The disruptions to society created by COVID-19 have been impressive. The public has embraced the notion that we won’t return to “normal” anytime soon, and when we do, the “new normal” will differ from the old in ways yet unknown. Similarly, COVID-19’s impact on American medicine has been disruptive in ways large and small. Some disruptions will produce lasting change. Although it’s early to speculate on what those might be, there are some indications.
I recently had the opportunity to ask a group of physician-leaders what they thought COVID-19’s impact on American medicine might be. Dr. Danette Taylor, medical director of movement disorders at Hauenstein Neurosciences/Mercy Health, responded, “What areas of US medicine have not been impacted by the COVID-19 pandemic? We’ve seen changes in administrative roles, salaries cut, colleagues furloughed, changes in the way we practice and patients shy away, despite instructions to be assessed.”
Dr. Heather Finlay-Morreale, assistant professor of pediatrics at the University of Massachusetts Medical School, echoed Dr. Taylor. “Telehealth is here to stay,” she commented. Others agreed.
“I think this will fundamentally change the way we see the outpatient setting,” said Dr. Susan Pohl, a family physician and medical educator at the University of Utah Health. “If reimbursement continues for telehealth, the physical clinic will be the center of a hub-and-spoke model. In primary care, some visits will be in person, some telehealth. We will think about chronic disease management in new ways. More care team members can interact fluidly with patients on a variety of platforms. Referral patterns could change drastically. If a patient can have their outpatient specialty evaluation done virtually, then distance is not an issue.”
Dr. Rashmi Mullur, the chief of telehealth for the VA in Los Angeles, indicated that a hub-and-spoke model reflects what her team is implementing. “Increases in telemedicine visits will also result in increased utilization of remote patient monitoring and wearable devices.”
Of course, telemedicine isn’t a panacea. While some physicians highlighted the capacity of telehealth to meet the needs of those in remote or rural settings, others pointed out the inherent inequities present for those with inadequate internet access or familiarity with the technology telehealth relies upon.
New Universal Precautions?
Just as the advent of HIV inspired rapid developments in how we protect ourselves from blood-borne pathogens, after COVID-19, I suspect we’ll never approach airway management the same again.
As Dr. Robert Canelli and his colleagues demonstrate in a video published by the New England Journal of Medicine, airway management entails a much greater exposure to potentially infectious particles than we typically previously envisioned.
Recent shortages of personal protective equipment (PPE) have brought the ingenuity and determination of physicians to the fore. From rain ponchos to acrylic boxes, from jerry-rigged respirators to N95-equivalent masks made of materials found in the OR, physicians have demonstrated commitment to devising ways to protect themselves and their co-workers. I suddenly find it difficult to imagine that for years, I’ve managed patients’ airways with my own airway exposed. I doubt that we will ever turn back.
National Emergency Preparedness
Few can deny that COVID-19 has shined an unflattering light on the preparedness of the United States for a national medical crisis. We can learn from that experience and work with the public to reshape our medical system for the future.
An event of this magnitude has highlighted numerous ways in which U.S. healthcare is fragmented. Competition among states for PPE and equipment makes it clear that our system lacks adequate national coordination. Furthermore, a system in which healthcare is largely funded by for-profit insurance companies has made it difficult, if not impossible, to pivot from funding extensive numbers of scheduled surgeries and on-demand services to large-scale public health and emergency preparedness efforts when the need arose.
I don’t pretend to know the solution to the massive problems surrounding healthcare financing in the U.S., but I would observe that when the community’s primary health need shifted from ad hoc provision of individualized services to a massive mobilization in response to a public health calamity, the billions of dollars Americans send to private health insurers annually were simply unavailable to meet the public’s most pressing healthcare needs.
The Social Determinants of Health
When I was in medical school, respected researchers taught that the high rates of hypertension among African Americans stemmed largely from genetics, often compounded by a high-sodium diet. As epidemiologist Dr. Camara Jones, MD, MPH, PhD, highlights in a powerful recent interview, we now know that the incidence of hypertension and other chronic diseases in the African American community has as much, if not more, to do with the stresses of poverty, including unhealthy environmental exposures, disrupted sleep, diet and the daily reality of a society where people with more darkly pigmented skin are chronically inadequately valued.
Likewise, the disproportionate impact of COVID-19 on communities of color is more likely due to various social factors than to genetic inheritance. Rather than drive a rush to tend more aggressively to the needs of the communities most heavily affected, that profound impact may not be taken seriously enough.
As health equities researcher Dr. Phyllis Nsiah-Kumi, associate professor of internal medicine at Case Western Reserve University, reflected, “Once it was publicized that elderly, black and brown communities suffered the most from COVID-19, it appears the caution and concern [which resulted in a societal lock-down] went away and everyone was ready to return to life before caution. Sure does feel like some populations are expendable.” As physicians, we have a duty and, I trust, a drive to serve all of humanity equitably; if that is so, this assessment should break our hearts.
Perhaps COVID-19’s most important impact is the wake-up call we physicians have been given. Let’s retain what we’ve seen and work to make the changes necessary for the health of our society.
Want to learn more about what COVID-19 means for medicine? Read:
- “This COVID-19 Practice: The Pandemic Wreaks Havoc on Neurology Research Funding and Finances, While Also Offering Opportunities” in Neurology Today
- “COVID-19 and Food Safety: Risk Management and Future Considerations” in Nutrition Today
- “Departmental Experience and Lessons Learned With Accelerated Introduction of Telemedicine During the COVID-19 Crisis” in the Journal of the American Academy of Orthopaedic Surgeons
- “COVID-19 Crisis Creates Opportunities for Community-Centered Population Health: Community Health Workers at the Center” in the Journal of Ambulatory Care Management
- “COVID-19 Study Predicts Lockdown Is Difficult to Remove Safely” in Oncology Times