On Miracles and Moving on (ADFM)
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* Chelley Alexander
* R. Allen Perkins

When Hurricane Katrina hit New Orleans in August of 2005, it brought depths of destruction to New Orleanians not previously experienced by an American city. Eighty percent of the city was flooded for weeks and at least 1,800 people died. Pictures still haunt our minds of the Superdome shelter and stranded families on roofs. Planning was inadequate and response from government at all levels was inadequate. People were stranded at shelters without food, and toilet paper, too, no doubt. As often happens, the poorest were hardest hit.

We are all in a similar place with the COVID-19 disaster, this pandemic storm which has caught us ill-prepared and has shuttered all vestiges of normalcy. For some, it has taken our loved ones and colleagues. It has affected us all, shredding plans for vacations and graduations, for national meetings and family get-togethers, and leaving us empty and grieving. We are grieving together, grieving a previous life that will not return and a loss of safety we cannot recapture.

And yet there are positives. Thrown into a dangerous storm we did not see coming, the importance of our work is being honored and appreciated by hospitals, communities, and patients. Factories donate masks, military planes fly overhead in formation, police officers and churches hold drive-in appreciation events, and suddenly we feel appreciated. Our schedules may be a bit more flexible and a bit more controllable, and perhaps work RVU benchmarks and quality requirements have been suspended for a glorious moment.

We have an opportunity to use this as a wakeup call, to examine the old normal and decide if we can create something better. That is not to say that we give up or minimize the grief of the moment, or that we forget those patients or family that we’ve lost. Rather hold on tight to that grief, wrestle with it, and, through it all, plan for something better—something that honors what was lost, improves our professional lives, and improves the lives of others moving forward.

We have a health system that is incredibly unfair and inequitable, and which deprives the poor of basic preventive care, denies them primary care, and relegates them to the worst, last-minute, costliest care. We measure our success by effort and quality metrics that pale in comparison to the impact we could have on our patients and communities. Care is expensive, inequitable, and difficult to access. Primary care physicians are burned out. Despite this, in response to COVID-19, we and others were able to transform the health care system in a matter of weeks. Can we use this crisis to retain the virtues of this new existence?

There seems to be at least a temporary awareness brought about by the pandemic that people without insurance need care, are more vulnerable due to lack of care, and that it’s not their fault. Can we take this opportunity to advocate with our state governments to expand and improve Medicaid drawing on the Families First Coronavirus Response Act for the additional resources needed? Can we ask Congress to make this expansion permanent?

Medicare and Medicaid have modified reimbursement regulations to allow payment for telemedicine which had heretofore been limited. As a result, many on Medicaid and Medicare are able to see their family doctor without the barriers caused by transportation, disability, or cost. Can we advocate to make this permanent and to make the payment equitable?

We now know that obesity and poorly controlled chronic illness contribute to the disproportionate death rates in people of color. We know that if we lessen the impact of social determinants of health on our patients it will improve the health of our most vulnerable patients and allow our specialty to fulfill its pivotal role as our patients’ primary health advocate. Can we advocate for improvements in the social fabric such as education and access to healthy foods that will allow our patients to be more resilient when the next pandemic comes?

Another opportunity is to revise our medical student and residency curriculum to take advantage of more adult learning styles. Perhaps we shouldn’t “return to normal.” Can we eliminate hours of sitting and listening to lectures in favor of having students explore topics on their own and using a wide range of instructional design models—flipped classrooms and case-based experiential learning with built in feedback loops to improve their ability to see patients in a wholistic manner?

There is a writer by the name of Frederick Buechner that talks of the curse of “everydayness”—that tendency we all have when things are “normal,” where we get in a rut, and barely notice how we got to work much less the beauty of the sunrise or the music of a child’s laugh. We forget to notice these tiny miracles happen to us each day—the smell of the roses, the thanks or even blessing we get from our patients as we go about our work, amid our harried, busy work.

We have an opportunity now, shaken out of our everydayness, our rut, to appreciate and be mindful of the small miracles—to hold more sacred our in-person time with family and friends, to notice the life in front of us, to practice more compassion for the grieving— the loss that everyone is feeling in one way or another. And we have the opportunity—perhaps a once in a lifetime opportunity—to transform our health care system, and the teaching of our students in one fell swoop.

Life is a fragile miracle—and while the pandemic is disruptive, and devastating for much that is important to us, it cannot deprive us of each other (at least virtually) nor keep us from transforming medical care and medical school into something better. “Its hardship is its possibility,” Wendell Berry wrote. Transforming health care is hard but possible, and this disruptive pandemic might just be the ticket.

In our states, the motto is Wash your hands, Wait 6 feet apart, and Wear masks. I would add to that: Advocate for those less fortunate, Admire your friends and family from afar, and Advance adult learning teaching methods!

We have transformed everything in our world—and will likely be asked to do so again as we create a new normal. Why not create something better than normal?

Stay safe and make change.

*   © 2020 Annals of Family Medicine, Inc.