This is a longer format article (there is lots to worry about after all - and lots to do!). To give you a quick sense of what is covered (and where in the article) this is a quick overview and table of contents. In this article major areas I cover are:

• Concerns and questions during the different phases of the pandemic:
  • During the Initial Phase
  • During the First Surge
  • After the First Surge
  • Ongoing Swells and Surges
• What can we do about it?
  • Understanding Disease Pathophysiology, Diagnosis and Treatment
  • Clinical Practice and Capacity
  • Improving Communication and Collaboration
  • Improving Education and Training
  • Reducing Inefficiency
  • Addressing the Disproportionate Impact on Certain Communities
  • Addressing Violence & Structural Racism
• Thinking about the Future
  • How can we think about being safe balancing social distancing vs relaxing and reopening?
  • Is there a large clinical backlog developing and how will we be able to catch up?
• Emerging concerns
  • When vaccines become available

Background

Disease outbreaks have always been a staple of daily news. In the last ten years alone, the world has seen about 30 epidemics of various scope - that’s three epidemics per year, on average.

MERS (Middle Eastern Respiratory Syndrome) emerged in 2012. I remember screening patients for it in my clinic, with one or two possible cases that I saw directly, but no actual exposures. The world paused for a moment to worry as news headlines sounded alarm bells, but within weeks the headlines turned elsewhere. Case numbers fell, and people carried on with their lives. MERS didn’t survive a long news cycle, although to this day, it persists in certain geographic locations.

Immediately on the heels of MERS, 2013 brought the Ebola outbreak. I had colleagues from the Division of Global Health and Social Equity prepare their wills, then travel to work in Liberia. Hemorrhagic fevers with a high lethality are very scary. Luckily Ebola was contained, and they returned safely.

After each of these outbreaks and others, the world returned “to normal” and seemed resilient and as indifferent as it always had. It was 2019 and we were so used to ingesting headlines about various public health crises over breakfast, that the scope and speed of COVID-19 blindsided us.

When the novel coronavirus first appeared in the news, many of us assumed its trajectory might be similar: an initial spike of cases with the usual media coverage that would dissipate within a few months. Needless to say, COVID-19 surprised us with its vast impact.

Many months into the pandemic, we continue to face problems so global (shutdowns of countries and economies) and so local (protecting ourselves and our loved ones), that it’s often hard to know what we should work on. While the default response is to focus narrowly on what is in front of and around us, there’s a lot to be gained by pausing to think bigger - especially about what you could do to have the biggest impact.

I did just this in May 2020. I wish I could say I had the luxury to focus on ‘one big impactful thing’. Instead, there have been many ongoing, evolving concerns that have arisen, and evolved for me as a father, as a physician, as an informaticist, and as someone who has trained in and cares deeply about global health and social equity.

I wrote this article to try to make sense of these concerns, and to push myself to understand and share what could be done about them. I hope it can help you find context and solutions. I welcome your concerns and especially how you, or we, might work to address them.

The Phases of the Pandemic

I noticed that the concerns and questions that I’ve been most worried about have changed over time during the pandemic. I’ve found it helpful to think of these in the phases of the pandemic. I think of these phases as:

• Initial phase (early 2020)
• First surge (spring 2020)
• Post surge (summer 2020)
• Ongoing swells and surges (fall 2020)
• The future

During the Initial Phase

At the beginning of the pandemic, as a physician I was most concerned with:

• understanding how the disease spreads
• understanding how to recognize / diagnose the disease
• knowing what could be done to help patients with the disease
• knowing how to practice safely and not catch the disease, or spread the disease to my patients or to my family and friends
• how to help build clinical capacity for the expected surge ahead

During the First Surge

In addition to ongoing learning about the earlier issues, I was working with an infectious disease colleague to help visualize and distribute data to clinicians. Through this it became obvious that rates of infections were very different across communities especially in areas of greater social inequality.

During the first surge, ICU facilities were greatly expanded, and special pathogen units were created at our hospital to care for patients who were diagnosed with COVID or were suspected of having COVID. At the same time, there was a tremendous reduction of most elective care, primary care and outpatient specialty care as physician practices closed, and patients stayed away out of concern for their safety. Some special centers for outpatient testing, and specific respiratory and non-respiratory clinics, were established. The use of personal protective equipment became more tightly controlled, but new mechanisms for disinfecting equipment helped to prevent actual shortages.

During this phase, new areas of concern developed in several areas, including:

Patient Care:

• how can physicians quickly be trained to be as useful as possible in the treatment of COVID patients?
• how can we use all clinical resources to help support the caring for patients safely?
• how can we help to continue providing primary care safely to our patients?
• how can we help our patients to not avoid needed care?

Disproportionate Impact on Certain Communities:

We began to see a much more serious impact in certain communities over others, especially in African American and Hispanic communities, as well as nursing homes.

This raised questions around:

• what could be done to lessen the greater harms being done in these communities?
• what could be done to ensure equitable access to care, now while it was supportive, and later when treatments and a vaccine would be available?

Violence & Structural Racism:

While this has been a longstanding and ongoing issue in the United States, it became acutely visible during this pandemic. It’s hard for anyone who considers themselves a healer not to play some part in mending the social fabric if they are truly to care for all their patients¹. This raised the question:

• how can all physicians be effective in helping to heal communities being hurt by structural racism and inequality?

After The First Surge

The social distancing practices implemented in Massachusetts in the spring of 2020 were, fortunately, effective. In summer 2020 we were at the end of the first surge. I watched the census within the hospitals decline, and services such as the additional ICUs and special pathogen units, virtual staffing and rounding programs stand down. As we entered the summer, we had data about some effective treatments that, while they could not cure the disease, helped to reduce the duration or most severe outcomes. Vaccination trials continued to proceed very rapidly and there continues to be hope that it will be the fastest vaccine development program in our history so far. All this said, some new concerns cropped up in summer 2020:

• how we can be safe in balancing relaxing and social distancing and be able to avoid much larger later surges?
• how can we tackle the large clinical backlog developing for other conditions, and how will we be able to catch up (especially in the area of vaccinations, chronic care, etc)?
• what the economic impact will be:
  • for our patients, and what will this mean for their access to healthcare, especially while, during the pandemic-induced economic crisis and high unemployment, and with the federal government actively dismantling infrastructure that would increase healthcare access?
  • for clinical practices and hospitals - what will be lost, what will be cut, and will this reflect what is most needed by patients, or what is most valuable to healthcare organizations?
• when more effective treatments and vaccines become available:
  • will they be made available to all, or will only the wealthy have access to them?
  • will they be safe - for those at highest risk of harm from COVID and for those at the lowest risk who have the longest lifetimes to experience any potential harms (such as our children)?

Ongoing Swells and Surges

My main concerns in this stage are about

1. the potential size of the surge and
2. exhaustion and burnout among healthcare workers and essential workers and
3. the limits of resilience (both emotional and financial) in our communities.

While many resources can be marshalled quickly for urgent needs, sustaining this for a long time can be exhausting. We will need strong ways to refresh and renew ourselves and the bonds of our communities to survive.

What can we do about it?

It would be hubris to think that one person could solve all these problems. That said, I’m trying to think and act holistically, and take some responsibility to consider all the questions or concerns that affect my patients, my family and my community, and to look for possible solutions. This may not be relevant to everyone, but I do think sharing possible solutions here might help us to work together to have a bigger impact.

Understanding Disease Pathophysiology, Diagnosis and Treatment

As a reminder, concerns about this include:

• understanding how the disease spreads
• understanding how to recognize / diagnose the disease
• knowing what could be done to help patients with the disease
• how can physicians quickly be trained to be as useful as possible in the treatment of COVID patients
• how can we use all clinical resources to help support the caring for patients safely
• how can we help to continue to provide primary care safely to our patients
• how can we help our patients to not avoid needed care

Some resources that help me as a doctor to understand the diagnosis and treatment of the disease, and to be able to describe the need for appropriate care to our patients include:

• CovidProtocols.org
  • a summary of the protocols that we use at Brigham Health to diagnose and treat our patients. I am actively helping as a section editor of the Ambulatory and Diagnostics sections and helping to create a semi-automated system to ensure we are systematically reviewing the literature and updating the site.
• Physicians Guide and Resources
  • from ACP that is updated frequently. I have contributed some work in the Wellbeing section (related to what I can control as a physician during COVID).
• UpToDate’s free Coronavirus content that is also frequently updated.

Clinical Practice and Capacity

• Knowing how to practice safely: my main resources here are local organizational policies described in CovidProtocols.org.
• Sharing information with patients, friends and family via CDC Guidance on what to do to protect yourself.
• Helping build clinical capacity for the expected surge ahead by building new resources or using existing resources more efficiently; the critical resources we need to build up include:
  • protective equipment
  • ventilators
  • hospital beds
  • people, e.g. nurses, doctors (intensivists, internists)

States and organizations have, in general, invested in resources to help expand these critical resources by:

• disinfecting masks, allowing us to overcome a shortage of masks
• bundling procedures and minimizing the number of people and times entering patient rooms, helping to reduce the protective gowns needed; video intercoms and some remote monitoring also helped
• developing in-house sheet cleaning systems, including recycling buckets and refilling them, when sheets became a limited quantity.

When it comes to using existing resources more efficiently, many unmet needs and invisible inefficiencies exist. The good news is, a lot of creative solutions are being tried. I think of improving effectiveness and efficiency in terms of these major buckets:

• improving communication and collaboration
• improving education and training
• reducing inefficiency
  • address diagnostic error
  • utilize underutilized resources
  • reduce overutilization of specific resources

Improving Communication and Collaboration

• Take a Team Approach: Effective medical care today requires a team approach.
• Effective communication and collaboration can transform an arduous, emotionally challenging process filled with unnecessary delays, into a smoother and more effective process.
• Set Up Rapid Knowledge Distribution: In a rapidly changing environment the ability to distribute knowledge efficiently across an organization, and the ability to update that knowledge, is critical.
• Choose Effective Communication Methods: Some approaches to communication, including commonly preferred approaches, are not always the best approach for the team.
• Recommendations:
  • favor asynchronous communication where possible to allow team members with varying workloads to provide input without interrupting them.
  • allow for quick conversion for messaging to become conversation, when complex decisions need to be made (such as through seamless audio or video conferencing)
  • use tools that automatically create context for users and let them catch up quickly (such as in channel- or topic- or conversation-based communication tools)
  • use tools that automatically track changes, so team members can quickly see what has changed since they were last there
  • designate a “synthesizer” (someone who will regularly summarize the care to date) to reduce the need for reading all the prior documentation
• Recommended tools and usage:
  • use real-time channel-based collaboration with appropriate behaviours (mentions when direct input needed, quick reactions, avoiding inappropriate posting) e.g. Slack, Microsoft Teams
  • practice multi-author collaborative documentation with track changes, e.g. wiki, GoogleDocs, collaborative Word
  • use email for announcements only, and store all messages on a searchable updated website
  • use paging for emergency summons only, otherwise use a two-way modality; set clear team expectations for using paging.
  • batch common communication, e.g. fixed rounding times with consultants, with nurses, etc.

Improving Education and Training

• Rapidly changing knowledge requires a different education and training approach: traditional development of curriculum is too slow and results in stale content. The priority for content delivery should be: point-of-care support, communities of practice, and active learning mini-modules.
• Providing cross-functional training during times when staff need to be minimized can be helpful, but with some caveats:
  • be careful of giving additional tasks to overwhelmed team members, as this can overwhelm them - some awareness of workload / stress / burnout is needed for all team members
  • quality vs efficiency: ensure certain tasks are done by specialized team members, where volume and experience are important to quality (such as procedures or radiological studies)
  • cross-train support staff: while there is a default approach that would add additional training to the person with the most general training (e.g. the internist), the suggested approach here is also that those team members supporting the critical resources be cross-trained to operate at the top of their license to offset any tasks (logistical or documentation) that do not require the critical resource.

Reducing Inefficiency

• Address and reduce diagnostic error
  • Diagnostic error is both wasteful and can lead to harms including direct patient harm as indirect through unnecessarily usage of resources
  • During increased stress or load, diagnostic error can be expected to increase
  • Strategies to reduce diagnostic error include:
    • heightened awareness
    • moving to probabilistic thinking
    • easy collaboration / oversight requests
• Utilize underutilized resources
  • during this pandemic, many physicians in subspecialties were furloughed; many of these joined a virtual staffing pool that help provide virtual staffing support
  • consider using this virtual physician staff pool to alleviate load on in-hospital intensivists and internists
• Reduce overutilization of specific resources
  • physicians will want to treat any patients assigned to them
  • set up automatic load-tracking and automatic staff allocation measures, based not just on numbers of patients (who can vary significantly in complexity and time required) but also stress and cognitive bandwidth.

Addressing the Disproportionate Impact on Certain Communities

What could be done to lessen the greater harms being done in these communities?

What could be done to ensure equitable access to care while it is supportive, and later when a vaccine is available?

Important approaches to this include:

• a focus on comprehensive public health measures, education, and interventions
• an explicit focus and measurement of:
  • variation on care and outcomes based on location, ethnicity, language, gender
  • explicit measurement of excess mortality or variation in outcomes based on this
• the impact would be largest, not just from accountability, but also from possible solutions if the data being measured was updated and available publicly.

Addressing Violence & Structural Racism

How can all physicians be effective in helping to heal communities being hurt by structural inequality?

Structural violence is challenging to address, and many have written extensively about this. Some possible approaches:

• engagement and input from physicians and public health policy: visibility and oversight into government policies is required
• engagement and connection with communities is critical; an idea would be for all physicians from an organization to be assigned into neighbourhood collectives that:
  • focus on understanding and helping co-create solutions to meet the health needs of that community (community health centers often have 50% of their board from the community so could be central to this effort)
  • involve and collaborate with the local community
  • dedicate time regularly for the physicians to meet in and work on these community issues

The Future

How can we think about being safe balancing social distancing vs relaxing and reopening?

A reasonable approach here is to continue to advocate for social distancing for all high-risk patients and for all those for whom it is possible, until a vaccine is available.

It is also important to emphasize to our communities, policy leaders and the public that the economic impact is from the disease itself and only a small percentage seems to be from the social distancing policies themselves (lessons learned from economic analysis of Sweden who did not socially distance and Denmark who did²). Lessons from the 1917 influenza epidemic suggested that the communities who better contained the outbreak did better economically are also important for all to consider³.

Is there a large clinical backlog developing and how will we be able to catch up?

Possible approaches to address this include:

• creating better systems of care for populations, by:
  • making wellness- and wellbeing recommendations, such as screening discussions and vaccinations not dependent on clinic visits
  • using remote monitoring programs and algorithms that more consistently help to achieve patient outcomes in important clinical areas including:
    • blood pressure management
    • cardiovascular risk reduction
    • weight loss and management
    • type 2 diabetes
    • heart failure
    • coronary artery disease
• creating more open and interoperable systems of care, by:
  • empowering patients to receive care where possible/convenient and, to truly enable effective care management, to be able to receive and exchange necessary data, especially the most important data of all - patient’s goals of care and care wishes.

What will the economic impact be for:

• Our patients? What will this mean for their access to healthcare?
• Clinical practices and hospitals? What will be lost, what will be cut, and will this reflect what is most needed by patients, or what is most valuable to healthcare organizations?

Two key observations:

1. Public health is a public good, and this pandemic has highlighted the economic, and ethical need to strengthen public health locally and internationally

• in particular, this pandemic may be more costly economically than any previous war ⁴,⁵
• investments in defence against pandemics can not be local only
• rationally this should result in:
  • massive investments in public health infrastructure
  • massive investments in access to healthcare for all citizens as an economic and moral imperative for all countries

2. Medical and economic social safety nets are critical to mitigate infectious pandemics

• since their lack facilitates spread, as people have less agency to maintain safe distance and take or invest in precautions
• concepts such as universal income, especially a global universal income could have radical impacts on public health, economic mitigation, and reduction in conflict and violence

Emerging concerns that I am exploring

When vaccines become available

• Will they be made available to all, or will only the wealthy have access to them?
  • Previous experience (such as with HIV treatment) and the lack of enforceable commitment to universal access suggests this is likely to be the case, with richer countries having earlier access. The UN and WHO have an important role to play if there is to be a hope of universal access.
  • Mitigating factors include:
    • Borders are not very effective against viral spread: We will see countries, who understand the fluidity of people and the nature of infectious spread, invest in the vaccination of other countries. Meanwhile, countries who are shortsighted and do not understand viral dynamics will ineffectually seek to close their borders rather than helping those at risk obtain vaccination.
    • Initially, the vaccine might be expensive and selected only for rich countries. Initially, the vaccine’s risks and side effects will also be less known.
    • It’s also likely that within a year, less expensive vaccines will become available and that worldwide advocacy and philanthropy will make millions of doses available.
  • Excess mortality due to the lack of access to vaccination during this time should be tracked and recorded as the price of inequality in humanity at this time in history… something that future generations will certainly look back on with mortification; a reflection of the lack of civilization in our time.
  • This is an opportunity to unite as a world and declare value in all human lives. We are interdependent.
• Will they be effective (and for how long) and will they be safe?
  • We will need to ensure that there is transparent oversight of vaccine efficacy, safety, regulation and marketing. Data and discussions need to happen in public to ensure the public’s interests are protected.

I have been really pleased to see the many institutes and academies start thinking about this and preparing recommended approaches and frameworks for equitable vaccine distribution. There is also a robust approach to vaccine safety advocated by organizations such as the CDC that include existing safety monitoring systems and expanded systems that we should all be aware of, and know how to use and advocate for their use.

Conclusion

COVID will be with us for some time, and a lot is required to address it. My hope was to share with you what I am worried about, and what I am trying to do about it, so that we can (1) recognize that we are not alone in our worries and (2) work together wherever we can (we will do much more together than apart). What I worry the most about are the gaps - so if there are areas that warrant attention that I am not thinking about, or doing something about, please share them with us in the comments.

References: