How a Department Chair Became America’s Covid-19 Correspondent

On the evening of April 10, Craig R. Smith sent an email to the Columbia University Irving Medical Center department of surgery. It was about hell.

“A man falls ill,” wrote Smith, the department’s chair. “He says goodbye to his wife on his way to an ICU. After three weeks on a ventilator, the man passes away, alone. The man’s children are spread across the country. He waits in a refrigerator truck for the family to make arrangements.”

This was the hell Smith had been describing in daily emails to his colleagues: the death, doubt, and loneliness the coronavirus pandemic had visited upon New York City.

Peter Liou, a surgery resident, read that email after finishing up a 12-hour shift caring for Covid-19 patients. Liou had come to look forward to these messages, which were packed with information and often ended with a flourish.

“The first group of sufferers Dante and Virgil meet,” continued Smith, alluding to hell in The Divine Comedy,” are people incapable of conviction, who are only interested in themselves, and who spend eternity chasing a meaningless banner (flag followers) around the anteroom to hell. They aren’t even worthy of Limbo.”

But, the surgeon continued, “those are not the people who have joined us in the fight against this ugly and indifferent virus.”

For Liou, Smith had captured another defining characteristic of the pandemic: the selflessness of the health-care workers he’d been working alongside. Neurologists, hernia surgeons, and orthopedic surgeons were all part of the same fight. In just a few paragraphs, Smith had laid bare the pandemic’s devastation while also finding a source of hope in the ranks of those who fought it.

Since the coronavirus arrived in America, people have been searching for information and direction. They can look to Andrew Cuomo’s midday address, when the New York governor gives a PowerPoint presentation about numbers of Covid-19 cases and deaths, and urges New Yorkers to stay inside. For a while, they had Donald Trump’s news conferences, where the president once suggested that injecting disinfectant into the body could help fight the disease.

And then there were Craig Smith’s evening emails to Columbia’s surgery department, posted to the department’s website and shared by fans on Twitter. For two months, the emails informed and unified members of the surgery department during a time when doctors were stripped of their regular duties and reassigned to pop-up intensive-care units. And they reached audiences beyond Columbia’s hospital, giving people a place to look for information grounded in facts and science, delivered with flair and confidence by an expert who saw it up close. At a time when leadership is being tested at all levels of American life, Smith’s emails offered a window into what happens when a department chair finds himself holding everyone’s attention.

On Tuesday, Smith sent his 59th and last daily email update to the surgery department. He was returning, he said, to the operating room and to a “new normal.”

Smith originally wanted to be a scientist, but enrolling in a biophysics doctoral program revealed an “appalling misunderstanding of my own nature,” he told The Journal of Thoracic and Cardiovascular Surgery in 2015. He didn’t want to stare at petri dishes for a living. So he dropped out of the program and, after a detour as a telephone lineman in Vermont, enrolled in medical school. He excelled at surgery, which he came to understand as an art, and he joined Columbia’s faculty in 1984. There he rose through the ranks, operating on Bill Clinton’s heart along the way, and eventually became the chair of the surgery department in 2007.

The pandemic revealed a side of Smith to medical residents like Liou that it’s taken other colleagues years to appreciate. His humor and encyclopedic mind appear in flashes — like when he randomly quoted Pulp Fiction during an operation, or opened his speech to the American Association for Thoracic Surgery with a poem by W.B. Yeats.

“He doesn’t say much,” said Emile A. Bacha, chief of the cardiac, thoracic, and vascular surgery division at Columba. “But it’s always important, so you better listen.”

From the first update, written as America began lockdown and cases in New York City rose, Smith was less restrained. The messages were laced with wartime metaphors, mountaineering analogies, and references to literature and history.

“Is this a false summit?” Smith wrote, as the New York crisis seemed to be leveling off after weeks of growth. “Many mountains have them; if you’ve done much climbing, you’ve stood on one.”

Later he reflected on a news story about a German zoo. Facing a food shortage caused by plunging revenues, the zoo had started feeding some of its animals to other animals. “Which animals go first, and who decides?” Smith wondered. “Is it based on nutritional value (large mammals first), or on popularity (snakes, rodents, hyenas first)?”

Also making several appearances was Balto, a husky who, in 1925, led a group of sled dogs to Nome, Alaska, carrying a cure for a deadly disease that had broken out there.

“Our cargo must reach Nome,” Smith wrote. “Remember that our families, friends, and neighbors are scared, idle, out of work, and feel impotent. Anyone working in health care still enjoys the rapture of action. It’s a privilege! We mush on.”

The surgeon has quoted John Wooden, John Prine, Emily Dickinson, Rudyard Kipling, and Vladimir Lenin. Smith’s own words have been quoted, in turn, by journalists writing about the pandemic — though he has declined media interview requests (including one from The Chronicle for this story).

Rob Kim/Getty Images

On March 20, he sent an email packed with statistics suggesting that a surge in Covid-19 cases might overwhelm hospitals. That day, 300 patients at New York-Presbyterian, the system that Columbia’s hospital belongs to, had tested positive for Covid-19, and 200 were awaiting results — roughly 50 percent more than the day before. At that rate, the hospital system could run out of ICU beds by the time the number of infections was projected to peak. And personal protective equipment was running low.

The email made waves. “Internal memos by the chief surgeon at New York-Presbyterian Hospital were intended to rally the giant medical center’s doctors and nurses as they prepared to confront a surge in patients with novel coronavirus,” wrote ABC News, “but they also revealed new estimates about the coming threat that had not previously been public.”

Some of Smith’s colleagues suspect that the higher-ups at New York-Presbyterian were unhappy that a doctor was releasing data with such dire implications. Smith’s next email included what seemed like a mea culpa. “Yesterday I realized that only planning, cooperation, execution, personal sacrifice, and maybe a little luck will allow us to avoid being overwhelmed within a few weeks,” he wrote. “In my update yesterday I overshared data to help make this point to you.”

Shunpei Okochi, a surgery resident, appreciated the fact that his boss was willing to be so upfront about what he and his colleagues were up against. He had been reading Smith’s emails every day in between his 12-hour shifts. Okochi saw these messages as a crucial part of an effort to get a department that’s filled with highly specialized surgeons, who usually have missions as disparate as weight loss, cancer treatment, and bone repair, to risk their health in order to achieve a common goal.

Okochi and a small group of residents gathered in a conference room to read the email in which the department chair acknowledged having “overshared.” He wanted Smith to know they were behind him.

“The candor with which you have shared up-to-date information with us on Covid-19,” he wrote in an email to Smith, “has been refreshing in a time when information is abundant and often contradictory or quickly changing.”

Notwithstanding the occasional misfire, Smith’s freewheeling, lyrical style has endeared him to members of his department. Tracey D. Arnell, the medical-education vice chair at Columbia, said she forwarded Smith’s emails to friends who were anxious that she had to go into the hospital everyday.

“I like to use it as a way to explain to people not to be so worried about me, and definitely don’t feel sorry for me,” she said. “I reassure them that I’m doing what I want to do.”

Smith’s emails unified the department, she said, by putting words to a shared experience.

“People want to be validated that what they’re feeling is not out of bounds,” Arnell said. “They validate people’s fears and motivations.”

The March 20 email was retweeted well over 1,000 times. The word was out about Smith and his writing. Stephanie Nguyen, a surgery resident, said medical professionals she knew in Australia, where she is from, read the emails. Smith’s daily messages, which started as internal pep talks, had become must-reads for people watching the pandemic in New York — and battling it first hand in their own countries.

“The whole world is on a journey with him and us as a program,” Nguyen said.

In late March, that journey took a personal turn when one of Smith’s colleagues got sick and became a patient at their hospital. Things got bad enough that he had to be intubated and put on a machine that pumps oxygen into the blood.

Peter Liou, the surgery resident, said that put everyone on edge. “It doesn’t become real to you until you realize that any of us can be affected by this,” he said.

“The enemy is inside the wire,” wrote Smith on March 27. His email that day read like a soldier’s diary, alluding to snares and land mines. Their colleague’s illness was “proof for everyone of how real this is getting, regardless of one’s personal proximity to the razor wire and the Claymores,” he wrote. “A widespread anxiety surge followed, with night-long text chains between the newly rattled. What is the proper response? First, at the most practical level, accept that there is no place to hide.”

Smith later described peering into the room where he usually performs operations and seeing it occupied by critically ill Covid-19 patients on ventilators.

“The scene in OR 22 captures many achingly familiar and universal features of this pandemic — our comfortable pavement and reassuring routines ripped up overnight and replaced by precarious hand-to-hand combat with a virus,” Smith wrote, “accompanied by vanishing productivity, extinction of familiar roles, personal and professional dislocation, illness, and loss of life.”

In the past few weeks, the number of new cases reported each day in New York has declined. Hospitals like New York-Presbyterian felt the pressure but did not experience the kind of overload some had feared. At the end of April and in the first weeks of May, Smith wrote about what the next phase of this crisis might look like, and he reflected on why he started writing these emails in the first place.

There would be no going back to normal, Smith wrote on April 16: “We are not returning to basecamp, we’re going down the other side into Nepal. When we get there, much will be familiar but much will not, and there is no way back.” People will be nervous about coming to the hospital for illnesses other than Covid-19, so he urged doctors to project confidence when meeting with patients.

Coronavirus Hits Campus

As colleges and universities have struggled to devise policies to respond to the quickly evolving situation, here are links to The Chronicle’s key coverage of how this worldwide health crisis is affecting campuses.

• Here’s Our List of Colleges’ Reopening Models
• Students’ Trust in Their Colleges Held Steady During Covid’s Early Days, Study Finds
• As More Stressed-Out Students Consider Dropping Out, Surgeon General Pushes College Leaders to Ramp Up Support

In a recent display of optimism, Liou, the surgery resident, organized a music concert at the Columbia hospital for patients and health-care workers. Smith wrote that the surgeon who had been sick in March stole the show by joining a chorus from a wheelchair, his condition vastly improved. (Smith also played the piano, but he didn’t mention that in his email.)

A few days later, he noted one of the problems with war metaphors that have been “widely exploited by me and countless others.” They send the message that the fight can’t let up until a definitive ending. “I will suggest replacing ‘defeat’ with ‘manage,’” he wrote.

Then on Tuesday, Smith wrote that the daily dispatches would end. To explain why he started this writing project, Smith pointed back to mid-March, when operating rooms and research labs were shutting down, and people were afraid. “Information was a salad of confusing rumors, rambling emails, and pronouncements from multiple sources,” he wrote. “I attempted to write a simplifying summary. I wrote another, then another. I sensed that people sharing such universal dislocation needed morale as much as information.”

Smith himself never stopped going into the hospital. Throughout the pandemic, in fact, surgery residents said they saw him there nearly every day. As much as they enjoyed the emails, it was meaningful to see him in person, checking in on them, making sure they had what they needed. And when they saw him, as Shunpei Okochi did on a recent Tuesday morning, he didn’t quote Dante’s Inferno or talk about Balto. He was the same person they’d known all along: quiet, supportive, and confident in their abilities.

As Okochi remembers it, Smiths simply said, “Good morning, Shunpei.”

“Good morning, sir,” Okochi replied.

“All good?” Smith asked.

“Yes, sir,” Okochi responded.

“Carry on,” Smith said.