Permanente CEO: Clinicians Need 'Psychological Safety'

John Whyte, MD, MPH; Richard S. Isaacs, MD


July 14, 2020

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  • As California's COVID-19 cases surge, the majority of patients are between 18 and 49 years of age.

  • Telehealth via video continues to be popular with both patients and clinicians.

  • Kaiser Permanente is working with community partners to address health disparities, which are directly related to disparities in wealth and access to care.

  • Healthcare institutions need to create a "culture of psychological safety" that breaks down the barriers between clinicians and leadership so that healthcare professionals can feel empowered to speak up about work challenges.

  • The recession could lead to a transformative approach to healthcare delivery over the next 5 years, focusing on technology and telehealth.

This transcript has been edited for clarity.

John Whyte, MD, MPH: You're watching Coronavirus in Context. I'm Dr John Whyte, chief medical officer at WebMD. I'm delighted to be joined today by one of our most popular guests, Dr Richard Isaacs. He's the president and CEO of Permanente Medicine. Dr Isaacs, thanks for joining us again.

Richard S. Isaacs, MD: Thanks for inviting me.

Whyte: We talked a couple of months ago, in the height of the pandemic, about what Kaiser and the healthcare community were doing to address the pandemic. Can you fill us in on what's been happening since we last talked?

Isaacs: When we last spoke, we were doing the victory lap here in Northern California, and we were preparing for a surge on the East Coast. We were celebrating how well California had done at flattening the curve, and we did an amazing job. But we're now seeing the inevitable, and we're seeing COVID-19 play out across the entire state.

Initially we did very well in Northern California. We had a couple of surge medical centers in southern Santa Clara County — our San Jose Medical Center and our Santa Clara Medical Center. The team really rose to the occasion and did exceptional work. These two medical centers are doing very well, and we're starting to see resurgence of COVID-19 through the Central Valley heading north.

Whyte: Do you think it's because we're seeing a greater incidence of cases in a younger population who may not be following guidelines? Is it not just more testing but improved sensitivity of testing?

Isaacs: Well, it's interesting that you say that because the majority of patients that we're seeing now are in the 18- to 49-year-old age range. And they're behaving differently even in the community.

We have far fewer critical care admissions. We're watching these critical patients very closely, and they're being managed without intubation and turning around much faster. I think that that relates to the lower age range. Watching the news media, it seems that the 18- to 49-year-old age group, particularly the 20s and 30s, don't really believe that there is a problem. That may be contributing to spread among that community.

Whyte: How do we educate folks about that? We know that public health measures work, but for whatever reason, people either don't believe in them or they're not observing them.

Isaacs: They need to trust their healthcare provider. We've been doing outreach to all of the membership at Kaiser Permanente nationwide. We are sending regular communications via secure messaging to all of our members, giving them education about how to protect themselves and their families, and how to eliminate the spread of the disease through their communities.

Whyte: We talked last time about the percentage of visits that were telehealth, and you mentioned it was roughly 80%. Are you still seeing 80%, or have the telehealth visits changed?

Isaacs: We're still seeing a fair amount of video visits. We've learned a tremendous amount, and there's satisfaction on both sides for the video visit. We created the opportunity for the patients to be seen face-to-face, and we're still sitting in the high 70% range for total video visits right now.

People are still concerned about coming in. We've done a great job of keeping all of our medical centers sterilized and clean. We have a regular process with regular social distancing. I like to say it's a lot safer to be in one of the Kaiser Permanente facilities than pretty much anywhere else in the community.

Whyte: I feel like we're not getting that message across — it's safer, everybody's temperature is checked, there are different entrances, and you have infection control. We know people aren't coming back nationally because we see a decrease in immunization rates and cancer screening. How do we convince them?

Isaacs: There's still a pandemic of fear. At this point, people know somebody who's been infected by the virus. I was talking with my sister-in-law over the weekend and she's very concerned. In watching what's happening on the news, she's worried about her family and her kids.

Remember, we talked about the two pandemics: the pandemic of the disease itself and the pandemic of fear. I still think there's a fair amount of fear. It's changing behavior, and these behaviors will probably be with us for a long time.

Whyte: How has Permanente Medicine been addressing those social determinants, especially now in the light of the George Floyd killing and the protests that resulted from that?

Isaacs: We've known for a long time that health disparities are directly related to access to care and wealth disparity. Those who have more wealth and job security tend to have more access to health insurance. Nationwide, Permanente Medicine is reaching out with community partners to address the health disparities that exist in our country. Kaiser Permanente is committed to improving the health of not only the population that we care for but the communities in which they live. We've got many innovative projects that we're using to network and reach out to those folks.

Whyte: One of the communities that you're responsible for is the community of physicians and other healthcare professionals. We talked several months ago about stress and burnout pre-COVID. What are employers doing to help address employee stress?

Isaacs: I can talk to you about the folks who work directly with me, and our focus. It's a model for other employers to follow. We focus on morale, physician wellness, and safety. It's top of mind for me. Since I became the president and CEO, it's been a priority as much as the quality and safety of our patients.

We've created a new infrastructure where we're empowering physicians to help me help them by identifying where are those pebbles in the shoes, the challenges that people have on a day-to-day basis, and recognizing what we can do as an organization to help support our workforce.

Whyte: Within the physician community, there has been a lot of talk about mental wellness and how to seek help. Historically, physicians were not ones who asked for help. What do you find are the barriers for physicians and other health professionals — nurses, pharmacists, others — to seek help, especially when it relates to their mental health and wellness?

Isaacs: It's about creating an environment, a culture of psychological safety. It's really important to me that there is a breakdown of the barriers between the people who are doing the work and their leadership. I've been working to transform the culture for 3 years now. We've done some surveys and have identified the biggest challenges people face that are closest to the work. We then initiated programs to break down the barriers to helping folks get the desired support that they need.

Whyte: Do you have an example of things that have been successful?

Isaacs: When you're in internal medicine, if you're seeing a patient and you need a particular supply that's not in the exam room, that's not satisfying. I heard from our physicians that this is a challenge. We have a process that replenishes those supplies, and we immediately created a project that provides constant flow of supplies into the rooms.

Whyte: I always ask you to make predictions. What do you think the impact will be of a potential recession? We've talked to other health systems and some of them mentioned losing billions of dollars a month. What's the short-term and long-term economic impact on the structure of the healthcare system?

Isaacs: We're going to all be pressured to provide high-quality care with contracting revenue. We're already seeing it play out as people are losing their jobs. They're transitioning from commercial insurance to the individual exchange and Medicaid in many states.

So as a healthcare delivery system, how do you survive in an environment where the expectation is the highest quality, the best convenience, but we're going to be seeing contracted revenue? That's going to drive integration of technology into our practice and new ways of doing things. I'm trying to inspire our physicians to think about what's possible with a video approach. How do we transition patients from the inpatient to the outpatient setting and from the outpatient setting to the home setting?

Over the next 5 years, I anticipate that we're going to see an incredible, transformative approach to care delivery in this country. And it's going to be forced by these external factors.

Whyte: What are you hopeful about?

Isaacs: I'm hopeful that this model of practice that I'm describing could actually transform the way that we deliver care. Consistent excellence across the nation, using the resources in the most effective ways, is creating operational excellence across all 50 states and creating exceptional care that's ultimately going to benefit the entire nation.

Whyte: Does anything keep you up at night?

Isaacs: Well, we've got the trifecta of uncertainty that I think a lot about: How long is COVID-19 going to be with us? How quickly will we have some type of herd immunity versus a vaccine? What impact will this have on the economy and people's livelihoods? I used to think, very optimistically, that we would have a V-shaped recovery. The jobs were diminished and they would bounce right back. It's now looking more like a Nike swoosh. Those are the things that keep me up at night.

The other trifecta piece is the health inequities and the social injustice that have been uncovered by this process and the systemic challenges that we've had for several generations.

Whyte: Before we leave, I want to congratulate you for being selected one of the 50 most influential people in clinical medicine. Congratulations. That's an honor.

Isaacs: Thank you. I credit my entire team. I've got an exceptional team here on both coasts, and they share this with me.

Whyte: Again, thank you for taking the time to share your insights.

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