Sarah Swank, Counsel, Nixon Peabody LLP, speaks with Ann Parker, Emily Brigham, and Alba Azola, Assistant Professors at Johns Hopkins University and co-founders and co-directors of the Johns Hopkins Post-Acute COVID-19 Team Clinic, about the work they are doing related to the long-term effects of COVID-19. They discuss how the pandemic has changed the practice of medicine, particularly the rise of telemedicine and its impact on the delivery of patient care. They also talk about some of the long-term cognitive and physical impairments seen in some COVID-19 patients, the resources that need to be devoted to caring for this unique population of “long haulers,” and the pandemic’s more long-lasting effects on the science of medicine.
To learn more about AHLA and the educational resources available to the health law community, visit americanhealthlaw.org.
Sarah Swank, Counsel, Nixon Peabody LLP, speaks with Ann Parker, Emily Brigham, and Alba Azola, Assistant Professors at Johns Hopkins University and co-founders and co-directors of the Johns Hopkins Post-Acute COVID-19 Team Clinic, about the work they are doing related to the long-term effects of COVID-19. They discuss how the pandemic has changed the practice of medicine, particularly the rise of telemedicine and its impact on the delivery of patient care. They also talk about some of the long-term cognitive and physical impairments seen in some COVID-19 patients, the resources that need to be devoted to caring for this unique population of “long haulers,” and the pandemic’s more long-lasting effects on the science of medicine.
To learn more about AHLA and the educational resources available to the health law community, visit americanhealthlaw.org.
Hello everybody and welcome to today's podcast. I have three amazing physicians with me, and we're gonna talk about the lingering effects of Covid 19. Uh, my name is Sarah Swank and I'm from the law firm of Nixon Peabody in the Washington DC office. Um, alright, let's get started. Um, who wants to start first? How about Dr. Parker? Why don't you introduce yourself?
Speaker 2:Oh, sure. Um, so glad to be here. So my name is Anne Parker and I'm an assistant professor in the division of Pulmonary and Critical Care Medicine at Johns Hopkins University. And along with Dr. Roseola and Dr. Brigham, uh, have co-founded and co-direct the Johns Hopkins Post-Acute Covid Team Clinic.
Speaker 1:Excellent. And Dr. Brigham, do you want to go next and introduce yourself?
Speaker 3:Sure. Good morning. Thank you for having us. My name is Dr. Emily Brigham. Um, I am also assistant professor in pulmonary and Critical Care Medicine at Johns Hopkins. And work with both Dr. Parker and Dr. Ola on the, the post-acute Covid team.
Speaker 1:And Dr. Zola. Last but not least, do you wanna introduce yourself? Thank
Speaker 4:You so much for having us today. My name is Alva a Zola, and I am an assistant professor of the Department of Physical Medicine and Rehabilitation. And I'm a co-director of the Physical Medicine and Rehab Packed Clinic. And it's been a pleasure working with these two amazing, um, inspirational ladies.
Speaker 1:Excellent. I'm, I'm so happy to have you all. Um, so Johns Hopkins is one of the first in the country to put up a, a, a clinic, um, to study the long-term effect of Covid. Uh, I'm, so I'm really excited to have you all here today and have you as a team together. So let's just talk a little bit about, um, and we o oftentimes on these podcasts, we talked to lawyers and others about like how Covid changed the legal profession or how ch Covid changed law. So it'd be interesting to hear a little bit about how Covid changed medicine. Um, who would like to go first?<laugh>, um, I can pick on you. I can, I can call on one of you, but how about, uh, how about Dr. Dr. Parker? Why don't we start with you since I started with you before.
Speaker 2:Sure, absolutely. So, I, I I think there have been a lot of things that have changed in the setting of covid. Some of them temporary, some of them may be long lasting after Covid, um, hopefully soon moves on. Um, I think a few of the, sort of the major changes have been the uptake of telemedicine and the wide use of telemedicine, um, to, to meet our patients' needs in the setting of infection and prevention control measures. Um, and in fact, I think that latter point, you know, of course the focus on infection control has really, of course driven a lot of these changes. So the uptake of telemedicine, there have been a lot of changes in terms of visitor policies, um, and restrictions for visitors. I think, uh, there have been a lot of changes in the setting of, um, not, uh, seeing patients in person and then patients of course experiencing some degree of, of social isolation in that setting as well. Um, but I am gonna let Dr. Brigham talk more about telemedicine because she really took the lead on that aspect of our clinic and getting things started from the JH PAC standpoint and working with the Johns Hopkins office of telemedicine and was just absolutely instrumental and making that happen on an incredibly short timeline. I mean, we're talking, we had to, on a basically day's notice, uh, be able to change our, our practices entirely and, and, and start seeing patients in a virtual format. And at that point, um, Dr. Brigham was, was, uh, functionally in charge of, of a lot of that switch.
Speaker 1:Uh, I think that'll be really interesting to hear about because I've, I've worked on telehealth I guess, for as long as it's existed. Um, cuz it's really technology based, right? I mean I can remember webcams and palm pilots and, and things like that. So I think it'd be really interesting to hear from the physician perspective, cuz we keep hearing from us lawyer perspective on the waivers coming and the lost, but we're not actually caring for the patients at the other end. So what was that like to launch that program?
Speaker 3:Uh, a very rapid learning curve.<laugh>, I would say it's the best way to describe it. So we had, um, we have an office of telemedicine at Johns Hopkins. And, and I know that this happened across the country, right at, at different institutions, but we have, we have and had an office of telemedicine, but a fairly small footprint of telemedicine at Johns Hopkins. And certainly we hadn't done any uptake of telemedicine in the division of pulmonary, um, where Anne and I practice. And I believe Dr. Ola can shake her head and mention Yep, not in, not in physical medicine and rehabilitation either. So, um, you know, with the advent of, of the pandemic and the concern about having patients come in person at the volumes that we were seeing prior to the pandemic, right? We were trying to do everything we could to reduce, um, in-person interface and, and contact at a time where we didn't know, uh, we were learning infection control precautions. Um, there was rapid uptake of telemedicine. And so I was in the position of medical director of about half of our pulmonary clinics at the time, working with another talented, uh, physician Christian Merlot, um, within this. And, uh, we were charged with the uptake of telemedicine across the pulmonary division. Um, which as you can imagine, as I mentioned to Steve, learning curve. So not only does there have to be new technology rollout, um, and educational for transformation across all providers in the network, which are department of medicine and really the whole institution put together. Um, but you have to teach a number of providers how to use it. There also has to be a strategy for uptake among patients and trying to make sure that there's equality of uptake among patients. Um, so a, a huge educational campaign, uh, basically went out, I think, uh, we reorganized and restructured the way that we, uh, essentially roomed patients. So traditionally you think of rooming patients in a literal room in the clinic and checking vitals and so forth, but we had staff learn how to, how to assist patients with logging on to telemedicine, how to adopt the technology and how to identify patients who were at risk of not being able to log on to a video visit, provide them extra resources to hopefully be able to achieve that. But then if unable to achieve that, make sure that we could connect by phone or try to get them in for a safe in-person visit and so forth. Um, and so there was a lot of additional, uh, person power that went into sort of constructing this infrastructure for the uptake of telemedicine. And I will say that, that while that was, that was a huge lift, um, it has been really transformational for the way that we deliver care and telemedicine is certainly not going away. This is something that's gonna stay with us for a really long time. And in terms of our ability to deliver care during, you know, covid 19 and our ability to, to create this multidisciplinary program, what telemedicine did is it, it dropped a lot of barriers for us for working together in space and time. It meant that we could really reach out and connect with patients in their home environment at the convenience of the patient, but also at the convenience of providers. We didn't have to get all the providers into one space to see patients at once and get them multi subspecialty care. We could see them over close, closely scheduled visits within the provider's own individual schedules, um, in the convenience of their own home and really help to help to provide a, a network and a team for them while they were, while they were at home.
Speaker 1:It's interesting cuz I've been thinking so much about this even though I've done fraud and abuse analysis on transportation for years as that has evolved after the Affordable Care Act and this idea. But it's really like the idea that you have to, and, and we we're seeing this with the vaccine and, and telehealth, like, you have to get in your car to go do, to get, to seek healthcare, to have access. And, um, and now it's like feels, sometimes I think, uh, I get, we just did a podcast with, um, two general counsels and I, I had been thinking about the idea that you'd have to get in your car in traffic to go have your blood pressure check checked while waiting in the waiting room for the doctor. And then they, you get your checked and then you get back into the car and get your blood pressure up to go home. It's like that that idea of, and that that, that, that might go away or that might change and how transformative that would be both for the patient and the physician. Um, because that, that, you know, that doctor's probably trying to, the physician's trying, trying to squeeze that patient in<laugh> that patient's trying to feel squeezed in and, and, and yet that, that that service needed to happen. But maybe there's a better way, and I use, I use that one as an example, sort of of half facetiously, but actually half not because that's patient monitoring that could prob maybe be able to happen at home. Um, so do you, so you think it's gonna, it's here to stay. Do you feel that, did, did you feel like you got a positive response from the patients and the physicians? And I mean, here we are a year, a year later. Um, you, how did, how did you think it went? I mean,<laugh>, what were some of the barriers and what were some of the opportunities you saw?
Speaker 4:So I wanted to chime in about that. That's what I've been running in my mind. I mean, I love, um, there's plenty of advantages to having telemedicine incorporated into our system, but there is something that is lost in the physical connection with the patient that you can't, um, kind of capture, uh, objectively. And, and to me as a physical medicine and rehabilitation doctor, a lot of what we do has to do with movement with, um, you know, kind of touching the patient, right? So we, I I really enjoy telemedicine, but I'm definitely more of a hybrid person, um, because I still need that physical contact with the patient population. Um, I feel like in general, patients have received it well because as a society we have changed towards kind of telecommunication in general. And, and you can still achieve some, you know, um, level of body communication, right? When you're, when you're seeing them and seeing the home environment is priceless. You know, being able to see, you know, if they're having trouble going up and down the steps, what do they look like? What kind of modifications you can suggest for them to improve mobility. That's been, um, excellent. Um, however, yeah, there's, I definitely like the hybrid model for sure.
Speaker 1:Yeah. This idea of healing. I know there's all these, there's, uh, studies being done on like artificial intelligence and interaction and whether, and I just keep going back to like biased<laugh>, the potential for biased and also the potential for this, this idea of healing or caring or something about the, I mean, we, if anything, I would think the pandemic shows this idea of like how, how we as humans need that contact and, and how we can like, you know, your professional judgment. I'm, I'm sure in some, in some cases really w is maybe hindered by the technology and other times maybe it's not. Right. Um, so let's also talk a little bit about your clinic and, and this, you know, I keep reading in the news and you can tell me whether you like this term or not, but these long haulers. So Dr. Braham, can you tell us a little bit about what, what are these lingering effects that we're, you're, you're fi that you were hearing about and or in the media, are they real? Is this a real thing?
Speaker 3:Yeah, so I, I'm happy to start on that. I know Dr. Parker and Dr. Ola will have more to chime in. So, yes. Uh, in and part of this, when we constructed this clinic, we were very, very fortunate to have insight from national experts, including Dr. Parker<laugh>, who had the, the insight into some of the effects that we know we are going to see post, post-critical illness. And we had a tremendous volume of patients moving through our intensive care unit, um, post covid 19 with covid 19 patients coming through the hospitalization, but recognizing the already known in the already established literature based for patients recovering from acute illness. So we expected to see a number of manifestations in cognitive health, physical health, mental health, sort of coming through the other side of this and covid survivors. Um, we had also, uh, in, in the setting of knowing all that we constructed very clear pathways for patients who were discharged from the intensive care unit, discharged from the hospital, and making sure that we were assessing those key components and capturing that information in order to best inform treatment for those patients. But we also recognize that there's, there's some information out there about, uh, what we have seen post other coronavirus epidemics, so MERS and sars, cov one and so forth. And that there was the emergence of these postviral syndromes, um, following those, those epidemics. And so with that, we built in a pathway for patients who may not have required I C U care may not have required hospitalization care, may have fallen, fallen in the initial mild category of acute illness, but still have potential for ongoing lingering symptoms. And turns out we're seeing that more and more. And it, it's hard for us to get a sense of the population prevalence of that, right? Because we are, we are a very biased source. We get the referrals for the patients that are having ongoing symptoms. But what I can say and what we can all say is that the volumes are, are tremendous. And we know that from other clinics that have popped up across the nation and been established specific to patients who were recovering from covid 19, is that once the doors to the clinic open the wing list becomes incredibly long and you have to garner additional resources to try to get patients seen in an expedient manner. So that includes physical manifestations such as breathlessness, right? We know acute covid 19, one of the primary things that puts you in the hospital is the effect on the lungs. Um, so ongoing breathlessness cough, um, Dr. Isola, I'll let comment a little bit more on some of the autonomic dysfunction that she's seen. Um, we see headaches, uh, that persist in patients. We see fatigue, um, and we see palpitations quite often. We work very closely with a cardiology team at LED by Nisha galore, one of our other, um, professors at Johns Hopkins. Um, and then cognitive, uh, dysfunction as well as mental health impacts, which I'm gonna, I'm gonna see to Dr. Parker to talk a little bit more about.
Speaker 1:So Dr. Parker, it's interesting cuz I, I obviously talked to people in healthcare cuz it's, I'm a health attorney and, um, even I was talking to somebody who was a C E O and he was uh, um, cuz we're all on Zoom calls, uh, uh, he was having like after effects of covid, a CEO o of a hospital. I mean, it's, it's, and we're all like, and then we're all, like, before we start the meeting, uh, sharing antidotes about our, you know, know stories about, oh yeah, I have this headache and I can't re so I, I mean, I'm hearing it even arou amongst my, like before we start our call<laugh>, um, with administrative people in hospitals, um, that they themselves are, are doing this. So it's, it is hard to get a, a grasp on the, on the numbers and like, and where that line is between, is that just like, I'm at home and I'm not working out, or is it, um, you know, I'm more stagnant than I used to be, or is it, is this like really more prevalent and, and, um, so I'd love to hear your your thoughts on that Dr. Parker.
Speaker 2:Yeah, absolutely. If, if I take a step back and, and kind of think about how the clinic came to be, you know, I, I had spent, um, almost the past decade really understanding and improving outcomes for survivors of critical illness. And so understanding exactly what Dr. Brigham pointed out, this constellation of impairments in mental health and cognition and physical function that we know are overwhelmingly common for survivors of critical illness and we know can persist for years after patients are discharged from the I C U. And so building on that framework, and with Dr. Brigham's position as our director and her just amazing ability to get things started, um, and to get things up and running and creative resource allocation, we said we need to start thinking now how we're gonna meet the needs of this just rapidly rising population of covid 19 survivors. And we knew that at least a subset would be in the I C U, many would be hospitalized. And as Dr. Brigham pointed out, she was a big advocate from the beginning and saying, and we don't know how many patients who were never hospitalized might also have persistent impairments. And so we were able to start using that framework and understanding building on decades of literature to start our clinic in April, which, which made it one of the earliest clinics. And very early on we recognized based on the I C U survivorship literature and recovery from a critical illness that many of the symptoms that patients might encounter that would persist, would be complex multifactorial symptoms, things like fatigue, dyspnea, these are, or certainness of breath. These, these are things that often have multiple contributing factors can be challenging in many ways to manage. And ultimately what we know from that prior literature is that it really takes a multidisciplinary approach that we really needed to rely heavily on our colleagues, especially our colleagues in rehabilitation, which is why we reached out to Dr. Oola and said, we can't do this without you. We need the Department of Physical Medicine and rehabilitation engaged in this. And they were just ready and willing and, uh, very eager to, to join us on this effort. Um, because we know that, again, a lot of the symptoms that patients are having are gonna be addressed with rehabilitation that starts early in the hospital stay, even for our critically ill patients. We start rehabilitation in the first 48 hours of an ICU stay. So while our patients are still on life support, while they're still in the th of critical illness, our default is to try to engage them in rehabilitation early in their stay because we know that improves outcomes and then that rehabilitation needs to continue throughout the continuum of care to the ward, to the outpatient setting. And so we weren't gonna be able to do this without our colleagues in rehabilitation medicine. Um, and that was absolutely essential, and I'll let Dr. Ola comment on that a bit more.
Speaker 4:Thanks, Dr. Parker. Um, yeah, so it, it's been a really interesting to, to join forces and to provide the rehabilitative care for these patients. And I just wanna kind of go back to that division between the intensive care patients, patients that had ex, you know, severe disease and went to the hospital, um, intensive care unit, and then there's a second group of those with milder symptoms that perhaps didn't need, um, hospitalization. So we knew from work of an institution that the rehabilitation of I C V patients, um, you know, and we had a pretty good groundwork on how to provide that. And, um, we have a continuum with within our department at the I C U, at the regular floors continuing onto rehabilitation units and then outpatient follow up for them. Uh, but the interesting part was, I mean, another interesting part was this postviral lingering symptoms, and that's been, uh, really fascinating to, to learn about and quickly be able to learn how to best provide care for this patient. Um, and for me it's about function, right? Um, that line between just, you know, you having coronavirus for a week and not feeling well and not going to the gym to, you know, a few weeks, three weeks pass and you're not able to, you know, walk around the block like you used to, or you're not able to take care of your two year old, you're not able to play for your basketball team, you know, and, um, these are all specific examples for patients that we see and, and that group of patients, um, you know, with those lingering symptoms of fatigue, shortness of breath, uh, difficulty concentrating, um, you know, that's a subgroup of patients that will kind of linger for at least, you know, weeks, months, and in some cases have been reported up to six months after, it's hard to say at this time with, um, specific data because of the lack of it, but that's one of our, you know, what we're working on. But there's definitely, um, a line to be drawn when the degree of impairment of function and ability to do your day-to-day activities is impaired. That that's when that's when, you know, we recommend reaching out for help and, and we are
Speaker 1:Working on providing care for them. Yeah. So if somebody was listening to this right now and said, boy,<laugh>, I am having a hard time walking around the block or going up the stairs, or, I mean, I think I saw an article, I wish I could remember which news source, but it was like an elite athlete who just said, I can't, like, I can't even go, I, I'm like on oxygen<laugh> like that. I think tho those are the stories that, um, hit people because they are thinking like doc, like Dr. Parker said, they do think about the people that are in the hospital and that kind of transition. How do you get back home and, and back to, to normal, but it's the people that maybe didn't get hit as hard who maybe sitting at home right now and say, boy did that, is that that isn't normal. Like maybe I should, I, maybe I should go to a clinic. How h how do you, what do you say to those people that are sitting out there right now?
Speaker 3:I mean, I think the first thing is contact the physician you have to start out with, right? So if you have a pre-existing care relationship with a primary care provider, that is the first person to go to. And then your primary care provider can help you sort through, make sure if there's anything that needs to be addressed immediately, anything that's emergent that they help to take care of that. And then hopefully are able to link you in if you have ongoing symptoms that are with nothing emergent, um, to, uh, post covid clinic for care. What we have found, and a again, this is not advice for every single individual, but we have worked very hard on the criteria for folks who get into our clinic, who require services through us. Um, and what we have said is that we, we very, anybody who's gone through the hospital, who the intensive care unit qualifies for, for care with our clinic, just given that really heightened risk for a lot of the things that Dr. Parker and Dr. Azula described based on decades of literature in this area. But for individuals who had more mild disease upfront, we have set our referral criteria for ongoing lingering symptoms at about eight weeks. And the reason for that is really about sometimes early on, we were getting referrals for individuals at about four weeks, and sometimes by the time that they get to see us in clinic, their symptoms had resolved. Now, please do not take that as an overarching statement that if you have residual symptoms at four weeks, that it, it is entirely normal and it's all gonna go away. We just don't know that. But that was the pattern that we were seeing in some individuals. So what we encourage is thinking that that could still be in the acute phase, absolutely keep in close contact with your doctors, with your physicians if you're having ongoing symptoms to make sure that you are being assessed for any emergent, uh, emergent issues. Um, but that, you know, we, we are really here for those folks who are unfortunately having a struggling with ongoing recovery at a later time point. Now for patients who don't have a primary care physician, and this is a, a huge proportion of our population, unfortunately, what that, what that, what that means is that urgent care is sort of the way to go urgent care of the emergency department. Those, those sort of catch all those safety net resources that are there for patients who have ongoing symptoms that are really worrisome, that are not going away. And ideally establishing a primary care physician because we wanna capture these populations for longitudinal care and make sure that they have the access that they need for all of their health issues. And that this isn't just a single time point and you only get care surrounding COVID 19. And I will, I'll branch a little bit on that question while we're talking about this too. Um, and I know Dr. Parker and Dr. Isola will have more to comment on this, but we've seen a tremendous number of patients that are moving through our acute care settings in the hospitals who have not previously been engaged in care. And this can be for a number of reasons. One, that they were previously completely healthy and just had not engaged with care previously, but also, uh, populations who did not have insurance, did not have a mechanism for engaging with primary care and so forth. And what has been amazing about, about acute covid care is that really the federal government stepped in with something called the CARES Act to cover all of those costs of acute hospitalization and the acute needs of covid 19, that equivalent does not necessarily ex, uh, exist for post covid care, um, for the duration that it is expected to be needed potentially. And so what we've, we've worked very hard, uh, with and taken up as a charge within our clinic, is working with social work, working with community health workers and so forth to ensure that patients who are recovering from those acute symptoms get looped in with longitudinal care via establishment of insurance of care networks and so forth to try to achieve equity in healthcare among those populations. And, and hopefully they recover from their, their lingering symptoms of Covid 19, but now have the access to resources that they need for, for care, for the rest of their lives.
Speaker 1:Oh, Dr. Brown, I'm really glad you brought that up because I think that's, you know, we ha this obviously has been unprecedented and, um, times and it would be nice to think that we could, something positive could come out of what was something so negative. And I I the things that, you know, we even think about the, the idea of interacting homelessness and like having this opportunity to care for people that we wouldn't normally maybe and, and wrap, um, services around them. I mean, I people, if you've listened to my podcast, the, we, we, we have all these warm and fuzzy words like social determinants of health and food insecurities, and I like just want to get past those nice, those words because I think then we really talk about what the, what the issues are. But I, I do. But the idea of a, a access, the idea that people did not have care before and now have care, and that's a, um, and a mechanism to hopefully have that care and access continue is I think is really important. Um, Dr. Parker, do you wanna add to what Dr. Brigham was talking about?
Speaker 2:Uh, sure. I think, I mean, Dr. Bergham said it so beautifully. I think, um, one of the, one of the things that we do in our clinic, I, I think that's so important is to acknowledge that our patients are having symptoms to acknowledge that we might not have all of the answers right now, but we are looking and searching along with them and we're gonna support them through the recovery process. So we're here for them and, and we're here from a multidisciplinary standpoint. And I think that's one of the most important things that we do to acknowledge, yes, you are having symptoms. Yes, they're likely multifactorial, they're not going to be fixed with one single medication that's gonna take it all away, and it's gonna take a lot of work on, on our end to support you through this. Um, and I, I really think that's one of the most important things that, that we do for our patients. And a lot of times, you know, our patients are facing a number of issues in recovery. They might have difficulty with cognitive impairment and they might also have difficulty with physical function. They might be weak, they might also be short of breath. And a lot of times when I'm seeing patients in clinic, one of the things I say is, what's the most important thing to you right now? What is the thing that you wanna try to tackle first? Because a lot of times it can seem overwhelming. And so I, I think being there, being a support, helping patients to, to take that first step in recovery. And, um, I I also like to say we're not gonna wait to feel better before we do something. So we're gonna get started. We're gonna take that initial step, and in doing so, that's also going to improve mood and, and help engage the mind and hopefully improve cognition and, and start moving that ball in terms of recovery.
Speaker 4:Yeah, I agree a hundred percent. I mean, the multidisciplinary aspect of our clinic has really, um, been, uh, a unique thing that has provided excellent care for our patients. You know, I don't have the pulmonary knowledge or the medical knowledge that, you know, Dr. Parker, um, and Dr. Brigham bring in. Um, but you know, I also can bring in the aspect of functionality and how that improves, um, the patient. And, and a lot of what we do really is reassurance, you know, just like Dr. Parker said, um, just allowing them to understand that this is, um, they're not alone. That there's a lot of people that are going through similar symptoms. Um, in my case, I've been helping people, for example, reintegrate to the workforce, which is kind of part of what we do as rehabilitation physicians and, um, you know, providing tools for them to, to find accommodations at work that allows them to perform, you know, at least a few hours a day and progressively start reintegrating. Um, uh, we also have incorporated a lot of tests from our neuropsychology team, um, especially in those for co with cognition impairments. Um, it can really help them ta tease out what specifically is the, the issue that they're having, and then what tools they can apply to compensate or to progress and improve that. So it's, it's definitely been a, a team effort and all the different members of the team bring in something that helps the patient, you know, and, and it's not one thing that causes the problem. Like, um, you know, a lot of the times after they've been ruled out for having any pulmonary or cardiac issues, we notice that they still have persistent symptoms. And, um, we have seen that some of these patients have more of a, the cellia, um, meaning, uh, dysfunction of the autonomic nervous system. It's having trouble regulating their blood pressures, their heart rate. And this is, uh, known to be a postviral, um, entity. And it has been seen in other pandemics, or not pandemic, but uh, for example, sars Covid one, um, pat definitely identified, um, an increase in patients with this. Um, so in that population, we know, um, measures to support them and support their, um, their this so that they can perform and be more functional. Um, it's not only about kind of one magic pill that's gonna make the heart rate go down. It's gonna be about, you know, how to, um, drink enough water, eat enough salt, um, wear compression garments, um, do progressive and pacing, uh, progression to exercise intolerance. Um, so you know, together with the physical therapist. And then there's the, you know, the anxiety and the unknown of, of having the symptoms and not being able to work. So that's where the psychology team also comes in, helping the patients cope with, with dealing with the impairments that are brought on by this.
Speaker 1:So, um, one of the things I wanted to ask you all, which is sort of what, what kind of, what drove you to, to medicine or care or healthcare, and then what was it like to be in this pandemic? And we've heard a lot about physician burnout even before we got to this pandemic, or we've heard a lot about, um, that during the pandemic, but, but what was it like, I'll, I'll start. Um, Dr. Ola, why don't I start with you cuz you were<laugh> since you were just talking. Why don't you talk a little bit about like what, what drove you, like, what drove you into this profession and what was it like, um, during this past year?
Speaker 4:Yeah, so, you know, it's really interesting. I, I had a very kind of, uh, long path to get to where I am. I initially went into medicine to do surgery and had a neck surgery in particular. And I realized during my training that, um, that wasn't consistent with myself, right? So I wanted to do something in medicine, which is, you know, what I love that was more compat compatible with me. And I found the path of physical medicine and rehabilitation, you know, and for me, what drove me to this field is helping people live within their bodies, no matter, you know, their bodies, exactly how they stand, you know, in the moment. And, and that's what I wanted to dedicate my life to. So, um, when the pandemic started, you know, I was, we were shuffled around to different services. It was, um, a really intense moment. Um, things were being built while we were rounding around us, you know, floors were being turned into, um, you know, um, covid floors. It was just a lot of, of shifting. I was actually covering renal transplant service,<laugh>. Um, but, um, you know, it was definitely an emotional moment and there was a sensation of a, of, of a need and a call for, for, for standing up and doing what we know to do as best we could, um, in whatever capacity. So that's, that's for me, like the, the first few months it was very much I was, you know, reading about managing ventilatory systems just in case I needed to go to the I C U. And, um, just trying to prepare to be able to be there for patients in any way possible. Um, as I started working with the post covid clinic, you know, and learning more about the symptoms and learning more about how the whole body is affected by COVID 19, um, it's been kind of another call for, for putting my energy and efforts into helping people, um, you know, improve and get back to their lives. Um, and this population of patients with lingering symptoms of covid is one that I, um, you know, because of the interactions that I have with the patients and, um, you know, and the, the knowledge, um, that we have so far on the, on the need for more knowledge, you know, it calls me to, to put an effort into it. And that's, that's what I'm doing, what I'm doing.
Speaker 1:Um, Dr. Brigham, why don't you tell a little us a little bit about your, your drive into this profession and what was, what it was it like during this past year?
Speaker 3:Yeah, so it's amazing. I Alvin I have a parallel. I didn't even know, I actually thought I was gonna go into surgery as well. Um,<laugh>, I, I was, uh, an athlete back in high school in college and got injured and had a lot of exposure to the medical system through that and decided absolutely I'm gonna become an orthopedic surgeon. This is it. I love working with my hands. I, this is very mechanical. I get to put things together like this, this is great, this is gonna be it. And through, um, sort of my medical training and education and so forth, really found my passion in medicine. And a part of that is, is this common theme of of teams. Um, so orthopedic surgery absolutely has teams and so forth. Um, medicine has teams, every single subspecialty that you go through and everything, every single specialty has teams. But what I found in medicine is that we would stand around talking about single patients for like an hour at a time. And I just love that going through all the details, working with so many different subspecialists, I could not get enough. The idea of, of being very detail oriented and working in such large comprehensive teens I loved. And, um, so that really drove me into medicine. And then further into pulmonary and critical care where you spend a lot of time in the intensive care unit and it's just, it's team teamwork at, at its highest, uh, one of the highest levels. I won't, I won't say<laugh> cause I think everybody works within teams, but have just along that whole, that whole spectrum enjoyed that so much. And I think that's a part of what drove me towards this service as well. The ability to continue to work in a multidisciplinary and comprehensive team. And I, I think we can't be clear enough that this effort is not possible without each other and without many people who don't appear on this podcast. I mean, physical medicine and rehab and pulmonary are equal partners in this. We are also equal partners with home care. Um, Dr. Oola has a co-director who's not, not here, Dr. Sue Kim as well. Dr. Parker and I work as a team to, to manage the pulmonary side of things. There's, there's really so many people who are working on this at once to suc success, to, to drive success forward for the benefit of our patients. And I do think that there's some comfort in having a patient from the patient perspective in being in front of somebody who represents a larger team. Meaning that they are really entering, entering this group where they have access to so many different resources and resources that they're gonna need. And when they have a certain specific issue, um, they know that they're gonna be connected to the, the best person at the institution to address that issue within this larger infrastructure. And I think even beyond what we have at Johns Hopkins, which we're, we're incredibly fortunate to have such talented individuals to work with folks who already have subspecialties in the, in really the resources that, that we think these patients need. But this is something that takes teamwork at a national and a global level as well. And this is not a one institution, institution solution. Um, this is something that so many institutions across the nation have, have taken charge with and, and taken up to serve the patient population of, of Covid survivors. And we have been and felt very strongly about working closely with those groups, with those individuals. We all have to lift each other up and cooperate to, for the success and for the, to optimize the recovery of, of Covid 19 survivors.
Speaker 1:Great. I'm Dr. Parker, how about you?
Speaker 2:Yeah. Um, so I, I think very much similar to Dr. Brigham went into internal medicine, uh, because I, I just loved the depths, I loved the teamwork. Um, and I was very quickly drawn to the I C U and really being in the I C U has been a passion for me for a long time now. Um, and it was exactly, essentially a year ago now, I was actually in the I C U, um, heard that es everything was shutting down in, in Maryland, right? Um, our schools were closing, um, my son's schools were closing. Um, and, and that, you know, was our first look at realizing that things were gonna be a lot different. Um, I was seven months pregnant at the time and very incredibly fortunate to have just tremendous support from our university and from our division, um, who said, you know, we don't think you're the person who should probably be in our covid ICUs right now. Um, and, and they did a great job of making sure that, um, people like me felt supported. Um, and, and I felt that I, you know, for the same reasons that I went into medicine, I wanted to help people. I wanted to jump in. It was crushing me that I couldn't be in the I C U to help. And so being able to dive in and support patients through our JH packed clinic was just, I mean, it was huge. It was incredibly rewarding. You know, I, I hope that we've helped patients and it's definitely, it, it, it has allowed me to contribute in the way that I've always wanted to contribute as a part of medicine.
Speaker 1:So, you know, one of the things I've been thinking about, one of the reasons why I, I got drawn, I've been in house and I've been in outside council, one reason I got drawn back to outside council, uh, was it's usually supporting people like you, to be quite honest with you. And it was just watching the explosion of, of medicine itself and science, cuz I do a lot of supportive, um, clinical research. And so there's part of me that thinks that this opportunity and barriers, again, this idea of like, in some ways a lot of research got paused, it felt like, but also that a lot of it, you know, that explosion of of of, um, just knowledge and genome and the, you know, matching drugs with your genes and like these kind of treatments and how everyth things were gonna work together with, with AI back in the background. Um, in some ways it feels like it got paused, but in some ways I wonder if there's, I mean, you're looking at vaccine development that happened in like a year. Um, so how do you feel about the, the progression of the science of, of medicine or the sci the science behind it, and where do we think we go? Kind of go from here? Um, Dr. Braham, do you wanna go first?
Speaker 3:Yeah, I, I mean, I think we, we tapped into what we can do when we all have a common goal in terms of pace, right? A lot of things that don't, don't seem possible in terms of getting things done become immediately possible when there's an emergency. So the pace of science has been incredible over the past year, and the focus of science over the past year has been on survival, um, which is<laugh> the most pressing need. Absolutely. And I think we saw, we saw science move forward very quickly in terms of vaccination and very quickly in terms of, um, therapies on the inpatient side to improve survival, keep patients alive, improve outcomes in the acute setting. I think we are, um, that was the absolutely the appropriate focus. I think we have a, a moment in time now and, and thankfully we have a number of, uh, talented groups across the country in the globe who have been working with Covid survivor populations and actually have amassed a, a substantial amount of experience and evidence surrounding this to make sure that we now place our focus on improving the outcomes of survivors. Um, and I think that the networks and the cooperation that we have established in the acute setting, which I mean we had all of a sudden there was, there was global cooperation to face this pandemic. Those same networks, those same cooperations are being put towards improving survivor care at this time. So it's, it's pretty transformational. Um, our hope, and I think this is the way that it should be, is that these networks and the advancement of science that we're seeing now never go away, right? These are things that we should utilize, we should build, we should invest in the infrastructure now to make sure that when the next crisis hits us, these things are already in place and we hit the ground running while we are continuing to address the current pandemic. But I will say it's, it's really been, um, something nobody ever wanted. But if we have to take something from it, it's been transformational and, and really something we can use to, to, to push us forward and push us forward, forward in a better place than we were.
Speaker 1:So, Dr. Brigham, we're, is there something that like, um, so we're gonna wrap up and I would love to hear, um, is there one thing that you would like to leave the audience with? Although that was a really good one thing. If I had to say<laugh><laugh>, that's, that sounds probably it. That's a good one thing, but is there anything else you'd like to, to add or, or leave the audience with?
Speaker 3:Um, I would just, I would echo some of those things. I think continuing cooperations, keeping the same collegiality that we've had throughout the pandemic to improve the health of our populations and really making sure that we're investing in the infrastructure that we need now, so that way when the next crisis comes and there will be future crises that these systems and networks are, are fully in place and shore up.
Speaker 1:And Dr. Parker, how about you? What's the one thing you'd like to leave the audience with?
Speaker 2:Uh, I'll piggyback on what Dr. Brigham said, and I, I think what this has pointed out is that we need a, an emphasis on the importance of science, the importance of healthcare, um, and, and really prioritizing those, those resources. Um, and, and I think making sure that we're prioritizing them in an equitable way. I think Covid 19 has really highlighted a number of disparities and we have an opportunity to build on what we have been faced with and to do better moving forward.
Speaker 1:Wonderful. And last but not least,<laugh>, Dr. Zola, do you wanna give us your, your one takeaway for the audience?
Speaker 4:Um, I agree with both Dr. Brigham and Dr. Parker. Um, but I just wanna add the, the back to the, the lingering symptoms of Covid and how impactful that can be on one's life, um, for people to acknowledge that this is actually a real thing, right? And that there, there is people that present with significant impairments, uh, you know, weeks after covid acute infection that may have not had a, a terrible infection, but that, you know, have limitations and that they're not alone. And that there are, you know, we're working very hard on finding ways to properly, um, provide the care that they need to get back into their lives. And, um, I think that that's, that's one of, you know, because there's a little bit of, uh, uncertainty, whether it's, am I going crazy? Is this real? And you know, it is real there, you know, and, and there is help that can be provided. So that's my main takeaway.
Speaker 1:Mm-hmm.<affirmative>. Oh, thank you so much for that. Yeah, I'll put an exclamation point on that, that this is real. That's why we're doing this podcast. We want people to get this, we want this information out. Um, and we want people to know that there's a place to go seek help if they need it. Um, I wanna thank, uh, the doctors of Johns Hopkins Clinic for joining me today to talk about the lingering effects of Covid 19. I wanna thank the audience for joining us for this American Health Law Association podcast. And thank you everybody.