Before you skim past this editorial for being just another piece about COVID-19, I promise you a somewhat different take. As the pandemic continues, it has become clear that we must learn to live with this “new normal.” Early in the pandemic, the message for patients and everyone else was to isolate. When New York City was one of the nationwide “hot spots,” most of us understood the gravity of the situation and strove for a full lockdown. That involved remaining indoors most of the time, with many of us whose essential occupations put us at risk being advised to sleep apart from our families. Extended family members who lived elsewhere were cut off, schooling was remote, and many of us had groceries, medications, and other necessities delivered; several of my patients reported that they were leaving their mail and packages untouched for 72 hours in an effort to allow any virus on the packaging to die off. If I were someone who traffics in conspiracy theories, I might even think that Jeff Bezos created SARS-CoV-2 to boost Amazon sales. (Amazon stock is up 94% as I write this letter on August 21, 2020, compared with its price on March 16, 2020, the day New York City closed the public schools.)
As a physician, my first order of business in those early days was to educate my patients, along with friends, relatives, acquaintances, strangers in my building, and anyone else who would listen. I explained the mode of transmission and the importance of social distancing, mask wearing, hand washing, and not touching one’s eyes, nose, or mouth. I explained the difference between N95 and KN95 masks, and even the difference between R95 and P95 masks. (Please let me know if anyone wants a tutorial; I will be happy to include one in my next letter.) I instructed my patients to stop wearing plastic gloves and just use hand sanitizer, and to open their mail when it arrives but wash their hands afterward. I told them that walking outside is safe as long as they maintain their distance from others and use a mask as needed.
I did have some difficult discussions with patients. There were weddings, birthdays, graduations, and funerals that could not be attended. Some patients had young adult children who were living at home and telecommuting but still socializing in person with friends, potentially placing everyone in the household (and others) at risk. Sadly, some patients chose to defer lifesaving treatment on the basis of a misguided calculation of risk.
We have made it through to the other side in New York City, at least for now, and it is time to help patients re-engage with life. But how safe are they? Various vaccines are moving forward expeditiously, but none offers a guarantee of success. Are we anywhere near to achieving herd immunity? Some experts say that only 70% or even 50% of a population must be exposed (or immunized) to achieve herd immunity. Others caution that herd immunity is elusive, given the rapid disappearance of antibody titers. We therefore must assume that we will be existing in this “new normal” for a significant length of time.
As such, we need to help our patients figure out what constitutes an adequately safe existence. I remind patients that although being isolated and hermetically sealed indoors is the only way to be perfectly safe from the virus, something more viable must be achieved. The attitude of fully hunkering down until this pandemic is over is not a viable option. I discuss with patients what they consider to be an acceptable level of risk, while bearing in mind that their actions can have larger effects in the community, and then help them determine what they need to do to achieve relative safety. Although I always knew that psychotherapy would play a large role in my practice, I find myself also playing the roles of epidemiologist, immunologist, and infectious disease specialist.
As I deal with patients who have a wide range of prognoses, I consider whether I want to be an optimist and tell them everything will be all right, or a realist and reinforce the need for vigilance and isolation for the long term. I try to remain consistent and am steadfastly honest, but my state of mind is colored by whatever news I have heard that morning and the level of anxiety I see in my patients’ faces. The question I am constantly asking myself is, “How do I best serve the patient in front of me?” I have concluded that whether you are a realist or an optimist, taking the time to talk to your patients regarding this is the most important thing.
Sincerely,
Richard R. Furman, MD