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  • Rosalind Kaplan, M.D.

What Do You Want from Healthcare After Covid?


In the last 6 weeks or so, the practice of medicine has been turned topsy-turvy by the Covid pandemic. So has life as a whole: in some states, businesses have started to open and people are out and about, but in many places, Southeast Pennsylvania, where I live, included, we are still on full stay-at-home orders. While we are entering the 7th week of this, it seems like an eternity. We have been so consumed with the ins and outs of Coronavirus, social distancing to flatten the curve, managing the fear and worry and dismay of the pandemic, and figuring out how to wear a mask without having our glasses fog up, that it's hard to remember Healthcare Before Covid.

But let's try, just for a minute. Let's try to remember what was happening in the world of medicine before the pandemic turned ER's and ICU's into war zones. Before shortages of PPE and ventilators and nasal swabs and pink culture medium. Before the President of the United States encouraged the use of unproven medications and suggested that ingestion of disinfectant could fight the rapidly spreading virus threatening every part of our country. Before patients with chronic conditions and acute illnesses, other than covid, disappeared from clinics and ERs and doctors offices, to be seen only on Telemedicine video screens. Before hundreds of doctors and nurses and PA's and MA's died as a result of providing patient care. Before those 'on the front lines' of the pandemic were called heroes, and Wawa started giving free coffee to healthcare workers, and military flyovers were staged to honor medical staff. Try to remember what your life in medicine looked like Before Covid. Healthcare Before Covid.

Were you burnt out? Were you frustrated and saddened by all the barriers to care- Were you prior authorizations and precertifications, outrageous copays, uncovered services, the outrageous costs of medications? Was your Epic inbox unmanageable? Were you fed up with administrative tasks, tyrannized by data entry, and dragged down in your work by understaffing in your office and poorly trained employees? Or were you just over scheduled and overbooked and overworked? Did you feel like there was no way to meet all the demands of a clinical practice without working at home every evening and on your days off?

I had already walked away from Primary Care/Internal Medicine before Covid. I'd been out of it for almost 2 years, for a host of reasons, most of which are listed in the previous paragraph. I was fried.

I wanted to be a great doctor and meet my patients needs for prevention and treatment of disease, management of acute illness, and a compassionate, kind person to be on their side. But after 30 years, I couldn't do it without sacrificing my own sanity. Giving less wasn't an option for me- I couldn't talk myself into lower standards. So I left, and started doing part-time shift work while I completed my MFA. Working in Urgent Care was busy but manageable for me, and once I got used to the pace, I started to like the idea of being there for people when they had an immediate need. I was still frustrated and saddened by health disparities, the patients who saw us because they had no insurance and scraped together the money for a single self-pay visit, but had no access to followup, the folks who had fallen through the cracks of the system and couldn't find a way to crawl out. Healthcare Before Covid.

Then the Coronavirus pandemic started, and suddenly, I was thrust into a few weeks of utter chaos, with moment-to-moment changes in procedures and recommendations. I saw enough patients with respiratory symptoms and fevers to fear for my safety, despite the use of PPE, mostly because we didn't have clear guidelines around isolation and testing. Then my health system divided up our urgent care sites, devoting some to Covid care and excluding suspected Covid patients from others. My site, as a non-Covid site, had a massive decline in patient visits. I've been seeing injuries and headaches and patients with chronic issues who need care but can't get in to see their doctors. I've been doing telemedicine and video calls, and wishing I had more patients each shift because I hate being useless. I've been wondering where all the acutely ill patients we used to see with chest pain, abdominal pain, and other symptoms have gone, wondering if they are just having MI's and appendicitis at home. Healthcare during Covid.

And I've been watching the economic disaster and the insane politicalization of this very real, very serious public health crisis. Our government couldn't (wouldn't) pull it together to provide appropriate testing and contract tracing. Our leaders seemed willing to sacrifice healthcare workers, other 'essential workers' and low-income communities rather than to obtain adequate PPE and enough ventilators for the critically ill. Conspiracy theories circulated and the alt right, with Trump's encouragement, started protests against stay-at-home orders, likening these orders to Nazis killing of Jews (really????) and storming around armed with assault weapons. These protestors seem to feel that the sacrifice of vulnerable older and immune compromised individuals, as well as of healthcare workers and minority neighborhoods, is warranted in the name of 'freedom' and 'saving the economy.' These people have declared expertise worthless (#FireFauci?) and subscribed to conspiracy theory, choosing to listen to entrepreneurs who distort statistics ( www.msn.com/en-

us/health/medica/california).

Meanwhile, much of the healthcare workforce has been furloughed while executives and administrators at healthcare systems take bonuses. And now more and more states are 'opening up' without testing or tracing or adequate public health staffing in place.

All the while, the public has started profusely thanking beleaguered 'front line' workers. Not just thanking, but calling those of us who show up for them every day 'heroes.' Banging pots, singing, sending food, posting signs. And last week, healthcare workers got a 'flyover' from military planes.

And I am so ambivalent. I WANT hospital workers and others who risk themselves to serve others to receive the credit due, the gratitude that is deserved. It's nice- no beautiful- to see the pouring out of thanks and respect. But I'm also really concerned that it took this to get us there. Doctors, nurses and other medical professionals have been out there working themselves into the ground for our patients for years and years before Covid. We had an epidemic of physician burnout, depression and suicide going on before Covid, and there didn't seem to be much concern. So now that a bunch of healthcare workers have DIED EN MASSE, people are paying attention. Other essential workers, like grocery workers and custodians and transit workers, have been underpaid and uninsured and abused by our society for years and years, and very few people paid any attention.

And while the heroes are being celebrated, they have not been protected, or properly cared for in any way. Look at Dr. Lorna Breen, the ER doctor in New York who died last week by suicide. Of course, I don't know everything about her situation, but I know she had Covid and felt compelled to return to work prematurely in a hot-zone, with death all around her. Where were the things she, and all the other front-line workers, really needed? Adequate PPE, adequate staffing, on-site mental health support? Free coffee and applause are nice, but they don't help people in desperate situations in any meaningful way.

So look back at where the health system was before Covid. Healthcare Before Covid. And look at where we are now. Healthcare During Covid. Don't let the pot-banging and the flyovers distract you. We have to get through this current crisis, which is not over by a long shot. And we need the tools to do it- testing, tracing, PPE, staffing. Public health workers. We can't have our healthcare workforce decimated by the econom. Somewhere out there are all the people with their chronic and acute non-Covid illnesses, and we are surely going to have a resurgence of Covid peaks sooner or later, probably sooner with the hapless way our nation is handling 'reopening.' We need to get the non-Covid patients back in care, clean up the mess, and be ready for whatever is on the horizon. And we need to care for everyone who has become exhausted, depressed, demoralized, anxious and sick from trying to do Covid battle without needed support.

Now look ahead. Life After Covid. Once this calms down (and it will), what do you want from the healthcare system? We all know we can't go back to the way things were. We were already failing. We can't have uninsured citizens in a supposedly civilized country. We can't have insurance tied to employment, risking mass loss of coverage in an economic downturn. We can't have vulnerable populations without care. We can't have 60% of physicians burnt out. We can't waste time and resources on useless prior authorizations and precertifications. We can't demoralize healthcare workers, understaff medical practices and raise copays for patients, while administrators and executives take bonuses and then complain that the health systems are bleeding money. Not if we want to be healthy in good times, and certainly not if we want to survive another crisis.

Let's let Healthcare Before Covid and Healthcare During Covid inform Life After Covid. We have to do better. We, physicians, nurses, PA's, NP's, MA's- need to lead the charge, because we clearly see what is at stake. We can't let ourselves be shut up by the people who either don't see it or don't care. We have to care, and we need to fight for what is right. We've been willing to suck it up for way too long, always feeling that we should pick up the slack. We were already teetering on the brink, and Covid pushed things over the edge. Life During Covid made it clear that there isn't any slack left, no more room to suck it up. Let's make Healthcare After Covid a better life for the health of our country.

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© 2017 Rosalind Kaplan