Michael Parkinson, MD, MPH, FACPM is a past president of the American College of Preventive Medicine and a retired Air Force colonel.
Donna Grande, MGA, is the Chief Executive Officer of the American College of Preventive Medicine
Earlier this month the New England Journal of Medicine published the editorial, Ten Weeks to Crush the Curve, by Dr. Harvey Fineberg, a call to action for a national response to COVID-19 - initiated by the Federal government and with the participation of all working in medicine and public health. ACPM, and every one of our Fellows, members, and residents are answering the call.
Here’s how we are responding to the six key components of Dr. Feinberg’s request:
1. Establish Unified Command
ACPM member physicians have expertise in managing population health and healthcare systems in government and the private sector, and can provide an immediate, informed perspective on how to improve the command and control function of organizations responding to COVID-19. This perspective informs both ACPM’s organizational response and guides a cadre of trained medical professionals for local, state and national response efforts. Our volunteer leadership board and professional staff have established a proactive plan to engage in the national dialogue, support our members and provide expertise to the COVID-19 response at every level.
We want to encourage all preventive medicine physicians to identify ways to contribute to existing or developing command structures within their own communities. Unified command allows a jurisdiction or organization to effectively and efficiently coordinate response across a community. Preventive medicine physicians with National Incident Management Systems training are further encouraged to establish appropriately scaled incident command structures in their own organizations, or to serve as incident managers, medical or science team leaders, or other appropriate leadership positions within their local incident command structures.
2. Make Millions of Diagnostic Tests Available
Last month we issued a strong statement regarding the need for a clear plan to meet the demand for testing. ACPM has routinely called for public health authorities to be the driving force behind recommendations for how to implement expanded testing capabilities in order to inform the implementation and easing of social distancing measures.
All preventive medicine physicians can contribute to laboratory testing protocols by advising their organizations about which tests to purchase and protocols for using those tests, including priorities for testing and whether tests are being used for clinical management and/or public health decision making. Preventive medicine physicians are uniquely trained in data analysis and interpretation of data to determine population-level strategies. Thus, we encourage our members at every level to contribute their skills to determining how the results of expanded laboratory testing can be used to implement and ease social distancing measures (ideally supported by regional data) in their own communities, by volunteering their expertise to their local and state health departments or incident command structures. Of equal importance, preventive medicine physicians should have a central role in crafting messages to the public about how and why testing is being done, what the results mean, how the results will be used, and what the tests cannot accomplish.
3. Supply Health Workers with PPE and Equip Hospitals to Care for a Surge in Severely Ill Patients
ACPM worked with the Council of Medical Specialty Societies to issue a joint statement calling for increased national provision of PPE. Furthermore, we’re supporting research regarding the current status of critical care and palliative care protocols to determine current surge capacity for severely ill patients.
Preventive medicine physicians, especially those with specific training or experience in occupational health, are encouraged to immediately engage with their local health care systems and public health departments to assist in determining PPE requirements, identifying resources, and providing expert guidance on PPE purchase decisions. In addition, preventive medicine physicians should work within their own organizations to identify whether ventilator management and palliative care protocols are adequate for this pandemic situation and assist in developing or updating those protocols. Preventive medicine physicians should assist with securing ventilators from state or federal stockpiles, work with state licensure boards to ensure proper scopes of practice for health care providers, establish just-in-time training modules for health care providers, and develop protocols to prepare for a surge in critically ill patients. Preventive medicine physicians should also consider if their clinical skills are amenable to service in newly established respiratory syndrome evaluation clinics or surge facilities.
4. Differentiate the Population into Five Groups and Treat Accordingly
This step specifically demands the expertise and contribution of preventive medicine physicians. Trained in epidemiology and the use of data to drive population-level interventions, preventive medicine physicians are primed to participate in decision making about the implementation and easing of social distancing, enhanced contact tracing with laboratory testing, population serosurveys, and other steps required to differentiate the population into disease, exposure and risk groups and treat them accordingly. We encourage every preventive medicine physician to reach out to community health, population health, epidemiology, or other relevant departments in their organizations or jurisdictions to make their skills and availability known.
5. Inspire and Motivate the Public
ACPM has and will continue to work tirelessly to amplify messages to the public about the need to take personal action. We all have a role to play in combating this epidemic, the actions of the public can provide immense support to the healthcare professionals leading the fight against this pandemic. We also call on all preventive medicine physicians to reach out via their work organizations, social media, local traditional media, and any other communication resources at their disposal to help their communities understand what we know now, what we are learning, and what to expect in the days to come.
6. Learn While Doing through Real-time, Fundamental Research
In addition to encouraging and participating in specific research protocols, we also encourage the real-time use of data for decision-making. Preventive medicine physicians are trained in population health data collection and analysis and should be actively developing, implementing or participating in local research studies within their organizations and jurisdictions. After-action reports are a critical observational research tool to improve both preparedness and response for future events. Preventive medicine physicians should be centrally involved in serving as observers or “Team B” leaders to carefully annotate protocols, actions, decisions, and leadership within their organizations. This documentation will be critical to improve local preparedness and response activities and to contribute to higher-level jurisdictional improvements.
Dr. Fineberg’s call to action is also a clarion call to our profession’s medical residents. Preventive medicine residents (PMRs) have chosen to train in a field designed for rapid response and adaptability, and thus offer another unique resource to the response effort. Already having advanced clinical training and master’s degrees in public health, PMRs are accustomed to rapidly assessing and adapting to highly varied practice settings, from health care systems to public health departments, from research rotations to field epidemiology, from policy writing to intervention implementation. In one program alone, PMRs’ duties have shifted to working on enhanced data collection for case tracking, developing infection control guidance for the Department of Corrections, research and data collection for a high-level medical advisory committee for resource allocation, and developing an online self-assessment with a self-care guide and nurse triage lines. We encourage every PMR and their program directors to identify and accommodate the specific needs of their home organizations and communities across Dr. Fineberg’s six steps and adjust their training and service rotations accordingly.
While it feels like we have been, as a nation, in crisis response mode, we must remember that pandemic response will be a marathon, not a sprint. If we can summon the collective will to aggressively and uniformly implement these six steps, we will be able to settle more quickly into a systematic and less chaotic response. When that happens, we will be able to begin analyzing how we more quickly and effectively identify, respond to, prevent, and mitigate the next pandemic threat.
We must wrestle with fundamental questions about the role of government, at every level, when infectious diseases threaten us. We must confront what it will take to rebuild our preparedness and response infrastructure and leadership in the public and private sectors. We must finally acknowledge that prevention is preparedness – that people with preventable chronic diseases are always more vulnerable during a pandemic, that societal vulnerabilities are always exacerbated during public health crises, that our largely for-profit health care and health care financing structure is not incentivized to be prepared for infrequent but devastating health events, that we cannot treat our way out of every health problem. These questions are not new, and they are familiar and fundamental to every physician who seeks a career in preventive medicine. It is time for us to speak boldly about the problems and the prevention-oriented solutions we can offer.