'A Race Against Time': A Conversation on COVID-19 and Health Equity with MGH Executive Dr. Marcela del Carmen

Interview by James Jolin

HHPR Editor James Jolin interviewed Dr. Marcela del Carmen, the Chief Medical Officer for the Massachusetts General Physicians Organization and Gynecologic Oncologist at the Center for Gynecologic Oncology. Marcela G. del Carmen, MD, MPH is a graduate of the Johns Hopkins School of Medicine. She completed a residency in gynecology and obstetrics at Johns Hopkins Hospital and a fellowship in gynecologic oncology at Massachusetts General Hospital (MGH). She graduated with a Masters in Public Health from the Harvard School of Public Health. Dr. del Carmen was on the faculty at Johns Hopkins before returning to join the faculty at Massachusetts General Hospital. Dr. del Carmen is board certified in Obstetrics and Gynecology and Gynecologic Oncology. Dr. del Carmen is an Professor of Obstetrics, Gynecology and Reproductive Biology at Harvard Medical School. Dr. del Carmen is also Chief Medical Officer of the Massachusetts General Physicians Organization. Dr. del Carmen has authored over 200 papers in the peer-reviewed literature and authored a textbook.

James Jolin (JJ): I know that you’re in an executive position at Massachusetts General Hospital (MGH) and that you still practice medicine. Could you describe to me your position and some of your responsibilities?

Marcela del Carmen (MDC): Over the last five years I’ve served as the Chief Medical Officer for the MGPO—the Massachusetts General Physicians Organization, which is the group that has oversight and responsibility around faculty practice. We’re a closed system, so every doctor that works at Massachusetts General Hospital is part of the practice and is part of a group of 3200 doctors. We have the largest primary care practice of an academic medical center in the country.

I do a lot of work around physician wellness, so trying to understand what leads to physician burnout, administrative burden, and then looking for ways to roll out programs that support doctors. And that includes work in IT and ways to improve our usability and the actual tool of the electronic health record. The other one, I would say, is practice resources—trying to make sure that doctors have the adequate allocation of resources to do their job well and programs focused on well-being such as nutrition classes, yoga, soulcycle. I also work in the realm of lobbying—so working with the American Medical Association to try to see if there are ways that we can decrease the regulatory requirements, especially around documentation. So it’s a little bit of everything.

JJ: That all sounds great! With regard to the COVID-19 pandemic, what has Massachusetts General Hospital’s experience been? In what ways have you promoted outreach to low income individuals and people of color?

MDC: Obviously, this was unprecedented. I don’t think any one of us in medicine expected, anytime in our lifetime, to live through something like this. I would say there are a few big takeaways from this experience.

One is the ability that we have in places like MGH to leverage innovation and technology to expand programs. Academic medical centers are sometimes criticized for the slowness with which they advance or change. I think we come from a field where we’re very evidence-based, and so a lot of times, we need evidence before we’re actually willing to take a chance. We still relied on that framework of safety and evidence-based practices, but we were able to very quickly harness a lot of brainpower around ways to innovate. And I would extend that to, say, the way that the vaccine programs were developed. Very quickly, within a year, we had three vaccines in the market.

Towards low income patients and people of color, one thing that we did very early on was deployment of healthcare workers to areas outside of their primary domain of clinical care, to be able to help with COVID-19 care. Our engagement in the community—for example, in Chelsea and Revere where we have a big population of underrepresented minorities—and making sure that we stood up services through our local clinics tended to the needs of those communities.

We had a program at MGH led by bilingual faculty, and these were doctors that were, for instance, pancreatic surgeons—people that were not necessarily attending firsthand to COVID-19 patients—who volunteered to cover 24 hours, 7 days a week, working as translators to be able to facilitate communication between family members and patients who were primarily Spanish speaking.

We were part of a city-wide effort to stand up a hotel in Chelsea, where we were able to accommodate recovery of patients that had a hard time with physical distancing at home. Once they were diagnosed with COVID-19 illness, they didn’t have the physical space to isolate at home. We stood up clinics where we did respiratory care for people coming in, especially at the beginning when testing was more limited, where we could see our patients with complaints of respiratory illnesses and do PCR-based testing and then triage them to either be admitted to the hospital or go home.

As you know, I think one of the challenges at the beginning was just the number of times within a week that guidance around PPE was changing because there was a lot that we didn’t know. Communication was an issue: MGH employs 20,000 people, so trying to understand when we went on lockdown, providing support for people who work remotely, and then providing the PPE that was appropriate for the people to do in-person care was a challenge.

Around the week of April 26, 2020 was where we hit our peak. We had just under 400 patients admitted to the hospital for COVID-19, and about 40% of them were admitted to an ICU. We were lucky in that we never ran out of ICU beds or ventilators, but it required converting a lot of our space to an ICU level of care. I would say there was a lot that we learned early about what services we needed to shut down in order to deliver care.

And then I think coming into the middle of the summer and the fall, things got better. And then we had another surge in the fall—but not as big as the one in the spring. Still, that also required activation of our hospital incentive command center. When this program is activated, the president of the hospital forgoes governance of the hospital and gives it over to a group, which is in charge of essentially carrying on our missions over the course of any kind of emergency event. They take over the governance of the hospital but not clinical activities. And so every day, there are meetings where people report on their domains and responsibilities. Somebody is in charge of reporting on inpatient care; somebody else is in charge of all of the ambulatory services, resources, physician wellness, staffing issues. So it’s a very organized system.

Now we are trying to recover and going back to essentially standard operations.

JJ: That’s all very interesting. Another crucial pandemic-related issue is vaccine rollout. How is MGH helping to accelerate vaccination in the Boston area and encourage confidence especially among historically marginalized populations?

MDC: We initially were told that vaccines would come to local hospital entities, so we stood up several patient vaccination sites and had the staffing to be able to deliver what we thought was going to be about 20,000 doses across every day. And then very early in that process, within a week, we had the governor say the state would take over the vaccination programs. And so we basically took everything down only to find out two weeks later that we were being asked to be part of the vaccination programs again. So those clinics were stood up again.

In terms of equity, we went with an age model. Essentially, we thought that it would be more equitable to use a very objective data point, such as your age, to allocate and prioritize the groups that should be vaccinated first. The initial wave was for patients 75 and older. The second way was for 65 and older, and we essentially generated lists based on our electronic health record.

To the issue of equity, because we understand that not everybody has access to their electronic health record remotely, we also had a venue for people to sign up through the phone, so they could have access to vaccine scheduling. We also went out into the vulnerable communities with a vaccine program for bilingual groups. For example, in Chelsea, we have a pretty high percentage of patients who are Spanish speaking only. So we made sure that we had people of that community who work at MGH—physicians, nurses, medical assistants and volunteers—that could speak to any concerns that patients had about vaccine safety, and would encourage them to get the vaccine.

JJ: That all sounds very interesting. Looking more broadly at the effect the pandemic has had on the hospital community, what kind of practices have changed and will stay the same? Will staff wear masks at all times? How will MGH support physician wellness moving out of this stressful period?

MDC: I think it’s a race against time. Until the world’s fully vaccinated, and there’s herd immunity, there’s always a chance that one of these variants will crop up that is not included or not covered by the vaccine. So it’s really a race against whether the virus comes up with a variant that is not covered by the current vaccine, or we have enough vaccination globally.

I’m worried more about countries that are low- and middle-income, like Latin America, and our ability to actually successfully stand up vaccination programs. As you know, the cold-chain vaccines are difficult to administer in rural areas because of the logistics. So I think we’re going to be wearing a mask for a while, and I think we’re going to continue to have some physical distancing guidelines.

There will be ways that we deliver care that are going to be different. The one that I think is the most obvious is telemedicine. I think that telemedicine is here to stay. There were clinics that were more advanced in that work before the pandemic, but I think now everybody, by necessity, has had to put up telehealth platforms. And I think those are here to stay, but what needs to be sorted out is which patients are appropriate for that level of engagement and when you have to bring somebody to the hospital for in person care.

Working remotely will be another big issue—understanding how to do that well and equitably. In places like Boston, where we have very limited space, it was proven that you don’t have to actually come into the hospital to do your work, depending on the nature of your job. But I think we need to look at that with some kind of equity lens to make sure that it’s not certain groups that are being preferentially allocated to a virtual working experience. I worry a little bit about doing that well over the future.

I think wellness will change. I think that some of the same pain points that were true before the pandemic will still be here—around documentation, practice resource allocation. But I think we’ve seen a huge need for health services. As you know, physicians are challenged in that, depending on the state where you're practicing medicine, sometimes the licensing process requires you to acknowledge if you’ve had any healthcare issues that have required any kind of intervention. So there’s a reluctance for physicians to get behavioral health services.

We will probably push harder on trying to change the language around licensing requirements so that you’re able to seek care without having to report it—as long as you don’t have an active issue that is impairing your ability to take care of patients.

There are also some gender inequities that have come up, where women in medicine have shoulder more burden around home responsibilities, especially as children and young people have had to learn from home. And I think that those inequities and disparities existed before the pandemic, but like everything else—including inequities in the way that we deliver care to our patient populations that are vulnerable—the pandemic has magnified them. I think that we’ll need to have very intentional programs to support young faculty women.

JJ: I saw you published, along with some colleagues, a paper titled “Trends in Ambulatory Electronic Consultations During the COVID-19 Pandemic.” Could you briefly discuss your findings and how they can be applied to the 'new normal' we are entering?

MDC: I think the findings are not outside of what we would expect to see. I think what we’ve found is that there are some disparities in who’s able to access that technology. I would say the big take-home message for me would be that before you’re able to stand up these programs, you have to make sure that you’re not creating inequities that were not there.

We have a program here, called the Virtual OPS Unit, which was stood up to actually provide care in the home to patients who were either discharged from the hospital after COVID care, or they tested positive for COVID but were deemed safe to go home. And so the program included having a paramedic visit the patient at home, and then connect the patient through some technological platform to a doctor at MGH. What we found was that many of our patients, especially those who are older Latinos and African Americans, were less likely to have technology at home to be able to access that service, and most of those patients have to do it through an iPhone.

So I think that our ability to understand, as I said earlier, who’s appropriate for telemedicine and making sure that those tools are there so that we’re not leaving behind vulnerable communities will be important.

JJ: One last topic I wanted to discuss was the idea of affordability in medicine, especially given the pandemic-induced recession. What are some of the programs that MGH has initiated during or before the pandemic to ensure affordability?

MDC: We’re lucky, in Massachusetts, that there’s universal care, so the state basically mandates that everybody has insurance. But not everybody has the same level of coverage, and sometimes you can have co-pays that are challenging.

Most of our work is channeled through our case-management services. We find ways to financially support patients, but we have some programs that are looking beyond that—for instance, in our accountable care organization (ACO) for patients, which we expanded to be “payer blind.”

We also have now built into EPIC, which is our electronic health record, a platform that surveys everybody who comes in to see a primary care doctor at MGH. And that survey is vetted to identify the needs around social determinants of health—and that includes transportation issues, food insecurity, etc. So if you demonstrate that you have some food insecurity issues, then I, as the clinician taking care of you, can go into EPIC and actually ask for support to address your needs.

So if you’re diabetic, you’ll be connected to a team that, depending on your hemoglobin A1C, will determine whether your food security needs can be met by just having us deliver food to your house. Or, if your hemoglobin A1C is high, then you’re paired with a nutrition counselor, and then the meals are actually prepared and delivered to you. We’re not just giving you the funding or the support for you to have a meal, but we’re trying to meet your medical needs.

I think that is the future of healthcare in the US. As you know, we don’t do a good job of preventative medicine. And I think unfortunately, in this country, a lot of the social determinants of health have been sort of left no one’s domain of responsibility. So it may be that it is going to fall on medicine to address those needs because you can’t be healthy unless those needs are met. I think the charge for the Biden administration, and probably the next ones to come, is going to be how we afford that.

JJ: Very interesting! Thank you so much for your insights, Dr. del Carmen. Our readers will surely benefit from your contribution. Is there anything else you would like to add before concluding?

MDC: The pandemic will be studied for decades. It was disruptive, but I think hopefully we will come out as better human beings, as better doctors, and with better systems through what we’ve learned over the last year and a half.