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The rapid evolution of our understanding of the coronavirus disease 2019 (COVID-19) pandemic and the international response has demonstrated sophistication far beyond the reaction to severe acute respiratory syndrome (SARS) in the early 2000s. The volume of information about the epidemiology, clinical course, and biology of the SARS coronavirus 2 (SARS-COV-2) virus has been at once breathtaking and overwhelming. The daily adjustments to labile governmental recommendations and policy have been unsettling, confusing, and occasionally unnerving. It seems that the world around us has become newly strange and, at times, unrecognizable.
Nowhere has this daily upheaval been more palpable than in our health care delivery systems. Whole hospitals have been completely redesigned and rearranged in days and new ones have been constructed and dismantled almost overnight. With what seems to have been a flip of a switch, clinics have gone virtual. Health systems in some areas, such as New York City, are overwhelmed and desperate. Yet, while coping with these wrenching changes, some aspects of this calamity have provided a certain comforting familiarity to general clinicians who have been practicing medicine for several decades.
The urgency of this crisis has forced our health care delivery systems to fall back on strengths and strategies that had eroded over the past several decades as these systems have become increasingly corporatized. Before large hospitals evolved into the specialty-focused behemoths of today, their primary mission was caring for a wide range of acute illnesses. Because of advances in medicine and the perversity of payment systems, the resources devoted to treating these bread-and-butter problems has gradually been supplanted to create more capacity for highly specialized care. In responding to COVID-19, much of the space, staff, and equipment allocated to the elective and semi-elective procedures that are largely performed by specialists have been repurposed to provide acute and intensive care for the patients who are severely affected. Although these urgent changes have been essential, it is not clear how hospitals will recover financially from the losses incurred. Moreover, the lack of proven treatments and established protocols for COVID-19 has meant relying on old-fashioned, careful medical treatment to support patients until they recover. Clinicians are discovering and addressing clinical manifestations and complications, which affect not only the lungs but also the heart, kidneys, liver, muscle tissue, and clotting system, as they arise and adjusting treatment protocols accordingly.
The most essential clinicians have included intensive care clinicians, hospitalists, infectious disease specialists, and emergency physicians as well as the nurses, respiratory therapists, pharmacists, and other professionals with whom they work. These physicians have been backed up by primary care physicians to triage patients and provide additional coverage when needed. All have stepped forward with incredible commitment and bravery without hesitation. These are not the professionals who command the highest salaries or, in ordinary times, necessarily receive much recognition. As head of a division of general internal medicine with approximately 360 faculty members, I have been repeatedly inspired by the countless ways my colleagues have dedicated themselves in recent weeks. From providing care to seriously ill patients in the hospital to screening and evaluating patients in a wide array of settings to ensuring that chronically ill patients at home receive the care they need to keep them out of the hospital, their efforts have been nothing short of phenomenal.
Equally important have been other employees who work in the background, such as housekeepers, engineers, and food workers. This crisis has starkly revealed the critical backbone of our health systems and highlighted the need to recognize and reinforce it when this crisis passes. Health care workers are not readily interchangeable, and highly specialized physicians cannot easily step into different roles. As is also the case with society at large, we have learned that we all too often take for granted our first responders, food services workers, delivery drivers, and others in the community.
Another prominent feature of the response has been the reemergence of front-line physician leaders. A few decades ago, prominent physicians who were recognized for their knowledge and clinical acumen typically led hospital systems. These attributes, however, did not always translate into the administrative expertise necessary to maximize revenue. Gradually, full-time administrators trained in health care management assumed these leadership roles. At present, clinical leaders in infectious disease, critical care, emergency medicine, and hospital medicine are returning to the fore. Patients and other health care workers are turning to them for guidance, information, and inspiration. In the health care system in which I work, as well as in many others around the country and the world, there has been well-informed, thoughtful, creative, and inspiring leadership. To use the battlefield metaphor, these physicians (along with many of our local governmental and public health officials) have been leading the charge to both meet the clinical challenges and to prepare for contingencies. The troops have responded enthusiastically.
There is also renewed public respect for scientists and academicians. National heroes and authorities of my generation have gradually been unseated in the public consciousness. The notable examples include Jonas Salk (developer of the first widely administered polio vaccine), Paul Beeson (considered by many to have been the prototypical academic internist of the 20th century through his work at such institutions as Emory, Yale, Oxford, and the University of Washington), and Helen Taussig (founder of pediatric cardiology). It is reassuring to see medical professionals and the public again looking to the most respected virologists, epidemiologists, and other scientists to decipher what is happening and to recommend solutions. In some instances, the leaders of health care systems have been surprised to learn the depth of scientific expertise in their own organizations. In my institution, for example, investigators who had been working in relative obscurity were suddenly besieged with requests to develop and implement new tests for COVID-19, design sophisticated models to forecast the number of infections and predict the demand for health services, and to recommend therapeutic approaches. At the same time, physicians in other fields, whose research has temporarily been put on hold, have selflessly come forward to work as clinicians, both in the hospitals and through telemedicine.
During ordinary times, physicians in diverse specialties routinely provide important and superb care. During the COVID-19 crisis, many have set their usual activities aside to protect patients, provide space, and conserve personal protective equipment. The pandemic continues to inflict pain and suffering, and it remains unclear when our lives will regain some semblance of normality. Although some of the societal adjustments to the crisis may remain, I worry that we will simply lapse back into many of our former patterns. Nonetheless, I hope that some of the new adaptations in our health care systems will persist, and that the respect for those who rose and sacrificed to meet the challenges will not rapidly fade. When the time comes to reassemble our health systems, hospitals, and clinics, we should keep in mind the lessons we have all learned in recent weeks.
Corresponding Author: Stephan D. Fihn MD MPH, University of Washington, Harborview Medical Center, Box 359780 325 Ninth Ave. Seattle, WA 98104-2499 (firstname.lastname@example.org).
Published Online: July 13, 2020. doi:10.1001/jamainternmed.2020.2498
Conflict of Interest Disclosures: None reported.
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Fihn SD. COVID-19—Back to the Future. JAMA Intern Med. Published online July 13, 2020. doi:10.1001/jamainternmed.2020.2498
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