All right. Well, good afternoon, everyone. Thank you for being here and joining us during this conversation about Return to Practice, an update on interventional spine and pain practice during COVID-19. It's a real pleasure to be here and an honor to be presenting along with my colleague and friend, Dr. Annie Purcell. My name is Mehul Desai. I practice in Washington, D.C., where really nothing has been going on for the last two to three months. And thankfully for us, in many ways, we've been sort of low on the COVID side of things. We were talking right before we jumped on together. We've had 275,000 Washingtonians that have been tested for COVID, of which about 18,000 have had positive tests. So I think that works out to be about 2% of the D.C. population has had or has COVID currently as of yesterday. I think we've only had about 658 deaths. Not that any deaths is good, but certainly we've had relatively few deaths compared to a lot of other places. I practice in private practice here in Washington, D.C., although we work in medical education quite closely. We help train the Georgetown National Rehabilitation Hospital residents and the GW medical students. And the joke is sort of that our practice, we call our practice privademics because we sort of take the best of private practice and hopefully combine it with some academic outlooks. Dr. Purcell, do you want to introduce yourself? Yeah. Hi, I'm Annie Purcell and I am sort of the opposite of Dr. Desai, as far as you can see. I don't have a lot of titles on there. I am in a small outpatient private practice in a rural community. I do outpatient musculoskeletal and interventional spine. My community is about a town of 90,000 people that serves an area of 200,000. And I am in California, but our demographics are very different from the rest of the state, which we'll get into later. I'm also involved with a reimbursement committee with AAPMNR and the AMA CPT advisor. Today's talk is mostly relevant to COVID-19 and interventional spine and pain. So looking forward to it. Well, thank you for that. I will say that I made up most of these titles, so they're just there for, I just cut and paste someone else's CV. A quick housekeeping announcement with regards to CME. As a reminder, you can earn CME for attendance in this session and your participation has been recorded. Due to high volumes, it may take up to 48 hours for all the data to be transferred to your Academy online account. For those attending the annual assembly in real time, the Academy recommends claiming your CME information beginning Wednesday morning to ensure that all will participation has been accurately transferred and to account for the high volume of current traffic on the internet with regards to the annual assembly. With that, we'll jump into it. I will talk about my disclosures, none of which are relevant, but they're sort of a stock slide that I've created for every talk I'm giving. None of these are relevant to today's conversation. And I think Dr. Purcell, I believe you don't have any relevant financial disclosures either, correct? Nothing to disclose. Thank you. All right, perfect. So from an objective's perspective, we want to discuss considerations of continued interventional practice. Many of us know that this was sort of a once in a lifetime event when we dealt with, or hopefully once in a lifetime event, at least when we initially started dealing with COVID-19 in the spring. And the decision for many folks to get back to work was a really, frankly, a fairly tortured decision that really had to take into a lot of moving parts, moving pieces and a lot of nuances that there's a lot of things we're going to talk about throughout the course of this conversation that will be relevant to that. So we'll discuss considerations of continued practice, talk briefly about gaps in treatment revealed by modified practice, where some of our patients might be falling through the cracks or may have difficulty, and to increase familiarity with guidelines and consensus statements regarding interventional care during COVID-19. There's been a variety of guidelines and consensus statements published and we'll sort of briefly touch on them. So we know that pain medicine provides an enormous healthcare burden. I mean, these talks almost always are full of statistics that are somewhat mind boggling. I always lead my talks with this statistic that in 2015, we spent about $650 billion on pain in the United States, the majority of which was indirect costs such as lost work and lost wages. That is more than the combination of what we spend on diabetes, heart disease, and cancer combined in the United States. So it's sort of, it always takes me aback to think of it that way. But even when we think about in the framework of COVID-19, pain remains a frequent cause for visits to the emergency room. And it accounts for anywhere from 45 to 75% of ER patient presentations with half of the patients who come in having moderate to severe symptoms. So there's a real, in the setting of emergency rooms already being overburdened, already being full, already trying to accommodate for patients who might have influenza or might have COVID-19, trying to differentiate those things. You add in patients who are now coming into the hospital or potentially coming to the hospital to be treated for their pain because of access related issues. And I think that provides, that's just another touch point that makes this such an important conversation that we're having. The Centers for Medicare and Medicaid recommended three tiered approach to triaging pain patients. This was put out in April of 2020, sort of low, low acuity or elective things that we want to postpone, intermediate acuity or urgent things that we want to consider postponement for and high acuity or emergent issues that we should not postpone. So that's something to keep in mind as we sort of triage these patients. There are a whole host of federal and local advisories. The challenge with this, to say the least, is that they're difficult to navigate. They are ever changing and they're often contradictory or sort of, what are we supposed to be paying attention to? The federal response, which has been at best, whatever side of the political arena you're on, somewhat fractured. Then you have a statewide, in many cases, or commonwealth wide responses. And then you have local jurisdiction based responses, counties, cities, things of that nature. It's important to keep in mind that this is a national emergency and an international emergency, but that responses remain national and local. Reconciling both local and national responses is really important because when they're contradictory, understanding which ones supersede the others and how to navigate those things. Because not only does COVID-19 bring up real healthcare related issues, it honestly also brings up human resources related issues. How do you work with your staff? How do you treat your staff? What's covered? What's not covered? Things of that nature. In my experience, local responses have been more vigorous and restrictive and often conflict with federal statutes. So we've had here in Washington, DC, I'm going to talk about it in a couple of slides. We now have a travel mandate in terms of where we're theoretically allowed to go and what are the rules and regulations that dictate travel. And Washington, to some extent, has escaped a lot of the severity of COVID by really clamping down on things, including travel and public gatherings of folks. And then there's this sort of evolving guidance on telemedicine. Many of us have been able to quickly move over to telemedicine when COVID-19 hit. And we were lucky enough to have sort of dabbled in telemedicine prior to this happening. So when it came about in earnest, we were able to pivot fairly seamlessly. But reimbursement and coverage for telemedicine is already changing. There's a couple of payers in our area that have stopped paying for telemedicine because from their perspective, this is actually adding costs to their coffers. And they're concerned that maybe COVID was getting better. Now, these decisions are not always made based on what we would do or science, but they're often bottom line decisions. So all these things are issues that we have to keep track of, unfortunately. This is just a flow sheet that I wanted to put out there. And the nice thing about this talk is it's available via PDF, so anyone can download it and look at it. And the source here is the DEA. And it basically just, it's a kind of an overarching, large scale look at how to prescribe control substances during the COVID-19 public health emergency and what sorts of things should you be doing. Those of us who have been practicing for long enough know that there's often incongruent, well, it's incongruous the response that even different federal organizations will have to how we're practicing medicine. So what I mean by that is while from a public health perspective, there may be a public health emergency ongoing, that doesn't necessarily reduce our liability with opioids with regards to controlled substances agreements or urine toxicology screenings or prescribing medications across state lines or practicing medicine across state lines. One of the challenges that COVID-19 has exposed with regards to the practice of medicine is that despite federal statutes and regulations that are continuously changing, medicine is regulated at the state level. So it's an incredibly decentralized process. And so it's sort of that conflict, that existential conflict between what the federal government might state and what is enforced and what individual states might mandate remains at the forefront of what's happening. So at your convenience, I think it may be worthwhile for folks who are interested or who prescribe opioids in their practice to familiarize themselves with this sort of flow sheet and how the VA has recommended that opioids are prescribed. Along those lines, one of the things we've had a lot of conversations in our practice about is that despite the fact that for many months, we were seeing people via telemedicine, there was no guidance on whether or not we should be still collecting urine toxicology screenings and how that should work and whether we should continue to collect those. And how do you collect those if patients aren't coming in? And do you mandate the patients come in just to provide a urine specimen? Does that expose them to risk, especially if they're elderly or have other risk factors? One of the maybe benefits that's come from or something that's maybe been accelerated along is that access to electronic or e-prescribing of opioids has really taken off. So a lot of states, a lot of jurisdictions, commonwealths, for example, the Commonwealth of Virginia now I think requires that all opioids are prescribed via electronic prescribing. So no longer are you even really supposed to give or allowed to give in the absence of an emergency a paper prescription to people in the effort to cut back on opioid abuse, misuse, or diversion. So some of the technological innovations that have occurred have been favorable, but at the same time, incorporating these technological innovations is not always as easy as snapping your fingers and turning it on. There are often significant costs associated with whether it's telemedicine or even e-prescribing. So just things to keep in mind. I thought these next couple of slides were really interesting because part of our goal was to make this as relevant and sort of draw upon our own experience dealing with COVID-19 and how it's affected our practices. So just recently, I think late last week, Washington, DC came out with an updated travel advisory. So basically, for visitors coming to the District of Columbia, before you come to Washington, DC, you're supposed to get a test. And if it's positive, don't come to DC. And the test has to be within 72 hours of arriving in DC. If you have a close contact of a confirmed positive case, don't travel. And if you're going to stay in DC for more than three days, you're supposed to get retested within three to five days of being in DC. So that's a pretty significant burden on folks who are planning on visiting Washington, DC, not only to get baseline tested, but to get tested after they've been here for more than 72 hours. Along with that, on the other side, Washington, DC currently advises against traveling to almost any state in the United States. So the only places that you're allowed to travel to theoretically in the United States are Maryland and Virginia, other than DC, Vermont and Hawaii. Those are the only places that are currently on the approved list or the low risk states. If you do travel, you're supposed to get a test within 72 hours of returning to, or at 72 hours upon returning to Washington, DC, and then waiting for the results, or self-quarantining and self-policing for 14 days. So as you can imagine, that could theoretically have an enormous impact on a small private practice, even a medium private practice, or really any organization that has folks that want to travel outside of the area to restricted geographies. That's in our practice has provided an incredible amount of angst for us as we're trying to sort of navigate this and provide guidance both for ourselves, but also for our employees and come up with policies that cover the safety of our patients, of our employees, but also of the ability to continue to practice medicine. So that's something that's been hitting really close to home over the last couple of days that I thought was a really interesting and relevant example. Now, guidelines and consensus statements. I mean, none of these are set in stone. Many of these have been published by really reputable, great organizations that are really hoping to give us as much guidance as possible. I certainly think those practicing interventional spine or pain medicine or musculoskeletal medicine should download and familiarize themselves with these guidelines or statements because they do provide some generalized infrastructure under which to practice and sort of to make the best possible decisions, both for yourself and for your practice and really fundamentally for your patients. So this first paper that I've sort of screenshotted and shared was published in Pain Medicine just a couple of months ago, and this is pain management best practices for multi-specialty organizations. This is nice, but one of the challenges with it is this really takes the lens of a large, almost academic or multi-specialty center and how they might look at risk and how they might approach patient care during this public health crisis. But still certainly worth a download and a read. There's some information, and again, I included some charts and tables that they talked about, really about how to triage patients appropriately. And this specific one I think is nice because it divides up the things that we do as interventionalists into sort of emergent, urgent, and elective procedures. And it really tells us how to approach those and sort of what decision points you might make in order to decide if you're going to bring those patients in or treat those patients compared to maybe not opening or maybe continuing with telemedicine. Now, much of this obviously has to be looked at through the lens of not just risk, but also what is the other side of this? When you deny someone an elective procedure, you may also then drive them to the emergency room, right? So then you've exposed them to risk in that other way. So I'm not suggesting that these things are written in stone or that you should follow one of the next couple of guidelines that I present, but rather that you make your best decisions based on reviewing these, potentially consulting a business consultant, or even an attorney to make sure that you've sort of looked at these appropriately and made the best decision, again, for your patients and your practice. This next slide talks about how to triage in a pain or musculoskeletal clinic, and what are some of the things you may want to look at in order to decide if the patient should be brought in versus having them stay home or treating them via telemedicine. So again, some pretty practical and user-friendly tables and recommendations are included in these guidelines that were published. Another set of guidelines were published, and these were sort of spearheaded more by more outpatient-based physicians. This is emergence from COVID coronavirus disease 2019 pandemic and the care of both chronic pain patients, but also from the perspective of interventional physicians. This was published in Anesthesia and Analgesia just a couple of months ago as well, and also has a lot of information about how to triage patients, what to look for, and when to bring patients in versus consider keeping them at home and seeing them via telemedicine, and how to continue to use telemedicine as effectively as possible. There was a group of podiatrists that put together sort of recommendations, not evidence-based, but certainly, I mean, not that it's not evidence-based, but not, and that wasn't published in a peer-reviewed journal, but did get into pain medicine news. Certainly, I think this is another really nice compilation of experts and people who are sort of looking at these patients from a comprehensive perspective to make recommendations on how to treat outpatient musculoskeletal patients and also pain management patients, and sort of looking at when to bring patients in and when not to, when to consider procedures, how to optimize telemedicine, and to keep patients out of the emergency room. So, I think I commend these folks for putting this together because anytime you put together a paper or recommendations, it's a labor of love oftentimes that requires a lot of time and energy. This next slide is just another one that talks about considerations for pain interventions and how to sort of look at specific considerations and then what are the right questions to ask about that. So for example, resource availability, will the procedure require critically limited supplies such as certain drugs or PPE or care such as a hospital bed? How do you answer those questions before you make these decisions for both your practice and in concert with your patients? So I talked a little bit about telemedicine. I think it's important that we continue to advocate for continued access. One of the things that the Centers for Medicare and Medicaid are doing, and I think that I do have to commend them on this, is that we believe that continued access for telemedicine will persist beyond COVID-19, that there's a push here and a play here to keep that as an option and as an alternative. And I think that has been sorely needed for a long, long time. Just because I practice in Washington, D.C., doesn't mean I don't have patients that can't get to see me or live far away or might live in a place where transportation is really, really challenging or they can't pay for parking or a myriad of other issues. And that may be on one end of the spectrum. The other end of the spectrum is maybe someone like Dr. Purcell who may have patients that live really far away and really can't get in to see her as efficiently and effectively regularly as they'd like. So I think that's one of the things that's been a positive that's continued. I will add that other payers are not necessarily preserving access. In our market, we have Anthem Healthkeepers, and then we have Anthem Healthkeepers Plus, which is a clever marketing way of saying you get less benefits if you have the plus than if you have the regular. Anthem Healthkeepers Plus is basically a Medicaid replacement plan. It's like an HMO, Medicaid replacement, and they've already gotten, they no longer pay for telemedicine as of, I believe, November 4th. So already some of these things that have been helpful to both patients, but also the practices have been rolled back as people sort of look at this epidemic or pandemic differently, depending on the lens that they're looking at it through. One of the cases that I wanted to make sure I talked about, because I think it's been sort of, to some extent, marginalized and not discussed as much, has been intrathecal drug delivery. So I do think that a fair number of physiatrists either take care of patients who have intrathecal pumps where they're receiving Baclofen or a myriad of pain medications through an intrathecal pump. And the fact that some of these patients couldn't get in and get access to refills can be life threatening. Baclofen withdrawal, an off-label use of clonidine and subsequent clonidine withdrawal, both can be life threatening. So this all happened. So we had access issues. We had patients who had these various drugs in their pumps, which are certainly put them at risk for withdrawal and subsequent mortality. But also, at the same time, we had one of the major manufacturers of pumps that didn't have any, had an FDA hold on their new pumps being manufactured. So you had a whole host of things happening where people were coming sort of to the end of their pump life, needed a new pump, couldn't get one. Patients who had previously had successful trials with either Baclofen or a pain medication couldn't get a new pump. And patients couldn't necessarily get in to see their doctors to get their pumps refilled. So the sort of conglomeration of negative issues happen all at the same time. So this has been a really interesting learning experience for folks like myself who do manage pumps to really try to understand how we're going to, with the fact that most likely there's going to be, we're in the midst of a second peak, a fairly large, much larger second peak. How are we going to continue to monitor and manage these patients who have these critical therapies that need continued management and need access? So I think these are some of the open questions that we have to continue to answer. And also the answers might be different depending on where you practice, what kind of patient population you have, and what kinds of things you put in patients' pumps. So in this case, other things to consider, what is the role of corticosteroids in immunosuppression? It's interesting because there's a lot, there's some data about the use of corticosteroids creating a situation where people are more susceptible to COVID-19. On the other side of things, dexamethasone is now being used routinely, seemingly for treatment of COVID-19. So there's some conflicting information there. And I don't know that I know the absolute answers, but it seems like that specific formulation is one that is having success in the treatment of COVID-19. Whereas using dabamedrol or methadone and some of the other formulations may lower or increase, I should say, the risk of developing or susceptibility to COVID-19. Similarly, what are the roles for using NSAIDs? And much of this information we don't have absolute answers to, and we're still sort of in the process of understanding better. With that, I think I'm going to turn it over to Dr. Purcell to talk about financial elements and to go from there. Thank you. So we've done a series of webinars together since COVID-19 started about the financial side of things and payroll protection loan, CARES Act. So it's sort of progressed as time goes by to where we are now. It looks like most people that could have, have received their payroll protection loan. And then I can report back that we just did have ours forgiven. The process for that was not as bad as we anticipated, although it was just more of waiting for any type of rules to come through and be able to submit our information. When we finally did submit it, it was forgiven and they just subtracted the upfront amount that we got for the EIDL loan. So that whole process seemed to work. And then an interesting thing, a lot of people applied for the EIDL loan, which was the much larger loan, but it has like a 3% interest rate. And we got that as well. And things sort of seemed to pick back up to normal in our practice. So I almost thought, you know, let me just give that huge chunk of change back. We didn't need it. But I had a little thought in my head, like, well, this thing's still going, let's wait and see. And that turned out to be the right decision to hold on to it because things have changed again in a major way. So that's one thing, Dr. Desai, that you and I really realized since this started as business owners is that you're a physician, you always felt like your career was recession proof, you know, and you never anticipated, was it pandemic proof? And we really had that time of reckoning where, no, it's not. And we were all kind of shut down and not knowing what would happen moving forward. And so I think that's made a lot of us reevaluate what kind of reserve of money that we keep on hand, how much of that should fall on the practice owner in order to keep things going. So that's been a huge process. The one thing that's a little bit newer since the webinars that we did is the Phase 3 of the CARES Act. I don't know if you applied for that. That was an additional amount of funds that's open to people who might have received Phase 2. And so that was the deadline to apply for that was November 6th, but that one seems like an unknown entity. I haven't heard much from other people. We applied for it and just no one that I've spoken to has heard anything back one way or the other. So I don't have a good outlook on what kind of money that would be to a practice. Have you heard anything about three from anybody? No, I think, I mean, it's interesting because we, despite the fact that we're a private practice, we are part of an integrated delivery network. And our understanding was that the amount of money in Phase 3 was going to be fairly limited and the process was not nearly as, as you said, the process was not nearly as transparent as the first phase or the first phases. A lot of people, our group basically advised us to either apply on our own or just to sort of forego it completely. Yeah, it's a pretty unknown entity. Another good reminder for people is if you did get the economic disaster loan, the time is right or it should be right around where you do have to attest. And so to make sure that you were notified, I got a phone call and an email, but you basically have to turn in like a board meeting notes from a meeting saying that you do accept it. And so they were really, you know, you've got to be careful that you know about that deadline and that you meet that documentation. And I think that's happening around now. We just did it like last week. Another, oh, the payroll protection repay, they also, they're going to keep the amount that you got for part of your EIDL. So practices should also keep that in mind. And then, you know, staffing, I'm going to do actually a timely case study about what has happened in my own practice and staffing issues are going to be, I think, ongoing until this, until this pandemic is under control. Whether it's, you know, your staff getting sick or your, my main one has been my staff losing childcare over and over again, it's been tough to keep up with the staffing. And then, you know, the risk to, to all of us for being on the front lines is, is ongoing. And it's, it's something that's very hard to juggle. Financially, I think all of us need to, you know, if our practices are going to survive, we need to be able to, you know, have a long emergency fund, something that physician practices really almost never had to have. I mean, you know, keeping a savings account, keeping a huge emergency fund, that seemed like a personal thing to do, but not necessarily a practice thing to do. So that's sort of changing the way we're all looking at our finances moving forward. Yeah, I got it. So for the EMGs, this was a, this was a tough situation about when to return to performing EMGs and how to do that when the pandemic first started. We were all looking for guidance and, you know, eventually this came out in muscle and nerve through the AANEM and it's a guideline that you can refer to, but it's always very, it's always very regional. And so, you know, some of the decisions are still going to be up to you. So when things first started, there were no guidelines and it was hard to give them out on a national level. And when I look at what happened in our practice, we were first down and we couldn't, we couldn't do EMGs because we didn't have the PPE to give to our patients and our patients didn't have PPE. And we stepped back into it by triaging only the more acute, you know, more urgent tests that needed to be done. And then we eventually got to the place where we were doing most of them, but with spacing. We kind of didn't have anywhere to turn. People were turning to the academies as far as guidelines, and we ended up reaching out to someone that we felt was a national leader in the field and see what they were doing and they were running the practice. So you know, that encouraged us to move forward. But looking back, we were, you know, back when we were so cautious, we didn't even have COVID in our area like we do now. And so, you know, things will have to be adjusted. I think the key point is looking at the positivity rate in your, in your community at the time and using that to help decide how extra cautious you're going to be. So that's been a tough one because it's a, it's a constantly changing number, and it's different anywhere that you go. Patient scheduling, we did start for EMGs, a lot of you guys can see on the guidelines to space them out. We're going to go over a lot of the different rules that I'm sure most of you are following, minimizing the amount of patients in the waiting room and all of those. But you know, it's still a tough call based on the numbers in your local community. This is just a guideline that you guys can look at, a stepwise response for interventional practices in the case of future pandemics that you can refer to. One thing that's really affected all of this are the different settings. A lot of interventional physiatrists do have in-office fluoro, and for us, we only do facility settings. So a lot of those things are less under our control, and we had to partner with, you know, other providers in our town that were able to, you know, give these services in the, in the office setting, help us keep our patients out of the ER because our facilities were shut down in the beginning of the pandemic. So that's all important to keep into consideration, and it's constantly evolving. Another question is, are the facilities that you're using for your procedures following the protocols that you feel are best for your patients? And we've struggled with some issues with that as well. So those are all things to keep in mind. So this slide is funny for me. So this is a slide Dr. Desai put in with tips for how to limit the effects of quarantined healthcare providers, and so we kind of adjusted our talk today because in the most timely manner ever, I was diagnosed with COVID two days ago, and my entire practice is literally shut down right now, and it's kind of remarkable the way that the series of events happened and was not what I was expecting. I know we've all been anticipating what will we do if this comes through our facility. So I'm going to go through, you guys, what happened in what order, and then I think it'll bring up some discussion and hopefully just give a little bit of perspective to look forward if you go through this in your, in your facility and in your own staffing. So I think just based on speaking with other physicians around the country or especially in my area, I would put myself on the like more cautious side as far as, you know, precautions against COVID or wanting to test and things like that. And so we basically follow all of these things here. You'll see for the office setting, all the screening, any guideline that's out there, we've definitely been following it to the T. And so the main thing is, you know, what, what symptoms would someone have that would cause you to require your staff to get tested? I mean, people have sniffles and allergy like things all the time. Are we going to test every sore throat, you know, things like that. I wasn't sure how strict I would be because a lot of the guidelines you read, it's about fever and shortness of breath. But you know, the lesson I can give from our situation is if you do want to be the most preventative of spreading COVID as possible with your own offices to test for almost anything that might be a symptom, because that I think that saved us a lot of exposure to our patients and our community. So the first thing that happened in our office was on November 2nd, Monday, a staff of ours said she just had a slight sore throat, a little bit of sniffles. And she felt like she had a fever, but it was only 99.0. So I was like, I almost felt a little hardcore, but whatever, stay home and get tested. So she couldn't get tested until November 5th, three days later, because of our testing around here. And we did not receive a positive result on her until November 10th. And she actually sat home that one day of little symptoms and then nothing. So the next day, she was fine. And it felt like kind of extreme for keeping her home, you know, for like another week waiting for this test to get done and the results to get back, but it's what you should do. And she that was her only symptoms was that one brief little thing. So before we got her positive result back, we were having a low suspicion the entire time. But on November 10th, the day that we got her test results back, before we got her results back, the other physician in our practice woke up and felt a lot of symptoms like terrible. So we canceled the whole schedule that day and had the physician get tested. And then we received the positive test during that day. So we knew it was probably going to be positive for the physician as well. So that day, I spoke to the health department and their recommendation was, you know, because who do I have to test and after talking to them, they only said I had to test anyone with an exposure or anyone with symptoms. So we had no one else with symptoms and we had two staff that did count as an exposure, which was being within six feet of another of the positive staff member for greater than 15 minutes, cumulative time. And so two girls said they have that exposure from the lunchroom, which, you know, that was hard, but they were honest. And so they had to get tested, but I just had a bad feeling about the whole thing. And I just decided to get the entire office tested. So we all got tested. We have two physicians and eight support staff, three or four are part-time. So we were only required to test three, but I tested 10. So the final results came back seven positive and only three negative in my office. And so I came back positive on this Tuesday, I have no symptoms. So when you have no symptoms, you have a 10 day quarantine from your positive test date because they can't time it out. And three staff had developed some symptoms overall out of all 10, that was just three. So some of the things that we went through for staffing considerations that you may not have thought about for your own practices, could you immediately go completely remote? Because we pretty much, everyone had to quarantine. Usually we've always been able to have at least some people in the office and then they can route tasks to other people. Does everyone have a good laptop and internet connection? Can you forward your phones? Can people get to the faxes remotely? Usually you always kind of feel like someone will be in there, but we had to be 100% remote at first while we were waiting for results. So we eventually got that going, but is it possible your entire office could get quarantined at the same time? I mean, mine was, and we had minimal symptoms from minimal people. So just something to look out for. The symptoms that the CDC, the current symptom list is fever or chills, cough, shortness of breath, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion, nausea, vomiting, diarrhea. So, I mean, it's almost anything. So it seems aggressive to keep testing for any little symptom that comes up, but you could be stopping that catalyst in your practice. So it was a big wake-up call about how many tests were positive. The thing that I noticed about who was negative and who was positive is, the people that were negative were the least interactive with the patients. It was an assistant who works in the back room, an assistant who was mostly home because of not having childcare, and then the one front desk who just answers the phone and does not check patients in or room patients. So, a lot of us are just having this high volume of patient-facing encounters and following every protocol should not give people the feeling of safety that they're not gonna get it. I mean, I totally thought I was gonna test negative. I feel like people make fun of me for how cautious I am about COVID. So it was a big eye-opener and my only symptom is losing my taste and smell, which I don't even know if I would have noticed if I wasn't trying to, if I wasn't testing and then knowing that I have it. So, the return to work criteria, it's kind of hard to figure out. I looked at national CDC guidelines and they are the same as our local guidelines. So, anyone with a mild to moderate illness that is not immunosuppressed, 10 days have to pass since the first symptom and then 24 hours with no symptoms, plus the symptoms are gone, especially including fever. And then if you have no symptoms, like I said, you have to do the 10 days after your first positive test. And then there are, which I didn't go by because I do feel like we have the luxury of being ultra cautious and we can just completely shut down our operations to be cautious. But there are actually criteria for healthcare facilities that you can look up. If you cannot run your facility, you can actually loosen the criteria of asymptomatic but positive people returning to work. And I just don't have experience with that because I don't think we need to, but a lot of certainly other facilities have to keep running. So, that's another option that people can look up. The other thing I wanted to say, and I'm hoping other areas have much better resources, but the response system in our county I think explains why COVID is completely out of control is that there's no one that has tested positive in our office has received a call for any sort of contact tracing whatsoever to happen. So, whether they ever get one or not, I think as physicians or healthcare providers, look at yourself as your own contact tracer and immediately reach out to anyone. I don't have any sense of confidence that anyone else is doing it. And so, that shows you how people aren't getting tested and how the spread is not being slowed down. So, that was kind of tough to see because you see it in the paper, it looks like they're doing contact tracing and they probably are on whatever they can, but there's just not enough help in it for me to see it personally. None of us have received any sort of contact tracing from the local health department. So, hopefully everything is okay. I think a lot of us have a lot of concern about reinfection as possible. Are we gonna go down this road over and over again moving forward? I don't know, but I was certainly surprised by the amount that it could spread through my one practice with every precaution. It's definitely been a big eye-opener. So, those are my main- I think- Go ahead. No, all I was gonna say is I think that really brings it home so much more. I'm sorry you're going through that, but it's such a sort of timely example of how this is constantly changing and constantly evolving. And despite, to some extent, despite our best precautions, you seem like the kind of person that's taking as many possible reasonable precautions as you possibly can for this to happen in your office. This just seems, I think, you know, sort of like not unusual, but just surprising, right? So- Yeah, it was surprising. And I've talked to- I almost felt embarrassed about it, like that it reflects on us somehow, even though I do feel like people think I'm extreme. And talking to other colleagues across the country that are in more frontline type of medicine than I am, the sense is really that when you have a high positivity rate in your community, there's not a lot, it's not as much under your control. You know, you still do the most that you can, but it is very hard to not get exposed and it's not necessarily a sign of lacking protocol. So, I mean, you feel a little bit better, but it also made me feel, you know, really concerned for everybody. And I'm not sure what the answer is. You know, we're a small community and when California first sheltered in place, they sheltered the whole state in place and that we had like no COVID here whatsoever, the whole time, just almost nothing. And then now, you know, it's completely out of control. And so I'm gonna have to look at shifting back to maybe how we were acting more in the beginning of the pandemic by my own choice, but just for what I think is right. For people. So it's all, I think, you know, basing your precautions on the rate of spread in your local community at the time. You know, I didn't see this happening, but the numbers are going for that happening. Well, I think you bring up a really important point. So before we get to that, if anyone out there who's listening or live with us has any questions, please feel free to put them in. We'll answer as many questions as we can. So again, please type them in and we're happy to answer them. But getting back to what you're saying, I think what's really interesting and kind of scary about this is we're sort of, while not completely so, we're sort of left on our own, right? So we were like sort of taking the best available data, meaning whatever the federal government puts out, whatever the local jurisdiction puts out, and then we're sort of trying to make the best decision based on that information. There's no clear cut, absolute right answer. It's not like shut down or not shut down or, you know, quasi shut down. Go to telemedicine 30% of the time or this patient group is the one that's most likely at risk. As you said, when it becomes sort of endemic in your area, very little you can do other than to continue to do what you're doing, but even then that's not purely protective of you, right? So I think that's both frustrating and scary. I think, you know, based on what the numbers look like in the next couple of sort of moving forward over the last couple of weeks, I wouldn't, as much as I don't want to be an alarmist, I wouldn't be surprised if we ended up having to have a second shutdown at some point because it's just the numbers are to some extent unsustainable, right? Like when you're talking about 145,000 cases a day or over 250,000 cases a day, which is what they're estimating could be happening soon, that 10 million cases that we have in the country will double if you're talking about 200 plus thousand cases a day. So with that, I think there's one question Dr. Singh asked. Actually, there's two questions from, two different Dr. Singhs. One Dr. Singh asks, how do you address a patient who refuses to mask or a patient with a pending COVID test? Do you wanna, what would you do with that, Dr. Purcell? So we just made, we made a 100% policy that if you refuse to mask, you cannot come into our facility. And that's what I recommend. We know there's really, there aren't valid medical indications unless it's literally like a skin condition or I mean, even that is tough. So we have a lot of people here who have a strong personal agenda against mask wearing and we don't, we are not willing to expose them to our staff. What about you? I know I 100% agree. I had a situation where a patient came in and started giving my nurse a hard time about mask wearing. And I was like, I overheard, I came up to the front. I said, look, we're not having this conversation. You can either put the mask on or the door's right there. There's no, this is not a, this is not a debate. It's not like, you get to give, yeah. This is not, there's no sides here. It's like, this is our business. We require it. You can either stay or not stay. Now, similarly, if someone has a pending COVID test. Yeah, yeah, absolutely. We tell them at the time that they schedule. The second part of that question is if you had a patient with a pending COVID test, we probably would reschedule them. That hasn't, anytime we've had any patients with pending tests or obviously positive tests, but pending tests, we just rescheduled those patients because it's just not, it's not worth it. I mean, that one patient coming in and then having contact tracing for, in our case, five to 10 to 20 employees, depending on how many people are in the office that day. It's just, it's not a worthwhile endeavor. There's a, there's another question by a different Dr. Singh who asked, are you wearing N95s when you see patients during procedures or just surgical masks? What are you doing, Dr. Prasad? We have worn N95s the entire time, the physicians, and then we give surgical masks to the staff. Some of them wanted to wear cloth masks, and I think I'm going to make it not an option moving forward that they can wear the surgical masks as well. What about you? Yeah, I mean, you put it, you talked about this a little. You alluded to this, you know, this idea like the personal freedom means that I can wear whatever kind of mask. We're not wearing a mask at all. I think, unfortunately, that personal freedom seems to leave the building when it comes to liability. Right, so like if we were to have a policy that allowed people to do whatever they wanted and then someone got sick, I don't think anyone would hesitate to blame us for that problem. Right, so I think more uniform policies are the best in this situation, at least where they're pertinent. We've been wearing surgical masks the whole time. Part of the reason we've been wearing surgical masks is that DC has been very much on lockdown from the beginning, and then we've had patients proactively calling us, telling us, hey, I got a COVID test, it's pending, I'm not coming in. I have a COVID test, it's positive, I'm not coming in. And we really haven't had anyone who's come in and then we found out later that they've been COVID positive. They've been so diligent about informing us of their COVID status that it's been a little bit easier for us to manage those things. There was another question. There's a question about wearing eye protection as well as wearing masks. In DC, it's a rule that you have to also wear eye protection and not just standard eye protection. You have to wear the eye protection with the side protections that aerosolized spray doesn't get into your eyes. I don't, what about you guys? For a clinic or procedures or both? Either one, you can take them both, whatever you. We did not have our whole staff wearing eye protection and we do for procedures. But I'll add on whatever else I can at this point. Yeah, and then did you see the other question about the notifying COVID positive patients? We only had one day where the physician saw patients where it would need to be notified. But the interesting thing is it's not required by any sort of guideline that they were masked and they don't count it as an exposure, which I think probably- Yeah, I think, yeah, I think from our purposes, we haven't had this come up, but if it was to come up, we would do. Similar to contact tracing, we would just let everyone who came in that day or for the 48 hours around that time. Not for any reason, as you said, it doesn't really count as an exposure if both parties were masked. But the other thing is, much as I hate to say this, I'm always very cognizant of liability related issues. And I think there's so much open liability around this, meaning like there just isn't, there's not a lot of precedents, right? There's not a lot of things you can say in the law that say that this works and this doesn't work. So, or you can do this and get it and it's enough and this isn't enough. So if someone can make a compelling case that you've been negligent and that's all that really needs to be, the case just needs to be made, not so much even anything beyond that. So I think to be on the safe side, we're doing that. We're doing the same things all the restaurants and bars in DC are doing. We're gonna take everyone's, in an iPad, we take your email and your name and then we text you when there's a COVID positive contact. No, I'm kidding about that part, but it's almost gonna go to that level, right? Well, if you think about it, it's almost embarrassing that some restaurants or salons seem to be more proactive about notifying their customers than some healthcare facilities about possible exposure. I mean, have you seen that? Because that's how it feels around here. No, I absolutely agree with you about that. I think there's a couple of different things. One is in our defense, I guess, for them to open up, they had to have that. They had to have certain things in place, I think, in order to, like contact tracing was something they had to be able to do. We didn't have that because we were sort of, as healthcare providers, we were considered, we could make the argument that we were essential and there were certain rules, I think, that were different for essential workers versus like restaurants and things of that nature. But I agree with you. I mean, I think these are things that, in the interest of public health and safety, we have to be doing as well, if not better than everyone else, because people, you know, like pointing the finger is a lot easier to do with us than it is at a hair salon, for example, or anything of that nature, so. Yeah. I don't think we have any more questions. I think in an effort to wrap up here, I think this has been really great. I really appreciate your time, Dr. Purcell. It's always good to hear your perspective on these sorts of things. I think my parting thought, and then I'll pass it over to you for your parting thoughts. I think this remains an incredibly fluid process. I think there's a lot of data that we're all trying to process and manage all at once. And I think that's going to remain that way for the foreseeable future, at least for the next several months. So I think any of these decisions that you make about your practice, about the safety of your patients, about the safety of your staff, and also your personal safety for those people who are in the audience, are really going to have to take all these issues into consideration. Getting some sounding boards, whether it's legal sounding boards or compliance sounding boards, probably won't hurt anything. We've done a lot of that recently. Talked to our lawyers, talked to our HR consultants, because we want to make sure we're not stepping into the middle of something that we shouldn't be stepping into the middle of. But as much as everyone wants, doctors have the answers. Cut yourself some slack. This is a very, very liquid situation. It's going to continue to remain fluid. I'll pass it over to you, Dr. Purcell. Thank you. Yeah, I would just, I would advise erring on the side of caution and being overly prepared for the worst to happen and how you might get through that. Because it looks like we're riding an exponential upward curve right now that it's going to be things none of us have ever dealt with. And I wasn't optimistic, but I just, I want to be more realistic and keep our patients safe and slow the spread of this, that's the most important thing to me. Yeah, absolutely. Well, thanks everyone for joining us. Thank you, Dr. Purcell for taking the time. And thanks to the Academy for hosting this. So stay safe, everyone. Thank you.

COVID-19 pandemic

guidelines

patient care

financial considerations

government support programs

testing positive

strict protocols

staffing

contact tracing