Over the past few months, COVID-19 has impacted almost every part of the healthcare system. Now that we are deep into conversations about “re-opening” both broader society and healthcare, I regularly hear from patients, colleagues and others that we need to “get back to normal.”
Unfortunately, the growing reality is that we can’t just “go back.” Instead, we are entering a “new normal” and should work hard to sustain the several positive changes that have occurred. These are eight shifts in healthcare that we must carry forward:
1- Virtual Care
After years of painfully slow incremental changes in adopting virtual care, there are now thousands of these visits occurring every week. However, it is also clear that improvements such as compensation and the security of the platforms we use are needed. (Perhaps we might also consider getting rid of faxes in healthcare – something even a pandemic has been unable to do.)
2- Long-Term Care (LTC)
The fragility and under-resourcing of LTC has been known for years and documented in numerous cases and reports. A tragic legacy of this pandemic will be the high number of deaths in our LTC homes. It is as devastating as it was predictable. Urgent funding and structural changes have started to set a new course. We must continue to make meaningful and multi-pronged investments in LTC, a part of the healthcare system that cares for thousands of our most medically vulnerable citizens.
3- Integrated Care
Canada, like other countries, has been trying to integrate care for more than a decade. In a matter of weeks, we have seen primary care, home care, hospitals and LTC working together in unprecedented ways. It has taken a pandemic to break down long-established silos and we should not allow them to be rebuilt. We should study how new partnerships have evolved and what is working well with a view to replicating it.
4-Public Health
Public health usually operates in the shadow of the rest of our healthcare system, periodically inserting itself into our consciousness during outbreaks such as SARS, H1N1 and now COVID-19. I am not advocating that our public health leaders need to remain a fixture of our daily news cycles (although a good argument could be made for that). But we do need to better fund public health infrastructure. We also need to incorporate the unique knowledge, skills, and infrastructure of public health into the regular working of our healthcare system.
5-Inequity
This pandemic has brought inequity in healthcare into stark relief. From gaps in data collection to food insecurity and death rates, the impact of COVID-19 on certain groups clearly has been more pronounced. Significant, if belated, efforts are being made to address the needs of marginalized and at-risk members of our society. We can’t let our focus on these groups slip as we return to normal. We can’t return to a health system in which we focus most on those for whom care is easiest to provide or ignore the impact of social determinants on health.
6- The power of data and science
Many of us had not thought about exponential curves and antibodies since high school math and science classes. Even fewer of us have thought about predictive modelling or the vaccine-creation process. In recent years, there has been well-documented erosion in science-based discourse. The pandemic has seen science return to the forefront. As one COVID-19 inspired YouTube song by Jon Lajoie put it, “Thank God for nerds right now” (warning – explicit lyrics). We need to continue to see the entrenchment of good science in policy-making, health-system design and media.
7- Caring for our frontline heroes
Frankly, I think those on the front lines have always been heroes for our health system and in society. We were aware before the pandemic began about the significant wellness challenges facing frontline healthcare workers. Issues around safety, burnout and poor mental health were increasingly discussed. The pandemic has forced an acceleration in the investment of resources and creation of programs to help address the wellness and mental health of frontline caregivers. This must continue.
I would also note that there has been more open discussion of mental health in general and many programs have been launched to help meet mental health needs.
8- #InThisTogether
Healthcare can be a fractured and fractious community. Turf wars, hierarchies, politics and power imbalances can divide the system and pull us away from the shared goal of better care. From senior leadership tables to the frontlines, new collaborations and partnership structures have emerged over the past few weeks. This has included different levels of government, varied parts of the healthcare system, private and public partnerships and others. We need to maintain these relationships and partnership structures to continue addressing the pandemic and help solve other healthcare challenges.
There are also two other items that we cannot go back on that I wish we could:
The first is that for some time, we are unlikely to go back to a healthcare system that does not include patients with COVID-19. This is important as we already had a healthcare system that was stretched beyond capacity. The challenges of operating a healthcare system with a steady (or waxing/waning) presence of COVID-19 will present a host of problems we are only beginning to think through. While maintaining some of the positive changes listed above will help, many more innovations and changes will be needed.
The second is the loss of thousands of lives. The daily bar charts and TV ticker-tape reporting of deaths can become numbing and abstract. There is a natural desire to rush forward and put the past few months behind us. But we should remember to grieve those who have died and those who will die. We need to extend comfort and support to those directly and indirectly affected by these deaths.
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thank you for this thoughtful summary Josh. I wholeheartedly agree.
_ Health insurance tied to employment.
_ Availability tied to profit. (See, e.g., the closure of rural facilities.)
_ Private equity firms and investors making decisions about medicine.
_ Ranking who “deserves” treatment. (Poverty as a character flaw; a person with disability has a less meaningful or successful or productive life; all the -isms and -phobias racism abilism classism sexism xenophobia homophobia transphobia etc.; pre-existing conditions and lifestyle choices are the reason for all sickness; undocumented immigrants cheat the system; the elderly have already had a full life; etc.)
_ Violence perpetrated against medical personnel.
_ Indifference to prisoners’ health.
_ Surprise! Unexpected or out-of-network billing.
_ Medical school = massive debt.
_ Health aides making minimum wage.
_ Pricing: opaque maze of individual rate vs. adjusted vs. write-offs, deductibles, OOP maximums, uncovered prescriptions or procedures, co-pays, preferred providers.
_ Unaffordable prescription medication.
_ Lack of school nurses and counselors.
_ No cohesive medical records system across geographic, insurance, and provider lines.
…we could do this all day
One good thing this pause taught us is to rely on self and family. The test of mental health is to be able to able to live with ones self in peace. I believe that was a theory of the philosopher Pascal. It is very strange that many people expect the government to do so many things that our immediate ancestors could do for ourselves. We seem to be devolving instead of evolving.
Well said Joshua. Regarding virtual care, I assume research is underway to evaluate the impact of this shift. The majority of the shift is absolutely right and long overdue. However there are likely situations arising in which the virtue approach is not appropriate or results in delay of the appropriate treatment which a face-to-face assessment would have enabled. Sound evidence-based guidelines regarding virtual care are fundamental and I expect we’ll see these evolve.
Thank you for highlighting that all of us have/will have our emotional, mental, physical, psycho-social and spiritual make-up affected by Covid-19. Our lives have been turned upside down, inside out and we will/can “never” be the same normal. Importantly, we will experience & find ways to address our unique way of grieving for our losses – be it loved ones, friends, jobs, etc. i.e. “what used to be”. Whether we currently acknowledge or, are consciously aware, these abrupt upheavals will profoundly impact us all. Though I have not lost a job, have a home, am healthy, I have lost dear loved ones and friends. I was unable to say goodbye. It hurts deeply knowing they died alone. Every day I awake and repeatedly realize “oh, yes, we are still in the midst of this storm, unable to see the horizon or, land ahead.” It is disorienting, unbalancing to say the least.
In the midst of it all we must support, treat ourselves and others kindly, with compassion. We have not been to this strange land before. I believe we will move through this time and eventually be better for it, as it will reveal what is really most important for us and our society.
Very interesting
I think when we say “back to normal” that what we mean, is back to some semblance of a normal rhythm of life. As in people get up, showered, dressed, go to work, have 3 meals (not all homemade and not composed of half a jar of nutella)
A normal where we go to ERs and get help on time. A normal where we get cancer diagnosed and treated on time. A normal where family MDs are all open and renewing messages. Many just completely closed, and won’t even renew psych meds online, won’t monitor or change dosages for people who need changes.
This is especially important for kids who need a sense of routine.
E.g. after the earthquake in Haiti, the first thing aid groups did was set up schools again, even if they were outdoor schools sitting on the grass. They could also feed kids, keep watch while parents rebuilt homes, get vaccinations done. It was critical for children’s health and sense of well being to do that.
Here, before covid19, we recognized that home was not always a safe place, with parents who could afford to provide 3 meals a day and space and a “stay at home mom” and devices for each kid with high speed internet and we had Schools and community services set up to help for that reason.
Now? We’ve entered some bizarre backwards world that thinks all homes are safe for all kids. A world that thinks an army of June Cleavers have suddenly shown up, who can cook, clean, homeschool the kids, pay for endless internet, do speech therapy and ABA therapy all on our own, all while holding down full time jobs, either out of the house, or working from home.
We also have an army of scientists advocating keeping schools and daycares and camps closed—even though we have solid evidence from the genetic progression of the disease that for once, children are not getting extremely ill, and children are not spreading to adults. Adults are giving it to kids! CDC announced that Covid doesn’t spread on surfaces, and that it’s almost impossible to spread outdoors, certainly not in chlorine filled pools. Instead of celebrating all that news, we’re denying the evidence completely, and keeping kids locked in homes, playgrounds closed, schools closed, daycares closed, and annoyingly camps closed even though Camp counselors are teenagers or 18-24 and no risk at all.
Correction: we aren’t even gathering evidence on kids in Canada, we are denying the evidence from every other country.
However, we are still keeping the long term care homes open and admitting new patients, all the time, even though we also have proof that’s a death sentence.
So yes, Josh, I would like to go back to normal, a normal where science matters, and risk is realistically calculated.