How a Brand-New Med School Faces the Biggest Health Care Crisis in a Century

By Sofia Sokolove in Features, Sept | Oct 2020 on September 1, 2020 at 9:00 am | No Comments

As soon as Clay Johnston’s video pops up on Zoom on the morning of June 19, the dean of Dell Medical School apologizes to me. “I’m a little distracted today,” he says, eyes darting across his screen.

“It’s not public yet, but we may have had over 1,000 new COVID-19 cases in Austin yesterday.” The closest the city had come to reaching that number was two days earlier: 220 on June 17. “So, 1,000 is like, unbelievable,” he says. “I’m distracted by how we’re going to have to change course—and what that means for our system that we’ve tried to link together across the city.”

From the outset of this pandemic in early March—just a few months before Dell Med was set to graduate its inaugural class—the school has been an integral part of Texas’ response, working with Austin Public Health and the state; furiously working on vaccine research and clinical trials; and leveraging already established community relationships to spread public health information. Scan any piece of local or national news about the virus in Texas, and you will likely find a Dell Med faculty member quoted as an expert source.

Unfortunately, there’s a lot of news about COVID-19 in Texas these days. At press time, Austin has consistently reported an average of 500 new cases per day. On the day I spoke with Johnston, Texas logged around 3,400 new cases of COVID-19. And Austin, it turned out, reported only 418 the next day—not the 1,000 Johnston was worried about, but still an alarming jump. Especially because less than a month later, on July 17, the state saw more than 10,000 new cases. Johnston’s concern back in mid-June was both prescient and ominous.

Since it was voted into existence by Austin residents in 2012, part of the overarching vision of Dell Med has been to address the challenges of 21st century health care and medicine—with a focus on community health. Now, just four years since the school opened its doors, it has been hit with the ultimate community health challenge: a pandemic. The Alcalde spoke with Johnston, who is also UT’s Vice President for Medical Affairs, about how the virus has shifted the school’s priorities, the overhauls happening across the health care system, and how racial inequity translates to inequity in health care. 

SOFIA SOKOLOVE: How is Dell Med uniquely suited to handle this kind of public health emergency? 

CLAY JOHNSTON: We’re a brand-new med school. And we are specifically designed to be linked to this community. The community helped support us. And we have this weird vision statement—to create a vital, inclusive health ecosystem. We talk about being a model healthy city. So, in that definition, we’re not just responsible for what happens in the clinics and hospitals. We’re trying to work in partnerships to elevate the health of our community. There are pillars in med schools: education, research, and care. We have a fourth—the community impact pillar—which is very unusual. I don’t know of other schools that call it out like we do. And then we have all sorts of creative people who are here to think differently about how to achieve health. You throw COVID-19 in the mix, and those are really useful skills.  

In most communities, public health is doing the public health thing, and the hospitals are doing the hospital thing, and the schools are doing some research on top of that. But for us, we’ve made it made it a much more coordinated response. That doesn’t mean that anybody could be successful in responding to this huge tsunami. But it does mean that we have been able to do some things that I think we can look back at already and be proud of.  

SS: What’s an example of something that makes you proud? 

CJ: The example I think that illustrates this best is the homeless population. We recognized early on that this is a population that’s particularly vulnerable. We brought in a fair amount of philanthropy from a few different sources to support that work. And then we could work with the other entities in the city—the safety net health care system, Austin Public Health, EMS, the shelters—and come up with a comprehensive approach to addressing homelessness.  

Fortunately, we had leaders who were already in that space that understood on the ground how these things work, had the connections, all of that. So honestly—the rates of positivity in the homeless population [at press time] are much lower than they otherwise would be. And lower than they are in many other cities. We took probably the most vulnerable group and we protected them.  

SS: What would this pandemic have looked like in our city—in our state, even—before Dell Med?  

CJ: It would have been harder. If we had giant public health institutions in Texas, like they do in California, Washington state, and  in New York, then the role of the schools could be narrower. In this instance, we’re under-invested in public health—Texas isn’t alone in that, it’s common. Everybody, for something like this, of course is under-invested. But we have been able to redirect and fill gaps and put things aside that we were working on so that we could fully focus on COVID-19—including myself. We have a whole health care system we’re trying to build, yet I have to push that aside, so that that’s about 20 percent of my time right now. Eighty percent is on the COVID-19 response. But how useful is that for us as a community, to have another person thinking, leading, pulling my people in to try to help out where we can? 

SS: This virus hit just as you were about to graduate your inaugural class—a natural time for reflection. Has this been an opportunity to evaluate your original mission, to look at what’s working and what isn’t?  

CJ: Honestly, there have been some really good things about this. There were a bunch of regulations and barriers and “we’ve never done it that way” kind of attitudes that were making change difficult for some of the things that we really wanted to do. And this has allowed us to just blow through that.  

SS: Telemedicine is a good example of that, right? That’s  a shift you have been a huge proponent of from day one—but it seems like something people had been slow to adopt until the pandemic. 

CJ: Right. How do you do an office visit without the office visit? What does that look like? How do you care for people online? And that won’t just be us, that’s everybody—we’re all moving to tablets. But we were able to turn that on within a day. We already had some of these systems built and as soon as we were given the freedom to go, boom, we turned it on. Now about three quarters of our visits are telemedicine visits. Some will convert back when it’s safe to convert them back. But I suspect at least half of what we converted to telemedicine we can continue to do through telemedicine. It’s just better for doctors and people. And it opens up other opportunities to think more efficiently about how we do care. Traditional office visits are incredibly inefficient, not just because of parking and waiting, but also space issues, putting people in and out, and the number of people required to check folks in. All of that can be done online much more simply, much more effectively, and you can get doctors and their expertise out much farther. And this is stuff that we’ve been working on, but all of a sudden now we can push through. Another one has been data: how data flows in the city, how data flows to improve outcomes for people. Our need to work together in this response has had us as a community starting to share data on a whole different level and seeing the benefit of that collaboration.  

SS: It sounds like in some ways, this crisis is forcing people’s hands and disrupting old systems of bureaucracy in health care. What do you hope sticks beyond the pandemic?  

CJ: Well, I think the thinking that’s been happening about the full population—how do you keep a population healthier?—is really important. But the conceptual change that needs to happen that hasn’t yet is that it’s not just about infectious disease. It’s about hypertension, diabetes, obesity, inactivity, extreme poverty. And equity. 

SS: Yes—we’re going through one pandemic against the backdrop of another: racial injustice. Can you talk about the intersection of the two? 

CJ: So, we’ve had a substantial investment in health equity from the beginning, and we’re ready to jump on that. We’re ready to say, “OK, what wave, what changes, is this moment going to produce?” Are there opportunities, for example, to think about how our emergency response for the mentally ill changes? Do we subject them to a police response or can we subject them to a response for somebody more likely to de-escalate, somebody able to understand that situation better?  

SS: You mentioned telemedicine as an opportunity for doctors’ expertise to reach further into communities. And it can help someone like a working single mom, who might need to find childcare—or take time off for their sick kid—and spend hours getting to the doctor. That’s an equity issue too, right? 

CJ: It is. Of course, it sets up other challenges sometimes. So, do you have access to the internet? But how important is seeing the person anyway? Those are some of the things that we’re trying to work on now. Saying, well, there’s a certain amount you can do in a phone call. There’s a certain additional amount that you do when you can see someone, but then how do we supplement that to start to produce some of the other things that we think today only happen in an office visit—and in an easy way? If this [Zoom interview] was your primary-care visit, then you know, what’s your blood pressure? And should we check your cholesterol, how would we manage that for you? But the reality is, the original Netflix approaches to these things—mail you a blood pressure cuff, have you mail it back—the whole red envelope approach could work for this too, right? Until every home has a blood pressure cuff. And then we’re at the new Netflix model. I don’t think any of that is insurmountable, but the regulations are critical to it. If insurance companies say, “We don’t care if you can do that, we’re not gonna pay for it,” then we can’t do it.  

SS: On June 3, 2020, you published “A Call to Action” on race and health on Dell Med’s news site, noting the ways that COVID-19 has demonstrated how deeply rooted racial and ethnic inequities run. “More than 75 percent of hospital admissions in Austin last week were of Latinx people,” you wrote, “and the case fatality rate among Black individuals is higher than for others.” What actions are you calling on the health care community to take? 

CJ: These are really complex, entrenched issues. We have to look at the spaces where we contribute to them and where we make them worse.  
And health equity, we’re responsible for that. First of all, there has to be awareness and ability to discuss these issues. So we have to work on that—our universal discomfort and surfacing institutional racism has to be addressed. We also have to make sure that the care we provide is delivering on what the promise is, and isn’t leaving people behind. We’re very focused on measurement—that’s been important to us from the very beginning—measuring outcomes from the patient’s perspective, and also measuring the traditional outcomes people follow.  So now the question is, if we’re really trying to achieve those optimal outcomes, we need to try to do that for everyone, right? That really is looking at the groups in which we fail: They’re the same ones that are impacted by health inequities. If our responsibility is to achieve those outcomes, then we need to invest more, actually, in achieving those outcomes for the groups that are falling through the cracks and potentially change our systems in order to do that. So, translation is a good example, but it could also be about follow-up or additional education. Maybe it’s the way in which things are communicated. Maybe it’s about not being able to cover costs for prescriptions. There’s a whole host of things that we haven’t taken responsibility for that we need to in order to achieve outcomes. And then there’s a whole research part of it. That stuff rolls up into research—we should be studying these things and understanding them and disseminating those findings.  

SS: That’s such a good point about data and measurement. We have a tendency to shy away from that when we’re talking about things like race or inequity, because it seems icky, or wrong, but what data does is hold us accountable to the less tangible things we’re talking about on this big-picture level.  

CJ: And the COVID-19 example with the Latinx population is a perfect one, right? You just look at our whole population, you might say, “OK, well, it’s not so bad.” But then you look at that pocket and it’s like, “Oh my goodness. Something horrible is happening over here,” or, “We let that happen.” 

SS: You mentioned communication as playing an important role in achieving outcomes. I feel like we’ve never at this scale learned alongside the medical community in real time, as research is happening. How do you build trust with the public and the community in the age of social media, when it feels like there is unfiltered access to so much information—and disinformation? 

CJ: Yeah, that’s a tricky, tricky thing. Everything that we are working on is rooted in that sort of pragmatism, which is really just another way of saying science. It can be a science applied to business, it can be a science applied to disease. But it’s that rational thought, trying to get as close to truth as possible. Trying to remove the biases where they exist so we can get as close to truth as possible because that’s how we know whether an intervention that we’re making is improving things or worsening things. Not because of a faith in a principle, but because of evidence that progress is being made, and understanding what progress is, and that progress is actually something that we all value. It may be that some value progress in a certain area more than others, or some receive the benefits and others don’t, but it’s still undeniable that there can be areas of progress where humanity improves, right? 

When the messaging gets all confusing and pushed toward an ideological extreme—and it doesn’t matter which extreme—when we pull away from that pragmatism then I think we lose that foundation. That’s the concern. Our political system has gotten so polarizing that it actually isn’t optimized for us to achieve the best outcomes.  

I try to be as apolitical as I possibly can be and stay as unbiased in my thinking about how to approach issues. The world that we live in isn’t quite that way. [Laughs.]  

And with COVID-19, it’s a good example where we’re taking extreme positions. Complete lockdown forever, that’s not good. That’s going to have negative health consequences. But opening up and staying open, even as cases go crazy high, that also isn’t rational. Both have ideologues pushing for them, when the truth is in the middle, and the pragmatic things that we can work on shouldn’t be ignored—and they’re being ignored. Adequate investment in testing and contact tracing, that makes sense. But we’ve forgotten about it. We don’t have it. We don’t have the adequate testing and yet we open everything up. Masking is another example. It’s become a polarizing issue. It should not be. There’s a science to it, the science isn’t as good as people would like, but it’s the best we have. Masking is good for the economy. There’s just no way around it. It doesn’t cost very much, it’s a hassle and we all hate it, but it allows us to go to a restaurant. So then why did it become part of this? You know, we’re human, so we’re imperfect. But it’s a shame that we’re being pulled by ideologues to be more imperfect.  

[This interview has been edited and condensed.]

Illustration by Jason Holly