Physician Patient

Lessons from the COVID-19 Pandemic: How will our medical care change?

Dr. Rick Morris (below) highlights (in a letter to his grandchildren. He’s “Bompa”) how medical practice is changing. Most of the changes he mentions are well underway.

The COVID-19 pandemic is forcing us to examine and face our medical and political clumsiness and limitations when dealing with a world-wide public health menace. Dealing with the morbidity and mortality of this highly communicable virus is the immediate problem, but we are also debating/wrangling political consensus on other public health “hidden enemies” such as global atmospheric pollution (CO2), shortages of fresh water, and disparities of health and mortality in the US and worldwide.

What are our models and how good are they? In medical school (1965) we were taught principles of public health (now reinforced by Drs. Deborah Birks and Anthony Fauci). Public health principles contrast with learning the craft of how to do Hippocratic best practices clinical care for patients. Minnesota’s Dr. Mike Osterholm and  academic epidemiologists have for years warned us about the population risks of vapor-borne influenza and other viruses. Do our flu vaccines reliably protect us? How can we be better prepared? We need a better plan for the future.

There is, obviously, overlap between good public health policy and quality medical care for individual patients. But the two are not equivalent, and managed population care often conflates the distinction.

In my psychiatric practice I forged and maintained professional partnerships with patients struggling with opioid and alcohol addictions who were motivated (often by family or others) to contact me to mitigate threats to health and wellness.

At MPPA we ask: Who will or should direct pay for the individual patient’s medical care? How will its price be determined? Information technology holds great promise for real marketplace transparency to consumers to address the high cost of medical care and medical care insurance in Minnesota.

I chose to learn and practice clinical psychiatry because I wanted to work directly with patients.  About the future of the specialty of clinical psychiatry raised by Dr. Morris (see Passion for Patients www.leebeecher.com), I hope there will be physicians who specialize in the care of their individual patients. All physicians espouse sound public health practices, because as physicians we can and should operate in both the worlds of public health best practices and individual patient care.

MUSING:  Crisis and opportunity (by Dr. Rick Morris below)

03-28-2020

You’ve heard me say that every challenge is an opportunity. I believe, and fear, that this viral pandemic will be the stimulus for enormous, and maybe ill-considered, changes to our everyday world. There’s an old adage, reprised by Rahm Emanuel, that “it’s a shame to waste a good crisis”. In Greek tragedy, a crisis led to catharsis, newborn hope and liberation from the dictates of the past. Change agents and entrepreneurs will deliver the catharsis in the aftermath of this global challenge.

I have a few ideas how some changes may look as a result of this viral crisis. One of the most obvious, already happening widely, is the use of virtual medical visits. “Telemedicine” was having trouble gaining traction until doctors’ offices were forced by the corona virus to close for all but critical illnesses. Traction won’t be a problem after this, with consequences that will be profound. With telemedicine the need for nurses to room patients and take vital signs will diminish, resulting in a drastic loss of job opportunities in outpatient settings, especially for those less-trained like nursing assistants and LPNs. Doctors initially will staff the telephones and video monitors, but diagnoses will be less certain, resulting in more testing and imaging to back them up, limiting the cost savings. Soon, telemedicine will be done mainly by PAs and NPs. More antibiotics will be prescribed on a “CYA” basis for colds, undoing a lot of education about over-using antibiotics and leading to more superbugs. Before long, human telemedicine providers will certainly be replaced by artificial intelligence operating on algorithms, and possibly even prescribing, which is the easier part once a diagnosis is made. Clinics are already being bought by large corporate entities, many of which are insurance companies (United Health Care, Health Partners, BlueCross, and many others) that will welcome the cost savings of virtual medical care. Doctors will be laid off and/or see their incomes drastically reduced, leading to inferior candidates for medical degrees. Maybe surgery and psychiatry will be the only areas that will need a personal M.D. and I’m not so sure about psychiatry. COVID-19 jump-started all this.

Education is another area due for radical change as a result of the virus. Students are now being taught virtually, at home. If this becomes the new normal, how many classroom teachers will be needed? If grade-level education can be done virtually, why would the country need any more than 12 teachers? If kids will be staying home for education, what will happen to the parents’ ability to work outside the home? Of course, many of their jobs will be virtual also. There might be an entrepreneurial opportunity for “day care” virtual classrooms to spring up, staffed by “monitors” rather than teachers. We know the federal Department of Education has already tried to standardize curricula and outcomes…this is their opportunity to rev up their engines of “progress”.

This period of social distancing won’t go away when the virus does. Social mores and customs will be more distant: handshaking might be obsolete; shopping will be more on line (for everything: cars are already bought this way; food; Amazon; insurance; banking; most other retailers are already past the trial stage); crowded movie theaters may be replaced by streaming new releases at home. But there will be some irreplaceable social services, like bars and barbers and nail salons and dry cleaners. I wonder about restaurants: survival of the fittest will eliminate many; drive-through fast food will expand. Will persistent social distancing reduce the market for mass transit? Will it reverse the movement to dense urban living? I would think so.

Basic medical science will be a winner. There will be more money spent on public and private research on virus behaviors, genetics, pharmacotherapeutics, vaccines.

You get the point. This global disruption won’t go away quietly; it will create new fortunes for clever entrepreneurs, and some unwelcome change for the rest of us. Change is always happening, thank goodness, but the pace of change isn’t linear. These “black swans” come along once in a great while, and clever people take advantage of them when they occur. Please offer your thoughts on other examples.

Winston Churchill said “A pessimist sees the difficulty in every opportunity, an optimist sees the opportunity in every difficulty.”

Bompa

I wrote this piece for my children and grandchildren (I’m Bompa). Regarding the medical part, do you agree? What else do you think may change as a result of the COVID-19 crisis?

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