Dr. Turck:
The COVID-19 pandemic has been a force of change, shaping the way we work, interact socially, and even think about the world and our place in it. And yet it's sometimes easy to forget just how chaotic the first days of the pandemic were, with healthcare and public health professionals scrambling to mount an effective response to this once-in-a-generation challenge. Both those chaotic early days and some of the changes that have arisen since have forged one physician’s unique perspective: one that recognizes the benefits that have come out of the pandemic and our response to it. And that physician is here with us today to share his thoughts.
Coming to you from the ReachMD studios, this is COVID-19: On the Frontlines. I'm Dr. Charles Turck. And joining me is Dr. Shantanu Nundy, a primary care physician, advisor to the AMA and World Bank, and author of a newly published book titled Care After COVID. Dr. Nundy also recently published his perspectives on this topic in The Washington Post. Dr. Nundy, welcome to the program.
Dr. Nundy:
Thanks so much for having me, Dr. Turck.
Dr. Turck:
Dr. Nundy, as I just mentioned, you recently published an article in The Washington Post titled, “A Surprising Pandemic Side Effect: It Has Improved Healthcare.” Now some people may be surprised by that take on the impact of COVID-19. So what exactly happened to make you stop and think that the practice of healthcare may have benefited in some way from the pandemic?
Dr. Nundy:
Yeah, thanks for the question. I think for all of us that have been in healthcare for a long time know that it's many, many failures, right? We know that it's inaccessible, it’s unaffordable, it's complicated, that there's longstanding, challenges around health disparities, mental health. So I think for all of us, COVID, if anything, was a magnifying glass. I don't think it was overly surprising for most of us that those things were true. And I think we also know that healthcare is pretty slow to change. I think that a lot of the things that doctors and nurses and others on the frontlines know would make for better care for patients had been things that we've struggled to actually get done.
And I think what's happened during COVID is that sort of driven by necessity in many respects in my mind, healthcare has actually
changed more in the past 12 months than it has in probably any 12-month period in its modern history. And in ways for the better, right? Care, in some ways, has become more flexible, right? We're able to offer video or audio tele-visits for patients who have barriers to getting into clinic. And I think a lot of us realized that's not perfect, but that it's for some of our patients, the only way that they could get access, and so it makes sense for them.
We've invested a lot of money in electronic health records and a lot of time and frustration on the behalf of doctors, but at least in my clinic, we didn't historically use the data in the electronic health record very much. And one of the things that we did, and many clinics did, was when the vaccine came out, and we wanted to specifically target it to individuals who qualified for the vaccine, we extracted data from the electronic record, created lists of patients to call who qualified for it and call them proactively. We didn't just wait for them to show up, and then tell them about the vaccine; we started calling them.
We also started moving more care into the community. So drive-through testing. That's an idea that makes a lot of sense, right? Getting people that are sneezing and coughing and putting them in a waiting room to sneeze and cough on each other and lead to transmission doesn't make sense clinically. And so drive-throughs make sense. Partnering with churches to increase vaccinations makes sense, even canvassing door-to-door.
So I think a lot of the things that we've done driven out of necessity are things that I think, in many respects, we should have done for a long time, and I think have a lot of relevance in the post pandemic world as well.
Dr. Turck:
Now, you touched on this a bit before, but the pandemic really spurred the widespread adoption of telemedicine. Would you elaborate on some of the ways in which virtual health visits have benefited both providers and patients?
Dr. Nundy:
Yeah, absolutely. And first of all, it's certainly been no panacea. I think we've learned a lot on both sides. So I work at a safety net clinic just outside of DC, almost all uninsured, largely immigrant population. And one of the things that I've seen for years is that typically, my no-show rate in clinic is 15 to 20%. And what really astounded me as we moved care to almost 100% virtual was that no-show rate went to basically zero. And that really struck me because people's social determinants haven't changed, right? They still have jobs that aren't giving them time off, they still have challenges with transportation, arranging childcare, all these sorts of deep challenges, health belief issues, concerns about systemic racism. But just the fact that they didn't have to miss a half day at work in order to come see me meant that a lot more then were able to attend to our appointments. And I think so that was really valuable.
I also think for patients, the follow-up was way better, right? So I think a lot of care needs to be in person. And I think we saw evidence of that the benefit of, especially for diagnosis of new conditions, seeing people in person is really important. But oftentimes, what happens is when we make a new diagnosis or we start people on a new treatment, we have to wait three months to see them again. And what I started doing during the pandemic was, I'd be able to follow them three days or a week later because it was just that much easier to get them in. And with that, I oftentimes discover things, right? I discovered that the medication I prescribed was actually too expensive. And so when I called them a week later, they said, ‘Actually, I went to the pharmacy, it was too expensive.’ Normally, I'd have to wait three months to find that out. And now with the much tighter follow-up, I was able to learn about that information much sooner.
But I think it's also worth noting the bad, right? I think for a lot of patients and doctors, telemedicine didn't work. They couldn't access it because of the digital divide. Because of that, a lot of them had to do audio only which it's much harder to build a trusting relationship over audio than it is over video. There's a lot of connectivity issues. And I think in some cases, care became more transactional too, right? Where we would only address the acute issue and not actually step back and ask them about their mental health or ask them about their chronic care or their preventive care.
So it hasn't been all positive. But I think what we've learned is if you can really focus on what is the use case, What is the patient's problem you're trying to solve that you can mix both virtual and in person in a way that expands access and also can expand quality.
Dr. Turck:
Besides telemedicine, would you elaborate a little bit on some of the other benefits to healthcare technology in practice that we're seeing?
Dr. Nundy:
Yeah, absolutely. One of the accidents that happened is once I was given a clinic iPhone - so I got an iPhone from my clinic for the first time to support these virtual visits, because that's how we did it. We did it using FaceTime or Whatsapp Video. And once I started doing that and I had my own clinic phone, what was really interesting was that I found myself actually messaging with my patients, right? So I'd message them and say, ‘Oh, I'm running five minutes late, I'll get you on FaceTime audio or FaceTime video in five minutes.’ But then after the visit, they would message me as well. They'd say, ‘Oh, thanks so much for a great visit.’ And then they'd send me an emoji or something, right? Or a week later, they'd say, ‘I'm so sorry to bother you, Dr. Nundy, but I have a question about the medication,’ or sometimes I'd message them.
And I think one of the things that we realized from that is healthcare is sort of overly formal, right? We have a visit, and then we don't really talk to our patients, and then we have a visit, and then we don't really talk to our patients, and then we have a visit, and that's not how we communicate with people we care about, right? I'll see my wife and during the day, I'll be messaging with her, and I think the ability for technology to keep us connected and to what I call digitally enabled care, I think we saw a lot of benefits of that as a sort of a side effect of the fact that we were doing more virtual care. And I think that's something that we need to really think about going forward as well.
Dr. Turck:
For those just tuning in, you're listening to COVID-19: On the Frontlines on ReachMD. I'm Dr. Charles Turck, and I'm speaking with primary care physician Dr. Shantanu Nundy about his perspective on the pandemic’s impact on healthcare.
So Dr. Nundy, you’d touched on this a bit earlier, but in addition to telemedicine, drive-through testing for viral illnesses was also provided in many parts of the country, which was something most of us alive today had never seen, at least certainly not on such a mass scale. Where does this leave us for the future in terms of determining the benefits of drive-through testing or even healthcare at large?
Dr. Nundy:
Yeah, one of the things I think we realized is for decades, healthcare in this country has been synonymous with clinics and hospitals, right? Healthcare starts the moment you step foot into a clinic or step foot in a hospital. And I think one of the things that we realized during the pandemic is that makes no sense. Right?
So one of the examples for me very personally was a couple weeks ago. I have two daughters, my older one who's 7 on a Saturday night around 7 pm was having trouble breathing. And she's never had that before. And so my wife and I, we happen to both be physicians, were looking at her and we're trying to give her some cough medicine and to put her in the bathroom and sort of steam up the bathroom to help her with breathing, and we took her outside to see if that makes a difference, gave her some allergy medicines. And at some point about an hour into her sort of struggling with breathing, we started getting really scared. And that's the moment where healthcare happens. Right? That's the moment when you have parents looking at their sick child and are worried about what to do, should we stay home, should we go to clinic; that's the moment that healthcare starts.
But that's not where healthcare starts, right? Healthcare - we wait ‘til someone shows up to the ER, shows up to the clinic, or shows it to the hospital. And then we often wonder, ‘Well, why are you here? You're in clinic, you should have been in the ER,’ ‘Oh, you're in the ER, you should have been in the clinic. This is not an emergency.’ And I think this is this whole idea of what I call “distributed care,” which is that care needs to start closer to where health happens. And where does health happen? At home and in the community.
And so drive-through testing I think is just one example of the type of massive shift we need, coming out of this pandemic, to have care meet people where they are. Going back to the old school, you know, house calls, going back to the idea of being able to support people virtually from their home environments. Leveraging community organizations, whether they're churches or barbershops to get people to preventive care and vaccinations they need. Or spinning up things like drive-through testing. We need to shift the frontlines of care from healthcare facilities into the community. And I think that's one of the really exciting things that has been accelerated during the pandemic as well.
Dr. Turck:
Now in your book titled Care After COVID, you talk about transforming our healthcare system across three dimensions. Without giving too much away to our listeners who may not have read your book yet, would you give us a preview of what those dimensions are?
Dr. Nundy:
Yeah, absolutely. I think one of the things I realized as I'm sure a lot of physicians were seeing our healthcare system sort of turned on its head and seeing our country turn on its head, I really spent a lot of time thinking what is the way forward? And one of the very simple ideas I had early in the pandemic was this idea of when we were all struggling to access testing, I said, ‘Well, how do we test people at home?’ Like we could actually have people swab themselves and either mail in a test kit or have a rapid test at home.
And one of the things that came out of that was an incredible amount of pushback from various stakeholders in the health system saying, “Well, patients can’t test themselves, they'll overuse the test,” or they said, “Well, patients can't possibly test themselves because they don't know how to do that,” or, “Patients can’t interpret the test themselves. Like you need to have a doctor that's known you for 10 years help you interpret tests.” And yet here we are, through a lot of advocacy, almost a year later, you can walk into any pharmacy, and over the counter, you can get for $14 a COVID-19 test, test yourself on your kitchen table, and get a result in 15 minutes.
And I think what that did for me, the whole experience of trying to get this sort of through the FDA and through policymakers is what I realized is we lack a common vision for where healthcare needs to go. And so that's really where this framework comes in is saying healthcare needs to become distributed. Care needs to happen where health happens at home and in the community as a starting point. It needs to become digitally enabled. We need to use technology to strengthen the core relationships in healthcare that matter. And third, is we need to decentralize. We need to put way more resources in the hands of frontline health workers and patients themselves like at-home testing so that they can drive more of their care decisions. And so that's the simple framework I’ve put together and sort of why I thought it was important to do so.
Dr. Turck:
Lastly, Dr. Nundy, relative to the early days of the COVID-19 pandemic, we've come quite a long way as a nation as has much of the rest of the world. From your perspective as a healthcare provider and a business person, would you share what you think our single biggest lesson in healthcare has been?
Dr. Nundy:
Yeah, I would say the biggest lesson we've had is that equipped with the right resources, the frontlines of care can be agile and responsive. Right? I think that there's been a lot of sort of cynicism that we've created and a lot of artificial barriers to creating real change on the frontlines. I think there's this notion, including amongst doctors and nurses and certainly policymakers and other regulators that ”Well, healthcare is just complex, and healthcare can't change. And doctors and nurses don't want to change.” And I think we've thrown all of that out of the window. We talked about the heroism of the frontlines in terms of the self-sacrifice and the work. It's also been true, just the incredible amount of ingenuity as well. If you look at the move to virtual and how fast we did that. In my clinic, we did in two weeks; we went from zero to 80% virtual, spinning up the drive-through tests, responding to new protocols, responding to changes with the vaccination guidelines that happened almost weekly, I think all of us should be looking at this and saying, “Wow, like the frontlines of care,” the people we have, it's not about the people. It's really about leadership, it's really about creating the right regulatory and policy frameworks. And if we can do that, the amount that we can get done is really incredible. And I think that's really my core message as well is that this has been a once-in-a-generation pandemic. It's also a once-in-a -generation opportunity to reinvent healthcare. We're not there yet by any stretch of the imagination. But this is a catalytic moment where the whole country focused on health and healthcare where we've shown that we can actually be agile and responsive to say, ‘Well, where do we go next?’ and I think that's really the question that I'm trying to raise around the country right now.
Dr. Turck:
Well, our conversation is reminder not only that healthcare is ever evolving, but also that it's essential for us as providers to evolve along with it so that we might continuously improve the patient care experience. And I want to thank my guest, Dr. Shantanu Nundy, for joining me today. Dr. Nundy, It was great having you on the program.
Dr. Nundy:
Yeah, it was a real pleasure. Thanks so much for your time. And thanks for so much for doing this series. I think it's super valuable. So thank you.
Dr. Turck:
Absolutely. Thank you.
I'm Dr. Charles Turck to access this and other episodes in our series, visit reachmd.com/COVID-19, where you can be part of the knowledge. Thanks for listening.
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