Join Dr. Kern TODAY! Tues July 28th at 12pm ET for a 30-minute Clinical Editor's Corner: Live webinar and discussion.
Dr. Kern will be focusing on online learning and telehealth in the post pandemic interventional world.
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Like many of my contemporaries, I am a boomer (aka baby boomer), a member of the post World War II generation. I grew up in the 1950-60s, graduated college in the Vietnam War era (1960-70s), and had a millennial-generation (1980-90s) daughter. Each generation experiences a distinct environment impacting how they see the world, communicate, work, and grow (Table 1, Figure 1). This has been the human evolutionary cycle from Day 1 (see Adam vs Eve in the Big Book, etc.).
Our pandemic of 2020, like that of 1918, has changed the world. We are fortunate to be able to see each other without having to leave our houses. In the movie-making business, you would now yell to the crew, “Zoom in on the Zoomer” (Figure 2).
Are You a Zoomer?
A zoomer is an informal term for a member of Generation Z (Gen Z), born in the late 1990s and early 2000s. Some call zoomers the Internet Generation, as it is the first generation born after the popularization of the internet. In Japan, the Gen Z cohort is described as digital natives who primarily communicate by text or voice, while neo-digital natives use video, video-telephony, and movies. The shift from PC to mobile and text to video among the neo-digital population continues to activate as well as overwhelm many boomers (OK, boomers?).
Gen Z has had an unprecedented amount of technology in their upbringing, with the use of mobile devices growing exponentially. According to U.S. consultants Sparks & Honey in 2014, 41% of Gen Z spend >3 hours per day using computers for purposes other than schoolwork, compared with 22% in 2004. They prefer to learn in novel ways (see Table in the JAMA publication “Mentoring Millenials” by Waljee et al1).
Are Zoom Meetings Our New Family ‘Table’?
The family table is where we gather to eat, talk, and share information, as well as hopes and dreams. Hannah Arendt, philosopher and author, said, “When you have a group of people sitting around a table talking, the table is what makes them a group...and if you take the table away, they’re just individuals, they’re not connected.” Will Zoom be our new table? Whether [the internet] will sustain a public world, as Arendt would surely hope, is hard to tell. We have no choice but to try.2
How Digitally Literate Are You?
Despite being labeled as digital natives, the 2018 International Computer and Information Literacy Study (ICILS) of 42,000 eighth-graders (or equivalents) from 14 countries found that only 2% were sufficiently proficient with information devices to justify that description, and only 19% could work independently with computers to gather information and to manage their work.3
Since the pandemic began, my cardiology conferences, lectures, and social/family meetings have moved to the zoom format (Figure 3). The ‘Virtual’ Society for Cardiovascular Angiography and Interventions (SCAI), American College of Cardiology (ACC), and other interventional cardiology meetings replaced those that I loved to attend. In this brave new world, the zoomer-boomer (ie, old guys who have to learn new tech and will really have to “retool or retire”4) is emerging. With my personal digital literacy in question, I wanted to find out my colleagues’ views on transforming from boomers to zoomers, and how our life in the cath lab will change. I asked them 5 questions:
- I like/hate zoom* meetings. Is this our future? (Nearly everyone said they like zoom meetings and yes, this is our future. I’ve included the naysayers’ comments.)
- True/false: I may never go to another large meeting.
- True/false: I hate wearing a mask to talk to my cath lab team; I am/am not going to wear a mask all the time. [By the way, if you don’t like wearing a mask, you’re really not going to like the ventilator – MK].
- How does my cath lab feel about Zoom/Facetime/other media to work with our follow-ups after percutaneous coronary intervention (PCI)?
- What will our cardiac invasive world look like in 3-5 years?
Christopher J. White, Ochsner Medical Center, New Orleans, Louisiana: About large meetings: Once we have a vaccine and/or effective therapy, I will attend large meetings because I get a lot done outside of the conference rooms.
About masks: Leaders masking sends a message that they care about their people.
About follow-up visits: We believe virtual visits will replace low-value returns for cath patients and surgery patients. In a value-based world, in-person visits are a “cost”, and should only be used when required for clinical decision-making or therapy choices.
The biggest change? There will be a new normal. We will use virtual visits and virtual meetings a lot more, but not exclusively. I would add that this is likely not the last pandemic we will face. What we learn with Covid-19 will inform better choices in the future.
Fred Resnic, Lahey Clinic, Boston, Massachusetts: Zoom meetings can be more efficient for attendees, and involve many more geographically disparate colleagues and collaborators.
About large meetings: They will be a hell of a lot smaller, and large professional organizations will have to determine how to provide ‘value’ to prospective attendees to have them pay to attend in person or online.
About masks: This is the new reality of life, and wearing a mask protects the team members, especially those who may be at higher risk than you.
About the cath lab follow-up: We love using telehealth to replace low-complexity follow-up visits for post procedure and many other patient groups. I believe there will be an ever-increasing number of home-based devices that will help us incorporate vitals, ECG and some exam/echo information into our telehealth visits.
The biggest change? In 5 years, things will be back to before Covid-19 (BC19) (except for broad use of telehealth), until the next “pandemic X” hits, when we will be better prepared to nimbly move into a crisis mode, and move back out using lessons learned from this event.
Jon Tobis, Los Angeles, California: I will feel comfortable going to large meetings when there is a good vaccine. The personal interaction is important. As video calls improve in technology, they will be easier for follow-up visits and for people who have to travel a long distance.
Bob Applegate, Winston Salem, North Carolina: Zoom meetings will be part of our future, but they need to control the over-talking. I believe there is a way to have central control of mute which will help. Why? People really don’t like to travel for less-than-full-value meetings.
About large meetings: I will be more selective in going to meetings. But the personal interactions are irreplaceable.
About masks: I do wear a mask, and will wear a mask. I completely agree with Chris that it shows I care.
About cath lab follow-ups: I believe the first follow-up should be face-to-face to reestablish a connection; the subsequent ones can be virtual.
Biggest change? I agree there will be a new normal with regard to communications. Work ups and procedures will likely not change.
Peter Block, Atlanta, Georgia: Yogi (Berra, philosopher and National League catcher) had it right: “It’s hard to make predictions, especially about the future.” However, the large meeting question is timely (pun intended). Do we need to fly hours to another Holiday Inn, spend 3 days with 10,000 of our closest friends, and spend other people’s money (and ours) if we can receive the same content at home? I suspect that allure will make future meetings a hybrid (both zoom and face-to-face), at least to start. The new format will reorganize the economics of such meetings, so likely the change [of format] will have pushback.
Kirk N. Garratt, Center for Heart and Vascular Health, ChristianaCare, Newark, Delaware: Zoomer boomer — love it. I’m good with Zoom/Microsoft Teams/FaceTime meets, as long as people use the video. Those who don’t have their video going probably aren’t paying attention. When I’m in a live meeting, I expect to be seen. We should have the same standard for virtual meets.
I won’t be going to a large meeting while coronavirus is circulating, but after it’s cleared, I look forward to going back to big meetings like SCAI, ACC, and TCT. I doubt busy people are taking the same days off, staying home, and virtually attending these meetings. I don’t, and as a result, I’m distracted by the work around me — I end up missing way more of the meeting than if I’d been there.
Wearing a mask: What?? Nobody likes wearing a mask, but little choice. I wear a mask all the time when I’m around others — not to protect me (doesn’t do that well), but as a show of respect to others by keeping my germs to myself (does that very well). I expect the same from others.
Like many, we’ve catalyzed our virtual health platform. It is now a major means of patient visitation. It will grow and it will be permanent. By the way, patients generally like it.
Biggest change in the next 3-5 years? The answers are only partly related to Covid-19. The good news: Virtual care will dominate. We’ll have secure systems to better evaluate patients (including emergencies) from home. We’ll move away from low-sensitivity tests like treadmill and pharmacologic stress tests to more sensitive methods like cardiac computed tomography-fractional flow reserve (CT-FFR); this will lower cath lab diagnostic volumes, but enrich the proportion receiving intervention. We’ll get much better at fast-tracking ischemic, arrhythmic, and structural patients, resulting in shorter hospital stays. We’ll see more surgical work go to the cath lab, especially valvular heart disease patients. The bad news: The financial aftermath of Covid-19 will lead to further practice absorption into large hospital systems. Smaller hospitals will close or be assimilated. Hospital systems rewarded for efficient population management will steer chronic cardiovascular care to primary medicine with much less specialty/subspecialty contact. Acute care organizations (ACOs) will do the same. A national single-payer system may be tried. All will cause downward pressure on workforce need (fewer jobs) and salaries for subspecialists.
Gary Mintz, Cardiovascular Research Foundation, New York City, New York: I appreciate zoom meetings and believe this will be part of our future. For the first time in many years, I can attend the Columbia University Cath Conference every week, albeit virtually. I have also participated in several webinars. However, the technology is not always perfect. I have had Webex crash PowerPoint repeatedly during my presentation and I have had RingCentral crash my laptop. Even a successful dry run does not guarantee a trouble-free live event. Sometimes it works flawlessly; sometimes not. Finally, inability to control video playback when commenting on images can be frustrating.
Barry Uretsky, Little Rock, Arkansas: I am unenthusiastic about zoom meetings. The current technology is not entirely satisfactory. I am uncertain if future improvements will approach the sense of an in-person meeting. It will be useful for some purely business (transactional) meetings, but I’m not sure how valuable they will be for educational purposes and/or many patient-physician interactions.
About large meetings: I find in-person meetings challenging in view of travel, time, etc., but as I am there for education as well as interacting with my colleagues, in-person meetings are better. I simply cannot watch a screen for a long period as a learning approach, so for me, zoom learning will remain a challenge.
About cath lab follow-ups: Telemedicine is acceptable, but not ideal. We are currently doing it, but in my opinion, it will not be as satisfying for patient and doctor as an in-person visit. It may be useful and fill in some medical issues for which an in-person visit really isn’t needed, such as the old office blood pressure check, which with the use of home monitors, has markedly decreased.
Biggest change? This C19 period will allow us to see what in-person practices can be modified and become more efficient without impairing patient care. However, the continuation of the in-person physician-patient contact is invaluable and should likely be continued. Patients need to feel confidence and safety in their doctor’s care, and there are limits on long-distance telecommunications.
Michael Kutcher, Wake Forest University, Winston-Salem, North Carolina: I like zoom meetings, but the details need to be worked out on issues such as uniform platforms, muting etiquette, central control, etc., to make them more efficient. It will be a part of our future armamentarium of communication. Security and identity issues are both an ongoing and future critical concern. As Chris White said, once a vaccine and herd immunity is present, there will be a time and a place for large medical meetings. We are a social species and learn more by in-person interchange across countries and nationalities.
Having worn a mask all my career during interventions, I now find it hard to wear it all the time. But it is important for us to do so as a sign of respect for others during this Covid-19 crisis.
Low-risk follow-up after intervention and hospitalization will be more efficient using some form of telehealth. Patients seem to like the fact that we make contact and in many instances, spend quality time with their cardiologist. It allows us to keep tabs and identify those who need more intense in-person office visits. However, the mechanism of reimbursement for professional time will be an issue.
Our interventional cardiology world will be very different, but better. There will be an amalgam of virtual communication, off-site interaction, in-person contact, and a return to national meetings, although somewhat muted.
Lloyd Klein, Sonoma, California: Zoom meetings are here to stay, and I like them for groups of 8 or less. Zoom saves time and the effort of travel. It’s great for informational meetings; education not so much, and when a real interchange is required, that’s best done in person. Large meetings are going to have to change. The old way is over, and really, let’s be honest, for years now, you can get breaking news faster by the medical media. Like all boomers, I don’t pay close attention when listening to these webcasts, and that’s a problem, but it may be my problem.
If you don’t wear a mask in my presence, I will walk away. This is not kidding around. If you have no respect for me, I will have none for you. Egotistical attitudes must fold to the reality of an infection that can kill you or me. This isn’t negotiable.
Telemedicine is here to stay. Reimbursement and clinical practices will have to readjust to this new reality. I think this is the silver lining in all of this. Not in our area, but generally, you’re going to see more people working from home and fewer office-based people sitting in front of the same computer they could be sitting in front of at home.
Carl Tommaso, Evanston, Illinois: I have mixed feelings about zoom meetings. Half of the meetings have technical glitches, and I’m not sure if this is the technology or the operator. I’m sure as the technology improves, us boomers will no longer have issues. The technology will make it possible for more to attend local conferences. At our hospital system, in the past, you might be able to hear and see the conference but not interact; now everyone can interact. I think there will still be a need for large meetings. The personal interactions are important. Industry will want live meetings so they can demonstrate and interact.
Wearing a mask is very depersonalizing, but very important during this pandemic. The effectiveness of some masks is not adequate. However, it serves as a reminder for us to act safely.
Patients very much seem to like telemedicine. It certainly has its drawbacks in terms of “laying on the hands”, but for much of my practice, it has been as adequate as an office visit. It will certainly become part of daily practice even after the pandemic.
One of the biggest changes to come is how we will interact with patients coming to the cath lab. I often meet the patient a few minutes prior to the procedure, and although they have been worked up by a fellow, advanced practice nurse, or cardiology colleague, the chance for me to meet with them the day prior to the procedure by telemedicine would go a long way to ease patients’ anxieties and clarify potential adjunctive issues. I will try to incorporate a telemedicine visit with patients the day prior to their procedure.
Bonnie Weiner, Worcester, Massachusetts: I think there are no black-and-white answers to these questions. Zoom meetings are fine as far as they go, but as a single type of meeting, they lack some of the personal interactions that make us who we are. The same pretty much goes for large meetings. Those are partly about the content, but also about the networking, interactions with friends/colleagues, and the unexpected or chance opportunity that arises.
Virtual patient visits and telemedicine are here to stay. Most follow-up and “routine” visits can be done this way, but again, there is something to be said for the “laying on of hands” in the doctor-patient relationship that needs to be factored in. One size probably does not fit all.
Michael Lim, St. Louis, Missouri: It’s interesting to me how zoom meetings have different issues, but are similar to live meetings in which “meeting etiquette” can be problematic; for example, the in-person bad etiquette of having a laptop open or not having your cell phone silenced. Zoom bad etiquette is not having your mic muted when others are speaking or not using video when all the rest of the group can be seen. Regardless, it’s here to stay and those that can maximize its benefits will be the “winners”. I prefer in-person meetings like my colleagues, as personal exchange often is better than listening to a lecture. I’m excited for the time when this can happen again.
Mask? Yes. The only reason why this is a question reflects the fact that a virus has actually become political. Virtual patient care is here to stay if it can provide similar care with more convenience for patients. It’s the preferred strategy.
The future? One may hope that the pandemic impact hastens the transition from fee for service and RVU domination toward a better way to deliver care. I urge my colleagues to help drive this rather than have others dictate to us.
Sam Butman, Cottonwood, Arizona: I like zoom meetings with patients and believe this will be added to our future. I actually enjoy seeing the patient with spouse/family in their home environment. Since the majority of my patients have coronary artery disease, it’s mainly history, history, history, notwithstanding the need for in-person visits as well from time to time.
When it comes to business and zoom meetings, this was a small part of our norm, since our sister hospital is 50 miles away. I think there will be more work from home as it has been tested, is more efficient, and works. We still will need in-person meetings, though, otherwise some will correctly feel ostracized or marginalized.
I will go to another large meeting again. They will probably be different, but that will depend on how this pandemic plays out and whether others are lurking in the shadows.
I do not mind wearing a mask to talk to my cath lab team; I do not wear a mask all the time.
How does my cath lab feel about zooming for follow-up after PCI? Not sure about this one, but zoom calls for follow-up by cardiac cath lab staff should be a plus over simple but less personal phone calls.
Biggest change? I believe our cardiac invasive world will look like 2019 in 3-5 years, but with newer technology, perhaps better screening for illness, in general, but also even way more fun and useful tools.
Steve Ramee, Ochsner Clinic, New Orleans, Louisiana: I worked as a virtual telemedicine hospitalist during the pandemic here and treated hundreds of Covid-19 patients for six weeks by phone or video/phone. It worked perfectly and allowed me to talk to the patients while I reviewed their charts. I’m convinced that telemedicine is here to stay, especially for follow-up visits, as long as we insist on it and don’t let others (insurers, hospital systems) tell us ‘no’. We will find more usable platforms that allow audio and video, and are reimbursable by all insurers in all states.
About telemedicine, I find Doximity to be the best, because of ease of use for both the physician and the patient. All they need is access to a smartphone. If they don’t have one, a family member can usually assist. It appears to the patient that you are calling from your office. Haiku by Epic is our institution’s favored platform; however, I find less than 30% of patients can make this work. FaceTime also is pretty easy to use, but your phone number is not disguised.
Chet Rihal, Mayo Clinic, Rochester, Minnesota: Although I’m tired of sheltering in place, I’ve appreciated a number of positives with virtual meetings. We have had a grand rounds series with speakers from around the world, including Singapore, Texas, China, and Bergamo, Italy talking about their experiences and studies with the virus. I’ve learned a ton and attendance is much higher than with face-to-face rounds, particularly since you can attend from anywhere. Departmental informational meetings have had hundreds of attendees for rapid dissemination (and is more effective than email), with questions asked using the chat function and attendees muted centrally.
I do miss our larger cardiology meetings, but mostly for networking and seeing friends — less for data and studies, which are readily available online. When we presented at virtual ACC, there was a large worldwide audience watching, with many good questions. The data were critically appraised and commented upon on Twitter by numerous individuals, and the paper is not even published yet (big potential downside to this, too, of course).
For initial patient consultations, telemedicine seems to work fine as long as we have images. Patients save travel expenses and time off from work. If they need to come for specialized testing or procedures, that visit is more streamlined.
As for masking/eye protection, I don’t enjoy it, but will definitely adhere to it while the pandemic is going on. I was just saying the most “normal” activity I have recently is golf, since it’s easy to distance.
E. Magnus Ohman, Duke University Medical Center, Durham, North Carolina: Zoom is here to stay. It can be much better, as it is always hard to get people to come to various conferences. I see several advantages. We just finished our cath conference this evening and we reviewed 5 cases in a very relaxed manner, most of us in our homes. You could even consider having a beer! Our Heart Team meetings with the CT surgeons can now also proceed with honesty and distance. Now we can participate with all the surgeons at 6:30 am and I suspect some may be in their pajamas, but nobody will know as the video is off, except for the fellows showing the cases. So I am very happy with this digital transition.
Jim Blankenship, Geisinger Clinic, Harrisburg, Pennsylvania: Biggest change? Here are some guesses about the future of the cath lab:
Invasive procedures may be less affected by Covid-19 than many other aspects of health care. Dr. Garrett is correct that more accurate diagnostics (eg, CTA) for coronary ischemia are likely to decrease diagnostic cath volumes.
Negative pressure rooms are best for Covid-19, but positive pressure rooms are best to minimize risk of infections. The solution? A positive pressure cath lab blowing air into a negative pressure anteroom. Existing cath lab suites may be modified so at least one room has this feature and new labs may incorporate this design.
Lingering fears about hospital environments may make ambulatory surgical centers (ASCs) look much safer to patients. CMS recently approved PCI in ASCs, but it remains restricted by many states. Expect increasing use of off-campus ASCs. The same lingering fear of hospitals may make patients think twice about pushing for a cath “to be sure” even though their physician tells them they probably don’t have coronary disease.
Testing strategies and technology are evolving rapidly so that it is impossible to predict the future, but pre-procedural Covid-19 testing will become routine. One more item to check off on the pre-procedural checklist.
Jeff Marshall, Atlanta, Georgia: Great questions for troubled times. I concur with all that has been said so I thought I’d share some personal levity. I was doing a telemedicine visit with 76-year-old man who lived alone and had no one there to help with the technology, so he could not link to the telemedicine application. So I said, “Why don’t we just FaceTime and then I can see you via your phone?” After a long pause, he replied, “How do you get to FaceTime on a Motorola phone?” Needless to say, I had to mute my phone.
Larry Dean, Seattle, Washington: I think zoom meetings will have a place going forward. We have noticed improved attendance at our meetings using zoom. Granted, that likely has something to do with more people having the time to attend with the Covid-19 impact, but it also affords attending without physically showing up if that is more convenient.
I still think there will be a place for continuing large meetings. It’s a chance to catch up with colleagues, if nothing else. Some meetings will have Zoom or similar technology that covers the main presentations live for those who don’t have the time to attend the meeting in person.
We have a relatively robust telehealth effort which was rapidly increased as a response to Covid-19. I suspect we will see increasing technology like wearables and other devices that will make this easier. PCI follow-up is a perfect use of this technology.
Biggest change? I think we will have a slow ramp back up to BC (before C19) with respect to elective PCI. It hasn’t really impacted our transcatheter aortic valve replacement (TAVR) business. I’d like to see more sophisticated integration of multimodalities in the cath labs. After all, x-ray has been around for more than a century.
The Bottom Line
Wear your mask until further notice. All agree. An available vaccine or herd immunity will open the country for safer business and leisure activities.
Become a zoomer. If you want to see friends and families or participate in educational meetings, you have no choice. Become digitally literate (at least know where the mute button on the zoom meeting control banner is).
Don’t hold your breath on when large meetings will be back. They’ll be mostly for face-to-face friendship renewals as much or even more than their content. I can’t wait to go, but that’s just me.
Virtual telemedicine is a done deal, and will be the way we deliver timely and perhaps better care (for some). There will always be a need for face-to-face with patients at some time or another.
What does the cardiac invasive world look like in 3-5 years? It looks very much like now (I mean 2019, not 2020), but busier, with more protections (C19 rooms), more FaceTime, shorter commutes, and better take-out lunch options for the cath labs. OK, zoomers? (I hope so).
Disclosures: Dr. Morton Kern reports he is a consultant for Abiomed, Abbott Vascular, Philips Volcano, ACIST Medical, and Opsens Inc.
Dr. Kern can be contacted at firstname.lastname@example.org.
On Twitter @drmortkern
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- ICILS 2018 Results. International Association for the Evaluation of Educational Achievement. Available online at https://www.iea.nl/news-events/news/icils-2018-results. Accessed June 23, 2020.
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