SEASON 1, EPISODE 6
In the second of this two-part episode of “Beyond the White Coat,” David Skorton, AAMC president and CEO, talks with Rep. Donna Shalala (D-Fla.) to discuss how the coronavirus has forced us to look at health care policy in different ways. It has exposed the weaknesses in our current health care system and opened up new opportunities for us to create a system that works even better for everyone.
David Skorton: I’m David Skorton, president and CEO of the Association of American Medical Colleges. And today, I’m joined by Florida Representative Donna Shalala. We’ve come together today to talk about how the coronavirus has forced us to look at health care policy in different ways. It has exposed the weaknesses in our current health care system and opened up new opportunities for us to create a system that works even better for everyone.
This conversation is part of a two-part episode, and I encourage listeners to also listen to my conversation with Missouri Senator Roy Blunt.
Representative Shalala, the longest serving health and human services secretary in the history of the United States, served as president of Hunter College, of the University of Miami, as well as chancellor of the University of Wisconsin, Madison, and has been elected to the National Academy of Medicine and the National Academy of Education. Just last month, Speaker Pelosi appointed her to the five-member Congressional Oversight Commission to oversee the implementation of the CARES Act, spending and financial programs.
Among her many, many accomplishments, Representative Shalala brings to the table more than 40 years of experience as an accomplished scholar, teacher, and administrator, and I’m so glad that she’s here to talk with us today. Thank you so much, congresswoman, for joining us on "Beyond the White Coat."
Rep. Donna Shalala: Thank you. David, it’s nice to get a chance to talk to you again.
David Skorton: Well, it’s a pleasure to have you here. Well, let’s jump right in. This pandemic has illuminated the fact that we need medical research now perhaps more than ever. And in fact, I’ve said that this could be the finest hour for scientific research. But all of us want this research to happen quickly. We want a vaccine now, for example. During your time as president of the University of Miami, you helped solidify its position among the very top U.S. research universities.
So Congresswoman Shalala, in your view, are there any ways of speeding up discovery in our great institutions of research, federal or otherwise? Not just by increasing funding, but by reviewing processes that might lead to better outcomes. For example, what can we do to develop new generations of researchers or inspire public/private partnerships that might work quickly and effectively on specific research projects?
Rep. Donna Shalala: You know, David, I’m of two minds about this. Obviously we want a vaccine quickly. And we’ve converted a lot of our laboratories in the great research universities to refocus on this particular virus. The reason I’m of two minds, is because the great American research universities, the public/private partnership with the multinational pharmaceuticals companies, and the way in which we’ve done research, that is investigative driven research, has led to extraordinary discoveries.
So, to shift that around and to pick out areas, to set aside money which I’ve always fought against in NIH. I just got a request yesterday as a matter of fact from an advocacy group on a very important disease to set aside money at NIH. Discovery isn’t done that way. I've got no problem in building in some redundancy on making more investments in young researchers. On our ability to be more nimble so that we can pivot and on a major investment, which we’re making now, in infectious diseases. You know, doubling Tony Fauci’s budget.
But it’s not just money, as we discovered in AIDS, for example. It’s giving world-class researchers enough time to develop approaches that are safe at the same time. All this rush on vaccines forgets that at the end of the day, we’re not going to approve something that’s not safe. So that’s a mixed message for me. But it’s also out of experience in how science is discovered. And that sometimes you’re going in this direction and you discover something in, that you didn’t anticipate for something completely different that turns out to be a Nobel Prize-winning discovery. So, we’ve got to do both.
But we’ve got to have more nimbleness, more redundancy built into the system, and a whole generation of young researchers that are interested in things like pandemics and infectious diseases. Laboratories all over the country. We have not really used them. We haven’t developed that laboratory strategy. The Times talks about it a little bit. But, we’ve had to rethink that. We did a decade ago and two decades ago. We were talking about it. But we never made the proper investments.
David Skorton: You know, you mentioned something about the next generations of researchers.
Do you share my concern that we may have a generation at risk, because we’ve had to shut down a lot of the great laboratories because of the wisdom of social distancing? And I’m concerned that we may lose some people as collateral damage in all the things that have had, that we’ve had to do during the pandemic. What are your thoughts about that?
Rep. Donna Shalala: Yeah, I worry about that too. I hope that we can get the laboratories opened as quickly as possible, observing social distancing. But we simply have to test everybody in the laboratories on a regular basis. We forget that testing would make a difference. And then you isolate someone that might be, that might have gotten, was a positive test.
But, I think that we’re in an era in which we’re going to have to test people regularly. And by the way, if we move into this self-test, the moment they walk in to the lab they can be tested and one person may have to go home, but the lab can keep operating. And it may mean weekly testing. It may mean daily testing. Whatever it takes, we have to get up and going again. If the restaurants can open, the labs can open.
David Skorton: You know, that’s for sure. You know, you mentioned public health before. Let’s continue thinking a bit about public health and specifically the patients whom we serve around the country. As the pandemic has taken hold around the U.S., the plight of vulnerable populations has become even more evident.
And I know that in Florida, you’ve seen its effect with the elderly population specifically. You’ve also seen this in the disparities among people who are homeless, poor, incarcerated. Those who are living with mental illnesses, addictions, other challenges. What do you think, congresswoman, the health care community can and should do to help these individuals working together with our colleagues in government?
Rep. Donna Shalala: You know, first of all we’ve got to have universal health care. Easy access to very good health care. We’ve put a lot of money into community health centers, federally qualified community health centers. They’ve been terrific through this pandemic. We have a lot of them in my district, for example. We’ve put so much emphasis on insurance, we’ve forgotten about the delivery of good health care.
And I think a combination of community health centers that have real ties and seamless transfers to specialists is one way to go. And to make sure they have electronic records. And many of them are serving people who already have insurance but don’t have access to primary care. So, we’ve got to think through the combination of those two, and not focus as much even though I want everybody to have good insurance. I want them to have access to good health care at the beginning.
On the pandemic and those populations, I was talking yesterday to the chair of the subcommittee, the HHS subcommittee, Rosa DeLauro from Connecticut. And I said, "Rosa, we know that a third of the people who are dying are in nursing homes." If you take nursing homes, jails, detention centers, 45% of the people in Florida who have died were in nursing homes. We need to target those populations. We need to make sure that every homeless person is tested, every nursing home employee as well as the people in nursing homes, the patients are tested, and oh, by the way, the jails and the detention centers scare me to death. These are petri dishes.
And while we’re running around with these broad policies, when you can target your testing and your strategies, your public health strategies, on a couple of places in your community that will make a difference, that’s what you ought to be doing. And we’re just not doing that. We talk about we don’t have enough testing supplies and enough PPE in the hospitals. We need to run over to those nursing homes and the jails and the homeless population, they all ought to be tested. That’s the way you’re going to get the trend downwards so you can really reopen. Because boy, you can contact trace in a nursing home when you’ve closed it off.
David Skorton: Well, thank you for bringing us all up to speed on these really unsung heroes who work in CHCs. Very, very important. Now you mentioned workforce, and you mentioned in passing nurses and so on. And obviously investing in a strong health care workforce is just critical to combating not only this but all health care challenges. Now you know, we’ve made some progress over the last few years in increasing the supply of physicians. But workforce issues across the broad range of providers are still very challenging as we continue to face shortages. What do you think our workforce should look like going forward in our so-called new normal?
Rep. Donna Shalala: Well, it’s got to be a team. We’ve been pushing the team concept. If you look at the VA, they integrate advanced practice nurses much better than academic health centers do. Academic health centers are still too hierarchical from my point of view. And they need much more integration with teams and letting people work up to their training. And I think that fee-for-service has literally destroyed some of this, and anything we can do to integrate teams for taking care of patients with a patient-centered approach is going to be critical in the future. That’s number one.
Number two, we’re just going to have to have a range of tests for people that work in public health. And number three, we’re going to have to make investments in not only helping young physicians pay off their debt more dramatically, but we’re going to also have to do the same kind of investments in nursing and physicians assistants. And we’re going to have to get over some of our thinking about hierarchy and who’s supervising whom, and think of teams for taking care of the patients. And our funding is going to have to follow that accordingly. Telemedicine is going to change it. What we do.
But I’m not convinced telemedicine is totally going to substitute for going to see the physician. I think it’s going to be a companion. It’s going to be an important follow-up. It’s going to keep people out of emergency rooms.
The other thing is, everybody’s going to have to get their flu shot. For heaven’s sakes. The universities here in Miami are going to require flu shots from all their students. We’ve always required them in our health centers, in our academic health centers. And for our providers. But we’re going to have to get everybody to get flu shots, because being able to distinguish between that and COVID-19 in the fall is going to be really important.
David Skorton: Congresswoman, you mentioned about the importance of getting flu shots, really something we should be doing every year, year in and year out.
And yet I know you’ve seen the recent polling that I’ve seen, that perhaps a third of Americans are not sure they would get a COVID vaccine. And you know, perhaps some of this goes back to that fraudulent study published in 1998 suggesting some sort of a link between autism and vaccination, which was shown to be fraudulent. The paper was retracted, subsequent studies showed that that was just not true in any way, shape, or form.
Yet there remain people of really a goodwill who just are concerned about vaccination for themselves and for their kids. What can you tell our listeners and the country at large about the importance of vaccination in all ways?
Rep. Donna Shalala: Well, first of all, vaccination has saved lives. There’s no question that vaccination has saved lives. Children’s vaccination has saved millions of lives around the world. And flu vaccinations have saved millions of lives in our own country over the years. There’s no question about it. I was so concerned about a flu pandemic, which is what we were all talking about, that I actually brought the supply chain for flu vaccines into the United States. We produce flu vaccines in the United States.
But convincing people that they should get these vaccines, particularly seniors, has been a huge public health lift. We did it for children by requiring before they went to school. But we’ve even designed a campaign that gets the kids their shots by the time they’re three. This anti-vaccine movement is dangerous. It will produce tragedy. And the people that have that position are being more than disrespectful of the population. They’re, it’s almost immoral for you not to get your child vaccinated, because you may infect not another child that’s vaccinated, but a baby that hasn’t gotten their vaccinations yet.
So, I’m a big vaccination person. I think the research is very clear. And we can start with adult vaccinations. I’ve just introduced a bill to make them all free for everybody that’s a senior. Every kind of vaccination, whether it’s the flu or any other vaccination we want seniors to take. And we will make this vaccination free and tell you the truth, some people may resist, but their employers are going to insist upon it. And employers all over this country are going to say, you’ve got to get this vaccination.
David Skorton: Really, really tough problem. You know, you mentioned the team effort, and you mentioned other providers besides physicians working up to the top of their license, as you put it. Do you think that we should increase the scope of practice formally for nurse practitioners and physician assistants?
Rep. Donna Shalala: I do. And as you well know, this is politics — and at the state level. Because it really is a state-by-state discussion. I think, since I wrote the Institute of Medicine, now the National Academy of Medicine, report on the future of nursing, our single strongest recommendation was expanding the scope of practice for advanced practice nurses. They can do about 70% of what a primary care physician can do. And frankly, we should save our docs for the ambiguity and the complexity. So yes, we can, we certainly should be expanding.
States on one hand have deep requirements for advanced practice nurses’ training, and then they limit them. And it’s not a red state or a blue state. States like New Hampshire have allowed nurses to write prescriptions. So, we just, in medicine, we just have to get over some of this. And we’ve got to think about how we can best take care of the patient and what that training is and what both the strengths and the limitations are of that training.
David Skorton: You know, I can give you a very brief personal testimony to the wisdom of what you’ve said. Way back when, I was a young faculty member at the University of Iowa, in Iowa City. We had a sub-subspecialty practice caring for adolescents and adults with inborn congenital heart disease. Very complicated deep sub-subspecialty practice. The person who ran the clinic operation was an advanced practice nurse. She did a lot of things autonomously, and I’ve got to tell you, congresswoman, she did a heck of a job. Well, I’m going to switch gears and –
Rep. Donna Shalala: You know, David, there isn’t a physician in this country that doesn’t have a story about what they learned from a nurse.
David Skorton: Yeah, that’s a, if we had more time. If I was interested in hearing about, hearing from you and not me, I could tell you a lot of stories. Well, I’m going to switch gears for a moment. You’ve also been a very, very distinguished leader in higher education. Three different times, headed very dramatically important institutions. And as you know, I’m a former university president. I’d love to hear your opinion about the stresses the pandemic has wrought on higher education, and what students of all types can gain from these very challenging times.
Rep. Donna Shalala: You know, the stresses have been real in higher education, in large part because only a portion of higher education has learned enough about teleteaching and teaching online. And it’s been a sharp learning curve for a whole generation of people that never thought they were going to have to figure out how to teach online. It will transform higher education forever. And higher education is now in the process of restructuring the traditional institutions.
Your Cornell, the University of Miami, the University of Wisconsin, are trying to figure out how they can bring students back to campus. Because that interaction is important. But it’s also crowds. And crowds produce, pass on infections. I remember during H1N1, and they still do this at the University of Miami. We put hand sanitizer machines in the line, as students lined up to get their degrees. The only ones that resisted, by the way, were the law students. But I told them I wasn’t going to give them their degree if they didn’t use the hand sanitizer. So they did it, so that I didn’t pass on disease from one student to another. But it worked, and they still do it, by the way. Which is an interesting way to reduce contacts.
But universities are crowds, and that student interaction is part of the educational experience. For students that have been learning online, for adult students, the mix of classroom and online has been something they’ve been used to. and a huge number of students in this country before this virus were learning online. I think American universities are going to do a mixture as a way of doing social distancing. It means that the faculty has to be a lot more flexible than they’ve been before.
David Skorton: Interesting is a very interesting word, congresswoman. And I totally agree with you. You know, as we look forward beyond the pandemic and think about the future of academic medicine just for a moment, how can we in academic medicine and the great schools of medicine, the teaching hospitals, the research labs, the community collaborations, how can we be of more value to the country? And how can we get that message across to you and your colleagues in Congress about our role in the country?
Rep. Donna Shalala: Well, as you know, we have a big bipartisan coalition for the National Institutes of Health. There’s no question about it. NIH is a favored child and it has bipartisan support. And frankly, we put billions in already. I think academic health centers have to do two things. Number one, many of them, and I’ve been online, are demonstrating what they’re doing in this pandemic. And to the extent that they can, we need consistent voices of medicine and public health in our communities telling everybody what they need to do.
I used to, I was horrified when they were doing these White House briefings. I never let anyone go to the White House. I’d never let Fauci get up in front of a podium in the White House. I kept him either at NIH or HHS and I made them put on their white coats. Tony will tell you that I made the surgeon general, the head of the ... Harold Varmus, Fauci, anyone that was speaking. The head of CDC. Anyone that was speaking, and certainly the surgeon general.
Anyone that was speaking had to put on their white coat. Because that’s what the public trusts. And so we had to take advantage of that and academic health centers, even if they just do it once a month and explain to the public what the virus is, how it’s contracted and how we can contract it, how we can starve it, in plain English with people with white coats on. That sends a message in the community. But everybody’s got to have a consistent message. We can’t have our usual academic style of everybody has a nuance.
David Skorton: Well, I’m going to thank Representative Shalala for joining us today as we move into a new normal. Members of Congress can help those of us in academic medicine to make an even greater impact on patients and providers across this nation, with a focus on patient care, innovative research, and helping our physicians thrive. Representative Shalala, thank you so much for sharing your wisdom with us today on "Beyond the White Coat."
Rep. Donna Shalala: Thank you very much, Dr. Skorton.
David Skorton: Well, thank you all for listening. I’ll see you next time for another episode of “Beyond the White Coat.”
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