Incremental risk amid COVID-19 re-openings: What do we value most? [PODCAST]

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“Grocery shopping is not optional; it’s necessary. But if you go every day and to multiple stores, you are increasing the chance you will be exposed. From my informal survey, this practice is extremely common. Yet, experts advise to consolidate shopping. In fact, in my experience, there is always at least one person (shoppers AND workers) in every store I have visited who is either not masked or masked incorrectly.

Many people report that they are going stir-crazy without seeing friends and family members or being among others. So the trade-off is clear: maintaining sanity is prioritized.

Everyone wants things to return to normal, so they are doing normal things, albeit with precautions. In reality, there is still so much that is unknown about coronavirus transmission, so it is too soon to attempt ‘normalcy.'”

Sara L. Merwin is an epidemiologist and co-author of The Informed Patient: A Complete Guide to a Hospital Stay.

She shares her story and discusses her KevinMD article, “Incremental risk amid COVID-19 re-openings: What do we value most?”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Sara Merwin. She is an epidemiologist, and she is the co-author of the book The Informed Patient: A Complete Guide to a Hospital Stay. Sara, welcome to the show.

Sara L. Merwin: Thank you, Kevin. Delighted to be here.

Kevin Pho: So you wrote the KevinMD article “Incremental risk amid COVID-19 re-openings: What do we value most?” So we’ll get into the article in a little bit, but first off, can you share your story and your journey to where you are today?

Sara L. Merwin: So after my first degree, I realized that I wanted to pursue medicine, and I went back to school for post-bac sciences and prepared to apply to medical school. But I couldn’t figure out a way to balance my family life, because I had children already, with the kind of dedication and time that I would have needed to do this. And I settled on a career in public health and went back to grad school, and that degree in epidemiology led me to this career in clinical research, mostly on the inpatient side, running the gamut from enrolling patients in clinical trials to patient and professional education, and ultimately to research methods pedagogy and study design.

So inside the hospital, I had this immersion in clinical medicine with all kinds of health care professionals: physicians, nurses, pharmacists, patient care, and other hospital staff. And because I was on soft funding for many years, I had to follow the money, and I got to work in so many different medical and surgical specialties: pulmonary critical care, hospital medicine, geriatrics, orthopedic surgery, and cardiothoracic surgery. This exposure has been really helpful in shaping my perspective.

I was writing a lot for the scholarly literature, but also translating IRB protocols into accessible language for a general audience for informed consent. In parallel, I found myself advocating for family members during their inpatient stays, and I began to be interested in demystifying the world of the hospital, which is so overwhelming for most people who come in to the emergency department and the hospital. And this led to writing The Informed Patient book with a hospice colleague, Karen Friedman.

Kevin Pho: Fantastic. And we’re going to talk about your article in a little bit, but I’m interested in hearing, from a patient standpoint, what are some things that we can do better?

Sara L. Merwin: From the hospital standpoint, we talk about shared decision-making and allowing the patient and family to be full partners in their medical care. I think that movement is growing, and it’s something that we encourage in the book, and also when I speak and blog: that patients have to be proactive, and the clinicians have to listen to them and include them in that partnership.

Kevin Pho: And when you say patients need to be proactive, what kind of questions should patients be asking when they have medical care?

Sara L. Merwin: They should really ask about everything. They should ask whether there is a less invasive, less painful, less harmful way to get diagnostics or therapeutics. They should pretty much question, in a polite way, decisions that they feel their health care providers are making for them.

Kevin Pho: So let’s get into this KevinMD article that you wrote, “Incremental risk amid COVID-19 re-openings: What do we value most?” So you wrote that article in the third week of August, and we’re speaking in the second week of September now, and we have schools reopening, we have various restaurants reopening across the country. Now, for those who haven’t read the article, can you share the story behind it and maybe walk my audience through it?

Sara L. Merwin: So from the time that we first felt the first whispering of the coronavirus coming to the U.S., because I’m a New Yorker and because I’m an epidemiologist, I was pretty much transfixed with following the story and the science, and I became a resource for friends and family. I was blogging about how to protect ourselves and how to make good decisions about not transmitting and not acquiring the virus. And I noted in these exhaustive conversations with people, particularly as reopening started, that there was a broad range of optional activities that people were pursuing, and I was studying the psychology of decision-making in the context of the pandemic.

So for example, people were advised by the top experts not to go grocery shopping too often, to consolidate their shopping trips. But I spoke to a lot of people who were going to the store every day, or very casually, and not realizing that every interaction out in the world brings risk of both transmission and acquiring the virus. So there was a sense of complacency, or denial, or risk-reward that I saw among people who really thought they were taking care of themselves. And then also, I think there was this “How do I balance preserving my sanity and my loneliness during lockdown?” Particularly as things started opening up, I saw that the wisest choices were not being made by some people. So I was really interested in that risk-reward balance, and that sense of denial that we have, because the pandemic was so unbelievable to us.

Kevin Pho: When it comes to measuring individual risk, there’s a lot that goes into that equation. It could be people’s value judgments, it could be where they are in life, and certainly it comes down to risk tolerance. What kind of questions should patients ask themselves when it comes to assessing their own individual risk tolerance?

Sara L. Merwin: Well, they have to look at their own health status. They have to follow the local prevalence; our town and county health departments publish those statistics. And it’s really important to see what the transmission rates are in the community, and to put that into the mix with their own health status and age. So it’s complicated for many people to make those assessments. I also encourage them to use these tools. There are infographics that explain what your risk is, all the way from taking a walk in the park by yourself, versus going to a baseball game, or being indoors in a bar with friends. So I encourage self-assessment, putting everything into the mix.

Kevin Pho: What are some examples of things that are high risk that you see people are doing regularly today?

Sara L. Merwin: I think people are moving about too much. I think if you can choose to reschedule non-essential visits, or going to the salon, or going to the barber, and do as much outdoors as possible. So with telehealth, it’s possible to meet with doctors for routine visits remotely, versus going to a waiting room where there may be other viruses or infections going around. There’s just too much moving around.

Kevin Pho: Now, from a clinician standpoint, we have a lot of clinicians who listen to this podcast. Do you have any advice that you can share with us on how we can improve that public health messaging, on how we can improve the communication when it comes to incremental risk to our patients?

Sara L. Merwin: I think clinicians have to be very forthright with their patients about the risk that people are incurring, and to encourage, obviously, mask wearing and hand washing and being outdoors whenever it’s possible, and protecting their loved ones who are most at risk, so the elderly and those with comorbid conditions that might predispose them to a bad infection and a bad outcome.

Kevin Pho: So I’m going to ask you to put on your epidemiologist hat. Now, we’re speaking in the second week of September, and there are a lot of predictions of another wave in the fall, especially as schools and colleges begin to reopen. Now, can you predict what you think is going to happen in the next few months from a public health standpoint, and what are some of the things that we can do to help mitigate some of that surge?

Sara L. Merwin: So I think as schools reopen, and I’m hearing local reports, just anecdotal reports, that in our local districts. And here in suburban New York, the pandemic hit us very, very hard, and I think before things get out of hand, it’s time to pull back and decide what is truly important. So there’s always this balancing of the economy, but if we can keep the kids from transmitting the virus, we’re going to go a long way in averting the kind of total catastrophic situation that we saw last April and May in New York.

Kevin Pho: We’re talking to Sara Merwin. She is an epidemiologist, and she wrote the KevinMD article “Incremental risk amid COVID-19 re-openings: What do we value most?” Sara, is there something that you know now that you wish you knew back before the pandemic started?

Sara L. Merwin: I wish I had trusted my own intuition. I’m a person who carries masks on board with me when I fly, always in my go bag. And in March in New York, I was going to stores, and no one was wearing masks. We knew that the virus was respiratory spread, so why weren’t we covering our faces? I think if I had trusted my own sense of vulnerability to the virus, I would have acted differently. There was conflicted public health messaging, and I think that set us back quite a bit.

Kevin Pho: Now, go into that. What were some of the conflicts that you saw in the public health messaging, and how can we improve on that going forward?

Sara L. Merwin: We were told not to wear masks, and that was because we needed to protect PPE for health care providers, and that was a primary focus. But it took a while to develop the idea that people could put a bandana over their nose and mouth, and although that wouldn’t do the same job as an N95, at least it would prevent some of the droplet spread. And of course, we didn’t know as much as we do now about aerosol spread. We were somewhat irresponsible about just discouraging people from being indoors.

Kevin Pho: Now, I’m going to ask you for a couple of take-home messages. Do you have one aimed toward patients, and do you have another one that you can aim toward clinicians?

Sara L. Merwin: My message to clinicians is to include patients and their personal advocates, family members, loved ones, and friends. Include them in the partnership to make good decisions, and listen to them. And of course, in the hospital, this is such a tragic time, when the most vulnerable people don’t have their advocates by their side, and that’s to protect health and safety for everyone. That’s the message for clinicians. And for patients: Be proactive, don’t let down your guard, be careful and prudent, follow the public health advice, and always advocate for yourself or your loved ones.

Kevin Pho: Sara, thank you so much for sharing your time and insight, and thanks again for being on the show.

Sara L. Merwin: Thank you.

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