"Horizontal" - A Lesson of Humility
Updated: May 18, 2020
Dr. Hansra is a chief cardiology fellow at the University of Massachusetts. He has been involved in the COVID Command Center since March 2020. Administratively, he was involved in restructuring how the hospital teams handled the surge of COVID patients. Educationally, he is a fellow whose expertise is in Cardiology but whose fundamental training is in medicine. He continued to work during this time both in the COVID Intensive Care Unit as well as on the general medicine floor. As a physician during the time of COVID, he made up for physicians losing a personal connection with patients by helping patients’ families to regain that connection.
The COVID Command Center was created to organize restructuring of the medicine division in order to support the COVID ICU and redeployments of residents and fellows to areas of the hospital that were in the most need (hotspots). The traditional vertical model of training was put aside and a horizontal model of training was created to better care for patients.
“We started planning for that (incident command center) in March – I remember because I was supposed to be flying out to my best friend’s wedding, but it was canceled – and I was approached by my division to participate. Since early March I have been a part of the command center and it consists of the Vice Chair of medicine, leads of hospital medicine, chief internal medicine resident.”
“We worked with the administrators on how we can restructure the normal vertical model of attending-fellow-resident-interns (which was our traditional model) to a more horizontal model, because we were expecting an increase in the volume of patients – to where interns-residents-fellows-attendings were all on the same level. They all carried patients, they all admitted and discharged so that we could utilize everybody to their full potential.”
The horizontal model is an academic model of humility and compassion. Dr. Hansra, along with other attendings and fellows from different specialties, responded to the call of duty by putting aside their titles and previously known specialty roles. During this time, everyone cared for patients – as an intern, resident, fellow or attending. We were all in it together.
“When I’m in the COVID ICU as a resident…I am not functioning as a chief fellow but as a resident/senior resident supervising and helping them (house staff). I’m one of the outliers who is interested in critical care. So for me, it was a natural progression to be able to come into this type of environment and buff up in some of the things I didn’t know, such as pulmonary but able to add some of the things like hemodynamics that I know very well from Cardiology…and help the team with that perspective.”
The horizontal model was one that existed in this time of need. It demonstrated that sympathy and care for patients dominated over specialty of career. It existed in this particular capsule of time, to care for COVID patients and for each other (healthcare providers).
“The horizontal model will probably be deconstructed and we will be going back to the more traditional vertical model. Hopefully we’ll be able to keep some of the good parts of it, such as being unit-based and cohorted so that residents don’t have to go to different areas of the hospital to take care of patients, and we know that there is improved communication between the providers, nursing staff, ancillary staff if you’re on a dedicated floor. You’re able to handle issues much more quickly since you’re on there. So I hope that when we go back (to the vertical model), we can keep some of the new things that we have learned that have been beneficial.”
-Caring for the Sickest of the Sick-
“When we first started the COVID ICU, the amount of anxiety was palpable from nursing staff, ancillary staff, respiratory and the providers. You could see a lot of fear in people’s eyes. Especially if a patient wasn’t doing well and you needed to go into the room, you had to think twice about putting on your gear including your PAPRs and N95s, which adds a lot of time. That part was difficult for providers.”
“For patients, we have minimal interaction with because many of them get intubated and then you want to get out of the room as fast as you can. So we’re really in there doing just the essentials. One thing I’ve noticed is we’ll be doing signout and a lot of the providers will be confusing genders for the patients because they’re not seeing them regularly (especially the night team)…it just shows that because we’re not going into the rooms as often, we’re not making that connection that we used to have.”
Dr. Hansra further described how difficult it was to have conversations with patients’ families when patients were deteriorating. As institutions across the country, University of Massachusetts included, instituted a No-Visitors policy during the time of COVID19.
“Having a conversation with family members over the phone about how a patient is doing is very hard, because they’re not able to see the patient, or the body language of the patient or my body language. I’m not able to show them the signs of when someone is not doing well. So there’s that disconnect…It’s created a lot of barriers for patients to see their family, understand their wishes, understand our goals and create a path going forward.”
Despite our advanced technology and inter-technological connectedness during this century, COVID19 interrupted that connection in a very quiet way.
“I think a lot of families have so much anxiety about this – this is the first time that we’ve limited visitors. So now a patient will be passing with their loved one on facetime or over the phone…and a nurse will be in the room, or one of us. It’s an incredibly awkward experience. We’ve never had to do this before…because how can you give your condolences to a patient over facetime? We try our best…to make the best of the situation.”
Dr. Hansra described the disconnection between providers and patients, but then the day-to-day attempts that healthcare providers had at trying to provide a connection between families and patients.
“We are up against a time crunch everyday because we are trying to transfer patients as soon as possible – whether it is to a different ICU because they’ve been ruled out for COVID or they can be transferred to another COVID acute care unit...to make room for another. So we’re not making much of a connection with patients…I am making connections with their families, calling them on a day-to-day basis. I try to find one thing to talk to them about, to check in on, try to understand what I can help them with – so that’s how I try to make up for that lost connection. To help families feel connected to their family member when they can.”
Barinder “Ricky” Hansra, MD
Chief Cardiology Fellow PGY-6
University of Massachusetts