Commentary

The growing threat of novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), now commonly known as coronavirus disease 2019 (COVID-19), has forced Americans to stay home due to quarantine, especially older individuals and those who are immunocompromised or have an underlying health problem such as pulmonary or cardiac disease. The federal government’s estimated $2 trillion CARES Act (Coronavirus Aid, Relief, and Economic Security Act)¹ will provide a much-needed boost to health care and the economy; prior recent legislation approved an $8.6 billion emergency relief bill,² HR 6074 (Coronavirus Preparedness and Response Supplemental Appropriations Act of 2020), which expands Medicare coverage of telehealth to patients in their home rather than having them travel to a designated site, covers both established and new patients, allows physicians to waive or reduce co-payments and cost-sharing requirements, and reimburses the same as an in-person visit.

Federal emergency legislation temporarily relaxed the Health Insurance Portability and Accountability Act (HIPAA),^3,4 allowing physicians to use Facetime and Skype for Medicare patients. In addition, Medicare will reimburse telehealth services for out-of-state-providers; however, cross-state licensure is governed by the patient’s home state.⁵ As of March 25, 2020, emergency legislation to temporarily allow out-of-state physicians to provide care, whether or not it relates to COVID-19, was enacted in 13 states: California, Colorado, Connecticut, Delaware, Hawaii, Idaho, Indiana, Iowa, Maryland, Minnesota, New York, North Carolina, and North Dakota.⁶ Ongoing legislation is rapidly changing; for daily updates on licensing laws, refer to the Federation of State Medical Boards website. Check your own institutional policies and malpractice provider prior to offering telehealth, as local laws and regulations may vary. Herein, we offer suggestions for using teledermatology.

Reimbursement

Prior to the COVID-19 pandemic, 16 states—Arkansas, Colorado, Delaware, Hawaii, Kentucky, Maine, Minnesota, Mississippi, Missouri, Montana, Nevada, New Jersey, New Mexico, Tennessee, Utah, and Virginia—had true payment parity laws,⁷ which reimbursed telehealth as a regular office visit using modifier -95. Several states have enacted emergency telehealth expansion laws to discourage COVID-19 spread⁸; some states such as New Jersey now prohibit co-payments or out-of-pocket deductibles from all in-network insurance plans (commercial Medicare and Medicaid).^9,10 Updated legislation about COVID-19 and telemedicine can be found on the Center for Connected Health Policy website. An interactive map of laws and reimbursement policies also is available on the websites of the American Telehealth Association and the American Academy of Dermatology. The ability to charge a patient directly for telehealth services depends on the insurance provider agreement. If telehealth is a covered service, you cannot charge these patients out-of-pocket.

Teledermatology Options

For many conditions, the effectiveness and quality of teledermatology is comparable to a conventional face-to-face visit.¹¹ There are 3 types of telehealth visits:

• Store and forward: The clinician reviews images or videos and responds asynchronously,¹² similar to an email chain.
• Live interactive: The clinician uses 2-way video synchronously.¹² In states with parity laws, this method is reimbursed equally to an in-person visit.
• Remote patient monitoring: Health-related data are collected and transmitted to a remote clinician, similar to remote intensive care unit management.¹² Dermatologists are unlikely to utilize this modality.

The Virtual Visit

Follow these guidelines for practicing teledermatology: (1) ensure that the image or video is clear and that there is proper lighting, a monochromatic background, and a clear view of the anatomy necessary to evaluate; (2) dress in appropriate attire as if you were in clinic, such as scrubs, a white coat, or other professional attire; (3) begin the telehealth encounter by obtaining informed consent,¹³ according to state¹⁴ or Medicare guidelines; (4) document the location of the patient and provider; (5) for live virtual visits, document similarly to an in-person visit⁵; (6) for all other virtual care, document minutes spent on each task; and (7) select only 1 billing code per visit.

In some states, regulations for commercial and/or Medicaid plans require that other modifiers be added to billing codes, which vary plan-by-plan:

• Modifier GQ: For asynchronous care (store and forward).
• Modifier GT: For synchronous live telehealth visits.
• Modifier -95: In states where there are equal parity laws or if you are billing a commercial insurance payer (may vary by plan).

Medicare does not require any additional modifiers.¹⁵ If the plan reimburses telemedicine equally to a face-to-face visit, use regular office visit codes. The eTable¹⁶ lists billing codes and Medicare reimbursement rates.

Secure Software

Several electronic medical record systems already include secure patient communication. Other HIPAA-compliant communication options with a variety of features are available to clinicians:

• Klara allows for HIPAA-secure texting, group messaging, photograph uploads, and telephone calls.
• Doximity offers free calling and faxes.
• G Suite for health care offers HIPAA-compliant texting, emailing, and video calls through Google Voice and Google Hangouts Meet.
• Secure video chat is available on Zoom for Healthcare, VSee, Doxy.me, and other platforms.
• Multiservice platforms such as DermEngine include billing, payments, teledermatology, and teledermoscopy and allow for interprofessional consultation.

The Bottom Line

Telehealth readiness is playing a key role in containing the spread of COVID-19. In-person dermatology visits are now being limited to urgent conditions only, as per institutional guidelines.⁴



Acknowledgment
We thank Garfunkel Wild, P.C. (Great Neck, New York), for their expertise and assistance.

The growing threat of novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), now commonly known as coronavirus disease 2019 (COVID-19), has forced Americans to stay home due to quarantine, especially older individuals and those who are immunocompromised or have an underlying health problem such as pulmonary or cardiac disease. The federal government’s estimated $2 trillion CARES Act (Coronavirus Aid, Relief, and Economic Security Act)¹ will provide a much-needed boost to health care and the economy; prior recent legislation approved an $8.6 billion emergency relief bill,² HR 6074 (Coronavirus Preparedness and Response Supplemental Appropriations Act of 2020), which expands Medicare coverage of telehealth to patients in their home rather than having them travel to a designated site, covers both established and new patients, allows physicians to waive or reduce co-payments and cost-sharing requirements, and reimburses the same as an in-person visit.

Federal emergency legislation temporarily relaxed the Health Insurance Portability and Accountability Act (HIPAA),^3,4 allowing physicians to use Facetime and Skype for Medicare patients. In addition, Medicare will reimburse telehealth services for out-of-state-providers; however, cross-state licensure is governed by the patient’s home state.⁵ As of March 25, 2020, emergency legislation to temporarily allow out-of-state physicians to provide care, whether or not it relates to COVID-19, was enacted in 13 states: California, Colorado, Connecticut, Delaware, Hawaii, Idaho, Indiana, Iowa, Maryland, Minnesota, New York, North Carolina, and North Dakota.⁶ Ongoing legislation is rapidly changing; for daily updates on licensing laws, refer to the Federation of State Medical Boards website. Check your own institutional policies and malpractice provider prior to offering telehealth, as local laws and regulations may vary. Herein, we offer suggestions for using teledermatology.

Reimbursement

Prior to the COVID-19 pandemic, 16 states—Arkansas, Colorado, Delaware, Hawaii, Kentucky, Maine, Minnesota, Mississippi, Missouri, Montana, Nevada, New Jersey, New Mexico, Tennessee, Utah, and Virginia—had true payment parity laws,⁷ which reimbursed telehealth as a regular office visit using modifier -95. Several states have enacted emergency telehealth expansion laws to discourage COVID-19 spread⁸; some states such as New Jersey now prohibit co-payments or out-of-pocket deductibles from all in-network insurance plans (commercial Medicare and Medicaid).^9,10 Updated legislation about COVID-19 and telemedicine can be found on the Center for Connected Health Policy website. An interactive map of laws and reimbursement policies also is available on the websites of the American Telehealth Association and the American Academy of Dermatology. The ability to charge a patient directly for telehealth services depends on the insurance provider agreement. If telehealth is a covered service, you cannot charge these patients out-of-pocket.

Teledermatology Options

For many conditions, the effectiveness and quality of teledermatology is comparable to a conventional face-to-face visit.¹¹ There are 3 types of telehealth visits:

• Store and forward: The clinician reviews images or videos and responds asynchronously,¹² similar to an email chain.
• Live interactive: The clinician uses 2-way video synchronously.¹² In states with parity laws, this method is reimbursed equally to an in-person visit.
• Remote patient monitoring: Health-related data are collected and transmitted to a remote clinician, similar to remote intensive care unit management.¹² Dermatologists are unlikely to utilize this modality.

The Virtual Visit

Follow these guidelines for practicing teledermatology: (1) ensure that the image or video is clear and that there is proper lighting, a monochromatic background, and a clear view of the anatomy necessary to evaluate; (2) dress in appropriate attire as if you were in clinic, such as scrubs, a white coat, or other professional attire; (3) begin the telehealth encounter by obtaining informed consent,¹³ according to state¹⁴ or Medicare guidelines; (4) document the location of the patient and provider; (5) for live virtual visits, document similarly to an in-person visit⁵; (6) for all other virtual care, document minutes spent on each task; and (7) select only 1 billing code per visit.

In some states, regulations for commercial and/or Medicaid plans require that other modifiers be added to billing codes, which vary plan-by-plan:

• Modifier GQ: For asynchronous care (store and forward).
• Modifier GT: For synchronous live telehealth visits.
• Modifier -95: In states where there are equal parity laws or if you are billing a commercial insurance payer (may vary by plan).

Medicare does not require any additional modifiers.¹⁵ If the plan reimburses telemedicine equally to a face-to-face visit, use regular office visit codes. The eTable¹⁶ lists billing codes and Medicare reimbursement rates.

Secure Software

Several electronic medical record systems already include secure patient communication. Other HIPAA-compliant communication options with a variety of features are available to clinicians:

• Klara allows for HIPAA-secure texting, group messaging, photograph uploads, and telephone calls.
• Doximity offers free calling and faxes.
• G Suite for health care offers HIPAA-compliant texting, emailing, and video calls through Google Voice and Google Hangouts Meet.
• Secure video chat is available on Zoom for Healthcare, VSee, Doxy.me, and other platforms.
• Multiservice platforms such as DermEngine include billing, payments, teledermatology, and teledermoscopy and allow for interprofessional consultation.

The Bottom Line

Telehealth readiness is playing a key role in containing the spread of COVID-19. In-person dermatology visits are now being limited to urgent conditions only, as per institutional guidelines.⁴



Acknowledgment
We thank Garfunkel Wild, P.C. (Great Neck, New York), for their expertise and assistance.

The growing threat of novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), now commonly known as coronavirus disease 2019 (COVID-19), has forced Americans to stay home due to quarantine, especially older individuals and those who are immunocompromised or have an underlying health problem such as pulmonary or cardiac disease. The federal government’s estimated $2 trillion CARES Act (Coronavirus Aid, Relief, and Economic Security Act)¹ will provide a much-needed boost to health care and the economy; prior recent legislation approved an $8.6 billion emergency relief bill,² HR 6074 (Coronavirus Preparedness and Response Supplemental Appropriations Act of 2020), which expands Medicare coverage of telehealth to patients in their home rather than having them travel to a designated site, covers both established and new patients, allows physicians to waive or reduce co-payments and cost-sharing requirements, and reimburses the same as an in-person visit.

Federal emergency legislation temporarily relaxed the Health Insurance Portability and Accountability Act (HIPAA),^3,4 allowing physicians to use Facetime and Skype for Medicare patients. In addition, Medicare will reimburse telehealth services for out-of-state-providers; however, cross-state licensure is governed by the patient’s home state.⁵ As of March 25, 2020, emergency legislation to temporarily allow out-of-state physicians to provide care, whether or not it relates to COVID-19, was enacted in 13 states: California, Colorado, Connecticut, Delaware, Hawaii, Idaho, Indiana, Iowa, Maryland, Minnesota, New York, North Carolina, and North Dakota.⁶ Ongoing legislation is rapidly changing; for daily updates on licensing laws, refer to the Federation of State Medical Boards website. Check your own institutional policies and malpractice provider prior to offering telehealth, as local laws and regulations may vary. Herein, we offer suggestions for using teledermatology.

Reimbursement

Prior to the COVID-19 pandemic, 16 states—Arkansas, Colorado, Delaware, Hawaii, Kentucky, Maine, Minnesota, Mississippi, Missouri, Montana, Nevada, New Jersey, New Mexico, Tennessee, Utah, and Virginia—had true payment parity laws,⁷ which reimbursed telehealth as a regular office visit using modifier -95. Several states have enacted emergency telehealth expansion laws to discourage COVID-19 spread⁸; some states such as New Jersey now prohibit co-payments or out-of-pocket deductibles from all in-network insurance plans (commercial Medicare and Medicaid).^9,10 Updated legislation about COVID-19 and telemedicine can be found on the Center for Connected Health Policy website. An interactive map of laws and reimbursement policies also is available on the websites of the American Telehealth Association and the American Academy of Dermatology. The ability to charge a patient directly for telehealth services depends on the insurance provider agreement. If telehealth is a covered service, you cannot charge these patients out-of-pocket.

Teledermatology Options

For many conditions, the effectiveness and quality of teledermatology is comparable to a conventional face-to-face visit.¹¹ There are 3 types of telehealth visits:

• Store and forward: The clinician reviews images or videos and responds asynchronously,¹² similar to an email chain.
• Live interactive: The clinician uses 2-way video synchronously.¹² In states with parity laws, this method is reimbursed equally to an in-person visit.
• Remote patient monitoring: Health-related data are collected and transmitted to a remote clinician, similar to remote intensive care unit management.¹² Dermatologists are unlikely to utilize this modality.

The Virtual Visit

Follow these guidelines for practicing teledermatology: (1) ensure that the image or video is clear and that there is proper lighting, a monochromatic background, and a clear view of the anatomy necessary to evaluate; (2) dress in appropriate attire as if you were in clinic, such as scrubs, a white coat, or other professional attire; (3) begin the telehealth encounter by obtaining informed consent,¹³ according to state¹⁴ or Medicare guidelines; (4) document the location of the patient and provider; (5) for live virtual visits, document similarly to an in-person visit⁵; (6) for all other virtual care, document minutes spent on each task; and (7) select only 1 billing code per visit.

In some states, regulations for commercial and/or Medicaid plans require that other modifiers be added to billing codes, which vary plan-by-plan:

• Modifier GQ: For asynchronous care (store and forward).
• Modifier GT: For synchronous live telehealth visits.
• Modifier -95: In states where there are equal parity laws or if you are billing a commercial insurance payer (may vary by plan).

Medicare does not require any additional modifiers.¹⁵ If the plan reimburses telemedicine equally to a face-to-face visit, use regular office visit codes. The eTable¹⁶ lists billing codes and Medicare reimbursement rates.

Secure Software

Several electronic medical record systems already include secure patient communication. Other HIPAA-compliant communication options with a variety of features are available to clinicians:

• Klara allows for HIPAA-secure texting, group messaging, photograph uploads, and telephone calls.
• Doximity offers free calling and faxes.
• G Suite for health care offers HIPAA-compliant texting, emailing, and video calls through Google Voice and Google Hangouts Meet.
• Secure video chat is available on Zoom for Healthcare, VSee, Doxy.me, and other platforms.
• Multiservice platforms such as DermEngine include billing, payments, teledermatology, and teledermoscopy and allow for interprofessional consultation.

The Bottom Line

Telehealth readiness is playing a key role in containing the spread of COVID-19. In-person dermatology visits are now being limited to urgent conditions only, as per institutional guidelines.⁴



Acknowledgment
We thank Garfunkel Wild, P.C. (Great Neck, New York), for their expertise and assistance.

Previously I urged you to take a look at a clinical report from the American Academy of Pediatrics that makes an excellent case for the importance of physical activity in the physical and mental health of children. I suggested we should view with some skepticism the authors’ recommendation that we include a quantifiable assessment of physical activity as a vital sign in our EHRs because I found it an unrealistic goal for most busy clinicians.

I also promised to write again and address the authors’ recommendation that we learn how to write an exercise prescription. The authors representing the AAP’s Council on Sports Medicine and Fitness and Section on Obesity observed that many pediatricians feel they lack “the experience or training to guide their patients toward meeting physical activity recommendations.” This is in some part because few if any medical schools or training programs include how to write an exercise prescription in their curricula. Certainly I don’t recall anyone sitting me down and telling me how to prescribe exercise. But, I submit that writing a workable exercise prescription for most patients doesn’t require any special training. However, it does require some common sense and touch of creativity.

Writing any kind of prescription means that you first must know the patient for whom you are writing it. What are his or her capabilities? If the patient has some physical disabilities, you may need to involve a physical therapist or the patient’s specialists in developing the options. But in most cases, common sense will provide you with a place to start.

More important than knowing the patient’s capability is discovering what kind of things the patient and his or her family already find attractive. Convincing people, young or old, they should exercise because it is good for them is more than likely destined to fail. Most of us who enjoy being active have found that it makes us feel better. It is very likely that we developed that affinity by first doing something active that we found enjoyable. Finding that fun gateway into an active lifestyle is where it helps to be creative and to have the patience to suggest multiple options as interest levels fade. For the patient or family who seems to enjoy numerical goals, pedometers and smartwatch fitness trackers can be a hook, but in my experience these gadgets seldom result in a sustainable activity habit.

Does your community have the resources from which the family can choose an activity to fill your prescription? You should know enough about your community’s recreational opportunities and the family’s financial and temporal limitations so that the activity you have prescribed is achievable.

The bottom line is that you must be prepared for failure because most of your thoughtfully crafted prescriptions won’t be taken or even filled. The inertia that we have built into our societies is often too great for families to overcome. But don’t give up. Ask at every visit about activity. Make follow-up visits to discuss the progress or lack of progress to demonstrate that you still consider exercise a valuable and potent piece of the wellness package. And continue to discourage excess screen time.

If you are feeling frustrated by your lack of success writing exercise prescriptions, you may discover that you can be more effective by speaking out at school board and recreation department meetings. Armed with the research included in the AAP’s recent clinical report, you may find powerful allies in the community who share your passion for helping children become more active.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

Previously I urged you to take a look at a clinical report from the American Academy of Pediatrics that makes an excellent case for the importance of physical activity in the physical and mental health of children. I suggested we should view with some skepticism the authors’ recommendation that we include a quantifiable assessment of physical activity as a vital sign in our EHRs because I found it an unrealistic goal for most busy clinicians.

I also promised to write again and address the authors’ recommendation that we learn how to write an exercise prescription. The authors representing the AAP’s Council on Sports Medicine and Fitness and Section on Obesity observed that many pediatricians feel they lack “the experience or training to guide their patients toward meeting physical activity recommendations.” This is in some part because few if any medical schools or training programs include how to write an exercise prescription in their curricula. Certainly I don’t recall anyone sitting me down and telling me how to prescribe exercise. But, I submit that writing a workable exercise prescription for most patients doesn’t require any special training. However, it does require some common sense and touch of creativity.

Writing any kind of prescription means that you first must know the patient for whom you are writing it. What are his or her capabilities? If the patient has some physical disabilities, you may need to involve a physical therapist or the patient’s specialists in developing the options. But in most cases, common sense will provide you with a place to start.

More important than knowing the patient’s capability is discovering what kind of things the patient and his or her family already find attractive. Convincing people, young or old, they should exercise because it is good for them is more than likely destined to fail. Most of us who enjoy being active have found that it makes us feel better. It is very likely that we developed that affinity by first doing something active that we found enjoyable. Finding that fun gateway into an active lifestyle is where it helps to be creative and to have the patience to suggest multiple options as interest levels fade. For the patient or family who seems to enjoy numerical goals, pedometers and smartwatch fitness trackers can be a hook, but in my experience these gadgets seldom result in a sustainable activity habit.

Does your community have the resources from which the family can choose an activity to fill your prescription? You should know enough about your community’s recreational opportunities and the family’s financial and temporal limitations so that the activity you have prescribed is achievable.

The bottom line is that you must be prepared for failure because most of your thoughtfully crafted prescriptions won’t be taken or even filled. The inertia that we have built into our societies is often too great for families to overcome. But don’t give up. Ask at every visit about activity. Make follow-up visits to discuss the progress or lack of progress to demonstrate that you still consider exercise a valuable and potent piece of the wellness package. And continue to discourage excess screen time.

If you are feeling frustrated by your lack of success writing exercise prescriptions, you may discover that you can be more effective by speaking out at school board and recreation department meetings. Armed with the research included in the AAP’s recent clinical report, you may find powerful allies in the community who share your passion for helping children become more active.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

Previously I urged you to take a look at a clinical report from the American Academy of Pediatrics that makes an excellent case for the importance of physical activity in the physical and mental health of children. I suggested we should view with some skepticism the authors’ recommendation that we include a quantifiable assessment of physical activity as a vital sign in our EHRs because I found it an unrealistic goal for most busy clinicians.

I also promised to write again and address the authors’ recommendation that we learn how to write an exercise prescription. The authors representing the AAP’s Council on Sports Medicine and Fitness and Section on Obesity observed that many pediatricians feel they lack “the experience or training to guide their patients toward meeting physical activity recommendations.” This is in some part because few if any medical schools or training programs include how to write an exercise prescription in their curricula. Certainly I don’t recall anyone sitting me down and telling me how to prescribe exercise. But, I submit that writing a workable exercise prescription for most patients doesn’t require any special training. However, it does require some common sense and touch of creativity.

Writing any kind of prescription means that you first must know the patient for whom you are writing it. What are his or her capabilities? If the patient has some physical disabilities, you may need to involve a physical therapist or the patient’s specialists in developing the options. But in most cases, common sense will provide you with a place to start.

More important than knowing the patient’s capability is discovering what kind of things the patient and his or her family already find attractive. Convincing people, young or old, they should exercise because it is good for them is more than likely destined to fail. Most of us who enjoy being active have found that it makes us feel better. It is very likely that we developed that affinity by first doing something active that we found enjoyable. Finding that fun gateway into an active lifestyle is where it helps to be creative and to have the patience to suggest multiple options as interest levels fade. For the patient or family who seems to enjoy numerical goals, pedometers and smartwatch fitness trackers can be a hook, but in my experience these gadgets seldom result in a sustainable activity habit.

Does your community have the resources from which the family can choose an activity to fill your prescription? You should know enough about your community’s recreational opportunities and the family’s financial and temporal limitations so that the activity you have prescribed is achievable.

The bottom line is that you must be prepared for failure because most of your thoughtfully crafted prescriptions won’t be taken or even filled. The inertia that we have built into our societies is often too great for families to overcome. But don’t give up. Ask at every visit about activity. Make follow-up visits to discuss the progress or lack of progress to demonstrate that you still consider exercise a valuable and potent piece of the wellness package. And continue to discourage excess screen time.

If you are feeling frustrated by your lack of success writing exercise prescriptions, you may discover that you can be more effective by speaking out at school board and recreation department meetings. Armed with the research included in the AAP’s recent clinical report, you may find powerful allies in the community who share your passion for helping children become more active.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

On the evening of March 24, I got the email. When the bolded letters “We ask for your help” flashed across my screen, I knew exactly what was being asked of me: to graduate early and join the fight against COVID-19.

It would be a lie to say that my immediate reaction was to volunteer.

For the 120 fourth-year medical students in my class at NYU Grossman School of Medicine, the arrival of that email was always more a question of when than if. Similar moves had already been made in Italy as well as the United Kingdom, where the surge in patients with COVID-19 has devastated hospitals and left healthcare workers dead or drained. The New York hospitals where I’ve trained, places I have grown to love over the past 4 years, are now experiencing similar horrors. Residents and attending doctors – mentors and teachers – are burned out and exhausted. They need help.

Like most medical students, I chose to pursue medicine out of a desire to help. On both my medical school and residency applications, I spoke about my resolve to bear witness to and provide support to those suffering. Yet, being recruited to the front lines of a global pandemic felt deeply unsettling. Is this how I want to finally enter the world of medicine? The scope of what is actually being asked of me was immense.

Given the onslaught of bad news coming in on every device I had cozied up to during my social distancing, how could I want to do this? I’ve seen the death toll climb in Italy, with dozens of doctors dead. I’ve seen the photos of faces marred by masks worn for 12-16 hours at a time. I’ve been repeatedly reminded that we are just behind Italy. Things are certainly going to get worse.

It sounds selfish and petty, but I feel like COVID-19 has already robbed me of so much. Yet that was my first thought when I received the email. The end of fourth year in medical school is supposed to be a joyous, celebratory time. We have worked years for this moment. So many of us have fought burnout to reach this time, a brief moment of rest between being a medical student and becoming a full-fledged physician.

I matched into residency just 4 days before being asked to join the front lines of the pandemic. I found out my match results without the usual fanfare, sitting on a bench in Madison Square Park, FaceTiming my dad and safely social-distanced from my mom. They both cried tears of joy. Like so many people around the world right now, I couldn’t even embrace my parents. Would they want me to volunteer?

I reached out to my classmates. I thought that some of them would certainly share my worries. I thought they also had to be carrying this uncomfortable kind of grief, a heavy and acidic feeling of dreams collapsing into a moral duty. I received a unanimous reply: “We are needed. It’s our time to step up.” No matter how many “what ifs” I voiced, they wouldn’t crack or waver. Still, even if they never admitted it to me, I wondered whether they privately shared some of my concerns and fears.

Everyone knows information is shared instantly in our Twitter-centric world, but I was still shocked and unprepared for how quickly I was at the center of a major news story. Within an hour of that email, I was contacted by an old acquaintance from elementary school, now a journalist. He had found me through Facebook and asked, “Will you be one of the NYU students graduating early? Would love to get a comment.” Another friend texted me a photo of the leaked email, quipping, “Are you going to save us from the pandemic, Dr. Gabe?!” “It’s not a small decision!” I snapped back.

I went through something like the seven stages of grief in rapid succession. I found that with each excuse I made why I shouldn’t volunteer, I somehow became increasingly more anxious. To my surprise, when I decided I would join 50 of my peers at NYU, graduate early, and volunteer, my mind settled. The more I thought about it, the more I was overtaken by the selfless beauty of the profession I’m entering. This is what it means to be a doctor. I recalled a key part of the Hippocratic Oath: “I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.”

I am going to fulfill my special obligations.

The fear is still there. I’m scared of COVID. I’m scared to infect others. I’m scared of winding up paralyzed and intubated. But I have also realized that all we have is each other. Healthcare workers supporting healthcare workers. New Yorkers supporting New Yorkers. Citizens of the world supporting citizens of the world. This is my time to be there for others, unwaveringly.

Logistical details continue to roll in, although they feel trivial in relation to the decision I have already made. The paperwork tells me that I will be onboarded to NYU’s internal medicine residency program. I will be compensated and protected under a similar contract to what current NYU residents sign. I have been promised that I will remain insured until I start my official residency program in July. My student loans won’t begin accruing interest until my normally planned graduation date. I am told that I will have personal protective equipment in line with the Centers for Disease Control and Prevention recommendations.

Questions still linger. Is it safe for me and my newly minted physician peers to continue living with our spouses, children, and friends? How long will I need to quarantine after my contract ends? Will there be a virtual graduation ceremony for my parents and loved ones to enjoy? In these challenging times, each day gives me a little more clarity about what exactly I am signing up for, but there are still so many uncertainties.

Am I naive to say that I do feel prepared? Or at least as prepared as anyone can be. With respect to my training, I have completed the requirements to graduate, which is why I am being permitted to graduate early in the first place. Our faculty points to our professionalism as the most promising indicator of our preparedness. They are heartened that we have embraced this truest test: our duty to others.

There is an eerie calm to New York City that contradicts what is shown on the news. With stores closed and streets quiet, it almost feels like Christmas morning here. Yet, inside the hospital, a fire rages. All the metaphors being used right now speak about violence, devastation, and immeasurable human suffering. “A war is being fought.” Or so I have heard. I guess I am about to find out.

Gabriel Redel-Traub is a fourth-year medical student at NYU Grossman School of Medicine. He will be starting residency in internal medicine at Columbia Presbyterian this summer. He is the former editor-in-chief of Dartmouth College’s Mouth Magazine, an editor of NYU’s LitMed Database, and has published most recently in the Hasting’s Center Magazine. Gabriel Redel-Traub has disclosed no relevant financial relationships.

This article first appeared on Medscape.com.

On the evening of March 24, I got the email. When the bolded letters “We ask for your help” flashed across my screen, I knew exactly what was being asked of me: to graduate early and join the fight against COVID-19.

It would be a lie to say that my immediate reaction was to volunteer.

For the 120 fourth-year medical students in my class at NYU Grossman School of Medicine, the arrival of that email was always more a question of when than if. Similar moves had already been made in Italy as well as the United Kingdom, where the surge in patients with COVID-19 has devastated hospitals and left healthcare workers dead or drained. The New York hospitals where I’ve trained, places I have grown to love over the past 4 years, are now experiencing similar horrors. Residents and attending doctors – mentors and teachers – are burned out and exhausted. They need help.

Like most medical students, I chose to pursue medicine out of a desire to help. On both my medical school and residency applications, I spoke about my resolve to bear witness to and provide support to those suffering. Yet, being recruited to the front lines of a global pandemic felt deeply unsettling. Is this how I want to finally enter the world of medicine? The scope of what is actually being asked of me was immense.

Given the onslaught of bad news coming in on every device I had cozied up to during my social distancing, how could I want to do this? I’ve seen the death toll climb in Italy, with dozens of doctors dead. I’ve seen the photos of faces marred by masks worn for 12-16 hours at a time. I’ve been repeatedly reminded that we are just behind Italy. Things are certainly going to get worse.

It sounds selfish and petty, but I feel like COVID-19 has already robbed me of so much. Yet that was my first thought when I received the email. The end of fourth year in medical school is supposed to be a joyous, celebratory time. We have worked years for this moment. So many of us have fought burnout to reach this time, a brief moment of rest between being a medical student and becoming a full-fledged physician.

I matched into residency just 4 days before being asked to join the front lines of the pandemic. I found out my match results without the usual fanfare, sitting on a bench in Madison Square Park, FaceTiming my dad and safely social-distanced from my mom. They both cried tears of joy. Like so many people around the world right now, I couldn’t even embrace my parents. Would they want me to volunteer?

I reached out to my classmates. I thought that some of them would certainly share my worries. I thought they also had to be carrying this uncomfortable kind of grief, a heavy and acidic feeling of dreams collapsing into a moral duty. I received a unanimous reply: “We are needed. It’s our time to step up.” No matter how many “what ifs” I voiced, they wouldn’t crack or waver. Still, even if they never admitted it to me, I wondered whether they privately shared some of my concerns and fears.

Everyone knows information is shared instantly in our Twitter-centric world, but I was still shocked and unprepared for how quickly I was at the center of a major news story. Within an hour of that email, I was contacted by an old acquaintance from elementary school, now a journalist. He had found me through Facebook and asked, “Will you be one of the NYU students graduating early? Would love to get a comment.” Another friend texted me a photo of the leaked email, quipping, “Are you going to save us from the pandemic, Dr. Gabe?!” “It’s not a small decision!” I snapped back.

I went through something like the seven stages of grief in rapid succession. I found that with each excuse I made why I shouldn’t volunteer, I somehow became increasingly more anxious. To my surprise, when I decided I would join 50 of my peers at NYU, graduate early, and volunteer, my mind settled. The more I thought about it, the more I was overtaken by the selfless beauty of the profession I’m entering. This is what it means to be a doctor. I recalled a key part of the Hippocratic Oath: “I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.”

I am going to fulfill my special obligations.

The fear is still there. I’m scared of COVID. I’m scared to infect others. I’m scared of winding up paralyzed and intubated. But I have also realized that all we have is each other. Healthcare workers supporting healthcare workers. New Yorkers supporting New Yorkers. Citizens of the world supporting citizens of the world. This is my time to be there for others, unwaveringly.

Logistical details continue to roll in, although they feel trivial in relation to the decision I have already made. The paperwork tells me that I will be onboarded to NYU’s internal medicine residency program. I will be compensated and protected under a similar contract to what current NYU residents sign. I have been promised that I will remain insured until I start my official residency program in July. My student loans won’t begin accruing interest until my normally planned graduation date. I am told that I will have personal protective equipment in line with the Centers for Disease Control and Prevention recommendations.

Questions still linger. Is it safe for me and my newly minted physician peers to continue living with our spouses, children, and friends? How long will I need to quarantine after my contract ends? Will there be a virtual graduation ceremony for my parents and loved ones to enjoy? In these challenging times, each day gives me a little more clarity about what exactly I am signing up for, but there are still so many uncertainties.

Am I naive to say that I do feel prepared? Or at least as prepared as anyone can be. With respect to my training, I have completed the requirements to graduate, which is why I am being permitted to graduate early in the first place. Our faculty points to our professionalism as the most promising indicator of our preparedness. They are heartened that we have embraced this truest test: our duty to others.

There is an eerie calm to New York City that contradicts what is shown on the news. With stores closed and streets quiet, it almost feels like Christmas morning here. Yet, inside the hospital, a fire rages. All the metaphors being used right now speak about violence, devastation, and immeasurable human suffering. “A war is being fought.” Or so I have heard. I guess I am about to find out.

Gabriel Redel-Traub is a fourth-year medical student at NYU Grossman School of Medicine. He will be starting residency in internal medicine at Columbia Presbyterian this summer. He is the former editor-in-chief of Dartmouth College’s Mouth Magazine, an editor of NYU’s LitMed Database, and has published most recently in the Hasting’s Center Magazine. Gabriel Redel-Traub has disclosed no relevant financial relationships.

This article first appeared on Medscape.com.

On the evening of March 24, I got the email. When the bolded letters “We ask for your help” flashed across my screen, I knew exactly what was being asked of me: to graduate early and join the fight against COVID-19.

It would be a lie to say that my immediate reaction was to volunteer.

For the 120 fourth-year medical students in my class at NYU Grossman School of Medicine, the arrival of that email was always more a question of when than if. Similar moves had already been made in Italy as well as the United Kingdom, where the surge in patients with COVID-19 has devastated hospitals and left healthcare workers dead or drained. The New York hospitals where I’ve trained, places I have grown to love over the past 4 years, are now experiencing similar horrors. Residents and attending doctors – mentors and teachers – are burned out and exhausted. They need help.

Like most medical students, I chose to pursue medicine out of a desire to help. On both my medical school and residency applications, I spoke about my resolve to bear witness to and provide support to those suffering. Yet, being recruited to the front lines of a global pandemic felt deeply unsettling. Is this how I want to finally enter the world of medicine? The scope of what is actually being asked of me was immense.

Given the onslaught of bad news coming in on every device I had cozied up to during my social distancing, how could I want to do this? I’ve seen the death toll climb in Italy, with dozens of doctors dead. I’ve seen the photos of faces marred by masks worn for 12-16 hours at a time. I’ve been repeatedly reminded that we are just behind Italy. Things are certainly going to get worse.

It sounds selfish and petty, but I feel like COVID-19 has already robbed me of so much. Yet that was my first thought when I received the email. The end of fourth year in medical school is supposed to be a joyous, celebratory time. We have worked years for this moment. So many of us have fought burnout to reach this time, a brief moment of rest between being a medical student and becoming a full-fledged physician.

I matched into residency just 4 days before being asked to join the front lines of the pandemic. I found out my match results without the usual fanfare, sitting on a bench in Madison Square Park, FaceTiming my dad and safely social-distanced from my mom. They both cried tears of joy. Like so many people around the world right now, I couldn’t even embrace my parents. Would they want me to volunteer?

I reached out to my classmates. I thought that some of them would certainly share my worries. I thought they also had to be carrying this uncomfortable kind of grief, a heavy and acidic feeling of dreams collapsing into a moral duty. I received a unanimous reply: “We are needed. It’s our time to step up.” No matter how many “what ifs” I voiced, they wouldn’t crack or waver. Still, even if they never admitted it to me, I wondered whether they privately shared some of my concerns and fears.

Everyone knows information is shared instantly in our Twitter-centric world, but I was still shocked and unprepared for how quickly I was at the center of a major news story. Within an hour of that email, I was contacted by an old acquaintance from elementary school, now a journalist. He had found me through Facebook and asked, “Will you be one of the NYU students graduating early? Would love to get a comment.” Another friend texted me a photo of the leaked email, quipping, “Are you going to save us from the pandemic, Dr. Gabe?!” “It’s not a small decision!” I snapped back.

I went through something like the seven stages of grief in rapid succession. I found that with each excuse I made why I shouldn’t volunteer, I somehow became increasingly more anxious. To my surprise, when I decided I would join 50 of my peers at NYU, graduate early, and volunteer, my mind settled. The more I thought about it, the more I was overtaken by the selfless beauty of the profession I’m entering. This is what it means to be a doctor. I recalled a key part of the Hippocratic Oath: “I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.”

I am going to fulfill my special obligations.

The fear is still there. I’m scared of COVID. I’m scared to infect others. I’m scared of winding up paralyzed and intubated. But I have also realized that all we have is each other. Healthcare workers supporting healthcare workers. New Yorkers supporting New Yorkers. Citizens of the world supporting citizens of the world. This is my time to be there for others, unwaveringly.

Logistical details continue to roll in, although they feel trivial in relation to the decision I have already made. The paperwork tells me that I will be onboarded to NYU’s internal medicine residency program. I will be compensated and protected under a similar contract to what current NYU residents sign. I have been promised that I will remain insured until I start my official residency program in July. My student loans won’t begin accruing interest until my normally planned graduation date. I am told that I will have personal protective equipment in line with the Centers for Disease Control and Prevention recommendations.

Questions still linger. Is it safe for me and my newly minted physician peers to continue living with our spouses, children, and friends? How long will I need to quarantine after my contract ends? Will there be a virtual graduation ceremony for my parents and loved ones to enjoy? In these challenging times, each day gives me a little more clarity about what exactly I am signing up for, but there are still so many uncertainties.

Am I naive to say that I do feel prepared? Or at least as prepared as anyone can be. With respect to my training, I have completed the requirements to graduate, which is why I am being permitted to graduate early in the first place. Our faculty points to our professionalism as the most promising indicator of our preparedness. They are heartened that we have embraced this truest test: our duty to others.

There is an eerie calm to New York City that contradicts what is shown on the news. With stores closed and streets quiet, it almost feels like Christmas morning here. Yet, inside the hospital, a fire rages. All the metaphors being used right now speak about violence, devastation, and immeasurable human suffering. “A war is being fought.” Or so I have heard. I guess I am about to find out.

Gabriel Redel-Traub is a fourth-year medical student at NYU Grossman School of Medicine. He will be starting residency in internal medicine at Columbia Presbyterian this summer. He is the former editor-in-chief of Dartmouth College’s Mouth Magazine, an editor of NYU’s LitMed Database, and has published most recently in the Hasting’s Center Magazine. Gabriel Redel-Traub has disclosed no relevant financial relationships.

This article first appeared on Medscape.com.

In the wake of the 2012 shooting at Sandy Hook Elementary, in Newtown, Conn., after 20 children and seven adults were murdered, American gun sales surged on fears of new restrictions.

Bytmonas/ThinkStock

In the ensuing months, 20 more children and 40 more adults died from unintentional shootings believed to be tied to that surge in gun purchases.¹ More recently, American gun sales surged in response to the COVID-19 pandemic with heated legal battles brewing over whether gun sales are essential.^2,3 The results of this surge in sales are yet to fully manifest, but I would like to discuss several risks.

The public health risks of firearm access are well established: Nearly every measure of harm, from suicide to negligent injury and death to homicide to shootings of police, increase along with access to firearms.⁴ That firearms in the home are associated with greater likelihoods of suicide, negligent injury and death, and intrafamilial homicide has been recognized for decades as has the substantially heightened risk in the immediate period after a firearm is brought into the home.^5,6 Defensive gun use is rare despite this being the nominal reason for firearm ownership among many.⁷ Even prior to recent events, there had been concerns of increased unsafe carrying and handling of firearms.⁸ It seems reasonable to expect such trends not to be diminished by recent events.

Added to this are several stressors, which one can reasonably expect to be associated with increased risks for unsafe use. There are new, broad social stressors from fear and uncertainty about COVID-19. Unemployment rates have skyrocketed, clinical care has been disrupted, and basic necessities have become scant. Children are home from school, unable to play with friends and unable to access mental health services as easily as before; risks of negligent and suicidal injuries and death may ensue. Couples and families are isolated in homes together for longer periods and with fewer avenues for relief; previously peaceful homes may see conflicts increase and homes with abuse have now trapped victims with their assailants. Social isolation is difficult for any person and may be even more traumatic for people with underlying vulnerabilities, including mental illness. The risks of being isolated in a home – struggling with worsening symptoms – with ready access to a firearm are self-evident.

For mental health professionals in our current situation, I would like to offer several practical ways we can intervene with patients and clients who might own firearms.

• Consider reassessing for firearm access. Patients may be in new homes, or there may be new firearms in their homes. Use gentle assumptions and focus on home access over personal access to elicit the most true, positive answers, for example: “I understand there have been a lot of changes recently; how many guns are in the home now?”
• Reinforce safer storage practices. Simple measures, such as storing ammunition separately and using trigger locks or safes, can make a substantial difference in injury risks.
• Do not forget aging clients; suicide risk increases with age, and there may be substantial risks among the geriatric population for suicide and murder-suicide. If using telepsychiatry, realize that the abuser might be in the home or within earshot of any clinical encounter, and this might put the client at heightened risk, during and after telesessions.
• Highlight access to local and national resources, including the Disaster Distress Hotline (800-985-5990) and the National Suicide Prevention Lifeline (800-273-TALK). Promote both numbers, and note that some people may be more comfortable reaching out for help for “distress” than for “suicide.”

References

1. Levine PB and McKnight R. Science. 2017 Dec 8;358(6368):1324-8.

2. Levin D. “Coronavirus and firearms: Are gun shops essential businesses?” The New York Times. 2020 Mar 25.

3. Robertson L. “Neither hurricanes nor 9/11 caused as big a surge in gun sales as coronavirus.” Miami Herald. 2020 Mar 25.

4. Moyer MW. Scientific American. 2017 Oct;317(4):54-63.

5. Kellermann AL et al. J Trauma. 1998 Aug;45(2):263-7.

6. Wintemute GJ et al. New Engl J Med. 1999 Nov 18;341(21):1583-9.

7. Firearm Justifiable Homicides and Non-Fatal Self-Defense Gun Use: An Analysis of Federal Bureau of Investigation and National Crime Victimization Survey Data. Washington: Violence Policy Center; 2019 Jul.

8. Towers S et al. bioRxiv. 2019 Apr 18;613687.
 

Dr. Rozel is the medical director of resolve Crisis Services at UPMC Western Psychiatric Hospital and president of the American Association for Emergency Psychiatry. He also is associate professor of psychiatry and an adjunct professor of law at the University of Pittsburgh. He has no conflicts of interest but has worked for a gun dealer to teach sales staff how to recognize people in crisis (rather than sell a gun).

In the wake of the 2012 shooting at Sandy Hook Elementary, in Newtown, Conn., after 20 children and seven adults were murdered, American gun sales surged on fears of new restrictions.

Bytmonas/ThinkStock

In the ensuing months, 20 more children and 40 more adults died from unintentional shootings believed to be tied to that surge in gun purchases.¹ More recently, American gun sales surged in response to the COVID-19 pandemic with heated legal battles brewing over whether gun sales are essential.^2,3 The results of this surge in sales are yet to fully manifest, but I would like to discuss several risks.

The public health risks of firearm access are well established: Nearly every measure of harm, from suicide to negligent injury and death to homicide to shootings of police, increase along with access to firearms.⁴ That firearms in the home are associated with greater likelihoods of suicide, negligent injury and death, and intrafamilial homicide has been recognized for decades as has the substantially heightened risk in the immediate period after a firearm is brought into the home.^5,6 Defensive gun use is rare despite this being the nominal reason for firearm ownership among many.⁷ Even prior to recent events, there had been concerns of increased unsafe carrying and handling of firearms.⁸ It seems reasonable to expect such trends not to be diminished by recent events.

Added to this are several stressors, which one can reasonably expect to be associated with increased risks for unsafe use. There are new, broad social stressors from fear and uncertainty about COVID-19. Unemployment rates have skyrocketed, clinical care has been disrupted, and basic necessities have become scant. Children are home from school, unable to play with friends and unable to access mental health services as easily as before; risks of negligent and suicidal injuries and death may ensue. Couples and families are isolated in homes together for longer periods and with fewer avenues for relief; previously peaceful homes may see conflicts increase and homes with abuse have now trapped victims with their assailants. Social isolation is difficult for any person and may be even more traumatic for people with underlying vulnerabilities, including mental illness. The risks of being isolated in a home – struggling with worsening symptoms – with ready access to a firearm are self-evident.

For mental health professionals in our current situation, I would like to offer several practical ways we can intervene with patients and clients who might own firearms.

• Consider reassessing for firearm access. Patients may be in new homes, or there may be new firearms in their homes. Use gentle assumptions and focus on home access over personal access to elicit the most true, positive answers, for example: “I understand there have been a lot of changes recently; how many guns are in the home now?”
• Reinforce safer storage practices. Simple measures, such as storing ammunition separately and using trigger locks or safes, can make a substantial difference in injury risks.
• Do not forget aging clients; suicide risk increases with age, and there may be substantial risks among the geriatric population for suicide and murder-suicide. If using telepsychiatry, realize that the abuser might be in the home or within earshot of any clinical encounter, and this might put the client at heightened risk, during and after telesessions.
• Highlight access to local and national resources, including the Disaster Distress Hotline (800-985-5990) and the National Suicide Prevention Lifeline (800-273-TALK). Promote both numbers, and note that some people may be more comfortable reaching out for help for “distress” than for “suicide.”

References

1. Levine PB and McKnight R. Science. 2017 Dec 8;358(6368):1324-8.

2. Levin D. “Coronavirus and firearms: Are gun shops essential businesses?” The New York Times. 2020 Mar 25.

3. Robertson L. “Neither hurricanes nor 9/11 caused as big a surge in gun sales as coronavirus.” Miami Herald. 2020 Mar 25.

4. Moyer MW. Scientific American. 2017 Oct;317(4):54-63.

5. Kellermann AL et al. J Trauma. 1998 Aug;45(2):263-7.

6. Wintemute GJ et al. New Engl J Med. 1999 Nov 18;341(21):1583-9.

7. Firearm Justifiable Homicides and Non-Fatal Self-Defense Gun Use: An Analysis of Federal Bureau of Investigation and National Crime Victimization Survey Data. Washington: Violence Policy Center; 2019 Jul.

8. Towers S et al. bioRxiv. 2019 Apr 18;613687.
 

Dr. Rozel is the medical director of resolve Crisis Services at UPMC Western Psychiatric Hospital and president of the American Association for Emergency Psychiatry. He also is associate professor of psychiatry and an adjunct professor of law at the University of Pittsburgh. He has no conflicts of interest but has worked for a gun dealer to teach sales staff how to recognize people in crisis (rather than sell a gun).

In the wake of the 2012 shooting at Sandy Hook Elementary, in Newtown, Conn., after 20 children and seven adults were murdered, American gun sales surged on fears of new restrictions.

Bytmonas/ThinkStock

In the ensuing months, 20 more children and 40 more adults died from unintentional shootings believed to be tied to that surge in gun purchases.¹ More recently, American gun sales surged in response to the COVID-19 pandemic with heated legal battles brewing over whether gun sales are essential.^2,3 The results of this surge in sales are yet to fully manifest, but I would like to discuss several risks.

The public health risks of firearm access are well established: Nearly every measure of harm, from suicide to negligent injury and death to homicide to shootings of police, increase along with access to firearms.⁴ That firearms in the home are associated with greater likelihoods of suicide, negligent injury and death, and intrafamilial homicide has been recognized for decades as has the substantially heightened risk in the immediate period after a firearm is brought into the home.^5,6 Defensive gun use is rare despite this being the nominal reason for firearm ownership among many.⁷ Even prior to recent events, there had been concerns of increased unsafe carrying and handling of firearms.⁸ It seems reasonable to expect such trends not to be diminished by recent events.

Added to this are several stressors, which one can reasonably expect to be associated with increased risks for unsafe use. There are new, broad social stressors from fear and uncertainty about COVID-19. Unemployment rates have skyrocketed, clinical care has been disrupted, and basic necessities have become scant. Children are home from school, unable to play with friends and unable to access mental health services as easily as before; risks of negligent and suicidal injuries and death may ensue. Couples and families are isolated in homes together for longer periods and with fewer avenues for relief; previously peaceful homes may see conflicts increase and homes with abuse have now trapped victims with their assailants. Social isolation is difficult for any person and may be even more traumatic for people with underlying vulnerabilities, including mental illness. The risks of being isolated in a home – struggling with worsening symptoms – with ready access to a firearm are self-evident.

For mental health professionals in our current situation, I would like to offer several practical ways we can intervene with patients and clients who might own firearms.

• Consider reassessing for firearm access. Patients may be in new homes, or there may be new firearms in their homes. Use gentle assumptions and focus on home access over personal access to elicit the most true, positive answers, for example: “I understand there have been a lot of changes recently; how many guns are in the home now?”
• Reinforce safer storage practices. Simple measures, such as storing ammunition separately and using trigger locks or safes, can make a substantial difference in injury risks.
• Do not forget aging clients; suicide risk increases with age, and there may be substantial risks among the geriatric population for suicide and murder-suicide. If using telepsychiatry, realize that the abuser might be in the home or within earshot of any clinical encounter, and this might put the client at heightened risk, during and after telesessions.
• Highlight access to local and national resources, including the Disaster Distress Hotline (800-985-5990) and the National Suicide Prevention Lifeline (800-273-TALK). Promote both numbers, and note that some people may be more comfortable reaching out for help for “distress” than for “suicide.”

References

1. Levine PB and McKnight R. Science. 2017 Dec 8;358(6368):1324-8.

2. Levin D. “Coronavirus and firearms: Are gun shops essential businesses?” The New York Times. 2020 Mar 25.

3. Robertson L. “Neither hurricanes nor 9/11 caused as big a surge in gun sales as coronavirus.” Miami Herald. 2020 Mar 25.

4. Moyer MW. Scientific American. 2017 Oct;317(4):54-63.

5. Kellermann AL et al. J Trauma. 1998 Aug;45(2):263-7.

6. Wintemute GJ et al. New Engl J Med. 1999 Nov 18;341(21):1583-9.

7. Firearm Justifiable Homicides and Non-Fatal Self-Defense Gun Use: An Analysis of Federal Bureau of Investigation and National Crime Victimization Survey Data. Washington: Violence Policy Center; 2019 Jul.

8. Towers S et al. bioRxiv. 2019 Apr 18;613687.
 

Dr. Rozel is the medical director of resolve Crisis Services at UPMC Western Psychiatric Hospital and president of the American Association for Emergency Psychiatry. He also is associate professor of psychiatry and an adjunct professor of law at the University of Pittsburgh. He has no conflicts of interest but has worked for a gun dealer to teach sales staff how to recognize people in crisis (rather than sell a gun).

Gene Kranz was the NASA Flight Director during the Gemini and Apollo space flights, including Apollo 11 (moon landing) and Apollo 13. He has written: “When bad things happened, we just calmly laid out all the options and failure was not one of them. We never panicked and we never gave up on finding a solution.”

2019-nCoV (coronavirus, COVID-19) will define this generation of health care providers. First identified in Wuhan, China, in December 2019 and first appearing in the United States on January 19, 2020 (NEJM 2020;382:929). COVID-19 is a coronavirus similar to SARS and MERS. The U.S. Surgeon General and multiple endoscopy societies have recommended (strongly) that elective surgical and endoscopy procedures be deferred. Availability of testing has been slow, but many centers now have developed testing capabilities (including drive-through testing) with 6-hour result turnaround. We do not know the full pathophysiology, R₀ (number of secondary cases attributed to an index infection), ease of community transmission, risk to providers, definition of people at high risk (for both acquisition and complications), and much key information n to base recommendations.

Health system and practice leaders do not yet have sufficient information to know which patients to defer, which patients should still be seen, visitor policies, how to segregate waiting rooms, or how to protect providers. Despite a lack of definitive knowledge, we must make critical decisions and know that recommendations can change hourly. As the Chief Clinical Officer at Michigan Medicine, I am spending 16 hours a day immersed in these decisions and find that one of my critical jobs is to keep people from panicking.

Schools, bars, restaurants, churches and other public gathering places are closing. Three countries (to date) have instituted complete quarantine. Digestive Disease Week^® has been cancelled. We are entering a time in which normal life is altered and many changes will open up our thinking about long-term alternative processes.

COVID-19 will define this generation. The public will understand the real need for science, policies based on real facts, robust public health systems, and leaders who inspire confidence based on expert guidance. And, I believe we will see gastroenterologists, health systems, hospitals, and practices all showing us what our “finest hours” look like.
 

John I. Allen, MD, MBA, AGAF
Editor in Chief

Gene Kranz was the NASA Flight Director during the Gemini and Apollo space flights, including Apollo 11 (moon landing) and Apollo 13. He has written: “When bad things happened, we just calmly laid out all the options and failure was not one of them. We never panicked and we never gave up on finding a solution.”

2019-nCoV (coronavirus, COVID-19) will define this generation of health care providers. First identified in Wuhan, China, in December 2019 and first appearing in the United States on January 19, 2020 (NEJM 2020;382:929). COVID-19 is a coronavirus similar to SARS and MERS. The U.S. Surgeon General and multiple endoscopy societies have recommended (strongly) that elective surgical and endoscopy procedures be deferred. Availability of testing has been slow, but many centers now have developed testing capabilities (including drive-through testing) with 6-hour result turnaround. We do not know the full pathophysiology, R₀ (number of secondary cases attributed to an index infection), ease of community transmission, risk to providers, definition of people at high risk (for both acquisition and complications), and much key information n to base recommendations.

Health system and practice leaders do not yet have sufficient information to know which patients to defer, which patients should still be seen, visitor policies, how to segregate waiting rooms, or how to protect providers. Despite a lack of definitive knowledge, we must make critical decisions and know that recommendations can change hourly. As the Chief Clinical Officer at Michigan Medicine, I am spending 16 hours a day immersed in these decisions and find that one of my critical jobs is to keep people from panicking.

Schools, bars, restaurants, churches and other public gathering places are closing. Three countries (to date) have instituted complete quarantine. Digestive Disease Week^® has been cancelled. We are entering a time in which normal life is altered and many changes will open up our thinking about long-term alternative processes.

COVID-19 will define this generation. The public will understand the real need for science, policies based on real facts, robust public health systems, and leaders who inspire confidence based on expert guidance. And, I believe we will see gastroenterologists, health systems, hospitals, and practices all showing us what our “finest hours” look like.
 

John I. Allen, MD, MBA, AGAF
Editor in Chief

Gene Kranz was the NASA Flight Director during the Gemini and Apollo space flights, including Apollo 11 (moon landing) and Apollo 13. He has written: “When bad things happened, we just calmly laid out all the options and failure was not one of them. We never panicked and we never gave up on finding a solution.”

2019-nCoV (coronavirus, COVID-19) will define this generation of health care providers. First identified in Wuhan, China, in December 2019 and first appearing in the United States on January 19, 2020 (NEJM 2020;382:929). COVID-19 is a coronavirus similar to SARS and MERS. The U.S. Surgeon General and multiple endoscopy societies have recommended (strongly) that elective surgical and endoscopy procedures be deferred. Availability of testing has been slow, but many centers now have developed testing capabilities (including drive-through testing) with 6-hour result turnaround. We do not know the full pathophysiology, R₀ (number of secondary cases attributed to an index infection), ease of community transmission, risk to providers, definition of people at high risk (for both acquisition and complications), and much key information n to base recommendations.

Health system and practice leaders do not yet have sufficient information to know which patients to defer, which patients should still be seen, visitor policies, how to segregate waiting rooms, or how to protect providers. Despite a lack of definitive knowledge, we must make critical decisions and know that recommendations can change hourly. As the Chief Clinical Officer at Michigan Medicine, I am spending 16 hours a day immersed in these decisions and find that one of my critical jobs is to keep people from panicking.

Schools, bars, restaurants, churches and other public gathering places are closing. Three countries (to date) have instituted complete quarantine. Digestive Disease Week^® has been cancelled. We are entering a time in which normal life is altered and many changes will open up our thinking about long-term alternative processes.

COVID-19 will define this generation. The public will understand the real need for science, policies based on real facts, robust public health systems, and leaders who inspire confidence based on expert guidance. And, I believe we will see gastroenterologists, health systems, hospitals, and practices all showing us what our “finest hours” look like.
 

John I. Allen, MD, MBA, AGAF
Editor in Chief

I am writing this editorial on a beautiful day in the high desert of the Southwest: a bright blue clear sky such as you see only in the mountain air, a sun warm and comforting, and birds singing as if they had not a care in the world. Spring has come early as if to dramatize the cognitive dissonance between this idyllic scene and a seemingly invincible winter of disease and death that has gripped the globe.

For now, my editorials will focus on the most threatening infectious disease outbreak since, perhaps, 1918. I have been teaching public health and pandemic ethics to health care professionals and trainees for more than a decade. I always tell the medical students, “it is not if but when” the next viral wave overwhelms society. It is human nature to disbelieve this inevitability and to ignore, dismiss, or even attack the infectious disease experts and science journalists who, like Cassandra, warn us of the return of the plague.¹

In the early 2000s, virologists were concerned that Avian influenza with a mortality rate of > 60% would mutate into a virus capable of jumping the species barrier with sustained human transmission; however, that threat has not materialized (yet).² Instead, in 2009 the H1N1 influenza pandemic struck viciously. The always capricious genetic mutations of viral combinations outwitted vaccine manufacturers, offering little protection, resulting in an estimated 12,469 deaths, tragically many of them children, young, and middle-aged people.³ In between, there were periodic eruptions of the deadly Ebola virus in Africa. In 2014, 11 Americans who had either served as health care workers or traveled in the region were treated in the US.⁴

This much abridged survey of recent pandemics reminds us of how wrong were those who returning victorious from World War II with newly developed antibiotics and at the zenith of American military medicine argued that we would also beat infectious disease.⁵ As my Army pediatrician father would tell me, “the bugs will always be smarter than the drugs.” For now, COVID-19 is outwitting those in science and medicine who are engaged in a desperate race to discover a vaccine or a drug to “stop the virus in its tracks” as the media is so fond of saying.⁶ Irresponsible news outlets are giving a panicked citizenry false hope. Experts recently testified before the US House of Representatives that according to the most optimistic estimates, a vaccine is a year away.⁷ Yet information is a double-edged sword, as the Internet also is able to communicate accurate lifesaving information from the Centers of Disease Control and Prevention and state health departments with unprecedented speed and reach.

The best chance for civilization to “flatten the curve” of the pandemic is, as it has been so many times before, through precautionary measures and preventive public health efforts. There is a reason that in 2007, readers of the prestigious British Journal of Medicine ranked public health interventions as the most important advances in medical history.⁸

The initial installment of this pandemic series will offer a primer in public health ethics. Just as almost everything else in daily life has rapidly and radically changed, from cancelled church services to school closures, so too public health ethics is significantly different in many important aspects from the clinical health ethics we are accustomed to in our practice.

The first difference is focus. In clinical health ethics the focus of the individual health care practitioner is the individual patient, but public health ethics focuses on “what we as a society do to keep people healthy.”⁹ In a pandemic when decisions must be made (to paraphrase Mr. Spock) “for the good of the many” this creates an intrinsic ethical tension for the health care practitioner whose ethos is to advocate for his or her patient.

The second difference is that in order to accomplish these communitarian aims, the law and political and cultural factors have much more influence in medical decision making than within the ideal dyad of a health care practitioner and the patient engaged in shared decision making about the patient’s health. This is nowhere more evident than in the President’s recent declaration of a public health emergency. “The Federal Government, along with State and Local governments, has taken preventive and proactive measures to slow the spread of the virus and treat those affected. . .”¹⁰ Federal and state governments can exercise wide-ranging powers that can restrict individual liberties in ways that would never be legal or ethically justifiable in the course of routine clinical care.

The third difference relates to the ethical principles that guide public health care decision making in comparison with those of clinical ethics. The primacy of autonomy in modern American medical ethics must for the health of the public sometimes yield to the overarching goal of preventing serious harm to the public and mitigating the transmission of the infection. Values such as nonmaleficence and justice become even more important than individual self-determination especially as the pandemic worsens and the demand for scarce ventilators and other life-saving resources outstrips the supply.¹¹

The fourth difference is that in nonemergent care, whether in the clinic or the hospital, the health care provider bears the primary responsibility for making decisions. Practitioners bring their knowledge and experience and patients their values and preferences to arrive at a mutually acceptable treatment plan. In stark contrast the profound and tragic life and death decisions made in a pandemic should not be left to the individual clinician who to the degree possible should remain faithful to the individual patient’s interests to preserve his or her professional integrity. Instead, decisions should be in the hands of highly trained and respected committees with diverse membership and expertise in accordance with evidence-based scientific protocols that are in response to changing pandemic conditions and the best available evidence. This process ensures that the values of consistency, transparency, and fairness which take center place in a public health emergency are the moral basis of decisions rather than ad hoc decisions that risk bias and inequity especially regarding vulnerable populations.¹¹

There is one characteristic of medical decision making that does not change whether in a routine checkup or resource allocation in an intensive care unit in a pandemic: the need to respect individual human dignity and to show compassion for the suffering of those who will not survive. In the Star Trek episode “Wrath of Khan,” Spock sacrificed himself to save his ship, his comrades, and his friends who mourned his death and honored his life.

I am writing this editorial on a beautiful day in the high desert of the Southwest: a bright blue clear sky such as you see only in the mountain air, a sun warm and comforting, and birds singing as if they had not a care in the world. Spring has come early as if to dramatize the cognitive dissonance between this idyllic scene and a seemingly invincible winter of disease and death that has gripped the globe.

For now, my editorials will focus on the most threatening infectious disease outbreak since, perhaps, 1918. I have been teaching public health and pandemic ethics to health care professionals and trainees for more than a decade. I always tell the medical students, “it is not if but when” the next viral wave overwhelms society. It is human nature to disbelieve this inevitability and to ignore, dismiss, or even attack the infectious disease experts and science journalists who, like Cassandra, warn us of the return of the plague.¹

In the early 2000s, virologists were concerned that Avian influenza with a mortality rate of > 60% would mutate into a virus capable of jumping the species barrier with sustained human transmission; however, that threat has not materialized (yet).² Instead, in 2009 the H1N1 influenza pandemic struck viciously. The always capricious genetic mutations of viral combinations outwitted vaccine manufacturers, offering little protection, resulting in an estimated 12,469 deaths, tragically many of them children, young, and middle-aged people.³ In between, there were periodic eruptions of the deadly Ebola virus in Africa. In 2014, 11 Americans who had either served as health care workers or traveled in the region were treated in the US.⁴

This much abridged survey of recent pandemics reminds us of how wrong were those who returning victorious from World War II with newly developed antibiotics and at the zenith of American military medicine argued that we would also beat infectious disease.⁵ As my Army pediatrician father would tell me, “the bugs will always be smarter than the drugs.” For now, COVID-19 is outwitting those in science and medicine who are engaged in a desperate race to discover a vaccine or a drug to “stop the virus in its tracks” as the media is so fond of saying.⁶ Irresponsible news outlets are giving a panicked citizenry false hope. Experts recently testified before the US House of Representatives that according to the most optimistic estimates, a vaccine is a year away.⁷ Yet information is a double-edged sword, as the Internet also is able to communicate accurate lifesaving information from the Centers of Disease Control and Prevention and state health departments with unprecedented speed and reach.

The best chance for civilization to “flatten the curve” of the pandemic is, as it has been so many times before, through precautionary measures and preventive public health efforts. There is a reason that in 2007, readers of the prestigious British Journal of Medicine ranked public health interventions as the most important advances in medical history.⁸

The initial installment of this pandemic series will offer a primer in public health ethics. Just as almost everything else in daily life has rapidly and radically changed, from cancelled church services to school closures, so too public health ethics is significantly different in many important aspects from the clinical health ethics we are accustomed to in our practice.

The first difference is focus. In clinical health ethics the focus of the individual health care practitioner is the individual patient, but public health ethics focuses on “what we as a society do to keep people healthy.”⁹ In a pandemic when decisions must be made (to paraphrase Mr. Spock) “for the good of the many” this creates an intrinsic ethical tension for the health care practitioner whose ethos is to advocate for his or her patient.

The second difference is that in order to accomplish these communitarian aims, the law and political and cultural factors have much more influence in medical decision making than within the ideal dyad of a health care practitioner and the patient engaged in shared decision making about the patient’s health. This is nowhere more evident than in the President’s recent declaration of a public health emergency. “The Federal Government, along with State and Local governments, has taken preventive and proactive measures to slow the spread of the virus and treat those affected. . .”¹⁰ Federal and state governments can exercise wide-ranging powers that can restrict individual liberties in ways that would never be legal or ethically justifiable in the course of routine clinical care.

The third difference relates to the ethical principles that guide public health care decision making in comparison with those of clinical ethics. The primacy of autonomy in modern American medical ethics must for the health of the public sometimes yield to the overarching goal of preventing serious harm to the public and mitigating the transmission of the infection. Values such as nonmaleficence and justice become even more important than individual self-determination especially as the pandemic worsens and the demand for scarce ventilators and other life-saving resources outstrips the supply.¹¹

The fourth difference is that in nonemergent care, whether in the clinic or the hospital, the health care provider bears the primary responsibility for making decisions. Practitioners bring their knowledge and experience and patients their values and preferences to arrive at a mutually acceptable treatment plan. In stark contrast the profound and tragic life and death decisions made in a pandemic should not be left to the individual clinician who to the degree possible should remain faithful to the individual patient’s interests to preserve his or her professional integrity. Instead, decisions should be in the hands of highly trained and respected committees with diverse membership and expertise in accordance with evidence-based scientific protocols that are in response to changing pandemic conditions and the best available evidence. This process ensures that the values of consistency, transparency, and fairness which take center place in a public health emergency are the moral basis of decisions rather than ad hoc decisions that risk bias and inequity especially regarding vulnerable populations.¹¹

There is one characteristic of medical decision making that does not change whether in a routine checkup or resource allocation in an intensive care unit in a pandemic: the need to respect individual human dignity and to show compassion for the suffering of those who will not survive. In the Star Trek episode “Wrath of Khan,” Spock sacrificed himself to save his ship, his comrades, and his friends who mourned his death and honored his life.

I am writing this editorial on a beautiful day in the high desert of the Southwest: a bright blue clear sky such as you see only in the mountain air, a sun warm and comforting, and birds singing as if they had not a care in the world. Spring has come early as if to dramatize the cognitive dissonance between this idyllic scene and a seemingly invincible winter of disease and death that has gripped the globe.

For now, my editorials will focus on the most threatening infectious disease outbreak since, perhaps, 1918. I have been teaching public health and pandemic ethics to health care professionals and trainees for more than a decade. I always tell the medical students, “it is not if but when” the next viral wave overwhelms society. It is human nature to disbelieve this inevitability and to ignore, dismiss, or even attack the infectious disease experts and science journalists who, like Cassandra, warn us of the return of the plague.¹

In the early 2000s, virologists were concerned that Avian influenza with a mortality rate of > 60% would mutate into a virus capable of jumping the species barrier with sustained human transmission; however, that threat has not materialized (yet).² Instead, in 2009 the H1N1 influenza pandemic struck viciously. The always capricious genetic mutations of viral combinations outwitted vaccine manufacturers, offering little protection, resulting in an estimated 12,469 deaths, tragically many of them children, young, and middle-aged people.³ In between, there were periodic eruptions of the deadly Ebola virus in Africa. In 2014, 11 Americans who had either served as health care workers or traveled in the region were treated in the US.⁴

This much abridged survey of recent pandemics reminds us of how wrong were those who returning victorious from World War II with newly developed antibiotics and at the zenith of American military medicine argued that we would also beat infectious disease.⁵ As my Army pediatrician father would tell me, “the bugs will always be smarter than the drugs.” For now, COVID-19 is outwitting those in science and medicine who are engaged in a desperate race to discover a vaccine or a drug to “stop the virus in its tracks” as the media is so fond of saying.⁶ Irresponsible news outlets are giving a panicked citizenry false hope. Experts recently testified before the US House of Representatives that according to the most optimistic estimates, a vaccine is a year away.⁷ Yet information is a double-edged sword, as the Internet also is able to communicate accurate lifesaving information from the Centers of Disease Control and Prevention and state health departments with unprecedented speed and reach.

The best chance for civilization to “flatten the curve” of the pandemic is, as it has been so many times before, through precautionary measures and preventive public health efforts. There is a reason that in 2007, readers of the prestigious British Journal of Medicine ranked public health interventions as the most important advances in medical history.⁸

The initial installment of this pandemic series will offer a primer in public health ethics. Just as almost everything else in daily life has rapidly and radically changed, from cancelled church services to school closures, so too public health ethics is significantly different in many important aspects from the clinical health ethics we are accustomed to in our practice.

The first difference is focus. In clinical health ethics the focus of the individual health care practitioner is the individual patient, but public health ethics focuses on “what we as a society do to keep people healthy.”⁹ In a pandemic when decisions must be made (to paraphrase Mr. Spock) “for the good of the many” this creates an intrinsic ethical tension for the health care practitioner whose ethos is to advocate for his or her patient.

The second difference is that in order to accomplish these communitarian aims, the law and political and cultural factors have much more influence in medical decision making than within the ideal dyad of a health care practitioner and the patient engaged in shared decision making about the patient’s health. This is nowhere more evident than in the President’s recent declaration of a public health emergency. “The Federal Government, along with State and Local governments, has taken preventive and proactive measures to slow the spread of the virus and treat those affected. . .”¹⁰ Federal and state governments can exercise wide-ranging powers that can restrict individual liberties in ways that would never be legal or ethically justifiable in the course of routine clinical care.

The third difference relates to the ethical principles that guide public health care decision making in comparison with those of clinical ethics. The primacy of autonomy in modern American medical ethics must for the health of the public sometimes yield to the overarching goal of preventing serious harm to the public and mitigating the transmission of the infection. Values such as nonmaleficence and justice become even more important than individual self-determination especially as the pandemic worsens and the demand for scarce ventilators and other life-saving resources outstrips the supply.¹¹

The fourth difference is that in nonemergent care, whether in the clinic or the hospital, the health care provider bears the primary responsibility for making decisions. Practitioners bring their knowledge and experience and patients their values and preferences to arrive at a mutually acceptable treatment plan. In stark contrast the profound and tragic life and death decisions made in a pandemic should not be left to the individual clinician who to the degree possible should remain faithful to the individual patient’s interests to preserve his or her professional integrity. Instead, decisions should be in the hands of highly trained and respected committees with diverse membership and expertise in accordance with evidence-based scientific protocols that are in response to changing pandemic conditions and the best available evidence. This process ensures that the values of consistency, transparency, and fairness which take center place in a public health emergency are the moral basis of decisions rather than ad hoc decisions that risk bias and inequity especially regarding vulnerable populations.¹¹

There is one characteristic of medical decision making that does not change whether in a routine checkup or resource allocation in an intensive care unit in a pandemic: the need to respect individual human dignity and to show compassion for the suffering of those who will not survive. In the Star Trek episode “Wrath of Khan,” Spock sacrificed himself to save his ship, his comrades, and his friends who mourned his death and honored his life.

The COVID-19 pandemic is an experience that is unprecedented in our lifetime. It is having a pervasive effect due to how mysterious, potentially dangerous, and sustained it is. We don’t know how bad it’s going to get or how long it’s going to last. We have natural disasters like hurricanes and earthquakes, but they are limited in time and scope. But this global pandemic is something we can’t put our arms around just yet, breeding uncertainty, worry, and fear. This is where mental health professionals need to come in.

The populations being affected by this pandemic can be placed into different groups on the basis of their mental health consequences and needs. First you have, for lack of a better term, “the worried well.” These are people with no preexisting mental disorder who are naturally worried by this and are trying to take appropriate actions to protect themselves and prepare. For such individuals, the equivalent of mental health first-aid should be useful (we’ll come back to that in a moment). Given the proper guidance and sources of information, most such people should be able to manage the anxiety, worry, and dysphoria associated with this critical pandemic.

Then there are those who have preexisting mental conditions related to mood, anxiety, stress, or obsessive tendencies. They are probably going to have an increase in their symptoms, and as such, a corresponding need for adjusting treatment. This may require an increase in their existing medications or the addition of an ad hoc medication, or perhaps more frequent contact with their doctor or therapist.

Because travel and direct visitation is discouraged at the moment, virtual methods of communication should be used to speak with these patients. Such methods have long existed but haven’t been adopted in large numbers; this may be the impetus to finally make it happen. Using the telephone, FaceTime, Skype, WebEx, Zoom, and other means of videoconferencing should be feasible. As billing procedures are being adapted for this moment, there’s no reason why individuals shouldn’t be able to contact their mental health provider.

Substance abuse is also a condition vulnerable to the stress effects of this pandemic. This will prompt or tempt those to use substances that they’ve abused or turned to in the past as a way of self-medicating and assuaging their anxiety and worry.

Interestingly, people with serious mental illnesses, such as schizophrenia and nonaffective and affective psychoses, seem to be less vulnerable to the stress-inducing effects of catastrophe. It’s possible that the pandemic could find its way into delusions or exacerbate symptoms, but somewhat paradoxically, people with serious mental illnesses often respond more calmly to crises than do individuals without them. As a result, the number of these patients requiring emergency room admission for possible exacerbation of symptoms is probably not going to be that much greater than normal.

How to Cope With an Unprecedented Situation

For the worried well and for the clinicians who have understandable fears about exposure, there are several things you can try to manage your anxiety. There are concentric circles of concern that you have to maintain. Think of it like the instructions on an airplane when, if there’s a drop in cabin pressure, you’re asked to apply your own oxygen mask first before placing one on your child. In the same way, you must first think about protecting yourself by limiting your exposure and monitoring your own physical state for any symptoms. But then you must be concerned about your family, your friends, and also society. This is a situation where the impulse and the ethos of worrying about your fellow persons—being your brother’s keeper—is imperative.

The epidemic has been successfully managed in some countries, like Singapore and China, which, once they got on top of it, were able to limit contagion in a very dramatic way. But these are authoritarian governments. The United States doesn’t work that way, which is what makes appealing to the principle of caring for others so crucial. You can protect yourself, but if other people aren’t also protected, it may not matter. You have to worry not just about yourself but about everyone else.

When it comes to stress management, I recommend not catastrophizing or watching the news media 24/7. Distract yourself with other work or recreational activities. Reach out and communicate—virtually, of course—with friends, family, and healthcare providers as needed. Staying in touch acts not just as a diversion but also as an outlet for assuaging your feelings, your sense of being in this alone, feeling isolated.

There are also cognitive reframing mechanisms you can employ. Consider that although this is bad, some countries have already gone through it. And we’ll get through it too. You’ll understandably ask yourself what it would mean if you were to be exposed. In most cases you can say, “I’m going to have the flu and symptoms that are not going to be pleasant, but I’ve had the flu or serious sickness before.”

Remember that there are already antiretroviral treatments being tested in clinical trials and showing efficacy. It’s good to know that before this pandemic ends, some of these treatments will probably be clinically applied, mostly to those who are severely affected and in intensive care.

Diagnose yourself. Monitor your state. Determine whether the stress is really having an impact on you. Is it affecting your sleep, appetite, concentration, mood? And if you do have a preexisting psychiatric condition, don’t feel afraid to reach out to your mental health provider. Understand that you’re going to be anxious, which may aggravate your symptoms and require an adjustment in your treatment. That’s okay. It’s to be expected and your provider should be available to help you.

Controlling this outbreak via the same epidemiologic infectious disease prevention guidance that works in authoritarian societies is not going to be applicable here because of the liberties that we experience in American society. What will determine our success is the belief that we’re in this together, that we’re going to help each other. We should be proud of that, as it shows how Americans and people around the world stand up in situations like this.

Let’s also note that even though everybody is affected and undergoing previously unimaginable levels of anticipated stress and dislocation, it’s the healthcare providers who are really on the frontlines. They’re under tremendous pressure to continue to perform heroically, at great risk to themselves. They deserve a real debt of gratitude.

We will get through this, but as we do, it will not end until we’ve undergone an extreme test of our character. I certainly hope and trust that we will be up to it.

Dr. Jeffrey A. Lieberman is chairman of the Department of Psychiatry at Columbia University. He is a former president of the American Psychiatric Association.

Disclosure: Jeffrey A. Lieberman, MD, has disclosed the following relevant financial relationships: Served as a director, officer, partner, employee, advisor, consultant, or trustee for Clintara; Intracellular Therapies. Received research grant from Alkermes; Biomarin; EnVivo/Forum; Genentech; Novartis/Novation; Sunovion. Patent: Repligen.

This article first appeared on Medscape.com.

The COVID-19 pandemic is an experience that is unprecedented in our lifetime. It is having a pervasive effect due to how mysterious, potentially dangerous, and sustained it is. We don’t know how bad it’s going to get or how long it’s going to last. We have natural disasters like hurricanes and earthquakes, but they are limited in time and scope. But this global pandemic is something we can’t put our arms around just yet, breeding uncertainty, worry, and fear. This is where mental health professionals need to come in.

The populations being affected by this pandemic can be placed into different groups on the basis of their mental health consequences and needs. First you have, for lack of a better term, “the worried well.” These are people with no preexisting mental disorder who are naturally worried by this and are trying to take appropriate actions to protect themselves and prepare. For such individuals, the equivalent of mental health first-aid should be useful (we’ll come back to that in a moment). Given the proper guidance and sources of information, most such people should be able to manage the anxiety, worry, and dysphoria associated with this critical pandemic.

Then there are those who have preexisting mental conditions related to mood, anxiety, stress, or obsessive tendencies. They are probably going to have an increase in their symptoms, and as such, a corresponding need for adjusting treatment. This may require an increase in their existing medications or the addition of an ad hoc medication, or perhaps more frequent contact with their doctor or therapist.

Because travel and direct visitation is discouraged at the moment, virtual methods of communication should be used to speak with these patients. Such methods have long existed but haven’t been adopted in large numbers; this may be the impetus to finally make it happen. Using the telephone, FaceTime, Skype, WebEx, Zoom, and other means of videoconferencing should be feasible. As billing procedures are being adapted for this moment, there’s no reason why individuals shouldn’t be able to contact their mental health provider.

Substance abuse is also a condition vulnerable to the stress effects of this pandemic. This will prompt or tempt those to use substances that they’ve abused or turned to in the past as a way of self-medicating and assuaging their anxiety and worry.

Interestingly, people with serious mental illnesses, such as schizophrenia and nonaffective and affective psychoses, seem to be less vulnerable to the stress-inducing effects of catastrophe. It’s possible that the pandemic could find its way into delusions or exacerbate symptoms, but somewhat paradoxically, people with serious mental illnesses often respond more calmly to crises than do individuals without them. As a result, the number of these patients requiring emergency room admission for possible exacerbation of symptoms is probably not going to be that much greater than normal.

How to Cope With an Unprecedented Situation

For the worried well and for the clinicians who have understandable fears about exposure, there are several things you can try to manage your anxiety. There are concentric circles of concern that you have to maintain. Think of it like the instructions on an airplane when, if there’s a drop in cabin pressure, you’re asked to apply your own oxygen mask first before placing one on your child. In the same way, you must first think about protecting yourself by limiting your exposure and monitoring your own physical state for any symptoms. But then you must be concerned about your family, your friends, and also society. This is a situation where the impulse and the ethos of worrying about your fellow persons—being your brother’s keeper—is imperative.

The epidemic has been successfully managed in some countries, like Singapore and China, which, once they got on top of it, were able to limit contagion in a very dramatic way. But these are authoritarian governments. The United States doesn’t work that way, which is what makes appealing to the principle of caring for others so crucial. You can protect yourself, but if other people aren’t also protected, it may not matter. You have to worry not just about yourself but about everyone else.

When it comes to stress management, I recommend not catastrophizing or watching the news media 24/7. Distract yourself with other work or recreational activities. Reach out and communicate—virtually, of course—with friends, family, and healthcare providers as needed. Staying in touch acts not just as a diversion but also as an outlet for assuaging your feelings, your sense of being in this alone, feeling isolated.

There are also cognitive reframing mechanisms you can employ. Consider that although this is bad, some countries have already gone through it. And we’ll get through it too. You’ll understandably ask yourself what it would mean if you were to be exposed. In most cases you can say, “I’m going to have the flu and symptoms that are not going to be pleasant, but I’ve had the flu or serious sickness before.”

Remember that there are already antiretroviral treatments being tested in clinical trials and showing efficacy. It’s good to know that before this pandemic ends, some of these treatments will probably be clinically applied, mostly to those who are severely affected and in intensive care.

Diagnose yourself. Monitor your state. Determine whether the stress is really having an impact on you. Is it affecting your sleep, appetite, concentration, mood? And if you do have a preexisting psychiatric condition, don’t feel afraid to reach out to your mental health provider. Understand that you’re going to be anxious, which may aggravate your symptoms and require an adjustment in your treatment. That’s okay. It’s to be expected and your provider should be available to help you.

Controlling this outbreak via the same epidemiologic infectious disease prevention guidance that works in authoritarian societies is not going to be applicable here because of the liberties that we experience in American society. What will determine our success is the belief that we’re in this together, that we’re going to help each other. We should be proud of that, as it shows how Americans and people around the world stand up in situations like this.

Let’s also note that even though everybody is affected and undergoing previously unimaginable levels of anticipated stress and dislocation, it’s the healthcare providers who are really on the frontlines. They’re under tremendous pressure to continue to perform heroically, at great risk to themselves. They deserve a real debt of gratitude.

We will get through this, but as we do, it will not end until we’ve undergone an extreme test of our character. I certainly hope and trust that we will be up to it.

Dr. Jeffrey A. Lieberman is chairman of the Department of Psychiatry at Columbia University. He is a former president of the American Psychiatric Association.

Disclosure: Jeffrey A. Lieberman, MD, has disclosed the following relevant financial relationships: Served as a director, officer, partner, employee, advisor, consultant, or trustee for Clintara; Intracellular Therapies. Received research grant from Alkermes; Biomarin; EnVivo/Forum; Genentech; Novartis/Novation; Sunovion. Patent: Repligen.

This article first appeared on Medscape.com.

The COVID-19 pandemic is an experience that is unprecedented in our lifetime. It is having a pervasive effect due to how mysterious, potentially dangerous, and sustained it is. We don’t know how bad it’s going to get or how long it’s going to last. We have natural disasters like hurricanes and earthquakes, but they are limited in time and scope. But this global pandemic is something we can’t put our arms around just yet, breeding uncertainty, worry, and fear. This is where mental health professionals need to come in.

The populations being affected by this pandemic can be placed into different groups on the basis of their mental health consequences and needs. First you have, for lack of a better term, “the worried well.” These are people with no preexisting mental disorder who are naturally worried by this and are trying to take appropriate actions to protect themselves and prepare. For such individuals, the equivalent of mental health first-aid should be useful (we’ll come back to that in a moment). Given the proper guidance and sources of information, most such people should be able to manage the anxiety, worry, and dysphoria associated with this critical pandemic.

Then there are those who have preexisting mental conditions related to mood, anxiety, stress, or obsessive tendencies. They are probably going to have an increase in their symptoms, and as such, a corresponding need for adjusting treatment. This may require an increase in their existing medications or the addition of an ad hoc medication, or perhaps more frequent contact with their doctor or therapist.

Because travel and direct visitation is discouraged at the moment, virtual methods of communication should be used to speak with these patients. Such methods have long existed but haven’t been adopted in large numbers; this may be the impetus to finally make it happen. Using the telephone, FaceTime, Skype, WebEx, Zoom, and other means of videoconferencing should be feasible. As billing procedures are being adapted for this moment, there’s no reason why individuals shouldn’t be able to contact their mental health provider.

Substance abuse is also a condition vulnerable to the stress effects of this pandemic. This will prompt or tempt those to use substances that they’ve abused or turned to in the past as a way of self-medicating and assuaging their anxiety and worry.

Interestingly, people with serious mental illnesses, such as schizophrenia and nonaffective and affective psychoses, seem to be less vulnerable to the stress-inducing effects of catastrophe. It’s possible that the pandemic could find its way into delusions or exacerbate symptoms, but somewhat paradoxically, people with serious mental illnesses often respond more calmly to crises than do individuals without them. As a result, the number of these patients requiring emergency room admission for possible exacerbation of symptoms is probably not going to be that much greater than normal.

How to Cope With an Unprecedented Situation

For the worried well and for the clinicians who have understandable fears about exposure, there are several things you can try to manage your anxiety. There are concentric circles of concern that you have to maintain. Think of it like the instructions on an airplane when, if there’s a drop in cabin pressure, you’re asked to apply your own oxygen mask first before placing one on your child. In the same way, you must first think about protecting yourself by limiting your exposure and monitoring your own physical state for any symptoms. But then you must be concerned about your family, your friends, and also society. This is a situation where the impulse and the ethos of worrying about your fellow persons—being your brother’s keeper—is imperative.

The epidemic has been successfully managed in some countries, like Singapore and China, which, once they got on top of it, were able to limit contagion in a very dramatic way. But these are authoritarian governments. The United States doesn’t work that way, which is what makes appealing to the principle of caring for others so crucial. You can protect yourself, but if other people aren’t also protected, it may not matter. You have to worry not just about yourself but about everyone else.

When it comes to stress management, I recommend not catastrophizing or watching the news media 24/7. Distract yourself with other work or recreational activities. Reach out and communicate—virtually, of course—with friends, family, and healthcare providers as needed. Staying in touch acts not just as a diversion but also as an outlet for assuaging your feelings, your sense of being in this alone, feeling isolated.

There are also cognitive reframing mechanisms you can employ. Consider that although this is bad, some countries have already gone through it. And we’ll get through it too. You’ll understandably ask yourself what it would mean if you were to be exposed. In most cases you can say, “I’m going to have the flu and symptoms that are not going to be pleasant, but I’ve had the flu or serious sickness before.”

Remember that there are already antiretroviral treatments being tested in clinical trials and showing efficacy. It’s good to know that before this pandemic ends, some of these treatments will probably be clinically applied, mostly to those who are severely affected and in intensive care.

Diagnose yourself. Monitor your state. Determine whether the stress is really having an impact on you. Is it affecting your sleep, appetite, concentration, mood? And if you do have a preexisting psychiatric condition, don’t feel afraid to reach out to your mental health provider. Understand that you’re going to be anxious, which may aggravate your symptoms and require an adjustment in your treatment. That’s okay. It’s to be expected and your provider should be available to help you.

Controlling this outbreak via the same epidemiologic infectious disease prevention guidance that works in authoritarian societies is not going to be applicable here because of the liberties that we experience in American society. What will determine our success is the belief that we’re in this together, that we’re going to help each other. We should be proud of that, as it shows how Americans and people around the world stand up in situations like this.

Let’s also note that even though everybody is affected and undergoing previously unimaginable levels of anticipated stress and dislocation, it’s the healthcare providers who are really on the frontlines. They’re under tremendous pressure to continue to perform heroically, at great risk to themselves. They deserve a real debt of gratitude.

We will get through this, but as we do, it will not end until we’ve undergone an extreme test of our character. I certainly hope and trust that we will be up to it.

Dr. Jeffrey A. Lieberman is chairman of the Department of Psychiatry at Columbia University. He is a former president of the American Psychiatric Association.

Disclosure: Jeffrey A. Lieberman, MD, has disclosed the following relevant financial relationships: Served as a director, officer, partner, employee, advisor, consultant, or trustee for Clintara; Intracellular Therapies. Received research grant from Alkermes; Biomarin; EnVivo/Forum; Genentech; Novartis/Novation; Sunovion. Patent: Repligen.

This article first appeared on Medscape.com.

On March 26, 2020, it’s hard to write or think of anything beyond the COVID-19 pandemic. Those of you who are on the front lines of the battle may find it strange that I am just a bit envious. Having stepped back from clinical medicine nearly a decade ago, it is frustrating to feel that there is little I can do to help other than offering to venture into the grocery store to shop for friends and neighbors who feel more vulnerable than I do.

jacoblund/iStock/Getty Images

Here in Maine, we are blessed by geographic isolation that for the moment seems to have damped the surge from the metropolitan centers to our south. But, the virus is here and, as the state with the oldest population, we are beginning to be affected.

For nearly a century, we could count on the outhouses here in Maine would be stocked with outdated Sears Roebucks catalogs when toilet paper was in short supply. Many outhouses remain but Sears Roebucks and its catalogs have disappeared from the landscape. I take a little comfort in the learning that I’m not the only human on the planet who can envision the horror of a week or even a day without toilet paper.

So I am left to sit on the sidelines and watch how my fellow Mainers are coping with the anxiety, depression, and loneliness that come with the forced social isolation. It is pretty clear that walking outside has become the coping strategy of choice. On a usual March day the walkers comprise a skimpy mix of dog walkers and wannabe arctic explorers testing the weather-defying capabilities of their high-tech outerwear. But, to say the least, this is not a usual March and the number of walkers has surged bolstered by gym rats forced off their sweat-drenched ellipticals and treadmills.

This increase in outdoor activity is clearly perceptible even on an overcast day, but it is far less than one would expect given the magnitude of the disruption to everyone’s routines. But, when the sun comes out! The doors fly open and onto the sidewalks and quiet rural roads spill scores of people I haven’t seen for months and in some cases decades. One can almost hear John Denver singing “sunshine on my shoulders makes me happy.” Everyone is smiling and waving to each other. It feels as though the community has, at least for a few hours, been able to throw off the burden of angst that the pandemic laid on us.

There has been a good bit of research about seasonal affective disorder, and I suspect that almost everyone has heard about the value of sunshine for depression. But it is unfortunate that the psychological benefits of just being outdoors – even on an overcast day – has gone pretty much unpublicized. As part of their marketing strategy, a local company that specializes in recreational clothing and gear is encouraging its customers to become “outsiders.” It may be that the pandemic will make more people realize the psychological benefits of being active outside. As physicians we should continue to encourage our patients to be more active and remind them that they don’t need to wait for a sunny day to do so.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” He has no relevant financial disclosures. Email him at [email protected].
 

On March 26, 2020, it’s hard to write or think of anything beyond the COVID-19 pandemic. Those of you who are on the front lines of the battle may find it strange that I am just a bit envious. Having stepped back from clinical medicine nearly a decade ago, it is frustrating to feel that there is little I can do to help other than offering to venture into the grocery store to shop for friends and neighbors who feel more vulnerable than I do.

jacoblund/iStock/Getty Images

Here in Maine, we are blessed by geographic isolation that for the moment seems to have damped the surge from the metropolitan centers to our south. But, the virus is here and, as the state with the oldest population, we are beginning to be affected.

For nearly a century, we could count on the outhouses here in Maine would be stocked with outdated Sears Roebucks catalogs when toilet paper was in short supply. Many outhouses remain but Sears Roebucks and its catalogs have disappeared from the landscape. I take a little comfort in the learning that I’m not the only human on the planet who can envision the horror of a week or even a day without toilet paper.

So I am left to sit on the sidelines and watch how my fellow Mainers are coping with the anxiety, depression, and loneliness that come with the forced social isolation. It is pretty clear that walking outside has become the coping strategy of choice. On a usual March day the walkers comprise a skimpy mix of dog walkers and wannabe arctic explorers testing the weather-defying capabilities of their high-tech outerwear. But, to say the least, this is not a usual March and the number of walkers has surged bolstered by gym rats forced off their sweat-drenched ellipticals and treadmills.

This increase in outdoor activity is clearly perceptible even on an overcast day, but it is far less than one would expect given the magnitude of the disruption to everyone’s routines. But, when the sun comes out! The doors fly open and onto the sidewalks and quiet rural roads spill scores of people I haven’t seen for months and in some cases decades. One can almost hear John Denver singing “sunshine on my shoulders makes me happy.” Everyone is smiling and waving to each other. It feels as though the community has, at least for a few hours, been able to throw off the burden of angst that the pandemic laid on us.

There has been a good bit of research about seasonal affective disorder, and I suspect that almost everyone has heard about the value of sunshine for depression. But it is unfortunate that the psychological benefits of just being outdoors – even on an overcast day – has gone pretty much unpublicized. As part of their marketing strategy, a local company that specializes in recreational clothing and gear is encouraging its customers to become “outsiders.” It may be that the pandemic will make more people realize the psychological benefits of being active outside. As physicians we should continue to encourage our patients to be more active and remind them that they don’t need to wait for a sunny day to do so.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” He has no relevant financial disclosures. Email him at [email protected].
 

On March 26, 2020, it’s hard to write or think of anything beyond the COVID-19 pandemic. Those of you who are on the front lines of the battle may find it strange that I am just a bit envious. Having stepped back from clinical medicine nearly a decade ago, it is frustrating to feel that there is little I can do to help other than offering to venture into the grocery store to shop for friends and neighbors who feel more vulnerable than I do.

jacoblund/iStock/Getty Images

Here in Maine, we are blessed by geographic isolation that for the moment seems to have damped the surge from the metropolitan centers to our south. But, the virus is here and, as the state with the oldest population, we are beginning to be affected.

For nearly a century, we could count on the outhouses here in Maine would be stocked with outdated Sears Roebucks catalogs when toilet paper was in short supply. Many outhouses remain but Sears Roebucks and its catalogs have disappeared from the landscape. I take a little comfort in the learning that I’m not the only human on the planet who can envision the horror of a week or even a day without toilet paper.

So I am left to sit on the sidelines and watch how my fellow Mainers are coping with the anxiety, depression, and loneliness that come with the forced social isolation. It is pretty clear that walking outside has become the coping strategy of choice. On a usual March day the walkers comprise a skimpy mix of dog walkers and wannabe arctic explorers testing the weather-defying capabilities of their high-tech outerwear. But, to say the least, this is not a usual March and the number of walkers has surged bolstered by gym rats forced off their sweat-drenched ellipticals and treadmills.

This increase in outdoor activity is clearly perceptible even on an overcast day, but it is far less than one would expect given the magnitude of the disruption to everyone’s routines. But, when the sun comes out! The doors fly open and onto the sidewalks and quiet rural roads spill scores of people I haven’t seen for months and in some cases decades. One can almost hear John Denver singing “sunshine on my shoulders makes me happy.” Everyone is smiling and waving to each other. It feels as though the community has, at least for a few hours, been able to throw off the burden of angst that the pandemic laid on us.

There has been a good bit of research about seasonal affective disorder, and I suspect that almost everyone has heard about the value of sunshine for depression. But it is unfortunate that the psychological benefits of just being outdoors – even on an overcast day – has gone pretty much unpublicized. As part of their marketing strategy, a local company that specializes in recreational clothing and gear is encouraging its customers to become “outsiders.” It may be that the pandemic will make more people realize the psychological benefits of being active outside. As physicians we should continue to encourage our patients to be more active and remind them that they don’t need to wait for a sunny day to do so.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” He has no relevant financial disclosures. Email him at [email protected].
 

A meme has been going around the Internet in which a Muppet is dressed as a doctor, and the caption declares: “If you don’t want to be intubated by a psychiatrist, stay home!” This meme is meant as a commentary on health care worker shortages. But it also touches on the concerns of psychiatrists who might be questioning our role in the pandemic, given that we are physicians who do not regularly rely on labs or imaging to guide treatment. And we rarely even touch our patients.

As observed by Henry A. Nasrallah, MD, editor in chief of Current Psychiatry, who referred to anxiety as endemic during a viral pandemic (Current Psychiatry. 2020 April;19[4]:e3-5), our society is experiencing intense psychological repercussions from the pandemic. These repercussions will evolve from anxiety to despair, and for some, to resilience.

All jokes aside about the medical knowledge of psychiatrists, we are on the cutting edge of how to address the pandemic of fear and uncertainty gripping individuals and society across the nation.

Isn’t it our role as psychiatrists to help people face the reality of personal and societal crises? Aren’t we trained to help people find their internal reserves, bolster them with medications and/or psychotherapy, and prepare them to respond to challenges? I propose that our training and particular experience of hearing patients’ stories has indeed prepared us to receive surreal information and package it into a palatable, even therapeutic, form for our patients.

I’d like to present two cases I’ve recently seen during the first stages of the COVID-19 pandemic juxtaposed with patients I saw during “normal” times. These cases show that, as psychiatrists, we are prepared to face the psychological impact of this crisis.

A patient called me about worsened anxiety after she’d been sidelined at home from her job as a waitress and was currently spending 12 hours a day with her overbearing mother. She had always used her work to buffer her anxiety, as the fast pace of the restaurant kept her from ruminating.

The call reminded me of ones I’d receive from female patients during the MeToo movement and particularly during the Brett Kavanaugh confirmation hearings for the Supreme Court, in which a sexual assault victim and alleged perpetrator faced off on television. During therapy and medication management sessions alike, I would talk to women struggling with the number of news stories about victims coming forward after sexual assault. They were reliving their humiliations, and despite the empowering nature of the movement, they felt vulnerable in the shadow of memories of their perpetrators.

The advice I gave then is similar to the guidance I give now, and also is closely related to the Centers for Disease Control and Prevention advice on its website on how to manage the mental health impact of COVID-19. People can be informed without suffering by taking these steps:

• Limit the amount of news and social media consumed, and if possible, try to schedule news consumption into discrete periods that are not close to bedtime or other periods meant for relaxation.
• Reach out to loved ones and friends who remind you of strength and better times.
• Make time to relax and unwind, either through resting or engaging in an activity you enjoy.
• Take care of your body and mind with exercise.
• Try for 8 hours of sleep a night (even if it doesn’t happen).
• Use techniques such as meditating, doing yoga, or breathing to practice focusing your attention somewhere.

During this crisis, tactful self-disclosure might be appropriate and therapeutic. All of our lives have been disrupted by COVID-19 and acknowledging this to patients can help them feel less isolated and vulnerable. Our patients with diagnosed psychiatric disorders will be more susceptible to crippling anxiety, exacerbations in panic attacks, obsessive-compulsive disorder symptoms, and resurgence of suicidal ideation in the face of uncertainty and despair. They may also be more likely to experience the socioeconomic fallout of this pandemic. But it’s not just these individuals who will be hit with intense feelings as we wonder what the next day, month, or 6 months hold for us, our families, our friends, our country, and our world.

Recently, I had one of the more surreal experiences of my professional life. I work as a consulation-liaison psychiatrist on the medical wards, and I was consulted to treat a young woman from Central America with schizophrenia who made a serious suicide attempt in mid-February before COVID-19 was part of the lexicon.

After an overdose, she developed aspiration pneumonia and acute respiratory distress syndrome and ended up in the ICU on a respirator for 3 weeks. Her doctors and family were certain she would die, but she miraculously survived. By the time she was extubated and less delirious from her medically induced coma, the hospital had restricted all visitors because of COVID-19.

Because I speak Spanish, we developed as decent a working relationship as we could, considering the patient’s delirium and blunted affect. On top of restarting her antipsychotics, I had to inform her that her family was no longer allowed to come visit her. Outside of this room, I vacillated on how to tell a woman with a history of paranoia that the hospital would not allow her family to visit because we were in the middle of a pandemic. A contagious virus had quickly spread around the world, cases were now spiking in the United States, much of the country was on lockdown, and the hospital was limiting visitors because asymptomatic individuals could bring the virus into the hospital or be infected by asymptomatic staff.

As the words came out of my mouth, she looked at me as I have looked at psychotic individuals as they spin me yarns of impossible explanation for their symptoms when I know they’re simply psychotic and living in an alternate reality. Imagine just waking up from a coma and your doctor coming in to tell you: “The U.S. is on lockdown because a deadly virus is spreading throughout our country.” You’d think you’ve woken up in a zombie film. Yet, the patient simply nodded and asked: “Will I be able to use the phone to call my family?” I sighed with relief and helped her dial her brother’s number.

Haven’t we all listened to insane stories while keeping a straight face and then answered with a politely bland question? Just a few months ago, I treated a homeless woman with schizophrenia who calmly explained to me that her large malignant ovarian tumor (which I could see protruding under her gown) was the unborn heir of Queen Victoria and Prince Albert. If she allowed the doctors to take it out (that is, treat her cancer) she’d be assassinated by the Russian intelligence agency. She refused to let the doctors sentence her to death. Ultimately, we allowed her to refuse treatment. Despite a month of treatment with antipsychotic medication, her psychotic beliefs did not change, and we could not imagine forcing her through surgery and chemotherapy. She died in hospice.

I’ve walked the valleys of bizarro land many times. Working through the dark reality of COVID-19 should be no match for us psychiatrists who have listened to dark stories and responded with words of comfort or empathic silence. As mental health clinicians, I believe we are well equipped to fight on the front lines of the pandemic of fear that has arrested our country. We can make ourselves available to our patients, friends, family, and institutions – medical or otherwise – that are grappling with how to cope with the psychological impact of COVID-19.

Dr. Posada is a consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va., and associate producer of the MDedge Psychcast. She changed key details about the patients discussed to protect their confidentiality. Dr. Posada has no conflicts of interest.

A meme has been going around the Internet in which a Muppet is dressed as a doctor, and the caption declares: “If you don’t want to be intubated by a psychiatrist, stay home!” This meme is meant as a commentary on health care worker shortages. But it also touches on the concerns of psychiatrists who might be questioning our role in the pandemic, given that we are physicians who do not regularly rely on labs or imaging to guide treatment. And we rarely even touch our patients.

As observed by Henry A. Nasrallah, MD, editor in chief of Current Psychiatry, who referred to anxiety as endemic during a viral pandemic (Current Psychiatry. 2020 April;19[4]:e3-5), our society is experiencing intense psychological repercussions from the pandemic. These repercussions will evolve from anxiety to despair, and for some, to resilience.

All jokes aside about the medical knowledge of psychiatrists, we are on the cutting edge of how to address the pandemic of fear and uncertainty gripping individuals and society across the nation.

Isn’t it our role as psychiatrists to help people face the reality of personal and societal crises? Aren’t we trained to help people find their internal reserves, bolster them with medications and/or psychotherapy, and prepare them to respond to challenges? I propose that our training and particular experience of hearing patients’ stories has indeed prepared us to receive surreal information and package it into a palatable, even therapeutic, form for our patients.

I’d like to present two cases I’ve recently seen during the first stages of the COVID-19 pandemic juxtaposed with patients I saw during “normal” times. These cases show that, as psychiatrists, we are prepared to face the psychological impact of this crisis.

A patient called me about worsened anxiety after she’d been sidelined at home from her job as a waitress and was currently spending 12 hours a day with her overbearing mother. She had always used her work to buffer her anxiety, as the fast pace of the restaurant kept her from ruminating.

The call reminded me of ones I’d receive from female patients during the MeToo movement and particularly during the Brett Kavanaugh confirmation hearings for the Supreme Court, in which a sexual assault victim and alleged perpetrator faced off on television. During therapy and medication management sessions alike, I would talk to women struggling with the number of news stories about victims coming forward after sexual assault. They were reliving their humiliations, and despite the empowering nature of the movement, they felt vulnerable in the shadow of memories of their perpetrators.

The advice I gave then is similar to the guidance I give now, and also is closely related to the Centers for Disease Control and Prevention advice on its website on how to manage the mental health impact of COVID-19. People can be informed without suffering by taking these steps:

• Limit the amount of news and social media consumed, and if possible, try to schedule news consumption into discrete periods that are not close to bedtime or other periods meant for relaxation.
• Reach out to loved ones and friends who remind you of strength and better times.
• Make time to relax and unwind, either through resting or engaging in an activity you enjoy.
• Take care of your body and mind with exercise.
• Try for 8 hours of sleep a night (even if it doesn’t happen).
• Use techniques such as meditating, doing yoga, or breathing to practice focusing your attention somewhere.

During this crisis, tactful self-disclosure might be appropriate and therapeutic. All of our lives have been disrupted by COVID-19 and acknowledging this to patients can help them feel less isolated and vulnerable. Our patients with diagnosed psychiatric disorders will be more susceptible to crippling anxiety, exacerbations in panic attacks, obsessive-compulsive disorder symptoms, and resurgence of suicidal ideation in the face of uncertainty and despair. They may also be more likely to experience the socioeconomic fallout of this pandemic. But it’s not just these individuals who will be hit with intense feelings as we wonder what the next day, month, or 6 months hold for us, our families, our friends, our country, and our world.

Recently, I had one of the more surreal experiences of my professional life. I work as a consulation-liaison psychiatrist on the medical wards, and I was consulted to treat a young woman from Central America with schizophrenia who made a serious suicide attempt in mid-February before COVID-19 was part of the lexicon.

After an overdose, she developed aspiration pneumonia and acute respiratory distress syndrome and ended up in the ICU on a respirator for 3 weeks. Her doctors and family were certain she would die, but she miraculously survived. By the time she was extubated and less delirious from her medically induced coma, the hospital had restricted all visitors because of COVID-19.

Because I speak Spanish, we developed as decent a working relationship as we could, considering the patient’s delirium and blunted affect. On top of restarting her antipsychotics, I had to inform her that her family was no longer allowed to come visit her. Outside of this room, I vacillated on how to tell a woman with a history of paranoia that the hospital would not allow her family to visit because we were in the middle of a pandemic. A contagious virus had quickly spread around the world, cases were now spiking in the United States, much of the country was on lockdown, and the hospital was limiting visitors because asymptomatic individuals could bring the virus into the hospital or be infected by asymptomatic staff.

As the words came out of my mouth, she looked at me as I have looked at psychotic individuals as they spin me yarns of impossible explanation for their symptoms when I know they’re simply psychotic and living in an alternate reality. Imagine just waking up from a coma and your doctor coming in to tell you: “The U.S. is on lockdown because a deadly virus is spreading throughout our country.” You’d think you’ve woken up in a zombie film. Yet, the patient simply nodded and asked: “Will I be able to use the phone to call my family?” I sighed with relief and helped her dial her brother’s number.

Haven’t we all listened to insane stories while keeping a straight face and then answered with a politely bland question? Just a few months ago, I treated a homeless woman with schizophrenia who calmly explained to me that her large malignant ovarian tumor (which I could see protruding under her gown) was the unborn heir of Queen Victoria and Prince Albert. If she allowed the doctors to take it out (that is, treat her cancer) she’d be assassinated by the Russian intelligence agency. She refused to let the doctors sentence her to death. Ultimately, we allowed her to refuse treatment. Despite a month of treatment with antipsychotic medication, her psychotic beliefs did not change, and we could not imagine forcing her through surgery and chemotherapy. She died in hospice.

I’ve walked the valleys of bizarro land many times. Working through the dark reality of COVID-19 should be no match for us psychiatrists who have listened to dark stories and responded with words of comfort or empathic silence. As mental health clinicians, I believe we are well equipped to fight on the front lines of the pandemic of fear that has arrested our country. We can make ourselves available to our patients, friends, family, and institutions – medical or otherwise – that are grappling with how to cope with the psychological impact of COVID-19.

Dr. Posada is a consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va., and associate producer of the MDedge Psychcast. She changed key details about the patients discussed to protect their confidentiality. Dr. Posada has no conflicts of interest.

A meme has been going around the Internet in which a Muppet is dressed as a doctor, and the caption declares: “If you don’t want to be intubated by a psychiatrist, stay home!” This meme is meant as a commentary on health care worker shortages. But it also touches on the concerns of psychiatrists who might be questioning our role in the pandemic, given that we are physicians who do not regularly rely on labs or imaging to guide treatment. And we rarely even touch our patients.

As observed by Henry A. Nasrallah, MD, editor in chief of Current Psychiatry, who referred to anxiety as endemic during a viral pandemic (Current Psychiatry. 2020 April;19[4]:e3-5), our society is experiencing intense psychological repercussions from the pandemic. These repercussions will evolve from anxiety to despair, and for some, to resilience.

All jokes aside about the medical knowledge of psychiatrists, we are on the cutting edge of how to address the pandemic of fear and uncertainty gripping individuals and society across the nation.

Isn’t it our role as psychiatrists to help people face the reality of personal and societal crises? Aren’t we trained to help people find their internal reserves, bolster them with medications and/or psychotherapy, and prepare them to respond to challenges? I propose that our training and particular experience of hearing patients’ stories has indeed prepared us to receive surreal information and package it into a palatable, even therapeutic, form for our patients.

I’d like to present two cases I’ve recently seen during the first stages of the COVID-19 pandemic juxtaposed with patients I saw during “normal” times. These cases show that, as psychiatrists, we are prepared to face the psychological impact of this crisis.

A patient called me about worsened anxiety after she’d been sidelined at home from her job as a waitress and was currently spending 12 hours a day with her overbearing mother. She had always used her work to buffer her anxiety, as the fast pace of the restaurant kept her from ruminating.

The call reminded me of ones I’d receive from female patients during the MeToo movement and particularly during the Brett Kavanaugh confirmation hearings for the Supreme Court, in which a sexual assault victim and alleged perpetrator faced off on television. During therapy and medication management sessions alike, I would talk to women struggling with the number of news stories about victims coming forward after sexual assault. They were reliving their humiliations, and despite the empowering nature of the movement, they felt vulnerable in the shadow of memories of their perpetrators.

The advice I gave then is similar to the guidance I give now, and also is closely related to the Centers for Disease Control and Prevention advice on its website on how to manage the mental health impact of COVID-19. People can be informed without suffering by taking these steps:

• Limit the amount of news and social media consumed, and if possible, try to schedule news consumption into discrete periods that are not close to bedtime or other periods meant for relaxation.
• Reach out to loved ones and friends who remind you of strength and better times.
• Make time to relax and unwind, either through resting or engaging in an activity you enjoy.
• Take care of your body and mind with exercise.
• Try for 8 hours of sleep a night (even if it doesn’t happen).
• Use techniques such as meditating, doing yoga, or breathing to practice focusing your attention somewhere.

During this crisis, tactful self-disclosure might be appropriate and therapeutic. All of our lives have been disrupted by COVID-19 and acknowledging this to patients can help them feel less isolated and vulnerable. Our patients with diagnosed psychiatric disorders will be more susceptible to crippling anxiety, exacerbations in panic attacks, obsessive-compulsive disorder symptoms, and resurgence of suicidal ideation in the face of uncertainty and despair. They may also be more likely to experience the socioeconomic fallout of this pandemic. But it’s not just these individuals who will be hit with intense feelings as we wonder what the next day, month, or 6 months hold for us, our families, our friends, our country, and our world.

Recently, I had one of the more surreal experiences of my professional life. I work as a consulation-liaison psychiatrist on the medical wards, and I was consulted to treat a young woman from Central America with schizophrenia who made a serious suicide attempt in mid-February before COVID-19 was part of the lexicon.

After an overdose, she developed aspiration pneumonia and acute respiratory distress syndrome and ended up in the ICU on a respirator for 3 weeks. Her doctors and family were certain she would die, but she miraculously survived. By the time she was extubated and less delirious from her medically induced coma, the hospital had restricted all visitors because of COVID-19.

Because I speak Spanish, we developed as decent a working relationship as we could, considering the patient’s delirium and blunted affect. On top of restarting her antipsychotics, I had to inform her that her family was no longer allowed to come visit her. Outside of this room, I vacillated on how to tell a woman with a history of paranoia that the hospital would not allow her family to visit because we were in the middle of a pandemic. A contagious virus had quickly spread around the world, cases were now spiking in the United States, much of the country was on lockdown, and the hospital was limiting visitors because asymptomatic individuals could bring the virus into the hospital or be infected by asymptomatic staff.

As the words came out of my mouth, she looked at me as I have looked at psychotic individuals as they spin me yarns of impossible explanation for their symptoms when I know they’re simply psychotic and living in an alternate reality. Imagine just waking up from a coma and your doctor coming in to tell you: “The U.S. is on lockdown because a deadly virus is spreading throughout our country.” You’d think you’ve woken up in a zombie film. Yet, the patient simply nodded and asked: “Will I be able to use the phone to call my family?” I sighed with relief and helped her dial her brother’s number.

Haven’t we all listened to insane stories while keeping a straight face and then answered with a politely bland question? Just a few months ago, I treated a homeless woman with schizophrenia who calmly explained to me that her large malignant ovarian tumor (which I could see protruding under her gown) was the unborn heir of Queen Victoria and Prince Albert. If she allowed the doctors to take it out (that is, treat her cancer) she’d be assassinated by the Russian intelligence agency. She refused to let the doctors sentence her to death. Ultimately, we allowed her to refuse treatment. Despite a month of treatment with antipsychotic medication, her psychotic beliefs did not change, and we could not imagine forcing her through surgery and chemotherapy. She died in hospice.

I’ve walked the valleys of bizarro land many times. Working through the dark reality of COVID-19 should be no match for us psychiatrists who have listened to dark stories and responded with words of comfort or empathic silence. As mental health clinicians, I believe we are well equipped to fight on the front lines of the pandemic of fear that has arrested our country. We can make ourselves available to our patients, friends, family, and institutions – medical or otherwise – that are grappling with how to cope with the psychological impact of COVID-19.

Dr. Posada is a consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va., and associate producer of the MDedge Psychcast. She changed key details about the patients discussed to protect their confidentiality. Dr. Posada has no conflicts of interest.