FEMALE SPEAKER: Welcome to Mayo Clinic COVID-19 Expert Insights and Strategies. The following activity is supported in part by an independent medical education grant from Pfizer Inc and is in accordance with ACCME guidelines.

DEVYANI LAL: Hello, everyone. And welcome to this episode of Healthcare During the COVID-19 Pandemic. I'm your moderator, Devyani Lal. More to come about me in a little bit. But I'd like to welcome my panelists. We have a very esteemed panel here with Dr. Kling, who is in women's health, Dr. Bendok, who is a neurosurgeon, and Dr. Bekaii-Saab who is a gastrointestinal cancer specialist.

This video cast is part of a COVID-19 Expert Insight and Strategies put out by the Mayo Clinic. And I am Devyani Lal. I am the course director of the COVID-19 Expert Insight and Strategy series. I'm a professor and consultant in the Department of otolaryngology at Mayo Clinic in Arizona. And I also serve as the associate dean for the Mayo Clinic School of Continuous Professional Development and also serve as the vice chair of education at Mayo Clinic in Arizona.

As part of my duties to my institution, I have served in creating educational content for healthcare providers, organizations, and administrators dealing with the pandemic. As part of that series, we are also creating some patient focused material and discussions that are relevant to everyone, including specialists and doctors that you see on the panel.

And today, I hope that our esteemed panelists will discuss some of the barriers that have challenged our patients to the pandemic. And also I hope they will be able to share some of their experiences with their patients that reflects the importance of ongoing care. And I also hope that you will be able to share with our listeners some of the safety practices and some of the technological solutions that you've adopted to caring for your patients during the pandemic.

So, none of the panelists have any conflicts of interest or disclosures. This educational activity is supported in part by an independent medical grant that was provided by Pfizer Incorporated. Our preparations today and all the presentations with the series on COVID-19 are in accordance with the ACCME guidelines. And that means that if you are a healthcare provider, you can visit our website, ce.mayo.edu/covidexpert and claim the relevant AMA Category 1 credit.

Our first panelist that I'd like to introduce is Dr. Tanios Bekaii-Saab. He is a professor of medicine and he's a consultant in medical oncology in the Division of Hematology and Oncology, and has a specialty interest in gastrointestinal cancers. He wears many leadership roles hats at the Mayo Clinic. And I'd like for Dr. Bekaii-Saab to give his own introduction as to why he went into medicine, what makes him passionate about healthcare, and how has his family dealt with seeking healthcare during the pandemic.

TANIOS S. BEKAII-SAAB: Yeah. No, Thank you. Well my interest in medicine, believe it or not, actually started at quite a young age. In fact, while visiting my family in Beirut in my early 30s, I found a little drawing book that I used to draw things and write little poems, kids poems. And I actually saw an autobiography that I had when I was 10 years old. And in it, I actually was talking about my trajectory into medicine and going to the American University of Beirut, which I actually where I ended up going for medical school.

So I think that interest comes also from a heavy presence in medicine in the family from a lot of my father's uncles on both sides, heavily vested into medicine. And so the curiosity about medicine ended up coming from quite a young age.

So I grew up in an environment that was conducive. But in terms of a choice for oncology, that came about as I was building my journey through medical school, and then ultimately through residency. And I found a natural attraction to the humane aspect of oncology that is certainly unrivaled. I mean all medicine is very humane, but in oncology I felt that extreme closeness to patients who are suffering and dying in quite a different way.

Also given my background in pharmacology, and my interest in drug development, hematology oncology offered the closest you can get to cutting edge research, drug therapies, and others. So, a lot of this came together and led my path and to where I'm at right now.

In terms of how my family had been dealing with COVID-19 as they live far away. They are in Lebanon, where there's not a single country that's immune to this awful disease. And they're both older and they've been, at least my parents have been, relatively staying put at home, I think, has affected them quite a bit both mentally and physically as it does for most of our patients unfortunately, and has certainly affected their capacity to travel, to visit family.

So, in a way isolated them. So, it has been a tough time for the family of course, and a tough time for all of us because it has limited interactions as well.

DEVYANI LAL: Well thank you so much for sharing such a human perspective to why you joined the field of medicine and how it means not just to be dealing with a pandemic as a doctor, but as a human being, as a family member, and sharing your experiences. And I have to say that I grew up in India. And I have had two aunts. I come from a very large family on my mother's side. Two aunts that came down with COVID, one of them fairly elderly after she was hospitalized for a fractured femur.

And thanks heavens because they are both OK. So, I thank you for sharing that. I'd like to next introduce Professor Bernard Bendok. Dr. Bendok is a professor of neurosurgery in the Mayo Clinic College of Medicine. And he actually holds joint appointments in radiology as well as in my department, otolarnygology and head neck surgery. And we work closely together in managing patients that have tumors of the skull base, which is at the junction of the brain with the rest of the head.

He is an extremely innovative person. And since I have worked with him so closely, I would say that the reason he is here is because of what he has done. And I welcome him to share some of those fabulous things that he is working on, endeavors and he has been working on at Mayo Clinic.

I will say that prior to inviting both Dr. Bekaii-Saab and Dr. Bendok, I did not know that they both had Lebanese heritage. So I talk a little bit about diversity later on, but we have to excuse that part. So, Dr. Bendok, if you don't mind telling us about what drives you, why you are in medicine, how your family here in the States and Lebanon are dealing with the pandemic, and in terms of healthcare.

BERNARD R. BENDOK: Well, if you've seen that movie is it, Big Fat Greek Wedding, most Lebanese believe the whole world is somehow related to us. So, we could all be Phoenician. So--

DEVYANI LAL: We are, actually.

BERNARD R. BENDOK: But so thank you, Dr. Lal for this invitation. And just briefly I am passionate about moving the story of our collective fields together forward from where I think we've been in what I call a traditional surgery era, let's say, or traditional healthcare to precision surgery, precision medicine. And that involves many things including augmented reality, virtual reality, 3D visualization, design of new devices, intraoperative advanced imaging. So I've been honored to work with you on that.

So those are the kind of things that drive me. And but in terms of COVID, COVID has been-- it's very interesting. When COVID first hit, it was like when I first moved to Phoenix five years ago. I was most worried about my kids, but it turns out that kids can adapt better than adults. And it's amazing to see how the kids have adapted. And on my end and Karen's end, my wife, we made the best of it. And but it has been challenging.

I think that the social challenges of not being able to see friends, not being able to visit, not being able to go to Dr. Lal's lovely dinner parties, those things all carry a toll on us. And I think that has been a big hit. My father just had COVID. So two weeks ago, he had some emesis. He had the GI version.

Apparently there's a GI onset, and got diagnosed with COVID. Daily fevers, eventually hospitalized at a government hospital in Lebanon where the-- and I don't mean to embarrass Lebanon, but in this particular hospital which is in my dad's hometown, the floor rooms are six patients a room, ICU is two patients a room. So maybe because of me a little bit and other connections, he got the ICU bed. I feel embarrassed even say that.

So most of the private hospitals are not admitting COVID. Very limited ICU beds. And so I feel very fortunate to be at Mayo Clinic, very fortunate to have the resources we have here. We can complain of course about things not being perfect in the United States, and they never are. But certainly I've gained a perspective on how lucky we are to be in this somewhat rich and well resourced environment.

And so I've become even more passion about trying to help improve systems. I visited Kuwait once as part of a consulting team. And they lacked for no money, but yet their neurosurgery hospital was very poorly running because they didn't have the right systems in place. And so I'm very pleased, and honored, and lucky to be at Mayo Clinic where we have systems.

I was just telling a student earlier today that if I was a musician I'd be in a band. Maybe I'd have my 10 minute solo. But I'd like to be in a band because I enjoy the teamwork. I enjoy working with Dr. Lal. I enjoy working with the otology team in those areas at the cross borders, things that we can do really well at Mayo Clinic. So that's my story in a nutshell.

DEVYANI LAL: Thank you. Thank you so much for sharing. How harrowing to be here far away from your father and knowing very well that the organization and the teamwork that really matters to your family is probably not as great as what is available to us in this country. So thank you for sharing that.

BERNARD R. BENDOK: Luckily, he is doing OK. He went home but it could have ended very poorly. So thank you for your kind words.

DEVYANI LAL: Thank you. And our third panelist is someone that I'm really honored to introduce Dr. Jewel Kling, who is an MD and MPH, and actually is an associate professor of medicine in the College of Medicine and is the interim chair in the Division of Women's Health Internal Medicine. And I have come to know her due to her work on diversity. She is a diversity leader at Mayo Clinic in Arizona that has several interests in terms of student outreach community clinics and a lot of research related to breast health, menopause education, LGBT healthcare m et cetera.

She's also a passionate educator, helps out the Mayo Clinic with several educational ventures. But there's a lot more to her that she has kept quiet about in her introductory slide. So Dr. Kling, if you don't mind sharing what drives you, what your passions are regarding medicine, patients. And love for you to share some experiences that you've had with yourself and the family member about the impact of the pandemic.

JULIANA M. KLING: Of course. Thank you so much for inviting me. I'm truly flattered and honored to be on a panel with these impressive colleagues of mine. I think maybe one thing that makes me stand out from the rest is that I'm the only native Phoenician represented on this panel. I was actually born in the same hospital in downtown Phoenix that I had both of my kids at and have stayed here and did my training here at Mayo Clinic, Arizona.

The thing that drew me to medicine, I think, becomes clear as you look through the slide. The kind of work that I'm doing, it really had to do with advocacy. And I realized the importance of advocacy through my parents' examples in their careers. My mother was a therapist for sex crime victims, or sexual assault victims. And my dad was a detective, a homicide and sex crime detective. And I saw them bring to their careers a passion for really helping people out.

And so that's what informed my decision to go into medicine. It seemed like such a beautiful way to advocate for people, both within the exam room, but outside of the exam room, which is really one of the reasons I got my master's in public health. It has definitely come in handy when we think about the intersections of a global pandemic and primary care and women's health in general.

I fortunately have stayed healthy as has my immediate family from COVID. But I do have lots of patients and lots of colleagues that haven't, lots of my friends I went to medical school with that are at the front lines in the ICU and in the hospital working long hours. And so, again, going back to that desire to be an advocate, I take that role very seriously.

And when I'm talking to patients, and friends, and neighbors trying to really preach the gospel about those good public health strategies so that we can reduce the spread in our communities and our clinics. So I think that with all the questions that you asked.

DEVYANI LAL: Thank you again. I don't know how many of you watch America's Got Talent, but for some reason America's Got Talent have all four American judges who were born outside of the United States. So thank you for being the one person from Phoenix. I had no idea. So that's great. And I think that just reflects on our organization that where we come from is not as important as what we do today. So fabulous.

So without much ado, I put together some thoughts. And thank you for reviewing these. And I thought we could have a broad conversation starting and sort of progressing organically through some of the factors in healthcare that have been severely upended, care as usual. And so what are your experiences? And how the pandemic affected the care of patients, ongoing, new patients?

And then I hope that Dr. Kling you can talk a little bit about preventative health care because Dr. Bendok and Dr. Bekaii-Saab are both mostly on the other end of specialty care, surgical and non-surgical And using examples, if you could tell us about how proactive care has been helpful, how you and your practices, or Mayo as an organization, has adopted practices that have delivered healthcare safely, that could be potentially adopted at other organizations.

And so maybe I could start first with Dr. Bendok. Dr. Bendok I was telling the other panelists before you joined that I'm going to ask you a question that might somewhat put you on the spot. But it's not going to be a tough question. And I'm just going to ask you. Since March, have you been to a doctor yourself?

BERNARD R. BENDOK: Interestingly I have. And the reason is not what you would think. I had the opposite effect of-- so I had ignored going to a primary-- I used to in Chicago, I moved here in 2015. I used to go see a primary doctor every year even though I didn't need much, just as a oil change, 10,000 mile checkup.

And but when I came here, I kind of got so engrossed in my work that I-- but one of things the pandemic I think has reminded me, and I think of this on a personal level, but also a global level. And I'm no expert on epidemiology or the medical manifestations of the virus. But just as an observation perhaps, almost at the lay level as a neurosurgeon, is that risk factor reduction is absolutely critical.

If you look at healthcare in North America and you look at how disadvantaged communities have been hit harder than others, and the risk factors that are more prevalent in those communities, whether we're talking about diabetes, et cetera. And simultaneously I've become more passionate about the concept of wellness and self care, and I actually I never sat down with a mentee now without-- and that's the first topic I always bring up.

What are you doing about wellness? Because without wellness, the rest don't matter. And I don't want to turn this answer dark, but in my career so far, I've lost about five to six colleagues my age to sudden death. And so I bring it up with all trainees. And, again, I'm not an expert on their, and I don't have deep knowledge into their healthcare, but they all seem to me to have risk factors. And both whether it's stress, et cetera, and other things.

But so I'm sorry. That's a long answer to your question. But so I think the pandemic has made me introspective about the world, about our healthcare, both individually my learner--

I remember the first case I did was a giant meningioma when COVID hit. And I actually asked my learners to stay out the case because at that point, it was a tsunami hitting. We didn't know, how do we protect our learners? So I told my learners, the fellows, not to go to the case because we still didn't know the exact-- now we know much more of course. But and so the well-being and wellness of our learners is perhaps our most important thing we can give them guidance on. And so I don't know if I answered your question, but that's sort of what's on my mind.

DEVYANI LAL: Thank you. And as always, I continue to be impressed by the fact that you actually had time, which I know you have very little time on your hands.

BERNARD R. BENDOK: Yeah. I snuck out.

DEVYANI LAL: And kudos to you. I think you're leading by example and the way you eloquently describe risk reduction is fabulous. So I'd like to jump to Dr. Kling next to take on from there because you deal with a primary care setting essentially for women. And perhaps talk about how the pandemic affected your ability to take care of your patients, whether they were established, or there were other folks that wanted to establish care with you. And share any personal anecdotes that you have.

JULIANA M. KLING: Yeah. It has certainly impacted things. And like Dr. Bendok was saying at the beginning, we weren't quite sure what to do. And so what that meant is that our full calendars got restructured. Many patients got canceled. We weren't set up at the beginning of March to do video visits, and so had to figure out some other way to reach out to our patients who really needed us, and so did phone visits and kind of learned as we went.

It was incredibly impressive and such an honor to lead the team in women's health as we were telling them to do medicine such a different way than they learned, calling their patients, figuring out how to do it from home. And thankfully, we were able to figure that out together. And I can think about many times where I reached out to a patient. And certainly a phone visit is not ideal, especially for a preventative visit.

But you could just hear their fear in their voice. And to have that opportunity for us to talk to them, and answer their questions about COVID, about their risk factors, was such a big thing. And it was really nice to work for an institution that did everything to help facilitate that so we could continue finding ways to care for our patients and rapidly went to being able to do video visits, rapidly went to creating infrastructure in our clinic that was safe, so for those patients that truly needed to come in face to face that we could see them and care for them safely and has throughout really been able to support us in doing that.

So there was a lot of times that were tough, both for us and our patients. But on this end of things looking back, we realize that it taught us the things that were truly important, and has given us this really beautiful opportunity to re-evaluate how we practice and where we practice. And we've taken those opportunities to look at models like teleworking for our working mom physicians, and video visits for our patients that are working and need to walk into the OR to do their surgery but maybe need to talk to us about their preventative care or their mammogram.

So it has been a roller coaster. But I think on this end of it, there's a lot of positives.

DEVYANI LAL: Thank you. In my practice as a ENT specializing in sinus and school based pathology, I can say that the impact of the pandemic was quick. We pivoted and we were able to come through with some safe protocols.

But I do still, I am seeing now patients that are presenting, whether it's cancer or non-cancer patients, that are coming to us in more advanced stages. And that is truly heartbreaking because these folks thought that they were protecting their health by not seeking care during the pandemic. And I don't think that strategy has served us well in that. So I'd like to ask Dr. Bekaii-Saab about cancer care during the pandemic. And what would you say to our patients?

TANIOS S. BEKAII-SAAB: I do think that you're right on. One of the biggest tragedies of this pandemic is delaying diagnosis, and folks delaying their preventive measures, which we know are their only opportunity for a potential curative surgery. There is also an aspect too for the quality of life also that has been compromised by delaying getting attention. Even a few months can make a big difference.

And I do understand the [INAUDIBLE]. We were all in that period between at least March and May, even trickling into June, we were all really short of answers. We were trying hard to understand the behavior of this disease, which came like a tsunami on us, trying to understand how to protect our patients most importantly, how to protect our colleagues as well. Because even two, three colleagues down, or quarantine, can affect the whole system. Also we were stretched for resources.

So these were tough times. And even although we do understand a little bit more the behavior of the disease and have things a little bit better control, then we've implemented a lot of great measures. In fact, I dropped wearing scrubs. As an oncologist, I don't wear scrubs. We adopted the scrubs because ultimately we had to ensure that we don't take back the virus back home, et cetera.

And two months ago, I was thinking, I come to work to probably the safest place I could come to. We take every measure possible to protect our patients and our staff. We assume that everyone is at risk, and we want to ensure that no care is interrupted. And so we take every measure possible to protect our patients, protect everyone from transmission. Mean we live in an environment that essentially ensures when we come to work at our Mayo Clinic to ensure that everyone is safe from the virus.

And so I went back to normal dress code, Mayo dress code with the suit and tie, and just thinking that not only I'm safe in this environment because of the protective measures, my patients are very safe. But also when I get back home, my family is also very safe because, again, everyone is masking up or putting glasses on, proper distancing, proper cleaning, proper screening, everything is done in a way that is actually very protective.

Now, going back to the question of know what have we done with our cancer patients, now, other than the fact that I remain concerned that we're going to see a lot more patients over the next few months trickling into the next year that will be presenting [INAUDIBLE] with their diagnosis or even beyond that, we had mostly uninterrupted care for most of our patients.

As you know, a lot of our patients undergo chemotherapy. And that chemotherapy is for some part of a curative regiment, for others part of a palliative regimen. And withholding chemotherapy can have tragic consequences at the same token. And so we had to essentially continue through, and muscle this through the early phases of the pandemic, ensuring that essentially our patients have uninterrupted care.

And I'm proud to say that we have not had, for most patients, any interrupted care. We're able to continue as normal as possible in terms of administering our chemotherapy. We had to be a little bit more creative in terms of how we do it. So thinking about for some patients how to deal intensify treatment?

So moving from an intensive to a less intensive treatment. Spacing out, when possible, treatment to minimize having patients to come too frequently if they don't need to. Ensuring that rather than having patients be seen all the time face to face, when we felt that we could replace a face to face visit by a video visit. And to Dr. Kling's point is that it took a little bit to get to the video visit, we had to start with the phone visits, but if we clump all these into virtual visits, we had to implement measures where to ensure that if patients didn't need to be on campus, being seen face to face, we were able to see them or meet with them virtually.

We also for some patients who were just having routine follow ups. We had to consider delaying-- I'm sorry. Delaying their visits by a month or two just to accommodate. So we had to be quite creative. And I'm proud to say that at least in our division, and we feel that we have not compromised the care of our patients. If anything, we've implemented every measure possible to ensure that the continuity of care doesn't stop, and the safety of our patients continues to be first.

DEVYANI LAL: Thank you. And both you and Dr. Kling mentioned telemedicine. And it's interesting to me that you come from a very specialized aspect of care Dr. Bekaii-Saab. And Dr. Kling, you come on the frontlines of preventative as well as curative treatments.

Can you describe the experience that you've had in terms of patient care, whether you're able to establish that relationship with patients? What has been the experience of your patients with regard to telemedicine? And Dr. Bendok, I know that you are a surgeon. And well yes. I do know that you're a surgeon. But what has been your experience with folks over a video visit? And what has been the reaction of your patients? And whoever wants to jump in first, please go ahead.

TANIOS S. BEKAII-SAAB: I mean I'm happy just to quickly take this through just to continue through the discussion. I will say that for a lot of our patients, that there was actually a pleasure for them, and for me, to be able to see actually the full face unmasked on televisits. These facial expressions say a lot, say a lot from the patient's side, but say a lot also from the physician's side when delivering good news or bad news. It's very important for the patient to be able to see the facial expression and to understand where we're going with this.

So part of this was a little bit more personal, although it was through a video. At the same time, I think, and I'll just summarize it. I think we learned so much about virtual visits that post-COVID, and there will be post-COVID, post-COVID, we will implement a lot of these measures because I think they do bring a level of quality to our patient care that we were kind of scared of before COVID.

So there was a moment, and I think a lot of tragedies bring some benefits to them. If there is any benefit to this, is that now we know especially that we care for a lot of patients who travel distances. We know that we can do it. We can do it well. We can do it safely. And we can benefit our patients tremendously by cutting down on their visits, their risk of being here, or even the inconvenience of traveling hours when we can do this through a video visit.

BERNARD R. BENDOK: Yeah. So would you like me to comment Dr. Lal?

DEVYANI LAL: Please. Please.

BERNARD R. BENDOK: And I know Dr. Kling has also been very involved with telehealth. But just briefly, I think it has been a big game changer for us in neurosurgery. I mean our patients have been very pleased. My favorite story is I saw a patient with leg pain from a disk in their back-- was on his boat somewhere on a beautiful lake. I thought it was a Zoom background. I said, that's a beautiful Zoom background. No, that's actually real. I could see the mountains behind him. And he was just delighted to be with his wife on their boat which is where he likes to hang out.

So in a way, we talked about Mayo Clinic in 2030 bringing digital health to patients, bringing the health to the patient rather than having the patient come to us. And I think the pandemic accelerated that. So I've been very pleased. You do get the occasional patient who still wants to be seen in person, not because it's a better care, but because they have this ingrained psychology around the idea of seeing a doctor in person. And there's nothing wrong with that. And you have to be sensitive to that there are some people who will prefer that.

But I do think it has enhanced our ability to deliver high level destination care by meeting the patient before they leave their home so that when they do come, they're lined up to get all the things they need and it's much more organized. And then for their follow up care, I think it makes it just very efficient for them just--

When we book a half hour appointment with me or you Dr. Lal, for us it's just maybe 20, 30 minutes. But for the patient it's a whole day. They have to take the day off work, they have to get in their car, they have to drive, find a parking spot, come to your clinic. Sometimes if we're running behind in surgery, hopefully that doesn't happen very often, but if it does happen it's an additional nuisance. And so I think this has really enhanced our ability to engage. And I think it's just the beginning.

Dr. Lal, as you know, you and I are engaged in virtual reality research where perhaps one day we'll have a beautiful clinic room with a view of Paris, perhaps where we can meet with the patient and they can pick their environment so to speak. But we can actually walk them through their brain or through their sinuses.

So, you can actually walk them through their sinuses to show them what you're doing in a way that you maybe couldn't do in person in a very scalable way, and by creating a virtual environment, not just of the patient and you, but of your tools, your surgeries, your educational platforms that you can share with your patient I think really is a game changer.

So it has been really good for us. And I think it's just the beginning. Just a final anecdote, is I started just to help our practice get back on its feet in terms of adjusting to the pandemic doing some Saturday clinic. And I hate to even bring that up because I know that we all work so hard and we all need to have that Saturday morning to be with our families and so on.

But there may be a way to also adjust to the needs of our practice in terms of people having different schedules so that if somebody works a Saturday morning, maybe they get a weekday off perhaps. And that is attractive to some people for various reasons.

But also one other dimension of that surprised me and I think is worth bringing up in this panel, is that when I met with patients with complex problems on a Saturday, all of a sudden their families from around the country were logging into the Zoom. So I got to meet the people that matter to them. When it's a weekday and they're coming to see you on your time or my time, their daughter or son or wife may be working. But when they see you on a, let's say in the evening, or on a Saturday morning, they-- all of a sudden I was getting this greater buy in because their family who may be in India, or in Eastern Europe, were also logging in because they could because it was a weekend.

And so and also, finally the internationals. So I met with somebody from China the other day. So I can't remember if it was late here. I got logged in at the end of my day which was the beginning of his day.

And so through the digital platforms, we're able to engage our international patients in a way that was used to require a $5,000 business class ticket just to meet us, whereas now we can meet them first and then we can be more strategic about when they should come, if they should come, how they should come, and what do they need when they come. And so I think that's all very important. Sorry for the long answer.

DEVYANI LAL: No. That's great. Dr. Kling.

JULIANA M. KLING: Yeah. I agree with most of everything that was already said. I think maybe a different perspective that I've had the opportunity to see is me and a fellow family medicine doctor supervised a clinic at Saint Vincent de Paul with the second year medical students. And that clinic has been completely virtual since the end of March.

And what we've seen is that the amount of patients that are actually coming for those visits. So the no-show rates have decreased significantly for the same reasons that we've been talking about, just that ease of being able to log in from wherever. I've seen so many patients on a construction site, or in their closet at their office, or in their car, where they're able to take a 10 minute break and join and ask those really important medical questions that they wouldn't have been able to without access to a video visit, or without access to a fantastic free clinic like Saint Vincent de Paul.

But it looks like it has helped facilitate care for people internationally, people on their yachts, and also people that are on the construction site that maybe wouldn't have been able to come in otherwise.

BERNARD R. BENDOK: Yeah.

DEVYANI LAL: As always, Dr. Kling, you bring in such a diverse and intelligent perspective. And shortly before we started the panel, you were talking about some of the older patients during the early stage of the pandemic were fearful of leaving their homes and especially coming to a hospital as we were still learning on the fly. Certainly true for some of my older patients too.

And telehealth, it has been that bridge. But I would say that by and large, most of my patients who were more worried are now coming back to the clinic, and, if they had elective surgery scheduled which they pushed out, they are willing to reschedule. I will agree with all of you. If there is a silver lining in this pandemic is the ability to take care of patients with telehealth, which has not always been the case due to regulatory barriers more than technological barriers.

And thanks to the pandemic, I hope that this temporary measure that allows us to see patients in other locales, states, countries, we will be able to certainly continue this going forward because the blend, especially in surgical practices like yours Bernard and mine, it's important to the exam, and in person care.

And like yourself Dr. Bekaii-Saab, I think Dr. Kling you mentioned it too. I mean if I were having surgery, I'd like to see the face of my surgeon. So one thing that I always do is now, and this sounds bizarre. I have a face to face. But since I instrument in the nose, I have to wear an N95 and all sorts of things for aerosol generated procedures. Patients are tested ahead of time. But I always wear that PPE because I know that if I fall ill, then the health of my patients, my family members, is at stake too.

So wear that, but then that means my patients don't see my face. So I will at least have one visit on the video so that we can see each other, family members can join in, and they can gauge the personality of the surgeon, or the emotional aspect of it that gets blunted with masking, et cetera. It has been quite the blessing.

So from the standpoint of surgery Dr. Bendok, I mean the operating room, especially for some of the procedures that you do through the nose, et cetera, that sometimes we do together, I mean it is an area that is considered to be a high risk aerosol generating procedures. And the first few cases out of China in the medical community were also purportedly from spread during a case done by neurosurgery through the nose.

And so early on in the pandemic, I remember we had a patient that needed urgent surgery. And we were running around looking for an N95. And we've come a long way since then. We have lots of protocols. And I wonder if you could share some of the safety protocols in terms of how we optimize care for our patients.

BERNARD R. BENDOK: Yeah. So I've been so impressed with one of the things-- that Mayo excels at many things. But one thing you realize when you're young in medical school you think that you want to be a great doctor. You think of it as a supermen act, or a superhero act, super woman act. But as I said earlier, my reference to the band. What you realize is that your performance and your safety is dependent on a lot of things that are happening in the background.

And Mayo excels at systems of care. And it was so impressive to watch how Mayo quickly adapted to the new realities on the ground to institute protocols, secure everything we needed for safety both for ourselves, our colleagues, and our patients.

So it starts with simple things, what we hear from the CDC every day, the social distancing. So first of all is protecting the staff. And so that's very important. Even the way we sit in the cafeteria, wearing of masks at all times at Mayo Clinic, washing of hands. Another good thing that came out of the pandemic is American hospitals have been trying to get people to wash hands for 100 years probably since the Spanish flu. Now, I think finally people are-- I'm not talking about Mayo. I'm talking about all hospitals. Now people are going to wash their hands.

And actually the new iWatch will measure how long you're washing your hands for. I think it's going to electrocute you if you don't wash your hands long enough. So that's a new feature on the new iWatch. But so that's in terms of the individual safety.

The other is that taking temperatures daily. And people I think have become more conscientious. It used to be in the old days before the pandemic, if you had a cold, especially if you were-- some people have this-- you just tough it out, you came to work. And now people are being smart.

So the other thing about telehealth is that it's in tele not just health, but also it affects all three of our [INAUDIBLE] We're doing teleresearch and teleeducation, teleconferencing. Is it has allowed people to continue their mission even when they may have, let's say they're quarantining, they can still do things from home.

So it has opened up a whole new way to re-think about how we run our lives. But in terms of now drilling down to the OR, as you know, our OR is we've really we do about a 10 minute briefings on every case. And there are a lot of criteria that the anesthesia have put in place so that people have to be COVID tested in advance of surgery in a very defined time point. There are detailed checklists that the staff go through to keep people safe. We limit the number of people who can come see the patient in the hospital. That has actually been a nuisance. Emotional burden actually, of the pandemic.

Probably the biggest I notice is when people have surgery, especially serious surgery, they want to have their loved one or significant other, or family member, with them. And that has I think been the biggest emotional burden for our patients. But knock on wood, we've been very lucky perhaps. But we've had tremendous safety in neurosurgery and an ENT, in our surgical specialties, and thankfully it's because we do put such great emphasis on systems of care. It's not so much about Dr. Lal and Dr. Bendok being very good surgeons. We try to be the best we can. But it's much more about following the same rules every time, and having a system in place.

So, when Dr. Lal learned from her colleagues at Stanford and in Asia that ENT nasal procedures were higher risk than the average surgery because of the aerosol, we quickly instituted with Dr. Lal's help and her colleagues' help protocols to add additional measures of protection in the surgery, whether it's the way we intubate, the negative pressure rooms as well, were quickly rigged essentially and put into place very quickly.

So I think it goes back to the Mayo model, that I believe Will Mayo quoted, that the interests of the patient come first. I'm paraphrasing. But when you think of it that way on a daily basis, what is safest for the patients? And the flip side of the Mayo model is also what's best for each other. We have to look out for each other at Mayo. And so, if we look out for each other, we look out for the patient, you quickly get to the solutions.

DEVYANI LAL: Thank you so much for, again, putting those points across. And I will say that it was fascinating how quickly we were able to come up with systems that [INAUDIBLE] on the surgical practices committee. I serve on the outpatients practices committee. Dr. Bekaii-Saab, you are the cancer center committee, and Dr. Kling, you sit on several internal medicine committees.

And but I think that at the end, what I realize is we put the patient at the center and patient care at the center. And we worked our way from there as to instituting protocols, so whether it is testing prior to coming to surgery or in certain specialties. And I have to say that sometimes I sit down with my patients. And some of them are actually cancer patients that have bad disease that require follow up. So they require follow up multiple times. And some of them have undergone testing in the teens, and it's almost like a proud badge. And I say I feel so bad that you have to undergo this. And they say to me, no. It keeps us all safe. It keeps me safe. And it keeps the person sitting next to me in the lobby safe.

So our patients have just been fabulous. And it has just been amazing to see every Mayo Clinic worker actually in terms of social, personal responsibility stepping up. But also to see services that perhaps were in the background like engineering that came around and rig rooms to negative pressure rooms put in HIPAA filters where necessary, enhanced cleaning procedures. Our supply chain, I am just blessed to be part of an organization where we truly never came to the point where we had to ration care because we did not have enough protective wear.

Yes, we still have to be very careful about how much PPE we use. But they kept us going. So as you said, it's a family that works together. But at the heart of that intent, everyone is just focused on effective, safe, patient care. Dr. Bekaii-Saab you take care of some of the sickest patients in the hospital. You mentioned that chemotherapy drives immune systems down, et cetera.

What are the safety measures that you undertake with these patients in terms of counseling, et cetera? Because I know some patients are just worried about going through treatment of any sort during the pandemic because they are worried about losing their immune systems and becoming susceptible to the virus.

TANIOS S. BEKAII-SAAB: Yeah. And it's when we talk about treatment, we talk about the checks and balances. I mean even before the pandemic, it was the same, although the pandemic added another dimension to the discussion. I think in our line of work, we're always talking about the benefits of treatment versus the risks, and the ratio, and why we tilt one way or the other. One can give multiple examples. So I'll give two brief examples about some of the discussions and why it's important to have them with patients, at any time, but even more so now.