COVID-19: What Spring Whispered to Winter

Reflections on fragility and agility in the face of a pandemic

A few weeks ago, a group of physicians gathered to discuss and reflect on the unfolding of COVID-19 in Canada this spring. While the population braces for more uncertainty as the season changes, the following thoughts borne out of their exchange aim to provide some insight into managing the next phase of the pandemic.

Q: To date, how would you assess the medical services provided for patients affected by the virus?

A: We would propose that this question is best asked of the more immediate stakeholders: the patients and their families. We can only propose an answer from our privileged perspective. Portugal, which showed a contagion curve comparable to Canada, has a 3.6% case-fatality rate. Quebec and Montreal have much higher case-fatality rates: 9.9% and 12.4%, respectively (as of July 16, 2020). The municipal figures are worse than Mexico’s (11.9%) and Spain’s (11.2%), and are close to those of Italy (14.4%). We have amassed a high number of fatalities despite two months of lead time, closed borders, and strict lockdowns. Overall, we were unable to capitalize on our experience with SARS.

Q: How should we allocate health care services and resources among COVID and non-COVID patients in the future?

A: Based on the Pandemic Influenza Plan, developed in 2005 and refined in 2009 and 2017, “there should be no difference in allocating scarce resources between pandemic patients and those with other medical conditions.” Accordingly, COVID and non-COVID patients should be triaged and treated equally. During the spring, a disproportionate amount of resources were allocated to COVID patients at the expense of others.

This is not specific to Quebec or to the post-COVID era—it is a long-standing global phenomenon. Domestically, Canada’s Security Intelligence Service (SIS) established the federal Integrated Threat Assessment Center (ITAC), which morphed into the Integrated Terrorist Assessment Center after 9/11. In its post-9/11 policy, from 2004, terrorism had been propelled to the top of the list of eight major national threats; a global pandemic was listed last—barely making the cut. Now, in 2020, we have witnessed firsthand how a pandemic can ravage society, at every level.

Q: As we prepare for the first winter with COVID-19, what should be done to prevent widespread outbreaks?

A: This pandemic is first and foremost an infection control challenge; then, it is a resource management challenge. We have learned many lessons from the past few months; one of the most important is that an infectious disease specialist, who is in charge of infection control, should be placed in each institution and that we need to provide them with all the resources required to perform their job optimally. These specialists should be included in every planning committee and their instructions should be the final say on all matters. In other words, no zoning, staffing, bed planning, or PPE distribution measures should be explored—much less approved or adopted—without their complete approval and guidance.

The rest of us should practice eyes-on, hands-off leadership: while ceding control and planning to local infectious disease experts, we must remain ever more vigilant about our own team’s decisions and front-line events.

Once we manage infection control and preventable outbreaks, human and protective resource management become much easier. Putting local infectious disease experts at the helm of our response operations is the second most important change required.

Q: What would you change to provide better medical care to patients in your local hospital?

A: An essential shift will be reframing the way we describe the pandemic. “The way we speak defines the way we think.” The language used to describe a problem and how a question is asked can have important effects and limitations on our cognitive processes, as well as on the responses and solutions that follow. We would offer the following propositions.

The fallacy of the second wave

The term “second wave,” albeit universally used, may be deceptive. What awaits us this winter will most likely be very different from the past spring. What will ensue has never happened in the history of the world. The first wave of SARS-CoV-2 hit a relatively intact planet at a different time of year—in our case, at the end of winter.

What comes next has some distinctive features: It will be the first SARS-CoV-2 epidemic in Canada to begin at the start of winter; It will unfold concurrently with the annual seasonal flu; It will impact an already financially-ravaged society; It will affect a population weakened by more advanced cancer, diabetes, and cardiac disease due to delayed services; And it will be handled by a health care workforce debilitated by physical exhaustion, chronic psychological distress, and professional demoralization.

A reasonable worst-case scenario predicts that the number of COVID-19-related hospital deaths in the United Kingdom will double between September 2020 and June 2021. This would equate to 7,000 more deaths in Montreal alone. How can we prepare for the unprecedented? This brings us to the planning fallacy.

The fallacy of planning

Much has been written about the superiority of emergent strategies in the face of uncertainty when compared to planned strategies. This concept is complicated by a much less known principle: Future rare and significant events cannot be predicted or prepared for by studying the past. Examples illustrating this idea are the 9/11 attacks, the 2008 financial collapse, and, most recently, COVID-19.

The first wave of concurrent SARS-CoV-2 and the flu—now termed the twindemic—hitting a population that is compromised three-fold is a classic negative black swan. “Setting oneself on a predetermined course in unforeseen waters is the perfect way to sail straight into an iceberg.” We can never specifically prepare for black swans since they are unprecedented, complex (not complicated), and wicked (not crisis) problems. We can only decrease our fragility by working at it continuously.

More agility

How do we decrease fragility? By moving away from rigidity toward agility—by focusing on purpose, competence, and adaptability, rather than on procedure and efficiency. We need a new network of dispersed yet associated operatives. We need to replace the culture of complying with commands and executing demands by rewarding individual initiative and encouraging critical thinking. We need to specify a minimum number of basic and simple principles and let each person, or each department in the context of health care, make the best choices based on contextual awareness. Widespread and extremely transparent information sharing leads to shared consciousness, and decentralized decision-making authority leads to empowered execution. These two elements should always co-exist.

The vertical, top-down management approach in our (and many other countries’) health care system is extremely slow in responding to an epidemic that evolves quickly. By the time the health ministry receives the report from the front lines, forms committees, makes decisions, and provides directives—that 127 Quebec hospitals must struggle to adopt—the original problem no longer exists. Quebec Premier François Legault expressed the need to modernize the way information is shared within the health care system, saying that it is “in the stone age.” A communication strategy that uses one-size-fits-all directives sent multiple times each day leads to email fatigue, confusion, and, in some cases, systemic desensitization. Mass casualty events, including pandemics, are VUCA (volatile, uncertain, complex, and ambiguous) situations and require distributed leadership, not reductionist hierarchical management.

Less cost

The economic advantages of distributed leadership in our health care system can be manifold. In our first attempt to fight contagion, the main strategy was to form committees, which yielded sub-committees ad infinitum. This self-perpetuating bureaucracy will not only prove inefficient and provide undesirable outcomes, but will also incur increasing costs that further strain our economy.

The output of these committees is usually rigid and disregards local variations, as well as the strengths and weaknesses of individual institutions. After consuming hundreds—if not thousands—of hours of human input, these directives require a similarly significant amount of time and effort for adoption by front-line leaders.

Instead, if physician leaders are empowered to manage the environments they know best, a significant number of committee work hours will be eliminated. The resulting economic savings can be directed toward providing the front lines with the major increase in resources that will again be needed, and any remaining resources can be contributed to the economic recovery of the State.

Engaging physicians

The most important change required is to engage the physicians who are the Aristotelian efficient cause of health care delivery. Physician leaders are at the heart of the distributed leadership model. According to the Canadian Medical Association (CMA), “Physician health and wellness outcomes are becoming a significant quality indicator in the practice of medicine and the overall functioning of health systems.” Physician health has been identified as an additional component of the “Triple Aim,” renamed the “Quadruple Aim.” The already rampant epidemic of physician burnout has been exacerbated by the acute stressors of the COVID-19 pandemic. Front-line health care workers “should be given priority not because they are somehow more worthy, but because of their instrumental value: they are essential to pandemic response. If physicians and nurses are incapacitated, all patients will suffer greater mortality and years of life lost.”

Flourishing is enabled by positive emotion, engagement, relationships, meaning, and accomplishment. Our most powerful motivators are the opportunity to learn, grow through responsibilities, contribute, and be recognized for achievements. In my opinion and based on first-hand experience, many of these elements are significantly jeopardized in community and tertiary-care hospitals where I practice.

Of the eight specific sources of physician stress related to the COVID-19 epidemic, three are workplace factors that we can target for improvement in our preparation efforts: adequacy of personal protective equipment; risk of work exposure to COVID-19; lack of access to up-to-date information and ineffective communication. The first two can be addressed by improving our infection control measures under direct guidance from local infectious disease specialists and, of course, accountable and transparent distribution of PPE. The last aspect—timely access to information—can be remedied by the proposed distributed leadership model.

Individual- and system-based interventions that can proactively minimize the compounding effects of acute COVID-19 stressors and the high rate of physician burnout have been highlighted in a recent article in the Journal of American College of Radiology.

Closing reflections

In keeping with the language of combat that has been adopted due to the complexity of the COVID-19 consequences, we have two choices in preparing for the upcoming war. On the one hand, we can continue to fight the last battle by remaining on the path of “inaction, short-range thinking, and a continual cycle of panic and neglect” that we and many countries have pursued since 1997, ignoring the lessons from H1N1, SARS, MERS, and now the first phase of COVID-19.

Alternatively, we can prepare for the inevitable winter calamity that awaits us by healing and supporting our front-line health care workers, allowing physician leaders to navigate their own ships through armadas of adversity, recognizing those who strive through these trials and tribulations, and collaborating with them to guide our health care system to a better future.

Dedication

The Lakeshore General Hospital was designated a COVID-19 center early in the pandemic. This put tremendous administrative and staffing pressure on the department of medical imaging, which managed a three-fold increase in the number of studies performed. Thanks to the superhuman efforts and strict adherence of our personnel to first principles and infection control guidelines, and, most important, their humane support and humble collaboration, we have not had a single case of infection in our department to this date. This article, if of any value, honours their past and ongoing efforts.

Acknowledgement

The author acknowledges the support of Leslie Breitner, DBA MBA, Senior Faculty Lecturer, Desautels Faculty of Management, McGill University, IMHL Academic Director, IMPM Academic and Module Director; and John Breitner, MD MPH, Canada Research Chair in Prevention of Dementia – Tier 1 ​, Pfizer Chair in Dementia Research Director, Centre for Studies on Prevention of Alzheimer’s Disease (StoP-AD), Douglas Research Centre, Full Professor, Department of Psychiatry, McGill University.

About the author

Khashayar Rafat Zand, MD FRCPC is an associate professor of radiology at University of Massachusetts Medical School and is a current participant in the International Masters for Health Leadership (IMHL) program at McGill University’s Desautels Faculty of Management.

A few weeks ago, a group of physicians gathered to discuss and reflect on the unfolding of COVID-19 in Canada this spring. While the population braces for more uncertainty as the season changes, the following thoughts borne out of their exchange aim to provide some insight into managing the next phase of the pandemic.

Q: To date, how would you assess the medical services provided for patients affected by the virus?

A: We would propose that this question is best asked of the more immediate stakeholders: the patients and their families. We can only propose an answer from our privileged perspective. Portugal, which showed a contagion curve comparable to Canada, has a 3.6% case-fatality rate. Quebec and Montreal have much higher case-fatality rates: 9.9% and 12.4%, respectively (as of July 16, 2020). The municipal figures are worse than Mexico’s (11.9%) and Spain’s (11.2%), and are close to those of Italy (14.4%). We have amassed a high number of fatalities despite two months of lead time, closed borders, and strict lockdowns. Overall, we were unable to capitalize on our experience with SARS.

Q: How should we allocate health care services and resources among COVID and non-COVID patients in the future?

A: Based on the Pandemic Influenza Plan, developed in 2005 and refined in 2009 and 2017, “there should be no difference in allocating scarce resources between pandemic patients and those with other medical conditions.” Accordingly, COVID and non-COVID patients should be triaged and treated equally. During the spring, a disproportionate amount of resources were allocated to COVID patients at the expense of others.

This is not specific to Quebec or to the post-COVID era—it is a long-standing global phenomenon. Domestically, Canada’s Security Intelligence Service (SIS) established the federal Integrated Threat Assessment Center (ITAC), which morphed into the Integrated Terrorist Assessment Center after 9/11. In its post-9/11 policy, from 2004, terrorism had been propelled to the top of the list of eight major national threats; a global pandemic was listed last—barely making the cut. Now, in 2020, we have witnessed firsthand how a pandemic can ravage society, at every level.

Q: As we prepare for the first winter with COVID-19, what should be done to prevent widespread outbreaks?

A: This pandemic is first and foremost an infection control challenge; then, it is a resource management challenge. We have learned many lessons from the past few months; one of the most important is that an infectious disease specialist, who is in charge of infection control, should be placed in each institution and that we need to provide them with all the resources required to perform their job optimally. These specialists should be included in every planning committee and their instructions should be the final say on all matters. In other words, no zoning, staffing, bed planning, or PPE distribution measures should be explored—much less approved or adopted—without their complete approval and guidance.

The rest of us should practice eyes-on, hands-off leadership: while ceding control and planning to local infectious disease experts, we must remain ever more vigilant about our own team’s decisions and front-line events.

Once we manage infection control and preventable outbreaks, human and protective resource management become much easier. Putting local infectious disease experts at the helm of our response operations is the second most important change required.

Q: What would you change to provide better medical care to patients in your local hospital?

A: An essential shift will be reframing the way we describe the pandemic. “The way we speak defines the way we think.” The language used to describe a problem and how a question is asked can have important effects and limitations on our cognitive processes, as well as on the responses and solutions that follow. We would offer the following propositions.

The fallacy of the second wave

The term “second wave,” albeit universally used, may be deceptive. What awaits us this winter will most likely be very different from the past spring. What will ensue has never happened in the history of the world. The first wave of SARS-CoV-2 hit a relatively intact planet at a different time of year—in our case, at the end of winter.

What comes next has some distinctive features: It will be the first SARS-CoV-2 epidemic in Canada to begin at the start of winter; It will unfold concurrently with the annual seasonal flu; It will impact an already financially-ravaged society; It will affect a population weakened by more advanced cancer, diabetes, and cardiac disease due to delayed services; And it will be handled by a health care workforce debilitated by physical exhaustion, chronic psychological distress, and professional demoralization.

A reasonable worst-case scenario predicts that the number of COVID-19-related hospital deaths in the United Kingdom will double between September 2020 and June 2021. This would equate to 7,000 more deaths in Montreal alone. How can we prepare for the unprecedented? This brings us to the planning fallacy.

The fallacy of planning

Much has been written about the superiority of emergent strategies in the face of uncertainty when compared to planned strategies. This concept is complicated by a much less known principle: Future rare and significant events cannot be predicted or prepared for by studying the past. Examples illustrating this idea are the 9/11 attacks, the 2008 financial collapse, and, most recently, COVID-19.

The first wave of concurrent SARS-CoV-2 and the flu—now termed the twindemic—hitting a population that is compromised three-fold is a classic negative black swan. “Setting oneself on a predetermined course in unforeseen waters is the perfect way to sail straight into an iceberg.” We can never specifically prepare for black swans since they are unprecedented, complex (not complicated), and wicked (not crisis) problems. We can only decrease our fragility by working at it continuously.

More agility

How do we decrease fragility? By moving away from rigidity toward agility—by focusing on purpose, competence, and adaptability, rather than on procedure and efficiency. We need a new network of dispersed yet associated operatives. We need to replace the culture of complying with commands and executing demands by rewarding individual initiative and encouraging critical thinking. We need to specify a minimum number of basic and simple principles and let each person, or each department in the context of health care, make the best choices based on contextual awareness. Widespread and extremely transparent information sharing leads to shared consciousness, and decentralized decision-making authority leads to empowered execution. These two elements should always co-exist.

The vertical, top-down management approach in our (and many other countries’) health care system is extremely slow in responding to an epidemic that evolves quickly. By the time the health ministry receives the report from the front lines, forms committees, makes decisions, and provides directives—that 127 Quebec hospitals must struggle to adopt—the original problem no longer exists. Quebec Premier François Legault expressed the need to modernize the way information is shared within the health care system, saying that it is “in the stone age.” A communication strategy that uses one-size-fits-all directives sent multiple times each day leads to email fatigue, confusion, and, in some cases, systemic desensitization. Mass casualty events, including pandemics, are VUCA (volatile, uncertain, complex, and ambiguous) situations and require distributed leadership, not reductionist hierarchical management.

Less cost

The economic advantages of distributed leadership in our health care system can be manifold. In our first attempt to fight contagion, the main strategy was to form committees, which yielded sub-committees ad infinitum. This self-perpetuating bureaucracy will not only prove inefficient and provide undesirable outcomes, but will also incur increasing costs that further strain our economy.

The output of these committees is usually rigid and disregards local variations, as well as the strengths and weaknesses of individual institutions. After consuming hundreds—if not thousands—of hours of human input, these directives require a similarly significant amount of time and effort for adoption by front-line leaders.

Instead, if physician leaders are empowered to manage the environments they know best, a significant number of committee work hours will be eliminated. The resulting economic savings can be directed toward providing the front lines with the major increase in resources that will again be needed, and any remaining resources can be contributed to the economic recovery of the State.

Engaging physicians

The most important change required is to engage the physicians who are the Aristotelian efficient cause of health care delivery. Physician leaders are at the heart of the distributed leadership model. According to the Canadian Medical Association (CMA), “Physician health and wellness outcomes are becoming a significant quality indicator in the practice of medicine and the overall functioning of health systems.” Physician health has been identified as an additional component of the “Triple Aim,” renamed the “Quadruple Aim.” The already rampant epidemic of physician burnout has been exacerbated by the acute stressors of the COVID-19 pandemic. Front-line health care workers “should be given priority not because they are somehow more worthy, but because of their instrumental value: they are essential to pandemic response. If physicians and nurses are incapacitated, all patients will suffer greater mortality and years of life lost.”

Flourishing is enabled by positive emotion, engagement, relationships, meaning, and accomplishment. Our most powerful motivators are the opportunity to learn, grow through responsibilities, contribute, and be recognized for achievements. In my opinion and based on first-hand experience, many of these elements are significantly jeopardized in community and tertiary-care hospitals where I practice.

Of the eight specific sources of physician stress related to the COVID-19 epidemic, three are workplace factors that we can target for improvement in our preparation efforts: adequacy of personal protective equipment; risk of work exposure to COVID-19; lack of access to up-to-date information and ineffective communication. The first two can be addressed by improving our infection control measures under direct guidance from local infectious disease specialists and, of course, accountable and transparent distribution of PPE. The last aspect—timely access to information—can be remedied by the proposed distributed leadership model.

Individual- and system-based interventions that can proactively minimize the compounding effects of acute COVID-19 stressors and the high rate of physician burnout have been highlighted in a recent article in the Journal of American College of Radiology.

Closing reflections

In keeping with the language of combat that has been adopted due to the complexity of the COVID-19 consequences, we have two choices in preparing for the upcoming war. On the one hand, we can continue to fight the last battle by remaining on the path of “inaction, short-range thinking, and a continual cycle of panic and neglect” that we and many countries have pursued since 1997, ignoring the lessons from H1N1, SARS, MERS, and now the first phase of COVID-19.

Alternatively, we can prepare for the inevitable winter calamity that awaits us by healing and supporting our front-line health care workers, allowing physician leaders to navigate their own ships through armadas of adversity, recognizing those who strive through these trials and tribulations, and collaborating with them to guide our health care system to a better future.

Dedication

The Lakeshore General Hospital was designated a COVID-19 center early in the pandemic. This put tremendous administrative and staffing pressure on the department of medical imaging, which managed a three-fold increase in the number of studies performed. Thanks to the superhuman efforts and strict adherence of our personnel to first principles and infection control guidelines, and, most important, their humane support and humble collaboration, we have not had a single case of infection in our department to this date. This article, if of any value, honours their past and ongoing efforts.

Acknowledgement

The author acknowledges the support of Leslie Breitner, DBA MBA, Senior Faculty Lecturer, Desautels Faculty of Management, McGill University, IMHL Academic Director, IMPM Academic and Module Director; and John Breitner, MD MPH, Canada Research Chair in Prevention of Dementia – Tier 1 ​, Pfizer Chair in Dementia Research Director, Centre for Studies on Prevention of Alzheimer’s Disease (StoP-AD), Douglas Research Centre, Full Professor, Department of Psychiatry, McGill University.

About the author

Khashayar Rafat Zand, MD FRCPC is an associate professor of radiology at University of Massachusetts Medical School and is a current participant in the International Masters for Health Leadership (IMHL) program at McGill University’s Desautels Faculty of Management.