‘We’re just not where we need to be in terms of supplies and testing’

The Trump administration and governors are weighing options for how and when to reopen parts of the nation. Even as some localities see a flattening of COVID-19 cases, concerns persist over the nation’s capacity to test, trace and isolate. “Without sufficient testing capacity, we cannot know which patients and communities are most at risk, where Dr. David Skorton the virus is spreading,” Association of American Medical Colleges CEO wrote in an April 13 letter to White House coronavirus task force coordinator Dr. Deborah Birx. Skorton, who has led the AAMC since July 2019, spoke with Modern Healthcare Managing Editor Matthew Weinstock about some of the key factors policymakers need to consider as they eye reopening the country.

MH: I know you have a broad membership, but what are you hearing from them in terms of their biggest challenges right now?

Skorton: No. 1 is that people are having to do things in a different way and with a different sense of urgency than they’ve ever done before in their careers. That’s a strong statement when you think about the breadth of careers represented in our membership, and even thinking about my own history of practicing medicine for decades and, for a while, running an intensive-care unit and so on. People are having to readjust expectations and thinking to deal with an unprecedented-in-our-lifetime kind of event.

The second thing that I’m hearing, unfortunately, is a set of concerns about things that are getting in the way of them doing an optimal job of (taking) care of patients, (detecting) the disease, (preventing) the disease, (treating) the disease.

There’s no vaccine. And even though there’s been a lot of talk about antibodyrich plasma from those who have come out the other side well, which is most people, it’s not available; but there are clinical trials being done. So you understand the frustration of physicians and other healthcare workers who are used to being able to attach a specific response to a specific problem. We’re mostly doing supportive care.

Third is the lack of certain things that we need to do an optimal job.

(Personal protective equipment) is a big one of course, and testing … that we need to do is still not as widely available as it needs to be. As the country begins to consider relaxation of some of the mitigation strategies like social distancing … we’re going to need testing more than ever because we’re going to have to do surveillance on what’s happening in the population, tracing cases when they do come up because they will come up. We’re just not where we need to be in terms of supplies and testing. That has been very frustrating for those on the front lines.

MH: You recently sent a letter to Dr. Deborah Birx and the coronavirus task force laying out some concerns on the shortage and adequacy of testing equipment.

Skorton: I do want to express my gratitude to Dr. Birx for reaching out to us.

We had a very important call with her.

The reason I sent the letter … was to lay out our concerns and make three suggestions: a web portal (to let labs report shortages); for more active work by the federal government in managing the supply chain, not just keeping track of it but managing it; and then increased transparency about what’s going on and where there are going to be roadblocks to testing based on the lack of supplies.

There is a cascade of things that have to work to do one of these tests. You have to have the machine of course to do it. You have to have the swabs to get the specimen, and many of those swabs in the earlier part of the pandemic were made in northern Italy. So you can just imagine the difficulty there with the supply chain. Then once you get the specimen, you have to use a transport medium to get it from the patient to the lab. Then you have to have all the supplies to run it, including reagents to extract virus RNA, and then, of course, the person who’s got to run the

machine has to be trained and has to have PPE. All these things need to be done more aggressively than are being done.

MH: COVID-19 has had disproportionate impact on minorities, African Americans in particular, given some of the underlying health disparity issues. How do you think this crisis will impact data collection and health equity overall?

Skorton: My fondest hope is that we do not go back to business as usual as a sector.

The coronavirus didn’t cause these inequities. These inequities were extant for generations. Some of them are based on the way we do healthcare coverage and access in this country. And then secondly, of course, there are generations and generations of structural racism in the country that have affected the African American population and immigrants.

When you add up all these things and mix into that the social environment, whether or not there is availability of healthy food choices and so on, then the odds are stacked against vulnerable populations. And then you add in … the fact that you have an enormous homeless population. How do we tell people to shelter in place when there’s no place to shelter in?

All of these things set the stage for something like the coronavirus pandemic to come in and exacerbate these preexisting tendencies for the country.

What we have recommended is a need to change the data collection system and develop a national standardized system that accurately captures race and ethnicity data; that we develop these kinds of data collection procedures in concert with our communities. Ask them what will work and collect granular data, not just ZIP codes, but go down more granular to the crowded neighborhoods, which sometimes exist within a single ZIP code, so we can better understand what people are facing.

MH: Looking more broadly, how are AAMC members thinking about returning to normal, or semi-normal operations? Are those conversations happening yet?

Skorton: It’s a daunting challenge, no question about it. But we are going to begin to see people brought back into the healthcare system who had been considered elective. For example, people who have a stable, but complex disease may be brought back in soon for ambulatory care. I’m a cardiologist and let’s imagine someone who has coronary artery disease, maybe has had a couple of heart attacks, also has high blood pressure, diabetes, maybe has a history of smoking or is still smoking. This is a complex management challenge. These people can be brought back in and leaders are discussing this sort of phased recovery of operations.

Now to do that, however, brings us back to the testing issue because the fact that we’ve known since January roughly that this disorder can be spread by people who are completely asymptomatic means that as we start to populate elective procedures, we have to protect the healthcare workers. We have to not overwhelm the staffs of these hospitals and health systems and need to make sure, of course, that there doesn’t end up being competition for PPE and other supplies between those caring for patients with COVID-19, and those caring for people who don’t have COVID-19.

And it is very important that we don’t forget the pressure, the stress that the workforce is under, not just the emotional stress of dealing with so many sick and dying people, not only the emotional stress of not having adequate PPE and the concerns about getting the virus themselves or bringing it back to their families or taking it to the next person they see, but also just the sheer physical exhaustion of what the work demands. We have to make sure that we pay attention to that factor as well. But the key elements will be a phased approach and a locally determined approach.

MH: What short- and longterm impact do you see the crisis having on residency programs?

Skorton: The residency programs are continuing to operate, but they’re thinking also about changes that may have to occur.

I’d like focus on the whole continuum of preparing the workforce of the future. We’re still predicting (a physician shortage) somewhere between 40,000 and 120,000 over the next decade roughly.

We’re going to bump into a bottleneck at residency training and we’re still living under a restriction of Medicare funding for residencies that’s been in place since roughly 1997 and we really need to move beyond that now so we can fully train all of those people who are getting through medical school.

One of the things we can learn from the COVID-19 epidemic is that we need all hands on deck to succeed. I hope we get to the point (after the pandemic) where we can (continue to) increase the scope of practice, obviously carefully, for experienced nurse practitioners, physician assistants and everywhere you are in the healthcare workforce, to the extent of your ability and training and not have artificial limitations. We also need more physicians, more residency slots. I think we need to have people (participating) to the greatest of their ability and increased scope of practice as makes sense. We’ll come out all right on the other end, but we have a lot of work to do. ●

“The coronavirus didn’t cause these (health) inequities. These inequities were extant for generations. Some of them are based on the way we do healthcare coverage and access.”