Toppling Silos, Testing Tech, and Trimming Egos: How COVID-19 May Remake Medicine
For all the grief and loss it’s caused, the pandemic may trigger some needed shifts and shine a light in the shadows.
The COVID-19 pandemic has stressed hospitals and healthcare like nothing else this past century. Physicians themselves have fallen ill or died, passed the infection to their loved ones, and weathered grief, burnout, suicides, furloughs, and financial losses. As case numbers and fatalities continue to mount, some doctors are pinning their hopes on the notion that the pandemic has rocked the foundation of medicine, deconstructing and reinventing standard procedures in ways that could improve care down the road. That by providing a footing for new ideas, new technology, new voices, and new ways of working, COVID-19 could change the practice of medicine.
“I definitely think that there'll be longstanding changes that come out of this, good, bad, and otherwise,” said John P. Erwin III, MD (NorthShore University HealthSystem, Chicago, IL). “And I think there are probably a few more iterations to come.”
This story is part of Envision Change, an end-of-2020 series imagining a different future for cardiology, medicine, research, and health. SEE ALSO: Transforming Clinical Research, Funding the Future, Heroes to Human.
“In medicine we try to be foolproof in any new plan that we implement, mainly for patient safety, but it was pretty clear that we had to make a lot of changes very quickly on how to respond to what was going on with the infectiousness of all this, how we operated every day, and that we weren't going to be able to hit perfect to start,” Erwin said. “I definitely think we've seen more expediency.”The first thing hospital and health systems had to do when the pandemic hit was to respond quickly and creatively—no mean feat for institutionalized medicine, which is not known for its dexterity.
New Tech Finds a Foothold
Almost everyone interviewed by TCTMD pointed to the rapid uptake of novel technologies to replace office visits, track patient care, implement up-to-the-minute strategies, and facilitate communication when in-person meetings weren’t possible. Many of these were digital health solutions that proponents have been recommending for years: trialed in pilot projects but never adopted on a larger scale. Their calls for change and modernization have typically fallen on deaf ears amid concerns that scaling up would take too long, cost too much, or wouldn’t be a great substitute for the status quo.
Eduardo Sanchez, MD, MPH, chief medical officer for prevention at the American Heart Association pointed to the oft-mentioned example of telehealth appointments, predicting that some form of virtual patient care will persist after the pandemic. Face-to-face patient appointments will always be preferable in some settings, he said, but particularly for follow-up, telehealth obviates the need for patients to get time off work or travel long distances just to make sure they are taking their medications, not feeling side effects, etc. “We figured out the boat floats,” said Sanchez. “The platforms for virtual health exist.”
We figured out the boat floats. Eduardo Sanchez
But there are other novel applications for videoconferencing that Sanchez hopes will get a toehold thanks to COVID-19. Uptake of cardiac rehab, for example, could get a tremendous boost if online programs allow patients to stay better connected and monitored after they leave the hospital. Discharge planning itself, and the whole “discharge experience,” could also benefit, he argued.
“We now know how to do Zoom. Why not actually do a discharge Zoom meeting that includes not only healthcare providers [at the hospital and] family care providers who maybe can't be at the hospital at that moment, but also other critical family members who for one reason or another want to be involved in understanding exactly what the discharge instructions are?” asked Sanchez. “Maybe their family doctor lives several states away? I do think that there's an opportunity there. It could also work with physician visits in clinical settings, in an office, and it could even work with grand rounds going on in hospitals where we have the technology now that allows for true patient and family engagement that maybe didn't exist before.”
COVID-19 brought about what Harriette Van Spall, MD, MPH (McMaster University, Hamilton, Canada), characterized as a “forced adoption of new ways of doing things that were traditionally resisted by the establishment,” even novel approaches that have little to do with direct patient care.
The quick pivot necessitated by the pandemic “has also translated to our academic activities,” Van Spall pointed out, using the example of early morning and after-hours meetings. In the past, these required face-to-face participation, effectively excluding junior physicians (especially women) with young families. “These meetings are now conducted virtually—an idea that was previously scoffed at when it was raised, at least in some institutions,” she said. “Funnily enough, they have actually increased attendance and engagement of participants, much to the chagrin of some. And so we have demonstrated nicely that efficiency, technology, and streamlined ways of delivering care haven't threatened healthcare—they have enhanced healthcare, and they haven't threatened our academic relationships.”
Yale New Haven Hospital President Keith Churchwell, MD, says his Connecticut health system was in the midst of instituting a multimillion dollar “data lake”—integrating electronic health records with demographic, financial, clinical, genetic, and other data sources—when COVID-19 hit.
“That opportunity has allowed us to sort of turbocharge relationships between our academic and clinical environment to think about the delivery of pathways of care, not only in the COVID situation but actually across the spectrum of how we deliver care, whether it be heart failure, whether it be UTI, whether it be COPD, whether it be appendectomy,” he explained. “Instead of having 15 different ways of doing things—which actually is expensive, hard to measure, and not really getting to the point of determining what is best, based upon where patients are in that particular continuum of care and where expertise is—let's have one or two pathways that we can truly measure, that people are invested in, and that can be iterated on a very quick cycle to get us to the best pathway that actually improves the overall quality of care.”
All of that was already in the works before the pandemic hit, said Churchwell. But caring for COVID-19 patients, amid such rapidly evolving approaches to treatment, made it abundantly clear—even to the skeptics—that this big data approach had merit. “Some people were reluctant to get on that journey prior to COVID, but they now understand that it's a journey we all need to be on,” he said.
Breaking Down Silos
Getting buy-in for big data or treatment algorithms across diverse hospital settings; having Zoom meetings that help flatten hospital and academic hierarchies; adopting technologies that foster cross talk across medical specialties, bringing patients into the mix—all of these may help revolutionize systems of care that have typically been territorial, evolving at a glacial pace.
Pulmonologist Cara Agerstrand, MD (NewYork-Presbyterian/Columbia University Irving Medical Center, NY), who heads up her hospital’s medical extracorporeal membrane oxygenation (ECMO) program, credits COVID-19 with destabilizing some long-established processes for patient care—for the better.
“One of the aspects of medicine that has been altered in a positive way is that there's been sort of a breakdown of some of these silos within disciplines, particularly during our surge in the springtime,” she said. “That’s led to a lot more cross-collaboration between physicians in different departments.”
Physicians have always consulted other specialists in the course of patient care: the marked difference during the pandemic’s first wave was that physicians and other healthcare workers had to step, sometimes abruptly, into new fields. That led to them learning new skills and sharing expertise.
One of the aspects of medicine that has been altered in a positive way is that there's been sort of a breakdown of some of these silos within disciplines. Cara Agerstrand
“I found there to be a lot more inter-department collaboration and cross-pollination, given that people were asked to fill some roles that they weren't typically used to,” she said, “outside of their own niche area.”
The hospital also implemented joint education sessions between different disciplines so that information could be rapidly disseminated, Agerstrand said. “I think, having had that experience, people formed more collaborative relationships.”
She believes this collaboration is helping now to keep hospitals from being as swamped as they were during the first wave of the pandemic. “I am confident that if we do get overwhelmed,” she said, “some of these successful approaches that we took in the spring will be kind of dusted off and used again, and probably improved on, but again relying on sort of multiple disciplines to fill the necessary roles, to take care of the patient that we have in front of us.”
Cardiologists have been a key part of that, noted C. Michael Gibson, MD (Baim Institute for Clinical Research, Boston, MA). COVID-19 offered cardiologists the chance to “reach back down and grab the inner internal medicine doc in us and become full-service doctors again,” he said. “It’s probably reawakened people’s Marcus Welby,” he added, referring to titular character of the popular TV drama from the late ‘60s and ‘70s who had a kindly bedside manner and knew all of his patients on a first-name basis. “Cardiologists are probably much more capable of being a full-service doctor than people may expect, and I think in some ways, some of us got some gratitude out of learning to care again for the whole patient. Some never forgot.”
The pandemic has also amplified different voices. People specialized in relatively narrow fields now roped into the battled against COVID-19—ECMO is a good example—have been tapped to educate others. Amid the shortage of intensivists, physicians with board certification in critical care have found themselves teaching crash courses to their sometimes much more senior peers in other specialties. And as other forms of education and physician communication have moved online, this too has had the effect of subtly upending existing hierarchies. After all, there are no front rows, no lecterns, and no cheap seats on Zoom. “Some people always sit in certain spots,” said Van Spall, referring to lecture theatres and meetings. “They're always in the spot of power, and there are some opinions and voices that definitely dominate.”
Add to that the humanizing effect of seeing your colleagues and rivals Zooming to work from their homes with all the children, pets, and background noise that might entail. It’s an observation that teachers have made about glimpsing the living domestic environments of their students during the pandemic, and that physicians have had of their patients’ home lives: videoconferencing has permitted rare insights you don’t get in a classroom or clinic. By the same token, getting a peek at the personal lives of one’s peers has paved the way for more compassion and collegiality, Van Spall suggested. “It’s a softer and warmer feeling than a conference room.”
Whatever positive impact COVID-19 might have on patient care, cardiology, hospitals, or the medical profession as a whole will come at a hefty expense. Untold deaths, lasting disability, and an unknown toll on the heart itself. Ask any cardiologist a question about the impact of COVID-19 in the heart disease realm and she will quickly mention the missing STEMIs and, as a result, an anticipated second pandemic of mechanical defects, heart failure, and heart rhythm problems down the road. Around the country, senior cardiologists whose age or risk factors raised their stakes for developing severe infection stepped aside leaving up-and-comers to take their place. Many practices had to scale back or shutter their doors as a result of dropping patient referrals and shut-downs, while hospitals furloughed physicians in many specialties, cardiology among them.
That’s been a bitter pill to swallow for some. Gibson recounted the story of a layperson’s astonishment when her physician husband received a call from the hospital telling him to cancel all his cases, even in symptomatic patients with serious cardiovascular conditions. “Talk about the shifting of the hierarchy,” he said. “This person went from being valued as a revenue center to being disposable. And I think a lot of cardiologists are feeling that they were the revenue centers, they were very important to hospitals. But right now, unless they are willing to become ‘Covidologists,’ they don't have the same value that they did as cardiologists. There's a little bit of a dethronement syndrome for some people, but I think, in the not-too-distant future when the vaccines come out and we get back to the usual world order, cardiologists will resume their ‘rightful’ spot within the hierarchy.”
Many, Gibson pointed out, are already playing a pivotal role in the pandemic. Cardiologists around the world have worked the COVID-19 wards at their hospitals and in many cases are dusting off skills they haven’t used since their training days. “The coronary care unit, as I lovingly call it, has now become the COVID care unit. It's still the CCU, and cardiologists are still the same people manning it. Cardiologists have an amazing skill set. It's not just confined to blowing up little balloons and putting stents in. I think they're thoughtful. I think they're hardworking and they're studious. They're evidence-based. They won't fall, or they generally won't fall, for hydroxychloroquine.”
Indeed, cardiology’s reputation as a data-driven specialty is another reason for shifting roles. While some have had to pause or halt enrollment in clinical trials or tweak follow-up plans, others have jumped on new opportunities. Particularly as physicians and administrators in leadership positions have been consumed by policy and service-line changes, younger physicians, said Ankur Kalra, MD (Cleveland Clinic, OH), have had the chance to lead research initiatives, many of these coming together at blinding speed. Existing national registries and data sets in cardiology tightly control access to research groups, he pointed out. In fast-growing COVID-19 cohorts, however, researchers have been able to pose questions, do those analyses, and get their results published quickly.
The coronary care unit, as I lovingly call it, has now become the COVID care unit. It's still the CCU, and cardiologists are still the same people manning it. C. Michael Gibson
“I think COVID-19 has been a great leveler in terms of it being a new disease,” he said. It’s offered almost unlimited opportunities “for early career folks who have the focus and the willpower, who want to put in the hard work.”
Coupled with the unprecedented turnaround times seen at most medical journals—where time from submission to acceptance has shrunk from over 100 days to just over a week—many early-career academic physicians have managed to quickly augment their résumés.
“I was looking at my Google scholar citation index,” said Kalra, “and it's gone through the roof for 2020 because of the opportunities COVID-19 presented. It’s sort of sad that we needed something like this pandemic, which has wreaked havoc in the lives of tens of thousands. But that has actually been a great opportunity for people with academic interests to have a go at it, garner new information, and publish meaningful work.”
Minding the Gaps
Several of the physicians interviewed pointed out that COVID-19, having highlighted so many disparities in healthcare access and delivery across the United States, could be the stimulus for lasting change.
“What COVID-19 has exposed is what's always been there, or at least there for the last several decades, and that doesn't really come to light until the system is absolutely stressed,” said Sanchez. “But for your underserved groups by race, ethnicity, or socioeconomics, this is their everyday, but it goes on in a way that's somewhat invisible. And what COVID-19 has done is it has made that not so invisible.”
He continued: “Seizing the moment is really important, and I think many of us hope that soon, whether it's completely post-COVID or just as things transition in a variety of ways—and in the United States, let's say politically transition—that there may be an opportunity to sit down and think about [change] . . . How do we institutionalize some of the changes that had to be considered and operationalized during COVID, that we saw benefit around? And how do we institutionalize those so they become permanent parts of the system?”
Part of that will be retaining the technological advancements that were swept in to fill the void when COVID-19 made face-to-face contact a hazard. Telehealth will be particularly important for rural Americans, underserved Americans, those who face transportation barriers, or who work in industries that make taking time off work for in-person appointments that much more difficult.
At Yale New Haven Health, the embrace of big data will be a lasting legacy that Churchwell hopes will also help redress some imbalances. In analyses they’ve done of their COVID-19 numbers, morbidity and mortality rates for African Americans and Latino Americans from COVID-19 have actually been less than those for white Americans. That’s the opposite of what has been widely reported elsewhere, including at a national level in the COVID-19 registry launched by the American Heart Association, where Churchwell is a board member.
He believes the Yale New Haven outcomes stem from successive iterations of pathways-of-care that they’ve implemented based on symptoms and risk factors identified in their data. Patients are treated according to those algorithms, he said, not on an individual doctor’s unconscious assumptions or biases about a person who walks through the hospital’s doors. What’s more, he pointed out, they’ll have the ability to continually track outcomes and make sure their approach is having an impact on patients’ lives.
I think too many times especially the physician part of the healthcare team tends to be sort of egocentric. John P. Erwin III
Within hospitals themselves, where minority groups often make up a larger proportion of the technical and service roles than they do the physician staff, COVID-19 has brought about some shifting views and an all-in-this-together mindset often lacking in medicine.
“I think too many times especially the physician part of the healthcare team tends to be sort of egocentric,” Erwin acknowledged. In prioritizing their patients’ care, doctors have been “somewhat callous, in the past, in terms of how that occurs and what all it takes to make that occur,” he continued. Dealing with COVID-19, he said, has made people more aware of all of the links in the chain. “I think our whole team understands our supply chain people are so important, our environmental service people are so important, the transporters that are moving our patients around the hospitals are so important. And I don't think that anybody in the past neglected that that was important, but I think just in terms of actually stopping and having a little bit more personal one-on-one to understand what the other person's job is has really been put under the spotlight here in the last several months.”
“Risk and hardship bring people together,” Van Spall agreed, adding that this might be more strongly felt in recent months by those who previously “might have had a false sense that they were more important than anybody else.”
“Even the issue of remaining safe in your space relies on everyone keeping themselves safe,” she said. “My handwashing is effective as long as everyone else is handwashing and cautious about their own infection control. So there's definitely a flattening of the power for those who might've seen themselves at a different level in the pecking order.”
Can Changes Last
Everyone who spoke with TCTMD seemed eager to look for a silver lining in what for many has been the single most difficult time of their careers. They spoke of fatigue and burnout as well as frustration with hospital administrators making decisions on processes and personal protection equipment without visiting the front lines. But they also praised the innovation, the pace of scientific discovery, and the nimbleness with which hospitals have instituted new protocols or approaches.
“The one thing that we do have to figure out is how, post-COVID, rather than focusing on all the bad things that happened is: how do we focus on . . . turning the lemons into lemonade?” said Sanchez. “The opportunity we have is to take what we've learned from the challenges and say to ourselves, what can we put in place that will make things work better and maybe, maybe prevent another calamity, and I would characterize the way that this played out in the United States as calamitous.”
Risk and hardship bring people together. Harriette Van Spall
“Everyone is just worn out right now, and I worry that there'll be a little hangover effect,” Erwin admitted. The palpable desire, felt in all aspects of life, to get back to normal could mean reverting to old ways of practicing medicine and delivering care, with progress set aside for old habits.
Erwin hopes that won’t happen. He pointed to the “little bit of a reprieve” that many hospitals enjoyed from the mounting COVID-19 cases in the summer and early fall.
“When things were kind of calming down a little bit, we did start to see a couple of those areas backsliding in terms of not being as nimble,” he recalled. “And I think we all called it out in the room and said, ‘Hey, you know, there's good parts to what we learned during this time.’ So I think the will is there. I just hope that everybody still has the energy and the stamina to get through this current wave. It's pretty rough right now.”
“Certainly people are stressed and things are hard,” said Agerstrand. “Everyone's so busy, but there’s this sort of willingness to adapt and give it your all and move forward in the interest of taking care of these patients. It is really, really quite impressive,” she said. “Thinking about our ICU, the attitude and the willingness and enthusiasm of literally everyone—from the nurses, to the custodial staff, to the X-ray technicians—the mentality has been: let's just dive in, give it our all, this is what we're here to do. It’s been really quite inspiring to see.”
When people ask Agerstrand how she feels about COVID-19—both the spring surge and the rising numbers now—she said she answers in the same way she’s heard her colleagues respond: “I say I feel very lucky. I feel lucky to be a part of this and helping out with our community in a way that not everyone can do. And I hope it does last, you know? Obviously things ebb and flow, but I really do hope it does last.”