The COVID-19 pandemic changed the face of U.S. health-care services in such rapid fashion that many providers were caught off guard, learning and preparing on the fly. Patients with cancer, given their multiple physical and emotional challenges, were especially vulnerable. To get a sense of the on-the-ground reality of this crisis, The ASCO Post spoke with Narjust Duma, MD, a young oncologist at the Division of Hematology, Medical Oncology and Palliative Care at the University of Wisconsin (UW), Madison.
Early Experience: Learning on the Fly
Please describe the environment in your oncology department at UW during the first stages of COVID-19.
During the second week of March, we were aware the virus was going to have a large impact on our services; just how much was still the question we were asking each other. I had recently transitioned from fellowship to independent practice, so my anxiety level was pretty high. I think it truly hit home when I was on one of my first clinics, and my nurse came up and told me the schools were closing.
A little bit later, at about 4:00 PM, I received an e-mail from the UW’s administration, where I’m on faculty, saying the entire university was closing down. Later, at about 6:00 PM, when I was home with my husband, sort of unloading my stress, I received another e-mail from our Chief of Staff stating we were transitioning to telemedicine immediately.
“I hadn’t been prepared during medical school or residency to discuss end-of-life care over the telephone with a wife who’d never again see her husband of 65 years.”— Narjust Duma, MD
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Since I was very young in my profession, I didn’t have the confidence of some of my more experienced colleagues. Although I have research grants, patient interaction is what I really love, and having to lose that felt like something precious was being taken from me. Naturally, we were fortunate this incredible technology allowed us to connect with our patients with cancer, but it was certainly a blow for me. My patients, who are all on active treatment, became very uneasy, which was understandable. On that first month, we learned a lot of things on the fly.
We had to adjust life basically overnight. I remember leaving my office, where I was working on grant deadlines and manuscript reviews, but my new priorities were to learn about the virus and help my colleagues on the front lines. And, more important, I needed to guide my patients with cancer through the challenging times, not having a clue when we’d ever return to normal.
My husband, who is immunocompromised, had to stop working. I went into preparation mode and developed a contingency plan for staying away from him. He had to use a different bathroom and sleep in a separate bedroom. I was to change clothes in the garage. Everything was happening so rapidly that our thought processes had to evolve to keep up with the new information and changing guidelines. It was really challenging, as my first thought was about how was I going to care for my patients with cancer in the new unknown territory we were rapidly entering.
Separating Fact From Fiction for Physicians and Patients
At that time, how knowledgeable were you about the virus and its potential impact on your patients with cancer?
Early on, I was so caught up in the changing logistics that my attention was directed on how to reconfigure our care model. Then I reached the point where I needed a knowledge base to better equip me for what lay ahead. So, I spent two 12-hour days researching COVID.
There were so much data from various sources, many of which were of poor quality, giving mixed messages. One source said we should be giving our patients hypertensive medications, erythromycin, or even hydroxychloroquine. Moreover, I began listening to the White House press briefings, which had their share of misinformation and political messaging to add to the confusion. And after that, many of my patients were demanding these unproven interventions, which put a new dynamic into doctor-patient conversations.
New Dimension to End-of-Life Conversations
Can you describe how your end-of-life conversations with patients and their loves ones changed during this challenging time?
I always have end-of-life conversations with my patients with cancer, asking them how they want to move forward with their palliative care options. However, the COVID pandemic added a new dimension to these discussions, as many patients with limited life expectancy were quarantined from their loved ones. One tragic part of this issue is the loss of precious time some of our patients had with their loved ones.
For instance, one of my patients was Peruvian, from Machu Picchu. We did everything we could to get him back there before he died, so he could reconnect with family during his last months of life. Then, the COVID-19 pandemic broke out, and travel ceased, so that was not an option.
I remember calling family members to update them about our plans. All patients were alone, and visitors were not allowed in the hospital. Specifically, for one of our patients with prostate cancer, his status was deteriorating quickly.
His cancer was progressing, the pain was worsening, and his cognitive condition was weakening. I needed to talk to his wife and tell her that her husband was dying. I hadn’t been prepared during medical school or residency to discuss end‐of‐life care over the telephone with a wife who’d never again see her husband of 65 years. She was crying, telling me that he was part of her body. He transferred to our hospice unit, and she stayed at home. She had COVID-19 and couldn’t come to the hospital, so she never saw her husband before he died. That was a true learning experience for me.
Steps to Ensure Continuation of Care
Once the gravity of the situation sunk in, what steps did you take to ensure continuation of high-quality patient care?
To begin, we were very fortunate to have a school of engineering, and all of the students pitched in and made three-dimensional, printed face shields, which, in fact, were better than the ones we were being issued. The school of pharmacy has large stores of 100% pure alcohol, and about 50 of the students began using it to make hand sanitizers. So, early on, we were covered with high-quality face masks and sanitizers. And, an entire wing of the hospital became a devoted COVID unit. Also, all staff were given a specific number of deployments and a tier of deployment. It was very well coordinated, and I believe we learned a lot from the New York experience.
Please offer some closing thoughts on what you learned about our cancer care system during this ongoing crisis.
As oncologists, we have chosen this challenging and complicated career. I’m a researcher and a scientist. I have a great career moving forward, full of exciting opportunities, but this crisis is reaffirming what I always knew. Our patients with cancer come first. It didn’t matter how many grant proposals I had out or about the paper I was writing. I shared this with some of my colleagues, and we all were on the same page. There’s always tomorrow to write a grant, but for our patients with cancer, time has a different set of priorities. And it’s up to us to be there for them. That’s why we became oncologists.
DISCLOSURE: Dr. Duma has served as a consultant or advisor to AstraZeneca and Inivata.