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Abraham Verghese, MD: Thank you so much for being with us, Lloyd. I'm truly grateful.
Lloyd B. Minor, MD: Thank you for inviting me to join you, Abraham. It's always a pleasure interacting with you. I'm sorry that the circumstances are so difficult at this time.
Verghese: That is exactly what I would love to talk about. We find ourselves in such a unique position in time. As I speak this morning [March 27], we have about half a million cases in the world, with 25,000 deaths. There are 86,000 cases in the United States and the hot spots in America are New York, New Jersey, California, and Washington. It's been so very dynamic. As the head of Stanford Medicine, this massive enterprise to which I also belong, how have you been holding up with the stress?
Minor: I'm holding up well because I have the privilege of working with amazing colleagues. We have an outstanding group of clinical department chairs and other leaders within Stanford Medicine and the university, and also outstanding leaders of our two hospitals. We're working together very well. I feel very honored to be able to work with such incredibly dedicated colleagues, and that provides me with energy, resilience, and sustenance. We all very much believe in our mission, which is to deliver outstanding patient care and to leverage the enormous intellectual and technological resources of this great university and to bring them to bear on this virus that we have so little understanding of. We have already done a number of exciting things in the research arena and there is a lot more to come.
I'm an avid reader, and I'm still trying to keep up with reading. There is no dearth of things to read associated with the virus, but I have begun to think about the implications for the human experience coming out of this pandemic. The implications are going to be significant and long-lasting. I have begun to read about previous pandemics and those effects on societies. How we come out of the current situation and how we reaffirm our values will tell a lot about how we move forward as a society—first in America and then the world more broadly. I'm not going to the gym now because the gyms are closed, but I'm still trying to get exercise every day, and that helps a lot as well.
Momentary Milestones
Verghese: Wonderful. Thank you, Lloyd. I'm sure that one day we'll look back and catalog the history of what we did with this virus—individually, as institutions, and as a nation. The past 6 weeks or so have been a succession of movements. What are the big milestones in your mind in terms of the evolving story at a major medical academic complex like ours?
Minor: One milestone was the realization when [the pandemic started in our area]. The Bay Area had one of the first clusters of cases in in the United States. We have not grown as rapidly as New York, for example, and that has enabled us to scale up our delivery system. It's been a much greater challenge for our colleagues in New York to do. We were one of the first to have a Food and Drug Administration–approved diagnostic to use in our delivery system, which was approved in early March when our surrounding delivery systems were still having to depend upon local and regional public health departments. Those public health departments rapidly became overwhelmed. Therefore, because we were able to bring our real-time PCR online and use it in clinical testing early, we started to identify cases. We saw that this was not just an isolated one, two, or three people, where all the contact tracing could be done and all the appropriate isolation and separation for the work environment could be done. We saw firsthand that this was growing very rapidly, and that enabled us to get a start on the planning.
We stopped doing elective cases. We opened our new hospital in November, but fortunately we did not tear down our original hospital. Therefore, we started thinking about how to bring beds back online and making staffing plans for that. We started making sure we had adequate supplies of personal protective equipment (PPE). We were able to begin this planning several weeks ago now. That has been a big help for us in responding. We have not seen yet the surge in cases that has been seen in New York and was seen earlier than that in Seattle. We're prepared for it and we still think there is a high likelihood that we will see a surge. It could be that the shelter-in-place recommendations in the Bay Area almost 2 weeks ago, and the fact that many of the tech firms told their employees to work from home (even prior to shelter-in-place), are helping us achieve a blunting or slowing of the growth curve in the number of infections in ways that have been a challenge to obtain in different parts of the country.
Lessons and Challenges
Verghese: It's unfortunate that even though we're very much a data-driven medical enterprise and a data-driven society, we have all been so hampered by the lack of data on the virus. We have been unable to do any sort of projections. We have not been able to test people who are symptomatic or know who was asymptomatic and got infected. That has been one of the most amazing things about this whole story—because we had the technology to get the data, but somehow as a nation, as a world, I don't think we were prepared. We had some warning, but even so, it's amazing how testing became such a bottleneck.
Minor: I agree with you. There are a lot of lessons to be learned and there will be a lot of analysis done and writings made about the opportunities which were perhaps missed early on in terms of how we were prepared in the United States. But right now we have to focus on what we're dealing with in real time today and the future, and make sure that we're as well prepared as we can be and that we're delivering outstanding healthcare to the people in our region and in the world.
Three Principles for Addressing a Crisis
Verghese: You run a huge enterprise with many, many people, and people are subject to fears and emotions. The downside to the digital age, I suppose, is that they also have access to all kinds of information coming from elsewhere. You have had to deal with palpable fear and match that with what is reasonable in terms of resources when it comes to PPE and so on. Can you talk about how the whole scenario has evolved here at our institution and maybe speak more generally about the issue of personal protection?
Minor: I think there are three principles in addressing a crisis such as the one we're in today, namely the crisis of the COVID-19 pandemic and the implications of that crisis. One of the most prominent implications is that we have not had the supply of PPE around the country to rapidly scale up to provide the protection we want to provide. That is improving, but certainly it's hit us much harder than we were initially prepared to deal with. The first principle is communication. Communication is absolutely critical in a crisis. Second is making sure that there is an understanding of roles and responsibilities. You want to have organizations, particularly in academia, that are very horizontal, and that character needs to be preserved in a crisis. But there is also a need to more succinctly define roles and responsibilities, because the third principle is execution. In the end, successfully managing through and being able to meet the demands imposed by crisis is dependent upon execution. It all feeds back to communication—communication, roles and responsibilities, and execution.
With those three principles, how have we approached PPE? Communication is absolutely essential. We began weekly virtual town halls. It is somewhat unusual to speak to 7000 people when there are only three or four people in the room, namely the people making the presentations, but we're learning how to do it.
Yesterday's town hall was devoted entirely to PPE. The Stanford Health Care vice president of supply chain, Amanda Chawla, talked about our supplies of PPE. She showed a graph of our utilization rate and shared information about what we have received and what we expect we will be receiving. For roles and responsibilities, we have a clinical operations resource team that meets every day, 7 days a week. We have added department chairs to the team because clinical department chairs need to be able to relay back to their departments what types of decisions are being made and also bring input from those departments to the decision-making body. Also, every single morning, we have a Zoom call with all the clinical department chairs, hospital leadership, and other key leaders within Stanford Medicine, in which we give an update on everything that is going on. People have a chance to express their concerns and give us feedback. That communication is really important.
The finally part is execution. Hundreds of people have reached out wanting to donate PPE. We've tried to make sure that we respond to every single one. Being able to look at and find new sources of PPE as we've done, to open new supply chains, to interact with state and local officials who have control over sources of PPE, is all a part of execution. We're in much better shape than we were even a week ago in terms of our supplies of PPE. What is sobering about all of this is that none of us knows exactly when the surge is going to be in our region. We know that shelter-in-place is absolutely the best way to bend the curve on the exponential growth of infections with the virus, but how quickly will we be able to bend that curve, and will we be able to sustain it over time? All this plays into determining how much PPE we'll need in the near term and in the longer term.
Leading a Charge
Verghese: That leads me to talking about what we do best at Stanford—cutting-edge science. What has this meant to the scientific enterprise both in terms of impairing some of its ability to work, but also in terms of opportunities to do something about this? You have championed something that we're proud of at Stanford, which is Precision Health, the idea that we need to bring our great science to bear during times of health in order to prevent the sorts of diseases that we have now.
Minor: Engineers have really exemplified the Stanford ethos of thinking outside the box when it comes to the pandemic and the crisis at hand. We've received dozens of proposals from our faculty with novel ideas about how to do everything from 3D printing of devices and technologies that will be beneficial in treating patients with the infection, to novel studies of the structure of the virus, to developing new therapeutics.
We're in a fortunate place—if you can use the word "fortunate"—in the sense that we, early on, had an FDA-approved diagnostic. At last count, we've tested over 6000 people for the virus using nasal pharyngeal swab screening. We've identified the virus in a large number of people, and that bio-repository now can be used to help us understand the virus much better than we have in the past. A lot of faculty are interested in doing that as well as in making Stanford a focal point for coordinating scientific studies related to the virus (eg, its biology, its control, and its treatment) and an epicenter for those activities. We will see a lot more in the days and weeks ahead. The Stanford faculty are amazing. Our faculty are not attracted necessarily to incremental problems. If there ever was a problem that was front-and-center and required really innovative thought and approaches, it is this crisis that we're in today.
Advice for Underresourced Settings
Verghese: You have practiced in many different settings, from inner-city Baltimore where you were chair of otolaryngology–head and neck surgery, and you were provost of Hopkins before coming here to Stanford to be dean. What would be your advice for a hospital without our kinds of resources? Perhaps a hospital like Elmhurst Hospital in New York, which is about to see a surge. What might you advise their CEO? You and our hospital CEO have such a wonderful relationship, which is something I've not really seen elsewhere work as well. I think of you in the same frame as I think of our David Entwistle in the hospital administration. What would be your advice to a center without our kinds of resources looking at this oncoming threat?
Minor: First, I think it comes back to the three principles: communication, roles and responsibilities, and execution. The first, communication, is particularly important when you're in the early stages of addressing a crisis and you don't have a game plan. You have a rough game plan, but it's not like you can lay out with a lot of evidence the things you need to do and say, "If we do them and do them well, then it's all going to be okay." With this crisis, we're oftentimes still struggling with defining what we should be doing and also achieving with any degree of certainty that if we do it, things are going to be okay.
The most critically important resource for any healthcare system, whether it be an academic medical center, community hospital, or large private system, is our people. People want to understand and they want information. Information also helps to address anxiety. There is a lot of anxiety and concern among the healthcare workforce in the United States today. We know the virus is principally transmitted through droplet spread, but how long does it stay viable on surfaces? When do people need to wear N95 masks? We have some guidelines from the Centers for Disease Control and Prevention, but those guidelines can be interpreted differently. For systems that are, relatively speaking, underresourced, the most valuable resource is and always will be the people. Making sure there is good communication and input from as many people as possible will go a long way to helping everyone do the very best job they can with the resources that are available. That is what we want to see in every situation.
Facing the Financial Ramifications
Verghese: You have a great fiscal responsibility as a dean, and this is a very large enterprise. What are the ramifications of this pandemic on the fiscal solidness of all medical enterprises and enterprises like ours?
Minor: It's going to take weeks and months to understand the fiscal ramifications. I understand that the $2 trillion stimulus package passed by the House does contain some relief for hospitals and healthcare delivery systems. When and how that will actually help to patch the financial hit that we're all going to take remains to be seen. In times like this, first and foremost you have to focus on doing the right thing. We're fortunate in that our hospitals and our university's school of medicine have financial reserves. Undoubtedly, some of those reserves are going to be tapped into to get us through this crisis. But that is the right thing to do.
Because we have ended all elective cases, we have intentionally reduced the inpatient census in our hospital in anticipation of a surge of patients with COVID-19. That has reduced a lot of our revenue streams. There will be long-term ramifications from this. Those ramifications will initially manifest themselves in terms of our capital projects and what we were planning to build. It's reasonable to say, even at this early stage, that a lot of those plans will need to be reevaluated and planned over a longer timeframe. But again, we absolutely have to focus on our people first and foremost. If we do right by our people, if we earn and sustain their trust, then I'm confident that we can get through any financial hit that may come from this crisis.
Enduring Human Spirit
Verghese: Can you share a personal anecdote of something that will stick in your memory long after this is over, that sort of reflects the triumph of the human spirit or something that has lingered with you from these past few weeks?
Minor: It's been so many things. It has been hearing our colleagues speak up and express their desire to help—their support, their willingness to help us all work through this difficult set of circumstances. No one has backed away; everyone has leaned in. That is what encourages me every day that we're going to make it through this. The virus is going to cause a lot of distress and human suffering, but we're going to get through this, and it's because of our strength and our people that we will get through it.
Verghese: Lloyd, I just marvel at the weight and the responsibility that is on your shoulders. Over the past few weeks, watching our town halls and mini versions of that in every department and every division, it almost seems as though we've been planning this forever. And yet you and I know that a lot of it has just been good people coming together and doing the right thing. It's been so impressive to watch. I'm sure it's true of many organizations and hospitals around the country—the fundamental nature of the physician calling is that when the going gets tough, people do lean in and step in. We feel very, very privileged to have had you. I know you're busy every hour of the day. Thank you so much for being with us. And we wish you the very best in what you're doing.
Minor: Thank you, Abraham. It's good being with you. And thank you for your leadership and for the way you inspire every one of us with your presence and your writings. It's truly a privilege to be your colleague.
Abraham Verghese, MD, is a critically acclaimed best-selling author and a physician with an international reputation for his focus on healing in an era when technology often overwhelms the human side of medicine.
Lloyd B. Minor, MD, trained in otolaryngology–head and neck surgery and worked as a faculty member at the Johns Hopkins University School of Medicine in Baltimore. Since joining Stanford as dean of the school of medicine in 2012, he has used his position to develop efforts in precision health.
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Cite this: 'We're Going to Make It Through This,' Stanford Dean Says - Medscape - Apr 10, 2020.
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