Thread by @Bob_Wachter

1/ Covid (@UCSF) Chronicles, Day 79

Grand Rounds: bit.ly/371fGv2. Moment called for wisdom & reflection, so I convened 4 wisest people I know: @SueDHellmann @cuttingforstone @seccurve & Mark Smith. If you can, watch. Per a colleague: “gripping, relevant & transcendent”

2/ Quick local update: @ucsfhospitals, just 8 pts, 3 vented. Lowest # s of both since 3/19. Wow. In SF, we’ve also turned corner: cases still ~20-30/d, but no new deaths in a week. Hospitalizations now 39 (Fig), 18 in ICU – both down ~50% from 1 month ago.

On to Grand Rounds…

3/ @ 5:00: I asked M. Smith how he was feeling as a black man – & dad of another –in America. “Hopeful…because of the depth and breadth of the reaction…to see how many people from all walks of life, all 50 states & around the world [protesting]…Gives me hope that people care.”

4/ @ 6:40: same Q to A. Verghese. “I’m witnessing this & watching the story unfold…We’re all trying to weave one narrative out of this; our own personal narrative… We need instruction on how to digest this – without the kind of leadership that would help us digest it.”

5/ @ 8:20, I asked Sue D-H about Covid. On vaccines, hopeful: “capacity of folks to innovate…more sharing, open-sourcing.” But she's also pessimistic. Lack of @CDCgov leadership, unclear public health messages, rapid politicization of public health “have taken me by surprise.”

6/ @ 15:50: I asked Ian M. why, with so much waste in healthcare, 10% cuts aren’t good thing (to prompt efficiency). Answer: “Covid & high-deductible healthcare are similar” – they’re both too-blunt instruments; they lead to cuts in both appropriate and inappropriate care.”

7/ @ 17:20: Long segment on telemedicine. M. Smith: “Every MD will be a hybrid doctor” – part in-person/part-virtual. Why did telemed take so long? Answer: Incentives were wrong, things were organized for MD/system convenience (rather than pts), & inertia. Covid overcame all 3.

8/ @ 20:50: A. Verghese on telemedicine. He worries re: loss of touch, but sees an upside: “The first time we can look into people’s homes” & observe their real life. “I’m all for it, I think it’s a wonderful trend.” Downside: “It’s really hard to teach [young MDs] effectively.”

9/ @ 25:50: Ian M. says the key question is this: “Are we just paving the cow path?” (substituting televists for in-person visits). Or is this only one part of a major digital transformation in the way care is delivered? I completely agree – that is the question.

10/ Adds Mark Smith: a digital practice requires rethinking every part of what MDs do. “If we can offload low value visits to non-physical means, you can see people more frequently or for longer…. But then you have to rethink your definition of what physician productivity is.”

11/ M. Smith: yes, there’s something lost, but human touch needn't be by MD – could be a nurse, or a high school graduate w/ good technology. If we get this right, “there is unlimited potential to redesign healthcare in ways that are more efficient, effective and higher quality.”

12/ Sue D-H: Makes point that it’s one thing to use digital (whether for patient care or for a workplace team) if you have an preexisting relationship. But we need to avoid assuming virtual is a perfect substitute for in-person, especially if you don’t have a prior relationship.

13/ @ 39:30, Ian M: Covid has exposed "The Game: the financial hydraulics” of US healthcare. Elective/surgical procedures are source of big profits; that pays for all the other stuff. He predict that Jan 2020 will be all-time high in U.S. employer coverage, as unemployment grows.

14/ Inevitably, @ 45:10: we talk Single Payer. Ian M.: Today's economy “calls the bluff on tying health insurance to employment.” BUT states are near-broke. Ian: “We’d love to do single payer but we have a $4 trillion deficit… And even Bernie can’t come up with $10 trillion.”

15/ @ 48:20: M. Smith thinks (over next 5 yrs) Covid has upped probability of universal coverage, but not of single payer. “Will people rise up and say ‘no more VA, no more retiree healthcare, no more Kaiser Permanente, all the insurance companies are banned?'…I don’t think so.”

16/ @ 50:40: Ian M. (as usual, tongue firmly in cheek):

“The good news is that we’re going to have a single payer system.

The bad news is it’s United Healthcare.” @UHC

17: @ 51:00: Sue D-H on Covid-led rapid publication (preprints, tweets), @FDAgov relaxing standards. “I think it’s mostly bad… and I’m surprised to hear me say that. One of the most important assets a product developer has is confidence… You don’t want a bunch of retractions.”

18/ @ 55:50: On vaccine challenge trials. Sue D-H: If you had a Covid cure, then a human challenge might be OK. But “I’m not going to challenge somebody if there isn’t a cure.” “I don’t think [the model of a human challenge] is crazy, but I understand why people are avoiding it.”

19/ @ 58:45: With all the discussions about ethical issues in Covid, Abraham Verghese says that the biggest ethical issue of all is “what we saw in Minneapolis.” “I feel ashamed about it… I think this is the moment of change.”

20/ @ 1:00:40: A. Verghese: “Great lesson of novels is that character is defined by decisions taken under pressure. It's been very revealing… to witness [Trump] make stupid decisions under pressure…[With the new critiques], I think that this is the moment, things are changing.”

21/ @ 1:02:00: Mark Smith: “Some of the anger… not just from black people… is informed by the widespread recognition of the disproportionate impact of Covid among people of color.” Covid-related disparities plus racial violence are leading to a new energy. “I’m optimistic.”

22/ @ 1:04:00: Can healthcare solve social determinants? No, but it can expose problems, push accountability. Who should? Ian: States, but they’re broke. “The very places that should be stepping up to social determinants are local govts, which won’t have the resources to do it.”

23/@ 1:12:40: I asked Mark Smith how people like me can understand the lived experience of being black in America. Mark recommended this @Trevornoah video, so I watched (18 min) bit.ly/2Y1FOln It's really powerful.

24/ That's it. It was the most interesting, mind-opening and, in the end, optimistic hour I've spent since Covid began. Grateful to Sue, Mark, Abraham, and Ian for an amazing, honest discussion. Again, it's here: bit.ly/371fGv2

Back tomorrow to sum up this crazy week.