Continuous improvement and adaptive change are two core elements that have been and continue to be essential to the success of our nation’s medical school communities. As I approach my fifth year as Dean and Chief Academic Officer of NSU’s MD College, I find myself reflecting on the culture of NSU and our medical school looking through the lenses of diversity, equity, inclusion, and belonging. NSU MD has made tremendous progress in matriculating a highly diverse student body, with our class of 2023 consisting of more than 35% underrepresented minorities, a milestone of which we are tremendously proud and will continue to work to improve. The power of the education offered through our unique curriculum is a life-changing opportunity for students to experience one of the most innovative active-learning medical programs in the country while being incorporated in a rich tapestry of contrasting yet complementary faces with a wide variety of perspectives. Considering the ongoing health equity challenges that our country is experiencing, it is crucial to ask how NSU MD can even better nurture a safe, inclusive environment of learning and discovery that fosters an appreciation for all cultures, backgrounds, and points of view.

Drawing from my own upbringing and life experiences as a European-American immigrant, I have acquired a cross-cultural perspective that I believe is helpful in framing broader conversations on diversity, equity, tolerance, and inclusion for our NSU and South Florida communities. Since starting my academic career as an assistant professor at Duke University in the early 1990s, I have been immensely grateful for being afforded a path to success involving the triple-missions of education, research, and the practice of medicine. I realized early on that a relentless pursuit of discovery and innovation was not only highly valued by the institution, but a natural inclination to be inquisitive and analytical were rewarded professionally as well. However, over the course of my professional career, the most valuable and impactful scientific breakthroughs I witnessed were achieved alongside the diverse collection of students, residents, and fellows with whom I had the privilege to work with, and later on, to mentor and advise. These incredible individuals came from all over the world, representing different races, ethnicities, cultures, and creeds. While interacting with them I learned about their personal interests, goals, successes, and failures. I saw myself in many of them, and the bonds, friendships, and connections formed over the decades with students, collaborators, and mentees have been a highlight of my academic career. Hence, it is my sincere desire to provide a similar opportunity to our students.

My immigrant experience helped develop an appreciation for how each of our perspectives is formulated through a complex fusion of cultural influences, personal experiences, aspirations, expectations, fears, and anxieties, many of which are rooted in our formative years. Over time, I learned to appreciate viewpoints that are in contrast to my own with a genuine sense of curiosity and respect. I discovered that as I listened to and pondered others’ perspectives, I always came away with some degree of resonance that was relevant for me. In this way, I was better able to appreciate the new perspective and to incorporate its essence into my own thinking, thus broadening and enriching my own worldview. Broadening one’s perspective fuels authentic curiosity and cultivates open mindedness, forming the very foundation of independent and critical thinking, which is so often absent from our increasingly polarized society today. It is human nature to follow whatever is perceived as the “norm” by the group with which we most identify. But, this “tribal mentality” (an overused term that I do not really like but find applicable here) is often limiting, as it seduces individuals into believing that they are right, and even morally superior while assuming others are wrong without ever really considering the alternatives. By discouraging individuals from even asking questions in the very beginning, it negates the opportunity to understand points of view that are not aligned with their own. However, by intentionally exposing oneself to new experiences and to people who are different from those with whom we most closely identify, we break down the barriers of tribal tendencies, and we open up a whole new world of possibilities that would otherwise not be apparent to us.  It is settings such as this that hold the most potential for personal and professional growth, discovery, and innovation, and this is exactly the setting we are endeavoring to provide for our students.

For physician educators, integrating the cultural dimensions of practice into the learning paradigms and pedagogies that students experience, dramatically influences them personally and professionally for the rest of their lives. It is incumbent upon us to equip our students with the critical thinking necessary to be self-reflective, as well as respectful and curious about other views, so that they are highly effective at cross-cultural care, avoiding implicit and explicit bias in the real-world environment. Health equity is a global challenge and as such, we have an awesome responsibility to create an environment for all of our students that prepares them to be open and curious, equity-seeking, cognizant of the value of all cultures and backgrounds, while actively eliminating bias, prejudice and stereotyping in all of its deviant forms. While it is not necessary or perhaps even desirable for students to agree with every opposing viewpoint, they must at the very least learn to listen, respect, comprehend, and welcome ideas that challenge their own. That is, after all, the foundational strength of our democracy and it is the most efficient and effective vehicle for continuous improvement.  Once students become adept at navigating points of view that are distinct from their own, learning truly occurs. Teaching student physicians how to make good decisions under uncertainty is hard. Teaching them to construct ethical frameworks for clinical decision making is even harder. Such frameworks are achieved by intentionally balancing individual needs with community needs, establishing models of health equity, and always accounting for diverse values and beliefs.

Progressing through the ranks over the years from physician to research scholar, to the department chair and to the dean, with roles and responsibilities shifting commensurately, I made a conscious decision to try approach each role with the same spirit of inquiry and discovery that I embraced as a young physician scientist, and that decision has served me well. Opportunities for interactions with students and other learners have remained plentiful, allowing me to hone my skills overtime in preparation for managing even more complex situations involving diverse perspectives, including those from colleagues in other disciplines and business partners who possess dramatically different expertise, skill sets, and world views. A lifetime of navigating interactions in a broad array of settings and with a variety of diverse individuals has led me to conclude that the most effective path to producing a useful, meaningful, and valuable collective impact is to build bridges that span chasms created by siloed thinking while embracing an authentic understanding of diverse, and often, divergent perspectives.

Perhaps most importantly, in my life’s journey, I have learned that advancing one’s professional career in medicine through intellectual achievement and scientific advancement is only one piece of the puzzle. The interconnectedness of humanity – expressing compassion, empathy, and inclusiveness as a way of life – adds a richness to the human experience that is powerful. This has led me to conclude that in the limited time we have in this world, we must seize the opportunity to live in the richest, deepest, and most meaningful ways. While human connection is innate to all of us, it is also in our nature to seek out those who are most similar to ourselves. That is why, as educators, we have an obligation to create an environment where our students are challenged to appreciate the richness of our human tapestry and to develop a sense of curiosity and wonder about people completely different from themselves and ideas completely different from their own. When we teach our students to listen, to positively engage, and to appreciate and respect all of the people around them, we are helping to create not only better physicians, but more compassionate and inter-connected humans, and hence, a better world.

Last week, Governor DeSantis announced the re-opening of Florida’s health systems, including the continuation of elective surgeries.  He also launched the “Re-Open Florida Task Force” to plan for a safe and robust re-opening of Florida’s economy. These decisions were likely prompted by tremendous economic pressures and have been justified by a gradual decline in the rate of new Covid-19 infections in Florida, which total 30,525 confirmed cases and 1,045 deaths, as of April 23. It should be noted, however, that due to present limitations in the availability, reliability, and frequency of SARS-CoV2 testing, new case rates are less predictive for successful viral mitigation than death rates, which have not yet shown a precipitous decline in our state.¹

Death rates are a lagging indicator that signal when community case transmission is on the decline, providing an additional degree of confidence that Florida citizens and business owners can gradually resume recreation and commerce in our state. Therefore, it is prudent to recommend activating South Florida’s re-opening only after experts detect a definitive downward trend, both in new cases and mortality, especially in the densely populated Miami-Dade, Broward, and Palm Beach Counties.

The pandemic has had a profound impact on higher education. Nationally, universities are grappling with uncertainties about student enrollments, demand for student facilities and services, online education capacities, campus workforce allocations, and suddenly smaller endowments. There is no existing gold standard for determining what constitutes a “safe” return to campus, nor is it clear how academic programs should be adjusted to the new normal. Moreover, there is no roadmap for how to achieve sustainable administrative efficiencies in the post-COVID-19 era. Clearly, this is a complex, multifaceted process that requires operational agility, careful planning, and expert execution.

On the NSU campus, the president, in consultation with university leadership, is taking a deliberate and measured approach for safely and effectively returning students, faculty, and staff to campus as soon as is reasonably possible. It is anticipated that there will be continual course corrections as more data become available while the rest of the State of Florida returns back to business.

Here, we have identified five essential elements that will help ensure the robustness of our master plan for the safe resumption of on-campus activities:

1. Use testing followed by gradual increases in student and faculty densities to lower the risk of on-campus transmission of SARS-CoV2.

Before returning to campus and resuming scholarly activities that involve regular contact with other individuals, a documented infection status via nasal swab PCR and/or serologic antibody testing should be required. If a person tests PCR positive, they must not return to campus and should maintain a self-quarantine at least 21 days after the onset of symptoms. Symptomatic individuals, regardless of their testing status, should not return to the workplace or resume social interactions for 21 days. Individuals refusing testing should not be permitted to return during the ramp-up phase.

While PCR testing is indicative of the presence of an active virus, evidence of a past Covid-19 infection will soon be available through commercialized antibody testing. A person who is antibody positive for SARS-CoV2 has been exposed to the virus and likely has protective immunity, although none of the tests can demonstrate protection, just a history of infection. While reliable antibody testing is not widely available at this time, Cellex, Inc. (Research Triangle Park, NC) has received FDA approval for testing under emergency authorizations and more than 90 other companies have developed serologic testing kits that could, once validated, be used as a marker for a safe return to the workplace.

While all this testing may sound rather burdensome, these practices are very similar to what is required for children (to confirm vaccinations or antibodies against measles, mumps, and rubella and varicella) before being granted entry into schools. Similarly, healthcare workers are required to present evidence of vaccination or antibodies to Hepatitis before being allowed to enter clinical environments.

Most experts recommend a staggered three-pronged re-entry approach with approximately 1/3 of the workforce and 1/3 of the student body to be permitted re-entry, once the individuals within these subgroups are confirmed PCR-negative. Two weeks later, a second wave would then re-enter, with staggered workday shifts so that campus community density remains lower than usual. After another two-week interval, the third wave would re-enter, still employing rotating shifts to maximize social distancing.

2. Develop an infection control plan for after re-entry

Students and employees should only perform on-campus work if clinically well and if using a Covid-19 self-monitoring app, adopted by the university. Well-documented disinfection procedures and protocols should be in place in all campus environments and places where people gather. Alcohol-based antiseptics should be used to disinfect all work environments on a regular schedule. Hand sanitizers should be readily available, and signage should be displayed reminding people to wash their hands with soap and warm water for twenty seconds. Special antiseptic cleaning procedures should be adopted for shared equipment and facilities, such as telephones, computer terminals, copy machines, door handles, break rooms, elevators, and bathrooms. Whenever possible, HEPA filters should replace traditional air filters within the HVAC system to remove particles that are greater than 10 nanometers in size. UV lights should be utilized in laboratories, safely installed to prevent prolonged human UV exposure. Finally, the use of surgical masks and glove infection control procedures should be used if there is a high likelihood of close contact with individuals within the environment who may be unaware of their Covid-19 test status. Activation of a Contact Tracing Protocol is highly advisable when new cases are confirmed on campus, which would entail prompt PCR testing beginning with the first contact, followed by a series of tests over days if indicated. Additionally, students and employees need to be advised to self-monitor and self-quarantine if indicated, and anyone with a hint of symptoms should be instructed to leave the work environment immediately, be tested, and contact tracing should then be initiated.

3. Maintain social distancing protocols

Even when all realistic testing precautions are taken to ensure that students/employees with active infections do not enter the campus, additional safeguards must still be taken if there are still active cases in the community. Auditoria, classrooms, conference rooms, workrooms, laboratories, workstations, buses, cubicles, and campus restaurants should be populated such that the physical space between students/employees is at least eight feet. Office environments with open cubicles will be particularly challenged but can be rendered safer with reductions in the number of cubicles, implementation of plexiglass barriers, and cubicles spaced further apart. Masks can be used in these situations and gloves are recommended for any contact that requires a transfer of potentially contaminated objects.

Additional precautions are needed for confined, shared spaces, such as elevators, stairwells, and waiting rooms. Elevators should be limited to two people at a time, located at maximal distance from each other. Stairwells should be limited to one person per flight of stairs. Waiting areas should have seating spaced at least 8 feet apart and provide markers indicating where people should stand to allow for safe social distancing. Break rooms/lunch areas should limit gatherings to a number that allows appropriate social distancing (6 feet, <10 people), and request staggering of lunch/meal breaks to minimize individuals being in small spaces without masks. Increased use of signage throughout university educational and office buildings should be employed, to remind employees of good infection control practices, including social distancing, hand hygiene, hand washing, cough etiquette, and a universal mask policy.

4. Adjust human resource policies

An important component of the post-COVID environment will be revisions to human resources policies and procedures. Teleworking and remote education should be encouraged until we can ensure that there is little or no risk of active infection in the community. Flexible and staggered work schedules should also be permitted to ensure that proper spacing of personnel is achievable. Gatherings of more than a few people in a confined space should be avoided and may require changes to past work routines. Liberal sick leave policies should be put in place to ensure that people with symptoms do not attend work. Employees at increased risk due to age or medical vulnerability should be encouraged to telework or remain at home until a safe workplace environment can be ensured.

Importantly, increased levels of anxiety, depression, and even symptoms of post-traumatic stress can be expected among students and employees following long periods of social isolation and fear from the pandemic itself. Employees should be informed about ways to access professional help benefits through employee assistance programs, or professional behavioral health services. Access to medical providers via telehealth services should be emphasized so that employees with symptoms or concerns know how to easily access competent care.  Employers should work to increase communications with employees. This will allow for information about the safety of the workplace to be shared, as well as for employees to give feedback to employers. Trust and transparency are powerful tools that enable everyone to feel more comfortable returning to work and other locations where people will be gathering.

5. Develop ongoing surveillance and monitoring plans

Even with stringent precautions, constant surveillance will be necessary. Screening procedures for students and employees need to be established so that anyone with symptoms such as cough, temperature elevations above 99.8 F, or generalized malaise, cannot come into close contact with other individuals. Apple and Google recently announced their launch of an automated contact-tracing system. It is different from conventional contact-tracing since it will allow people to know who they have been in close proximity to and, also, will ensure safe social distancing. Most importantly, it can operate at a far greater scale than conventional contact tracing, which will be necessary given how far the outbreak has spread in most states and countries. Finally, it will be important to monitor ever-changing recommendations from credible sources such as the CDC or local public health departments and adjust processes and procedures accordingly.

Conclusions

New resources, policies, and procedures will have to be implemented to ensure a safe campus and workplace environment. At a minimum, such resources include:

1. Enhanced disinfection and cleaning protocols prior to ramp-up and during the ramp-up phase.
2. Body temperature monitoring at all university entry points, consistent with EEOC guidelines.
3. App(s) for self-monitoring and to interface with employee health services.
4. Serologic and PCR testing availability via Quest Diagnostics or other clinical laboratories, along with immediate deployment of contact tracing by medical staff.
5. New HR policies and procedures to encourage continued remote work and learning, while allowing for flexible works schedules to minimize crowding.

Once a vaccine or other effective treatment for COVID-19 is available, the paradigm will shift. It will then be much easier to ensure that people are protected and remain healthy. In the meantime, reasonable precautions and best practices will enable us to take safe steps that can bring us closer to a return of normal campus life. While the post-COVID-19 world may never look exactly like it used to, we can create a path forward that ensures necessary precautions and, with adjustments, enable a return to more normal ways of living, learning, and interacting.

¹ https://www.nytimes.com/interactive/2020/us/florida-coronavirus-cases.html