Watch the AMA's daily COVID-19 update, with insights from AMA leaders and experts about the pandemic.
Featured topic and speakers
AMA Chief Experience Officer Todd Unger speaks with Brad Dreifuss, MD, an emergency physician and public health specialist on the front lines in one of the U.S.’ COVID-19 hotspots, Arizona.
Learn more at the AMA COVID-19 resource center.
- Brad Dreifuss, MD, emergency physician and co-founder of HCW Hosted
Unger: Hello, this is the American Medical Association's COVID-19 update. Today, we have a special front-lines update with Dr. Bradley Dreifuss, who will give us an inside look at being a physician on the front lines in Arizona, one of the hotspots in the country challenged by COVID-19, and his extraordinary efforts to protect health care workers and their families.
Dr. Dreifuss is co-founder of HCW HOSTED, and an emergency physician and public health specialist in Tucson, Arizona. I'm Todd Unger AMA's Chief Experience Officer in Chicago. Dr. Dreifuss, you recently wrote an article that appeared in the New York Times, and was picked up by a number of other media outlets, describing the harsh reality of being a frontline physician in a hotspot. What can you tell us about your life in the emergency department in Arizona right now?
Dr. Dreifuss: It's been a bit like the twilight zone, frankly. Yeah, volumes have been going up. We kind of saw it coming, and of course it's here now. We've got patients who are now being transferred up to Phoenix, because there are no beds in the city, especially for ICU patients. And so, it's definitely upon us. I think my last shift had 50% or more of my patients were COVID, or COVID suspected patients.
Unger: I understand you have your own personal challenges in terms of living situations, just like many physicians have gone through on the way to Arizona. How has it been for you?
Dr. Dreifuss: It's been challenging. We've tried to take a progressive approach, kind of watching what happened in Wuhan and in Italy, and then in New York, where health care workers needed to be housed away from their families to protect them and their families. And that's provided its own challenges as far as trying to figure out the emotional and psychological effects on families, et cetera. And so, it's actually led to us putting forth an effort to build an organization to address that as well. Working at nights in the emergency department, and trying to build the HCW HOSTED during the day.
Unger: I had a chance to talk earlier in the pandemic to a number of physicians in different parts of the country, some of which had not been a hit by the pandemic yet. There've been a couple of months since the peak of this in New York. How have you and your colleagues been spending that time to prepare?
Dr. Dreifuss: I've been working with a transdisciplinary group of folks from around both the university and the city, to try and figure out how we can protect our workforce. And we started with housing, and getting some folks into Airbnbs and hotels, and others have rented houses. And had started, I have built a psychologic first aid, and I'm moving more towards peer led emotional support groups, and also adding resources like childcare, and other services for families.
Unger: Getting that infrastructure in place to free positions up to respond to the search. Is that how you've used that time?
Dr. Dreifuss: Yeah, it's not as much been physicians, quite frankly, as it's been nurses, and respiratory therapists, and aides who work in longterm care facilities. As you know, our longterm care facilities have just been ravaged, and so, folks who have at-risk people at home, aren't needing a place to stay, people who become positive need a place to stay. And it's not something that our health care model, or health care companies, have as a mandate, nor do the federal, state, or local governments.
And so, we've been trying to figure out how to put that together, and how to make it community based, because the community really wants to support the health care workforce, and our teams. And again, I like to emphasize, it's not just physicians. In fact, we're one of the smaller numbers of folks working in the front line. It's our entire teams, because people are emotionally stretched exceptionally thin. We've had colleagues die already, non-physicians and at this point here. And it just weighs heavily, and it's like being deployed for a long period of time without actually having any relief.
Unger: You described health care workers as "close to breaking." In addition to these challenges, what are the factors that are impacting their physical and mental health?
Dr. Dreifuss: I mean, people are being estranged from their social supports, and their friends and family. Their family members worrying about catching COVID from us, especially if they're living at home, if they are quarantining. Yeah. As you know, what happens in the health care workspace, isn't always in line with what's actually beneficial for patients or staff guidelines aren't exactly covering the safest protocols, or what could be the safest protocols for PPE. And not just for those of us who are physicians, but also for our unit coordinators, and our social workers, et cetera.
And so, people recognize their worth. They recognize they could be doing other things. They're recognizing the strain and stress and in a community that has not been primed to really be at terms with vulnerability, people are reckoning with it now. And we're trying to find ways to actually use that vulnerability in positive ways, to be able to express our needs, and hopefully have more of a lobby in that regard.
Unger: What did you have a chance to learn from physicians on either coast that have been through this pandemic surge before? What kind of lessons have you taken from them that you've tried to employ in your setting?
Dr. Dreifuss: I mean, frankly, my friends in New York are some of the top notch physicians I know, who have been deployed with NSF, and also work in global health as I do, and are very resilient people. And honestly, the beginning of April, they were close to breaking. I would call and check in on them and they were totally emotionally spent. And so, it made me realize that we needed to band together, so my partner and I have been pushing, pushing, and now since the op ed came out, and the voice is out there, that folks are actually comfortable coming forward and stating their needs, sharing their stories a bit more.
I think it's ubiquitous now in our corporate health care models that employees and those of us who are working on the front lines are scared of what our employers will say or do. You saw it around the country, people were being censured, or fired. And of course there's legal ramifications for that, but even more, it has drastic effects on the morale of our frontline workforce. And we haven't been seen as anything other than blind items on a profit loss spreadsheet, and I think now our health care companies are starting to realize, they can't easily replace us. And so, we need to have our needs met, and we need to be working together to try and share the burdens..
Unger: One of the first areas where physician voices were really heard in the initial stages of the pandemic was around PPE and the shortages of it. How is that for you right now?
Dr. Dreifuss: I think a lot of us have gotten our own N95 respirators, so that's been helpful since our hospitals are now allowing us to use our own. But it doesn't mean that all the staff have been allowed to use them when they're not in patients' faces, and the reality is, that patients are all over the place. They're up and going to the bathroom. We don't have our emergency departments or our workforce structured in a way that really allows us to curtain off specific areas. The workplace has not been designed for COVID-19 and there haven’t been major adjustments, at least in the emergency departments to address that.
And so, it's just been a matter of trying to make sure everyone's using it, trying to create the culture of safety. And then of course, everyone being on guard all the time, people get fatigued and get somewhat complacent. Trying to create a culture of safety is something that some of us push really hard, but that's not a top down effort. I don't feel like it's those of us who actually understand the risks and what it would do to lose more people on our team.
Unger: You and several others started the collaborative that's called HCW HOSTED to help health care workers and their families cope with many of these issues. Can you tell us some background about it?How did you start it? Why did you start it, and what does HCW HOSTED do?
Dr. Dreifuss: Yeah, it started with my wife and I. She's finishing her public health degree, and she defends it on Friday, but we reached out to our medical anthropology colleagues, and some of our other public health colleagues, and psychology colleagues to really try and brainstorm and figure out what we could do besides just housing. We developed a model. We essentially deployed it, worked with the County, worked with our chambers of commerce, and visit Tucson, which was huge because we need to have a real strong community rooting to whatever you're doing. Especially because this needs to be city or county wide, at least, because if one hospital goes down because folks aren't protected and supported, it affects the rest of the hospitals. It affects the whole population.
These are really community-based issues, and so, kind of redirecting attention there, and we've had great success. We've been housing folks from the longterm care facilities. We've housed some firefighters. We've housed physicians, nurses. I think we've housed or provided services for about a hundred people.
Unger: Beyond housing, what do you say are the kind of most important, or challenging services that you need to provide to frontline workers?
Dr. Dreifuss: We've helped a small crowd because we weren't an organization until recently. We were using a community impact model, and so, we were trying to engage with the university and with the health care systems, and they didn't really have a mindset for how to address it, so we incorporated. But we have been providing psychologic first aide through iCares, which came out of 9/11 first responder work, and are moving more towards a peer-led emotional support groups.
There's also arranged childcare for folks with special needs children, and are looking at, especially as school starts back, to what kind of teaching support we can be able to put together for health care workers, and their families, because often we have households with both parents trying to work, and taking care of the kids, and making sure the kids are on task is obviously a huge challenge. This is going to be a year long, at least, that we're in the trenches, so we need to be able to provide the supports. And frankly, really ... sorry.
Unger: No, go ahead, as you think about the pandemic kind of rolling through these different areas, what advice based on what you've been doing over the past few months, would you give to physicians and health care teams?
Dr. Dreifuss: Really think about the team, really change your orientation from us being in control all the time, to really thinking about the teams. How do we advocate for everyone's wellbeing really with a mind of equity? Well, I have some colleagues who have been paying to be in a hotel during the two peaks. Most of our colleagues on the frontline with us can't afford to do that. Many are single parents, and we need to be thinking with a mind of equity. If we're going to actually have functional teams, how are we going to make sure our environmental services, or our respiratory therapists, our social workers, our nurses, our techs—how can we keep everyone supported so we can all work together?
Moving away from a physician-centered model, I think will also be useful, as we are going to need to reimagine our health care systems. COVID stands to break our systems, especially this winter with COVID, and flu, and other viruses, really increasing the burden, and really creating a need for having a more holistic approach to health care.
Unger: Do you see any measures being taken in Arizona to help curb what you're seeing as a pretty significant surge?
Dr. Dreifuss: It's become obviously very political issue, which we need to move away from politicizing this. This is a human issue. This is a community issue. And so, there has been more of a push for masking with the municipalities. Cities can enforce their own rules at this point, but there needs to be a state or federal based mandate for both on masking and physical distancing.
If we open too early, which we did, but if we closed down and reopened again too early, we're going to be worse than we already were before. And people fail to think about the longterm consequences to the health of the workforce, and our competitiveness, and both the global, and national economy. Our small business owners, are they going to be able to work hard and scale their businesses if they have residual lung, kidney, and heart issues? Not to mention the strokes and other cognitive issues that are coming into play.
Unger: And so, this is really not just an issue of physicians making a lot of sacrifice. We really asking the public to do the same.
Dr. Dreifuss: That's exactly right. If we want to have a health care system that's able to care for our communities, the communities need to rise up as well. We need to take very much of a World War 2 mentality where everyone sacrificed, everyone contributed. And we don't quite have a Rosie the Riveter figure at this point, but we should, and we need to rally around it, and not make it a political issue. Wearing a mask is not a political statement. It's a public mandate and if people aren't wearing masks, it's foolish, especially with the data that shows that there's significant impacts in decreasing COVID.
Unger: I think the term that you used was health citizenship. It was an interesting way to describe that. Where did that come from?
Dr. Dreifuss: That came from Mark Nichter, one of my medical anthropology colleagues. Mark and Amy Nichter have been absolutely invaluable in helping us frame and put into social science terms a lot of what we know needs done. And the reality is, when we're talking about communities, we need to be involving our social scientists in our medical training these days, we need to be moving much more towards the integration of our sociologists, our anthropologists, our psychologist, because what we're doing every day is working with humans, who we work at bedside one to one, but really we're also treating the whole family, and we often acknowledge that.
And when it comes down to it, we're treating whole communities, so we need to have much more of our social scientists, and their frameworks really entering into what we do in the emergency department, and clinical spaces across the board.
I mean, we've talked about code switching now, which is great, because that's what most of us who are effective in our jobs and what we're trying to teach do, but we need to put those in much more social science terms and integrating even more of the qualitative research so we can figure out how effective we're being in our messaging and working with our patients, and their families.
Unger: Do you have any suggestions on that end of things that you've found that have worked?
Dr. Dreifuss: Absolutely. I mean, one of the biggest ones right now is when we're talking with our patients, when we we're interviewing our patients at the bedside, asking about the house, realizing that COVID-19 is a household disease, the weakest link in that household, and people going out not masked, not physically distance, going out and partying, et cetera; being social, is the cause for people's illness. You can be adhering to everything as the patient, but if you have one person who is a weak link in the household, everyone stands to get sick, and very sick, at that.
Unger: Yeah, it was very interesting over the weekend, over 4th of July weekend, along with other millions of other people to watch Hamilton and see, and be struck by how freedom, independence, have been very individualized and not really as much applied to our country. And I really like your message about health citizenship, and the responsibility that individuals need to take to help physicians, and the rest of our country.
Dr. Dreifuss: We actually, we have a lot to learn from other countries as well. I mean, most of what I've learned along the way has come from my colleagues in Uganda, and Ghana, and Nepal, and places where social cohesion is much higher. We are rugged individualists, and I honestly don't feel that serves us very well, because we're global citizens at this point, as COVID has just made exceptionally clear, and SARS-1 should have as well, and Ebola showed as well. But I think now is the opportunity to actually learn, learn, really learn from it. Yeah, health citizenship is absolutely, it needs to be framed that, and masking being patriotic.
Unger: Dr. Dreifuss, how do you take an idea like HCW HOSTED that has started more regionally in Arizona, and expand that to a much broader geographic area?
Dr. Dreifuss: Thanks. That's a great question. And honestly, it has to be from the very genesis. As we watched COVID sweep across the world, and then across our country, we recognize the fact that we need to build the supports, and it needs to be community-based. Whether we're talking about housing, where in any city or any town you have hotels. You may have a university in dorms. You have folks who are willing to volunteer their homes. You can set up spaces. You need to be working with the business community, because you're talking about the vitality of a community and sharing the economic generation of that local community is intact.
And so, we built this with the mindset of both equity and being able to have it be in whether it be Tulsa, or New York, or Cleveland, or Uganda, because you could have based in basic resources. Creating a platform to do that, a tech platform, is something we've done in kind of a 1.0, where we can manage the housing. We can manage the symptom monitoring, and we'll hopefully be testing results, so you can move folks who are asymptomatic and working, to housing where people have symptoms, to another where they've tested positive, and can be moved back with both treatment sources, and remote patient monitoring, telehealth, et cetera.
Dr. Dreifuss: Yeah, we've been really fortunate, and we are incorporating as a formal organization, and are applying for private 1(c)(3) status. We were accepted into the UA forge startup incubator accelerator program, and really working on building out a social entrepreneurship business model to allow for linking of community-based resources to a more top down resources from health care companies, and local municipalities to have this first aid. And the first peak of the first wave was essentially to get the operation down, and understand what needs to be in place. The feedback mechanisms from the health care workers using the services, to then inform what needs to be in place, because of the different phases, and when you have different prevalence levels, people have different needs, whether it be housing, emotional support and really be prepared for what could be a tsunami of COVID and flu this winter, just so we can support our health care workforce, and try and guarantee the resilience or better guarantee the resilience of the workforce over the long haul.
Unger: Well, thank you, Dr. Dreifuss. I think that's really important how you've defined surge capacity, not just in terms of room for patients, but also building an infrastructure to support our health care teams as they fight the pandemic.
I want to thank you for joining us. I'm sure you're exhausted, and I wish you and your colleagues the best of luck as you fight this pandemic in Arizona. Thanks for being with us here today. For more resources on COVID-19, go to AMA/assn.org/COVID-19. Thanks for joining us and take care.