The heart of the matter
An interview to a Sicilian cardiologist amidst the coronavirus crisis
In Sicily, two months ago, we were experiencing the beginning of the never-before-experienced lockdown and waiting for the deadly virus to come down from the wealthy Northern Italy. Rather predictably, waiting for the virus – that in the North was brutally taking its toll – was far scarier than the virus itself. My mother called and told me about an exchange between two workers she overheard while queuing at the baker’s. The exchange went more or less as follows:
“Cicciuzzo died a week ago.”
“And was it…?”
“Luckily it wasn’t… the thing. It was his terminal lung cancer.”
Reporting on the contents of the verbal exchange miserably fails to account for the distinctive Sicilian conversational style, with its sombre tone, grave pauses, and much frowning, grinning and a final (and much welcome) cathartic relief. However, I dare say that the irony of the situation won’t be lost on anyone and will introduce the overarching questions that prompted this interview: what are the consequences of the pandemics on general medicine and healthcare facilities not dealing with COVID-19? How has our risk perception been modified in such a short time-frame and how can we make sense of all the expert and non-expert advice about our well-being and safety? Is the suspension of disbelief going to last? People have not stopped being ill, not stopped to die (and for reasons other than COVID-19), but apparently all other medical concerns are stuck in limbo.
We have been literally swamped by information on the deadly virus and everyone seems to think to be entitled to confidently and skillfully talk about medicine, vaccines, epidemiology, containment measures, face masks. The “new small talk” is about flattening the curve, paucisymptomatic, intensive care and overrun hospitals.
Everyone talks, posts and comments on an incredibly rich and complex range of topics, most likely never heard before the crisis. Global media are rapidly adjusting to this revolution and contributing to change our mindsets in what worries and scares us, by means of daily national bulletins, a massive injection of infographics and up-to-date online publication of an unprecedented volume of materials that are usually unavailable to the general public, such as math predictive models or experts’ epidemiological reports, virus map playable simulations, or pretty detailed explanation of the ferocious rampage of the coronavirus through the body, including vivid visuals of its extensive damage in human lungs in 3D models based on computerized tomography scans.
Infographics have perhaps never been so popular than today as people crave for data, even though, as a linguist, I cannot but question how deceptively complex these generally are, and especially so when the volume of data is staggering but what we really know is limited. If we hail the wide availability of (apparently) accessible data, I doubt that an untrained eye is likely to grasp, for example, the visual difference between a linear and an exponential curve and fully understand its visual implications.
What happens if we diligently think we understand when we actually don’t? What happens if the amount of information is too vast to process and if we don’t have the cultural background to quality control – and filter our sources?
Even though this infodemic may appear as unparalleled, at least in the last decades, the decline of trust in medicine and the dangerous development of health self-made toolkit in popular belief has a precedent in the MMR (Measles, Mumps and Rubella) debate in UK in the late Nineties. Following the publication of a paper that presented connection between a rare bowel syndrome and autism, one of the authors hinted at a possible link with MMR vaccine at a press conference. Even though there was neither explicit reference or evidence in the written paper, the media took over a news story that started to circulate globally to the point that take up of vaccine dramatically fell and no-vax movements rapidly seized the opportunity. This is, I believe, one of the angles from where we can get a glimpse of the current scenario.
Since then, everyone has felt entitled to talk about medicine. Experts are invited in talk shows along with politicians or media pundits who contest experts as if they were all speaking from a symmetrical position. Politicians have their say into scientific debates to the point of ridicule, as when Trump invited people to inject disinfectant to prevent infection or the Italian Welfare council deputy in Lombardy Giulio Gallera claiming that if Rt index is 0.51 (<1) there should be at least two infected people “at the same time” to infect one.
In the current scenario, how can we make sense of what we read, hear and see? Information and self-appointed counter-information challenge well-established social practices, such as trusting the expert.
In the following, questions from different members of the collective (including myself) are asked to a cardiologist, Giuseppe Andò, currently working at the City University Hospital in Messina (Sicily).
How did you have to adjust your interactions with patients because of the risks of contagion? (Q. by Elisabetta Adami, University of Leeds, UK)
We started immediately to distinguish wards that were exclusively devoted to the treatment of COVID-19 patients (or suspects of being so) and the other wards, including mine. This has made possible a lighter approach to PPE, except when dealing with patients waiting for infection diagnosis. For these patients, PPE had to be used so as to contain potential infections, even though my patients checked in for conditions other than COVID-19. Being geared up for these “limbo” patients has had a huge impact on how I interacted with them and not only because PPE restrained possibility of direct contact, but also dramatically reduced my time for interaction for the extremely time-consuming donning and doffing procedures (also because in theory we had to change PPE for each single patient). PPE put physical barriers between the doctor’s and the patient’s body, but psychological as well and on both ends. Such equipment has been designed to protect from high infection risk (in this case, rated 3 out of 4, when 4 is maximum risk). Seeing and being inspected by a doctor with PPE is scary and generates a degree of stress and anxiety greater than what I am used to in my ward.
Furthermore, any ward other than COVID-19-specific ward is endowed with a “grey area” in which the patient is waiting for diagnosis of SARS-COV-2 infection before admission in any other ward. It goes without saying that permanence in this “grey area” is highly stressful for patients. Taking care of patients in this area is demanding for doctors and nurses as well, because we need to constantly check that patients’ stress does not go out of control and because we are under the pressure ourselves for the much higher degrees of security measures to avoid cross-patients’ infections (something that is not so crucial in COVID-19 wards, where patients do have a common diagnosis).
How do you manage your role of mediating communication between medical research and the patient? (Q. by Elisabetta Adami University of Leeds, UK)
My patients usually trust me for advice on medical topics other than those strictly linked to heart-related diseases so, amidst general chaos, I have tried hard to stick to what was known and true for sure (for example in terms of hygiene measures that prevent airborne virus transmission and with advice taken from official sources, such as WHO) recommending to avoid misinformation and ruminating over conflicting news, mainly conveyed by mass media and digital unchecked sources.
How do you respond to questions about the risk that your patients face if infected with COVID-19 compared to the general population? To what extent can you afford to be honest with them especially when the patients are children and you are advising their parents on whether or not it is safe to send their children to their early childhood centre or school? (Qs. from Emilia Djonov, Macquarie University, Australia)
I was certain from the very beginning that COVID-19 would be life-threatening for my patients, so I was completely open in talking about the risks and suggested maximum care in trying to avoid infection. This is why I already advised my patients to get seasonal flu vaccination every year. Actually, I could not afford to be dishonest with them, hence I told them the ugly truth straight away. The question with children is of course context-dependent, because in Italy we did not have the chance to discuss the option of sending or not sending children to school, as it was decided by the central government to keep the school closed. In any case, the main issue – that has not been definitively answered so far – is that we still do not know if children are effective spreaders of SARS-COV2 or not. This poses challenges in a number of contexts, for example for the safety of teachers, parents and the elderly, even though I am aware that lockdown measures have put enormous social pressure on families.
Have cardiologists started giving more care to their patients? Have they become more tender with their heart patients because they are at more risk now with COVID-19? (Q. by Najma Al Zidjaly, Sultan Qaboos University, Oman)
I am trained (as well as other doctors) to use a communication style with my patients that is fit to the communicative purposes, for example we need to be explicit and clear in giving bad news to people who suffer from chronic or severe conditions but avoid upsetting or throwing our patients in despair. Hence I would not say that my style has changed, as we all take special care in talking to vulnerable and fragile people. Luckily, I have not found myself in the situation of other colleagues in Northern Italy, who, probably for the first time, had to manage situations with relatives asking for information on their parents (or even children) only once a day, over the phone and being forced to deny access to the hospital even for a last goodbye to their dear ones.
Has your communication with your beloved ones changed due to the fact that you have been working with patients who are or may be infected by COVID-19? (Q. by Styliani Karatza, National and Kapodistrian University of Athens, Greece)
My standpoint is uncommon, because my wife is a cardiologist, so we had the same concerns. Luckily, we share the same cultural background that allowed us to openly discuss about what was going on at the hospital and, more generally, at global level. We took care in communicating with our children (years 10 and 6) by conveying reliable and truthful information that was nonetheless apt for their age, cognitive and emotive development.
As reports on risk on infections in healthcare settings have now gained momentum, people may severely underestimate the possibly higher risk of deciding not to take action for the protection of their health, for example in the context of chronic illness and heart disease prevention. What do you think doctors (and the general public) can do to address the consequences of this risk? (Q. by Maria Grazia Sindoni, University of Messina)
My idea was to set up a hotline number to address our patients’ specific concerns, even though I would not recommend the development of apps for diagnosis (that at the moment are a hot topic in many scientific domains) to substitute a doctor. I do not think that a system that allows input of individual symptoms can come up with a reliable diagnosis, at least not with current technologies, even though they are making huge strides. Healthcare, and health in general, need an approach that only a person with clinical experience can successfully deal with.
Have you experienced a drop of patients checking in at the hospital in your usual healthcare practice since the beginning of the outbreak? If so, how have you addressed this issue? (Q. by Maria Grazia Sindoni, University of Messina)
Absolutely, the drop has been significant and alarming. I also struggled to convince my patients suffering from chronic illness to take care of their health despite the lockdown. We observed a severe drop of hospitalization for chronic conditions over the lockdown, even though I would like to point out that while the lockdown has reduced the risk of worsening chronic severe conditions, objective troubles to access routine healthcare treatments have had an enormous impact in terms of effectiveness and timeliness.
Which piece of advice would you give to a layperson who tries to make sense of the COVID-19 pandemics? Should we read more or less? (Q. by Maria Grazia Sindoni, University of Messina)
As a rule of thumb, it is a truth generally acknowledged that the more you read and are informed by first-hand sources and materials, the better you will be equipped to understand and decide for yourself with full awareness. However, when it comes to such complex and highly specialised phenomena, it depends on the kind of reading you are referring to and on the kind of information you expect to find.
What I have found alarming in the past few months is a sort of publication rushing on the COVID-19 topic in most academic journals. While I am sure that the intentions are certainly good, and I fully understand that the need to search and validate with scientific evidence is urgent, the consequences of this somehow indiscriminate rush still need to be gauged and fully understood. The quality of peer-review has been reduced to a significant extent, most likely due to time pressure on journals’ editors. A striking and recent example is the retraction of two papers (valued as flawed in the best-case or as fraud in the worst-case scenario) from the journals Lancet and New England Journal of Medicine. If two of the highest reputation journals are currently publishing contentious materials, imagine what could happen when a layperson freely downloads papers already available in public databases, but with much looser quality control, to say the least. If quality control procedures loosen and research is published by weakening essential monitoring measures (such as shrinking embargo times) even communication within our community is at risk. The road to hell is paved with good intentions!
I would like to thank you Maria Grazia Sindoni and Giuseppe Andò for sharing with us such an interesting article.
I’m really very worried about what is going on here in Greece. After having received a huge amount of information regarding covid-19 and all the people were talking about it, the situation here in Greece nowadays is really odd. Nobody talks about it anymore. In the evening news the daily cases or even death(s) are announced among other issues (political scandals, tourism and so on), but they are not the main (or even one among the main) issues discussed. As if nothing really happened and nothing can happen in the near future. No news for covid appears in my FB wall for many days. Nobody seems to notice it. It’s also very scary the idea expressed by not so few people that God will save them, that COVID-19 was not a true danger.. Maybe it’s the same in many countries, people are so tired to be afraid. However, the interesting part is the orchestration of the media made by the government. ‘Feel free to go out, go shopping, and go on holiday and so on’. The exact opposite of what was being said a few months ago. During the lockdown, 20 million Euros were given by the government to the main media of the country, so their prioritization follows the policy of the government. For the moment it’s quite important to give the impression that Greece is a safe place for holidays.
Let me finish with an example of ‘ racist’ behavior due to COVID-19. There is a municipality in Greece called Xanthi where a lot of cases of COVID-19 were detected. It is situated in the northern part of Greece, right next to Bulgaria. For the moment, Xanthi is highly targeted as the mainly inflicted area for the moment (it’s not so true, but…). So media want us to believe that covid-19 is a local problem. If a person from Xanthi wants to book a hotel, usually he/she is not accepted. However, people from Bulgaria are well accepted, although nobody really knows how COVID-19 free they really are.
We have far more deaths now than during the lockdown, but nobody really talks about it. It’s a clear sign of how much Media ‘fabricate’ issues.
I wish you all the best and keep up the good work.
Thank you Maria for this article. It was fun and informative. Most importantly, it clarified many issues I was wondering about.
Thanks Najma for your reading and for your question for the interview! I’m happy that you liked it 🙂
Thanks for giving us so much to think about, Maria Grazia Sindoni and Giuseppe Andò! Yes, the rush of research publications is a very worrying trend, and so too is the fact that those of us who do not read the medical journals, and rely on the popular press and media instead, may not even learn that this or that study has been withdrawn. As for the drop in patients with chronic illnesses, I believe this may be a worldwide trend, which is partly due to people limiting any non-urgent contacts with others, partly being afraid to go anywhere near COVID19 wards or even drive-through testing stations, and partly (at least here in Australia) due to implicit messages from the government (e.g. a ban on all elective surgery, for which people may have been on a waiting list for over a year) about not putting additional stress on the healthcare system.
As for children with heart conditions, they have received no attention in the media here as most of the focus has been on elderly people (with or without heart disease) being vulnerable. Our paediatric cardiologist reassured us, in mid February, that the risk is not higher than it is for children in the general population. I wonder what his advice would be now.
Many thanks for your comment, dear Emilia! And thanks for your reading. I’m not qualified to answer the question about the drop of hospitalization of chronically ill patients, but it seems a worldwide phenomenon. As you say, it may be due to a range of different reasons, including widespread fears about the possibility of getting covid19 infections in hospitals and other healthcare facilities. As far as I know, now access for covid19 and non-covid19 patients has been differentiated, but risks may still be a possibility. With reference to paediatric cardiology, we should ask Giuseppe, but it’d be interesting to compare ideas from different contexts.
Thank you Emilia for having focused on the enormous difficulties in caring of patients with chronic conditions in the COVID-19 era. With respect of children with heart disease, most considerations depend on the seriousness, whether it consists for instance of a complex structural disease or, on the other edge, of arrhythmia in a structurally normal heart. Generally speaking, flu and flu-like respiratory infections can become complicated in children with serious congenital heart disease. Hence, they have an overt indication to vaccination for influenza and recurrent lung infections may be one of the presentation symptoms of congenital heart disease. The actual risk of being infected may not be greater in cardiopathic children, but it cannot be ruled out that COVID-19 may be more serious in children with complex heart disease than in non-cardiopathic children.
This article is so spot-on in addressing such crucial aspects of the pandemics, beside the strictly clinical ones. The virus has taken its toll on communication, at any level, but the fact that the publication rush has been affecting even (what we used to think of as) reliable, high-quality scientific communication media is quite worrying -which adds to the communication short-circuit generated by the often conflicting opinions about Covid provided by different virologists on Tv and the internet. While we wait for the vaccine, we should build antibodies against that infodemic which has played a significant role in the crisis.
Many thanks Roberta for your reading and comment! I 100% agree with you, antibodies against the infodemic are today more than needed. I wonder if in contexts other than Italy, the phenomenon of virologists and epidemiologists on talk shows is so pervasive. In Italy, as you very well know, their presence has been sometimes quite annoying considering the number of facts and counterfacts that have been circulating. I’m actually fed up with their claims and subsequent retractions – it’s been confusing, alarming and in the end no-one really knows what is reliable and what’s been used as a click bait.