By Marissa Wagner Mery
COVID-19 has highlighted that pandemic preparedness and management requires a strong, well-functioning health system.
Shoring up the health system and its workforce should be a national priority post-pandemic. First and foremost, we must recognize that the greatest asset of the health system is its people, and the system must reflect this. Second, our hospital-based, competition-driven health care landscape should be reformed to better meet the needs of our communities.
The Health System’s Greatest Asset
Last March, a hypothetical ventilator shortage incited mass frenzy. States pondered rationing protocols as COVID-19 cases mounted, and healthcare hackathons pivoted their foci. Friends and former colleagues joined the worldwide effort to devise ventilator prototypes with 3D printers or items found in the aisles of Home Depot.
It’s true that resource scarcity influenced mortality rates, but I count myself among those who failed to predetermine what would be our most valuable resource. Americans didn’t die from a lack of a ventilators; they died from a lack of individuals properly trained to manage ventilators and the critically ill patients requiring them.
Staffing and specialization impacted mortality in both hospitals and long-term care facilities. Patients in hospitals with <50 Intensive Care Unit (ICU) beds had significantly higher mortality than those in higher volume facilities with greater than 100 ICU beds. High-volume centers have multidisciplinary teams dedicated to nuances of respiratory care and rehabilitation that often go unnoticed. Similarly, in nursing homes and other long-term facilities, higher nurse staffing levels correlated with lower COVID-19 case counts and deaths among residents.
I can’t imagine these data surprise anyone working in health care. As providers, we value our colleagues for both clinical and emotional support; as patients, we place ourselves and our trust in the hands of people, not machines. For a system whose output is so contingent on the quality of its workforce, health care often relies far too much on its practitioners’ altruism and invests far little on the creation of a bilaterally supportive relationship.
In the early and most frightening days of COVID-19, some institutions crafted a narrative of heroism when they should have inculcated a culture of safety. Nurses and physicians in New York too often brought their own personal protective equipment (PPE) or fabricated it out of household items such as garbage bags.
Similarly, inadequate planning stymied vaccine rollouts in some of our nations’ most lauded institutions. Stanford utilized an inappropriate algorithm that prioritized senior physicians, some of whom worked from home, ahead of frontline physicians. At Mass General Brigham, a first-come, first-served web app meant those actively caring for patients couldn’t access early appointments and felt undervalued. These failures reflected a perceived apathy more than ineptitude, as both institutions are more than capable of crafting effective deployment strategies.
In an age with ever-shrinking hospital margins, physicians and other providers often feel they are viewed as mere expenses on an institution’s income statement as opposed to valued assets. COVID-19 has done nothing to improve this situation, and in many cases seems to have exacerbated feelings of disillusionment and burnout.
“Fixes” are complicated and not readily prescribed, but they could focus on a common goal – for institutions to commit to activities and processes that make the workforce feel valued. Institutions should invest in tools that facilitate the workforce’s activities and ameliorate pain points, and be creative in how to best invest in employees themselves.
For example, hospitals aggressively deploy technologies that improve billing and compliance, but less often use tools such as dynamic knowledge systems or virtual scribes to ease clinical decision-making and administrative burdens.
Moreover COVID-19 is unique in that it challenged the intrinsic motivation, or internal satisfaction, of many health care workers. As hospital beds filled and deaths mounted, exhaustion and a sense of futility followed. While there is some evidence that some external rewards risk blunting intrinsic motivation, showing appreciation or accolades might prove useful in COVID-19 where working conditions are far more strained than typical. Extrinsic motivation can be financial rewards, but they can also assume the form of vacation, flexibility, increased autonomy, or explicit recognition.
The Failure of Hospital-based Health Services
As a health system, we didn’t prevent disease effectively, nor did we deploy expertise efficiently among our hospitals. Instead, a national epidemic was clinically managed as if it were a series of local problems.
Rates of community transmission repeatedly surged, and prevention efforts encountered strong political resistance. Some hospitals were severely overburdened, while others were less so. Overrun institutions’ patients were up to twice as likely to die; and the poor and most vulnerable bore this superfluous burden of death and disease.
While this might appear an intractable problem, I propose it’s relatively easy to advance on.
Health and illness are lived at home. Even for the sickest among us, over 90% of our lives occur outside hospital or clinic walls. There is growing evidence that community health worker programs can improve chronic conditions in U.S. populations by meeting patients where they live, at home. A permanent cadre of community health workers, when appropriately chosen and managed, would form the frontline of primary systems for the most complex patients, and could flex into broader public health roles when called upon, such as during a pandemic.
The U.S. should also regionalize its network for critical illness. For trauma centers, a tiered network exists so that patients are appropriately triaged to facilities that can manage their needs. A severely ill patient goes to the hospital best suited for their injuries. For COVID and other critical illness, patients go to their local facility and receive care escalation only if another facility is willing to “accept” them, and acceptance is too often driven by insurance status, as opposed to need.
Finally, we could better leverage the world’s health workforce for a global threat. Come nightfall Emory Healthcare ICUs are sometimes staffed by Emory critical care physicians living in Perth, Australia. The 12hr time difference allows them to work during Perth’s daylight hours to care for patients during Atlanta’s nights. An initial trial saw a reduction in physician burnout, improved satisfaction, and increased collaboration. We should build on these promising results. Additional efforts could trial options whereby physicians in countries less burdened by a global health threat could support exhausted clinicians located elsewhere.
COVID-19 exposed our health system’s fault lines while elevating the capabilities and heroism of those confronting it. We must learn from this experience to improve not just COVID care, but health care writ large.
Marissa Wagner Mery, M.D., MBA, is a critical care physician and assistant professor at Dell Medical School at the University of Texas at Austin.
This post is part of our digital symposium, In Their Own Words: COVID-19 and the Future of the Health Care Workforce.