Leading during a Pandemic

After more than two years of battling COVID surges, supply and staffing shortages, and spiking operational costs, hospital administrators are evaluating lessons learned and which pandemic-related changes will be retained. We talked about these and other topics with Paul Ramsey, MD ’75, CEO of UW Medicine, executive vice president for medical affairs and dean of the University of Washington School of Medicine, and Peter Slavin, MD ’84, an HMS professor of health care policy who was the president of Massachusetts General Hospital from 2003 through early 2021.

HMM: You each have said that referring to large health care systems as academic medical centers with a clinical, research, and education triple mission is an inaccurate description of your institutions, that the true mission is to improve the health of the public. Could you describe how population health became central to your institutions’ mission statements?

Ramsey: In 1992, the University of Washington restructured the leadership of our medical school and hospitals to have a single leader for an integrated health system that includes the medical school, the hospitals, the clinics, and some other nonprofit organizations.

In 2000, the UW Medicine Board, which oversees UW Medicine, voted unanimously to endorse a single mission, to improve the health for the public—meaning to improve health for all people around the world. To advance that mission, we need integrated excellence in our clinical, research, and learning activities. A single leader and a clear mission: to improve health.

Slavin: For similar reasons, about fifteen years ago, I recommended to our board that we change our mission statement to explicitly recognize community health as being one of our four missions, arguably our first mission given the history of the institution. If indeed we are here to improve health—and 80 percent of health is driven by what happens in the community, not within our walls—then I think it’s incumbent upon us to understand those forces and be engaged in doing something about them.

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With this change, we created new structures within the hospital to buttress the community mission: a board subcommittee, an executive committee that our chief of medicine chairs, and a senior vice president, who is responsible for community and equity. Perhaps the more significant integration that’s occurring has been happening across the system: the formation of the Mass General Brigham system. Each hospital composes the health system.

HMM: These priorities are large and require significant resources. How do you balance their needs?

Slavin: I don’t see these missions in conflict with one another; they are synergistic and critical to improving health. But in terms of balancing, I think it comes down to how the economics of the institution work. Of those four areas of focus, only one of them—the clinical mission—generates a margin. The others absorb margin or require investments to sustain them. So that does require balancing. How do you generate enough margin from clinical activities or supplement it with things like philanthropy to be able to carry on robust activities in the other three mission-critical areas?

Ramsey: I agree. The clinical, research, and learning activities are synergistic and organizationally we should strive to integrate them in an efficient way that promotes synergy. Our mission is to improve the health of the public, and a major part of providing the best care for all people is the research that advances the knowledge for prevention, diagnosis, and treatment. Because research is changing medicine so rapidly now, lifelong learning for the entire workforce is critical.

Some of the best learning for our students, even those students who go into a specialty career or research, comes from their experiencing the practice of medicine in a community that is so small and so remote that it often has one or two family physicians and then quite a bit of telehealth.

Our community-based teaching programs have included telehealth since the 1970s, and we have experienced a dramatic increase in digital health connections over the past two years, during the pandemic.

HMM: What other changes has the pandemic brought to your institutions?

Ramsey: I have nearly fifty years of time in medicine, and I have never, ever seen so much change and so much uncertainty as I have in the past two years. But I believe strongly that we can learn from the change and continue to make positive changes that are needed. For me, those changes fall in four areas.

I’ll start with health care equity and diversity, equity, and inclusion. The pandemic has made us focus on the inequities related to COVID diagnosis, treatment, and prevention. The distribution of the vaccines enabled us to identify health care inequities and develop solutions. We have more work to do to achieve health care equity.

As I’ve mentioned, telehealth changed. In just the first two months of the pandemic, we moved ahead more than five years in the implementation of our telehealth strategic plan. Telehealth is transforming medicine and provides an opportunity to connect with patients in an efficient and timely manner.

Another area of pandemic-related progress has been value-based care efficiencies: the way we work and cost-effectiveness. This is important to an integrated health system that is heavily focused on advancing knowledge via research. I have never seen translational research move so fast—from basic science research to practical clinical application. This goes beyond the implementation of the COVID vaccines. We’ve accelerated translational research in many areas and are focusing on improving our internal infrastructure to continue to do that.

But one of the greatest challenges presented by the pandemic has been our workforce’s well-being. Our staff, faculty, students, and residents have been working exceptionally hard and have had to move fast to meet changing circumstances. UW Medicine’s offices of health care equity and faculty affairs support faculty and staff across all the sites and throughout the pandemic has focused on well-being, frequent and comprehensive communication, and resilience in the workplace.

I think if we build on these, we can really improve medicine and deliver better on our mission.

Slavin: That’s a nice summary, Paul, of what we’ve both been experiencing during this pandemic.

I would start by saying that it has been for me both the best and the worst of times. Just seeing all the suffering of patients, many isolated from their families, was incredibly hard. What our caregivers have been through, after three waves of COVID, has been truly hard. I think for the first wave, adrenaline was at record levels. But that adrenaline wore off in subsequent waves. This pandemic has really been stressing our workforce.

So many areas that were experiencing changes before the pandemic have seen those changes accelerate throughout the pandemic to a breathtaking degree. I am on the board of a telemedicine company in Boston, so I’ve been especially aware of the activity in that area. Prior to the pandemic, I think less than 1 percent of our outpatient visits were conducted by telemedicine. At the peak of the pandemic, it was over 80 percent. I think it’s now settling in around 20 percent or so, but the pandemic is teaching us that telemedicine is very feasible for a whole range of different clinical situations: it’s more convenient for patients and it’s more environmentally friendly because patients don’t need to drive into the hospital or to a practice. The challenges that we face going forward include what the reimbursement for its use will ultimately be. Will it be economically viable?

Another issue raised by the pandemic and the use of telemedicine is state licensing of physicians and the inability of physicians to practice across state lines unless they’re licensed in the other state. This has been a huge challenge. I think—I hope—that the attention raised by this problem will lead to national licensing of physicians. State-by-state licensing is a real barrier to progress.

We also have seen progress in how the whole research community has stepped up in an incredible way, pivoting to study COVID at the fundamental level and the clinical level.

At Mass General, we entered the pandemic with a robust clinical research program, but during the pandemic we built, almost overnight, an infrastructure that scanned the entire hospital for COVID patients. We made decisions about what trials to offer every patient and a very high percentage of COVID patients were enrolled in clinical trials. It was astounding.

Our systems also alerted us to the fact that our intensive care beds were being filled with patients from a relatively small number of communities, some of the lower-income communities that surround the hospital. So, we swung into action and met with the leaders in those communities to see what we could do to try to mitigate the disease and its spread in the communities. Our community health activities went on steroids. I don’t know if we’re going to be able to sustain the pace of change and innovation indefinitely, but I do hope we will sustain some of it. What happened was remarkable.

HMM: Each of you has mentioned the pressures placed on members of your workforce during the past two years. Could you describe what it has been like for your workforce and what you have been doing to counter these pressures?

Slavin: I think we did more of what we’d done previously, but there has not been one magic bullet for this problem. Part of the issue is the psychology of our workforce and the debilitating effects of the stress they have felt in what are challenging clinical situations. Adding to that stress is the fact that, particularly during the omicron surge, a significant percentage of our workforce has been sick. We’ve had people leaving the profession because they’ve had enough, and we’ve had people who couldn’t work because they were COVID-positive. This has caused huge staffing shortages that have only made things worse.

In terms of some of the things that we’ve done, I think one important thing is just leadership visibility. That’s something that I’ve tried to do from the very beginning of my tenure, but I’ve stepped it up dramatically during the pandemic, as did other people in leadership, hospital trustees, and other senior leaders, who have been out there with our staff, showing them that what they were doing is incredibly important, listening to their concerns, and trying to do something about those concerns.

We also offered and continue to offer employee assistance programs for people who need help. Over the years, we’ve had an ongoing effort to identify ways to reduce physician burnout, from providing free opportunities to use a cycling place across the street to providing housing during the height of the pandemic—anything to show our workforce that we value them and to make their working environment as tolerable as possible.

Ramsey: Our workforce also has faced the combination of extremely hard, stressful work and longer hours in a setting of uncertainty and change. With surge after surge, we wonder, will this ever go away?

We have focused on enhancing communication not only for our workforce but for members of our regional community. At least weekly we had thousands of people participating in virtual town halls to discuss change. In these town halls, we listened to what was working, shared some best practices, and heard about specific challenges that we worked together to address. We’ve never had as much internal communication as we’ve had during the past two years. We also have been reaching out to local and regional communities to determine how we can better serve vulnerable populations.

We’ve also increased access to mental and behavioral health services, the need for which have only increased with the pandemic. Prior to the pandemic we hired someone to lead well-being at UW Medicine. She and her team have made a tremendous difference, including their creation of a large menu of activities so that individuals with different needs have different solutions available to them, ranging from exercise to childcare.

And engagement with community leaders has been important throughout this period. We have been working with them to better serve vulnerable populations. Fortunately many donors stepped up; in the first two months of the pandemic, we raised $30 million that we used for equity purposes, such as increasing COVID testing in these communities, providing vaccines, and producing information materials in multiple languages.

HMM: What sort of financial pressures have come with all this change?

Slavin: I think the strongest business pressure is the wage pressure for the workforce. The other things are relatively modest in comparison. One of the things that has put a lot of pressure on wages is the surge pricing charged by nursing agencies during the pandemic.

With traveling nurses doubling, tripling their rates, it creates difficulties within your organization. Staff nurses know that travelers are making twice what they are. That’s not a formula for achieving stable wages or a stable workforce. And when you try to address the nursing wages, the domino effect occurs in other parts of the workforce, where people feel that they’re underpaid and facing shortages. I left Mass General about six months ago, but my understanding is that the wage pressures have not abated.

Ramsey: The wage pressures for us were most severe in January 2022, but we expect ongoing challenges to our budgets due to increases in workforce expenses. I would add one thing to Peter’s assessment: the current reimbursement system in general doesn’t adjust to increases that are needed, such as increases in workforce expense. The current reimbursement system doesn’t recognize and incentivize programs that would make health care better and more affordable, especially for post-acute care settings, including home health care, which have been hit very hard. When we can’t find a post-acute care setting in which patients can continue their care, we keep the patients in the hospital. That’s a tremendous expense for the hospital system.

HMM: What makes you optimistic about medicine and health care as we look toward a post-pandemic period?

Slavin: I think the future of medicine is incredibly bright. There are obviously huge challenges, but I’m always inspired by the young people who are coming into the field and how bright they are and how committed they are to trying to help their fellow humans. I think the science of medicine has never been more exciting.

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The changes ahead for the scientific basis of health care will transform every nook and cranny of medicine and of patient care in unimaginable ways. I think the other exciting megatrend that we’re in the middle of is the digital health revolution. We’ve talked about telemedicine, but the effect that artificial intelligence, machine learning, and natural language processing will have on health care has just begun.

Ramsey: When I speak with our first-year medical students I tell them that I envy them, that I wish I were starting medicine now. We have the ability now to focus on health care equity, and we recognize it is mission-critical to advancing our goals for equity, diversity, and inclusion. We can measure population health and measure the outcomes of our care in ways that we couldn’t before. This ability will help us achieve continuous improvement in health care and delivery. And then there’s the accelerated application of what we’re learning in the laboratories to improve health. That’s so exciting. I think it is a wonderful time to start in medicine.

Ann Marie Menting is the editor of Harvard Medicine magazine.

Images: Mattias Paludi