Author: Shantanu Nundy, MD
Conversation Series: Distributed, decentralized and digitally-enabled care
Shantanu Nundy, MD, MBA, chief medical officer of Accolade, and Richard J. Baron, MD, president and CEO of the American Board of Internal Medicine and the ABIM Foundation, discuss distributed, decentralized and digitally-enabled care after COVID-19.
Read Shantanu Nundy’s blog post: How COVID-19 may be the catalyst we need to accelerate trust in medicine
- Rebuilding a Foundation of Trust
- Building trust for healthier lives
- Building organizational trust in health care
- The overlooked role of physician trust in patients
- Advancing health equity and trust in health care
- Generating verified content to dispel misinformation
- Countering medical misinformation through social media
- Counteracting medical misinformation
- Building trust through community partnerships
- Intentionally building trust through system changes
- Addressing the loss of trust in safety culture
- Building trust after causing harm
How COVID-19 may be the catalyst we need to accelerate trust in medicine
A couple months into the pandemic, as my clinic settled into the new normal, my nurse urgently summoned me to see a patient in our drive-through testing site. I ran out to the parking lot to find a Pakistani gentleman in the front passenger seat, his wife in the driver’s seat, and his four daughters packed in the back—all alert and scared. He was coughing and wheezing and had an oxygen saturation hovering between 89% and 91%. After examining him, I concluded that he should go to the emergency room. While he didn’t quite need oxygen yet—as someone in his late 60s with long-term exposures to air pollution—he might have needed it soon, and I preferred him to be closely monitored in a health care facility.
His daughters’ eyes widened at the suggestion. New immigrants to the country, they were mistrustful of the government and hospitals. They were also uninsured and scared about what it would mean for their family’s finances. He asked if there was another way.
After stepping aside to think about their situation, I instructed the family on how to support and monitor his condition at home. I gave them a pulse oximeter that they could use to monitor his oxygen levels. I also instructed them to go to the emergency room or call us immediately if the levels consistently dropped below 88%. And finally, I gave them my personal cell phone number and had them text me to make sure they had the right number.
The next day or two were touch-and-go. They messaged me a few times about his lack of energy and fatigue. I called them once when his oxygen level was briefly low. But, we ultimately decided to keep him at home. And after a couple of seemingly very long days, he turned the corner.
Today the family still comes to see me in clinic and never hesitates to bring me sweets or other small tokens of their appreciation.
COVID-19 changed health care for the better
COVID-19 magnified many longstanding failures of the health care system. Perhaps none of these were starker than the deep lack of trust in doctors, health systems, and public health in general that had already been increasing in the past several years.
At the same time, I’m optimistic. COVID-19 has also accelerated changes to health care that I believe create a catalyst to rectifying this longstanding failure. As I’ve written in my book, during the pandemic, health care became more distributed, digitally enabled, and decentralized.
By distributed care, I mean that care will increasingly happen where health happens: at home and in the community. During COVID-19, we saw virtual visits skyrocket and home visits increase. We provided testing and vaccination at drive-through sites, churches, and football stadiums. By bringing care to patients rather than making patients go to care, we saw them on their terms. We met them where they were – not just physically but often emotionally as well.
Care also became digitally enabled. We finally recognized that the real role of technology in health care should be to increase the care in health care. Outfitted for the first time with a clinic iPhone, and already calling my patients over FaceTime and WhatsApp for their virtual visits, I found myself messaging with my patients between visits. I texted them about whether they picked up their medications yet, and they would message me to let me know that they tried picking up the medication, but that it cost more than $100 and they couldn’t afford it. Often these exchanges would end with warm appreciation and emojis – of smiling faces or namastes.
Care also became more decentralized. We put more resources in the hands of frontline care teams and patients. My safety net clinic received grants to support proactively calling people who needed the vaccine or canvassing door-to-door. We also empowered patients with equipment like the pulse oximeter we gave Mr. Salim, and we taught patients more about self-care – like how I talked to his family about how to support him and when to escalate care to an emergency room.
COVID-19 changes may catalyze greater trust
The “three Ds” accelerated by COVID-19 (distributed, digitally enabled and decentralized) map well to the “four Cs” the ABIM Foundation has developed for enhancing trust.
Competence. Often what doctors do seem to be a mystery. You don’t know what’s in their head or why they’re doing things. The shift towards decentralization, where patients are given more resources to make their own decisions, will help. Rather than “Hey, you need to go to the emergency room,” we’ll tell patients that we recommend the ER because their oxygen is low and medical guidelines say that oxygen below certain levels are dangerous. For my patient, this led to an acknowledgment that his oxygen level was on the border and that based on his preferences, there was an alternative option his family. This may be no more or less competent from my perspective, but from his family’s perspective, it became clear. I imagine that if his oxygen level did dip below 88% after a day or two, he would have a lot more trust that he truly did need to go to the emergency room, whatever the ramifications might be for his family.
Caring. Often the best way to be caring is to have empathy – to see and understand people as a whole person, and not just a patient in a gown. Virtual care and particularly video visits offer doctors a window into the home. Seeing patients in their own environment helps me understand who they are. Seeing the Pakistani gentleman with his wife and four daughters – something that is often hard for families to do in a clinic-based environment due to logistical and financial barriers – allowed me to tap into my own empathy in order to treat him. He was no longer a COVID-19 patient with respiratory symptoms. He was a father and a provider to the five women in the car with him.
Communication. Communication in health care is often very formal. There is a visit followed by weeks or months of silence before the next visit, and so on. This is not how we communicate with the people we care about. We send emails and texts and have phone and video calls. Digital communication can sustain and strengthen relationships that were originally built in-person. Knowing that he and his family could each contact me – that I was just a text away – was critical to their having enough trust to take care of their father at home.
Comfort. Care that happens increasingly at home and in the community is care that happens on patients’ own turf – sometimes literally. In an era when many lack access to medical facilities or are too mistrustful to step foot in one, the fact that care can start in their own environment can be a great source of comfort, particularly as relationships are still being built.
Many of the changes I described may reverse after the pandemic; the changes so far have been important, but small. COVID-19 is simply a possible catalyst. It is up to us to seize this opportunity to rebuild trust with our communities and our patients.