December 17, 2020 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program

Dr. Archer's Updates on COVID-19

General DOM News & Events

| 17 December 2020

1) Major outbreak of COVID-19 at Joyceville Institution: 80 inmates and 4 staff (click here) (click here)

2) COVID-19 volumes continue to increase in KFL&A related additional super spreader event at another place of worship (see update from KFL& A Public Health):

3) COVID-19 Vaccine FAQs

4) KHSC’s new screening questions effect visitors and health care workers differently: an introduction to “workplace isolation” for health care workers

5) Ontario has had 148,967 cases with 2432 new cases since yesterday, a total of 17,084 active cases and 919 people in hospital (click here)

6) Canada’s second wave of COVID-19: We have had 485,928 total cases to date, with 77,193 active cases (click here):

7) The COVID-19 global pandemic has seen ~1.657 million deaths and 74.7 million cases (click here)

8) Good news: DOM QIM does amazing holiday rounds by ZOOM

Regular reminders and updates:

KHSC bed capacity (not updated at time of note)
Use the Mobile Screening Tool to expedite clinic visits
KHSC visitor policy
COVID-19 testing at Beechgrove Community Assessment Center: (click here):
Increased outbreaks and deaths in Long Term Care facilities (LTC)
COVID-19 in toddlers and young children: (click here).

Major outbreak of COVID-19 at Joyceville Institution (click here) (click here): This is a preliminary report-subject to formal verification by the Correctional Service of Canada (thanks to Ms Stephanie Hartwick for her assistance with this story)

Per reporting in the Kingstonist and anonymous comments from staff within the institution ~ 70 inmates were tested for COVID-19, and 77 of those tests came back positive. The Kingstonist notes, “The Correctional Service of Canada (CSC) reports to its own Public Health Unit, and publicly reports inmate test results daily (Monday through Friday) on their website. However, that page has not been updated since Tuesday, Dec. 15, and does not reflect the 301 tests administered at Joyceville Institution, nor the 77 positive results.” The Kingstonist acknowledged that they have not received formal confirmation of the outbreak form the CSC-so stay tuned. The CSC has issued a press statement indicating visitations are now suspended “In the interest of the health and safety of the public, our employees, inmates, and their families, CSC has temporarily suspended in person visits at all of its Ontario Institutions and CCCs as of December 16, 2020,” .

As I completed the note Global News has been able to confirm that 80 inmates and four staff members have tested positive for the virus so far (click here). The impact of this large outbreak is not yet known-stay tuned.One very important points that the prison system uses an antigen test for SARS-CoV-2,which by its nature is more prone to false positive results than the PCR test we use in our KHSC lab in in the Ontario Public Health labs. The antigen test is quick; but this multi-well assay is prone to inter-sample contamination. So Bottom Line: We should all await confirmation of test results by the definitive PCR assay (which I understand is in process).

2) COVID-19 volumes continue to increase in KFL&A related additional super spreader event at another place of worship (see update from KFL& A Public Health):

The total number of cases in KFL&A since the pandemic began is now 438 and has doubled over the past month in Kingston. There have been 41 new cases in the KFL&A region since my note on Thursday. There are now 115 active cases in the region (see data below) and community spread is occurring. There are 2 patients hospitalized at KGH with COVID-19, including 1 in intensive care.

Recent outbreaks include another COVID-19 cluster of 15 cases in an unidentified place of worship (click here), the third day Worship Center (click here) the Chevrolet-Cadillac dealership in Gananoque (click here), and multiple Queen’s University-related, off campus, house parties (click here). The city is now charging people in violation of public health regulations (click here). A CTV report indicates the City of Kingston’s bylaw officers filed 31 charges under the Reopening Ontario Act related to indoor social gatherings of more than 10 people. The charges relate to investigations that began in November and continued into December. Each Part 3 Summons under the Reopening Act includes a minimum $10,000 fine upon a conviction. The individuals who received the Part 3 Summons will need to appear before a Justice of the Peace in the new year.” (click here).

Although Kingston remains in the province’s yellow COVID-19 zone in this recent Global News report, Dr Kieran Moore is quoted as saying, if numbers did not decline over the coming week, that Kingston could skip orange and go straight to the red zone.

KFL&A is experiencing a concerning rise in local cases (and this does not include cases from the Joyceville Institution)

Bottom line: Neither youth nor religion will protect a person from COVID-19! The vaccine will protect us; however, it will take months to get a critical mass of Canadians vaccinated.

Meanwhile:

Be extra vigilant because the case load is now high in our region!
Continue to wash hands, mask, and maintain physical distancing
Do not assemble in large groups-this is what drives super-spreader events!
Avoid travel to red zones like Toronto, Peel, Windsor and Ottawa.
Avoid shopping in confined spaces
Avoid large group assemblies both for safety and to avoid being charged!
Get vaccinated as soon as it is offered

3) COVID-19 Vaccine FAQs

1) Are side effects common? Approximately 1/20 who receive vaccines will have some minor side effects like redness and pain at the injection site as well as fever, chills, muscle aches and headaches. Most will have no noticeable side effects. These minor reactions are brief, lasting <1 day. This is largely a sign one’s body’s immune system is being activated-which is the whole point of a vaccine! Serious side effects are not more common with the vaccine than in the placebo group in the Pfizer study. In the initial vaccine role out there have only been 2 allergic reactions, both mild and nonlife threatening, both in Alaska (click here). There were 2 more serious reactions in the UK. These “anaphylactoid reactions” to the Pfizer-BioNTech vaccine occurred on Dec. 8 – the first day the U.K.’s vaccine program – and affected individuals who had a history of severe allergic reactions and carried adrenaline auto-injectors (click here). That’s why they cautioned individuals with allergies to any of the ingredients in the Pfizer-BioNTech vaccine to avoid receiving the shot.

Avoid the vaccine if you are allergic to one of these ingredients or have a severe allergic reaction to other vaccines (for now).

Remember adverse events are only “real” and related to the vaccine if they are more common in the vaccine group than in the placebo group. There is no risk of viral infection with the Pfizer and Moderna mRNA vaccines, which are the 1^st two vaccines that Canada will see. While even mild symptoms may make a person worry they are developing COVID-19 infection, infection from these vaccines is not possible. The Pfizer and Moderna vaccines contain no virus; not even live-attenuated virus. These vaccine only contains the genetic code (mRNA) encoding one viral protein, the spike protein. The vaccine prompts our cells to make spike protein and then our immune cells make neutralizing antibodies and voila, we have immunity without ever being exposed to the virus!

Bottom line: Health Canada stresses: “They have identified “no major safety concerns” for the Pfizer-BioNTech vaccine and its benefits outweigh the risks.” (click here)

2) How long does immunity last? We know it lasts 2 months because that’s how long the clinical trial data studies have reported out. It may last much longer. Time will tell.

3) Do we still need masks once the vaccine rolls out? Yes, for a while until >70% of the population is vaccinated. Until there is herd immunity and/or until we know whether the vaccine prevents the vaccinated person from being able to carry and transmit the virus, ongoing public health precautions will be required.

4) How quickly will the vaccine give me protection? The evidence that the vaccine works rapidly and well is compelling. The graph below shows the data from Pfizer’s vaccine study of 43,661 people. It shows that the vaccine is 95% effective. Protection occurs within 10 days of the first vaccine (note the early divergence of red placebo curve from blue vaccine curve). The booster dose at day 28 doesn’t appear to change the already high early protection; however it may enhance the durability of the effect.

The Pfizer vaccine provides protection within 14 days (blue line)

5) How many vaccines are approved in Canada? As of the writing of this note only one vaccine, made by Pfizer, has been approved. 30,000 doses of the Pfizer-BioNTech vaccines, enough for 15,000 people) arrived in Montreal on Sunday night. Health Canada is still reviewing the Moderna vaccine, based on a clinical trial of 30,000 people, as is the FDA. Decision on the Moderna vaccine (which will be easier to ship and store) are considered imminent in both Canada (click here) and the USA (click here) countries. Canada has secured 168,000 doses of the Moderna vaccine (which also requires 2 doses/person) which will arrive in late December (if Health Canada approves).

6) Who will get vaccinated first? It depends on where you live. Quebec began with vaccination of residents of two long-term care homes on Monday. The first vaccines in Ontario are being used in Toronto and Ottawa for frontline healthcare workers. Kingston is preparing all the resource’s necessary to receive and distribute the vaccine and KGH will be the regions distribution site. Our vaccine in arms date has not yet been announced.

7) I’m young and healthy why bother getting vaccinated? You are a potential vector who could pass the disease to other and in these folks, especially the elderly and those with co-morbidities the disease can be lethal. Infections are most common in young people (under 40 years of age) (see graph below).

Also, even healthy young people have been severely damaged or killed by SARS-CoV-2. Also, the vaccine is THE only way Canadian society and its economy will be able to return to normal. Mass vaccination, ideally 80% or more of all Canadians, is essential to establish herd immunity and to permanently reopen our economy. Vaccine’s will also be required for our borders to open. Even if vaccines are not made mandatory I’m reasonably sure that certain privileges will be tied to proof that one has been vaccinated. So…lots of reasons to accept the vaccine when offered!

8) Will the vaccines get us back to normal? Probably, assuming there is widespread uptake of the vaccine by the public. Based on logistical challenges of production and distribution (and 14% of people who say they may not take the vaccine) it will be summer-fall before we would likely hit a rate of vaccination that will truly reopen Canada.

9) Are Canadians open to getting vaccinated? It varies by region but as the second wave intensifies and vaccines are now a reality, acceptance is increasing. An Angus Reid pole showed the following (click here):

screenshot of a news item showing a gloved hand holding a bottle of vaccine

48 % of people surveyed between Dec 8-11 said they would immediately get the vaccine, up 8% from one month ago, see graph below. Another 31% would get vaccinated eventually, but prefer to “ wait a bit”. Seven per cent were unsure. Most concerning, 14 per cent said they had no intention of getting inoculated, a figure that has remained mostly static (see graph below). The West of Canada seems to be a different case, much higher proportion of the population do not want to be vaccinated: Alberta (27%), Saskatchewan (21%) and Manitoba (19%). Unfortunately for the Western provinces, where the disease is spiking, the virus does not respect personal choice and if this large a proportion of the prairie provinces population balk at the vaccine, they will provide a rich refuge for COVID-19.

graphic showing what percentage of people are willing to get vaccine

The challenge of vaccination is getting the public to broadly accept that it is safe, effective and necessary

4) KHSC’s new screening questions effect visitors and health care workers differently: an introduction to “workplace isolation” for health care workers

Although COVID-19 has increased in frequency in our region we are still relatively low compared to Ottawa, Toronto, Peel, Windsor or America. Ideally, one should avoid travel to and from these regions. However, life is not always so simple. For example, many of our trainees and staff live in a red zone and commute to work. When it comes to COVID-19 entering our region it is usually imported by a traveler from a high prevalence area (red zone). Likewise for hospitals, COVID-19 infections are almost always acquired in the community and brought into hospitals (not vice versa)! Thus, we must be vigilant about keeping COVID-19 out of the hospital. Consequently, KHSC is implementing new screening questions about travel to and visitors from Red Zones. This question also applies to visitors from outside Canada. The consequences of failing screening (i.e. answering “yes” to the question about travel to and from the red zone or red zone visitors) is understandably different for visitors (who are not essential to running a hospital) versus health care workers (who are needed to keep the hospital running).

Visitors that fail the screening question: If a visitor answers positively (i.e. they have been to a red zone or been visited by a red zone resident) they will not be allowed to enter KHSC facilities.

New KHSC screening questions

Healthcare workers that fail the screening question (assuming they are asymptomatic): When COVID becomes prevalent it is challenging to staff hospitals and therefore we have to carefully manage health care workers who have low potential for exposure and who are entirely asymptomatic. This does not apply to people who have tested positive for the virus, who should be at home. Moreover, if the health care worker is not essential and has failed screening then, like a visitor, they should not come to work (albeit after talking to Occ Health)!

Health workers who are essential and fail the screening questions because they have been to a red zone or live in a red zone, but who are otherwise well, usually with no known COVID-19 exposure, will be reviewed by occupational health and may be permitted to work under our workplace isolation policy. If Occ Health deems you to be safe to work you will be placed on “work isolation”. In this case you must:

stay on work isolation for 14 days after your last exposure to the COVID-19 risk or confirmed positive case; (unless Occupational Health has informed you otherwise) OR
stay on work isolation until your close contact/household contact with acute respiratory symptoms is confirmed negative for COVID-19

Work isolation requires you to:

Wear a procedure mask at all times when in the workplace along with any additional PPE as indicated by your Point of Care Risk Assessment (POCRA).
Self-monitor for the development of symptoms and take your temperature twice daily.
Do not eat your meals in a shared space or remove your mask in the presence of others.
Where you have removed your mask to eat, use a disinfectant wipe to clean any surfaces you were in close contact with.
Work in only one facility.
Identify yourself as being on “work isolation” at the staff screening station.
If you are a “high risk” close contact of a person who is positive for COVID-19:
1. you are also required to self-isolate when outside of the workplace; and
2. travel to and from work in your private vehicle but if you must take public transit, wear a procedure mask and perform hand hygiene before/after travel to work.
Should you develop symptoms while at work, you must promptly remove yourself from providing care/working, and contact your manager/supervisor and Occupational Health Safety & Wellness (OHSW) (KGH site x4389; HDH site x2265)
Should you develop symptoms while at home, self-isolate in your home, do not attend work, and contact your manager/supervisor and Occupational Health, Safety & Wellness (OHSW) (KGH site x4389; HDH site x2265)
If on a weekend or at night physicians need to contact occ health for instructions (e.g. say someone developed a cold etc. and not sure what to do), they should call KHSC switchboard and ask for the occ health on-call nurse.
For more information on How to Self-Isolate while working or at home, see:

How to Self-Isolate while Working for Health Care Workers https://www.publichealthontario.ca/-/media/documents/ncov/ipac/ipac-covid-19-work-self-isolation.pdf?la=en

How to Self-Isolate (At Home)

https://www.publichealthontario.ca/-/media/documents/ncov/factsheet-covid-19-how-to-self-isolate.pdf?la=en

5) Ontario has had 148,967 cases with 2432 new cases since yesterday, a total of 17,084 active cases and 919 people in hospital (click here): It is very concerning that we are now consistently over 2000 new cases of COVID-19 per day and the viral R0 (its reproductive value) is over 1.0-meaning every 1 case generates 1.04 new cases (a recipe for growth of the infection in society).

Ontario’s pandemic at a glance December 17th (click here)

Ontario’s provincial rate has passes 1000 cases/100,000 population for the first time. (1002.2/100,000 population) has doubled in the past month and is now almost 6X higher than in KFL&A (199.8 cases/100,000 population). However, for those following the local pandemic our prevalence has increased 4X since the summer! There were 2432 new cases today, up +1.7% from yesterday (click here). There have been 4058 deaths in Ontario since the pandemic began. The rate of positive SARS-CoV-2 tests in Ontario since the pandemic began is remains high at 4.0% today (which is decreased 1.1% than yesterday) (click here).

COVID-19’s large second wave in Ontario is still rising. Note the increase in hospitalizations (black line).

Peel (on Toronto’s western border) remains the hot spot in Ontario with 2066.7 cases/100,000 population. Toronto’s prevalence remains high at (1582.8 cases/100,000 population, more than double the rate 2-weeks ago (711 cases/100,000) and ~8 times higher than Kingston) (see map below). Ottawa also remains a hotspot, with a prevalence of 873.1 cases/100,000 population. Eastern Ontario, around Cornwall, has also passed the 500 cases/100,000 population mark since last Thursday. Note that the province is gradually turning orange and red as cases rise broadly in Ontario (see map below).

map of Ontario highlighting areas of high covid prevalence

COVID-19 in Ontario: Dec 17^th 2020

Neighborhood variation in COVID-19 in Toronto: Most of Toronto’s neighbourhoods are COVID-19 hotspots and have a cumulative prevalence of over 1000 cases/100,000 population (click here).

Toronto waterfront and skyline with CN tower

Toronto remains a collection of neighbourhoods with vastly different COVID-19 realities due to differences in social/economic, racial and health circumstances. Although COVID-19 is increasing in the city as a whole, case load is widely variable amongst Toronto neighbourhoods. We should avoid travel to and from these hot spots from lower prevalence areas, like Kingston.

Since the pandemic began the Thistletown-Beaumond neighbourhood has had 4943 cases/100,000 residents, roughly 11X the burden of COVID-19 in the more affluent Beaches neighbourhood (450 cases of COVID-19/100,000 residents).

When one examines recent cases (i.e. those diagnosed since Nov 25th), case prevalence is still concerning-ranging from 40 cases/100,000 residents in Runnymeade-Bloor West Village to 1094 cases/100,000 residents, in Thorncliffe Park.

COVID-19 infection rates in Toronto neighbourhoods since pandemic began: The highest cumulative prevalence is in Thistletown-Beaumond neighbourhood.

6) Canada’s second wave of COVID-19: We have had 485,928 total cases to date, with 77,193 active cases (click here): We have had 485,928 cases of COVID-19 in Canada since the pandemic began (see below). 81.8% of all cases to date have recovered. There has been a 2.1% mortality rate amongst people diagnosed with COVID-19. Most cases of COVID-19 in Canada have been (in descending order), in Quebec, Ontario, Alberta and BC. Canada has done ~14.8 million COVID-19 tests and has a cumulative test rate positivity (since the pandemic began) of 3.26%. Ontario remains the province with the most testing (7.1 million tests, 2.06% cumulative positive rate).

COVID-19 second wave sees a marked rise in hospitalizations-Dec 17^th 2020

Rates of infection are high in all Western provinces (BC to Manitoba) but with introduction of more aggressive public health measures these provinces are hitting a plateau.

Rates of new infection are low in all Maritime provinces, although highest in New Brunswick. There are outbreaks in the North in indigenous communities in Nunavut (click here). The rates in Nunavut are fortunately declining rapidly. Although Quebec still has a higher rate of test positivity (13% cumulative) than Ontario (3% cumulative), its rate of case increase is flat and the total number of cases it accounts for, while still the greatest in Canada, is being approached by Ontario and Alberta (click here)

7) The COVID-19 global pandemic has seen ~1.657 million deaths and 74.7 million cases (click here): There are now 74.7 million cases globally, up 2 million + from Monday. There have been 1,657,706 deaths. The number of cases has increased almost 5-fold since the beginning of August, 2020, when there were 16,296,790 cases globally. The pandemic hot spots are in the USA, India, Brazil, and Russia (click here).

The USA with 17,147,989 cases and 309,859 deaths tops the COVID-19 list and accounts for ~23% of the global pandemic (up from 21% 2 weeks ago), while the USA only accounts for ~4% of the world’s population (see below). The COVID-19 incidence map below shows the high incidence of infection in the US and the western half of South America, as well as in Europe (the bigger the yellow dot the higher the incidence-cases/100,000 population). Note the concerning accelerating rate of new infections in the bottom right graph (orange line). The ONLY solutions to this are adherence to public health measures and rapid, mass vaccination.

global map and ranking of countries leading by covid cases

Global COVID-19 burden continues to accelerate: Dec 17^th 2020

USA positive test rates (click here): In contrast with Ontario’s ~3.2% rate of positive tests, the USA has an average positive test rate of 11.2% (click here). There was a definite rise in rates of test positivity after a Thanksgiving that saw much of that country ignore public health guidelines about limiting travel and large group gatherings and the use of masks in indoor spaces (see blip on the right side of the graph). While vaccines are coming, these data reminds us we can do irreparable damage in the meantime by ignore science and public health (and conversely that with attention to both we can bridge the next 3-5 months until vaccines are widely deployed).

Rates of positive testing remain a staggering 41.1% today in South Dakota and 15% in Arizona (both down from last Thursday). Illinois and New Jersey have positive test rates of 8.5 and 7.3%, respectively. The US-Canadian border will remain closed for routine travel at least until the December 21, 2020 and, for other countries, borders remain closed until Jan 21^st 2021 (click here). That said, Canadians can still fly to America (although certain rules apply) and as discussed in my note 2 weeks ago, Canadian citizens can return to Canada from America, with a number of requirements, including quarantine) (click here).

traffic signs at Canadian USA border at Port huron

Regular reminders

KHSC bed capacity: Bed capacity at KHSC has 76 beds available (versus 78 beds on Monday last week) (see below). Ventilator capacity (46) also remains good. However our ICU capacity is extremely limited (by non-COVID-19 cases). Elective care including procedures and outpatient clinics continues but may soon have to be ramped down.

KGH capacity is limited with little capacity in our intensive care beds

Use the Mobile Screening Tool to expedite clinic visits: Complete the COVID-19 pre-screening tool here and you will be able to “skip the line”: One way to safely expedite entry of patients into our facilities is to have all patients complete our pre-screening questionnaire before their clinic visit. This will screen out people who are sick and expedite entry to the facility for everyone. Reducing lines waiting to enter the clinics will be particularly important as colder weather arrives. The mobile screening tool only takes a few minutes to complete and you will receive an email with confirmation to bring with you, along with your appointment slip, in printed form or on your mobile device. To complete the mobile-screening in English, click here and in French, click here.

screenshot of pre screening tool app for KHSC

KHSC visitor policy: One of the hardest aspects of COVID-19 care in the hospital is the need to restrict visitors to ensure we don’t import COVID-19 into the hospital. A very few cases of COVID-19 can paralyze the hospital, particularly if they are brought in by visitors and then spread undetected. All details on the policy can be found using this link (click here).

COVID-19 testing at Beechgrove Community Assessment Center: (click here): All COVID-19 test must be scheduled appointments (versus walk in). Appointments can be scheduled using our on line scheduling system. Before booking a test, individuals should complete the online tool to determine whether they qualify for testing (click here). The Beechgrove Complex is south of the King St. West/Portsmouth Avenue intersection. Signage will direct people through the Complex to the Recreation Centre building at 51 Heakes Lane for walk-in testing. Operating hours: Testing hours will return to 9 a.m. to 4 p.m. daily. To be tested you will require: A valid Ontario health card or a piece of photo identification. You must also wear a mask and maintain physical distancing at all times while in the walk-in line (click here).

Memo outlining covid assessment moving to Beechgrove

image showing female getting nasal covid swab test and where the swab goes once inside the nasal cavity

Because health care workers (doctors and staff) are increasingly having to miss work because their children have been sent home from school or daycare with symptoms of a upper respiratory tract infection, we have arranged that their children can access expedited testing at Beechgrove . The goal of this service is simply to allow the healthcare worker to return to work as quickly as possible for the public good. The children of staff will be tested between 1230 -1300 by appointment, 7 days/week. The new program for families applies to children up to age 18, an includes children of staff and physicians who provide clinical care and service. Staff and physicians themselves should contact occupational health to book their testing appointment. To book an appointment for a child, KHSC staff should call 613-548-2376. Testing of clinical staff and faculty and their children is processed at the KHSC lab with an average turnaround time of less than 24 hours.

Increased outbreaks and deaths in Long Term Care facilities (LTC): We have 4060 LTC beds in KFL&A. As discussed in many prior notes, most COVID-19 deaths occur in people who are not only old but who are also frail and live in nursing homes and long term care facilities (LTC). As of today, the 2446 deaths in nursing homes (up 46 cases from Monday) account for ~60% of all deaths in Ontario, click here. In the last month the rate of death amongst LTC residents continues to increase daily and is now >50/week! Outbreaks in nursing homes usually start with a person in the community (health worker or family) acquiring the infection and importing it into the facility. Thus, protecting LTCs is best done with a combination of reducing community spread of COVID-19 and ensuring single occupancy rooms in LTCs (as well as appropriate pay for PWS workers, provision of PPE and rapid testing capacity). To this advice we now happily add the early vaccination of support staff in these facilities!

COVID-19 in toddlers and young children: (click here).

Fortunately kids remain much less likely to be infected by SARS-CoV2 and when they are infected they usually become much less ill (click here). The vast majority of upper respiratory tract infections in kids in Ontario are caused by other viruses, like rhinovirus and RSV. Thus, health policy makers and parents of young children should recognize that while children are not immune from COVID-19 infection, infections are relatively uncommon and outcomes are usually excellent for those who are infected.

Children are usually infected by an adult, usually in their home, rather than by other children. The number of cases in school age children (which includes teenagers) has increased dramatically to 4884 up from 3365 case just 2-weeks ago and ~5 times the number from ~ 1 month ago (985 cases).

Amongst younger children and toddlers COVID-19 remains relatively rare. In Ontario’s 5,500 licensed child care centres and over 120 licensed home child care agencies there is a very low COVID-19 burden (see table ). The rise in cases has been modest in these young children. 644 toddler age children have now been infected to date, up from 464 cases 2 weeks ago.

7) Good news: DOM QIM Residents provide amazing holiday rounds by ZOOM Our amazing Medicine residents held a festive and hilarious ZOOM holiday party. Doctors have traditionally had to be masters of the 3As: available, affable and able. In the COVID era we need docs that also are masters of the 3Cs-courageous(recognizing they entered Medicine to protect and heal people and this involves some exposure to personal stress and some risk), confident (that the screening and PPE keep them and their families safe and that the COVID-19 risks are manageable) and consistent (in their use of evidence based medicine and avoidance of fake news). Our residents get 3As from me for the 3Cs that have characterized their deportment during the pandemic. The future of Medicine is in good hands!

tweet of zoom screenshot of three people

Stay well!