Abstract
Times of transition are when trust really gets tested. These are the times when we can determine who has earned trust and who has not. For organizations, it is a competitive differentiator to have trust–trust by patients, but also trust by the workforce, by your doctors, your nurses and your other personnel. These are issues that organizations are really grappling with as they navigate the redesign of care in a time of incredible change. I would say that we are doing pretty well, but we have plenty of work to do. It is an important and timely issue as never before in my career.
We have a lot of data and we have now pivoted to be able to talk to the community about how we have kept our staff safe as well as how we have kept the non-COVID patients separated and safe from the COVID patients so that we did not in fact increase the pandemic by cross-exposure.
Jefferson has really paid heavy and careful attention to trying to ensure that we have proper PPE. We went to an all-mask environment very early, in the third week of March of 2020. Anybody entering our hospitals or ambulatory facilities must wear masks throughout the entire time that they are in the building, for any reason.
I think about that a lot because when I was the Health Commissioner I had to get people to pay attention to public health. No one runs a campaign for mayor to be a public health mayor. Maybe they might now, after COVID-19, but they certainly did not before. Because public health is successful when we, by definition, prevent something from happening, it makes it so that there is no face of public health. Our work is invisible. And when it is invisible, no one cares about it, and so it becomes the first thing on the chopping block.
In fact, that is what we have seen. We have seen this disinvestment in public health that has been detrimental. We have lost around 20% of our local public health workforce in the last two decades. 1 The money that the CDC and the federal government allocates to local public health has consistently declined despite the increasing needs.
We are seeing all this coming back to roost when we see that, in the face of this biggest public health crisis of our lifetimes, we do not have the infrastructure in place to handle COVID-19. Now we are seeing that health departments cannot handle their other duties because all the resources are diverted to COVID.
We are now trading off all the work on cardiovascular disease and on opioids and on maternal health to focus on COVID-19, which, of course, makes no sense.
I hope that after we have a chance to recover from COVID-19 and look at the lessons learned that one of the things that we will do is to really invest in public health, because now there is a face of public health, finally. But in the meantime, I really worry about how science and public health have been sidelined.
One would think that in the middle of a public health crisis that the people leading should be public health experts. One would think also that science and data should be driving decision-making, but unfortunately that is not what is happening. I am not trying to make a partisan statement at all, but rather, this is objectively what is happening, and unfortunately, the consequence is going to be more preventable infections and more preventable deaths.
Dr. Nash, ironically, we wrote a chapter in the second edition of our textbook, “Health System Science,” which included a future scenario in which a pandemic swept across the United States, and medical students joined in and helped out by doing contact tracing and community interventions. We really have a long way to go in medical education, but there are many schools and programs on the forefront that are working hard in this area now.
One of the ways in which the medical education community came together was to bring all of the organizations across the accrediting and regulatory spaces through a group called the Coalition for Physician Accountability. The Coalition developed a number of national guidelines to try to stabilize the disrupted educational processes.
For example, this year, students will not be doing in-person interviewing for residency. They will be interviewing via online video. They will not be doing away rotations. Because of the possibility of the geographic transfer back and forth of students to different health systems, they cannot do audition rotations.
This has really changed the way in which those students, particularly those who are entering their fourth year, will match for residency. We have had to come together as a national community to set forth guidelines around PPE, around travel, around interviewing, and around expectations of training so that these students and residents feel that they are in good hands, and they can trust their leaders and the health care systems they train in it. Our hearts go out to those students as they are right on the front lines of COVID-19.
What I wonder is, how does that translate into what Dr. Lee described earlier in terms of trust? Because one of the things that I think learners profoundly benefit from is the global idea that the medical and the health care professions are trustworthy overall. At this time, I wonder whether that trust gets shaken a bit, and what does that mean for us long term in terms of people's self-identity and how they interact with patients in a world where all of our visual and social cues that help us read each other's behavior is interfered with because we are all wearing masks, and we are all wearing gear that prevents us from reading physical cues and that kind of thing.
Trainees are coming into a very, very different learning environment, and so are our patients.
Unlike a lot of other places, Jefferson went all in. We had virtually every provider, every specialty, everything you could imagine, doing some degree of telemedicine, so when we had to ramp up for COVID, we appeared visionary. We never anticipated a pandemic was coming, but we thought value-based care was coming. It turns out the telemedicine vision aligned nicely.
But let me tell you, there are early adopters and there are people who are slow to adopt. Our early adopters took the ball and ran with it right away. You can imagine the one-third of providers who did not want to do telemedicine now all wanted to be trained right away. There were some logistical hurdles to overcome, but let me share with you two sets of numbers. In one of our primary care groups in New Jersey, they historically performed about 125 visits per month, but that grew to be around 6,000 in March of 2020. And we switched gears in the middle of the month, so this is an unbelievable accomplishment.
Our internal medicine group in Center City, Philadelphia, would do about 1,000 visits a day. A small handful of them would be telemedicine. Within a given weekend, obviously, the in-person visits plummeted a bit, but we were able to maintain about two-thirds of our visits, and we went from a single-digit percentage of telemedicine to 90% telemedicine.
Within that, there were technical challenges, but there are also challenges in communicating via video. We had to teach people how to show empathy, how to be caring, how to do a physical exam, and how to make patients that had technical difficulties feel like they were not the problem, that it was not their fault. I could go on forever, but I will not. There were challenges, but we were fortunate that we had a good head start, and we rolled over fast from in-person to telemedicine, so we were able to care for, most importantly, all of our non-COVID patients and make them feel safe, as well as our COVID patients.
I like to say telemedicine is best encapsulated by one statement. It is just a care delivery model. There is not telemedicine care. You get cardiology care. There is no difference in the care you receive—whether the cardiologist is in the room with you, or on the other side of a clear partition, or at the other end of a telecommunication exchange. We need to make adjustments in quality metrics based on the limitations of the technology.
If you are dealing with someone with sinusitis, for instance, the quality measures for telemedicine are the same as the quality measures with an in-person visit. They can be assessed using the Choosing Wisely guidelines for patients with this condition. The difference is, we now need to both scaffold the education and training into the curriculum, as Dr. Skochelak spoke about, and then we need to scaffold the quality programs into each department or division with the content expertise to make sure that quality metrics are being met for that disease. So I, as a telemedicine expert, cannot do quality in urology because I know nothing about urology quality. I need the urologists to learn how to do telemedicine quality the same way they do other quality within their division or department for in-person visits.
It should not be that hard unless people can't overcome to obstacle of thinking of telemedicine as something different from seeing a patient in the office. But it is not. Again, it is just a care delivery mechanism.
At Press Ganey, we started a national patient safety organization (PSO) PSO a year ago, and we are going through our first 3,000 COVID-related safety events now. Tejal Gandhi is leading the analysis. Most of these safety events are actually workforce safety events, where it was the workforce that was either put at risk actually suffered harm. We are realizing that there is a new world of telemedicine safety improvement that we will all eventually end up with, although I would guess Jefferson is probably going to be there faster than other institutions.
Those things include having a national coordinated strategy, whereas in this country we have had this piecemeal approach. I still cannot believe this, but as all of you know, states are bidding against each other for PPE and ventilators. In my state, which is Maryland, our governor had to procure tests from South Korea. When does a state negotiate with a foreign country? After getting 500,000 tests from South Korea, these tests were held in an undisclosed location, protected by the National Guard, to prevent the federal government from confiscating these tests. I mean, that is how ludicrous it is for us to not have a national strategy.
And of course, the consequences of this fall on our frontline health care workers who did not have necessary equipment, and we still are not nearly prepared for if we have another surge in cases. We also, of course, have not had clear, direct communications. There has been muddled messaging and even contradictory messaging and messaging that goes directly against public health.
The other component that Dr. Nash mentioned is also really important to talk about, which is, how have other countries been able to rein in the infection? Well, we have been talking in this country a lot about social distancing and shutdowns and these overall lockdowns that have saved lives, but really are that blunt instrument. That is what we had to do when the precision instruments could not work anymore. And the precision instruments actually are testing, contact tracing, quarantining, and isolation.
That is ideally what we would have been able to do at the beginning of this outbreak. If we had sufficient testing at the beginning, one can make the argument that we could have reined in the infection at that point, as other countries like South Korea, Singapore, and Taiwan were able to do. There were many other examples of jurisdictions and countries that were able to rein in the infection by finding every positive case, identifying all the contacts that they were exposed to during their infectious period, and then isolating those, even building facilities for people who had no other way of isolating and quarantining all those contacts, as well. That is how, according to Tom Frieden, to box in the infection.
In America we had to, unfortunately, resort to the overall societal shutdowns, that blunt instrument, because we could not do the precision instrument. The genie was out of the lamp at that point. The horse had left the barn. It was too late. We could not, at that point, contain the infection anymore using those precision instruments, so we had to go to the blunt tool of social distancing.
That was meant to buy us time. That was meant to prevent our hospitals from becoming overwhelmed, to buy us the time so that we could get our testing, contact tracing, and isolation capacities to a robust enough level and to get our cases low enough that we could once again resort to the precision instruments. We have unfortunately reopened before we met those criteria, and because the reopening was not only too fast, but it was done in a hasty manner without having clear guidance on how to do things safely, and I am afraid that we are now at a point that the number of cases are rising again, we still do not have the testing, contact tracing, et cetera, capabilities that we need, and as a result, we are going to see more infections, we will have to resort to lockdowns again. Unfortunately, I do not think we have the political will to do that, and the consequence is going to be that we do have more preventable infections and deaths.
What we are trying to do on a national level is to work with organizations to help them measure and take action. We have instruments on burnout and resilience that we can share with organizations to survey their learners as well as their workforce to see what the level of burnout and anxiety is.
Dr. Nash, I also have to say one area that we have been especially worried about is our colleagues of color with the added stresses of racism and police brutality that have been so prominent in recent weeks. And we worry that even in education that there may be, like with COVID-19, a disproportionate effect on our communities of color. There may be a disproportionate effect on our students in the education system. This is something that we all need to mindful of and watch for.
It is the organizations that have to help. You cannot just do yoga and get yourself out of these high-stress situations. You cannot just do mindfulness-meditation to improve burnout. The organizations have to be the entities that we can turn to for help in this important time.
I think it is critical for us to really look at our colleagues. One of the things that we have discovered is that our mortality rate in our hospital is almost threefold that of our baseline mortality rates pre-COVID. Because that has been so compressed in such a short period of time, none of our colleagues really have time to process that in any substantive way. We are very worried about – and maybe this is a variant of burnout, but really, sort of a PTSD kind of a phenomenon over the next year as people get time to process the mortalities that they have seen in the hospital. And, you know, we are very worried about a burnout factor of, “I just cannot go back to that ICU and face that again if we have another wave in the fall.”
And so it is incumbent on all of us to really be proactive about mental health in a profound way, and we are working around group therapy, around a proactive reach-out rather than waiting for people to ask for help to try to accomplish that.
But I think communication goes through the whole thing. There is communication with the community pertaining to social distancing, wearing masks, and staying inside. And unfortunately, again, to use Dr. Wen's term, without getting partisan, there has not been a consistent message across the country.
There is communication with the patients about when and where to get care. Initially, they were all afraid. That seemed reasonable. As we transition back into safety and patients have the ability to safely come back for in-person visits, we need to communicate that. And you heard Dr. Meyer talk about that.
But there is also communication with the providers, administrators, and staff. And what is lost by Zoom meetings is the water-cooler and hallway conversations. I have found that that has created an enormous amount of difficulty as people who like to feel in the loop and hear a little tidbit of information that is normally outside their “swim lane” no longer stay as informed. There are things going on around them, and there is no way to make up for those water-cooler conversations that were some common. So to me, the one word we need to work on, or what I learned most, is the better we communicate, the less problems we will have.
My nurse and I were joking, because she was wearing a mask the entire time due to hospital policy, and she said at some point she was going to see me in a grocery store and want to give me a hug, you know, when we can give each other hugs, and I am going to say, “Well, who is this person coming up to me?” because I never saw her face.
I was worried when I was giving birth about whether I would contract COVID-19 from asymptomatic carriers. But then at some point, I remember when my nurse was holding my hand as I was in labor, I thought, “What if I have COVID, and I am going to give COVID to her?”
And it just brings up this point that we are in such different times to be worrying about each other and for each other, and I think this is a time that really underscores the shared humanity that we are experiencing in a very different way. I hope that we come out of this much stronger and feeling this sense of interconnectedness than we ever have.
It really challenges all of us to say, we do not want to keep going on without fixing some of these things that absolutely have bothered us before, but in this particularly stressful time, makes us understand, it is not tolerable just to be accepting, but we really have to work for change and improvement.
They have not been thinking about what will break even or be profitable under fee-for-service at all, because they knew it was going to be hopeless. They knew that they were going to have enormous deficits, and they were addressing first things first.
I actually think population management is much more important now than it was at the start of 2020, because everyone realizes we have to take care of populations first. We have to meet their needs. And meeting their needs means, you know, cycling back to the beginning, making them feel safe, giving them the kind of contact that telemedicine makes possible without putting themselves at risk and having the frequent contacts that telemedicine makes possible.
Empathy became a front and center priority, and no one has been talking about breaking even under fee-for-service payments. We are going to adjust the payment system now, having recognized what is really important because to a certain extent our vulnerability helps us to see things more clearly.
We cannot lose that opportunity, so I think the lesson for me has been that there are no more excuses about how hard or politically complicated necessary change is, regardless of the thousand points of veto around them. Let's get rid of unnecessary variation in health care. We proved we could do it for COVID-19. Why can we not do it for everything else?