At issue: How endocrinologists, diabetes specialists are responding to COVID-19
As the COVID-19 pandemic continues to worsen, endocrinologists are confronting changes large and small to the way they practice medicine. For some, that means preparing to abandon the typical clinic day and assist as needed as internists. For others, it means navigating an unprecedented, nationwide shift to telemedicine and virtual communication, all while prioritizing the patients who still urgently need an in-person consultation and the risks that come with it.
Professional societies are reminding individuals with endocrine conditions, such as diabetes, adrenal or thyroid disease, to make sure they have adequate supplies of insulin, hydrocortisone or other needed medications, despite U.S. manufacturers reporting no anticipated drug shortages. That has many endocrinologists working to ensure patients have the medications they need to avoid an adrenal crisis or diabetic ketoacidosis at a time when hospitals are beginning to fill with COVID-19 patients.
Healio and Endocrine Today spoke with endocrinologists and diabetes care and education specialists in the United States to see how they are confronting these and other changes in the midst of the COVID-19 outbreak.
Alice C. Levine, MD
Professor of Medicine, Endocrinology, Diabetes and Bone Disease
Icahn School of Medicine at Mount Sinai
I’ll start with the positives. I’m an endocrinologist of a certain age, who was only somewhat computer and tech savvy, who has had to really hit the ground running very quickly, learning how to do everything — and I mean everything — remotely and efficiently. That’s been a great learning curve, and this will change the way that I practice and teach and do my scholarly activities in the future.
I’m the course director for the endocrinology pathophysiology course for the Mount Sinai medical students at the Icahn School of Medicine, and it happens to take place in March, in New York City. After the first few days of “old-fashioned” class, it quickly turned into Zoomamania. We all learned how to do it together. In some ways, I have gotten to know my students much better this way than I have in past years. You can see who is actively participating, who is understanding. I feel quite pleased with how we have all responded, and by all of us, I mean, the faculty, the medical education office, and the students. We’ve all bonded, and it’s become a social thing for us. We’re all so happy to see each other. A lot of students were sent home and feel quite isolated if they are still staying in dorms. I hope the course didn’t suffer for it.
My outpatient practice has changed literally overnight into primarily video visits. Again, something that neither I nor most of my patients knew how to do before. With the help of a lot of administrative staff, also learning on their feet, we have been able to convert many visits to telemedicine. There are the usual glitches, but, overall, it works and will likely remain in place for some patients long after the crisis has resolved.
I’m also a fellowship director. There, the situation is more difficult because inpatient medicine cannot be done virtually and our fellows and attendings are on the front lines. All sorts of medical and practical issues have come up, particularly regarding the management of diabetes in-house. This is a rapidly evolving situation, with each day bringing some solutions, but even more challenges. We communicate in person, albeit from a distance. Our tight working relationships have become much stronger as we are all in this together.
In short, this pandemic has created a revolution in our work world. Remarkably, even the more mature have acquired the skills and made the rapid adjustments needed to do the job.
Maria Fleseriu, MD, FACE
Endocrine Today Editorial Board Member
Professor of Neurological Surgery and Professor of Medicine
Division of Endocrinology, Diabetes and Clinical Nutrition in the School of Medicine at Oregon Health & Science University
Director, OHSU Northwest Pituitary Center
My practice is pituitary and adrenal disease, so we could not move everything to telemedicine. We have patients with urgent needs, losing vision because of large pituitary tumors, for example and these are the patients we still must see in clinic. We try to take all of the necessary precautions, of course to decrease risk of infection for patients and healthcare workers.
The most important thing I did lately, over several days, was to look through all of our lists of patients with more complex and complicated diseases. This is an academic practice, so I am very lucky to have a database that helps me with this. We called several of our patients with Cushing’s disease to make sure they have enough medication and checked to make sure they have enough reserves to take the right doses. I also wanted to speak with every patient, either by phone or by video, to discuss their higher risk for COVID-19, because they are slightly immunosuppressed, and they all need to understand that and stay home.
For patients with Cushing’s who had adrenal insufficiency in the past or who have been admitted with adrenal crisis while on medications for Cushing’s, I decreased their doses. You must balance being “perfectly” controlled during a time when you cannot conduct labs.
For patients with adrenal insufficiency and /or risk for adrenal insufficiency, we contacted everyone who needed to have at home extra hydrocortisone or dexamethasone emergency shots; we wanted to make sure they had at least two at home. Some insurance companies gave us a hard time about this, but it’s getting better. We told everyone to have at least another month of reserve medication. I told some patients that if they get really sick — if for 2 to 3 days, you have a fever — you can triple your hydrocortisone dose. This is not a time to underdose anyone. Usually, I tell patients at every visit that being on the low-dose side is important and better to decrease your cardiovascular risk and bone disease risk. Now is not the time to do that.
I’m triaging patients who are referred to us with pituitary tumors from several states. That is something I used to do for 15 years. Now, what complicates this is I can’t see the patients all of the time. For some, I cannot even send them to the lab. This is probably the most complicated thing, and we just have to think it through. If the patient already had a MRI, and the MRI shows a tumor is pushing on the eye and it is an older patient, then yes, they need to be seen. Do I want to patient to leave the house if they are not experiencing vision changes? No, probably not. If they can get labs done locally in their community at a small lab, maybe, but even that I think should be an overall risk/benefit balance issue to discuss with patients.
In normal times, I would see everyone with a large pituitary tumor within 2 weeks. That was a different time. Now, not getting patients sick is the priority. In the hospital, we still need to see patients, and it is very interesting how, during this time, I have changed my perception of ‘perfect’ treatment. If I decrease a subcutaneous medication used, for example, to treat acromegaly in the hospital, two times a day vs. three times a day to preserve some masks and gloves for nurses, does that really change what we’re doing? The answer is, probably not, and we can definitely arrange for different dosing to aim for improvement rather than “perfect” labs. I went to medical school in a communist country, so maybe I am a little more prepared for these changes. First, we do no harm. We balance what is best for the patient with what resources are available to us.
Susan Weiner, MS, RDN, CDCES, FADCES
Endocrine Today Editorial Board Member
Owner and Clinical Director, Susan Weiner Nutrition PLLC
Last week, after more than 25 wonderful years of running a successful office-based nutrition, diabetes education, and lifestyle counseling and coaching private practice, I moved to a home-based, virtual HIPAA-compliant platform (www.susanweinernutrition.com). It’s extremely important for clinicians to continue to respect each individual's needs and wants — both emotionally and physically — during this challenging time and beyond. Using a virtual platform allows me to see and connect folks, no matter their current circumstances. So far, even those who were initially skeptical to use “cameras” and “computers” are extremely thankful that we can be together. I’m doing all that I can to make this transition as seamless as possible. I've decided to lengthen the time of each session, so people who feel isolated do not feel rushed and they can share their concerns. It's vital for every health care professional to let those we work with and care for know that we are here for them and that they are not alone.
Richard Auchus, MD, PhD
Professor of Pharmacology and Internal Medicine
Endocrinologists are internists, so we are getting bombarded with preparations for inpatient service. Right now, most of my efforts involve keeping up with all of the emails about what is happening in the hospital that I, normally, have nothing to do with. Our clinic is definitely suffering. We are shifting to video and phone call visits and trying to make sure people have their supplies of insulin and hydrocortisone. Our special procedures are shut down, so for our primary aldosteronism patients who are trying to get adrenal vein sampling done or need surgery, we are just treating them medically until we can get back to that. We are just doing the best we can. At the same time, we are trying not to kick the can down the road. If people reschedule their appointment for later, well, later will be a backlog, too. We are trying to get done what we can without the face-to-face contact.
We’ll survive this as a nation and as a health care system, but I think the silver lining is, in the next year, our health care system will advance by a decade. We are not going back. Once a chronic-stable patient realizes that, for a 6-month how-are-you-doing visit, they really do not need to come in for a physical exam, and instead can do it remotely, the consumer will demand this mechanism of care. Medicare and private insurance are going to have to pay for that service. There is going to be no more, call the doctor with a new problem or question, do this by phone without compensation. Virtual care is care, just like direct in-clinic care. It is going to be more efficient. It is going to save patients time and money. The VA has been doing this for years, and there is no reason that the rest of the country should wait any longer. Even if we get past the novel coronavirus, we still have the flu, which will kill more than 30,000 people in the USA this year. How many deaths from influenza could be prevented by conducting video visits instead of having people come to see the doctor when they really don’t have to? We have to remove these barriers, and I think finally, we will.
Theodore C. Friedman, MD, PhD
Chairman, Department of Internal Medicine and Endowed Professor of Cardiometabolic Medicine
Charles R. Drew University of Medicine and Science
The move to telemedicine is going in a one-way direction. I don’t think there is any going back to face-to-face visits once patients see the advantage of staying at home and not having to park, particularly in California. This is going to be a major change in the way we practice medicine, all because of COVID-19. For my lower-income patients, the show-rate used to be about 60%, so 40% didn’t show. By phone, they’re all answering, so this is providing better care because it is easier for the patients. For my private practice patients, we’re conducting visits by video chat. I’m also doing this now with out-of-state patients. I had a lot of people who said they wanted to see me but couldn’t afford to travel, and now they’re jumping on the chance to do a virtual visit from out of state.
In my private practice, I’m really worried about this economically. This month, people can still pay their mortgage. But once people are out of work, and they can’t pay their mortgage or their rent, they’re certainly not going to have the money to pay to have a consult with me. The economics is going to hit the medical profession drastically. People will say, ‘I can’t afford to see my doctor,’ particularly for those in private practice. I’m trying to think in advance. I’m giving people Amazon gift cards if they keep their appointments. That way, for the people who maybe are still able to afford the visit but things are tight, perhaps this will help. It will incentivize them.
Jonathan D. Leffert, MD
Managing Partner, North Texas Endocrine Center
Past President, American Association of Clinical Endocrinologists
We are currently under a shelter-in-place order here in Dallas, so everyone, unless they work for a company considered an essential business, is home. We’re all adapting to so many rapid changes, the biggest being the move to telemedicine. It was challenging for the entire office, from our front office staff to our providers. We’ve done it reasonably successfully. To think about how much of a change it is, from walking in and seeing a patient — something I have done for 29 years — to getting on a call and having a face-to-face on a computer, it’s a very different experience. We can’t get a weight, a blood glucose, an HbA1c, all of the things we routinely do during a diabetes visit, we can’t get in this setting. We have to go with what the patient has on their blood glucose meter, or what they have if they’ve downloaded CGM data. We’re limited, definitely. I’m also refilling a lot of prescriptions and making sure people have what they need. I’m not taking on new patients at this time.
We do still see some patients who come into the office. In our setting, because it has a small hospital, physician offices and a rehab in it, the hospital is screening every person who comes in the building, every day. I am screened every day, which is a good thing. At least we can tell our staff that everyone has been screened. The biggest issue for us down the road is, if we happen to see a patient or staff member who becomes ill and exposes our staff, we will need to self-quarantine and would have to still try to conduct telemedicine visits from home.
There is a financial significance as well. We’re seeing about half of what we normally see, in terms of patients. That means half the normal revenue we normally bring in. That is going to be challenging, to make sure staff gets paid, and make sure all the bills are paid. From our perspective, it’s whether or not we have to furlough staff for some period of time, because we can’t afford, or don’t need, as many staff as we normally do, because we’re not seeing as many patients. Those are the kinds of decisions I will be facing here over the next number of weeks. That is the other thing that makes this anxiety provoking. No one knows how long this will go on, or what this looks like down the road. – by Regina Schaffer