Dr. Tishler is Senior Vice President of Medical Services for Commonwealth Care Alliance, Boston, MA. She is also Editor-in-Chief of the Journal of Clinical Outcomes Management.
Just as we were moving toward remote work in the face of COVID-19, a nonmedical colleague said to me, “I’ve never really seen a doctor in a crisis; you’re so calm.” I answered with, “Thank you. This is what our training is for.”
Let’s face it. At this point in my career, I’m not really on the front lines. I’m not running into ICU rooms, proning people with COVID-19 to stave off the need for a ventilator. I’m not holding up my iPad to enable a Zoom family conference. I’m not a caregiver in a COVID-19 isolation and recovery center for people experiencing homelessness. I’m not a member of anyone’s field team, continuing to provide home care in high-risk settings. Nope. My job now is to take care of the caregivers on the front lines who are doing all that—and the people who are supporting the caregivers doing all that. And in supporting our frontline clinicians and staff, I’m using some of the skills that I’ve gained from the relatively short time I’ve been a physician leader, but many more from the long years of being a clinician.
Late in January, I had a meeting with our chief medical officer. As our meeting was ending, I said to him, “You might think this is silly, but we need to start thinking about this new coronavirus and how it will impact our patients and our staff. I think we’ve probably got only a short time before we see a case here.” Leadership agreed, and we started our clinical Coronavirus Task Force that afternoon. Our executive leadership supported us, with consistent messaging that our organization would listen to the science and that the health of our members and employees was paramount.
Our timing and planning turned out to be correct. The first coronavirus case in Massachusetts appeared not even a week later. The infamous Biogen meeting took place late in February. By March 13, our entire workforce of more than 1000 people was at home. By March 24, we had retooled our integrated complex care organization to ensure that our most at-risk patients were still getting the home care they needed and that our staff were appropriately protected when they went into those homes. After years of debating about virtual care—telemedicine—we embraced it. As we worried deeply that our patients would be impacted by this virus in terrible ways—they are dually eligible for Medicare and Medicaid, poor, and quite sick—we discovered a level of resilience among many people that gave us great satisfaction and hope.
Over these past weeks, that Task Force has grown to become our Command Center. It’s grown from a group that was thinking about masks and hand hygiene (still important!) to a 10+ workstream, technology-enabled, working group that breaks down silos and solves problems in real time. We have made more than 1000 home visits, preserving employee health and PPE. We use dashboards to help us see trends and act appropriately. We add streams and remove them as needed. We use research (where it exists) and case studies to help inform our decisions.
When I was thinking about organizing this group and wondering how I was going to drink daily from a firehose, I heard in my head the voice of my very first resident during my internship. She said, “Present the patient by telling us the events of yesterday, followed by data—exam, vitals, and labs. Then, tell us what you need help with and your plans for tomorrow.” Suddenly, it seemed just that simple. I did know how to do this. We started what we called “rapid rounds,” and each day, each stream tells us what they’ve done, what data they have collected—that might be the number of patients seen in the field, the number of masks needed, or the number of our patients who are ill—what they need from the other members of the group, and what their plans are for tomorrow.
Working together to meet the challenges presented by the pandemic has been extraordinary. We see, every day, the power of a dedicated, diverse group of caring clinicians and nonclinicians to take a good idea and make it better. Over these past weeks, my colleagues have come up with amazing ideas that have helped us to provide excellent care for our members and for our staff. Like the best of medicine, it is science, art, and a lot of heart. New ideas abound. Many of these ideas will survive the lockdown. We have a weekly webinar to update hundreds of viewers on the ever-changing medicine and ever-changing processes related to COVID-19 as we learn more. We have developed ways to ensure people who are at the end of their lives can make appropriate choices for their goals of care. We have found ways to share, use, reuse, and decontaminate PPE. We have ensured that personal care needs for disabled members are met. We’ve informed the organization and worked closely with our Commonwealth. Along the way, we’ve become a tight team, sharing daily bright spots and some sad stories, new baby chicks and knitting projects, with pets and children making welcome cameos.
Yes, this is what we trained for. Not for a global pandemic, of course. But to be able to make sound, well-informed decisions with the best information possible, given the circumstances. Once those decisions are made, we need to share them, communicate them, and support our patients and each other. We need to acknowledge when we misstep and reorganize to be better next time. If one solution doesn’t work, we must go forward and try another. In the midst of horrible times, there is the opportunity, every day, for medicine to be at its very best.