Alicia Morgans: Hi, this is Alicia Morgans, GU medical oncologist and Associate Professor of Medicine at Northwestern University in Chicago, Illinois. I am so happy to have here with me today, Dr. Tom Beer, who is a Professor of Medicine in the Division of Hematology and Oncology at OHSU, Oregon Health and Sciences University, where he is also the Deputy Director of the Cancer Center, the Knight Cancer Center there. Thank you so much for being here today to talk with me, Dr. Beer.

Tomasz Beer: It's my pleasure. Thanks for having me.

Alicia Morgans: Wonderful. We have talked with you before and are so happy to catch up with you again on how things are going in your cancer center and your GU oncology practice for your patients themselves in the setting of this COVID-19 pandemic. I'd love to hear your thoughts on how things are evolving.

Tomasz Beer: Well, starting with our GU practice, we're hanging in there. We're doing okay. We have rapidly converted most of our care to remote care, increasingly via video but still by phone. I think the institution had a five-year plan to build telemedicine that was implemented in three weeks, so it's been an amazing transition. Almost all of my patients have responded really well to remote care and have done well. I've been grateful for that. We work in a very large state geographically that's thinly populated, so we have a lot of patients who often travel many hours. I expect that this telehealth approach is going to be here to stay even as the pandemic hopefully comes under control.

Our clinical trial operations have continued. We have had to forgo some elective things like pharmacokinetic sampling or in-person care that's not directed at immediate patient wellbeing. But therapeutic studies that are treating patients are allowed to continue, and we're continuing to treat our patients so long as the procedures that we carry out are designed to directly, positively impact the wellbeing of that particular participant. So that's limited things to patient safety and patient treatment, and peeled away some of the correlative work that's important for scientific progress but doesn't serve that particular participant. But we've been pressing on in that sense so I think we're doing okay.

The broader cancer center is much more complicated than the GU practice. We've had to create specialized treatment areas for folks who have been exposed to COVID so they can be cared for separately from patients who are not involved. We've seen a dramatic decrease in elective procedures, primarily impacting our surgical colleagues, but also our emergency department and so forth. Like most centers, we've seen an enormous economic hit from all that. And as a consequence, we're seeing some significant impacts on our organization, pay cuts, and real struggles to maintain operations going forward. So the cancer center-wide impact's been, I think, much greater than just the GU practice.

Alicia Morgans: I'm sorry to hear how things have been impacted. I don't think you are alone in that at all. I wonder as we as a nation are moving in some ways into a sort of post-peak but continued vigilance in our consideration of COVID-19, do you expect any of these things to change with further time or do you think that some of the changes that you've experienced are going to be really permanent parts of your practice and your cancer center? You mentioned that telemedicine is ... that timeline was dramatically moved up as it was for all of us. It sounds like that was something that was in your plans and may be there to stay. Are there other changes that you think may be longer-lasting?

Tomasz Beer: Well, I think we're in for a prolonged period of ongoing challenges that are not as dramatic hopefully as the first month of this crisis, but I think most people that look at what we can expect from this virus do not expect it to subside. We expect it to continue to be present in our communities. Likely a flare-up here and there, hopefully in a manner that is manageable and doesn't overtax our healthcare systems. So, in that context, I expect that many of the precautions that we've put into place with reduced physical contact, social or physical distancing if you will, waiting room rearrangements, all the things that we've done to try to interact with one another in a less physically close way, I think are likely to continue for the foreseeable future. Perhaps in a year's time, we'll have a vaccine or something will change. But I think realistically, we don't expect this to get back to the old normal in the next few months, and perhaps to some extent, never.

I think if you think about other major crises in our nation's history. We recover and we move forward, and we find a way forward, but that doesn't mean we go back to the way things were before. That's what happened after the Great Depression. That's what happened after 9/11. I think we're going to see telemedicine persist. I think we're going to see perhaps a greater awareness of infectious transmission risk persistent in the future, and some of the things we do will be a little bit different. Telemedicine is an obvious one that I see continuing.

Alicia Morgans: I agree with you. And I think that part of accepting that things may be changed forever, in some ways, is challenging, both for clinicians who have really made a life around caring for patients with cancer, and certainly for our patients and for their families who in many ways sought solace in seeing us and that human connection. How are you and the folks at OHSU supporting the psychological distress that both patients and clinicians might be feeling as they're realizing that this is not going to go away anytime soon?

Tomasz Beer: Probably not as well as we should, in the sense that we had to begin with ... I mean, we have wonderful social workers and support systems for our faculty and employees at OHSU. Those systems were staffed at a level that was designed for the ordinary course of human events. This crisis, in many ways, has created a great deal more distress than is present at baseline and there's just not ... we can't hire hundreds of new social workers to help, so I think we're doing the best we can. And in some ways humans are ... in the midst of crisis, I think humans are pretty resilient. At least my interactions with some of my patients in the first month or six weeks have impressed me about how folks are responding and managing.

I think the harder time is ahead. I think as we settle down into a longer-term situation where the sort of adrenaline-filled initial response wears off and we have to deal with the new reality, that's when I think distress is going to begin to increase. And I saw the first signs of that this last week and I'd be happy to share that with you if you'd like.

Alicia Morgans: I think that would be really helpful for everyone because that's exactly the stage that I feel many of us are moving into and our patients are moving into, so I would love to hear how your experience has been.

Tomasz Beer: I was really struck by my clinic this week, and I've been thinking about it since then, in that, I visit with 20 odd patients every week on my clinic day via video or phone, and the first few times everyone was highly focused on staying safe and making sure that they can avoid this virus. And obviously our patients are well aware that they are at an elevated risk, even by virtue of their age but also by virtue of having cancer, and so they were uniformly really stepping up to protect themselves and so forth.

This week, for the first time, I heard from a number of patients, not the majority but more than one or two, that ... something to the effect of, "I'm old and I need to see my grandkids, and I can't do this much longer." There were various versions of that. From, "I don't have forever to live and there are things I want to be doing," to kind of more of a grandkids or kids-focused comment. But I'm beginning to hear a real and understandable wariness with the solitude that we've imposed on ourselves to deal with this COVID crisis. And I'm beginning to hear it from folks who may not have that many years ahead of them. In part because they're in their mid-80s, and in part because they have cancer. It made me realize that the very people that need to be protected the most may also be the people that have the most to lose.

I as a 55-year-old person, if I have to give up six months of social contact, God forbid it's that long, I still hopefully have another 30 years to catch up. But some of my patients don't and I'm beginning to see that emotional suffering emerge, and I didn't have good answers for my patients about that. It was kind of eye-opening. The fatigue with the physical distancing is not just amongst the college students, which I see a lot of in my kids who are really tired of not seeing their friends, but it is amongst those people who, for medical reasons, should remain largely separated from others to protect their health. But I can see how that's not going to be possible forever without real emotional burden. And for many people, I think eventually they will begin to make different decisions, just because they will say, "I understand the risks but I can't live the rest of my life without seeing my grandkids and visiting with the people I love, and doing what life's all about." I think it's a real challenge for our country now.

Alicia Morgans: I completely agree and have been hearing many of the same things. From things like, "I'm going to be fine. You don't have to worry about me. I've made it this far, I can do this," to, "I just want to get takeout again. Can I just do something like that and be somewhat normal?" And of course, "I miss my grandchildren. They're trying to teach me how to use Zoom but there are technical challenges." So, I agree with you. I think that now that the initial fear has worn off, we as a community need to continue to support our patients, perhaps even more so in that psychological way, in addition, of course, to caring for their cancer. Because like you said, the adrenaline is wearing down. We have to adapt to whatever is going to be next. There will still be risk involved, but there's also risk of continued isolation for our patients. So, lots to learn.

Tomasz Beer: Yeah. I agree, Alicia, with your sentiment about the value of in-person healthcare. I think although telemedicine is great and it can be very efficient, especially for people who live far away, the connection's not the same and the comfort is not the same. A big part of what we do is not just prescribing medications, but being that source of strength and support that our patients can lean on. So what I'm hopeful we'll see is some hybrid system where we will use telemedicine when it's appropriate, or every other visit or every third visit, reduce unnecessary travel. But I don't really see that we can wholesale replace in-person care without really amputating a significant component of what it is that our profession does and what our patients really need.

Alicia Morgans: I agree. Well, I wish you, your colleagues, your patients, your family, everyone out there in Oregon the best as you all move forward and deal with this new normal. It sounds like you are well on your way. And it also sounds like you have in mind those things that we need to keep very aware of as we continue to go down this road. Thank you so much for your time, Tom.

Tomasz Beer: Yeah. Thanks for having me.