 I'm on Think Tech, I'm Jay Fidel. This is much more on medicine, much more. You know, everybody always wanted to be a doctor, even the guys who wanted to be locomotive engineers, really in their hearts, they wanted to be doctors. And it's very important that we talk to a doctor about coronavirus and see how it has changed her life, her practice and the lives and occupations, I suppose, of her clientele, her patients. And we have Nadine Tensal, who is an extraordinary doctor, I'll tell you why in a minute, to join us today by remote. Nadine, thank you so much for coming around, I really appreciate it. No, thank you for having me. Yeah, you remember the measles, I remember the measles, I don't mean when you were a kid, but the measles about six months ago it was, and you were out there with Josh Green and Samoa, checking out the measles epidemic. And I said, gee, there's not a lot of doctors from Hawaii out in Samoa right now. Nadine Tensal, again, distinguishes herself as a community person. What makes you like that, Nadine? Oh, that's a loaded question. I'm not sure what makes me like that. I think I've had a lot of mentors and colleagues who have equal heart. And I don't consider myself, honestly, this is not false humbleness. I consider myself amongst a great crew of professionals rather than rising above. Okay, all right, that could be my opinion and you can have yours. So, the other thing is you're active in the medical community, you're more than most, you're out there with medical organizations trying to organize the profession and so forth. What makes you do that? I think it's a, for me personally, not to speak for the profession itself, for me personally, it's wanting to commit to the hypocritical, we made a pledge to help people, to serve, to heal and care for the sick and the needy when possible. And then I combine that with the fact that I live in a community, the community being Hawaii and I feel that it's my responsibility and I wouldn't use the word duty to help in any way that I can. And my way is with my profession, something that I am quite proud of, I view it somewhat as an art and I constantly look for ways that I can contribute. And if I'm not contributing, ways that I can help. That's beautiful, I'm sorry I said that, but it is beautiful. So, what about your practice? It's so, pediatrics, what is it? Geriatrics or everything in the middle? Demographically, you are correct. I was trained in internal medicine and pediatrics. The expression is med-pede. So, demographically, it allows me to care from cradle to grave. I have a soft spot for pediatrics. You know, I do quite a bit in pediatrics and I serve as chief of pediatrics at Queens. My private practice, which I maintain a full-time practice, is I would think about 60, maybe 65% pediatrics, the remaining being adult medicine. So, I do practice both. Okay, well, I guess I'm focusing more on the geriatric side of things these days because they're more vulnerable. And here you are, you know, running your practice and serving at Queens and all that. And presto digital, out of nowhere in the left field, we have a viral epidemic, pandemic now. And the mission here today is to try to understand how that affects your practice that you've maintained for years and years. All of a sudden things in the world, things in the community and things in medicine have changed dramatically. How have they changed for you in your practice of medicine? I think I can answer that a couple of ways. Well, I'll give credence to the geriatric population. I'm gonna speak more generally and then aim back in. For my private practice, while I am no less surprised than the rest of the world, there's many aspects of this that I do not find surprising. You've reckoned back to just six months ago with the measles. We have been forewarned in many, many ways that there are things that make us as a community and a society vulnerable. Whether it's something as straightforward as hepatitis A more recently, the measles, while it didn't hit our community, Hawaii as significantly as it did Samoa, the months just 18 months prior hit us. Now we're being hit with even a stronger pandemic, which is coronavirus. So where am I going with this? There's some changes for my practice that I've had to do just like everyone else. And there's others that to me, this is a continuum of us and healthcare being prepared for the unexpected. In my practice, the things that we've had to do is break up for the fact that unlike hepatitis A, unlike the mumps, unlike the measles, we're dealing with something that we don't have our usual tools. And what are our usual tools? Specific ways to prevent vaccinations and being able to test in a timely manner without regard for the number of tests that need to be run. And lastly, then having medication to treat when the patient becomes positive or incurs the disease. So all of those typical tools have been taken away. And then you dump me in coronavirus. What do we do? So in my private practice, we've done a couple of things. I have an incredible team. I have a physician assistant and some really well-trained, well-educated medical assistants. And we've decided how we wanna triage the office. I have to divide my life a little bit in two. The American Academy of Pediatrics is still asking us to see the children. All well-child visits and even sick visits should be seen as appropriate. And particularly the infant and the toddlers. Whereas my adult patients, we have a little bit more discretion. What can we do? What can we vary away from the office? Possibly use telemedicine instead. And then as you referred to also my more vulnerable population which would be my geriatric patients. Geriatric being someone who's about 65 years or older. So we've had a triage system to kind of figure out who should we see in the office and who should we not. Telemedicine has been the big changer, the big game changer. We've all to a certain extent have used telemedicine in the past. And what we are now allowed to do in COVID-19 in less than two weeks I might add is we're allowed to do it and not be penalized for doing it. What was the penalty before? I mean, I remember, was it Queens organized a telemedicine program? Some fellow came from East Coast, one of the big hospitals and tried to build something in Hawaii along those lines but it failed, nobody wanted to do it. Now it looks like it's a good idea. But what was the penalty before that discouraged people? I think if there's any lesson we'll get out of COVID-19 it will be the very question you're asking. Why is it possible now and it wasn't possible before? I think before everyone was caught up in all the things we should worry about whether legal, IT, compatibility, where right now we've basically been given license. If you're essentially doing the right thing, do it, make it work and you will be given credit. Now, when you use the word credit immediately people think compensation. And to a certain extent it is about being compensated but compensation doesn't always mean money. It also means that you can use it officially as a means of having seen the patient. And in two weeks time, after five to 10 years of discussion after discussion after discussion almost all of us are alive on telemedicine utilizing it. And if the authorities that are involved whether it be the insurance company, CMS and other regulatory bodies, if they continue to allow us to do what we're doing we've literally gone light years in less than two weeks what we could not accomplish in five years. And that's why bureaucracy. Yep, fabulous though. It sounds to me like it's a permanent change. And when we come out the other side it'll be with us and we'll be better off for it. But you're also better off because, go ahead. What I'm curious about is how they're gonna try to shove this genie back in the bottle. This telehealth genie that is coming. This is gonna be- Can't let them do that. Well, also now, first of all there's two sides to that equation of course. Let me talk for your side at first. So you have a highly contagious disease and you can try to take preventative steps in your office and the hospital. That's pretty scary because you're never sure if those steps are sufficient. We don't know exactly how this contagion works. And so you're exposed as a practicing physician. The telemedicine reduces that risk, deletes that risk. So that's a really big benefit because we want you to be healthy, Nadine. We want you to be there in this conflagration. The other thing is that I can call you. It was not so clear before. I can call you, I suppose make an appointment to see you and we can talk just like this maybe on Zoom or one of the others. Are you using Zoom? Yes, as a matter of fact, I am. There's several platforms out now and I've done most of them. I'm pretty much circled around maybe three, top four that are usable. So let's role play a little bit just for creativity. So Dr. Tansal, I have this fever and I'm not feeling very good and I'm really tired and I'm having a shortness of breath. You think I have it? Now you're going to ask me some questions. You're going to ask me to take my temperature. What are you going to ask me at that point? Well, interesting because some visits such as this, we might pre-triage. I don't know if I would actually make it a complete visit because the minute you have symptoms like that, I need to put my stethoscope on you and it's very difficult to do with this type of medicine. But that being said, let's assume that you're calling in and you have these upper respiratory track or flu-like symptoms that you want me to understand if you should be tested. The first thing I'm going to try to do is get a list, just as you said, and it's going to sound runny nose, cough, malaise, fevers, other flu-like symptoms, timing them to the degree. Have they all gone away with just simply taking Tylenol and poof, you're feeling better. The second is going to be about your potential risk. A lot of my patients do know in advance that either someone they know has tested positive and they've had significant contact, they've been traveling, something to put them into a higher risk category. And then that begins to put in place, should I test them? The ability to test is becoming a little bit easier. If you had asked me this two weeks ago, if you sounded like I could give you medication, whether over-the-counter or prescribed, and most of what you were experiencing you could do at home, I would highly, highly discourage you from being tested. And that's where we were about two weeks ago. Just recently, our two laboratories in the community, CLS, which is clinical laboratories and DLS, which is diagnostic laboratories, are now able to do testing on Island. And they are at about 200 tests a day. And while that sounds like a lot, we have 1.4 million people. There's an infectivity rate of coronavirus at about 3.5%. That puts us at about 50,000 people who if we do nothing will be exposed or possibly have symptoms that are consistent enough to need to test for the coronavirus. We can't keep up with that. So what I think is sometimes a mixed message is we still need to triage who should really be tested and how important is it to know whether you're positive. And those are about to be hospitalized. I'm thinking of hospitalizing you or you have symptoms that indicate that you should not be at home. And then there's softer categories who you live with might be at so at risk that not knowing may put another individual at risk. Wow, that's a heavy moment, isn't it? But you'd be my primary contact as my primary doctor. And I would call you, make an appointment, talk to your staff and I would present to the extent I could. Maybe I would take my temperature and you triage and find out what else you needed to know. Let me footnote that by saying, I recall the last couple of days that there's this easy test, it's 15 minute test. I don't know if the patient could administer that test himself or whether I have to go to a laboratory for it. But if assuming for a moment that I could administer that test and get a pretty accurate result in 15 minutes. So like a pregnancy test, how about to take the test and it comes back and says, no, you don't have the coronavirus, Jay, but you're pregnant. That would be pretty interesting. So really quick. And then I could tell you that and then we'd be a step ahead and hopefully that is in the near-term future, don't you think? And in a short answer is yes. You brought up about four or five different points. One of them was what would we do with you back in that original scenario at this point? And that would be decide whether or not we thought you were safe enough to come in into my private practice. And if we really thought you had it, it's not likely we would allow you here. We would send you to a place like a drive-through where you could be more safely tested and move on. And then in the community, there are urgent cares, Queens as well as HVH has the drive-throughs to go through and to get testing where you limit the number of people and providers that you might expose to your illness. The second point I think you tried to raise was how can we get to the point of faster testing? So we went from the first testing that the DOH was doing where we're literally sending it back to the mainland. It was taking a minimum of three to five days. Now we're at the point that we can do it on Island and it's called the PCR and turnaround is about 24 hours. And then what you're referring to is the fact that there's just been a release of these rapid tests that are similar to the flu tests that we do in our offices where within about anywhere from five to 15 minutes, you can know your answer. The problem with that is they're not widespread. They're not in every office. And then you brought up another point. A lot of these tests are really once you explain to an individual whether it's a well-trained medical assistant or maybe a most patients could the average person self-administer it. Many of these tests we don't have that you could just drive up to Safeway or Longs and get them. But there's a lot of discussions about that from everything from pregnancy which we have in place to struck throat urinary tract infections. And now you're trying to take the same idea to coronavirus. So yes, yes, yes, but it's not widespread. And we can't use it as a public health measure right now in our presence. But you know what? We learning things now. Now this is going to be endemic I think. It's just going to be there like forever. Maybe in a lesser emergency, but you know, virus is going to be around with us. I saw a very interesting end. Anybody can look it up. It's a TEDx speech by Bill Gates in 2015 where he predicted all of this. I mean, it's a remarkably accurate what was going to happen. And I say to myself, well, after this one there'll be another one. You know, the whole issue will not go away. It's the human condition. And so all of what we're learning today under duress hopefully will be built into the system going forward so we can deal with other newer coronaviruses later. But one thing you said I want to pursue and that is, you know, you may not want me to come into your office because you don't want to catch it and we don't want you to catch it. And we don't want your other patients in the wedding room to catch it. So what kind of precautions do you take? Are you wearing a mask all day? Are you, how careful can you be? Are you being in dealing with the public in general not just somebody who presents as maybe having the disease but the public in general? I'm going to answer you very specifically which is different than the message you would give to the general public. So when you ask me as a healthcare provider that question I am constantly assessing what particular situation I'm in. So when I'm in the hospital and there's a patient they call them a PUI, a person under investigation and I'm anywhere near that individual maybe they've been formally placed in isolation. The guard that I put on the type of mask, the category of masks that need to have that mask fitted for me such as an N95 is something that I would don. And typically I don't have to do that in my office. I should say I don't have to do that in my office. Quite recently as recently as I shouldn't say quite recently but as recently as yesterday, Queens decided to put forward that on the campus if you're on the campus as a healthcare provider or a staff you should be wearing a mask. Now a mask is a very general term. It has nothing to do with being able to stop N95. But they're taking the steps to somewhat protect our healthcare providers as well as protect others when we might happen to have a mild cough or cold. So it's a two-way protection. But the masks that you're expected to wear now on campus are just a step in between having nothing on. In my office, we went through this in stages. So prior to us actually having a significant number of cases here in Hawaii, I met with my staff in the same way that I just explained to you. I explained that we have something coming. We are going to be at risk. We are not at risk now. We began to triage how patients come through the office. For instance, we do well in the morning and we see sicker patients toward the end of the day. So we somewhat separate patients out. And I understand your next question about asymptomatic patients, but we have to be realistic and just deal with what we can see. We started having the staff wear garb whether it's mask or gloves any time they were near any sick patients. Within a week, we had to transition as the numbers went up that now they have to wear garb whenever they go near patients. And as of two days ago, just reading what was going on in the news, watching where other countries and other states had to change their guidelines as their numbers went up, which means your incidents of coming across it increase. We too are wearing masks. So I'm in my office right now and I'm talking to you in my office, my office within my office and I don't have a mask on, but all day long, we are now wearing masks while the office is open. And then we unmask and then when we leave, it's my staff's discretion whether or not they wanna continue to wear a mask until they go home. So personally and professionally, are you afraid of catching it? And I mean, of all the implications of catching it, it wouldn't just be that you'd be personally at risk, is that the people around you would be at risk. You would not be able to perform your function. How do you feel about that? I mean, you're a dedicated doctor. It makes it even more complex. I'm gonna answer it two ways. The first is when you refer back to Bill Gates' TED Talk, while it seems incredibly insightful as you look back, I think most doctors and people who are in healthcare and public health understood that these were things that we knew. And that while the coronavirus is very unique, we have been amongst this for a long time. And a lot of this, while I'm not implying that I or anyone else is immune, it is along the lines of the rules that we knew that existed for viruses in the flu. What makes coronavirus scarier is it instead of it happening over an entire season, it's happening within a month or two. It's happening when we have nothing to ameliorate the rise in the curve. Normally, if we had a particularly virulent flu, we would have taken the basic flu vaccine and then made a serotype for that flu vaccine and then passed it out and we would flatten the curve. We have three very excellent anti-flu drugs that will not stop you from getting the flu, but it will at least ameliorate your symptoms and make it less likely that you'll get worse, end up in the hospital, end up on a vent. So when you ask me, am I afraid? I'm not afraid of something that is still by all everything that we can see following the rules of viruses. I do consider the fact that I may be put out of commission if I get it, putting my personal family at risk as well as turning my practice on its head. But I also put things in place such as telemedicine. Like I said, I have a very strong physician assistant which we work with that allows me to then flex as a team. And if we end up having to close the practice, I think that's another discussion. The fact that we've built a healthcare system that does not, is literally unable to deal with crises or flux in healthcare such as outbreaks. And then that's another big discussion that I think after this coronavirus burns itself out and it will, it'll take us two to four months to kind of burn through it. We have to come back to these questions. If this were to happen again, do we think our healthcare system is robust to manage this? Have we created a healthcare system that basically assumes that everything stays the same, there's never any big crises and there will never be a strain on the healthcare resources? You said two to four months and I like to be optimistic along those lines but on what basis do you say that? Is it a medicine issue? I mean, will they come up with a cocktail that can really ameliorate this? Is it the virus itself that it loses its virulence over time? What makes you say two to four months? I also have to be careful. The minute I said it, I realized that I probably should qualify what I mean by that because there's so many ways to measure this. The disease itself, once you get it, it takes about two weeks, right? If we did nothing, we would have probably started to see a peak in our numbers already but because we're an island, we've closed our borders, we have taken a lot of steps and we live in a really good community for the most part, people are being very compliant. So we're seeing that it's not likely if we hit a peak that we're gonna see this peak for at least another maybe three weeks. So we hit our peak. Now, if a significant portion of our population then gets infected, while that is a bad thing, the good thing is that then we'll see a number of people who have had the disease, only a small fraction will actually end up needing hospitalization or ICU. That would mean after say April, you give all of May, or into June, a significant portion of our population should have experienced the coronavirus in some manner, either just getting it, got it and is over with or is starting to get it. That puts us then at about July that it should have burned through. And I'm making this up but I'm following the basic curve that is followed through pretty much in all other parts of the world. You can see that the virus still acted like a virus in a very predictable manner. And that the, when we talk about the curve, it's when the curve of when the virus comes into a community and then when it peaks. And the only thing that seems to change the shape of the curve is how well people were able to distance themselves and that they could spread out how when the peak occurred, instead of the peak occurring all at once, it was over an extended period of time. And no matter how you stretch that out, there's an endpoint to it. Whether or not it will reoccur like a flu, that's a second, you know, like a flu season. That's a second discussion. But for this season, this coronavirus, it seems for all intents and purposes, it will be time limited. And everybody is all a good guess. So when I threw out four months there, I was throwing out, hitting a peak, recovering, having to clean up the shambles afterwards and then starting to feel a certain normalcy. But yeah, you have to be very careful when you say time or put a time to this. Yeah, well, nobody knows as part of our adventure. It's just a bad word for this, our adventure with this. You know, and what comes to mind is, you know, I understand that after a certain percentage of people have experienced the disease, whether it's mild or extreme, you know, it is likely to diminish, whether by the herd immunity concept or just the virus changing itself. But, you know, and we've all heard, we've all heard so many times, a hundred, 200, 300 times, you know, to wash our hands and all that stuff. I wonder, you know, I really, let me say this, I'm gonna say it publicly. I really don't want to say this. I really don't. I really, really don't. I don't be part of all these statistics. So what's the added thing? What's the most important thing for me to avoid those little buggies getting into my respiratory system? What can I do to be as sure as I can personally be to stay away from danger? Honestly, there has been nothing to show that this bug does not follow the rules. So you cannot get sick if you're not exposed to it. That's one. So the more that you can isolate yourself is probably your strongest tool. Again, I'll give an off-color joke. It's like you can't get pregnant if you don't have sex. Yeah. That would be... That's very good, that's very good. The second one is, in the end, you do need to go out. There are reasons that you have to go out. You may even need it for your own mental health. And how can you protect yourself and minimize your risk of getting it? For all intents and purposes, we have seen this bug is spread by respiratory droplets. And while people will talk about others, such as the overt respiratory droplet of the spray from the cough or the sneeze and that spray out, that's one. Then there's two. Those spray or droplets, how long do they linger in the air? Diseases that are far more infectious than coronavirus, for instance, the measles, that can linger in the air for a long period of time. And the risk of catching the measles after walking into a room of someone else that had the measles, if you're susceptible, is so high, it's like 96%, just to give you how relative it is to catch one versus the other. So your risk of getting is something like catching the flu. You need to have been exposed to someone. But there's so many others line of ways. You may go and touch a surface that someone else just sneezed on and put their hand on. So how can you protect yourself from that? Well, avoid touching surfaces. After you do, keep your hands clean or clean them, whether if you're out and about and don't have access to soap and water, then there's the hand sanitizers. The second would be when you do have soap and water, please use them. Those will do everything for you. We're being made to feel very frightened of the asymptomatic carriers. And I'm not saying that they don't exist. It is just, it's less, it's probably less of what you're gonna come across. So what do you do about the mysterious asymptomatic? Asymptomatic means no symptoms at all. Probably the best thing you could do is wear a mask and again, be very aware when you're out and about. Did you really need to lean on that surface? Do you really need to rub your eyes and put your hands in your mouth and bite your nails? Those are all habits we probably are going to have to put aside during this time. Yeah. One last thing, can I ask you one last thing? We were running out of time here and that's this. You know, we've alluded, both of us have alluded to the sort of the connection between this incident of the virus and maybe the next one and the connection between, you know, the community of patients, the medical community. And let me add the public health community, which is not the same as what you're doing. It's public health is special people and training and government positions for that. And government in general, seems to me that all of those various, you know, communities are involved in dealing with it and making plans for the future to deal with it. That is the community of patients, the community of doctors. I suppose you could add the community of hospital frontliners, you know, that's kind of different than office pediatrician, geriatric doctor. And finally, the government. So how does that connect up? It seems like what we have seen here is maybe the connection wasn't really good enough for everybody being on the same page to deal with this virus and going forward, it's all got to be connected so we can all play our specialties in some kind of collaborative coordinated way to beat the next wave of virus. What are your thoughts about that? So you got me a loaded question. How much time do I have? Take as much as you want. I think after we get past the scare and the collective shock of coronavirus to me, this is gonna be the million dollar question. What are we gonna do moving forward? We should not allow this to happen again. There's parts of me that agree and disagree with what you just said. I think the solution is about bringing all the parties to the table. And I think if I were to look back what I've seen being part of healthcare and I wanna call myself somewhat of a healthcare leader is we need to put our swords down. There is often a battle of who's in charge and whose school of thought and whose training should lead in this. I think historically the doctors were very dominant. Basically on the doctor I said you do whatever I say and then make it work. Then we went through a period of time where I think the public health, my colleagues came and we needed to build it all so that it would fit very neatly under public health umbrella. And I think where we are right now, not to point any blame, but I think business, business insurers have a disproportionate amount of power and say in the way healthcare is being delivered, the models that are put in place to take care and protect patients. And I would like to see that we reconvene, we rethink our model and we think about the fact that the only way that this is probably gonna work is to work collaboratively because what is being done right now and then just the very recent past, it's clearly not working. And this is the perfect example right now in coronavirus that it's not sustainable, it cannot work and the healthcare system we have in place is only meant for the healthiest and the best of times. I think the last thing I would say, I know quite a few of, I'm gonna dub them healthcare leaders in our community. And that term is not necessarily just awarded to physicians. It could be our public health colleagues, it could be our insurers, the presidents of our insurance. We have the right individuals in this community. We just need to come together with a different intent, the intent to put together a health system that will work that is actually for the benefit of the people of Hawaii as opposed to trying to make it fit into a business model in which you can only be successful when you save and make money. Yep, there you have it. This is, that's a fundamental rethinking though. And I hope we can do that one way or the other. I hope that leaders, both medical and government and public health and business can get together and identify the better model and then implement that better model. Maybe this will encourage them to do that. And certainly your remarks will encourage them to do that. Thank you, Nate. They did pencil out a fabulous doctor, a fabulous member of our medical community coming around and sharing with us. Thank you so much, Nate Dean. Aloha. Take care.