COVID-19 and health care: How have we changed?

From a medical perspective, COVID-19 is not the public health care emergency it was five years ago. But for the chief medical officers of the Corridor’s three largest hospitals – UnityPoint Health – St. Luke’s Hospital, Mercy Medical Center and UI Health Care Medical Center – the pandemic represented a seminal moment in health care, and brought dramatic changes in both health care practices and the overall approach to large-scale medical crises.

Initial response to pandemic

All three local health care leaders agreed that the initial response to the pandemic was exemplary, given the extraordinary circumstances.

Dr. Theresa Brennan, chief medical officer of UI Health Care in Iowa City, noted the state’s first COVID-19 patient requiring hospitalization arrived at the Iowa City hospital March 11, 2020, but preparations for the pandemic’s arrival in Iowa actually began in January, shortly after the first U.S. case was reported in Washington state. “In a time when people didn't know what to do, our people came together and really worked hard,” Dr. Brennan said. “When we were first hearing about this virus, our hospital epidemiology team brought a small group of our emergency response team together to start preparing, which made us prepared for that very first patient when that patient arrived. That preparation, that we do routinely for emergencies, really set us up well to be prepared and as ready as one could be for an unknown [phenomenon] like this pandemic was.” Dr. Tony Myers, chief medical officer at Mercy Medical Center in Cedar Rapids, said he was communicating regularly with other chief medical officers throughout the pandemic, but not belonging to a larger hospital network was actually beneficial in many ways. “Being an independent hospital actually made it easier for us, in many ways, to bring in the expertise that we had,” he said. “We were certainly dealing with all sorts of uncertainty, but to get into a room and get everybody there, whether it was staff or providers, we were able to make decisions rapidly. We had already started down a path of dealing with something, just because we were able to do it, and we didn't have to wait for a system, for everybody to get on the same page.”

Dr. Myers also noted Mercy’s leaders made a concerted effort early in the pandemic to prioritize the health of the hospital’s staff, as well as its patients. As part of that effort, Mercy was the first hospital in the state to enact a COVID-19 lockdown, and Dr. Myers noted that a pandemic plan, developed by Dartmouth College in the late 1990s to deal with a flu epidemic, helped guide Mercy’s response to COVID-19. That plan, he said, included advice on “triggers” to respond to various stages of a health emergency, such as stockpiling supplies and establishing treatment protocols. Mercy also imposed a travel ban for all hospital staff. “There was a lot of pushback on that one,” Dr. Myers admitted. “There were some people that had planned vacations in Mexico, which was challenging. But in an organization our size, there are always people going to conferences and meetings, and all of that was shut down. We stopped doing any kind of gathering.” “Early in the pandemic, I can remember arguing with physicians about ‘well, it’s not in Linn County,’” he added. “But the few cases that were in Iowa at that time were in Iowa City. If you understand how pandemics work, if it’s 20 miles away, it’s here. So we needed to start treating everything like it was in town, because it was essentially here. So since we had that focus on keeping the staff safe, we could start to trigger those things pretty quickly. That was very helpful to us ... we made a decision as an institution that every role in this hospital is critical.”

Dr. Dustin Arnold, chief medical officer at UnityPoint Health – St. Luke’s Hospital in Cedar Rapids, said he felt being part of a larger hospital network was beneficial for dealing with the pandemic, in terms of resource availability. “I thought UnityPoint handled it very well,” Dr. Arnold said. “When you're in a system like UnityPoint, you can lose a lot of autonomy at the local level because you're trying to do things in such a macro, but we had the whole support of the [UnityPoint] system at all times during the pandemic. With supplies, we could say, ‘hey, there's extras here, send it there.’ The same with staffing. That was a huge benefit, and I'm proud of that.” He also noted that the hospital’s Infectious Disease Council, formed “around 2013” with a group of physicians, pharmacists, nurses and hospital leaders, continued to meet regularly during the pandemic and helped the hospital make informed decisions quickly. Dr. Myers said he felt overall, local hospitals had enough time to prepare for COVID-19 patients, but said the availability of resources became an issue relatively quickly. “If we would have had a couple of more months, I think we could have been in a much better place from a supply (perspective),” he said. “And there was legitimate fear, especially with some of the more advanced protective equipment, that health care providers were putting their lives in danger. We were very lucky that we didn't have a physician provider that died from this, because many places did.”

Dr. Myers said he was put into a previously unfamiliar role – that of spokesperson. “At the time, I thought that this wasn’t my job,” he said. “I'm the CMO of a hospital. I'm not supposed to be giving press conferences every day. But after going through it all, that is actually what should happen, because we have the continual resources and the expertise and the knowledge, whereas the public health system really doesn't have the resources, or in a pandemic, the type of practical knowledge of taking care of patients, and they there's no way to expect that they should. They're not health care providers. I sort of moved around to the idea that we need to be prepared to take that type of leadership role in this kind of a situation, and to accept it as a responsibility, because it's one of the things that came out of going through that.” The sense of teamwork among area hospitals and health care officials was “fabulous,” Dr. Brennan said. “Working with (Iowa) public health, Johnson County Emergency Management, working with our local hospitals,” she said. “We collaborate with them with patients moving back and forth all the time, but we're not really in direct conversations on a regular basis, and during the pandemic, we were. We were having weekly meetings with the leadership of the smaller community hospitals, even the larger hospitals in Iowa, really collaborating on how we can make sure that every Iowan gets the care that they need.” In addition, she said the establishment of the hospital’s special pathogens unit in 2014, when Ebola cases were surging, was tremendously beneficial in the initial COVID-19 response. “That unit has an anteroom to don and doff (protective equipment), it has its own autoclave, and that’s where we put our first patient,” she said. “I remember being here that night, and until I’m demented, I’ll remember watching how our team took care of that patient, just like it was a normal, everyday illness, when it was a virus that reportedly was killing people at a high, high rate. The leader of the unit was there. The team was there. They put on their protective equipment, and they just went in and took care of the patient, just like they would take care of any other patient. And I think that prepared us, because those people who were in that unit were used to how to put on and take off the protective equipment to protect yourself. They felt comfortable. That patient had to come by ambulance, so the EMS team had to be fully prepared, and the special pathogens unit actually allowed that, because we worked with our local EMS so that they were prepared as well. That patient came through the ER and straight up to the unit.”

Impact on hospital staffing

The pandemic’s impact on hospital staffing levels has been well-documented. According to a February 2023 survey report from the National Council of State Boards of Nursing, about 100,000 nurses had left the workforce due to pandemic-related burnout and stress. Another report, from an analysis of medical claims data from Definitive Healthcare, said more than 230,000 physicians, nurse practitioners, physician assistants and other clinicians had quit their jobs as of August 2022. “Devastating is probably too strong of a word, but it’s been incredibly challenging,” Dr. Myers said. “From a nursing side, we were already walking a line before this happened. We were already short, primarily on nursing staff, and when this happened, all of a sudden it pushed us over.” Dr. Arnold noted that physician and nurse retirement rates accelerated, especially in the pandemic’s early years, and most hospitals have yet to fully recover. “We've had 109 RNs retire from 2020 to 2024, and that comes out to like 3,200 years of experience,” he said. “I think if we wouldn't have had a pandemic … some of them would have stayed around a couple more years, but it was just too much.” Dr. Brennan noted that the health care industry frequently sees “ups and downs” with staff shortages. “I do think the pandemic played a role in some people ending their career early, or deciding that health care wasn't for them anymore,” she said. “We were pretty fortunate and blessed that our people stuck it out... We were also fortunate to keep our people safe, and that was a top priority. As a health care professional, your focus is always on the patient, but during the pandemic, that focus had to equally be on the people that are taking care of the patients.” She also acknowledged the long-term impact of the pandemic. “I think burnout was bad nationally, and it's certainly had an impact on our people here,” she said. “It’s had an impact on the patients as well. In general, patients are less tolerant of things that they may have been tolerant of before. We continue to look for the skilled workers that we always look for – docs, nurses, respiratory therapists, pharmacists. We're going to feel that for a while.”

Financial impact

While specific figures weren’t available, all three leaders acknowledged the pandemic response’s impact on their hospitals’ finances. Dr. Myers said one of the biggest expenses for Mercy, aside from medical equipment and supplies, was the cost of traveling nurses. “At the peak of (the pandemic), a traveling nurse was costing us about four times what a regular nurse would cost,” he said. “We typically would have around 15 or less travelers in this system at any given time. At the peak of the pandemic, we had well over 100. You can do the math on that one.” Some costs were alleviated, he said, by recently retired nurses that returned on a short-term basis. “They weren’t necessarily at the bedside, but they helped in a lot of ways, like ramping up our vaccine clinics,” he said. Dr. Myers noted that the Centers for Medicare and Medicaid Services (CMS) were reimbursing hospitals at a somewhat higher rate for COVID-19 patients, but ”that in no way came close to the amount that was being spent across the institution for increased staffing costs and supply costs.” “It was a tremendous expense, and there were some pretty bleak numbers,” Dr. Arnold agreed. “But I think we’ve recovered from that insult, and we’re starting to see things back to normal.” Dr. Brennan said unlike other health care institutions, UI Health Care didn’t have to institute layoffs due to pandemic financial pressures. “That was a concerted decision,” she said. “We did everything we could to not lay off people, because that would put our people in a very bad spot to not have that employment. Remember, we stopped doing surgeries, so many institutions didn’t have resources available for the backlog of patients. It was a very smart decision, but it took a lot of effort to make sure that, in the throes of things, we were able to keep people on board and be creative about how we did that.” She also stressed that financial concerns were never a factor in delivering care. “Our leadership at the time recognized that this was a really big deal, and really focused on how we made sure we had everything we needed, not what it cost,” she said. “We never had conversations about costs. It was ‘what do we need, how are we going to get masks, and how are we taking care of our people?’ I think that was really important.”

Trust in health care, politicization

As the pandemic became as much a philosophical issue as a medical one, local leaders said the perception of health care providers and institutions was altered dramatically. “During the pandemic, you saw a lot of politicization of medicine and science, and that's just not how science works,” Dr. Arnold said. “Even in my own practice, I'd find that I look for studies from 2018, because I know it's before the pandemic. With the National Institutes of Health, you used to have such reverence for them, and now you're like, I don't know. I do think it illustrated how government officials, particularly in the FDA, they’d approve a drug and then they go to work for Big Pharma afterwards. For health care in general, I think there is some lack of trust… I think people still find their own personal physician trustworthy, but it certainly created some doubt.” In some sense, skepticism of medicine is nothing new, Dr. Myers said. “What clearly has changed is the voice of that mistrust, and that's the most disheartening thing that has come out of this,” he said. “There's so many positives to me, and far and away, the majority of our patients are so thankful and do believe that we know what's best for them, but the voice of that distrust and the amount of misinformation out there has changed, and it’s going to take a long time to change back.” For the first time, Dr. Myers said, patients were openly questioning the validity of a medical pandemic and the safety of vaccines. “This was such an opportunity for us to come together and do the right thing,” he said. “I've always felt like a period of super stress or challenge is a time to help us come together, and now, I'm not so sure if that's true. It felt like we missed an opportunity to come together in a broader way. We certainly [came together] it locally. But it didn’t pan out in terms of renewed trust in the medical system.” “I think globally and nationally, it probably has created more skepticism for patients,” Dr. Brennan said. “But most of the time, a patient and a health care provider's relationship is based on that trust that you develop by being that provider for the patient. So I think that's overcomeable. I think the place where I see the biggest impact is just the trust in science, in what the researchers are doing, what they're telling us is that the right thing? Are they doing things that are appropriate and effective in getting us to a place where medicine is advancing? I think that trust from the public has been harmed. But hopefully that patient-provider relationship helps to overcome that, and they know that we’ve got them, we're here for them.”

Possible changes in hindsight

One of the luxuries of hindsight is the opportunity to assess a situational response in its current context. Dr. Arnold identified a specific aspect of the pandemic response that he would have changed. “The thing that I am the most frustrated about is that it went from an issue of timing to an issue of number of cases,” he said. “And I think that was a mistake. Early on, the lockdowns [were] trying to flatten the curve, so not everybody was sick on a Tuesday, which would have overwhelmed the health care system. That was the right thing to do. But then over time, we should have changed the lockdowns to just include high-risk people, people that are most susceptible to COVID, rather than just a generalized lockdown. You can't prevent cases. You can't beat Mother Nature.” He tells a story about his daily commute from St. Luke’s to his home in Robins along Interstate 380. "One day, along the on ramp, a stalk of corn had grown in a crack in the cement,” he said. “A kernel of corn fell off a truck, and it grew. That's just the power of nature. You couldn't have done that on purpose. You cannot isolate or vaccinate your way out of a pandemic. It was done with the best of intentions. But when it became not a matter of when everybody got sick, but the total number of people getting sick, that was the wrong thing to focus on.” In most cases, COVID-19 wasn’t a severe illness for generally healthy people, he said, especially as vaccines became more widely available. “Thankfully, it turned out to be rather a mild virus,” he said. “As long as you’re healthy, it doesn’t overwhelm healthy people. It certainly overwhelmed people that were at risk, and we saw that. As with a lot of coronaviruses, it did exactly what they do. When they start out, they’re pretty intense, but they tend to get weaker as they evolve, because they want to get into the next host. That’s why Ebola never went over the whole planet, because it’s so virulent it can’t get out of the jungle, because it kills people before they can travel.” For Dr. Myers, the pandemic demonstrated the overall strength of the nation’s health care systems. In retrospect, however, more defined lines of leadership would have been helpful. “I don't see any big misses, other than the general support and direction from across the country in general,” he said. One concern expressed by both Dr. Myers and Dr. Arnold is the backlog of patients who weren’t able to get routine screenings for cancer and other serious conditions during the height of the pandemic. “One of the big concerns that I have is that we’ve seen an increasing number of cancer cases, especially in younger people,” he said. “When we delayed those screening tests for that period of time, I'm afraid we’re going to have this tsunami of cancer patients in the early 2030s or something like that. That's just my theory, but we went a long time without screenings, colonoscopies, mammograms, all that. And I think that we’ll feel that someday.” For Dr. Brennan, the pandemic was unique not only in its medical impact, but its impact on society as a whole. “It affected every aspect of our lives,” she said. “People not being able to work, children not being able to go to school. I think that puts it in a whole new place. Plus, the death rate – the large number of people and the rapidity with which people were dying in lots of areas around the world – was just astonishing… The techniques we used to care for people, including the rapidity of getting a vaccine out, probably helped us to get to a better place faster in how we care for patients and how we prevent other people from being infected than in any other pandemic in the past. But in the moment, it felt like we learned very slowly.” If Dr. Brennan could make one change, she said, it would be to recognize the mental impacts of a pandemic on patients, children and providers alike. The hospital’s COPE team helped providers deal with the trauma and tragedy of the pandemic, but there could have been many more steps taken, she said. “If I could have done one thing more, it would have been to figure out how we could make sure that everyone was being taken care of while they're here and when they go home at night,” she said. “For our children, and I think for the average patient, it was a terrible time of suffering. A lot of good things were done. I would have loved it if we could have done better, but we had to focus on medical care. And again, I applaud the team that we have here, and many teams across the nation, who were really focused on caring for caring for the people that care for our people.”

Moving forward – ‘business as usual?’

It’s tempting as a society to move on from a traumatic period and to return to a “business as usual” mentality. But with COVID-19, that transition won’t ever be fully realized, leaders say. “Perhaps COVID-19 won't continue to circulate, but there's other viruses that will,” Dr. Arnold said. “It’s already been a brutal flu season – not the worst that I've seen in 28 years, but worse than we’ve had recently. COVID-19 by itself, that particular strain, is probably historical, but there could be a new strain, and we have to stay vigilant for that and be prepared to deal with it when it comes.” For Dr. Arnold, the greatest concern moving forward is adequate staffing. “You can’t just turn out a doctor next week,” he said.“ ... Replenishing the staff — that’s the issue that I think would be the biggest challenge.” In Dr. Myers’ view, society has been forever changed by the pandemic, even with something as simple as the commonality of mask-wearing in the general public. “You see people that are just out wearing masks, and there’s a reason for that,” he said. “Often when we see that now, some people are scared of getting sick, but a lot of them just don’t want to give somebody else whatever they’ve got, and they will be that way moving forward. That won’t change.” Dr. Brennan said routine collaboration throughout the health care system has improved since the pandemic. She fondly recalled the proliferation of public signs espousing the notion “we’re all in this together.” “That support from the community, whether it was putting a sign in your yard or neighbors bringing food to health care workers, or restaurants providing food — it was such a hard time,” she said. “And the idea that the people in the grocery store had to be there – everyone appreciated those essential workers. I think that that sort of collaboration was amazing, people sewing masks and bringing them in. Even when masks were in short supply, everybody had a mask. I was really proud to live in Iowa at that time.” COVID-19 will continue to be a health care concern, even if it’s on a lesser scale moving forward, Dr. Brennan said. “I think it's a balance,” she noted. “It’s nowhere near what it was when we first saw it, but we will always have COVID, just like we always have people that have the flu or the common cold. I do think that people should go about their life and do the things that make them happy and continue to be productive. But we shouldn't forget the pandemic… We went through it, we learned from it, and it should make us better in the future, but I don't want people to worry about the next one coming… And if and when it comes, we're going to be ready, and we'll do our best to care for patients, just like we do for all medical conditions that we care for.” This is one in a series of stories documenting the impacts of the COVID-19 pandemic on the Corridor, five years after the first case was reported in Iowa.