This week’s Grand Rounds conversation — yes, conversation — looked starkly different from its predecessors: no slideshows, no medical jargon, no outpouring of research on the latest vaccine trials or antibody tests. With the backdrop of protests over police brutality and the killing of George Floyd, that would not do. Instead, Dr. Bob Wachter, chair of the Department of Medicine at UCSF, facilitated a conversation about the intersections of race, COVID-19 and the future of healthcare.
“I realized that I did not really want to talk about a narrow issue,” Wachter said. “ … Rather, I wanted to talk about the state of our healthcare system, the state of the country, the state of the world.”
Wachter’s first question for Dr. Mark Smith demonstrated just how different this conversation would be: as a black man in America, he asked, “what’s going through your mind and your heart?”
“Let’s start with the hopeful part,” said Smith, former president and CEO of the California Health Care Foundation. ” … to see how many people from all walks of life in all 50 states and actually all over the world reacted to this, gives me hope that people care.”
But Smith also said he worried for protesters amid the COVID-19 pandemic and he noted, “there’s also a little bit of ominous edge around the mood of the country now that I think we need to talk about as well.”
And they did. Uncertainty and an inkling of hope ran through the conversation as the five participants considered our country’s narrative: where are we, what led to this moment, and where are we going?
“Deadly” Inequities in Health Care
What Wachter described as a “terribly sad moment” in the wake of Floyd’s death soon opened up into a wider analysis of how his death and the disproportionate impact of COVID-19 on communities of color are part of a larger picture of racial inequity.
Dr. Abraham Verghese, senior associate chair at Stanford Medicine and the best-selling author Cutting for Stone, said this story begins in 1619, the date slave ships first arrived in the United States. “We’re all trying to weave one narrative out of this,” he said. This narrative, of course, includes the healthcare system.
Smith said knowledge of the disproportionate impact of COVID-19 on people of color has fueled anger in protesters. Using a mocking tone, he described how earlier in the pandemic the effects of systemic racism were disguised under claims that the higher rate of COVID-19 in black communities was being blamed on hypertension or diabetes.
Social determinants of health and other racial inequalities, he said were the problem. Dr. Sue Desmond-Hellmann, former CEO of the Bill and Melinda Gates Foundation, agreed.
“This pandemic shows us that the inequities we talk about in our healthcare system are not just shocking, they’re deadly.”
Teleconferencing with patients has also given doctors new insights into the lives of their patients.
“The few telemedicine visits that I’ve had a chance to sit in on have made me appreciate how much we just give lip service to things like social determinants of health,” Verghese said. When healthcare providers summon patients to clinics, they fail to see the lives of their patients.
The future of healthcare
Telemedicine also offers a less expensive way to deliver health care at a time when COVID-19 has “exposed the financial hydraulics of American healthcare,” said Dr. Ian Morrison, a self-titled “healthcare futurist” and founding partner of Strategic Health Perspectives.
“Cheaper, that’s what people want,” said Smith, spelling out the word while other attendants laughed. He noted how quickly doctors and patients realized the amount of time and money lost “moving humans rather than information” in a pre-COVID world. In a matter of weeks, healthcare providers made the transition to telehealth, which has struggled to take off for the last 20 years. He predicts that all doctors will be “hybrid” doctors four years from now.
As the conversation continued, the speakers went back and forth on whether smaller hospitals would be at more or less risk than larger systems that rely on private insurance. The fact that some hospitals lost $5 million per day in March was not lost on the speakers. This reality contrasts greatly with the “flush of cash” health insurance companies have because no one is filing claims.
Of course, the question of insurance brings up another host of problems when one considers insurance coverage through employers. “It seems like that’s a fine and dandy idea when the unemployment rate is 3.7 percent,” but less so when nearly 20 percent of Americans are unemployed, Morrison remarked. And while he’d love a single-payer system, Morrison said there just isn’t the money for it right now.
Smith, however, saw the COVID-19 pandemic as an opportunity to change the story moving forward. Speaking on the previous ‘tough luck’ attitude towards people who don’t have insurance, Smith said “I think that notion is dead.”
“Will anything fundamental change?”
Discussing the day-to-day ethical challenges that the coronavirus presents (such as who to give ventilators to, whether or not we should have a human challenge model, how quickly vaccines should be fast tracked), Verghese touched on “the biggest ethical dilemma of all”—our current two-tier society highlighted by the killing of George Floyd.
As they approached the end of their discussion, Wachter asked the big question: “Will anything fundamental change?”
Verghese remains an optimist. “I think that this is the moment and things are changing, but it’s up to us to keep that momentum going.”
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