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Physician Work Environment and Well-Being
July 13, 2020

COVID-19—Back to the Future

Author Affiliations
  • 1Harborview Medical Center, University of Washington, Seattle
JAMA Intern Med. 2020;180(9):1149-1150. doi:10.1001/jamainternmed.2020.2498

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.

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Article Information

Corresponding Author: Stephan D. Fihn MD MPH, University of Washington, Harborview Medical Center, Box 359780 325 Ninth Ave. Seattle, WA 98104-2499 (sfihn@uw.edu).

Published Online: July 13, 2020. doi:10.1001/jamainternmed.2020.2498

Conflict of Interest Disclosures: None reported.

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    3 Comments for this article
    Past, Present and Future Healthcare in a COVID-19 World
    Michael McAleer, PhD(Econometrics),Queen's | Asia University, Taiwan
    In the illuminating presentation, a medical expert evaluates COVID-19 from a "back to the future" perspective.

    The volume of informed, uninformed, and ill-informed discussions, especially in politics and social media, as well as high quality academic research publications in leading journals and across a wide range of disciplines, especially in medical and biomedical research, has been truly staggering.

    Health care systems, first responders, and health care providers at all levels have shown just how brave and effectively they can function and how hard they work, frequently in situations and in conditions which present life-threatening danger to those whom
    we need the most.

    The "comforting familiarity" expressed in the Perspective parallels the popular science fiction time travelling trilogy, "Back to the Future", where a teenager is propelled from 1985 to 1955 in a DeLorean time machine.

    The modern medical time traveller takes us on a health care journey that highlights the strengths and strategies associated with general medical care for a wide range of illnesses, as well as emphasizing medical disciplines and subdisciplines associated with complicated technical and costly specializations.

    These issues are highlighted in a COVID-19 world in terms of changing hospital wards, accessing PPEs, conducting intensive medical research to develop safe, efficient and affordable treatments and vaccines to tackle the SARS-CoV-2 virus, and providing health care facilities to enable frontline medical and health workers to support patients infected with a deadly virus and disease that can lead to multiple organ failure and death.

    In the "Back to the Future" trilogy's first outing, the teenager who time travelled to 1955 was able to befriend his future father and mother, albeit not under life threatening circumstances.  

    It has been said that when the going gets tough, the tough get going, which holds especially true in a world that COVID-19 has thrust upon us all.

    Such heroic behaviour is heartening to everyone who relies heavily on the many dedicated, talented, inspirational, and courageous healthcare providers in times of great need.
    Laboratory medicine
    Mark Wickham, MBChB | Pathologist New Zealand
    The article overlooks significant contribution of laboratory medicine in terms of massive increase of workload and staffing capacity required to deal with universal testing demands.
    COVID 19: a reaffirmation of the traditional humanistic values in medicine
    Jonathan Mcfarland, BA ( Hons) in Humanities | Head of Academic Writing Office, Sechenov University, Moscow, Russia + Lead for The Doctor as a Humanist
    The COVID 19 pandemic has undoubtedly changed the game plan, and we now talk about pre-COVID and post-COVID in a similar fashion to pre-AIDS and post-AIDS. The entire world has been affected to greater or lesser degrees, and the main question is what will happen after, or to put it another way, what will we learn and will we implement the positive things learnt into the new scheme of things, in all aspects of society but importantly in healthcare and medicine.
    This succinctly and elegantly entitled article addresses the important topic of how the clinicians, health care workers, indeed
    all those involved in looking after those afflicted by this terrible disease, have responded with great bravery and resilience. The order has been to some extent reestablished with those treating patients taking the lead, as well as those working behind the scenes, for instance laboratory doctors and technicians.
    What I wish to stress is how medicine seems to have returned to the core essence of treating and caring for the patient. The pandemic has highlighted that the humanistic side of medicine should most definitely be strengthened and set at the centre of healthcare, for in essence medicine is only ever about the relationship between carer ( physician, nurse etc) and patient.
    Just over one hundred years ago, Sir William Osler addressing students at Oxford university called for a union between the old humanities and the new science, stating, " Twin berries on one stem, grievous damage has been done to both in regarding the Humanities and Science in any other light than complementary". Let us move forwards after this pandemic by looking back and learning from the past, and re-establishing the correct balanced relationship and order between the humanities and the sciences for one without the other has no meaning and no sense, and especially now.