The COVID-19 crisis may be easing; here are 5 lessons we must carry forward
Lois Margaret Nora, MD, JD, MBA
As COVID-19 mortality in the US surpasses 1 million, it is difficult to see much good in the pandemic that has dominated life over the past two years. However, while the losses are devastating, the pandemic has shed new light on important issues and accelerated progress that I hope will continue well into the future.
Some of these are conversations we should have been having all along. Others involve newer trends that hold potential to benefit many if we can seize this moment of opportunity. Creating change in a system as large and complex as healthcare has never been easy – but the pandemic has shown us how much we can do when we are aligned around a common goal.
Medical schools and other institutions of health professions education will play a key role in applying the lessons of COVID-19 and facilitating progress toward a better system of care.
Here are five lessons that we should carry forward.
We must bridge the health equity gap
The health disparities laid bare during the pandemic were well known to public health professionals long before the crisis, but the exacerbation of those disparities as COVID-19 took hold captured a new level of attention from the general public. Reports that people of color were at higher risk of developing COVID-19, faced greater likelihood of severe disease outcomes, and often held jobs that put them on the front lines of the pandemic converged with increased attention to issues of social justice and systemic inequities.
It is difficult to overstate the scope of the challenge. The causes of health inequity are “diverse, complex, evolving, and interdependent in nature,” according to a 2017 report from the National Academies of Sciences, Engineering, and Medicine. In medicine, they involve access to care, how care is provided, and even the underlying assumptions of biology and disease on which care is based. Because inequity is omnipresent, action on the part of a few committed stakeholders will not be enough. We will need all hands on deck. And we must seize this moment.
Fortunately, many have risen to the challenge. And some of the most interesting efforts have bubbled up in our institutions of health professions education.
Consider efforts by medical students Pooja Chandrashekar and Victor A. Lopes-Carmen to ensure COVID-19 information is accessible in dozens of languages. Early in the crisis, students across the country put together small armies of volunteers to help with outreach, and they worked with leaders of their schools to take action. Meanwhile, medical education programs are leading research, examining and overhauling curricula, training faculty, and striving to expand the diversity of the student population.
The disparate health outcomes we have seen through the pandemic and throughout history are unacceptable. And yet, the momentum coming out of the pandemic is promising. We – students, educators, clinicians, leaders -- must put the plans and systems in place to ensure we do not lose it.
Clinician burnout is an urgent priority
Clinician burnout was a serious issue before the pandemic, but it didn’t necessarily register beyond the ranks of those most affected. The early pandemic’s focus on the heroism of nurses, physicians, and other clinicians (coupled with attention to inadequate supplies of personal protective equipment and other issues) put healthcare working conditions in the spotlight.
Two years later, burnout has sparked not only an alarming mental health crisis, but also staffing challenges that will have ramifications for years, if not decades. McKinsey found that while 20% of nurses were looking to leave the profession early last year, that figure was 32% by the end of 2021. In some specialties, the picture is far worse. The American Association of Critical-Care Nurses found that 66% of critical care nurses have considered leaving the profession through the pandemic, and 92% believe the experience has cut their careers short.
It is difficult to see the good in any of this, but persistent shortages of nurses and other clinicians have forced a conversation about healthcare workplaces that might otherwise not have happened. To solve workforce challenges, we must address their root causes – in particular, asking too much of professionals while providing too little support. I have been heartened by attention to these issues on the part of institutions like the US Health Resources and Services Administration, the National Academy of Medicine, and the Accreditation Council for Graduate Medical Education, which are leading productive conversations about what has gone wrong and how to reverse it. Meanwhile, the Dr. Lorna Breen Health Care Provider Protection Act, recently signed into law, will provide resources to help ensure clinicians have the support they need.
Telehealth needs a permanent place in our systems of care
For some care, there is no substitute for an in-person visit. But amid the rapid escalation of telemedicine early in the pandemic, many healthcare professionals were surprised by how much care could be administered from afar, with the right technology.
Mental healthcare is a particularly interesting example. While the promise of remote mental healthcare had been discussed prior to the pandemic, it took a crisis to increase uptake beyond the low single digits. One study reported that telehealth was used by more than half of those with a behavioral health condition during the first two months of the pandemic – a higher rate of utilization than reported even for chronic physical conditions. Telehealth also opened the door to people who might otherwise forgo mental healthcare.
The flexibility to obtain care from anywhere may be particularly important given persistent shortages of mental health professionals that are expected to worsen. Across the US, just 28.1% of need for psychiatric care was met as of Sept. 30, 2021, according to the Kaiser Family Foundation. Meanwhile, worsening shortages for marriage and family therapists, mental health and substance abuse social workers, and others may be on the horizon. This is a crisis that won’t be entirely alleviated by remote care, but telehealth tools are certainly useful for managing the wide regional variation in unmet need.
Access to care is an important piece of the puzzle, but it is not the only reason to fully explore the possibilities of telehealth for behavioral and other health needs. Remote care channels also offer healthcare professionals an interesting window into the lives of their patients and clients. For example, licensed therapist Jenn Turner, who specializes in trauma in her work with individuals and couples, has noticed people are less guarded when they join therapy from home, potentially allowing care to progress more rapidly. Meanwhile, psychiatrist Dr. Alisa Burch and colleagues note life complications such as caregiving and work schedules are less likely to interfere with remote care. These considerations are important for continuity of care while also helping ease persistent business challenges like cancellations.
Much of the flexibility that allowed the rapid escalation of telehealth was granted on a temporary basis. While it’s clear that telehealth is not going away, nor should it, it will take commitment to make the necessary changes to enable its use on a permanent basis. We also have work to do as we determine the optimal use of remote, in-person, and hybrid care. As we do so, we will help ease workforce challenges, enhance convenience for patients and professionals, and improve health outcomes.
We should make better use of our interprofessional care teams
As COVID-19 surges have strained supplies of nurses, physicians, respiratory therapists, and others, we have seen the limitations of our healthcare workforce. We have also discovered and leveraged previously untapped flexibility that holds promise for continuing to expand access and enhance continuity of care after the pandemic subsides.
Consider the wide variety of professionals who joined the effort to administer COVID-19 vaccines. Not just physicians, nurses, and other traditional providers of vaccines, but also dentists, emergency medical technicians, veterinarians, and others. The contributions of these health professionals not only rapidly expanded the vaccinator workforce; they also opened up new access points for vaccination at a time when it was important to remove all possible barriers to care.
The pandemic also opened new avenues for enabling care continuity even as practices and hospitals managed overwhelming patient volumes. Physicians shifted from their usual specialization to emergency departments, critical care units, and other places where need was high. Meanwhile, we saw allied health professionals like respiratory therapists take on new tasks for which they are trained but not always engaged. And advanced practice professionals stepped into expanded roles that allowed them to work at the top of their game while relieving burdens on their colleagues, some of whom were needed elsewhere.
The flexibility we gain when we expect and allow professionals to practice at the top of their training is important for a crisis, but it can also be a solution to challenges in ordinary times, particularly in underserved areas. We should look for opportunities to enable all professionals to make the most of their skills. We should also look beyond our hospital and practice walls to community health workers, who have been a lifeline in many areas where physicians are in short supply. What progress could we make if we better channel the expertise of all health professionals after the worst of this crisis has passed?
Our public health system needs attention and resources
Public health professionals often say the most effective public health systems go largely unnoticed by the general public. People do not see the outbreaks that are prevented and the disasters that are thwarted. Unfortunately, this means problems like chronic underfunding, poor organization, and communication gaps also go unnoticed until crisis hits.
The pandemic put a spotlight on these issues. While a novel virus would have posed a challenge to even the most robust framework, the public health system in the US lacks the clear and consistent organization and structure needed to coordinate preparation and response to a threat like COVID-19. It is no surprise that testing, contact tracing, even communication about how to stay safe were so difficult to manage. Agencies that have long seen their budgets raided to fund other priorities had neither the technology and staff, nor adequate empowerment and coordination to effectively do this work.
The public health system also lacks a consistent approach to more routine but no less important aims like reducing tobacco use and conducting injury and disease surveillance. It is difficult to overstate the consequences of not attending to these priorities. However, addressing them holds promise for improving the state of health in America — and for solving many of the challenges that became clear during the COVID-19 crisis.
Looking toward a better healthcare system
Perhaps the most important takeaways from the pandemic involve the interconnectedness of our world. It does not take long for an emerging disease threat in one part of the world to reach people everywhere. And what started as a health issue quickly affected our financial, educational, and political systems. In healthcare, COVID-19 was not just a problem for infectious disease professionals and critical care teams to manage. It challenged us all.
The solutions may also be similarly interconnected, and we may see some interesting and beneficial emergent properties arise as we build them out. These outcomes may in fact ease some of the most pressing issues in medicine.
For example, as we develop more effective interprofessional teams, we may also uncover opportunities to enhance clinician well-being. Moving from concentrated workflows where physicians are heavily involved in all care for all patients to shared-responsibility models that spread tasks across the practice team may even help restore joy to the practice of medicine, to borrow a phrase from Dr. Christine Sinsky, whose work heavily focuses on these issues. These changes may also have implications for practice management. In fact, Sinsky and Dr. Mark Linzer argue that some of the administrative and documentation changes put in place temporarily during the pandemic transformed practice efficiency with seemingly simple changes such as allowing physicians to relay orders verbally to colleagues for entry into the electronic health record. Yet another change that we should be learning from as we move forward.
These lessons and changes will affect existing healthcare professionals. They will also have an indelible impact on the institutions of health professions education, which form the foundation of our healthcare workforce. Today’s students are tomorrow’s leaders, and those who embark on their careers with the right skills will play an outsized role in making the most of the lessons of the pandemic.
As COVID-19 evolves into an endemic disease and an unfortunate fact of life, the crisis phase of this experience will pass. However, the pandemic has shaped and scarred our world. It is my hope that we can honor the sacrifices made by so many, including so many in healthcare, by applying the hard lessons we have learned to make our healthcare and health professions education systems better.
This piece was first published on LinkedIn.
