This week, around 20,000 fourth-year U.S. medical students will learn which hospital they are assigned for their residency during the annual National Resident Matching Program. Normally, they would begin serving patients in July, but there’s a way to do it now.
If medical schools instead confer MD degrees immediately, instead of waiting until the end of the semester, these hospitals could hire, train and deploy an extra 20,000 physicians at a time when we are straining to “flatten the curve” of the covid-19 coronavirus. This proposal is a few weeks old and has already passed from Columbia University to New York State. But others should take up the idea of accelerating fourth-year medical students into their chosen life of service.
At Columbia, most of our medical students — representative of similar medical students throughout the country — want to help, even if it is not their time. But the fourth-year students are fully prepared. They have completed all the clinical rotations required for the MD degree. Under normal circumstances they would now be taking electives or conducting research, perhaps not even seeing a patient during the final few months of medical school. They would in the normal order receive their MDs in May and begin as interns (first-year residents) by July.
I propose instead that medical students be graduated now and given the opportunity to serve in this time of great need. I imagine most would jump at the opportunity. If they were not caring for covid-19 patients directly, they could free more experienced physicians to undertake that necessary work.
Donald W. Landry is physician-in-chief, chair of the Department of Medicine and director of the Division of Experimental Therapeutics at New York-Presbyterian Hospital/Columbia University Medical Center.
House mild cases in hotels
By Jeremy Samuel Faust and Cass Sunstein
One of the toughest decisions facing physicians and public health officials is where to send patients who test positive for the covid-19 coronavirus. For the small but significant proportion with severe or critical illness, the decision to hospitalize is trivial. But where to send the apparently large majority of cases that are mild or even symptom-free?
These patients, often young, need to be isolated to reduce spread. But using a hospital bed for isolation alone takes up capacity, puts others at risk and chews through protective equipment that doctors, nurses and other staff desperately need.
A natural alternative is to send people home, with clear instructions to self-isolate. But in some cases that is not feasible, and it poses evident risks. The World Health Organization recommends placing mildly ill patients in dedicated covid-19 facilities as the gold standard for isolation. While countries such as China have the logistical capability to erect new hospitals for this purpose in a matter of days, most places cannot achieve that.
Fortunately, there is a potential answer: America’s prodigious hotel industry. And in case you haven’t noticed, there is plenty of room at the inn.
The federal government should use its financial and legal resources to temporarily convert some large hotels, reeling from the current economic situation, into covid-19 isolation facilities. Under recently issued federal guidance, these spaces are not required to provide medical attention.
Under ordinary circumstances, the suggestion that the federal government might seek to take over a hotel would run into serious legal objections. But under current conditions, we suspect that many hotel executives would line up to draft temporary and renewable lease agreements with the government. This could also help stave off unemployment in the travel industry.
Yes, all of this needs to be paid for, and strong steps would have to be taken to reduce health risks to housekeepers and staff. But whatever the upfront costs and risks may be, the downstream benefits — in terms of health, economics and more — are likely to exceed them.
Jeremy Samuel Faust is an emergency physician at Brigham and Women’s Hospital in the Division of Health Policy and Public Health and an instructor at Harvard Medical School. Cass Sunstein is Robert Walmsley University Professor at Harvard and a former administrator of the White House Office of Information and Regulatory Affairs.
Forget stimulus checks. Send prepaid cards instead.
The administration and members of Congress have proposed giving Americans a significant amount of cash to stimulate the economy, such as a check for $1,000 or more to every American adult.
Stimulating the economy by providing spendable cash is a good idea, but what would prevent those in the financially well-off categories from simply investing that money instead of stimulating the economy by spending it?
One way is to provide immediate cash to all adult Americans, but in the form of prepaid Mastercard or Visa cards that expire in a certain time — such as three months — rather than in the form of paper checks.
This approach has several advantages. First, it virtually guarantees that recipients will spend the cash. Facing the possibility that their stimulus cash will expire, recipients in all financial brackets will be anxious to use the money. Even the well-off will hate the idea of losing free money that they could have spent.
Second, recipients of prepaid cards can use them immediately, whereas a check needs to be deposited first. Although electronic banking with online check deposit is increasingly common, many people do not have access to such a service. And going to the bank violates infection-control guidelines.
Third, amounts on prepaid cards that are not injected into the economy can revert to the U.S. Treasury and perhaps be recycled for later use. With paper checks, the Treasury recovers only those that are not deposited, whether or not they are spent.
The fundamental principle is to increase the likelihood that spendable cash sent to consumers will be spent immediately. Regardless of the details of such stimulus program, that principle should be observed.
Herbert Lin is a senior research scholar and the Hank J. Holland Fellow at Stanford University.
Provide health care at the neighborhood level
As a neurologist living in a Washington, D.C., suburb, I want to propose a strategy to help reduce the burden on hospitals as this pandemic plays out.
Many doctors have begun practicing telehealth from our home offices. But I wonder if clinicians might be able to organize, in concert with their local hospitals, to help their communities in some way.
Once organized, and if given some medical supplies, we might help with screenings at our neighbors’ houses. Perhaps we could monitor neighbors recently discharged from hospitals. Or, in my own field, I might visit a person concerned that their facial weakness might be a stroke. A simple examination or an online consult might determine it to be a less serious Bell’s palsy, potentially avoiding an emergency-room visit.
I don’t know if this is practical, and I know hospitals do not have the resources to set up such a system or offer supplies right now. But with the help of social-networking services for neighborhoods, clinicians could self-organize. They could indicate their expertise, their availability and what they would be willing to do. It is not a lot of work to do it now and perhaps it may pay off.
The writer is a neurologist at the Parkinson’s & Movement Disorders Center of Maryland.
Let patients test themselves at home
By Shantanu Nundy and Marty Makary
Missing from the current discussion about rapidly ramping up testing for covid-19: doing it at home. Testing for the coronavirus can be performed using a nasal swab (the equivalent of putting a Q-Tip in your nostril). There is little scientific reason as to why this can’t be done by people at home under the direction of a doctor. Research on seasonal flu comparing the accuracy of self-collected swabs vs. professionally collected swabs shows that they are nearly equivalent.
Here is how at-home testing could work:
Step 1: Individuals with symptoms call in to their doctor’s office or use a telemedicine service to be assessed by a qualified health-care professional who can order tests, often billing a patient’s insurance company directly.
Step 2: Those who meet CDC guidelines for testing and are able to test themselves and be safely managed at home are sent a testing kit by overnight mail or direct delivery from a nearby facility (which could include labs, pharmacies or specially set-up public-health depots).
Step 3: Individuals would then self-swab, guided by an instructional video or a virtual health-care professional, and then mail the sample to a testing facility or drop it off. All three steps could be done completely from home — not only convenient for those who are already feeling ill but also ensuring social distancing.
Governments and private organizations should issue guidance on at-home testing for clinicians, laboratories and public health professionals. Also needed: removing state and local regulatory barriers that slow down and sometimes prevent labs from processing samples collected by patients. And government and private organizations should provide funding to laboratories and researchers to invest in validating and improving the effectiveness of at-home testing.
With swift action, at-home testing could ensure widespread, equitable availability of care and slow the spread of covid-19.
Shantanu Nundy is a primary-care physician and chief medical officer at Accolade Inc. Marty Makary is a professor at the Johns Hopkins School of Public Health, editor in chief of MedPage Today and author of “The Price We Pay.”