COMMENTARY

Will the Coronavirus Pandemic Trim the Nonsense in U.S. Healthcare?

John Mandrola, MD

Disclosures

March 12, 2020

The news from China, Iran, Italy, and other areas hard hit by Coronavirus is chilling.

In Italy, previously "normal" hospitals have been transformed into giant intensive care units. There are no more specialists; everyone is just a doctor caring for the sick. In China, new hospitals were built in days to deal with the emergency.

A word that describes these actions: nimble.

A word that could never be applied to the U.S. healthcare system.

Our system places inane coding rules over humanity; it allows insurance regulators to adjudicate medical decisions; it rewards productivity, however ineffectual; and it gives nonclinical administrators power over bedside caregivers.

This metastasis of nonsense occurred slowly enough that it became accepted as normal.

Coronavirus upends the routine; it exposes the farce of administrative bloat.

Can you imagine doctors in Northern Italy fussing about the number of components of their review of systems? Do you think administrators roam the halls of Lombardy hospitals making sure everyone has completed their corporate modules? In emergencies, there is no time for nonsense.

As I write these words, many U.S. cities have yet to feel the onslaught of coronavirus.

Despite the fact that some of the biggest medical organizations have cancelled their annual meetings, and major American universities have told students to stay home  after Spring Break, and Google has asked thousands of its employees to work at home, elective procedures, stress tests, and the yearly check-ups continue. Last month, this was normal. Today, it is ignorance.

Coronavirus forces a change in norms. Sending an elderly patient into a hospital for urgent evaluation of a benign arrhythmias was okay; now it is not.  In-clinic checks of patients with cardiac devices should now be done remotely whenever possible.  And why wouldn't we postpone elective things, such as yearly history and physicals and joint replacements?

It's as if everyone forgot their math classes on exponential growth.

Here are some of the direct changes I hope coronavirus brings:

Hospital employers should permanently jettison any policy that financially penalizes clinicians from staying home when sick. A policy that has a healthcare worker use vacation time when ill, or garner “penalty points” against their record is counter to patient safety. Coronavirus will show the difference between the façade of patient safety and real patient safety.

I hope coronavirus teaches all of us the correct ways to use personal protective gear. I wonder how many of you know the correct way to put on and take off protective equipment? I surely did not.

Centers for Medicare and Medicaid Services director Seema Verma’s ideas on simplifying medical coding should be widely embraced. The medical note must stop being an impediment to true care. Notes that work in emergencies ought to suffice in normal times.

From the beginning of this pandemic, I have felt a smallness to much of what I do in electrophysiology. Colleagues in China and Italy have converted their hospitals into ICUs to treat the dying, and I am ablating a premature beat. This humbling is good—especially for us specialists.

Then there is the power of science. In a JAMA podcast, Anthony Fauci, MD  discussed the desire to treat critically ill patients with unproven medicines. He paused and said that if we did that, we would lose the opportunity to know what works.

The only way to know what works, Fauci emphasized, is to do randomized trials of different agents. In a disease with spontaneous remission, such as COVID19, it is essential to have a control group. Coronavirus offers us another chance to demonstrate the awesome power of proper randomization.

Finally, I hope coronavirus emphasizes what medicine is for—namely, treating the ill, not the well. Medicine is most pure, beautiful even, when we are helping people who are asking for our help.

John Mandrola practices cardiac electrophysiology in Louisville Kentucky and is a writer and podcaster for Medscape. He espouses a conservative approach to medical practice. He participates in clinical research and writes often about the state of medical evidence. 

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