Rella and colleagues reported in Scientific Reports on the outcome of a new model designed to show how a vaccine-resistant strain could rapidly transmit through a highly vaccinated population if transmission mitigation interventions are dropped too soon.⁶

The authors wrote that the success of a vaccine-resistant strain making inroads into a population depends on the obvious – it finds populations with a low rate of vaccination. What is not so obvious, the authors wrote, is that a vaccine-resistant virus does its worst when transmission is not well controlled in a highly vaccinated population. What can prevent a surge like this are social behaviors and public policy that decrease the chain of transmission of SARS-CoV-2, such as vaccination, masking, and testing.

It is people’s behavior, and ineffective public policy, that are so frustrating to us. The WHO’s secretary general warned against relying solely on vaccines in December. “Vaccines alone will not get any country out of this crisis.”

Omicron takes a new mindset. What we were doing before is not protecting now. Unchecked spread is overwhelming our health care systems and putting the vulnerable in our population at risk. The ramification of this unchecked spread reaches everywhere – into the economy, our educational system, and our nation’s mental health.

When the pandemic started, the policies to control its spread rested on local government and public agencies; we all would have been better served had there been a unified, national response to an infectious threat that does not obey municipal or state boundaries.

 The universal sentiment among health care workers is frustration with local and state governments that are either dictating policy that can harm the public we are trying to protect.

As of September, at least 23 state legislatures have passed laws changing a governor’s executive power reach. Many have taken it away. Others are fighting in the courts over mask mandates.

As for when the pandemic will subside, that appears to be up to the public and public policy makers. They will determine how long this will last and how many will die or be disabled before its end.

Health care’s modern-day version of the Greek chorus is growing louder and more persistent. My colleagues and I have long been among them.

In news conferences, journal articles, and podcasts, this chorus is pleading with the public to pay attention to its message: SARs-CoV-2 is not done with us. Omicron can kill; it can infect the vaccinated.

We have found, like everyone else, that Omicron runs on its rules; with Delta, two vaccine shots were able to lower the positivity rate. With Omicron, two shots have not been enough.

The WHO used the word “surprise” in its November announcement that Omicron was a variant of “concern.”

So did Trevor Bedford, a computational biologist and infectious disease scientist at the Fred Hutchinson Cancer Center in Seattle, who said that Omicron “took me and everyone by surprise.”¹ Speaking on KevinMD’s podcast, he told his host that with the degree of immunity in the global population, he was expecting subsequent evolving strains to have minor, subtle genetic mutations, akin to how flu varies from year to year. What was a surprise was the giant leap in evolution that occurred with Omicron, which contains 36 mutations in the spike protein and approximately 50 mutations in total. Because of these mutations, the original two-shot mRNA COVID vaccines becomes only 40% effective against symptomatic disease after several months (thankfully a booster shot increases this to ~80%).² But the decreased vaccine protection without a booster, along with relaxation of mitigation measures, brought us to where we are now.

In Chicago, we knew the Omicron variant would move quickly, considering how it moved through South Africa and the United Kingdom. What we didn’t anticipate was that in one week’s time, our hospital would need to add another 100 dedicated COVID ICU beds. Nor did we anticipate the extent that Omicron would affect staffing levels in the same amount of time.

At our hospital, we have eliminated elective surgeries that require a hospital stay, which includes surgeries for cancer. One of my colleagues, Ryan Merkow, MD, a surgical oncologist, remarked recently he had to cancel half of his scheduled surgeries because of a lack of hospital space.³

Dispelling Myths

What is concerning about this current wave is how many unvaccinated are hospitalized. Because Omicron is so infectious and because of lower vaccination rates in younger adults and children, we have a younger group of adults and children admitted with COVID, who had been uninfected by previous surges.

A major myth that makes health care workers so frustrated is the tale that Omicron is milder. Unvaccinated people infected with this variant are seriously ill and are dying. Despite its “mild” label, once a patient is hospitalized, Omicron can be just as severe as its predecessors.⁴ For many, getting vaccinated is the difference between staying at home with some symptoms and being in the ICU.

As of January 10, according to the CDC, although 88% of people over the age of 65 are vaccinated, only 37.5% have gotten boosters which are key to restoring protection against Omicron. And among children, only 54% between 12- and 17-years-old are fully vaccinated, and a mere 17% of children aged 5 to 11 have gotten both of their shots.

Remember the conversations regarding natural immunity? Omicron has muffled that conversation. Those who have been infected with SARS-Co-V2 before can still get infected and very ill with Omicron. So now is the time to get vaccinated.

Transmissibility

We knew SARS-CoV-2 could spread 1 of 2 ways: large virus-carrying droplets that enter through the nose, mouth, and eyes, as well as miniscule airborne droplets of virus that float in the air and travel further than 6 feet. However, prior to Omicron, transmission of these smaller droplets via the air was not as frequent. But with Omicron, while it still travels by larger respiratory droplets, it appears to have more airborne spread.

In late December, The Lancet Regional Health published results of research conducted one month earlier at a designated quarantine hotel in Hong Kong.⁵ The index case was housed in the room across a hallway from the second case, who developed their case 8 days into quarantine. Testing showed the Omicron variant in both cases. Environmental testing of the walls and ceiling suggested airborne spread of the virus in places unreachable by large respiratory droplets.

Now with Omicron, people need to wear high-filtering masks that fit tight against the face, such as a N95, KN-95, or KF-94 if possible. And when removing the mask to eat and drink, one should be in well-ventilated areas, away from others.

People should avoid getting Omicron, regardless of vaccination status. This variant is so infectious that, compared to the Delta variant, people are twice as likely to infect others that live with them. And infecting others leads to a chain of transmission that can close schools, take over hospital beds, and disable or kill the most vulnerable in our communities.

Public and private behavior, and public policy

In July, months before that WHO announced Omicron’s existence, Rella and colleagues reported in Scientific Reports on the outcome of a new model designed to show how a vaccine-resistant strain could rapidly transmit through a highly vaccinated population if transmission mitigation interventions are dropped too soon.⁶

The authors wrote that the success of a vaccine-resistant strain making inroads into a population depends on the obvious – it finds populations with a low rate of vaccination. What is not so obvious, the authors wrote, is that a vaccine-resistant virus does its worst when transmission is not well controlled in a highly vaccinated population. What can prevent a surge like this are social behaviors and public policy that decrease the chain of transmission of SARS-CoV-2, such as vaccination, masking, and testing.

It is people’s behavior, and ineffective public policy, that are so frustrating to us. The WHO’s secretary general warned against relying solely on vaccines in December. “Vaccines alone will not get any country out of this crisis.”

Omicron takes a new mindset. What we were doing before is not protecting now. Unchecked spread is overwhelming our health care systems and putting the vulnerable in our population at risk. The ramification of this unchecked spread reaches everywhere – into the economy, our educational system, and our nation’s mental health.

When the pandemic started, the policies to control its spread rested on local government and public agencies; we all would have been better served had there been a unified, national response to an infectious threat that does not obey municipal or state boundaries.

 The universal sentiment among health care workers is frustration with local and state governments that are either dictating policy that can harm the public we are trying to protect.

As of September, at least 23 state legislatures have passed laws changing a governor’s executive power reach. Many have taken it away. Others are fighting in the courts over mask mandates.

As for when the pandemic will subside, that appears to be up to the public and public policy makers. They will determine how long this will last and how many will die or be disabled before its end.

What the Future May Hold for Covid-19 Survivors

More than 3 million Americans¹ have been hospitalized with Covid-19, and 770,000 of them have died. ² As of this writing,  49,000 Americans are hospitalized, with 12,000 remaining in intensive care units.³ With growing numbers of patients being discharged from extensive stays in the ICU for severe Covid, it remains to be seen what the long-term impact will be on these patients, their families and on society writ large.

And these are just the patients with severe Covid: those who were never hospitalized are also showing deleterious effects from the effects of their illness.

Covid in the ICU

 What we know is that prior to Covid, 10% of all patients were admitted to ICU with acute respiratory distress syndrome⁴ (ARDS), despite receiving such life-saving measures as mechanical ventilation, medication, and supportive nutrition. Those who do survive face a long journey.⁴ Besides the specific respiratory recovery needed in those with ARDS, patients who have spent time in the ICU can develop multiple non-respiratory complications, including muscle wasting, generalized weakness, and delirium. The physical, cognitive, and psychological impairments that follow an ICU stay are termed postintensive care syndrome (PICS). PICS is an underrecognized phenomenon that describes the immense complications of an ICU stay for any reason. Recognition of this entity, and education of patients, is particularly important now as we face an ongoing pandemic which is creating a burgeoning number of ICU graduates.

PICS

Cognitive dysfunction is one hallmark of PICS. Delirium is a common complication of any hospitalization, with critically ill patients particularly susceptible given the severity of their illness and their exposure to medications such as sedatives. However, persistent global cognitive impairment is unique to PICS. Up to 40% ⁴ of ICU survivors have been found to have cognitive test results similar to those with moderate traumatic brain injury 3 months after discharge;  approximately 34% were still affected at 1 year. Similar findings were seen in a different study of ARDS patients.⁵ Hopkins et al. found that in these patients the rate of neurocognitive deficit persisted in 47% of patients at their 2-year follow-up. Patients describe being unable to re-enter their prior lives, troubled by difficulties with complex thinking and activities of daily living.

The second aspect of PICS is its psychological component. In the Hopkins study,⁵  23% ultimately reported persistent symptoms of depression and/or anxiety two years afterwards. Some patients have described intrusive distorted memories from their time in ICU; one patient detailed a recurring memory of an hallucination in which the nurses were transformed into demons hovering over his bed. Others have described feelings akin to depression, anxiety, and posttraumatic stress syndrome (PTSD).

The final component of PICS is physical impairment. Those who are critically ill commonly suffer intensive care unit-acquired weakness,⁶ which is a term to describe generalized limb and diaphragmatic weakness with no other medical cause. Risk factors for this entity include sepsis, multi-organ failure, mechanical ventilation, hyperglycemia, extensive immobilization, and exposure to steroids and neuromuscular blocking agents. ICU-acquired weakness can resolve within weeks to months but in some studies can persist for years. It has been observed that survivors of ARDS experience persistent physical limitations, even 5 years later.

Covid in the ICU

Estimates of the incidence of PICS due to Covid are evolving. A report on 1700 Covid hospitalized patients in Wuhan, China demonstrated a large prevalence of residual symptoms at 6 months. The most common symptoms were fatigue and weakness (63%), insomnia (26%), and anxiety or depression (23%).⁷ Furthermore, one-fourth to one-third of those with severe illness fell below the lower limit of normal for a 6-minute walk test. An Italian study demonstrated decreased global quality of life indices for Covid ICU survivors⁸ 3 months from discharge, particularly with mobility, eating, and resuming usual activities. In a Michigan observational⁹ study, which included all hospitalized patients with Covid including those never in ICU, one-third of respondents said they continued to cough or have shortness of breath. Only one-fourth had returned to work, with many of them having to modify activities or reduce hours due to their health. Nearly half reported being negatively emotionally impacted by their health issues. Last, a single French hospital¹⁰ discovered that Covid patients 4 months after hospital discharge experienced numerous, persistent symptoms. 38% of patients confirmed some form of cognitive impairment, with 17% reporting memory difficulties, 10% mental slowness, and 10% concentration problems. Of patients who were intubated, one-third still reported subjective dyspnea. Nearly a third still struggled with weakness.

As more centers track the progress of their ICU graduates over time, we can better understand the profound impact of critical illness on our Covid patients and better educate our patients and families on what to expect. One might be able to gain some clues from what is known regarding the prior coronavirus epidemics, severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS). In these diseases, a meta-analysis showed significant rates of      lung function abnormalities,¹¹ physical deconditioning, and mental health disorders during the 6 months after discharge. It might be that the impact of SARS-CoV2 is even more profound on survivors; additional studies need to be done.

Additional issues

What is particularly unique to Covid is the prevalence of long-term symptoms in those who were never hospitalized for Covid. Recent estimates of non-hospitalized patients who had Covid are showing at least 25% of them have had long-lasting effects, including stomach pain and respiratory issues.¹² We are continuing to learn more about what is described as “long-haul syndrome.” It has been described in both hospitalized and non-hospitalized patients, and therefore it can be hard to distinguish which symptoms are attributable to long-term effects of Covid infection versus the critical illness/PICS itself. These long-haul symptoms range from persistent lack of smell and taste, cognitive dysfunction, fatigue, decreased exercise endurance, and an increase in mental health disorders. The prognosis and spectrum of disease, as well as treatment, have yet to be determined, and the NIH is initiating a multicenter research study, RECOVER, to better characterize this syndrome.¹³  Patients who are interested in enrolling can fill out an interest form at recoverCovid.org.

Financially 1/3¹⁴ of patients were impacted by their hospitalization for Covid, with nearly 10% using most or all their savings, despite many being covered by cost-sharing waivers for Covid care. A study reviewing Medicare data noted that the mean cost of a hospitalization for Covid is $21,752,¹⁵ increasing to nearly $50,000 if mechanical ventilation is needed. This does not account for the cost of rehabilitative care, as 40%¹⁶ of patients are discharged either to home with additional services or to other facilities (skilled nursing facility, hospice). As insurance companies increasingly lift the cost-sharing waivers and patients assume more responsibility for paying more of this cost, the financial burden on individual patients will increase. Furthermore, given a prolonged course of mental and physical disabilities after severe Covid, patients may lose their ability to return to work, their medical insurance, or their ability to provide childcare, further compounding their family’s financial woes.

Conclusion

The long-term effects of hospitalization from Covid argues further for continued work on increasing the vaccination rate of our population. Even with Delta variant, vaccines decrease the risk of hospitalization and death by more than a factor of 10.¹⁷ The profound medical and financial effects of severe Covid, and the repercussions on their family, should compel us as health care practitioners to inform those who are vaccine hesitant and to inform patients that they are eligible for vaccine boosters. The combination of colder weather and loosening of social distancing has already led to another surge of Covid infections and makes expedient vaccination the priority.

What the Future May Hold for Covid-19 Survivors

More than 3 million Americans¹ have been hospitalized with Covid-19, and 770,000 of them have died. ² As of this writing,  49,000 Americans are hospitalized, with 12,000 remaining in intensive care units.³ With growing numbers of patients being discharged from extensive stays in the ICU for severe Covid, it remains to be seen what the long-term impact will be on these patients, their families and on society writ large.

And these are just the patients with severe Covid: those who were never hospitalized are also showing deleterious effects from the effects of their illness.

Covid in the ICU

 What we know is that prior to Covid, 10% of all patients were admitted to ICU with acute respiratory distress syndrome⁴ (ARDS), despite receiving such life-saving measures as mechanical ventilation, medication, and supportive nutrition. Those who do survive face a long journey.⁴ Besides the specific respiratory recovery needed in those with ARDS, patients who have spent time in the ICU can develop multiple non-respiratory complications, including muscle wasting, generalized weakness, and delirium. The physical, cognitive, and psychological impairments that follow an ICU stay are termed postintensive care syndrome (PICS). PICS is an underrecognized phenomenon that describes the immense complications of an ICU stay for any reason. Recognition of this entity, and education of patients, is particularly important now as we face an ongoing pandemic which is creating a burgeoning number of ICU graduates.

PICS

Cognitive dysfunction is one hallmark of PICS. Delirium is a common complication of any hospitalization, with critically ill patients particularly susceptible given the severity of their illness and their exposure to medications such as sedatives. However, persistent global cognitive impairment is unique to PICS. Up to 40% ⁴ of ICU survivors have been found to have cognitive test results similar to those with moderate traumatic brain injury 3 months after discharge;  approximately 34% were still affected at 1 year. Similar findings were seen in a different study of ARDS patients.⁵ Hopkins et al. found that in these patients the rate of neurocognitive deficit persisted in 47% of patients at their 2-year follow-up. Patients describe being unable to re-enter their prior lives, troubled by difficulties with complex thinking and activities of daily living.

The second aspect of PICS is its psychological component. In the Hopkins study,⁵  23% ultimately reported persistent symptoms of depression and/or anxiety two years afterwards. Some patients have described intrusive distorted memories from their time in ICU; one patient detailed a recurring memory of an hallucination in which the nurses were transformed into demons hovering over his bed. Others have described feelings akin to depression, anxiety, and posttraumatic stress syndrome (PTSD).

The final component of PICS is physical impairment. Those who are critically ill commonly suffer intensive care unit-acquired weakness,⁶ which is a term to describe generalized limb and diaphragmatic weakness with no other medical cause. Risk factors for this entity include sepsis, multi-organ failure, mechanical ventilation, hyperglycemia, extensive immobilization, and exposure to steroids and neuromuscular blocking agents. ICU-acquired weakness can resolve within weeks to months but in some studies can persist for years. It has been observed that survivors of ARDS experience persistent physical limitations, even 5 years later.

Covid in the ICU

Estimates of the incidence of PICS due to Covid are evolving. A report on 1700 Covid hospitalized patients in Wuhan, China demonstrated a large prevalence of residual symptoms at 6 months. The most common symptoms were fatigue and weakness (63%), insomnia (26%), and anxiety or depression (23%).⁷ Furthermore, one-fourth to one-third of those with severe illness fell below the lower limit of normal for a 6-minute walk test. An Italian study demonstrated decreased global quality of life indices for Covid ICU survivors⁸ 3 months from discharge, particularly with mobility, eating, and resuming usual activities. In a Michigan observational⁹ study, which included all hospitalized patients with Covid including those never in ICU, one-third of respondents said they continued to cough or have shortness of breath. Only one-fourth had returned to work, with many of them having to modify activities or reduce hours due to their health. Nearly half reported being negatively emotionally impacted by their health issues. Last, a single French hospital¹⁰ discovered that Covid patients 4 months after hospital discharge experienced numerous, persistent symptoms. 38% of patients confirmed some form of cognitive impairment, with 17% reporting memory difficulties, 10% mental slowness, and 10% concentration problems. Of patients who were intubated, one-third still reported subjective dyspnea. Nearly a third still struggled with weakness.

As more centers track the progress of their ICU graduates over time, we can better understand the profound impact of critical illness on our Covid patients and better educate our patients and families on what to expect. One might be able to gain some clues from what is known regarding the prior coronavirus epidemics, severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS). In these diseases, a meta-analysis showed significant rates of      lung function abnormalities,¹¹ physical deconditioning, and mental health disorders during the 6 months after discharge. It might be that the impact of SARS-CoV2 is even more profound on survivors; additional studies need to be done.

Additional issues

What is particularly unique to Covid is the prevalence of long-term symptoms in those who were never hospitalized for Covid. Recent estimates of non-hospitalized patients who had Covid are showing at least 25% of them have had long-lasting effects, including stomach pain and respiratory issues.¹² We are continuing to learn more about what is described as “long-haul syndrome.” It has been described in both hospitalized and non-hospitalized patients, and therefore it can be hard to distinguish which symptoms are attributable to long-term effects of Covid infection versus the critical illness/PICS itself. These long-haul symptoms range from persistent lack of smell and taste, cognitive dysfunction, fatigue, decreased exercise endurance, and an increase in mental health disorders. The prognosis and spectrum of disease, as well as treatment, have yet to be determined, and the NIH is initiating a multicenter research study, RECOVER, to better characterize this syndrome.¹³  Patients who are interested in enrolling can fill out an interest form at recoverCovid.org.

Financially 1/3¹⁴ of patients were impacted by their hospitalization for Covid, with nearly 10% using most or all their savings, despite many being covered by cost-sharing waivers for Covid care. A study reviewing Medicare data noted that the mean cost of a hospitalization for Covid is $21,752,¹⁵ increasing to nearly $50,000 if mechanical ventilation is needed. This does not account for the cost of rehabilitative care, as 40%¹⁶ of patients are discharged either to home with additional services or to other facilities (skilled nursing facility, hospice). As insurance companies increasingly lift the cost-sharing waivers and patients assume more responsibility for paying more of this cost, the financial burden on individual patients will increase. Furthermore, given a prolonged course of mental and physical disabilities after severe Covid, patients may lose their ability to return to work, their medical insurance, or their ability to provide childcare, further compounding their family’s financial woes.

Conclusion

The long-term effects of hospitalization from Covid argues further for continued work on increasing the vaccination rate of our population. Even with Delta variant, vaccines decrease the risk of hospitalization and death by more than a factor of 10.¹⁷ The profound medical and financial effects of severe Covid, and the repercussions on their family, should compel us as health care practitioners to inform those who are vaccine hesitant and to inform patients that they are eligible for vaccine boosters. The combination of colder weather and loosening of social distancing has already led to another surge of Covid infections and makes expedient vaccination the priority.

What the Future May Hold for Covid-19 Survivors

More than 3 million Americans¹ have been hospitalized with Covid-19, and 770,000 of them have died. ² As of this writing,  49,000 Americans are hospitalized, with 12,000 remaining in intensive care units.³ With growing numbers of patients being discharged from extensive stays in the ICU for severe Covid, it remains to be seen what the long-term impact will be on these patients, their families and on society writ large.

And these are just the patients with severe Covid: those who were never hospitalized are also showing deleterious effects from the effects of their illness.

Covid in the ICU

 What we know is that prior to Covid, 10% of all patients were admitted to ICU with acute respiratory distress syndrome⁴ (ARDS), despite receiving such life-saving measures as mechanical ventilation, medication, and supportive nutrition. Those who do survive face a long journey.⁴ Besides the specific respiratory recovery needed in those with ARDS, patients who have spent time in the ICU can develop multiple non-respiratory complications, including muscle wasting, generalized weakness, and delirium. The physical, cognitive, and psychological impairments that follow an ICU stay are termed postintensive care syndrome (PICS). PICS is an underrecognized phenomenon that describes the immense complications of an ICU stay for any reason. Recognition of this entity, and education of patients, is particularly important now as we face an ongoing pandemic which is creating a burgeoning number of ICU graduates.

PICS

Cognitive dysfunction is one hallmark of PICS. Delirium is a common complication of any hospitalization, with critically ill patients particularly susceptible given the severity of their illness and their exposure to medications such as sedatives. However, persistent global cognitive impairment is unique to PICS. Up to 40% ⁴ of ICU survivors have been found to have cognitive test results similar to those with moderate traumatic brain injury 3 months after discharge;  approximately 34% were still affected at 1 year. Similar findings were seen in a different study of ARDS patients.⁵ Hopkins et al. found that in these patients the rate of neurocognitive deficit persisted in 47% of patients at their 2-year follow-up. Patients describe being unable to re-enter their prior lives, troubled by difficulties with complex thinking and activities of daily living.

The second aspect of PICS is its psychological component. In the Hopkins study,⁵  23% ultimately reported persistent symptoms of depression and/or anxiety two years afterwards. Some patients have described intrusive distorted memories from their time in ICU; one patient detailed a recurring memory of an hallucination in which the nurses were transformed into demons hovering over his bed. Others have described feelings akin to depression, anxiety, and posttraumatic stress syndrome (PTSD).

The final component of PICS is physical impairment. Those who are critically ill commonly suffer intensive care unit-acquired weakness,⁶ which is a term to describe generalized limb and diaphragmatic weakness with no other medical cause. Risk factors for this entity include sepsis, multi-organ failure, mechanical ventilation, hyperglycemia, extensive immobilization, and exposure to steroids and neuromuscular blocking agents. ICU-acquired weakness can resolve within weeks to months but in some studies can persist for years. It has been observed that survivors of ARDS experience persistent physical limitations, even 5 years later.

Covid in the ICU

Estimates of the incidence of PICS due to Covid are evolving. A report on 1700 Covid hospitalized patients in Wuhan, China demonstrated a large prevalence of residual symptoms at 6 months. The most common symptoms were fatigue and weakness (63%), insomnia (26%), and anxiety or depression (23%).⁷ Furthermore, one-fourth to one-third of those with severe illness fell below the lower limit of normal for a 6-minute walk test. An Italian study demonstrated decreased global quality of life indices for Covid ICU survivors⁸ 3 months from discharge, particularly with mobility, eating, and resuming usual activities. In a Michigan observational⁹ study, which included all hospitalized patients with Covid including those never in ICU, one-third of respondents said they continued to cough or have shortness of breath. Only one-fourth had returned to work, with many of them having to modify activities or reduce hours due to their health. Nearly half reported being negatively emotionally impacted by their health issues. Last, a single French hospital¹⁰ discovered that Covid patients 4 months after hospital discharge experienced numerous, persistent symptoms. 38% of patients confirmed some form of cognitive impairment, with 17% reporting memory difficulties, 10% mental slowness, and 10% concentration problems. Of patients who were intubated, one-third still reported subjective dyspnea. Nearly a third still struggled with weakness.

As more centers track the progress of their ICU graduates over time, we can better understand the profound impact of critical illness on our Covid patients and better educate our patients and families on what to expect. One might be able to gain some clues from what is known regarding the prior coronavirus epidemics, severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS). In these diseases, a meta-analysis showed significant rates of      lung function abnormalities,¹¹ physical deconditioning, and mental health disorders during the 6 months after discharge. It might be that the impact of SARS-CoV2 is even more profound on survivors; additional studies need to be done.

Additional issues

What is particularly unique to Covid is the prevalence of long-term symptoms in those who were never hospitalized for Covid. Recent estimates of non-hospitalized patients who had Covid are showing at least 25% of them have had long-lasting effects, including stomach pain and respiratory issues.¹² We are continuing to learn more about what is described as “long-haul syndrome.” It has been described in both hospitalized and non-hospitalized patients, and therefore it can be hard to distinguish which symptoms are attributable to long-term effects of Covid infection versus the critical illness/PICS itself. These long-haul symptoms range from persistent lack of smell and taste, cognitive dysfunction, fatigue, decreased exercise endurance, and an increase in mental health disorders. The prognosis and spectrum of disease, as well as treatment, have yet to be determined, and the NIH is initiating a multicenter research study, RECOVER, to better characterize this syndrome.¹³  Patients who are interested in enrolling can fill out an interest form at recoverCovid.org.

Financially 1/3¹⁴ of patients were impacted by their hospitalization for Covid, with nearly 10% using most or all their savings, despite many being covered by cost-sharing waivers for Covid care. A study reviewing Medicare data noted that the mean cost of a hospitalization for Covid is $21,752,¹⁵ increasing to nearly $50,000 if mechanical ventilation is needed. This does not account for the cost of rehabilitative care, as 40%¹⁶ of patients are discharged either to home with additional services or to other facilities (skilled nursing facility, hospice). As insurance companies increasingly lift the cost-sharing waivers and patients assume more responsibility for paying more of this cost, the financial burden on individual patients will increase. Furthermore, given a prolonged course of mental and physical disabilities after severe Covid, patients may lose their ability to return to work, their medical insurance, or their ability to provide childcare, further compounding their family’s financial woes.

Conclusion

The long-term effects of hospitalization from Covid argues further for continued work on increasing the vaccination rate of our population. Even with Delta variant, vaccines decrease the risk of hospitalization and death by more than a factor of 10.¹⁷ The profound medical and financial effects of severe Covid, and the repercussions on their family, should compel us as health care practitioners to inform those who are vaccine hesitant and to inform patients that they are eligible for vaccine boosters. The combination of colder weather and loosening of social distancing has already led to another surge of Covid infections and makes expedient vaccination the priority.

Cheryl K. Lee, MD, an Assistant Professor of Medicine at Northwestern Feinberg School of Medicine, practices internal medicine and pediatrics at Northwestern Memorial and the Ann & Robert H. Lurie Children's Hospital, both in Chicago, IL. She also serves on the Northwestern Medicine Covid Quality Committee and as core clinical faculty in the Internal Medicine Residency. 
 

Is it fair to say that for hospitalists, the pandemic has been a sobering experience, why so?

Dr. Lee: There are several reasons; one stems from the increasing impact of Covid on children. Early in the pandemic, young children, teens, and young adults were not infected or hospitalized at the rate of older adults.¹ For those of us who care for hospitalized patients, that early finding was somewhat of a relief, knowing at least one portion of the population wasn’t as heavily affected. In fact, I normally split my time as a pediatric and adult hospitalist, and I was reassigned to work full-time in the adult hospital because so few children had been admitted. But all that changed with the arrival of the highly transmissible Delta variant and the loosening of social distancing and masking guidelines and other regulations. The American Academy of Pediatrics² reported that, as of October, 8,364 of every 100,000 children have been infected by Covid, largely driven by  the summer surge. Furthermore, pediatric Covid hospitalizations increased five-fold in August 2021 as compared to the prior 6 weeks. And these numbers likely underestimate the true impact, as several states did not release complete reports and did not account for long-term sequelae from milder infections.

What other issues were far-reaching for hospitalists?

Dr. Lee: Early in 2020, we were scrambling to learn about a novel, deadly, highly transmissible disease. Some groups in our population were experiencing a high fatality rate, and the medical community had no proven treatments. We felt helpless in caring for these patients who pleaded for our help and ultimately died. When data proved that medications like steroids were effective and the vaccines arrived, I had hoped that the pandemic would be ending. But now with the quick dissemination of false information and the evolution of new variants, we are left caring for seriously ill, unvaccinated patients along with younger patients. The heartbreaking thing is that these are largely preventable tragedies now that we have effective vaccines.

What medications have changed the course of Covid in the hospital?

Dr. Lee: Steroids are interesting; they are a good reminder that Covid has different stages and that we should be mindful of how we treat patients within those particular stages. Simply, Covid infection begins with a phase of viral replication characterized by fevers, cough, loss of taste and smell, and gastrointestinal symptoms. In time, this is followed by a second phase of high inflammation and immune response, sometimes causing hypoxemia and respiratory failure. What we know is that steroids such as dexamethasone reduce mortality, but they are only effective during this second phase, and only in those whose oxygen levels are low enough to require oxygen. This was not an intuitive finding, since steroids do not help, and may harm, those with other viral pneumonias, such as influenza. Steroid use in severe, hypoxemic Covid, however, is life-saving and the mainstay of inpatient care which might include antivirals and interleukin-6 inhibitors³ in select patients. As with steroid use in other patients, physicians should watch their Covid patients for hyperglycemia⁴ and delirium. That said, steroids provide a  mortality benefit that strongly supports their continued use -- in tandem with management of those expected side effects. Last, it is important to note that steroid use has been associated with possible harm when given to those with mild Covid,⁵ so its use should be avoided, in light of its expected side effects, unless a patient requires supplemental oxygen.

That said, although steroids can be helpful for our sickest patients, vaccines are the best medicine of all because they can allow patients to avoid hospitalization and death  -- outcomes that far outweigh what steroids or any other medication can do for the gravely ill.

Given the complexity of the evidence surrounding the treatments for Covid in the hospital, no wonder some people are confused about which medicines work.

Dr. Lee: First, let me say that I have yet to encounter a patient or family member whose motivation to ask questions or question a loved one’s treatment wasn’t grounded in concern and fear for their loved one.

What do they ask about?

Dr. Lee: They ask about alternative treatments, anti-parasitics, even vitamins. I agree with them that there is so much out there about Covid that it is difficult for anyone to know what is true or false. I then explain what therapies are proven – medications such as steroids and supportive care such as oxygen and prone positioning. I also review the lack of good evidence for the alternative treatments that they ask about. It is sometimes surprising to folks that all research isn’t conducted with equal rigor, and that false conclusions can be made based on faulty evidence. A good example is how providers used hydroxychloroquine early in the pandemic, but ultimately it didn’t prove to be helpful. Although we are always hopeful and looking for new therapies, I say, those specific alternatives haven’t worked out. And I end with a promise that I will continue to keep up with the literature and let them know when something new does look promising.

Your responses to the above questions prompts this one: How do physicians who are treating Covid-19 stay on top of what is being learned about Covid-19? At last count, there were 191,968 results in PubMed, found using that sole keyword.

Dr. Lee: One of the amazing things about the Covid era is that members of the scientific community dropped everything to research Covid. But on the flip side, there is now a lot of research out there, and it frankly has become difficult to keep up with it. Our hospital system identified a core group of collaborators with backgrounds such as pharmacy, nursing, infectious disease, pulmonary, and hospital medicine to regularly review the evidence and identify anything that has strong enough evidence to change our system’s clinical practice. Furthermore, I regularly tap consultants in various specialties to help me contextualize new research. And I’ve found it helpful to review the living practice guidelines from the Infectious Disease Society of America and the NIH.^3,6

What else has been remarkable about the last 19 months?

Dr. Lee: I have never spent this much time talking with patients and their caregivers. I’ve always been one to talk a lot with families, but it feels like the pandemic has created another level. My guess is that many colleagues are experiencing the same thing. Caring for hospitalized Covid patients is not only intense from a medical standpoint, but also from a psychosocial vantage point. Patients are ill and usually scared, and they are supported by friends and family who are equally afraid for them, who furthermore can’t visit because of isolation needs. And I often forget that, besides Covid, families have gone through immense social and financial changes. Sometimes communication can be fraught because of that stress. I am trying to be mindful that patients and families come into the hospital with a lot of these burdens, so that, if the conversation takes a tense turn, I will try not to take it personally. Some days are harder than others.

What you are describing isn’t necessarily an innate skill.

Dr. Lee: Absolutely. As have many others, our medical school and residency program has been incorporating communication skills into the standard curriculum, analogous to teaching anatomy or heart failure treatments. We are more aware that handling a difficult conversation isn’t an instinctive thing; that it must be modeled and learned. But I was surprised at how communication in a pandemic, when caretakers can’t see their loved ones, is truly a unique challenge. It is challenging for me despite being in practice for several years.

What will happen when the pandemic subsides? How much of the impact of Covid will stay with you, when dealing with a broken leg, or a patient with osteoporosis?

Dr. Lee: There will be lasting effects of this era on the health-care workforce, but I honestly can’t predict how severe that impact will be or how long-lasting. Already we are seeing health-care workers drop out of the workforce, driven by effects of the pandemic itself, increased workload, or being underpaid.⁷ This is occurring alongside a national conversation that cannot agree on life-saving interventions such as vaccines. I worry that the current environment will lead to many more dropping out.

What can hospital administrators do now to put stop gaps in place? What advice would you give to them?

Dr. Lee: Workers in each hospital will have unique needs and stressors, so it makes sense that the first step is to provide an opportunity to make their opinions heard. It may be tempting for hospitals to jump on quick fixes such as offering classes in “resilience training,” but that may not be a data-driven solution, particularly if burnout is being driven by an ever increasing workload.

Cheryl K. Lee, MD, an Assistant Professor of Medicine at Northwestern Feinberg School of Medicine, practices internal medicine and pediatrics at Northwestern Memorial and the Ann & Robert H. Lurie Children's Hospital, both in Chicago, IL. She also serves on the Northwestern Medicine Covid Quality Committee and as core clinical faculty in the Internal Medicine Residency. 
 

Is it fair to say that for hospitalists, the pandemic has been a sobering experience, why so?

Dr. Lee: There are several reasons; one stems from the increasing impact of Covid on children. Early in the pandemic, young children, teens, and young adults were not infected or hospitalized at the rate of older adults.¹ For those of us who care for hospitalized patients, that early finding was somewhat of a relief, knowing at least one portion of the population wasn’t as heavily affected. In fact, I normally split my time as a pediatric and adult hospitalist, and I was reassigned to work full-time in the adult hospital because so few children had been admitted. But all that changed with the arrival of the highly transmissible Delta variant and the loosening of social distancing and masking guidelines and other regulations. The American Academy of Pediatrics² reported that, as of October, 8,364 of every 100,000 children have been infected by Covid, largely driven by  the summer surge. Furthermore, pediatric Covid hospitalizations increased five-fold in August 2021 as compared to the prior 6 weeks. And these numbers likely underestimate the true impact, as several states did not release complete reports and did not account for long-term sequelae from milder infections.

What other issues were far-reaching for hospitalists?

Dr. Lee: Early in 2020, we were scrambling to learn about a novel, deadly, highly transmissible disease. Some groups in our population were experiencing a high fatality rate, and the medical community had no proven treatments. We felt helpless in caring for these patients who pleaded for our help and ultimately died. When data proved that medications like steroids were effective and the vaccines arrived, I had hoped that the pandemic would be ending. But now with the quick dissemination of false information and the evolution of new variants, we are left caring for seriously ill, unvaccinated patients along with younger patients. The heartbreaking thing is that these are largely preventable tragedies now that we have effective vaccines.

What medications have changed the course of Covid in the hospital?

Dr. Lee: Steroids are interesting; they are a good reminder that Covid has different stages and that we should be mindful of how we treat patients within those particular stages. Simply, Covid infection begins with a phase of viral replication characterized by fevers, cough, loss of taste and smell, and gastrointestinal symptoms. In time, this is followed by a second phase of high inflammation and immune response, sometimes causing hypoxemia and respiratory failure. What we know is that steroids such as dexamethasone reduce mortality, but they are only effective during this second phase, and only in those whose oxygen levels are low enough to require oxygen. This was not an intuitive finding, since steroids do not help, and may harm, those with other viral pneumonias, such as influenza. Steroid use in severe, hypoxemic Covid, however, is life-saving and the mainstay of inpatient care which might include antivirals and interleukin-6 inhibitors³ in select patients. As with steroid use in other patients, physicians should watch their Covid patients for hyperglycemia⁴ and delirium. That said, steroids provide a  mortality benefit that strongly supports their continued use -- in tandem with management of those expected side effects. Last, it is important to note that steroid use has been associated with possible harm when given to those with mild Covid,⁵ so its use should be avoided, in light of its expected side effects, unless a patient requires supplemental oxygen.

That said, although steroids can be helpful for our sickest patients, vaccines are the best medicine of all because they can allow patients to avoid hospitalization and death  -- outcomes that far outweigh what steroids or any other medication can do for the gravely ill.

Given the complexity of the evidence surrounding the treatments for Covid in the hospital, no wonder some people are confused about which medicines work.

Dr. Lee: First, let me say that I have yet to encounter a patient or family member whose motivation to ask questions or question a loved one’s treatment wasn’t grounded in concern and fear for their loved one.

What do they ask about?

Dr. Lee: They ask about alternative treatments, anti-parasitics, even vitamins. I agree with them that there is so much out there about Covid that it is difficult for anyone to know what is true or false. I then explain what therapies are proven – medications such as steroids and supportive care such as oxygen and prone positioning. I also review the lack of good evidence for the alternative treatments that they ask about. It is sometimes surprising to folks that all research isn’t conducted with equal rigor, and that false conclusions can be made based on faulty evidence. A good example is how providers used hydroxychloroquine early in the pandemic, but ultimately it didn’t prove to be helpful. Although we are always hopeful and looking for new therapies, I say, those specific alternatives haven’t worked out. And I end with a promise that I will continue to keep up with the literature and let them know when something new does look promising.

Your responses to the above questions prompts this one: How do physicians who are treating Covid-19 stay on top of what is being learned about Covid-19? At last count, there were 191,968 results in PubMed, found using that sole keyword.

Dr. Lee: One of the amazing things about the Covid era is that members of the scientific community dropped everything to research Covid. But on the flip side, there is now a lot of research out there, and it frankly has become difficult to keep up with it. Our hospital system identified a core group of collaborators with backgrounds such as pharmacy, nursing, infectious disease, pulmonary, and hospital medicine to regularly review the evidence and identify anything that has strong enough evidence to change our system’s clinical practice. Furthermore, I regularly tap consultants in various specialties to help me contextualize new research. And I’ve found it helpful to review the living practice guidelines from the Infectious Disease Society of America and the NIH.^3,6

What else has been remarkable about the last 19 months?

Dr. Lee: I have never spent this much time talking with patients and their caregivers. I’ve always been one to talk a lot with families, but it feels like the pandemic has created another level. My guess is that many colleagues are experiencing the same thing. Caring for hospitalized Covid patients is not only intense from a medical standpoint, but also from a psychosocial vantage point. Patients are ill and usually scared, and they are supported by friends and family who are equally afraid for them, who furthermore can’t visit because of isolation needs. And I often forget that, besides Covid, families have gone through immense social and financial changes. Sometimes communication can be fraught because of that stress. I am trying to be mindful that patients and families come into the hospital with a lot of these burdens, so that, if the conversation takes a tense turn, I will try not to take it personally. Some days are harder than others.

What you are describing isn’t necessarily an innate skill.

Dr. Lee: Absolutely. As have many others, our medical school and residency program has been incorporating communication skills into the standard curriculum, analogous to teaching anatomy or heart failure treatments. We are more aware that handling a difficult conversation isn’t an instinctive thing; that it must be modeled and learned. But I was surprised at how communication in a pandemic, when caretakers can’t see their loved ones, is truly a unique challenge. It is challenging for me despite being in practice for several years.

What will happen when the pandemic subsides? How much of the impact of Covid will stay with you, when dealing with a broken leg, or a patient with osteoporosis?

Dr. Lee: There will be lasting effects of this era on the health-care workforce, but I honestly can’t predict how severe that impact will be or how long-lasting. Already we are seeing health-care workers drop out of the workforce, driven by effects of the pandemic itself, increased workload, or being underpaid.⁷ This is occurring alongside a national conversation that cannot agree on life-saving interventions such as vaccines. I worry that the current environment will lead to many more dropping out.

What can hospital administrators do now to put stop gaps in place? What advice would you give to them?

Dr. Lee: Workers in each hospital will have unique needs and stressors, so it makes sense that the first step is to provide an opportunity to make their opinions heard. It may be tempting for hospitals to jump on quick fixes such as offering classes in “resilience training,” but that may not be a data-driven solution, particularly if burnout is being driven by an ever increasing workload.

Cheryl K. Lee, MD, an Assistant Professor of Medicine at Northwestern Feinberg School of Medicine, practices internal medicine and pediatrics at Northwestern Memorial and the Ann & Robert H. Lurie Children's Hospital, both in Chicago, IL. She also serves on the Northwestern Medicine Covid Quality Committee and as core clinical faculty in the Internal Medicine Residency. 
 

Is it fair to say that for hospitalists, the pandemic has been a sobering experience, why so?

Dr. Lee: There are several reasons; one stems from the increasing impact of Covid on children. Early in the pandemic, young children, teens, and young adults were not infected or hospitalized at the rate of older adults.¹ For those of us who care for hospitalized patients, that early finding was somewhat of a relief, knowing at least one portion of the population wasn’t as heavily affected. In fact, I normally split my time as a pediatric and adult hospitalist, and I was reassigned to work full-time in the adult hospital because so few children had been admitted. But all that changed with the arrival of the highly transmissible Delta variant and the loosening of social distancing and masking guidelines and other regulations. The American Academy of Pediatrics² reported that, as of October, 8,364 of every 100,000 children have been infected by Covid, largely driven by  the summer surge. Furthermore, pediatric Covid hospitalizations increased five-fold in August 2021 as compared to the prior 6 weeks. And these numbers likely underestimate the true impact, as several states did not release complete reports and did not account for long-term sequelae from milder infections.

What other issues were far-reaching for hospitalists?

Dr. Lee: Early in 2020, we were scrambling to learn about a novel, deadly, highly transmissible disease. Some groups in our population were experiencing a high fatality rate, and the medical community had no proven treatments. We felt helpless in caring for these patients who pleaded for our help and ultimately died. When data proved that medications like steroids were effective and the vaccines arrived, I had hoped that the pandemic would be ending. But now with the quick dissemination of false information and the evolution of new variants, we are left caring for seriously ill, unvaccinated patients along with younger patients. The heartbreaking thing is that these are largely preventable tragedies now that we have effective vaccines.

What medications have changed the course of Covid in the hospital?

Dr. Lee: Steroids are interesting; they are a good reminder that Covid has different stages and that we should be mindful of how we treat patients within those particular stages. Simply, Covid infection begins with a phase of viral replication characterized by fevers, cough, loss of taste and smell, and gastrointestinal symptoms. In time, this is followed by a second phase of high inflammation and immune response, sometimes causing hypoxemia and respiratory failure. What we know is that steroids such as dexamethasone reduce mortality, but they are only effective during this second phase, and only in those whose oxygen levels are low enough to require oxygen. This was not an intuitive finding, since steroids do not help, and may harm, those with other viral pneumonias, such as influenza. Steroid use in severe, hypoxemic Covid, however, is life-saving and the mainstay of inpatient care which might include antivirals and interleukin-6 inhibitors³ in select patients. As with steroid use in other patients, physicians should watch their Covid patients for hyperglycemia⁴ and delirium. That said, steroids provide a  mortality benefit that strongly supports their continued use -- in tandem with management of those expected side effects. Last, it is important to note that steroid use has been associated with possible harm when given to those with mild Covid,⁵ so its use should be avoided, in light of its expected side effects, unless a patient requires supplemental oxygen.

That said, although steroids can be helpful for our sickest patients, vaccines are the best medicine of all because they can allow patients to avoid hospitalization and death  -- outcomes that far outweigh what steroids or any other medication can do for the gravely ill.

Given the complexity of the evidence surrounding the treatments for Covid in the hospital, no wonder some people are confused about which medicines work.

Dr. Lee: First, let me say that I have yet to encounter a patient or family member whose motivation to ask questions or question a loved one’s treatment wasn’t grounded in concern and fear for their loved one.

What do they ask about?

Dr. Lee: They ask about alternative treatments, anti-parasitics, even vitamins. I agree with them that there is so much out there about Covid that it is difficult for anyone to know what is true or false. I then explain what therapies are proven – medications such as steroids and supportive care such as oxygen and prone positioning. I also review the lack of good evidence for the alternative treatments that they ask about. It is sometimes surprising to folks that all research isn’t conducted with equal rigor, and that false conclusions can be made based on faulty evidence. A good example is how providers used hydroxychloroquine early in the pandemic, but ultimately it didn’t prove to be helpful. Although we are always hopeful and looking for new therapies, I say, those specific alternatives haven’t worked out. And I end with a promise that I will continue to keep up with the literature and let them know when something new does look promising.

Your responses to the above questions prompts this one: How do physicians who are treating Covid-19 stay on top of what is being learned about Covid-19? At last count, there were 191,968 results in PubMed, found using that sole keyword.

Dr. Lee: One of the amazing things about the Covid era is that members of the scientific community dropped everything to research Covid. But on the flip side, there is now a lot of research out there, and it frankly has become difficult to keep up with it. Our hospital system identified a core group of collaborators with backgrounds such as pharmacy, nursing, infectious disease, pulmonary, and hospital medicine to regularly review the evidence and identify anything that has strong enough evidence to change our system’s clinical practice. Furthermore, I regularly tap consultants in various specialties to help me contextualize new research. And I’ve found it helpful to review the living practice guidelines from the Infectious Disease Society of America and the NIH.^3,6

What else has been remarkable about the last 19 months?

Dr. Lee: I have never spent this much time talking with patients and their caregivers. I’ve always been one to talk a lot with families, but it feels like the pandemic has created another level. My guess is that many colleagues are experiencing the same thing. Caring for hospitalized Covid patients is not only intense from a medical standpoint, but also from a psychosocial vantage point. Patients are ill and usually scared, and they are supported by friends and family who are equally afraid for them, who furthermore can’t visit because of isolation needs. And I often forget that, besides Covid, families have gone through immense social and financial changes. Sometimes communication can be fraught because of that stress. I am trying to be mindful that patients and families come into the hospital with a lot of these burdens, so that, if the conversation takes a tense turn, I will try not to take it personally. Some days are harder than others.

What you are describing isn’t necessarily an innate skill.

Dr. Lee: Absolutely. As have many others, our medical school and residency program has been incorporating communication skills into the standard curriculum, analogous to teaching anatomy or heart failure treatments. We are more aware that handling a difficult conversation isn’t an instinctive thing; that it must be modeled and learned. But I was surprised at how communication in a pandemic, when caretakers can’t see their loved ones, is truly a unique challenge. It is challenging for me despite being in practice for several years.

What will happen when the pandemic subsides? How much of the impact of Covid will stay with you, when dealing with a broken leg, or a patient with osteoporosis?

Dr. Lee: There will be lasting effects of this era on the health-care workforce, but I honestly can’t predict how severe that impact will be or how long-lasting. Already we are seeing health-care workers drop out of the workforce, driven by effects of the pandemic itself, increased workload, or being underpaid.⁷ This is occurring alongside a national conversation that cannot agree on life-saving interventions such as vaccines. I worry that the current environment will lead to many more dropping out.

What can hospital administrators do now to put stop gaps in place? What advice would you give to them?

Dr. Lee: Workers in each hospital will have unique needs and stressors, so it makes sense that the first step is to provide an opportunity to make their opinions heard. It may be tempting for hospitals to jump on quick fixes such as offering classes in “resilience training,” but that may not be a data-driven solution, particularly if burnout is being driven by an ever increasing workload.

Cheryl K. Lee, MD, an Assistant Professor Of Medicine at Northwestern Feinberg School of Medicine, practices internal medicine and pediatrics at Northwestern Memorial and the Ann & Robert H. Lurie Children's Hospital, both in Chicago, IL. She also serves on the Northwestern Medicine Covid Quality Committee and as core clinical faculty in the Internal Medicine Residency.  

Dr. Lee reported no disclosures.

You have been treating COVID-19 patients since before the US Food and Drug Administration (FDA) granted emergency authorization to 3 pharma vaccine producers. But now you have patients, on oxygen or under observation, who have foregone vaccination. What do you think about that?

This question raises a good point that is often missed: how the unvaccinated are often portrayed. The reasons these patients remain unvaccinated are not necessarily uniform.

What we know based on attitude surveys done by the Kaiser Family Foundation¹ is that people are vaccine hesitant for varied reasons. And this finding isn’t unique. The pediatric literature shows that those who are opposed to childhood vaccination do not share the same motivations.² Yes, some are strident about their beliefs against vaccination, usually in concert with popularized myths. Many unvaccinated people are hesitant based on misconceptions, do not have access to a clinician who can answer their questions, can’t afford to lose a day of work due to the vaccine’s expected side effects, or understandably mistrust the healthcare community based on personal or historical context.

What do the unvaccinated have in common? Education levels, income levels?

We know from surveys³ that generally, more men than women are hesitant. Those who are uninsured or underinsured⁴ and those of lower socioeconomic status are more hesitant than their counterparts. It's changing a bit, but those who are in minority communities, Black and Latinx communities, are more likely to be unvaccinated compared to other groups. Even in Chicago, where we have a relatively good vaccination rate (59%),⁵ Black and Latinx communities are under vaccinated as compared to those who are White or Asian. The reasons for this are complex and include historical disinvestment in communities and decreased access to medical care. Some wonderful agencies are pairing up with community leaders in target neighborhoods to address this equity gap.

What do you say to these patients, if anything, about their status?

It’s not what you might expect. At first, I listen. I find that most are well-intentioned people trying to make the right decision for themselves and their family. It is, therefore, helpful to hear what their motivations and fears are first, before delving into facts. Furthermore, although facts are wonderful and necessary, what is more persuasive is a personal anecdote. I will tell folks my personal story about deciding to be vaccinated. I talk about how I found accurate information about the vaccine and what a relief it was afterwards to know that I would be safe, especially as a mom. I even talk about feeling tired and achy after the second shot, which means that the vaccine is working. I joke that it is the only time I’ve felt so relieved to feel sick. Last, I often say that it’s okay to feel scared or apprehensive, and that they deserve to get the best information. What’s important is that these conversations feel genuine.

Can you share an anecdote or two?

A few months ago, I took care of an unvaccinated gentleman who was in the hospital for a chronic medical condition. Before this hospitalization, his personal physicians had tried to convince him to get the vaccine over a period of several months.

It would have been easy to assume that he would remain unvaccinated and that I should put my energy into convincing someone else. However, I found him surprisingly open to discussion, and we were able to have many conversations about what he'd heard from nonmedical sources. We bonded over the sheer volume of available information and how difficult it is to know what is true. We then walked through what was truth vs fiction, and I tailored the discussion to how the vaccine could specifically improve his quality of life and his family's. He confided that what made his decision more difficult was the fact that he hadn’t met anyone who had gotten the vaccine among his friends and family. He ultimately did decide to get vaccinated, along with a family member. We made the appointment for the week after he was discharged. What a feeling it was to get a text message from his clinic physician saying that he got his first shot and that it went great!

I wasn’t the only physician who had spoken to this patient about getting vaccinated; others had done the same before he came to the hospital. It is a good reminder that each conversation can act like a gentle nudge in the right direction.

In terms of the data on the unvaccinated–reasons they stay away, what their backgrounds are and so forth–how close do those data play out in real life?

It is not advisable to assume why someone would be unvaccinated based on first impressions. I find the reasons are highly specific to that individual, ranging from false impressions about fertility to concerns about missing work. In my experience, several patients simply wanted to get more facts from a healthcare worker directly before signing up. Pregnancy is particularly important to talk about, considering how devastating the Delta variant has been to this group of women. One gentleman that I spoke to was worried about affecting his wife’s pregnancy with the vaccine. We know now that vaccines are safe and prevent pregnant patients from getting seriously ill and dying, but that knowledge isn’t widely known to the public. So many kind and well-meaning people have foregone vaccination because they're concerned about doing anything to upset the pregnancy.

How long, generally, does it take for unvaccinated patients to discuss the reasons for their choice?

It takes time, and that's a real barrier for many healthcare professionals, especially in a clinic setting where the luxury of extra time is nonexistent. How much time differs for everyone, and usually a change of heart takes more than one conversation.

Truly, the first conversation is just to listen, to understand their hesitation, and to develop trust. For anyone to really hear what I have to say, they must trust that what I'm saying is solely motivated by caring about what happens to them and their family.

One gentleman said something pointed during our first conversation: Thank you for listening. When I tell people I am not vaccinated I can feel them judging me, that they've already decided what to think of me.

I always tell people that they have good questions because they do. I respect the fact that they're feeling open enough to share what they're hearing or what they're afraid of. It's a privilege for me to be involved in that conversation.

What advice would you give other hospitalists in terms of treating and counseling patients who are unvaccinated?

Every hospitalization, whether it’s COVID-related or not, is an opportunity to speak with those who are still unvaccinated. Every encounter can be used to further the conversation about vaccines, by increasing their trust in the healthcare community, answering their questions, and providing facts in place of confusion. Using those opportunities is the best way to get us out of this pandemic.

That said, it's been a long two years, so it's okay if physicians don't have the emotional bandwidth or the time to have these discussions. Maybe save that conversation for another day. But for some providers, perhaps knowing that those who are unvaccinated can change and that anxiety could be preventing some from getting their shot will motivate them to start these conversations with their patients.

Cheryl K. Lee, MD, an Assistant Professor Of Medicine at Northwestern Feinberg School of Medicine, practices internal medicine and pediatrics at Northwestern Memorial and the Ann & Robert H. Lurie Children's Hospital, both in Chicago, IL. She also serves on the Northwestern Medicine Covid Quality Committee and as core clinical faculty in the Internal Medicine Residency.  

Dr. Lee reported no disclosures.

You have been treating COVID-19 patients since before the US Food and Drug Administration (FDA) granted emergency authorization to 3 pharma vaccine producers. But now you have patients, on oxygen or under observation, who have foregone vaccination. What do you think about that?

This question raises a good point that is often missed: how the unvaccinated are often portrayed. The reasons these patients remain unvaccinated are not necessarily uniform.

What we know based on attitude surveys done by the Kaiser Family Foundation¹ is that people are vaccine hesitant for varied reasons. And this finding isn’t unique. The pediatric literature shows that those who are opposed to childhood vaccination do not share the same motivations.² Yes, some are strident about their beliefs against vaccination, usually in concert with popularized myths. Many unvaccinated people are hesitant based on misconceptions, do not have access to a clinician who can answer their questions, can’t afford to lose a day of work due to the vaccine’s expected side effects, or understandably mistrust the healthcare community based on personal or historical context.

What do the unvaccinated have in common? Education levels, income levels?

We know from surveys³ that generally, more men than women are hesitant. Those who are uninsured or underinsured⁴ and those of lower socioeconomic status are more hesitant than their counterparts. It's changing a bit, but those who are in minority communities, Black and Latinx communities, are more likely to be unvaccinated compared to other groups. Even in Chicago, where we have a relatively good vaccination rate (59%),⁵ Black and Latinx communities are under vaccinated as compared to those who are White or Asian. The reasons for this are complex and include historical disinvestment in communities and decreased access to medical care. Some wonderful agencies are pairing up with community leaders in target neighborhoods to address this equity gap.

What do you say to these patients, if anything, about their status?

It’s not what you might expect. At first, I listen. I find that most are well-intentioned people trying to make the right decision for themselves and their family. It is, therefore, helpful to hear what their motivations and fears are first, before delving into facts. Furthermore, although facts are wonderful and necessary, what is more persuasive is a personal anecdote. I will tell folks my personal story about deciding to be vaccinated. I talk about how I found accurate information about the vaccine and what a relief it was afterwards to know that I would be safe, especially as a mom. I even talk about feeling tired and achy after the second shot, which means that the vaccine is working. I joke that it is the only time I’ve felt so relieved to feel sick. Last, I often say that it’s okay to feel scared or apprehensive, and that they deserve to get the best information. What’s important is that these conversations feel genuine.

Can you share an anecdote or two?

A few months ago, I took care of an unvaccinated gentleman who was in the hospital for a chronic medical condition. Before this hospitalization, his personal physicians had tried to convince him to get the vaccine over a period of several months.

It would have been easy to assume that he would remain unvaccinated and that I should put my energy into convincing someone else. However, I found him surprisingly open to discussion, and we were able to have many conversations about what he'd heard from nonmedical sources. We bonded over the sheer volume of available information and how difficult it is to know what is true. We then walked through what was truth vs fiction, and I tailored the discussion to how the vaccine could specifically improve his quality of life and his family's. He confided that what made his decision more difficult was the fact that he hadn’t met anyone who had gotten the vaccine among his friends and family. He ultimately did decide to get vaccinated, along with a family member. We made the appointment for the week after he was discharged. What a feeling it was to get a text message from his clinic physician saying that he got his first shot and that it went great!

I wasn’t the only physician who had spoken to this patient about getting vaccinated; others had done the same before he came to the hospital. It is a good reminder that each conversation can act like a gentle nudge in the right direction.

In terms of the data on the unvaccinated–reasons they stay away, what their backgrounds are and so forth–how close do those data play out in real life?

It is not advisable to assume why someone would be unvaccinated based on first impressions. I find the reasons are highly specific to that individual, ranging from false impressions about fertility to concerns about missing work. In my experience, several patients simply wanted to get more facts from a healthcare worker directly before signing up. Pregnancy is particularly important to talk about, considering how devastating the Delta variant has been to this group of women. One gentleman that I spoke to was worried about affecting his wife’s pregnancy with the vaccine. We know now that vaccines are safe and prevent pregnant patients from getting seriously ill and dying, but that knowledge isn’t widely known to the public. So many kind and well-meaning people have foregone vaccination because they're concerned about doing anything to upset the pregnancy.

How long, generally, does it take for unvaccinated patients to discuss the reasons for their choice?

It takes time, and that's a real barrier for many healthcare professionals, especially in a clinic setting where the luxury of extra time is nonexistent. How much time differs for everyone, and usually a change of heart takes more than one conversation.

Truly, the first conversation is just to listen, to understand their hesitation, and to develop trust. For anyone to really hear what I have to say, they must trust that what I'm saying is solely motivated by caring about what happens to them and their family.

One gentleman said something pointed during our first conversation: Thank you for listening. When I tell people I am not vaccinated I can feel them judging me, that they've already decided what to think of me.

I always tell people that they have good questions because they do. I respect the fact that they're feeling open enough to share what they're hearing or what they're afraid of. It's a privilege for me to be involved in that conversation.

What advice would you give other hospitalists in terms of treating and counseling patients who are unvaccinated?

Every hospitalization, whether it’s COVID-related or not, is an opportunity to speak with those who are still unvaccinated. Every encounter can be used to further the conversation about vaccines, by increasing their trust in the healthcare community, answering their questions, and providing facts in place of confusion. Using those opportunities is the best way to get us out of this pandemic.

That said, it's been a long two years, so it's okay if physicians don't have the emotional bandwidth or the time to have these discussions. Maybe save that conversation for another day. But for some providers, perhaps knowing that those who are unvaccinated can change and that anxiety could be preventing some from getting their shot will motivate them to start these conversations with their patients.

Cheryl K. Lee, MD, an Assistant Professor Of Medicine at Northwestern Feinberg School of Medicine, practices internal medicine and pediatrics at Northwestern Memorial and the Ann & Robert H. Lurie Children's Hospital, both in Chicago, IL. She also serves on the Northwestern Medicine Covid Quality Committee and as core clinical faculty in the Internal Medicine Residency.  

Dr. Lee reported no disclosures.

You have been treating COVID-19 patients since before the US Food and Drug Administration (FDA) granted emergency authorization to 3 pharma vaccine producers. But now you have patients, on oxygen or under observation, who have foregone vaccination. What do you think about that?

This question raises a good point that is often missed: how the unvaccinated are often portrayed. The reasons these patients remain unvaccinated are not necessarily uniform.

What we know based on attitude surveys done by the Kaiser Family Foundation¹ is that people are vaccine hesitant for varied reasons. And this finding isn’t unique. The pediatric literature shows that those who are opposed to childhood vaccination do not share the same motivations.² Yes, some are strident about their beliefs against vaccination, usually in concert with popularized myths. Many unvaccinated people are hesitant based on misconceptions, do not have access to a clinician who can answer their questions, can’t afford to lose a day of work due to the vaccine’s expected side effects, or understandably mistrust the healthcare community based on personal or historical context.

What do the unvaccinated have in common? Education levels, income levels?

We know from surveys³ that generally, more men than women are hesitant. Those who are uninsured or underinsured⁴ and those of lower socioeconomic status are more hesitant than their counterparts. It's changing a bit, but those who are in minority communities, Black and Latinx communities, are more likely to be unvaccinated compared to other groups. Even in Chicago, where we have a relatively good vaccination rate (59%),⁵ Black and Latinx communities are under vaccinated as compared to those who are White or Asian. The reasons for this are complex and include historical disinvestment in communities and decreased access to medical care. Some wonderful agencies are pairing up with community leaders in target neighborhoods to address this equity gap.

What do you say to these patients, if anything, about their status?

It’s not what you might expect. At first, I listen. I find that most are well-intentioned people trying to make the right decision for themselves and their family. It is, therefore, helpful to hear what their motivations and fears are first, before delving into facts. Furthermore, although facts are wonderful and necessary, what is more persuasive is a personal anecdote. I will tell folks my personal story about deciding to be vaccinated. I talk about how I found accurate information about the vaccine and what a relief it was afterwards to know that I would be safe, especially as a mom. I even talk about feeling tired and achy after the second shot, which means that the vaccine is working. I joke that it is the only time I’ve felt so relieved to feel sick. Last, I often say that it’s okay to feel scared or apprehensive, and that they deserve to get the best information. What’s important is that these conversations feel genuine.

Can you share an anecdote or two?

A few months ago, I took care of an unvaccinated gentleman who was in the hospital for a chronic medical condition. Before this hospitalization, his personal physicians had tried to convince him to get the vaccine over a period of several months.

It would have been easy to assume that he would remain unvaccinated and that I should put my energy into convincing someone else. However, I found him surprisingly open to discussion, and we were able to have many conversations about what he'd heard from nonmedical sources. We bonded over the sheer volume of available information and how difficult it is to know what is true. We then walked through what was truth vs fiction, and I tailored the discussion to how the vaccine could specifically improve his quality of life and his family's. He confided that what made his decision more difficult was the fact that he hadn’t met anyone who had gotten the vaccine among his friends and family. He ultimately did decide to get vaccinated, along with a family member. We made the appointment for the week after he was discharged. What a feeling it was to get a text message from his clinic physician saying that he got his first shot and that it went great!

I wasn’t the only physician who had spoken to this patient about getting vaccinated; others had done the same before he came to the hospital. It is a good reminder that each conversation can act like a gentle nudge in the right direction.

In terms of the data on the unvaccinated–reasons they stay away, what their backgrounds are and so forth–how close do those data play out in real life?

It is not advisable to assume why someone would be unvaccinated based on first impressions. I find the reasons are highly specific to that individual, ranging from false impressions about fertility to concerns about missing work. In my experience, several patients simply wanted to get more facts from a healthcare worker directly before signing up. Pregnancy is particularly important to talk about, considering how devastating the Delta variant has been to this group of women. One gentleman that I spoke to was worried about affecting his wife’s pregnancy with the vaccine. We know now that vaccines are safe and prevent pregnant patients from getting seriously ill and dying, but that knowledge isn’t widely known to the public. So many kind and well-meaning people have foregone vaccination because they're concerned about doing anything to upset the pregnancy.

How long, generally, does it take for unvaccinated patients to discuss the reasons for their choice?

It takes time, and that's a real barrier for many healthcare professionals, especially in a clinic setting where the luxury of extra time is nonexistent. How much time differs for everyone, and usually a change of heart takes more than one conversation.

Truly, the first conversation is just to listen, to understand their hesitation, and to develop trust. For anyone to really hear what I have to say, they must trust that what I'm saying is solely motivated by caring about what happens to them and their family.

One gentleman said something pointed during our first conversation: Thank you for listening. When I tell people I am not vaccinated I can feel them judging me, that they've already decided what to think of me.

I always tell people that they have good questions because they do. I respect the fact that they're feeling open enough to share what they're hearing or what they're afraid of. It's a privilege for me to be involved in that conversation.

What advice would you give other hospitalists in terms of treating and counseling patients who are unvaccinated?

Every hospitalization, whether it’s COVID-related or not, is an opportunity to speak with those who are still unvaccinated. Every encounter can be used to further the conversation about vaccines, by increasing their trust in the healthcare community, answering their questions, and providing facts in place of confusion. Using those opportunities is the best way to get us out of this pandemic.

That said, it's been a long two years, so it's okay if physicians don't have the emotional bandwidth or the time to have these discussions. Maybe save that conversation for another day. But for some providers, perhaps knowing that those who are unvaccinated can change and that anxiety could be preventing some from getting their shot will motivate them to start these conversations with their patients.