Christina Lefebvre and Lynne Goltra Oral History, 2020/09/24


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Christina Lefebvre and Lynne Goltra Oral History, 2020/09/24

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An interview with a Massachusetts General Hospital OBGYN detailing the struggles of COVID and how the medical community has responded to the pandemic.

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Northeastern University

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Christina Lefebvre

Interviewee (Bibliographic Ontology)

Dr. Lynne Goltra

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United States of America

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abstract (Bibliographic Ontology)

An interview with a Massachusetts General Hospital OBGYN detailing the struggles of COVID and how the medical community has responded to the pandemic.

Transcription (Omeka Classic)

Christina Lefebvre 0:00
Could you talk a little bit about your regular job in any ways that your routine and responsibilities have changed since the COVID outbreak?

Lynne Goltra 0:09
Sure. So my regular job is as an OBGYN at MGH, Massachusetts General Hospital, which involves several things. One is seeing patients in the clinic both patients who are pregnant and then women who are not pregnant, as well as performing surgery, and then working on the labor floor. And since the pandemic, we have reduced a lot of appointments to minimize how many times patients need to leave their houses and come to the hospital for care to try to prevent or reduce the chance that they get exposed to the virus. And so, in our department, as in every department of medicine, everyone looked at what are essential visits and non essential visits and every non essential visit got canceled with idea of reducing the number of people who are exposed to the virus to try to flatten the curve, and not max out the resources of any hospital at one time. So for us, that meant canceling almost all GYN clinic visits because most are not urgent. And there's still every day, a doctor in the office for any emergency GYN visits, but those are very infrequent, then that meant canceling almost all surgeries except those that are emergent. So probably 95% of our surgeries and our GYN appointments were canceled. We have worked over time, it's taken a few weeks to undergo this change. But we have managed to start changing a bunch of the GYN visits to virtual visits, that has taken some efforts because it's not the way we used to do things. So it required new technology as learning the new technology, making sure that it was a kept patient information confidential. It requires working with insurance companies to make sure that this is approved. So it took a few weeks, but we're now offering a lot of virtual GYN visits. And then the OB visits, you can decrease the number of visits. There's several visits during a pregnancy that are essential, and you have to come in whether it's the ultrasound to check on the baby's anatomy or the diabetes testing. But those visits don't occur very often, and so a lot of the OB visits have been spread out. And several have gone to virtual visits, and the labor force still going full force. Obviously deliveries can't be virtual or can be canceled. And so the labor force is still going quite a bit. So I would say that our field has, in fact, I think someone today said that of all the departments in the hospital, ours is the most I think they use the term "patient facing." So we are seeing the most number of patients in the outpatient setting probably of anyone outside of the respiratory clinics who are seeing urgent, sick patients. But I also had been volunteering for the respiratory clinics. So there was an announcement that the respiratory clinics were sort of overwhelmed because of the number of patients coming in and that they needed additional staff. And so I volunteered and have been working in those clinics taking care of patients there which of course I wouldn't normally be doing.

Christina Lefebvre 4:05
Are there any memorable patient experiences from working either kind of in your normal setting or in the respiratory clinics that you could share?

Lynne Goltra 4:15
So I had a patient who was in the middle of her pregnancy, and she's a nurse at MGH, and she had a stuffy nose and she thought you know maybe she had a sinus infection, she had a sinus infection before but she otherwise felt well. And this was early on and so her symptoms weren't very concerning for COVID but she is an apology nurse and takes care in the hospital and takes care of really immunocompromised patients, and she really wanted to protect them like she was way more worried about her patients than she was even about herself or her pregnancy and like she knew that from the current data, it didn't look like pregnant women were at more risk from COVID. And she overall felt fine, but she really wanted to protect her patients. And so she, at that time, the testing criteria has evolved, but at that time, a stuffy nose didn't qualify you for testing. But she sort of advocated and they listened, and they tested her. And it was surprisingly positive. And which is kind of true for the arc of the story, just that we have learned more and more about COVID, as we went. Some of the things we initially thought turned out not to be true and other things that, you know, we understood, right from the beginning, but it's been an evolving process with COVID. And so she was positive. And she, then all of her, then she was very worried about her immunocompromised patients, and they all got tested. And fortunately, they were all negative. So yes, she was so happy. And then she, she fully recovered. And she was shocked that that was her COVID experience. But to me, it says that there's so many levels of worry, in COVID, it is about your own, you know, personal health and well being. If you happen to be pregnant, then there's a worry about your baby, and is your baby going to be affected by this? But then there's the worry about, you know, others around you. And if you're like a health care provider, you worry about bringing it home to your family, you worry about transmitting it to your patients. And especially as information about the virus evolved, and we at the beginning of this thought that the asymptomatic carrier wave was 1%, but then now it's 25%. I mean, that evolved in the space of like four or five, six weeks. And so then as we learn that, that there's a higher carrier rate than we thought, then your concern about whether you're, you know, bringing it home or transmit it to patients rises. And then there's just a concern about, you know, what, if you get sick, you know, most people don't get very sick. And most of the people who do get very sick, have medical conditions or are older, but there's plenty of stories of young healthy patients who died. And that is a level of worry that I think everyone carries with them. And then that's just the health concerns. And because then there's the financial impact. They're the people who are losing their jobs, they're losing their daily income and worried about not being able to pay their rent or worried about not being able to buy groceries. And then there's, you know, kids, and and parents who are working from home and all the reports of how abuse and neglect is rising. And so there's there's so many levels of worry and stress that are caused by the virus and our response to the virus.

Oh, there was another patient of mine who was pregnant, and she was very worried because so her job is in retail at the, at the mall. And she couldn't afford not to go in and her boss said she had to come in, and otherwise she was going to lose her job. But she said there were a lot of homeless people that she would need to kind of go by to get to work. And she was very worried and about getting the virus and we talked to her a lot about ways to protect yourself. But two weeks later, she had the virus, and she got really sick. And fortunately, she recovered. But that's another example of how she didn't have the luxury of not working like she had to keep work in order to provide for her family. So it's there's levels of this that are medical, and then there's levels that are economic, and then there's social and and then of course, there's the impact on communities like Chelsea, where they're being hit very hard. And it's a lot because of socio economics.

Christina Lefebvre 9:30
And then you talked about how you were switching the majority of your visits to the telehealth visits. Would you say that that kind of shift is one of the bigger challenges in patient care? And are there some others that you could talk about?

Lynne Goltra 9:47
Yes, that was a challenge to make that transition for all those reasons, I said, but now that we've made the transition, it's actually going pretty smoothly. And there's a lot of benefits, like patients love not having to come in, especially when there's a virus around. But I can imagine that even when the pandemic is over that for certain patients, I mean it doesn't work for every condition and sometimes you have to see someone in person and do an exam, but for certain conditions in certain patients they're going to love not having to drive in, not having to wait a long time in your waiting room, and like the convenience of just being able to schedule something from home. And similarly, I think providers are gonna like that, you know, there, there's a lot when employers enable paid employees to work from home, I think they'd benefit because the employees don't have to spend the time commuting, they can spend their time working, so they're more productive, they can, you know, balance life and work better. And so they're less likely to have to, like miss work or be stressed. They often, I think, are more loyal employees because if you have a job where you feel like you can get a work life balance that is better for you, you're more likely to stay with it. So I can imagine that this is going to be a shift that stays for the future and is going to benefit patients and providers alike. I would say one of the challenges has been the anxiety about the virus. And that has manifest itself in many ways. And sometimes it's an anxiety about coming in for essential care. Like I've had patients who have contemplated having a home birth rather than coming to the labor floor for a delivery because they're worried about COVID. And so we've had to do a lot of education about the safety of that the hospital the low risk of infection in the hospital, that it's actually lower than the risk of infection in the community, about the risks of home birth, and patients have been reluctant to come in for other aspects of care, like not coming in for diabetes screening. And so we have to have a long conversation about, you know, the safety of coming in, the risks of not coming in. Same way, some patients have anxiety about not coming in, that they worry that they're missing essential care. And they, they think that if we're skipping visits, then they're they're, that's not going to be enough care for their baby. And so we've had to have conversations about why it's okay to miss some of these and why we're balancing that with the risk of infection by coming in there. And then there's the anxiety about just, you know, how is this going to affect my pregnancy and the fact that we don't have a lot of data about the this Coronavirus in pregnancy. We do have data about other coronaviruses that we can sort of use to guess. But that's created a lot of anxiety for patients. So I think the anxiety around this has been a big piece that has required a lot of time and effort to address.

Christina Lefebvre 13:27
Right, I actually wanted to ask you about mental health resources. Obviously, achieving physical health has to be a priority. But are there resources available to patients? And then also, could you talk about the mental health resources for doctors and healthcare professionals as well.

Lynne Goltra 13:45
So, for patients, unfortunately for a long time, the resources have been well less than the need. And so there's, you know, far more patients who need mental health care than there are mental health providers and support. And this is even more true now when society is experiencing a uncommonly stressful period. So the resources are the same the traditional resources where our social workers provide a lot of counseling. We have psychiatrists who specialize in care and pregnancy and those are still available to patients but again, that with no more no additional resources and then there's support groups in the community and there there's therapists in the community. I think a lot of therapists have managed to take their practices virtual. In fact, I know over the Brigham or social work department went from all in person to all virtual visits within a matter of weeks. It was like a Herculean task, but then it's amazing. And, again, shows that it can be done. So the those are the resources right now. And I think also in the community, I think different community organizations are recognizing that different communities need more support. And I've been focusing like, I know, there's that I've forgotten the name of the fund. But there's a huge find, it might even be called the Boston COVID fund that many people and organizations have been donating to. And so there's money there to help communities that are particularly are hit particularly hard in terms of COVID and including mental health resources for providers. There has been an awareness that support for mental health and for well being was needed at an early stage, both from our department and from the hospital, just because the amount of change that was asked of everyone, and that people were being asked to put themselves, potentially at risk by taking care of patients with this virus that we're still learning a lot about, you know, how it's transmitted, and how infectious it is, and how morbid it is that there was a lot of stress around that. And different people were more or less comfortable with putting themselves in that situation like some of my colleagues felt uncomfortable volunteering to work in the respiratory clinics, it was it really concerned them, it was hard to think about doing them and potentially bringing the virus home to their families. And so there's a range of reactions to this. But there's been support groups that are available that you can phone in and join multiple times a week, there are grand rounds, speakers and meetings with departments that are dedicated to well being and taking care of yourself. And our chair regularly talks about taking breaks and finding time for family and finding time for exercise and finding time to be outside and reaching out if if you're struggling and that that is encouraged and not, you know looked at as a source of weakness. So that the hospital is focused a lot on providing support for physicians and nurses.

Christina Lefebvre 17:48
That's awesome. I wanted to go back to the respiratory clinics, were you provided any additional training for working in that setting?

Lynne Goltra 17:59
Absolutely. And that was, I think that was one of the reasons that some of my colleagues felt uncomfortable volunteering, because, I mean, we haven't done a lot of that kind of care for, you know, 20 years. And so it's [inaudible} outside our comfort zone, and I felt uncomfortable walking in. But the great thing is, there was such thought and care in planning the clinics, and they were designed so well and, and set up so well, that they they thought about that. And so anyone outside of the medicine got a, well anyone coming to the respiratory clinic for the first time got us an orientation, and I think they even had a separate one for non-internist, anyone who's not a primary care physician. And so I felt like supported there and then when I showed up, there was a physician dedicated to my orientation. So he just showed me everything I needed to do and there are people watching to make sure that all the time you put on your personal protective equipment correctly so that you were safe. And then he like showed me how to access all the the the order sets to order labs and the note sets to for documentation and showed me like the flow of the clinic and everything that could be done and introduce me to the other interns who are going to be working there and they were amazing. Like they never they were in they encouraged me to ask them any questions they didn't mind when I was I was like, "I think I want to run everyone by you just to make you know, sure because they [inaudible] a long time" and they were so understanding, so supportive. That it it really, I felt quickly at ease there.

Christina Lefebvre 19:59
Do you feel like the sense of community among health workers has strengthened during the pandemic?

Lynne Goltra 20:05
Oh so much, so much. There's such a sense of camaraderie and shared purpose among, you know, physicians and nurses, and there [inaudible] really special at MGH is the leadership has been extraordinary in terms of planning, I mean, they they've been working on emergency preparedness for, you know, 15 years. And once this pandemic started, it was on their radar from the beginning. And so for, for many, many weeks before, even the first patient was in the United States, they were working on a response plan. And so they were always 10, they've always been 10 steps ahead, as things happen, because they thought about it, you know, 10 steps ago. Once, like the first patient arrives, they knew what to do, once the volume of patients started increasing, they knew what to do. And so they were really prepared every step of the way, they were proactive about taking the steps that needed to be done to address each phase. They were really good at communicating things to all of us. And so we felt like we knew what was going on, it didn't feel it's it still felt overwhelming, but it felt manageable. It felt like someone was captaining the ship in a way that you felt like, Okay, we got this, even though this is, you know, a big shift and a big ocean, we've got that sense of there's been a very strong sense that we are ready, and that we can handle this. So it's been, it's felt really good to be a part of an organization that was so capable, and doing such a good job managing this.

Christina Lefebvre 21:51
That's really great. Could you talk a little bit more about the health and safety precautions that they implemented? And if you feel like they're enough when you're working?

Lynne Goltra 22:02
Yeah, I feel like the hospital has always prioritized our health. I think it was, it's been challenging, because are there many factors that have to be taken into account and that that need to happen for provider and patient safety to occur? And some of those things are either control. And some, you know, there's individual risk, and then there's population sort of risk. And so you have to, I mean, for example, you have to make sure there's enough PPE for everyone. So you need to, in the beginning, if you don't have enough N95 respirators for every provider, you have to direct them to the providers who are doing the most risky care. And so that's aerosol generating procedures. Sometimes, some providers would feel uneasy and think, "Oh, no, I need an N95 respirator to be fully protected, and a surgical mask isn't enough." And that was hard, because if you only have a certain number, you need to prioritize and use them for the riskiest procedures. And in addition, there the information about it was evolving constantly. Like initially, we didn't think masks were important. And so we weren't wearing in the beginning. But that's because the vast majority of the information didn't support that. Not because there wasn't there weren't enough masks. And then as the information evolves, and masks were recommended. But there was a there was a period in that transition where more and more staff members thought, "No, we should be wearing masks", and yet it wasn't recommended and wasn't being provided. And that's, that's hard. But that wasn't because the hospital didn't care. The hospital has always tried to provide to, to approach this in an evidence based way that makes sense, and not just a you know, "This is what we think we should do." But I feel like that our health has been a pri- priority. And it's just if there ever questions or like changes, it's more because resources have to be prioritized or information is evolving.

Christina Lefebvre 24:23
Would you say that the kind of lack of evolving information is one of the most difficult things about working during the pandemic?

Lynne Goltra 24:33
Definitely, because there's been a range of information that even if most of the information points one direction, if there's a little information that contradicts it, it is unsettling for people. So, you know, for example, most of the information as as indicated that babies are not at risk for acquiring COVID. But then, you know, patients would come in and say, "But I saw this report, and it says that babies can get it." And, and it's hard, and because you can't read absolutely everything that's out there. And and there might be some conflicting information. And so you have to talk about how you have to go with what the majority of information is. But it's also hard if the information changes, so you initially give advice, based on the information you have at the time like, it's, initially we thought that it was being transmitted mainly by hand to eye, nose, or mouth contact, and that the respiratory route was less significant. And so masks weren't recommended. And so we were telling patients, you know, wash your hands, that's really all you need to do. And then more information came out. And it turned out that respiratory transmission was a more important component. And so we had to sort of backtrack and say, "Well, actually, we need to use masks." And being able to communicate that in a way to patients that makes sense, that you still maintain their confidence is is challenging is tricky.

Christina Lefebvre 26:22
Right. And then kind of shifting gears a little bit, have you had to take any precautions with your immediate family when you go home?

Lynne Goltra 26:31
Yes. So when I come home, I always wash my hands. And before anything else, when I go to the respiratory clinic, when the risk of exposure is a lot higher, I do come home and I throw everything in the wash right away, and wash like my hands and face. When I come home from other clinics, because the risk of exposure is not as high, I have not been doing that. And there's, you know, information out there that the respiratory droplets don't necessarily stick to you and your clothing, you know, that there's there's actually wind currents when we're walking that cause the respiratory droplets to like, bypass us and then just fall to the ground. And so I changed my clothes, but I don't necessarily like throw them right in the wash. I and in in our family like Alexis goes to the store. And I I don't run the errands because we want to keep just one adult sort of out in the community. And also be if maybe I've been exposed more do I not want to put myself out in the community. But then when we come home, you know, I have not separated myself from my family. Because I just I think the risk that I am exposed is low. And also I can't, I mean, I think that would just be really hard to do for, you know, eight weeks. But it weighs on you, you know, every once in awhile, I think when I give one of my daughters a kiss, I'm like, "Did I just give them something?" And and so you and you think about it, for sure.

Christina Lefebvre 28:11
Right. And then it sounds like you're definitely happy with the way that MGH prepared for the outbreak. But are there any things that you feel we could have done differently as a society to prepare for and respond to COVID?

Lynne Goltra 28:27
I think in terms of society, there have been variable responses across the nation in terms of how people isolated or not. And the community response has had a huge impact. So like in Massachusetts, it's absolutely flattened the curve, and really saved us, because in the a lot of the major hospitals, and MGH in particular, there was a great concern that our resources were going to be maxed out. That it's that either we would run out of staff, because staff will be getting sick and there wouldn't be enough staff to take care of the high number of patients, or we would run out of space, or we'd run out of respirators. And we, fortunately, looks like we we came close to maxing out but did not max out and so did not have to start the dreaded rationing of health care. And if the curve had not been flattened so dramatically, I'm guessing that we would have maxed out. So I think the community response was absolutely critical in this and that in in our area they did, the community did a magnificent job of staying home. It seems like that response is variable. And it varies community by community. And, and there are many factors to that, you know, you know, whether leadership and governors are saying it's important to stay home or not. It's whether your job actually affords you the opportunity to stay home or not, which gets to socio-economic factors. It's an outlook and a mentality. You know, there have been some cities where people are sort of revolting and saying, "We won't stay home anymore." And there's, you know, many factors in that. I think that, here, we've done an amazing job, and it requires a huge sacrifice. My impression is, and I haven't followed this closely is that other communities haven't always been as strict. And my impression is that that sometimes has had a detrimental impact on the pace of [inaudible] gotten sick.

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