Missed Opportunities, Lying, and Disparities in Patient Outcomes

What happened to the playbook for pandemic response? What ethical issues surround vaccine mandates? Do we need to improve physicians or the systems that affect physician practice? What about physicians who are not truthful with their patients?

These are just some of the topics Matthew K. Wynia, MD, MPH, FACP, director of the Center for Bioethics and Humanities at the University of Colorado, discussed with SoundPractice host Michael J. Sacopulos, JD, CEO of the Medical Risk Institute.

Mike Sacopulos: Matthew Wynia is a physician trained in infectious disease and public health and a nationally known bioethicist. He has authored over 160 articles and has appeared on CNN, ABC News, MSNBC, and NPR. Dr. Wynia currently serves as the director of the center for bioethics and humanities at the University of Colorado Anschutz Medical Campus. Welcome to SoundPractice.

Matthew Wynia: Thank you for having me, Mike.

Sacopulos: You’ve spoken of a pandemic playbook that we had available, but did not properly use when COVID-19 appeared early last year. Can you tell me what’s in the playbook?

Wynia: Oh, that’s such a great and expansive question. There is an enormous body of research — not as enormous as it probably ought to be, I’ll acknowledge that — but there’s a good deal of research on how to respond to a pandemic, some of which is as recent as 2009, when we did experience the H1N1 pandemic in which 60 million Americans caught a novel influenza virus.

We got very lucky in 2009, that only about 12,000 people died. It was a novel virus, everyone was susceptible. Huge numbers of people were infected, but it also turned out to be a rather mild virus. And so for most people who caught influenza in 2009, it was not a big deal. But you could imagine, in early 2009, when we started seeing reports of this, both from the U.S. and from elsewhere around the world, we thought when the flu season came around in, September, October of 2009, that we were about to be just creamed.

We thought the healthcare system was about to be swamped. We thought that we were going to see situations where we had many people who needed artificial ventilation and we would not have nearly enough ventilators to go around. So that prompted a lot of preparatory activity.

And then after 2009, as this played out and it turned out we didn’t need many of those plans, we sort of filed those plans away for next time, knowing that there will be the next time. We are not going to be done with pandemic disease because viruses continue to mutate and evolve. And at some point, you see a novel influenza virus to which no one has any immunity or you see a novel coronavirus to which no one has any preexisting immunity. And when that happens, you have the potential for very large numbers of infections all at once.

And we knew in advance because of the planning, not only for H1N1 but for prior pandemics…we’ve been having pandemics forever. So we have masking ideas, we have what needs to be in the stockpile in terms of spare resources. We have plans for how to allocate ventilators if we do get swamped.

All of those things had been thought through and planned out. And to some extent, those were used sporadically here and there in different states in different ways. I think where we fell down in terms of not using the pandemic playbook was at the federal level, where it was not even taken off the shelf because there was a sort of ideological sense that states ought to be handling this.

With the notable exception of a tremendous effort to create a vaccine. And that was a federal effort. It was recognized right off the bat that would need to be a federal effort with enormous resources put into it. And that did happen and paid off amazingly with multiple highly effective vaccines coming online within a year. I don’t think we should underplay the miracle of that.

Sacopulos: I think “miracle” is the right term for it. But as you listed off these things that are in the playbook or what resources we should have thought about, actions we should have taken, it does seem to beg the next question of why this hard-earned knowledge was not applied.

Wynia: I think there will be many PhD dissertations written about this. There are already books being written about it, looking at what the factors were that caused folks in the federal government not to respond in the way that we sort of assumed the federal government would respond in the event of a disaster of this magnitude, a catastrophic global pandemic.

So I think this is the first cut in history now. And I think the first cut is bound to be wrong in some respects, almost certainly oversimplified. But I sense that there was a sort of ideological and a political agenda at play here, which was that the federal government should step aside as much as possible and let states manage this.

And to some extent, by the way, that is baked into our disaster response frameworks. All disasters are local is a truism in disaster response. And here we were dealing with a catastrophic, not only nationwide, but global disaster occurring everywhere all at once. And the idea that that scale of the disaster could be managed mostly at the local level is just flawed thinking, but it is thinking that is resonant in America, right?

In America, we have states’ rights. We have the idea of states as laboratories. We have the notion that we want to devolve power as far down toward the individual as possible. And all of those things serve us very well in most circumstances, but in a global pandemic, they served us very poorly.

Sacopulos: Really kind of an antebellum view of public health. So let’s talk about earlier times, I’m a resident of Terre Haute, Indiana, and I can tell you that in the early 1850s, there were several cases of smallpox here in Terre Haute, and citizens were required to get vaccinated/inoculated, no options, right? When did the attitude toward public health skew libertarian?

Wynia: First off, I think I would say there was a skew libertarian in the 1800s and early 1900s as well. That’s why we end up seeing a Supreme Court case, not out of Terre Haute, but out of Boston, around smallpox vaccination in the early part of the 1900s. 1906, I believe, was the Jacobson case. It’s this famous case of mandatory vaccination for smallpox. A person said, “I don’t want to do it and I don’t want to pay the fine.” The Supreme Court said, “Well, you will either get the vaccine or you will pay the fine. The state is authorized to create mandates like this and to impose some kind of a penalty for the mandate.”

I think we’ve always had a segment of the population in the U.S. that says “You’re not the boss of me. You can’t tell me what to do,” and in particular, they’ll say “You can’t inject me with something against my will.”

Vaccination was put into that same bucket in 1906 by the Supreme Court, and it has been upheld repeatedly, including very recently in the Houston Methodist decision, which allows for vaccination mandates in hospitals. And I expect it will continue to be upheld because it’s a core thing that a civilized society does, in fact, constrain individual liberty to some extent to keep everyone safe.

And “where are the limits?” is where the really interesting conversations arise because you can overstep this. We have, in the history of mankind, seen states that overstepped and went way too far in the direction of constraining individual liberties in pursuit of public good or public wellbeing. The most infamous case being the Nazis who felt like individuals had zero individual rights. It was all about the Volk. It was all about the larger community. And so we have that historical legacy that prevents us, I think, from going too far down that path. But it doesn’t mean we can’t do anything that constrains individuals to protect the community.

Sacopulos: So here’s something that bothers me. Is it too late? Has the opportunity to address concerns and vaccine hesitancy passed? I fear that some of our fellow citizens have entrenched in their anti-vax position. Tell me I’m wrong.

Wynia: Well, yes. I think you are right in one regard, which is that there is a fair portion of the population, a relatively small portion, but there are people for whom anti-vaccination belief systems have become a part of who they are. It’s a piece of their integrity. And to the extent that someone holds a belief — whether it’s a religious belief, a political belief, or a scientific belief — a belief becomes a part of who you are. It becomes very challenging to change that belief.

Even when you see data to suggest that the belief is wrong, the way people change beliefs that are that entrenched is there has to be a storyline that is coherent about how you moved from what you believe today to what you believe in the future.

People don’t just change because of data. They need a story about how they transformed their belief. It’s hard, but it is not impossible. Some people have moved from one set of beliefs to a different set of beliefs over time. And hopefully, the second set of beliefs is more fact-based, more in line with the reality of the situation.

But you are not going to get people from a current belief to a future belief by just telling them the current belief is wrong, by just giving them data, charts, figures, and graphs. You need to help them develop the story for how they move from one belief to the other belief.

By the way, I mentioned this is a pretty small segment of the population. It’s a minority of the people who haven’t gotten vaccinated so far. So, at least according to the survey data we have on this, most of the people who haven’t gotten vaccinated so far are not hardcore “This is who I am! I will never buy your vaccine. I think there’s a microchip in it.” Those kinds of conspiracy theories exist, but they’re not the majority.

Most of the people who haven’t gotten vaccinated so far are of the “I’m going to wait and see,” or “I just don’t see why it’s of value to me. I’m glad my grandma got vaccinated, but why should I get vaccinated? Look at the data on survival rates for people my age. Most people my age, the vast majority, survive. So why should I take the risk of an unknown vaccine?” And I think for folks like that, they’re going to need to talk to someone else who believed that as well, and then changed their mind because they realized, I’m destined to get this.

Everyone is going to get this at the rate things are going right now. So my choice is not between getting vaccinated and taking my chances. My choice is between getting vaccinated and getting COVID, because everyone is going to get COVID eventually. And a certain proportion of people who get vaccinated end up having a fever for a couple of days and have to take a day off of work. And that’s no fun, but a certain proportion, a similar proportion of people who get COVID, are sick for two weeks and are out of work for two or three weeks. And a small portion of them still feels terrible three months later. Right?

So your choice is not between vaccination and take my chances, your choice the way things are going right now, is get vaccinated or get COVID. And I think people will start to see that. And this, by the way, is why we are seeing an uptick in vaccination right now because of the spread of the delta variant and the fact that people are seeing their friends and neighbors get sick and some of them are dying.

Sacopulos: Well, that’s at least a little bit more hopeful than where I think I started my question. So let’s transition from COVID-19. Dr. Anna Holtz McKee, the chief medical officer for The Joint Commission, appeared on SoundPractice. Dr. McKee spoke of disparities in healthcare as a patient safety issue. Do you think that’s correct? And if so, what are the implications to physicians if it is correct?

Wynia: It’s interesting. I haven’t heard that episode, so I’m not sure how she was thinking, but there are two ways to think about disparities and patient safety. One is that we have data going back at least 15 years, but a very recent study reconfirmed this.

I believe it was the Robert Wood Johnson Foundation that put out a study just in the last few months looking at disparities in patient safety events by race and ethnicity. And it turns out not surprisingly, I guess, but it turns out that racial, ethnic minority communities in the U.S. tend to experience more patient safety events, more medical errors, more adverse outcomes as a result of inappropriate care than White patients do. Much of that, but not all of it, is driven by the fact that minority communities tend to receive care in lower-quality hospitals and at lower-quality clinics.

Some of that is attributable to the differences in quality delivered by different hospitals and clinics. That, of course, does not solve the problem. It just explains where things are. But I think you do need to take a step from that and say, well, why is it that minority patients end up being seen more often in lower-quality hospitals that have more errors? That’s not an accident.

The segregation within our healthcare system, like the segregation within our school systems, did not arise by chance. It was designed. And so the ongoing segregation and the ongoing lower-quality services that are provided to minority communities....this is what people talk about when they say, “systemic racism.” It’s not about individual doctors treating patients differently by the color of their skin. It’s about structures in society that lead minority communities to receive lower-quality services because they go to lower-quality service providers and those lower-quality service providers are under-resourced and so on.

That’s one way to think about patient safety and disparities — there are disparities in patient safety. The fact is that minorities are two or three times more likely to catch and then die from COVID or end up hospitalized from COVID. That is a patient safety issue. And I’ve been pushing this view for about 12 or 15 years now that we should look at racial disparities in health outcomes and racial disparities in care delivery as a medical error. And it’s just a way to frame that conversation. It’s a way to think about it.

We’ve spent a long time in healthcare coming around to the view that when an error occurs in a hospital, it’s seldom the result of a single person making a terrible decision with no external forces at play. When we do root cause analysis of medical errors, on average, there are seven or eight places where that error could have been caught and mitigated so that it wouldn’t have harmed a patient. We’ve talked for a generation now about just culture and the need to be able to speak openly and to learn from medical errors because they’re not about bad doctors, they’re about bad systems. How do we improve the systems of care to avoid errors?

I think we need to apply that same lens to the racial disparities that we see in healthcare. They’re not about bad doctors. It’s about a bad system that leads to these disparate outcomes by race and ethnicity and by socioeconomic status. And by rural-urban status, right? There are disparities in a lot of ways, not just racial disparities. Why is it that we see rural communities having worse health outcomes than urban communities and so on?

So I think if you start thinking about the quality of care by applying the patient safety lens, what you get from that is a move away from blame and shame, and calling out individual doctors for not doing as good as they could.

By the way, we shouldn’t ignore that. Some doctors don’t do as well as they should and do need remediation and so on. So I’m not ignoring that, but I would say that’s not the majority of the reason we see health disparities by race and ethnicity. It’s not individual doctors saying, “I’m going to treat this Black patient worse because I don’t like Black people.” That is pretty rare. It happens, but it’s relatively rare compared to the systemic factors that lead you to say, “Well, I’m going to treat the Black patient the same while they’re in my clinic, but then they’re going to go home to an environment that doesn’t allow them to follow through on the prescription that I just gave them and that’s going to lead to a worse health outcome.” That’s a systemic factor and we need to approach that on a systems level, not just on an individual level.

Sacopulos: You’ve done some research or studies in the past about physicians being untruthful or lying to patients. And I was very interested in that. Can you tell me a little bit about that research?

Wynia: Well, you took me back. This is when I was at the Institute for Ethics at the American Medical Association, and one of the things that we were interested in was physicians who might be misleading insurance companies to get things covered that they thought the patient needed, but that the insurance company might not cover. And doctors using different codes than might have been completely accurate, that kind of thing to get drugs covered, testing covered, etc.

And so we did a national survey looking at that issue. And one of the things that came up in the context of looking at misleading insurance companies was that there were also doctors who said, “Yeah, and do you know what, if I don’t think something is going to be covered, and there’s not a way for me to get it covered, sometimes I just won’t mention it to patients. Sometimes I’ll just ignore it.” And the rationale was something like, “Why should I bring something up as an option if it’s not an option for this patient, because….”

Sacopulos: Because you were taunting this patient.

Wynia: As though you’re taunting them with, “Well, in an ideal world, I’d like to get you this, but no way you’re going to be able to afford this and the insurance company’s not going to cover it. So I’m just not going to bring it up with you.” And to some extent that is misleading the patient by omission, right?

So it’s not exactly a lie, but it is a lie by omission, by not bringing something up. And we were disturbed by that finding. We thought that that was of concern. Again, not because I think an individual doctor is necessarily a bad person for making that. That’s a very difficult choice to make, to say, “I’ve got this test that I would like to be able to do, but the insurance company will never cover it. I’m just not going to mention that.” I think that’s a tough decision to make because of that issue you just mentioned about is it just taunting the patient to bring that up?

So, that is a systems problem. If there are truly valuable things that the insurance company is not covering, we should know about that. We should be talking about that. That should be part of our policy discourse, etc. It shouldn’t be something that is having to be dealt with at the bedside, by the individual clinician, making these tragic, difficult decisions.

It’s an illustration, by the way, of what we were just talking about, where you can look at this at the individual level and say, “Bad doctor, why are you lying? Why are you not telling your patient everything?” but that’s not going to solve the situation. That’s going to make the doctor feel bad, but it’s not necessarily going to get them to make a different decision next time. And it’s certainly not going to get other doctors to make a different decision next time. To do that, you have to look at this from a systems perspective.

Sacopulos: I’ve read that you oversee an art gallery at the University of Colorado. Is that correct? Can you tell me about how that came to be and about the gallery?

Wynia: My center is the Center for Bioethics and Humanities, so we do a lot of work on art and medicine, music and medicine. We have a wonderful music and medicine initiative. There are features of the work that we do that you really can’t learn in a textbook, but you can learn them in a play or a novel, or by looking at a work of art together. So we very explicitly use the arts to help people understand the social context of being a doctor or a nurse or a pharmacist or a dentist — the sort of communal decision-making that we often have to undertake.

We do this art of our observation program, which is wonderful where we get different people to look at this from different training backgrounds to look at the same work of art. And what you’ll see is that different things pop out to different people — and it’s not that one view is right or wrong. When they step back from it and then talk together about — what did you see? what stood out to you? — you get a richer understanding of the story that the piece of art is telling these different individuals.

We use that as a way to approach the idea that different people will see patients differently. They’ll each come away from the patient with something else that stood out to them. And the richer understanding of the patient’s story will come when the different caregivers can share what they saw and compare notes.

And that’s how you get a better decision. So we use it to talk about teams. We use it to talk about disparities. We use it to talk about the difference between what you see and how you interpret what you see and stereotypes and things like that end up coming up in some of the art that we look at. So that’s how we use the art gallery. It’s also a public gallery, so we invite the public in to see the work there.

Sacopulos: It seems that medicine is both art and science, and so much of training focuses on science and not art. I was very interested in your approach and, to your knowledge, is that somewhat unique?

Wynia: I don’t know that it’s as unique as it may have used to be. There are quite a number of places now that are explicitly incorporating the humanities into medical training. The AAMC has a whole initiative around how best to incorporate the humanities into what we do.

I think the irony to some extent is that anyone who’s actually in medical practice realizes that the knowledge piece, the science piece, is the easier of the pieces in terms of practice. Learning everything you need to learn feels insurmountable when you get started in medical school, of course, but eventually, this is work and it’s a job and you will get good at the knowledge part because you’ll be practicing that for the rest of your life. So the knowledge piece is critical and you do need it from the outset, but it also will get continually reinforced.

The art piece is where people struggle throughout their careers. That is the most challenging part of this: how to maintain empathy, how to maintain humility, how to maintain strong relationships with patients and not become inured to human suffering.

We see suffering and then we have to move on to the next patient. The work that we do is challenging to our humanity sometimes, but it can also be nurturing to our humanity, albeit only if we make an effort to make it so. Otherwise, I think the work that we do is a challenge to the humanism of the doctor.

And we’ve seen this repeatedly: The people who get in trouble as physicians, they’re not always in trouble because they had a bad knowledge base. They’re typically in trouble because their humanity had been eroded. Their empathy had been eroded. Their humility had been eroded and they end up doing stuff that they very well know they shouldn’t do if they were to stand back and think about it.

Sacopulos: I’m interested in what bioethical issues you think we’re going to be focusing on in years to come, things that you might see coming before the rest of us do.

Wynia: We do an annual program up in Aspen called the Aspen Ethical Leadership Program where we bring in C-suite folks, many physicians, but also lawyers, chief legal officers, and so on. And we talk each year about what we see coming.

This year’s program is coming up in October and it will focus on how we use the lessons learned from the pandemic from this last, terrible year. How do we use lessons about health equity? How do we use lessons about resilience, wellbeing, and burnout? How do we use lessons about the increasing use of technology? The rapidity with which scientific knowledge is being advanced, the use of artificial intelligence, things like that — how do we bring those together to create a better health system?

Again, this maybe goes back to our systems thinking, and that I think is the way of the future right now — moving away from thinking about the ethics of just an individual and building up individual character, which is important.

So again, I don’t want to be mistaken for saying that’s not important. That is very important. And unethical behavior, just like unsafe behavior, just like poor quality care, can be thought of in a systems approach. What has the system done that creates the person who becomes inured to human suffering, who becomes cold and hard-hearted, who then ends up harming someone?

Looking at unethical behaviors as a function of a system and not just a function of a bad person, I think that’s the direction that we are going to be taking in the study and the application of bioethics over the next few years. And I think there’s an enormous amount that will be learned from the pandemic because we did place doctors and nurses in untenable, ethical circumstances. Sometimes there was no choice, but sometimes there were things that we could have done as a system that would’ve avoided that.

Sacopulos: Well, Godspeed on that. Dr. Wynia. I wish you tremendous luck because we certainly need to learn some lessons and apply some knowledge. Thank you so much for your time today on being on SoundPractice.

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About Our Soundpractice Guest

Matthew K. Wynia, MD, MPH, FACP, is director of the Center for Bioethics and Humanities at the University of Colorado. He previously directed the American Medical Association’s Institute on Ethics for 15 years and founded the AMA’s Center for Patient Safety.

He has led projects on a wide variety of topics related to ethics and professionalism, including understanding and measuring the ethical climate of healthcare organizations and systems; ethics and quality improvement; communication, team-based care, and engaging patients as members of the team; defining physician professionalism; public health and disaster ethics; medicine and the Holocaust (with the US Holocaust Memorial Museum); and inequities in health and healthcare.

Dr. Wynia has published more than 160 articles, chapters, and essays, and co-edited several books. He also has discussed his work on the BBC, ABC News, CNN, MSNBC, National Public Radio, and other media outlets.

A past president of the American Society for Bioethics and Humanities (ASBH), he has chaired the Ethics Forum of the American Public Health Association (APHA) and the Ethics Committee of the Society for General Internal Medicine (SGIM). He is an elected Fellow of the Hastings Center and serves on the Fellows’ Council.