Responding to the COVID pandemic: a lesson in coalescence [PODCAST]

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes

“When faced with an existential crisis, any organization, as large as a nation or as small as a marriage, will go one of two ways. Either it will bond together, coalesced in a common purpose, or it will collapse in a spasm of blame and shame. While our health care institutions displayed the inestimable value of coalescence, our political leaders demonstrated the catastrophic impact of divisiveness. And our national statistics confirm the result. More than a half million deaths to date from a preventable pandemic.

Is there any hope for our nation? Can we learn an important lesson from the health care industry? Can we find the will to coalesce as health professionals have done? I believe we can. We have done so many times in our history, and the current administration is already displaying a penchant for facing the truth, learning from science, and promoting the collaboration needed to overcome our common foe. Coalescence. Let’s support our leaders in this welcome change.”

Nate Link is chief medical officer, Bellevue Hospital, New York City, NY, and author of  The Ailing Nation: Lessons from the Bedside for America’s Leaders.

He shares his story and discusses his KevinMD article, “Responding to the COVID pandemic: a lesson in coalescence.”

Did you enjoy today’s episode?

Please click here to leave a review for The Podcast by KevinMD. Subscribe on your favorite podcast app to get notified when a new episode comes out!

Do you know someone who might enjoy this episode? Share this episode to anyone who wants to hear health care stories filled with information, insight, and inspiration.

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 Nate Link. He is an internal medicine physician and chief medical officer of Bellevue Hospital in New York City, and he’s the author of The Ailing Nation: Lessons from the Bedside for America’s Leaders. He wrote the KevinMD article earlier this year titled “Responding to the COVID pandemic: a lesson in coalescence.” Nate, welcome to the show.

Nate Link: Kevin, thank you for having me on your podcast, and thank you for hosting your website, which gives doctors like me a chance to voice our views.

Kevin Pho: Wonderful, and thank you so much for your contributions and for being on the show. We’ll talk about your book and article in a little bit, but first off, can you share your story and journey to where you are today?

Nate Link: Yeah, sure. Well, as you pointed out, I’m an internal medicine physician, and I have spent my entire career, almost four decades, at Bellevue Hospital. Bellevue Hospital is a public safety-net hospital in New York City. It’s the oldest public hospital in the United States; in fact, it’s almost 300 years old. In my long tenure at Bellevue, I spent much of my career learning and teaching about the topic of evidence-based medicine. At the same time, I grew in my leadership role year by year. I became chief of medicine at one point, and now I’ve become the chief medical officer for the hospital as a whole.

Along the way, I learned many lessons in leadership. I often learned the hard way, but I’ve come to realize that the health care setting has become very advanced, evolved, if you will, in its approach to leadership: for example, the way we use evidence to make decisions, the way we handle mistakes, the way we promote quality and safety, and the way we treat patients and staff. I think it’s very impressive, the level, the standards that the health care world has achieved in this regard. I’ve also come to recognize that our political world is nowhere near close to this in standards, just as I have mentioned.

So, being cognizant of this gap, I decided to write the book. The book is essentially stories from Bellevue, where each chapter starts with a story leading to a lesson in leadership, which I then translate to the political world of our nation’s leaders. One of the lessons is coalescence, which was the topic of my article on your site.

Kevin Pho: Wonderful. So let’s transition straight into that article first, “Responding to the COVID pandemic: a lesson in coalescence.” Now, for those who didn’t read the article, Nate, can you just walk my audience through it and share the story of why you decided to share that particular one?

Nate Link: Yeah. So this is a true story, and it goes back to approximately a year ago, when COVID was about to descend on New York City. I think we were all aware that we were about to be swamped by a tidal wave of COVID patients, and at a crucial time in mid-March, we realized that we were going to have to truly transform our hospital to accept that challenge: transform it by reconfiguring all of our spaces to create much more inpatient space, and redeploying all our staff into new roles. We would have to do that almost on a dime; we literally had just a couple weeks to get ready.

So, for example, we moved all of our ICU patients off the ICU floor. We closed down the surgery, we closed the ORs, we moved our ICU patients into the recovery area, and then we converted our entire 56-cubicle ICU floor into a COVID ICU floor. Each of the cubicles was converted into a negative pressure space by the installation of some HEPA filters and some exhaust fans, and literally, as we converted each space, it got filled with a COVID patient. They came flying into the ED, on death’s door basically, in huge numbers, but we had stood up a couple hundred extra patient rooms very quickly to handle that.

At the same time, we deployed all our physicians. The surgeons became medical doctors, the medical doctors became COVID specialists, the ophthalmologists joined the ICU team, the neurologists ran a medical team, and the orthopedists became the proning team, turning patients prone and supine every day to improve their respiratory status in the ICU. The anesthesiologists became proceduralists to support everyone else. So between the doctors and the nurses and all the facility staff, the whole hospital came together, and we were able to take that hit without really compromising our standards.

By the time that wave had passed, we were breathing pretty hard at that point, feeling pretty good about ourselves, and then we looked around the outer boroughs and saw that it was much worse in Brooklyn and Queens and the Bronx. The hospitals were still just overrun, especially in their EDs. So then we did a remarkable thing. With the support and encouragement of our system leadership (we are an 11-hospital system in New York City), we began to bring transfers in to our hospital, patients with COVID, to add to our census. We took 10, 15, 20; we started taking 40 patients a day, and over the course of several weeks, we brought in 600 patients from other hospitals into our hospitals, on top of what we had done.

And we weren’t the only hospital. Every hospital in New York City was faced with this, and we were all having similar challenges to overcome, and did so, actually. But because of that, we were able in New York really to manage what was the greatest challenge, I think, of the last hundred years in the city, health care-wise. I do feel like the great lesson of what happened was the way we pulled together. Everybody gave up every selfish interest, every territorial concern, to move in alignment with the greater goal of the hospital, which was just to take care of these patients and save their lives. And the way health care institutions do this, not just from this example but many others, I call this coalescence. It’s the alignment of forces, and it’s one of the important attributes of leadership to bring that about when you’re facing a great challenge, whether you’re an organization or a nation.

Kevin Pho: Now, this is such an inspiring story on so many levels. This is a once-in-a-century pandemic, and there’s obviously no playbook that hospitals have to go by to tackle something like this. So as you were going through the worst part of that pandemic last year and bringing everyone together, can you share some of the challenges that you faced specifically and what you did to overcome those challenges?

Nate Link: Well, I’ve learned this over my career: One of the biggest challenges in a crisis is alignment, and to achieve that, you need great communication. In my book, I tell the story of Superstorm Sandy, which was another huge challenge, where we had to evacuate our hospital completely, under great duress. I remember after that was all over and done with, I regretted that we had not done a better job of communicating across the hospital every step of the way as we coped with that disaster. When COVID came along, I was determined that we wouldn’t make the same mistake.

So this time around, when we began to activate our great transformation, we set up a lot of communication links, but one of the things we did was to have a daily one-hour huddle of all the hospital leaders, over 100 people, every morning for a hundred straight days. Every item of concern was addressed, brought to the table, dealt with, and shared, and with mutual problem-solving, our leadership came together. At the same time, every evening we had an hour-long meeting, a huddle over Webex actually, with all of our physician leaders, and we dealt with all the clinical questions, again as a big team. This communication, doing this work all together, is the example of coalescence that I’m talking about, and that’s how we overcame that challenge.

Kevin Pho: We’re talking at the beginning of April, and hopefully we’re near the tail end of the pandemic. Now, looking back at the past year, is there anything that you would have done differently if this were to happen again?

Nate Link: I’ll tell you, I’m not sure we would do anything differently. I’m really proud of how we handled it. But I do recall, in our planning, and this is interesting to note, back in January a year ago, when we first heard about the Wuhan virus, we had a big discussion about what we would do if we had a COVID patient. We worked that all out, and then somebody said, “Well, what if we get two patients?” Then, as time went on, we began to say, “Well, we might get 20 or 30 patients,” but no one imagined that we would someday have 400 patients at once with COVID in our hospital, which is what happened a year ago on Easter Sunday. So I think in future planning, I’m going to try to have a little more of an expansive view of what the possibilities are as I’m beginning to consider an impending disaster.

Kevin Pho: In hospital systems, and especially those as big as Bellevue, normally there are factions, people are siloed, and I’m sure there are some points of contention between state administrators and physician leaders, and even between different departments. Now, during that time when you all came together, were there any points of contention that had to be overcome between different parts of the hospital?

Nate Link: So in real life, in normal circumstances, that is all true. We have our typical silos and turfs and battles, all in good faith, but definitely lots of tension and sometimes conflict. I’m going to tell you honestly, in this COVID response, there was not an ounce of that. I think disasters do bring out the best in people, as kind of a selfless quality, but people who work in a safety-net hospital are mission-driven. We definitely had the right leaders in place. At no point was there any obstacle in the way of our alignment and our coalescence, and it almost brings tears to my eyes to think about the way people came together.

But I want to say that one of the reasons I wrote this article was to contrast our health system and hospital culture with national leadership. In truth, our national response to COVID was anything but coalescence. I mean, we’re all aware; we can pick on Trump in particular, but from the very start, there was a denial of the truth. There was a desire not to test because positive tests would make the government look bad. There was no attempt to bring all of our states together into one uniform response, so states were competing with each other for supplies and staff. And then it even became a political bone of contention: lots of division about PPE and wearing masks and social distancing. It almost became a red state versus blue state thing. So instead of coalescing as a nation, like we normally do in a war, which this pandemic absolutely is, it’s a war, our leaders took steps that led to divisions developing, and we lost that alignment, and it crucially hurt our response.

Kevin Pho: We’re talking to Nate Link. He is an internal medicine physician and chief medical officer of Bellevue Hospital in New York City. He’s also the author of the book The Ailing Nation: Lessons from the Bedside for America’s Leaders. Nate, as I said before, we’re speaking at the beginning of April, and we’re hopefully toward the tail end of the pandemic. What do you see are the remaining challenges that we face going forward?

Nate Link: Well, I think our first big challenge is not to be complacent, because it’s not over. We have these variants developing. We’re trying to get the vaccine out; it’s really a race, and it’s crucially important that we knock down the burden of virus in the population so it doesn’t form new variants. But if you’re following the news, you saw that yesterday there were 70,000 new cases of COVID. There were a thousand deaths just yesterday. So the point here is that this is far from over, and as people begin to relax, I’m just afraid there’s going to be a resurgence in the virus.

Kevin Pho: All right, let’s switch over to your book now, and like I said, it’s titled The Ailing Nation: Lessons from the Bedside for America’s Leaders. Now, from an individual clinician standpoint (and I have a lot of individual clinicians who listen to this podcast, and I’m an internal medicine physician myself, and I practice in a small community hospital in New Hampshire), what are some of the leadership lessons that physicians can take away from your book?

Nate Link: Yes, OK. Well, I hope, you know, the first two chapters of my book are entitled “Atonement” and “Forgiveness,” which is an unusual topic for leadership, but I think one of the important lessons for physicians is how to handle mistakes when we make them ourselves and how to handle them when others make them. And I think, again, the health care world is quite evolved. I know you’re familiar with morbidity and mortality reports, which are a way that physicians confront mistakes and share, where a person who had a bad outcome with a patient presents their case to a group of colleagues, tells the story, and shares what they wish they had done differently.

In days gone by, in the early part of my career, the M&M conference was something like a trial. We picked people to present a case in a way to sort of punish them for the crime, you might say, and the consequence of that was that people were afraid to admit mistakes. They kind of hid things and went underground. But over the years, we’ve evolved to a much better culture, where we don’t blame and shame but actually offer support to people who make mistakes, and the M&M conference has become educational. So when that person comes forth and shares their case, the discussion is about the education of everyone in the room. We empathize with the presenter, we thank them, and in a way, that sharing of their mistake and the education of others is an exercise of atonement, which helps people feel better about things.

This has become a standard in hospitals across the country, and it’s a change in culture. We now use this term called the “just culture,” which is an approach to leadership that recognizes that our staff, our professional staff, are always trying to do the right thing, and when things go wrong, it’s not because they’re being malicious. In fact, they usually feel worse than anybody. So the goal in a just culture is to support people who experience mistakes and to learn from those mistakes in a way so that they don’t happen again, from anybody’s point of view, and that approach tends to focus on systems changes, finding defects in a system that failed to support somebody.

I gave an example in my book of a nurse who failed to answer an alarm that went off for an ICU patient, and because the nurse did not respond, the ventilator malfunctioned and the patient died. Everybody immediately blamed the nurse: She didn’t do what she was told. It looked like a malicious error, a failure of her duty. But when we talked to her colleagues, we learned that they had all stopped answering the alarms because they went off constantly, day and night, just for every little thing. The alarms wouldn’t stop going off, so the nurses had alarm fatigue. That was a system problem; it really wasn’t the nurse’s fault. Once we realized that, we fixed the defect. We fixed the alarm so they didn’t go off constantly, we retrained the nurses so they respond appropriately, and then we monitored everything. In the end, it all got better, because we didn’t focus on blaming and shaming a person but focusing on a system.

This approach is called the just culture, and I think physicians are not all aware that this is a standard now in hospitals. The goal of a physician should be not to make mistakes if they can help it, but to understand, if they do, it’s human, and there’s a way past this that can restore their good sense of themselves and help others not make similar mistakes.

Kevin Pho: Now, Bellevue Hospital is such an iconic institution, and you did mention that you spent most of your career at Bellevue. What’s something about Bellevue that we may not know about?

Nate Link: I don’t know if people know the history of Bellevue. It’s an incredible history. It started as an almshouse in 1736, but by the mid-1800s, it was one of the leading medical centers of the world. Bellevue has many stories of interactions with U.S. presidents, actually. Many surgical techniques were developed at Bellevue. We had the first hospital-based ambulance service, the first maternity ward; there are many firsts for a hospital this old. It was one of the first hospitals to treat psychiatry as disorders of illness, as opposed to bad behavior. The history is so rich, even people who work at Bellevue are not so familiar with the stories. But I felt that our response in the COVID epidemic, our response to Superstorm Sandy, and our response to AIDS, which was one of the other big challenges of my career, are all part of Bellevue’s legacy as the first-line hospital defense in New York City.

Kevin Pho: OK, my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Nate Link: Well, I started in the hospital in my book, and I went to politics, in the world of national leadership. I want our voters, my colleagues who vote, fellow citizens, to think of their role in voting as being the board of directors for our nation, the people who pick our leaders, and to think about attributes of leadership that are crucial to governance, like facing the truth, accepting evidence and science, accepting mistakes, admitting mistakes, forgiving others, having a just culture, and achieving coalescence. I think the most important role of a leader in leading a nation to face a challenge is the ability to align and coalesce the people, and I think our voters need to keep all this in mind when they go to the polls.

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

Nate Link: Thank you.

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes