The Future of Clinical Leadership
Lessons from Crisis Management from COVID-19 Pandemic
The enormous disruption to clinical care caused by the COVID-19 pandemic has required new models of clinical leadership not just for intensive hospital care but also for the large population of patients with chronic post-infection complications. Since the weight of the pandemic has fallen more heavily on minority populations, having clinical leaders that understand the Hispanic-majority community in South Texas is crucial. Given the high fraction of COVID-19 patients who are disabled long after recovering from the infection, Monica Verduzco-Gutierrez, M.D., chair of the Department of Physical Medicine and Rehabilitation at the Joe R. and Teresa Lozano Long School of Medicine at UT Health San Antonio, found herself in the midst of the crisis.
“I had to change what my vision of leadership was going to be because of the pandemic. It was a period of uncertainty with high levels of stress. Everyone’s life had changed because of COVID-19. As a leader, I had to be supportive of the community’s needs and be adaptable with my faculty,” she said.
When hospitals shut down all non-emergency care to be able to handle the surge in COVID-19 patients, the rehabilitation in-patient service was closed. “I then saw the growing number of patients who were surviving the virus. We had an opportunity to serve the physical, mental, cognitive and functional needs of these patients,” Dr. Verduzco-Gutierrez said. She then opened the first COVID-19 Rehabilitation Clinic with services available at the UT Health clinics and at University Hospital, the main hospital partner of UT Health.
“Texas has turned out to be a red area for patients being treated for COVID-19. Unfortunately, the number of those hospitalized was high for quite a while,” she said. “Patients who become critically ill with COVID pneumonia in the hospital are intubated for at least a couple of weeks. Within 10 days, these patients can lose 25 percent of their muscle mass and strength. However, while we know early intervention will help them, there were concerns about introducing new therapy providers into their rooms and so they got more debilitated.”
Start intervention early
Dr. Verduzco-Gutierrez and her team started discussing the best process for helping these patients. “We want to rehab them so they can get back to their regular lives as strong as possible. We know from previous ICU patient data that after one year, one third of patients can’t do all their daily activities to live independently.” She believes rehabilitative medicine should start in the intensive care unit. “Patients do better long term if we can start rehab early in the ICU,” she said, adding that she does rounds in the ICU with the neurosurgical team as well to address the needs in other critical populations. Thus, Dr. Verduzco-Gutierrez and her team began providing ICU patients with rehabilitation plans that would extend long after they were already home.
“Every post-COVID patient seems to have a different experience, even ones who were not hospitalized. Some symptoms are much more severe than others,” she said. “Our team is helping patients who need someone to acknowledge they are having these symptoms and assuring them we will do everything we can to help.”
Many of the patients feel very alone, Dr. Verduzco-Gutierrez said. “They are also dealing with what is being called ‘COVID brain’ after surviving the virus. Some people are having cognitive issues and trouble finding words. We can tell them that we are seeing MRIs now showing that the hippocampus, which is the part of the brain involving memory, has been affected by COVID.”
She is ensuring her team does a systematic screening with each COVID patient to make sure they identify symptoms, such as shortness of breath, swelling in the legs, autonomic dysfunction and ongoing loss of smell and taste. “Then depending on their presentation and symptoms, patients can have lab tests, echocardiograms and EKGs performed. We can refer them to a cardiologist or pulmonologist if they need specialized care.
“If they are having problems breathing and still need oxygen, we can do a pulmonary function test and see if they need pulmonary rehab or to be seen by a pulmonary specialist,” she said. “If they are having nightmares and PTSD symptoms because of their time isolated in the hospital or because they are worrying about family members contracting the virus, we will refer them to a behavioral health counselor.”
Dr. Verduzco-Gutierrez said the virus causes strokes in some patients because of the clotting it causes. “We are seeing patients who will be dealing with these issues for the rest of their lives. We want to do everything we can as soon as we can to help them regain their quality of life.”
Knowledge decreases anxiety
One of the most important components of successful rehab is patient and family education. “Knowledge decreases anxiety and improves compliance, which is key to seeing improvement,” she said. Dr. Verduzco-Gutierrez and her team also use all manner of social media to keep the community informed as well. She has thousands of Twitter followers, a platform she used to promote masking
and social distancing early in the pandemic.
She said their work with COVID has been markedly improved by telemedicine. “Today a lot of our work with COVID patients involves telemedicine, but we are still trying to learn more. Are we conducting these virtual exams in the best manner? Are we documenting them correctly? How well can we do certain aspects of a physical exam? We are working on getting grants so we can determine how to improve this process. This is a great opportunity to improve virtual care.”
Her work in San Antonio with COVID patients also highlights health disparities among underserved communities. “We have to look at the disparities of certain populations that are being more affected by COVID-19. Plus, if we are offering telemedicine, these populations may not have home internet or access to good Wi-Fi. This will continue to increase the disparities in health care. We must figure out what we can do to make sure health care is inclusive. We want to make sure everyone gets the best health care,” she said.
Turning disruption into knowledge
Dr. Verduzco-Gutierrez said they collect data on all of these patients to share research findings in the future. Collecting this data will be important because they are seeing such diverse post-COVID symptoms and sharing this data with the rest of the nation’s rehab efforts will make everyone better. It also provides those whose academic careers are disrupted by COVID-19 with a ready opportunity to write manuscripts for publications. “Data is showing women’s academic careers have been more affected by COVID-19 than men’s careers. They have written fewer manuscripts and grants since the pandemic, likely due to more family demands. Thus, we need to provide as many academic opportunities to women as possible.”
Another crucial aspect of leadership during the pandemic was to prevent frontline faculty and staff burnout, Dr. Verduzco-Gutierrez said. This could be a vicious cycle because once someone falls off the clinical care team the others have to pick up the slack, creating further stress. Each person has different stress points, child or elder care, lack of time off, and their own health issues, including some faculty members who had immune-mediated diseases. Dr. Verduzco-Gutierrez met with each individually in person or virtually to identify these stressors early and defined a plan to prevent them from becoming limiting.
What did we learn?
The more you plan, the more you select for black swans. “We found that we needed plans for how each component in a service line would be used, but also plans for when each component failed. It was impossible to predict which component of the system would fail, but it was usually one that we had not foreseen,” Dr. Verduzco-Gutierrez said.
“We also found that relying on any one source for any component of a service line means you are held hostage by them,” she said. “We need many sources for any given component of a service line, service or lab. We created relationships with other rehabilitation facilities because the hospital was full of COVID patients. We created pathways to get emergency privileges at these other facilities, and created teams to round there in real time, as the need arose,” Dr. Verduzco-Gutierrez said.
Finally, she admits that medicine is a team sport. “We all depend on each other,” Dr. Verduzco-Gutierrez said. “PM&R is a partner for everyone, because our patients come from every type of specialty, and cultivating these relationships is crucial to building a successful COVID-19 care program,” she said.
Leaders cannot forget to lead themselves. She lives the mantra: “You have to put on your own oxygen mask first.” “It does the team no good if you prevent everyone’s burnout but then you yourself decompensate. I tried to keep a rigorous schedule not just for work but for exercise as well. I scheduled runs by myself at any time of the day or night, and I really enjoyed evening walks with my husband,” she said.
“I went into rehab medicine to improve stroke recovery and reinvented myself as a COVID-19 rehab physician,” Dr. Verduzco-Gutierrez said. “This is something really important for my team to make a real contribution to, but only if we are
all flexible enough to reinvent ourselves,” she said. That flexibility is also important to reducing stress. “We must recognize that COVID-19 is permanently changing medicine, and we are not fully controlling the story line. We need to be able to self-assess enough to change when our patients need us to, and they need us to change right now,” she said.
Work where your heart is
Dr. Verduzco-Gutierrez recalled that the specialty of rehabilitative medicine was a result of the polio pandemic. One of the largest polio hospitals in the U.S. was in Houston, giving rise to the rich rehab medicine heritage there which ultimately attracted her to the field during her training. “Because our field started with the polio pandemic, we are uniquely fit to care for the population of chronically debilitated COVID-19 patients.”
Dr. Verduzco-Gutierrez grew up in South Texas, and never dreamed that she would one day return to San Antonio to become the third ever Hispanic female full professor and chair of a department of Physical Medicine and Rehabilitation in the United States. “I’m excited because here I get to serve the people of South Texas. I am returning to my roots,” Dr. Verduzco-Gutierrez said. “When you care about the place where you work, you really want to make a difference,” she said.