One thing I have not written about very much (if at all) is the broader relationship between hospitals and the communities that they serve. Most thought and attention here, including by me, has been on the shifting relationship between clinicians and patients. I am not sure if there was ever a time when patients were passive and obedient to the life-saving ministrations of a doctor making a house call, just as I am not convinced that, in the era of Dr. Google, patients have become universally obstreperous or confrontational as they have been portrayed. But lost in this focus is the relationship between hospitals and their home communities. Just like the more personal example, I don’t want to buy into nostalgia or stereotype, but post-COVID, this relationship feels more strained than before.
I am not talking about care delivery. It is not about a hospital’s ability to distribute Z-Pac’s and knee braces, but in being fully functioning contributors to the community. Where the hospital leaders are also leaders in the community. I remember being in Michigan, pre-COVID, where the local hospital was made the grand marshal in their Founder’s Day parade, celebrating the hospital’s role as a major employer and as a critical provider of health care. Now, it seems the relationship between hospitals and towns is more nuanced. This difference is not necessarily negative, but it is different after the pandemic.
Like with all essays in this series, I feel the need to draw some lines around the topic. Unlike the other essays, where I was able to avoid the elephant in the room, here I will have to address it. In retrospect (and even at the time) COVID felt more like a political and cultural pandemic than a medical one. Like with the other essays on economics, I will talk about this political facet without the subtext of what is right or wrong. The point of this essay is not to cast aspersions or rose petals. It is to explore how this tension over the pandemic has changed the overall relationship between hospitals and the towns they are in.
I am not interested in being factually accurate in this essay1 so I will not go down rabbit holes about whether mask mandates are useful or even if, based upon the definition of the word “mandate” we ever actually had mask mandates. This is not an essay on the value or risk/benefit of vaccinations or social distancing. If you want to call me out in the comments for being a shill for big-pharma or for being milquetoast for not calling out the behavior of the sheeple, you are certainly welcome to. Just remember that you will also be proving my point about the COVID exposing our inability to have thoughtful conversations.
There is a key razor’s edge that this essay will have to dance along. This is the, at times, fuzzy distinction between healthcare as a many-headed beast and the specific brick-and-mortar of a hospital or health system that sits in a city. COVID exposed this weird cognitive dissonance where someone can hate the medical field but still run to the emergency department when they break a leg.2 In some ways, it is the same relationship people have had with education. People may ridicule universities as effete ivory towers filled with politically correct professors who have never had a callus on their hands but still take civic pride that their town has a prestigious school and will wear the colors and root for the team, even if they have never been a student there.
Pre-COVID, hospitals were not just for sick people. They would offer classes to prepare people who were about to have knee replacements or about to be parents. Beyond education targeted at people who were about to use the hospital, hospitals would also offer classes on stroke awareness, dealing with an aging parent, the importance of sports physicals, or managing chronic pain. These would often be run by a doctor, so it served a dual purpose by introducing the physician to the community and advertising a new service or service line provided by the hospital while at the same time educating the public. Hospitals also ran (or were principle sponsors of) health fairs, blood drives, and screening events. To the cynics out there, YES, you might say that this was simply a self-serving way that the hospital could drum up new business. But since these things were free, it was also a low-impact way to develop relationships within the community that were not centered exclusively on some specific care intervention. They certainly helped the hospital, but they also helped the hospital help the community.
But then COVID came and hospitals immediately put an end to any on-site activity that was not essential. Even if none of these events had people in care spaces, no hospital wanted to be ground-zero for a spreader event. Visitors were no longer able to see patients. Cafeterias closed completely or radically reduced service. Even public drinking fountains were shut down. This led to a bizarre dichotomy where care spaces were often overflowing with patients everywhere, even in the hallway, while the rest of the hospital was a ghost town.
After the halo effect of banging pots and signs saying “heroes work here,” the pandemic developed a decidedly political bent, and hospitals were left with a dilemma. Science and self-interest said that hospitals should be championing masking, social distancing, and sheltering in-place and when the vaccine appeared, also encouraging people to take the shot. But with how quickly the issue was politically charged, hospitals also wanted to be neutral, separated from the fray. They were concerned that taking a stand might drive people away from their door and from healthcare generally. So, they were silent. I, personally, never saw a hospital CEO on the local news encouraging people to get the vaccine. I never saw a public service announcement sponsored by a hospital system telling people to mask and avoid public gatherings. If you did, please share your experiences in the comments. This is not meant to be an indictment of health systems, but simply to point out that this lack of a message was, itself, a message.
As experts, their silence was often misunderstood. Some saw it as the hospital not knowing what was right or wrong or what was best-practice. A vaccine was created much faster than any had been created before. Reasonable people were skeptical of its efficacy because of the speed. Liberals were suspicious of anything the Trump administration did or said. Conservatives were focused on “don’t tread on me” opposition to anything that threatened their individualism. Both would have benefited from a local healthcare leader giving the facts as they knew them in a sober way. If hospitals were not speaking out, clearly, hospitals didn’t know if any of this stuff would work or not.
Some saw this silence as the hospital not caring, or even profiting from the misery. Ironically, this lack of empathy was expressed on both sides. I read thousands of patient comments, both in surveys and in complaint and grievance letters they sent in. Some felt judged because they were asked their vaccination status even if they were there for a broken leg. Others expressed frustration because the hospital was not doing enough in waiting rooms to protect them from those who would not mask or socially distance.
Either way, the damage was done. By being silent, the community assumed that the hospital was not taking this event seriously, or, worse, the hospital supported the position that the community member opposed.3 By not taking a stand, when combined with the hospital shutting off all non-urgent interactions with the public, hospitals shut off any communication that they had with the community.
From here, inertia and self-protection compounded the problem. Emergency Response Teams were erected by hospitals to create new policies and procedures—the things that shut down all of the non-clinical-care reasons for people to be at the hospital. They were fast to build the new rules, but incredibly slow in reviewing, modifying or removing them. This led to a lot of confusion among staff as to whether they could resume in-person joint camps or patient and family advisory councils(PFAC). That confusion was compounded if the hospital was part of a hospital system. It did not take long for different hospitals to interpret the rules differently, so a year or two later, some hospitals still had their PFACs suspended, others were running them virtually, and still others were back to in-person meetings.
Sometimes it was simply a failure of organizations to revisit their past policies, or to effectively cascade any changes out to the front line. I remember being at a meeting where I asked about turning on the public drinking fountains. I was told that they all should already be back on. I showed them a photo I had taken at a hospital where there was still a sign posted saying that the fountain was turned off. Those in the meeting assured me that they would take care of this. Two months later, I was back at that hospital, and the water fountains were still turned off. Organizational inertia is a real thing.
But moreover, there is a mordent fear to take the responsibility for loosening up something that was locked down. I remember after 9/11, the federal government created the National Terrorism Advisory System (NTAS), which was a color-coded system (green, blue, yellow, orange, red) to alert the public on the danger of a terrorist attack. When instituted, not surprisingly, it was immediately set to RED. I was teaching at the time, and I told my students that it would NEVER not be red. Not because we would never be safe, but because no one wanted to take responsibility for downgrading us to ORANGE and then suffer the blowback if another, even small and localized, terrorist attack occurred. There was great incentive to raise and no incentive to lower.
Likewise, a hospital that opened its doors back up risked being the cause of a new outbreak. Even if it wasn’t true, the mere perception that the hospital caused a resurgence was enough for the Marketing and Legal departments to lobby against such a decision. So, more of these policies were ignored or forgotten, than overwritten. It seems that, much like the big family argument at last Thanksgiving, hospitals were happier to let sleeping dogs lie and ignore the conflicts over last six years.
But, by not examining how the pandemic impacted not just our financials and staff, but also our relationship to our communities, we miss an opportunity to consciously reengage with our service area. I remember being in a brainstorming session, helping an organization prioritize key issues post-pandemic. I was in a subgroup with the CFO of the system. He obviously knew the financials intimately and would be expected to demand we focus on getting the books balanced. Instead, though, he said, “We have spent the last three years with our hands in our pockets, not taking sides. We need to reach out to our communities and let them know we are still here and we want to work with them.” Hospitals have spent most of the past six years addressing their staffing and budgets and most have made important headway in this space. But I have not seen them trying to reestablish the low hum of day-to-day interaction, at least not in a coordinated way. Opening up campuses is great, but by not addressing what the last half-decade has done to our relationship to the communities we serve, we are missing an opportunity to strengthen that bond. And if the pandemic has forced systems to cut service lines or even close hospitals, that silence continues to deteriorate that bond.
1My father would be quick to point out that I rarely let factual accuracy interfere with a good story.
2My legal team informed me that I should point out that, if you have a broken leg, you should not be running anywhere. Having someone drive you to the emergency department is best-practice.
3I do think it is fascinating that we often assume that someone who is not vocally supporting us is clearly in opposition to us.
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