How physicians can emerge stronger after 2020 [PODCAST]

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“With 2020 behind us and the pandemic still raging, it is incumbent upon us to take a close look in the rear-view mirror. While the vaccines’ approval gives us all hope, the vaccination initiative’s slow rollout should worry us. Physicians, health care providers, nurses, and essential workers, and patients and family members have borne the brunt of the pandemic. On the last count, about 3,000 health care workers had lost their lives due to COVID-19. The toll that the pandemic is wrecking on the health care community’s emotional and mental health is only starting to become apparent. Health care systems, local, state, and federal governments have responded in different ways to ease the pandemic burden. While we can debate the level and adequacy of the response, we may have a larger problem on our hands if we fail to learn lessons and make the necessary changes going forward. I want to offer my perspective on the changes that physicians and health care providers should pursue that would allow us to emerge stronger.”

Manish Thapar is a gastroenterologist.

He shares his story and discusses his KevinMD article, “2020 in hindsight: What we can learn.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Manish Thapar. He is a hepatologist, and he wrote the KevinMD article “2020 in hindsight: What we can learn.” Manish, welcome to the show.

Manish Thapar: Thank you. Thank you for having me on. It’s an honor.

Kevin Pho: We’ll get into your article in a little bit, but first off, can you share your story and your journey to where you are today?

Manish Thapar: Well, I have been in this country for more than 20 years, and I’ve been involved with medicine, as a resident and then out of training, since then. For the past 10 years, I have been in the Philadelphia area, and I’ve been working at academic centers and seeing how medicine has changed, and that’s where I am. I did not expect to be in a pandemic, but I am, as is everybody else.

Kevin Pho: So you are a liver specialist at an academic medical center. Tell me how the last year and how the pandemic is affecting the cases that you’re seeing.

Manish Thapar: The pandemic has obviously taken a toll on patients. Patients have been exposed to COVID, and a lot of liver patients come in, and they’re likely to do poorly, especially if they’re decompensated cirrhotics. The hospitals have been on surge. They were on surge or locked down in the spring, and now there’s definitely an element of delay in care, where patients are not coming in for their appointments.

There are also patients who are still scared to come in. I frequently get emails or messages from patients saying, “Hey, listen, do I really need to go in and get these tests?” It’s going on a year now. So it has taken a toll on the patients, certainly. It has also taken a toll on the providers who are providing the care.

Kevin Pho: So you mentioned that patients with cirrhosis are not going to do as well when they get infected with COVID-19. Now, what is it specifically about cirrhosis that makes that a poor prognostic indicator if they get admitted with COVID-19?

Manish Thapar: I’m talking mostly about patients who have decompensated cirrhosis. If they have ascites or renal failure, if they get COVID, it’s another hit, and it’s just prolonged recovery. They tend to do poorly. So it’s a risk factor for doing poorly, although not as much talked about or researched as other risk factors for COVID.

Kevin Pho: One of the things you mentioned was that providers also weren’t doing well during COVID-19. Can you explain more why that is?

Manish Thapar: I think part of it is, that’s what I write, the toll that the pandemic is taking on the providers. It’s just starting to become apparent. It has taken a mental toll. Everybody is stressed. It’s not easy wearing a mask, scrambling for a mask to start off. I remember when this started, and there was obviously rationing of surgical masks, and I was in the hospital. I sneezed in my mask, and I had to go look for another mask. It’s not good; the system was not set up for this.

So it’s the mental toll; it’s the emotional toll on the providers. I have seen residents, a number of them, between two hospitals that I work at, who’ve been exposed to COVID. Yes, they’re young. Yes, they’ve recovered. But I feel for the residents too.

Kevin Pho: Speaking of your article, let’s transition into that. It’s titled “2020 in hindsight: What we can learn.” Now, for those who didn’t read that article, can you just walk my audience through it and share the story of why you decided to write it?

Manish Thapar: Looking at how health care systems, how the government, how everybody has reacted to the pandemic. Yes, medicine, I believe, still is a very noble profession, and most of us do it to help other people. We call it a wartime effort right now, but nobody is looking at what you’re doing and what actions have been taken to make this a successful effort.

I think, hopefully, with the vaccine, things will get better. It does not give a free pass to everybody who has had a chance to make decisions. We need to understand what decisions they made, why they made those decisions, and how you can make better decisions next time around, hopefully, when this comes around. I think we will be doing a great disservice to ourselves, our patients, and our peers if we don’t have a conversation.

I think physicians are busy and, for various reasons, are very uncomfortable in having these important conversations on where the direction of the health care system should be. So that’s why I thought it’s important to have this written now.

Kevin Pho: Now, we’re about one year into the pandemic and one year into intermittent lockdowns, and we have situations with lack of PPE and everything that we’ve gone through. Now, what are some of the top things that you’ve learned over this past year during the pandemic?

Manish Thapar: I wanted to offer some constructive suggestions in my article, like a starting point: “Hey, listen, this is what we ought to be doing.” I think one of the first things that I mentioned is telehealth. Now, telehealth has been a boon for all of us, for patients. There’s no reason that we should go back to anything less than full and complete coverage for telehealth.

Then I talk about reform for malpractice, a reform for licensure. A lot of governors have taken emergency powers from the pandemic and tried to say, “OK, your license is going to be valid for three years. You don’t need.” They’re waiving off all these requirements. It makes you question: Why were these requirements there in the first place? Why can’t a license be valid for three years? Why does it have to be two years? I have licensure in two states and two DEA licenses. It costs thousands of dollars to maintain. It doesn’t make any sense. So we’re really feeding on an industry which makes no sense, and as the pandemic has shown, it is really of no use.

And lastly, I think the third thing that I mentioned in the article is health care organizations like JCAHO or OSHA, whatever you want to call them. They were missing. Every rule, everything was thrown out of the window in a pandemic, and I’m not saying it should not have been, but it makes you question: What is their role? We need to really sit down, critically examine their role, and see, “OK, this is your role in health care.” And we have to decide as a country, as physicians: How are we going to treat health care? How are we going to take care of the patients? How are we going to take care of the providers?

Kevin Pho: Now, you mentioned three things that you’ve learned over the past year that could use reform: telemedicine, licensure, and medical liability. Now, tell me about telemedicine. What’s its role right now, and how are you using telemedicine?

Manish Thapar: I have been very fortunate. One of the health systems that I work at was a pioneer. They had been trying to pioneer telemedicine for the past two years, and I think within a few weeks, there were up to 70, 80 percent. But other places were not. They didn’t have this on their radar, and they have picked up over the past year.

The point I’m trying to make is, I think there was something introduced in the House to pass a comprehensive telehealth bill. I think that’s the right way to go. I just think insurance companies need to continue paying for it at rates that they pay for an office visit. But in addition, for it to be successful, you need to do away with things like where the patient’s located, and how EMRs are going to be required to cover it, and what’s the method, with HIPAA compliance and things like that. So that whole thing has to be looked at and made sure it’s there to stay.

Kevin Pho: Now, what about medical liability? What kind of reforms do you think need to be done there?

Manish Thapar: Well, medical liability, I think it’s too hot a topic for anybody to touch or do anything about. But I think from a telemedicine standpoint, you have to go for the low-hanging fruit. I am told that I have to be careful when I’m seeing a patient who is not in a state where I hold licensure. So if I see a new patient who is, let’s say, in Washington state, right, I can’t see them, because I don’t have a license in Washington. With telemedicine, you have to look into that, and you have to try to reform that situation going forward.

Kevin Pho: What are some things that we as individual physicians can do to help make sure that telemedicine payments are enduring and make sure that interstate licensure is what you want? What are some things that we can do to help make those changes happen?

Manish Thapar: As physicians, we have to take out the time to talk to the stakeholders, who are the people who are making the decisions: “This is what is needed.” I think whatever organization you’re part of needs to start speaking up: “Hey, listen, this is what’s needed, and it’s needed now.”

The analogy is, this is a wartime effort, right? There’s no reason why there is not availability of masks even a year later. How would you send off soldiers to the war without giving them battle gear? A year later, there’s no reason. Those are the things you need to say: “OK, this is not going to happen. You’ve got to produce the masks.” I think you’ve got to start speaking up and talk to your organizations, your societies, and then make sure the voice is heard.

Kevin Pho: We’re talking to Manish Thapar. He is a hepatologist, and he wrote the KevinMD article “2020 in hindsight: What we can learn.” Manish, we are speaking towards the end of January, and we’re, like I said, one year into the pandemic. What do you anticipate the next three to six months to bring? And I guess, from the suggestions that you recommended, whether it’s telemedicine, medical liability, or licensure, do you see any movement in terms of those reforms in the near future?

Manish Thapar: I think the biggest thing that physicians need to talk to and advocate for is reforming the medical licensure system. There was some movement. I think 25 states banded up and said, “OK, there should be reciprocity of licenses, especially in contiguous states.” If you share a border, there’s no reason why physicians should be mandated to have licensure in each individual state. They should be mandated to accept each other’s licensures on reciprocity. Ideally, you would have a national licensing system, where you’re not confined within the country to go anywhere and practice. I think that should probably be the next step.

And then I think it’s probably going to take a lot of pressure on the federal government to look at these licensing organizations, which deal with hospitals and health care systems, to assess their role from top to bottom. You’ve got to look at them and see what they did and what they did not do, or what they could do better.

Kevin Pho: My final question: Do you have any take-home messages you want to leave with the KevinMD audience?

Manish Thapar: The health care system is very complex in our country. Physicians and providers still play a key role. I would encourage everybody who reads to speak up, and, like you say, if you see something, you say something. That’s the only way you can say, “OK, this is how change is going to be made.” Otherwise, the next time we have a situation such as right now, we will be in the same boat, if not worse.

Kevin Pho: Well, thank you so much for sharing your time and insight, and thanks again for being on the show.

Manish Thapar: Thank you for having me. It’s an honor.

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