COVID: Where Do We Go From Here

Program announcer

Welcome to the Peds Ethics Podcast, where we talk to leaders in pediatric bioethics about a hot topic or current controversy. Here's your host, John Lantos, from the Children's Mercy Bioethics Center in Kansas City.

Dr. John Lantos

Hi, and welcome back, everyone. This is John Lantos from the Children's Mercy Bioethics Center in Kansas City, Missouri, with our Pediatric Ethics Podcast. We're thrilled to have with us today Dr. Sherry Barkin, who's the William K. Warren Foundation Chair in Medicine, the Marian Wright Edelman Professor of Pediatrics and Director of the Division of General Pediatrics at Vanderbilt University. She's done a lot of work on violence prevention, obesity prevention, and I'm sure has been involved with the COVID epidemic. Thanks so much for coming on, Sharon.

Dr. Shari Barkin

It's my pleasure. Thank you for the invitation.

Dr. John Lantos

Can you tell us a little bit about what the COVID pandemic has been like there at Vanderbilt in Nashville?

Dr. Shari Barkin

I think what is shared across the country is that everyone is quickly reinventing the work that they do to benefit the patients that they serve. And the work that all of us are doing across the country is maximizing access to care that's needed at the right time for families. And this looks like for us reinventing primary care in a hurry and ensuring that we are baking in focus on health equity and access.

Dr. John Lantos

So what does that actually look like? How has care changed? Maybe you could start by telling us a little bit about your division of general pediatrics, how many docs, how many sites, and what it looked like before.

Dr. Shari Barkin

We serve more than 18,000 unique families in the Division of General Pediatrics at Vanderbilt University Medical Center. They come from diverse populations, largely underserved Medicaid-insured populations. About 40% of our families are non-English speakers, and we are a site...

Dr. Shari Barkin

where we're educating the next generation of pediatricians. We have more than 72 pediatric residents that are providing care. We also are connected to the Vanderbilt University School of Medicine and the Meharry College of Medicine as well. So it's about bringing in students to train them about delivering high quality primary care as well as our resident integrated clinics. We serve as a medical home, so we are really addressing comprehensive, coordinated care to maximize good health outcomes for our families, many of whom have a disproportionate burden of chronic conditions such as asthma.

Dr. John Lantos

And have you seen many COVID cases?

Dr. Shari Barkin

Well, we were all ready. The whole idea here is not to panic. It is to be prepared. So the institution across the medical center, pediatrics and medicine, we, as many of us across the country, you roll your sleeves up and you say, what does it mean to be prepared? As we were preparing, we clearly were seeing the data coming out of the countries that had been hit by COVID before us, recognizing that children seem to be, in general, the winners for COVID, not true for other common... infectious diseases like measles, but very true for COVID. And we saw that reflected here with not many of our pediatric patients testing positive for COVID. However, their parents could test positive and certainly their grandparents. So our goal was about prevention to ensure that we reduced the likelihood that our patients who were more at risk would be affected by COVID, such as our medically complex kids. So to answer your question, very few COVID positive pediatric cases, even fewer that required hospitalization.

Dr. John Lantos

But there were some unintended consequences, maybe unforeseen consequences for the general peds clinics and population of patients who served?

Dr. Shari Barkin

Well, what's interesting, when you look through the lens of COVID, It means that you're trying to detect any cases and keep your children safe so that they are not exposed to COVID. But what gets lost is everything else that needs to happen. We are not only receptacles for the virus of COVID-19. functioning human beings and especially for children. We want to ensure that you are developing and growing correctly, that any issues, medical issues that could be detected early are detected early, that are not COVID related, and importantly, that you stay up to date on your immunizations. While we are waiting for the immunization for COVID-19, we want to ensure that our families receive the immunizations we already have to keep them healthy and safe. Ultimately, we want to prevent an epidemic on top of a pandemic.

Dr. John Lantos

So what were the biggest challenges in trying to keep kids healthy as this thing swept through communities and shut down the economy, shut down a lot of clinics? Did you develop some online programs or other ways of reaching families?

Dr. Shari Barkin

We fired on all cylinders trying to identify ways to reach our families with accurate information. to be able to create ease of access. So if they needed to be seen, we could fast track that in a safe way. And also to really stand up telemedicine for families who were unfamiliar with technology. They might have less access to internet. They might have less technologic literacy. And they still had the same need for the potential of telemedicine. So to address this, we did many things. The first is we examined how we could reach our families who needed to be reached safely with telemedicine. And that created a whole series of N of 1 trials. And each thing we did, we learned forward together. We created it in a systematic way so we could collect data. And by the end of the day, we could look back to say what worked for whom, how, and when. And that allowed us to learn forward to try to better hone how we could create telemedicine that was accessible to our populations. The second thing that we did is we ensured that we were open for business. Of course, if you are in medicine, you're never closing your doors. You're just changing how you get in to the system to ensure that things are as safe as possible. So we continued to have a triaging process where it started with telephonic triaging. It could then be escalated to telemedicine if appropriate and if families could access that modality. And then it could be escalated or elevated to in-person care. The next thing that we did is we re-engineered our space. So there is nothing sacred about how we set up our space. We have to work, and I really call this thinking inside the box for our team. You've got the floor plan that you have. How do you use the space and the staffing and the time wisely and well to meet the needs of your patients? So, for example, is there even a need for a waiting room? There's nothing sacred about a waiting room. So how do we re-engineer that and, whenever possible, skip the waiting room? So that was a lot of trial and error, and especially working with our medically complex kids. We never wanted them to be in the waiting room. We wanted to find safe, easy ways right into the exam room. And that's reengineering the space. The fourth thing that we did is we looked at how we could create accurate education to our families in the community. And that meant that we were curating what information was out there that was true knowledge and how we could reach our non-English-speaking families as well as our English-speaking families working with our partnerships in the community. So that could be faith-based communities. It could be community centers or libraries. But we activated all of our community networks so that we could create digestible, health-literate, health-numerate information and then language consonant information that we could connect and disseminate through our community partners. That was really important and still in many ways is the most important foundational thing that you can do because we're not done with a pandemic. We are just moving through it and ensuring that you're building a foundation that you can utilize to connect to your families with accurate information is foundational and critical.

Dr. John Lantos

How many of these changes do you think will be permanent, will last beyond the pandemic?

Dr. Shari Barkin

I am fond of saying that this isn't a Band-Aid. We're not trying to identify how we put a Band-Aid on a wound. We're actually striving to build a bridge forward. And there is nothing like a pandemic to push innovation forward and to allow us to do things we couldn't have done before. For example, we were given the opportunity to construct and redesign telemedicine with our families in their home setting. That just wasn't possible before the pandemic. That allows us to then look at primary care through a different lens. In fact, there are many conditions that could be better served with telemedicine. There isn't anything that says that every visit needs to be served in the same way. I believe we're building a bridge to redesigning primary care. And many of the things that we're learning will bring us to a different structure to deliver this type of care in a way that if we do it right and intentionally should improve access and quality to our families.

Dr. John Lantos

Yeah, I'm hearing that as a theme in a lot of the conversations that we're finding not just different ways of doing things, but better ways. A lot of people are starting to question why we didn't do some of these things before. When you're collecting data on the

Dr. Shari Barkin

telemedicine

Dr. John Lantos

visits, what sort of lessons are you learning? Are you starting to develop triage algorithms where you know which patients can better be served by telemedicine and who needs an on-site visit?

Dr. Shari Barkin

We're learning many things. So telemedicine... sounds like it should be the great equalizer, especially if you can reach people in their homes, until you begin to look at all of the other elements that need to be in place for it to work effectively. You need broadband access to Internet. You need a device that is stable. You need to know how to maneuver and utilize that device. You need to have clear access to multiple languages. And those things don't exist equally throughout the community. So we began to learn quite quickly which types of technologic platforms seem to be most useful. And anytime you had to download an app, that created burden and confusion. Anytime you needed to follow a multi-step process, that created a lot of confusion. striving for one-click access that brings you into the virtual waiting room, that is a winning strategy. We learned that you also needed to create clinic flow that looked different using our staff and our clinic team in different ways. So our nurses and our medical assistants were now being utilized to reach out to families ahead of time to prepare them for the visit. and to prep them 15 minutes ahead of time the way that you would if you were coming into the clinic and you were called back to be triaged. But this too doesn't work equally for all populations. And understanding that while we are moving in really good directions, we won't be able to create systems that are one size fits all. We're going to need to create adaptability to match people and meet them where they are. So that means that some of our families, we have been able to identify when telemedicine serves you and it's completely accessible and works for you. And those are the ones that we can create triage to say if you are able to match the need of the patient with the technology that they have and this is a specific type of issue that can be better served with telemedicine, that's a triage tool. If instead you don't meet all of those, you can't pass through all of those gates, then we want to fast track you in a safe way to be seen in person. So the key lesson here is to simplify and to understand where your patient is coming from. It's not merely the chief complaint. It's the context of the patient.

Dr. John Lantos

Sounds like it could lead to a much more personalized approach to delivery of primary care.

Dr. Shari Barkin

I agree. I think that that's the hope, is that ultimately you understand the context of your patient. You look at the interaction of chief complaint and context of your patient to find the best way to deliver the care to maximize good outcomes.

Dr. John Lantos

That sounds very exciting. There's been a lot of concern about children's mental health during the pandemic. Children are home. The schools are closed. They don't have a lot of their social networks or contacts with friends. Have you developed programs to address children's mental health needs?

Dr. Shari Barkin

Mental health is so important. Even pre-COVID, we knew that there was an increase in children's anxiety, depression, and suicidal ideation. So you take that as a pre-COVID background and you add to it all of the anxiety that everyone naturally feels as we're swimming in these uncertain waters. It's so important to recognize that we in the healthcare system don't exist to solve all problems in isolation. We exist to be active partners with the larger community. It's very important that we don't see ourselves in isolation as the only problem solver, but that healthcare works in partnership with the many community organizations that makes a society strong. What we've been doing is working with many of our community partners. That includes schools, libraries, parks and recreation, a lot of our food banks, such as Second Harvest Food Bank and the Nashville Food Project. You need to remember, and for your listeners, in Nashville, not only are we dealing with the pandemic, but right before the pandemic started to surge, we had a series of tornadoes, and it's taking time to rebuild our communities. In fact, if you were to ask our community what concerns them the most, it's the devastation of the tornadoes, plus the challenge of maintaining economic security during a pandemic. So working with our partners, we have been able to generate a whole series of new ways to reach our families. And I'll just give you one example. Currently, my division of general pediatrics is working with Parks and Recreation and Head Start, and we're developing summer virtual programming. And we're doing that for different age ranges as well, working with our partners. This allows us to create grab-and-go meals that families can receive that are healthy, as well as linking them to pro-social, pro-active, good-for-your-body-and-mind programs experiences, and activities, really looking at children in the context of their families and families in the context of their community.

Dr. John Lantos

Your message seems much more upbeat than a lot of the things I've been hearing on the news and even some of the interviews I've been doing with other medical center leaders. As you look ahead, do you think we're going to come out of this better off than we were before?

Dr. Shari Barkin

I wish I had a crystal ball. I don't know what it looks like when we come out of it. I think that the process is the product and being intentional about what we believe we want to create as a resilient society is critical. And we can't know what the end looks like, but we can know right now what the middle looks like and be intentional about what are the bridges that we're building, a bridge to what, and how would we get there. And how do we stay accountable? One of those elements, I would say, is a real focus on equity in general, health equity, and how we bring health back to health care. And that needs to be intentional. So this is a moment in time that is incredibly challenging. And it's also a shared human experience. So how do we take our resources to create the best possible possible outcome with what we have right now. It certainly won't be perfect, and we won't be able to fix everything that we need to fix. And in some cases, we don't even know what that will look like. But we can make good decisions now to build a strong foundation. So as we're building that bridge, we end up in an intentional place that benefits children's health.

Dr. John Lantos

Well, the children of Nashville are lucky to have you there helping to develop these programs and guide them through this tough situation. We've been talking to Sherry Barkin, who's director of the Division of General Pediatrics at Vanderbilt University and the Monroe Carroll Junior Children's Hospital there in Nashville. Sherry, thanks so much for taking the time to talk to us.

Dr. Shari Barkin

Thank you, John. What a pleasure.

Dr. John Lantos

And this is John Lantos and the Pediatric Bioethics Podcast from Children's Mercy Hospital in Kansas City. Thanks for listening.