Facing change together

A hospitalist calls for collaboration during the pandemic.

Rarely do major disruptions happen suddenly in health care delivery. One example of this type of event is the introduction of the electronic medical record (EMR), which made sweeping changes to the way medicine was practiced and exacerbated some already tense relationships in the hospital. Physicians struggled with how to talk with patients while sitting behind computer monitors. Simple orders suddenly became complicated. And time spent with patients decreased.

I once saw an orthopedic surgeon point in the face of a hospital president and say, “The blood is on your hands,” referring to anticipated medical errors and adverse patient outcomes resulting from the launch of our EMR. It was one of the most stunning things I had ever heard. I found myself impressed by the response from the hospital administrator, which was calm and empathetic but never defensive. And I became keenly aware that we were all in this together.

Dr Walker
Dr. Walker

Fast forward nearly 10 years, and the crisis that is COVID-19 is upon us. The pandemic has thrust oft-forgotten details of what it takes to deliver patient care into the forefront of everyone's mind. Suddenly PPE and the supply chain are urgent matters, the financial distress of many hospital systems is national news, regulations are seemingly nonexistent, and the need to respond quickly to an ever-changing landscape is paramount. Stories of physicians being fired for speaking out about inadequate resources have also made headlines.

The disgruntlement of doctors has already been well described in recent years. The reasons are myriad but include diminished time at the patient bedside (often blamed on the EMR), loss of autonomy, and increased oversight. With the similarities between physician burnout and the chronic post-traumatic stress disorder suffered by soldiers, it seems appropriate now that members of the military are providing advice to physicians on how to adapt and endure the battle against COVID-19. For example, military veteran Mark Hertling offered his advice in “Ten Tips for a Crisis: Lessons from a Soldier” in the May 2020 Journal of Hospital Medicine.

In addition to the existing challenges, for the first time in my career, I see physicians openly struggling with what degree of exposure they are willing to risk for themselves. Many have chosen to live in hotels away from their families to protect them from COVID-19. Conversations are being had about rationing of PPE and other resources and about the impact of delaying health care for non-COVID-19-related illnesses. The same difficult conversations that physicians always have with patients and families continue, but they are happening from six feet away, by phone, or by video. Physicians lament being unable to touch the hand of a grieving mother or to unmask their faces while talking to patients and families. Many feel powerless as our colleagues, friends, patients, and family fall victim to disease. Despite our being hailed as heroes, the level of moral distress is high in the physician community.

Yet this is an occasion to which many rise. In the areas impacted most by COVID-19, ophthalmologists have become hospitalists and orthopedic surgeons are now emergency medicine doctors. The old way of doing things seems suddenly obsolete, a faint memory, and the change is being embraced. Burdensome regulations seem to have evaporated during the pandemic, and concerns about billing of services and impeccable documentation have vanished. The desire to be at the bedside seems to be heightened yet telemedicine is becoming ever more common due to the severity of the disease. The long-term impact of any of this is yet to be understood.

Both physicians and hospital administrators must realize that their decisions—both past and present—have contributed to our ability to respond to COVID-19. Physicians must embrace our role as stewards of our resources now more than ever. Gone are the days in which we could demand more supplies than absolutely necessary for patient care. We must be mindful of instrument contamination, PPE utilization, and waste. And though billing has not been the primary focus of many, physicians must once again consider the revenue generated from our services, which helps keep us all afloat. We must also respect our nursing, environmental services, and other ancillary staff members as vital resources without whom our work would be hindered. Our ability to adapt, to lead, and to scrutinize our own actions and decisions will determine our success in this endeavor.

The mistrust between hospital administration and physicians that I witnessed back at the launch of EMRs may or may not be improved by our collective experiences. During this crisis, physicians and health care workers have been accused of misappropriation and even theft of supplies. Many physicians suspect that administrative decisions are driven solely by finances rather than patient care or staff safety. Yet the truth is that in a hospital without robust finances, our choices become severely limited, and our current concerns about decreased compensation and economic uncertainty may become our reality.

As we navigate this pandemic and its exposure of the imperfections of our health care system, we will have to decide how best to forge ahead together. Will we be able to candidly discuss our choices and their impact on one another? Can we seize the opportunity to create a better health care system, one that restores a sense of fulfillment for physicians and enhances both access and quality of care for even our most vulnerable patients? Or will we be left pointing fingers at one another and saying, “The blood is on your hands”?