John Minchillo/AP Photo
Medical workers in the emergency department at NYC Health + Hospitals/Metropolitan in East Harlem, New York City, May 2020
The Open Mind explores the world of ideas across politics, media, science, technology, and the arts. The American Prospect is republishing this edited excerpt.
Alexander Heffner: Doctor, you've seen on the front lines, how surgery and the landscape of hospitals have been altered, perhaps permanently, as a result of COVID?
Dr. Jeffrey Matthews: It's been an unprecedented time and my perspective will be from someone who runs a major portion of what hospitals do, the surgical services, who is not a public health expert, who is not an expert on pandemics; who's not an expert on these kinds of disruptions that happen to a health system. And yet, [I] was in the middle of having to respond and create an approach from a hospital and a hospital system as events unfolded over the course of the last couple of months.
The University of Chicago Medical Center had stood up a command center and response team to begin to plan for the pandemic actually in January. But the wave of patients didn't really start to hit us here in Chicago until the middle of March, which is when we sort of went into the response mode. We had to do a lot of things very quickly. We had to prepare the hospital to be able to have the capacity to care for patients in unknown numbers with inadequate patient protective equipment, PPE, without a real tool kit, or a playbook for what this virus was all about.
Heffner: How did the pervasive comorbidities that patients were experiencing factor into the surgical responses that were most frequently employed?
Matthews: That was at the core of the question that we asked ourselves, which was how to understand which patients were too sick to have surgical procedures in a pandemic versus which patients were too well to have surgical procedures during a pandemic when resources were limited.
We thought about it in a number of different dimensions. Really for the first time, we've had to think about hospital resources: Did we have the beds? Did we have the capacity to do it? What was our volume capacity? Could we do 10 percent of our usual volume? Could we do 20 percent, 30 percent?
Then we looked at the types of diagnoses that a patient might have, that led them to need a surgical intervention. Were there alternatives that could either be used on a temporary basis, or, could things really be pushed back further?
So, for example, if somebody had cancer, I'm a pancreas surgeon, so somebody with pancreas cancer who came up, it was diagnosed during the pandemic, we had to ask ourselves, was it better to move ahead with surgery right away? Well, it turns out that we actually have the ability to treat with chemotherapy and radiation treatments upfront, and that's excellent treatment, and, actually, a way that we're handling these cancers a lot more, anyway.
We would push these patients towards having the chemotherapy, not surgery, first. We knew that patients that were at a high risk of acquiring COVID could have bad outcomes from surgery. People who had pre-existing lung disease; people who smoked or people with asthma or other diseases; and people who were overweight seemed to be a particular risk. [For] those types of patients, we would try harder to see whether we could postpone.
This system that we came up with actually scored the patients with respect to the pandemic—the risk of delaying the surgery and then the specific characteristics of the patient themselves. Did they have lung disease, heart disease, immunosuppression, diabetes? We could come up with a score that actually has performed very well in terms of giving us a sense that we were making the right decisions on whose operation should go first.
Now we're in a different phase, which is another interesting challenge: To reintroduce the needed care for the patients who were postponed. How do we decide which patients to do first? How do we convince ourselves that it is safe to restart surgery, so that the risk of a patient acquiring COVID, either in the hospital or bringing COVID into the hospital, was or wasn't going to be a problem?
This pandemic has highlighted the systemic problems that we have with racism in this country and how that has impacted communities and access to health.
Heffner: What you would like to hear from the state and federal authorities on how we can improve outcomes, as someone who has helped organize a major hospital’s response to pandemic? What kinds of policy reforms either within hospital systems or externally?
Matthews: There are so many ways that one could take that question, but I will start with the most important one: This pandemic has highlighted the systemic problems that we have with racism in this country and how that has impacted communities and access to health.
The fact that we've had problems in different socioeconomic and different geographies in our cities of how patients are affected by COVID and how they can see disease just highlights the big, public-health issue on access to care. This, more than anything else, has just dramatized what we've known for decades about the inequities in our system, in terms of access to care and outcomes for care. If we can't act on [after] COVID to implement a more just health system in this country, then we haven't really learned our lesson.
The other thing that has been highlighted is the need to have better state and national coordination for hospital supplies. Hospitals are in this business of medicine. If you look at our supply chain and supply-chain management, it has been managed incredibly tightly over the last couple of years. When you're talking about things like N95s and other PPEs, to then be in a situation where we don't have a supply chain for that in an emergency, that's really something that needs to be addressed.
It’s time to rethink how we stock in our hospitals and inventory in our hospitals for some of these critical things. The idea that we have international supply chains on them for some of these critical items may not be the best approach. Those would be two areas that are incredibly important to be looking at the state and federal level.
Heffner: Would you say that that part of the issue is the inequity within medical centers or hospital systems—how they're staffed or the resources they have? Or is it really before you even get to the doctor or hospitals?
Matthews: It’s at many different levels. If somebody has more out-of-pocket expenses or they can't leave their work because they won't have health insurance and they can't seek out the care, that’s a problem. At the University of Chicago, we are a tertiary academic medical center that takes care of the most complex diseases. We’re pretty well staffed and we work pretty well.
But on the South Side of Chicago, we provide maybe 10 percent, 15 percent of the care on the South Side. There are a lot of hospital partners that we have here on the South Side. [There are] a lot of places [where] care is delivered: in a federally-qualified health centers; in clinics; and doctor's offices that simply are not resourced the way that they could be—because the population is under insured or uninsured. We don't really have the ability to pay for what's needed.
So when you have a dramatic event like a pandemic, or you could imagine another mass-casualty event, the system is not capable to be able to flex up to provide those needs.
Heffner: In the midst of the pandemic in the absence of a therapeutic or vaccine, do you go big for holistic reform or a specific one in meeting the needs of the communities most plagued by the pandemic?
Matthews: That is the question and it's something that all of us could have opinions on. I'm not sure that my opinion is more informed than many policymakers and eally thoughtful people who have who have worked on this. We need to provide the basics for health care—for access to care—and fund it. Perhaps we're fully implementing the Affordable Care Act, so that just at baseline, we don't have this dependence on employer-backed health systems; we have a better sort of public approach whether that's Medicare for All, or some sort of basic level of care that can be provided, so that at least primary services can. That [didn’t] seem like it was out of reach. We were well down a path for that in years past.
There was more consensus on that before it got too politicized. If we can go back to that, we will have made a lot of progress that really did help. More sweeping reform is ultimately needed, but, you're right, the politics of that is extremely diverse.
