In this episode of Radio Advisory, host Rachel (Rae) Woods sits down with Jeremy Boal, the chief clinical officer of Mount Sinai Health System, to have a candid conversation about his experience being on the frontlines of a Covid-19 surge—and why health care leaders must remain vigilant during this time.

Rachel Woods: It's August, which means that here in the United States, we've been battling the novel coronavirus for about six months—and the fight is far from over. There have been more than 4.4 million coronavirus cases in the country and more than 150,000 deaths. And we continue to see cases rise across many states.

But despite the grim outlook, I've been hearing many leaders express the desire to return to "normal," saying that they never saw a peak, and they're not expecting one to hit their community. And there's a real danger in thinking that, especially when at a national level, we're seeing in-patient bed capacity inching near at the same peak we hit in April.

So today, I want to talk about how important it is for leaders in health care to remain vigilant in the face of Covid-19. To do that, I've brought Dr. Jeremy Boal, the chief clinical officer at Mount Sinai Health System.

Jeremy, let's start by just talking a little bit more about you. Tell us about your role at Mount Sinai.

Jeremy Boal: I have two roles at the Mount Sinai. In my role as the chief clinical officer, I oversee quality and safety and clinical excellence. And I'm also the president of what we call Mount Sinai Downtown, which is a network of a couple of hospitals and a number of ambulatory sites in Manhattan below 34th street.

Woods: How long have you been in New York?

Boal: I've been in New York since about 1994—a long time.

Woods: So this means that you were a leader at the forefront of one of the major search markets here in the country. In fact, I think most folks think of New York City as the place that's been associated with the peak of the coronavirus. I want to start by going back to January or February, right before the surge. Cases had begun to rise in China and Italy, the World Health Organization had declared a global health emergency, but the story in the United States had really just begun. What were you thinking back then?

Boal: In January, we had started having regular system meetings of our emergency command structure to start to organize our thoughts around what was happening, how quickly it was moving, and what we needed to be prepared for. So by February, we had accelerated that work—although not to the extent we were going to need to as the pandemic arrived on our shores.

Woods: I'm curious, in that moment, was that preparation for something that you thought might never actually come? How realistic did you think it was going to be at that point?

Boal: Looking back, we had seen other outbreaks around the world in the last decade that hadn't turned into full-blown pandemics, so it wasn't clear yet that this was going to be what it became.

And I think there was probably a little bit of denialism about just how severe things were going to get. So although we were watching it, and we were preparing, there was this moment where we probably had an opportunity to reach out to colleagues in China or in Italy or in other places that were already experiencing much more of the impact of the pandemic and have more detailed conversations about what it actually felt like. I regret that we didn't do that.

You know, we were getting very mixed messages at the time from the news media, from CDC, and from all sorts of different sources. On one hand, we were hearing that this was just like a bad case of the flu, but then we were also getting sporadic reports about mass casualties and overwhelmed hospitals. And I wish that we had done more at the time to dig in on that and try to gain more clarity, because I think that would have advantaged us as this went along.

Woods: Now, while recognizing that we're not actually in anything close to an "after" yet, I'm curious to know at what point you, as a leader, know that things were going be dramatically different in our industry, that telehealth would be normal, or we're going rethink our approach to how we're managing hospital capacity—moments where there's a "before" and "after" coronavirus?

Boal: I think it's happened over time as we gain more insight. You know, there were moments where it became obvious to us that telemedicine was probably here to stay in a way that was very different than pre-pandemic. The way we work is very different now. And we long for the day when we can be in large groups again and have more interpersonal contact. But we also have gotten really good at working remotely and reading body language over a Zoom call and checking in on our colleagues and the like, even though we can't all be in the same place at the same time. So that's different as well.

I suspect in New York, there are all sorts of "after Covid-19" changes to our collective consciousness about what the health system needs to be prepared for. Even if this is a once-in-three generation event, our health system, which we always considered mighty looking, felt incredibly puny in the face of a tsunami of Covid-19, and I think that has dramatically changed how we think about preparedness. So, I would say it's been evolutionary all along the way. We've been gaining insight into what a post-Covid-19 world looks like, and I think the insights are going to keep coming

Woods: Well, let's come back to the story of Mount Sinai in New York City. We all saw the news headlines across March and April and May, but I want to hear more from you about what Mount Sinai actually went through as part of the surge. What was that experience like at the peak?

Boal: I want to start by saying that in my whole career, I have never been prouder of a group of people coming together to do whatever it took to save as many lives as possible and to take care of each other and to take care of our city. At the peak, which was in the first week of April, we were admitting a patient with Covid-19 infection every six minutes into our health system—that's 250 in a 24-hour period. And, you know, we only have about 2,200 beds in the whole system. And patients who have Covid-19 and who are admitted are incredibly sick and have incredibly long lengths of stay.

So you can imagine if we had continued to see those kinds of volumes for any length of time, how quickly our region would have become overwhelmed. But it was an extraordinary, all-hands-on-deck moment where over the proceeding six weeks, we had developed the capacity and the capability to take care of an enormous number of critically ill patients. And we never reached a point where we couldn't take care of everybody who needed care. We never ran out of ventilators. We had enough personal protective equipment (PPE) for our staff. We had enough to take care of everybody. And that was because of this incredible mobilization effort, the likes of which I have never witnessed before.

Woods: I think that some folks might actually take that level of mobilization for granted—and perhaps that's coming from more of the general public than from health care leaders, but I'm kind of getting the sense of folks saying, "Well, we never overwhelmed the hospitals back in March and April. New York was actually okay." But I'm not sure that folks realize everything that went into making sure that the hospital wasn't overrun.

Boal: It was really two things, Rae. It was that massive mobilization effort—this incredible effort on everybody's part to do whatever it took, to make sure that we had the assets we needed, the space, the staffing, the equipment, the clinical protocols, to push through and take care of everyone—but it was also the shutdown of the region that bent our curve.

If we had had another week of the kind of growth that we were seeing, which absolutely would have occurred in the absence of a total shutdown two to three weeks before we hit the peak, the system would have been overwhelmed. There's no doubt in my mind, there would have been many, many patients who didn't receive basic modern medical care that were used to being able to give to anybody who needs it in this country. It just wouldn't have happened.

Woods: Just how close you got to being overrun?

Boal: We peaked at about 2,000 Covid-19 positive patients in our system. We run about 2,000 beds normally, and we were working to increase our capacity by at least 50%. But a lot of those beds were still taken up with non-Covid patients. Again, if the growth had continued at the pace that it was, we were about a week away, I think, from cracking—and not just our health system, but every hospital and health system in the region. They were doing their very best, but at some point, the volumes just become unmanageable.

Woods: As a physician yourself, and you share any stories of what it was like to be a physician or a nurse or a member of the leadership team in this moment of crisis.

Boal: As a member of the leadership team, the work was incredibly intense; we'd start the day incredibly early in the morning and essentially conk out at midnight or 1:00 a.m. And we never felt like we were ahead of the game. We were always working to track down more ventilators or trying to cut another deal to get protective gear. And staffing was incredibly challenging; critical care staffing is typically at a very high ratio and that expertise is incredibly unique.

So there were an endless series of hurdles that we had to get over on a constant basis. One minute, we're working to set up a tent hospital in Central Park—the first one since the Civil War—to hous more patients, transfer patients from our outlying hospitals in Brooklyn and Queens that were becoming overwhelmed. And the next minute, we are desperately trying to figure out how to stay ahead of the number of deaths that we were seeing in our hospitals and making sure that we had enough morgue trucks available to be able to take care of the deceased.

It was an endless series of logistical challenges, and there was no time to process what we were going through. A lot of the emotional processing really occurred after as we came down the other side. As a doctor, I wasn't involved in direct patient care. I spent a lot of time with physicians and nurses and others who were in direct patient care and they gave everything that they had, absolutely everything I think out of a love for their colleagues, out of a love for their patients and our communities, out of a sense of duty and despite fear and uncertainty.

Woods: I want to talk to you about something hypothetical. You mentioned that in the very early stages in February, you were preparing for a world where coronavirus would come and hit the United States, but that you wish you had paid closer attention to what was happening in China and Italy—if you had given those areas a bit more notice at the time, what would you have done differently?

Boal: There are things we would have done sooner. Rather than having about six weeks to mobilize, we probably would have had eight weeks, and that extra two weeks in the face of a potential onslaught makes it easier to get ready. So what were we doing in those weeks? We were opening a lot of mothballed space on our campuses and converting it into clinical space. We were opening that tent hospital. We were procuring supplies and equipment, as well as more staff from around the nation to help us. So having extra time makes it, not so much easier—there's nothing easy about any of this—but more doable, at least. I think that's what we would have benefited from primarily. It's just having the extra time to do the work.

Woods: I'll admit the reason why I'm asking this is because when I talk to health care leaders across the country, there's this variable response, with some saying, "We're never going to be what happened to New York," or, "It's not going to happen to us." And there's this kind of this move to go back to normal. And that cognitive dissonance is something that all health care leaders, and frankly, all people can face.

So I'm curious as somebody who went through a surge in New York, if you were to send a message to those who might be digging in their heels, who might be slowing down their preparations, who might be ignoring the time that they have now to prepare, what would you tell them?

Boal: This is normal human psychology; we went through it in New York. As I said, I'm incredibly proud of how we responded and that we were able to treat everybody and save thousands and thousands of lives—but we did go through that kind of vibe of thinking early on. How much attention do you divert to something like this in the midst of everything else that you have to attend to?

That said, once we made the decision that we were going to go all in, we went all in. You know, I remember our CFO essentially approving everything we said we needed without question, which is not something that normally happens in the health system, nor is it healthy, right? You need those checks and balances, but in the face of what we finally appreciated we were likely to see, all of the silos in the organization that traditionally exist and all of the give and take that slows things down melted away, and we were able to move very fast.

So I would say to people in those other regions is to do the scenario planning. Figure out what would it take for you to be successful in managing through this and figure out what the thresholds are that you're going to make sure you achieve. So consider what's happening in other markets, and ask yourself: Assuming we see those types of volumes, how much PPE do we want to have on hand? What do we want to have in our warehouse so we don't have to rely on anybody else and we can keep our people safe? What do we need in terms of pharmaceuticals? What do we need in terms of surge capacity?

And then you can make some very reasonable decisions about investments to make today or work to make today to be ready tomorrow. I think the same approach applies to thinking through how are we going communicate with our people if this happens and things are evolving very dynamically.

You know, one of the things that we learned was we needed to really make it easy for people to know what was going on, because protocols change very quickly. So we made a decision early on to put everything we had on a public facing website and employee resource website for Covid-19. And that became a critical tool for us to stay connected with everybody. We set up an email address covidquestions@mountsinai.org for our staff, where they could email 24/7 questions, concerns, ideas, and we would get back to them in real time.

Sometimes they just had a question about how to use something, like a new piece of PPE, and those kind of questions told us that we needed to do a better job of pushing out information. Other times they had a question about their own health, or wanted to share their own ideas for the system—ways we could do better. And to date, we've had over 1,800 members of our workforce use that email to be able to send us information or a question and get something back. So a lot of that stuff can be set up today and be activated as needed. I would encourage people to take a look at our Covid-19 resource website; it's public facing, and it'll give you a sense of what are the kinds of materials and protocols and communication tools that we've used to help people through this.

So I think doing a lot of tabletop exercises, "what if" scenarios, thinking hard about procurement materials, management, clinical protocols, all that kind of stuff—much of that can be done without spending a lot of money, but then being really thoughtful about spending where you need to. The unforgivable scenario as far as we were concerned was ever being in a position where we couldn't keep our people safe. We needed to own that and that meant that we moved heaven and earth to make sure we had what they needed. That's the kind of thing we feel very strongly that that health systems need to do.

Woods: And you mentioned at the start that you yourself or that leadership at Mount Sinai themselves fell into this trap of cognitive dissonance in the early stages. Is there something that would have led you to take the risk more seriously, or is there something happening that you want to make sure other leaders take very seriously right now?

Boal: One lesson I learned was that we should have found a way to reach out to hospitals in parts of the world that had already been affected to gain some real world insight into what they were seeing and experiencing. Picking up the phone and talking to hospital administrator in Italy, or people in the public health sector, or others—I think would have cut through a lot of the noise and given us deep insight that we could have applied differently. And that's a lesson that we'll take going forward. So I would say that it applies to parts of the country that haven't yet experienced this.

Woods: Does that mean that you're giving out your phone number to the parts of the country that might be saying, "I'm not sure how to prepare, but I'd love to talk to someone in New York?"

Boal: Absolutely, absolutely. It's one of the things that we can do to pay this forward, and it's something we ourselves got really good at as the pandemic hit—reaching out and talking to others who had been through this before and also to our peers in our region in terms of what they were seeing and thinking about how we can collaborate. My only regret is I wish we had done that a little bit sooner. I think those are deep insights that cut through a lot of the noise.

Woods: I'm curious right now I'm hearing a lot of Covid-19 fatigue and frankly, change fatigue, regulation fatigue. It's something that I think every human being—and certainly everyone in health care—is feeling right now. So for you personally, what are you doing day-to-day to remain vigilant, to keep your nose to the grindstone and to not let yourself fall into that trap of some Covid-19 fatigue?

Boal: I can answer that on a couple of levels. To be completely honest, I fought my way through the peak and the down slope and didn't do a lot of processing. We all did what we had to do, but coming out of that, it was very emotionally challenging for me as I started processing everything we'd been through and all the suffering of our staff and all the loss of patients and impact in our communities. But I knew that was coming because we had been very thoughtful about looking at what happens to people and what happens to organizations when they go through these kinds of traumas.

And so on a personal level as a leader, I felt it was very important for me to be honest about that with others, that we can expect this to happen and that I was experiencing at myself and to role model reaching out for help, to role model talking about these things without shame and to doing what I needed to do to take care of myself because I think that is the most important thing we can do as leaders in a time of crisis. And particularly in the time of prolonged crisis is to make sure that we are in a very, very good place physically and mentally to lead our people with a sense of determination and optimism.

But that looks different for different people. For me, it means trying to get as much sleep as I can. For me, meditation has been enormously useful and powerful, as has strengthening my social contacts and my relationships with friends and family rather than withdrawing and making a point of connecting at work by offering acknowledgement and praise and gratitude. It is incredibly important as a bulwark against Covid-19 exhaustion and everything else, to strengthen ourselves and help our organization stay resilient.

Woods: I love that answer because you, you answered as a health care leader and as a physician, but also as a human being. It's what any person can do in this moment where we're dealing with great tragedy and great stress and the need to remain vigilant, whether you are running a hospital and a health system, or whether you're just trying to get through the day to day six months in.

Boal: Yeah, absolutely. Absolutely. And I don't think we were doing anybody a favor by not talking about this stuff. I think it's a tremendous sign of strength to talk about our struggles rather than a sign of weakness, because they're real and they're real for everybody around us. And if people are feeling off kilter and yet nobody's talking about it, that is much worse because then people tend to feel very alone. And it's very, very hard to build up resilience for the long haul, if you feel alone and isolated.

Woods: And that brings me to my final question: In this moment, there's a lot of leaders and markets and communities that might be feeling a bit complacent. What message do you have for those leaders when it comes to staying vigilant right now?

Boal: For me, and I think for many of us here, it's really trying to cultivate a mindset that we don't know what's coming next. Even within the constraints of this pandemic, the idea is to be on the lookout for new information that changes our perception of where we are or what we need to do and cultivate that curiosity about it. You know, are we seeing an uptick in neighboring regions? Are people becoming more complacent with their own behaviors? Have we done a consistent job of messaging why it's still important to be vigilant or why it's still important to act in a safe manner? Are we seeing any signs at all that tell us that we're not as prepared as we need to be?

So I think cultivating a curiosity about that and a mindset that what we're doing today is probably not going to work for us tomorrow; we're going to have to constantly reevaluate what we're doing and try new things and be okay with not getting it exactly right. Learning from our mistakes, trying new things, evolving along the way, I think is really what it comes down to.

The good news is that in many ways, that's a hallmark of the scientific method, and that's what we're all trained in. So, I think we can lean on a lot of natural ability and skill that we have to look at the facts and draw insights from that and change what we do and not get overwhelmed by it.