These days, I’ve started leaving for the hospital a few minutes earlier to account for time spent at one of three checkpoints outside the building. There I’m asked about symptoms — cough? fever? — and about recent travel and sick contacts. After a quick “no” to all of the above, I’m allowed onto the wards, ready to care for patients in a time of pandemic.
In some ways, this morning screening feels moot. The number of COVID-19 infections rises more each day, community-based transmission is taking off, and it seems like infection is inevitable. Add that sense of doom to the fact that we could have done more sooner, and the sinking sense of inadequacy sets in stronger than my morning cup of coffee.
When I began medical school, I expected to be immersed in the science of illness. But in light of the present COVID-19 pandemic, I’ve realized that I’ve been immersed into the science of health systems as much as in basic and clinical science. Throughout my training, I’ve observed the shortcomings and strengths of the health care system from the perspective of the next generation of physicians. Within the last few months, these observations have been framed by the context of the wider political discussion around the necessity of health care reform.
The American approach to medicine is largely reactionary. It’s no secret that treatment for chronic diseases represents an impressive chunk of health care expenditure (3.5 trillion dollars in 2017, according to the CDC). And though the Affordable Care Act upped Medicaid reimbursement for preventative health services, many of these services focus on secondary prevention — screenings to detect the presence of disease after it’s rooted — instead of on primary prevention, which emphasizes tactics to avoid illness before it ever sets in. We’re more likely to order hemoglobin A1c tests to catch diabetes than we are to help our patients develop the dietary and exercise habits known to reduce diabetes risk in the first place.
Our response to the COVID-19 pandemic caricatures this reactionary approach to medicine. On a macro-level, we’ve seen a lack of standardized protocols to contain the pandemic, leaving hospitals and other organizations to develop their own containment policies. In many states, patients are screened for COVID-19 in tents erected outside of emergency rooms. College campuses have shuttered their doors, transitioning exclusively to online learning for anywhere from a few weeks to a whole semester.
Further, a shortage of test kits available as the virus reached our shores ensured a missed opportunity for containment; in practice, only the sickest were tested — and only after testing for other possible illnesses was negative. Overwhelmed and underfunded state health services have yielded slow turnaround times for presumptive positives, and confirmation of diagnosis by the CDC takes another few days. Our inability to screen patients as well as delays in diagnosis likely both contributed to COVID-19’s abrupt spread in the past few weeks. We talk about “flattening the curve,” but right now we’re playing a game of catch-up, for which we remain ill-equipped despite the funds made available two weeks ago with the declaration of a national emergency.
Even our medical equipment reflects our lack of foresight in addressing this outbreak. COVID-19 is a respiratory illness that attacks a specific brand of pneumocyte. In the most severe cases, patients end up on ventilators. A 2010 study in Disaster Medicine and Health Preparedness surveyed the quantity and quality of ventilators in the U.S., concluding that “[t]he number of mechanical ventilators per U.S. population exceeds those reported by other developed countries, but there is wide variation across states in the population-adjusted supply.”
This means that access to an essential critical care device depends not only on how many people get sick, but also on where you live. More than simply needing more ventilators, the fact remains that we don’t have the numbers of ICU beds or trained personnel available to thwart a major catastrophe. According to a 2017 American Hospital Association survey, there are around 94,000 ICU beds in the United States — a large enough number until you consider the potential magnitude of the outbreak and the number of people needing intensive care.
A few weeks ago, President Trump asserted that we were “very, very ready” for a massive COVID-19 outbreak. But like many other areas of medicine, it’s become clear that our anticipatory measures are falling woefully short of our needs. Nearly half of Americans have a chronic disease, putting them at increased risk of COVID-19-associated morbidity and mortality. Not only have we done a poor job at instituting measures to prevent COVID-19 infection, we have also failed at mitigating underlying risk factors linked to worse outcomes.
I am currently rotating on the internal medicine service of a small Veterans’ Affairs hospital. In the past two weeks, I’ve watched medical staff work tirelessly to protect uninfected patients while delivering the best care possible to the infected. There have been discussions about how best to transport infected patients to their rooms, avoiding busy hallways in a building that never anticipated the degree of patient isolation required in a pandemic. I’ve watched residents learn to don and doff protective gear safely. I’ve watched regulations shift, been a part of morning screenings, felt the impact of short staffing as those exposed in the line of duty are quarantined.
I am impressed by the dedication of my attending physicians and residents. Many are coming in early; more are leaving late. Residents who were supposed to have time off have stepped in for their quarantined colleagues. Overall, I am proud to be joining this guild.
But I am also coming of age in medicine at a time when it has become obvious that heroic health care workers and our reactionary methods are no longer sustainable. Our lack of preparedness and de-emphasis on chronic disease prevention likely portends worse health outcomes for many COVID-19 patients. I think about my sister, who has an autoimmune disease, and my grandfather with cardiovascular disease, and I’m frustrated with a system ill-prepared to support them in a time of crisis.
At a time when health care reform is in the spotlight, I see a cohort of new physicians acutely aware of the consequences of maintaining the status quo. We’re ready for change. Are you?