This article is part of Fast Company‘s Lessons of COVID package, exploring some of the ways America has changed since the pandemic hit and what we have learned from it. Click here to read the entire series.
If any of us had forgotten that doctors are among our most valuable and knowledgeable resources, the pandemic arrived to remind us. But rising numbers of cases in the U.S. show that many aren’t heeding medical advice. On December 9, the U.S. surpassed 3,000 deaths from COVID-19 in a single day.
Health officials have been pleading with the public since March to wear masks, keep a 6-foot distance from others, and wash their hands as frequently as possible. Many Americans have continued to ignore these three simple directives. Even worse, some have taken to the streets to call the virus fake and the public health response a threat to their individual freedoms. Meanwhile, emergency rooms around the country are overrun with new cases, ICUs full to capacity.
Throughout the year, Dr. Megan Ranney has been working at Rhode Island Hospital’s emergency room, where she’s had a front-row seat to the repercussions of the will of the people. Ranney is also a public health researcher, an associate professor at Brown University, and director of the Brown Lifespan Center for Digital Health and has been taking notes on how health systems have changed during the pandemic and how we should be thinking about the future. The conversation has been edited for brevity and clarity.
Fast Company: Rhode Island, like many places across the country, is seeing a spike in cases right now. How is this wave different from the first big wave in April?
Megan Ranney: So, it’s really different now in a few ways. I can test anyone that I think might have COVID, whereas early on I couldn’t. I just had to guess. Unless someone was sick enough to be hospitalized, there were no tests to be had. It’s also different in that I now have a protocol for what to do with these patients. In the first week, we had no idea how to best treat it. We were just trading tips constantly on the internet, on WhatsApp, to try to figure out the best way to take care of these patients with this really brand-new conflux of symptoms. I’ll never forget, because there was this group of us that were like, “We’re all seeing blood clots in patients.” There was like this aha moment and we started saying, “Well, can we give them aspirin? Can we give them blood thinners?” So, there’s this increased clinical comfort now. And our protocols are more stable. We know how to handle them. We know how to don and doff PPE. It’s certainly overwhelming and anxiety-producing, but the actual clinical care feels much more stable and certain.
However, there are also a lot of really negative things. Back in the spring, our overall ER volume dropped to a trickle. We basically were just seeing COVID, and a little bit of our normal mental health and substance-use problems, and occasional surgical emergencies. There was very little trauma. There was very little of the normal chest pain/belly pain visits. People were staying away. Sometimes to their detriment.
People [have] put off so much care that now we’re seeing people that are truly ill from a wide variety of things that are not just COVID. So, while our COVID volume is through the roof and actually higher than it was at the height of the spring surge, we also have a tremendous volume of heart attacks, and strokes, and trauma, and overdoses, and all these other things that would be normal emergency department care. We’re normally overflowing in non-COVID times, so now we have this surge of COVID on top of our normal everyday emergencies, which is a big difference and it makes it much more difficult because we just don’t have the space or the staff.
The last thing is because community spread is so high right now, it has a much more personal impact on many of our staff. We’re having a lot more trouble having adequate nurses, and techs, and physical therapists, and pharmacists. They’re all getting ill, not necessarily because of working in a hospital, but because their families are out and about and going to work.
FC: Did you see that in North Dakota the governor was actually directing nurses to keep working if they tested positive but had no symptoms?
MR: That is ridiculous.
FC: I think that’s a really extreme example of how resources have been stretched thin. But I am curious what your experience has been like with stretched-thin resources. In what ways has your hospital had to compromise or what has that meant for you?
MR: As ER docs, we are used to making do with less. We’re used to a night where we get five shootings all at once or a bus turns over. The difference now is that it just keeps going—we’re persistently on the edge. At least at my hospital, we have not compromised our care of our patients, but we have done that at the expense of our caregivers.
When you’re wearing PPE, it’s tough to go to the restroom or to take a drink. Every time you doff your PPE, you’re potentially putting yourself at risk of exposure, so you don’t take care of your own personal needs. Also, many of us are stepping up and working extra shifts to cover either for our colleagues who are sick or to cover for those who are now opening our field hospital. I think the toll on our healthcare workers has yet to be fully felt.
FC: What has that meant for you?
MR: I am taking on more clinical responsibilities and more backup calls than I normally would, and that’s true of everyone in my group.
But just the practice of going into the ER, it’s different now. I have these sores behind my ears because I wear glasses. I wear two different masks and a face shield, and the pressure of those on my glasses has made sores behind my ears. It’s a very little thing, but the thought of putting PPE back on, sometimes you go, “Oh, I just don’t want to.” You know you’re going to do it and you’re going to be able to take care of your patients, but it has just shifted the tenor of our work.
I’ve been an ER doc for almost 20 years now, 16 years to be exact. Part of being an emergency physician is knowing that you’re going to deal with angry patients. People are going to be annoyed about the wait, or have personality disorders, or they’re going to be in pain and mean because they’re in pain. And you just kind of expect that going in. In the spring, nobody was mean. Everybody was appreciative. It was just this gorgeous thing of I could take care of people and feel like I could truly be an ally with them. They weren’t suspicious of me. They weren’t angry at me. That’s all gone now. And patients are not just frustrated by waits and by lack of treatment options, but some of them are also angry about COVID, and about the fact that they have to mask, and at the fact that their lives have changed as well as mine. So, there’s that aspect as well, which is frustrating and exhausting.
FC: I think exhaustion has been a huge theme, especially for care workers. A thing I’ve been thinking a lot about is that the healthcare system was already burdened before COVID-19. There was a shockingly high suicide rate among doctors. So, I’m curious, from your perspective, what issues have become more pressing? Or have some of the old issues become more exacerbated?
MR: COVID-19 has ripped the band-aids off of some of these preexisting issues: the fact that we have inadequate primary care, the fact that we have inadequate data infrastructures, the fact that our public health departments are persistently underfunded and understaffed, the preexisting burnout of physicians and nurses. These were all things that existed already and that many of us had been warning about and COVID has made impossible to ignore.
Structural racism, the effect of racism and economic inequality on health, another thing that was there before, but its effects have been so out in the open during COVID. But there are other things too that we still haven’t paid attention to and I think my biggest fear is that we’ll make it through this pandemic and that people will go, “Okay, we don’t have to worry about the healthcare system anymore,” and not use this as an opportunity to turn from being a reactive system, where we wait until the pandemic hits to do something, into a proactive system, where we talk about all of these things that bring people to my ER every day and try to do something about it.
An example here is substance use. Opioid overdose, and violence, and mental health are things that have been problems for a very long time in our society. Certainly among doctors and nurses, but even more so among the community. And we’re seeing increasing rates of those in the emergency department. Similarly, child abuse. The number of reports have gone down, largely because kids aren’t in school, but the number of hospitalizations for severe injuries from child abuse have gone up.
And these are things that it’s very easy for us to turn a blind eye to. It’s not dramatic the way that COVID-19 is. But they are affecting our society and our community’s health just as deeply. I don’t want us to turn a blind eye to the chronic overcrowding of our healthcare systems, the fact that our rural hospitals are underfunded, that our safety net system sucks, and that we have all of these behavioral health issues that drive the physical health issues that we’re seeing.
FC: I know that you and everyone that you’re working with is in reaction mode. At the same time, I do wonder if you are developing new ways of working that have an opportunity to be more long term. What are the potential for positive repercussions?
MR: We’ve seen so many of these things that we were told we couldn’t do that have dropped away during the pandemic. So, some examples are: We found ways to allow physicians and nurses from one state to go volunteer in another state to help out. That wasn’t something that used to be possible. Medical licenses don’t translate from state to state. But we managed to remove those barriers to helping each other during the pandemic.
Another example is around telehealth and digital health. Magically, we got rid of the requirement for the telehealth video service to be HIPAA compliant. Suddenly we’re able to FaceTime or Skype or Zoom with our patients, whatever it is that is easiest for them. And that’s just tremendous because trying to get an older adult or a minimally literate adult to download some fancy telehealth system, a brand new app, it’s just not going to happen.
I’ve seen just this dramatic rise in interest and investment and use of both telehealth and in more complex digital health interventions. There’s recognition of the value of wearables, the value of doing these remote interventions, the value of doing remote medication compliance, even things like remote palliative care consults. So, that’s really exciting, and I think it’s going to stick around.
I’m also seeing increased data sharing because of the pandemic. That is something, again, that we have been calling for for a very long time, and I think that this may be the push that finally gets us closer to interoperability and better data sharing.
The last thing that I’m seeing that I’m excited about is this dropping of classic turf wars between hospitals or between specialties. There’s a reality that we are all in this together. Hospitals recognize you can’t leave COVID patients waiting out in the waiting room where they might infect people. It’s things like many hospitals are saying, “We can’t let patients board in the ER. We’re going to figure out a way to get them upstairs no matter what.” This is something that ERs have been asking for for decades, because when you’re boarding patients in the ER, A, the boarders get worse care because the ER nurses and doctors are not in-patient nurses and doctors. And B, it means that there’s all those patients out in the waiting room when there are no beds to see them in. I hope that that’s something that will stick around.
FC: There was a lot of talk about preventative health prior to the pandemic. Do you think COVID-19 has reinforced its importance?
MR: What we’re actually seeing is rates of preventive care are dropping. We’ve seen a decrease in mammography, colonoscopy, childhood vaccines, because people are afraid to come into the doctor’s office. Dental care is woefully underutilized right now. So, I think it’s going to require some real messaging and thoughtfulness on the part of both our elected officials and our healthcare leaders. Whether we get to a better preventative healthcare system depends much more on the incoming administration and the incoming secretary of HHS.
FC: What about Medicare for All? Has the pandemic made the case for universal insurance coverage?
MR: I am not confident that this will be the driver to get to Medicare for All. There are some positives in the way that things have been funded during COVID, such as making sure that COVID tests for people with symptoms are free for all. But it has not been done with an eye toward sustainability. So, I think it really depends on whether our healthcare leaders are finally able to endorse the changes in reimbursements that Medicare for All would lead to.
I think sometimes healthcare has been its own worst enemy in the fight to get coverage for all Americans. My hope is that we have seen the harm of persistent underfunding of public health infrastructure. I’m hopeful that we will take the investments that we have made during the pandemic and sustain them so that we don’t end up in the same spot two or three or five years from now. I hope that we will take things like the data infrastructure, the vaccine distribution plans, assuming that those come to pass, the information sharing that has been set up often ad-hoc between state and county health organizations and between hospitals. I hope it will turn those into something sustainable. But a lot of that, unfortunately, depends on politics.
FC: At the beginning of the pandemic, I think a lot of workers were really galvanized to fight COVID-19, and NYU notably let its med students graduate early so they could get out there and help support existing healthcare infrastructure. I’m curious what it’s like now from a mood perspective and . . . I don’t know. I guess I’m just trying to ask you what we can do for our healthcare workers. I imagine they’re quite exhausted.
MR: I will say that across the country applications for medical school have increased this year, and applications for schools of public health have also increased. So, we’re still attracting great people into our profession.
I really think that when we get through this, we’re going to need to acknowledge the sacrifice and the loss of ordinary Americans. We’re at almost 300,000 deaths now and millions of infections. Each of those has a ripple effect, so we owe it to our country to take a moment to adequately grieve those lives that were either lost or forever changed because of COVID. We can’t just brush it under the rug. We also need to acknowledge the sacrifice of healthcare workers. And I would love nothing more than to see this lead to some sort of reform of education debt for those who stepped up.
I was in New York City during 9/11, and I think about those first responders down at Ground Zero and what they gave up and the long-term health impacts that, for some of them, their volunteerism or their paid service caused, both mental and physical. And I worry that we’re going to face the same thing among the healthcare workers who have stepped up during this pandemic.