Last week, Asaf Bitton, a primary care physician at Brigham and Women’s Hospital and executive director at Ariadne Labs, published a piece emphasizing the importance of social distancing, “Social Distancing: This is Not a Snow Day.” Bitton recently spoke with Steven Berkow, Advisory Board Vice President of Provider Research, about social distancing and how health care leaders should be responding.
'A new period of social pain': How to help patients, and yourself, survive social distancing
Question: Asaf, thank you for joining me. Your article came at such a crucial time in our nation's response to the coronavirus epidemic, and it really spoke to me on both a professional and personal level. The disconnect you explored between a person agreeing with social distancing in theory and the difficulty in actually putting those ideas into practice is compelling and alarming. But before we dive too deeply into what you wrote, let's start by simply confirming what social distancing means.
Bitton: The most basic definition is keeping at least six feet between you and another person. It's a practice that has been around for years, but we need to be clearer about what the concept means and focus on physical distance as opposed to social isolation. In hindsight, physical distancing might be a much better way to refer to social distancing because, putting on my primary care hat, we really need to emphasize social connectivity right now. But we need do it at least six feet apart from each other.
This can be very hard because humans have an imprinted need for touch and closeness. Fortunately, there are a host of connective tools today and we need to harness them. I worry a lot right now about populations of socially isolated elders and those with behavioural health issues. And I worry about kids of all ages and all stripes. For them, this is a big challenge. And I get how hard it is, but the key message is what we do now matters a lot. Not going to bars or not going to playdates—the annoying, uncomfortable measures— they are really important right now.
Q: As a dad of three kids, I'm learning first-hand how hard social distancing can be for children, as I'm sure you're experiencing in your own home. But is what you're saying , if you are getting through a day without personal sacrifice in terms of social distancing, you're not really hitting the mark? This should be painful.
Bitton: Absolutely, this needs to be uncomfortable and even a bit painful. Any half-measure approach won't work. This disease has an asymptomatic window of up to five days. I think we have to look at the world right now and assume everyone has coronavirus, and ask yourself: Do you really want to go out right now? Should I really be letting my kids out for playdates with other families? Is this really the responsible thing to do for members of your community who have underlying health issues? Right now, you can be a hero by doing almost nothing. At home.
Q: I'd like to switch tracks a bit. One of the things that we are thinking about is the huge megaphone that physician leaders and hospital leaders have in their communities and the message they should be pushing to their communities. How do you strike that right balance between scaring people into action, but not panic? How do you sound the alarm without petrifying people?
I live that every day. Practicing primary care teaches you to be pragmatic but also how to be alert to the times when it isn't run-of-the mill or benign. My public health training teaches me to be comfortable with scary numbers and exponential thinking—where your reality in a week is going to be very different from the week prior because of the power of exponentiation and rapid change.
All models out there point to a similar fact: If we don't take aggressive measures now, the health care system gets overwhelmed and will eclipse our ability to respond effectively, not only to COVID-19, but to all the usual stuff that comes into the hospital. That is the true measure of resilience, or lack of resilience, of a health care system: Can you respond not just to the shock, but also continue to function for other important health conditions? That's what’s at stake right now and why we need to be so urgent and stringent in our calls to action at this point.
Q: Physicians are actually held in very high regard by their communities, but I've seen very few physicians directly and unapologetically say to their patients and communities, "these are the sacrifices you need to make" to practice social distancing and head off this virus. Why?
Bitton: We have developed a perplexing fear of transmitting complex and often stark realities to folks. And we underestimate people’s ability to understand this information and step up to handle it. But the real risk is actually abrogating leadership because we fear telling people the difficult truth or asking them to sacrifice now for the common good. We are a society that has real issues with social and political discourse and rancor, but this moment relies on everyone stepping up, arguing less, and acting together. We need to trust that people can make these sacrifices and be straight with them about why they are needed, what the possible timeline will be, and how we are going to mitigate some of the consequences of social distancing.
Q: Getting back to the point of your initial article. How we act—and to narrow the focus a bit, how physician and hospital leaders act—is key?
Yes. I'd emphasize to health care leaders and the general public that this is the critical time for aggressive action to stem the spread of this disease. I want that head of a service line in a mid-sized suburban hospital in a mid-sized city to take action while they still only have a handful of cases in their state because what we do now matters. We cannot wait.
Q: If you had recommendations for health care professionals to help people take social distancing to heart and take advantage of the current window we have to stop the spread of the new coronavirus, what would they be?
Bitton: First, I would begin with the social or, better yet, physical distancing concept. If the community hasn't closed all social gatherings, you have to do that now. We have to practice this now and follow through with it, potentially for even a few months. And there may be a later uptick of cases in the fall that could even necessitate a resumption of some social distancing methods again.
Second, we need to ramp up testing capacity in all forms rapidly. We must ramp up testing by private, public, state, and academic institutions. We have to test using different methods than usual for the American health care system: We need drive-thru testing centers, like they pioneered in South Korea and the University of Washington.
Third, we need to rethink our ambulatory services right now. We need to convert to telehealth as much as possible because our inclination toward in-person visits puts patients and staff at risk. Health systems need to consider centralizing walk-in ambulatory surge capacity into a central respiratory clinic to ensure we have the right people with the right equipment triaging patients and getting those with mild symptoms who test positive for COVID-19 back home to be socially isolated with a care plan, and obviously triage sicker patients to higher levels of care.
Fourth, health system and hospital leaders need to bolster back up and surge capacity through effective contingency planning now. What happens when your ICU is potentially overloaded? How will you staff these beds, especially if part of your workforce gets sick? How can you safely and effectively cancel non-urgent procedures now? Are you ready to separate the hospital? You need to make sure certain wards or areas are specifically designated for COVID-19.
The final part of this is thinking about your supply chain backups. How can you be sure you have the necessary amount of personal protective equipment, and where can you find extra ventilators? Who can you talk to about getting these ventilators now, and what new staffing models can you build to extend the reach of your current staff to help with ventilating more patients?
And don't just think about doctors and nurses, you've got to think about janitors, patient attendees, lab techs, radiology techs—everyone who is needed to make a hospital function. They're all doing heroic work in putting themselves at risk. What is your surge capacity for each of those types of worker? And how can you support them all during this unprecedented time?
You as hospital and health system leaders may be tested as never before. But you can, and you will, step up and meet this challenge. There is no other option. You will succeed by using your ingenuity, leveraging the talent of your entire team, and supporting your health care workforce every day to do what they do best: care for their community.