Difficulties for Clinicians
The ways in which medical specialties are being affected by the COVID-19 pandemic caused by the global spread of the novel coronavirus are widely varied. On one end of the spectrum, some specialists have been all but taken out of the picture. With the marked restriction of nonurgent medical services, specialties such as dermatology, various surgical specialties, etc., have been restricted to only emergency care, which may create financial stress for these clinicians and their employed staff, and it can make them feel benched when their natural medical instincts would incline them to want to jump in somehow.
Other clinicians — such as inpatient specialists, hospitalists, ICU clinicians and pulmonary specialists — find themselves drawn into the immediate front line, working long shifts with all that entails, including the direct fear for personal safety and that of their families.
In the time of COVID-19, some clinicians have to determine how to reinvent their practices and adapt for safe practice. Many will be asked to assist outside of their normal scope if demand requires it. In New York, orthopedists are working in the ICU, managing ventilators. Meanwhile, babies will be born, hips will break and heart attacks will occur, and the respective medical teams will have to figure out a way to provide safe care for these non-COVID medical needs. Even more mind-bending in complexity is mapping a plan of care to meet the medical needs that arise in patients who are COVID-19 positive while also needing care for a normal-occurring medical issue, such as a COVID-positive mother in labor or a COVID-positive patient requiring acute surgery.
Many healthcare providers, including first responders, physicians and RNs, find themselves socially isolated from their own families, in some situations having to live entirely separately from their families to protect them from COVID-19 exposure risk. I am one of the few primary care doctors in my area who still actively admits my patients and follows them in hospital when admitted. At this time, I have sequestered to my office; although, I fully anticipate a time when I will be needed in the hospital on a full-time basis, perhaps within the month. At that point, I will have to live separately from my family.
At my primary care practice, as our community developed higher rates of asymptomatic carriers over recent weeks, it became clear that it is impossible to identify this risk and therefore to safeguard our staff and other patients from exposure. In the past week, we quickly transitioned — within six hours of making a final decision — to a secure patient care model using a telemedicine platform for our patients. We saw ourselves in the counterintuitive dilemma of closing our doors to in-office patients for the first time in 35 years in order to protect them.
We are a 14-provider primary care practice with 40,000 patients in a tri-state area. We realized that if one of our providers or staff members tested positive for COVID-19, the entire office would be closed due to a mandated quarantine, which would result in 40,000 patients being left without access to their primary care providers. We have required all staff to take an oath for extra stringent social isolation/safe practices to minimize putting one another at risk for contracting COVID-19. The response of patients, the obvious relief and gratitude when we connect with them through telehealth, has been overwhelming.
Taking Care of Ourselves
For many reasons beyond the scope of this conversation, medical providers are disproportionately at risk for addiction, stress-related mental health issues, depression and anxiety. We are conditioned to care for others but struggle with self-care. Many of us even feel shame asking for it. Many don’t even have a personal physician.
One of the hardest things about what we are facing in this pandemic is how much of it is unknown. We have no playbook for any of this, nor do we know how long this will last. Many clinicians will be dealing with death on a scale that, even as seasoned professionals, we have never previously faced. This may be directly in the care of ill and dying patients. We will also be needed to provide support to many of our long-term patients as their families undoubtedly are impacted by the loss of family members. It stands to reason that many of us will be shouldering the weight of this responsibility while also dealing with the loss of our own family members and loved ones. An unprecedented number of physicians have been updating their wills and advanced directives in the face of this pandemic. We are very aware of our own risk and vulnerability. We are struggling ourselves to know how much social distancing is needed to protect our families. The normal stresses of sleep deprivation, interruption of normal leisure activities and social supports, and a lack of exercise are an added challenge.
My personal road map is to attempt to maintain as much normalcy as possible. I have been a lifelong rower/athlete, and this is an essential for me. I walk the dogs (more than they want, maybe). I am trying to protect my sleep schedule (not always possible) and maintain a healthy diet. I have received great moral support from the outreach of family, friends and many patients from far and wide. I am blessed with a large family, both locally and around the world (Canada, Spain, Ireland and Australia), and we have been video chatting and connecting often. All across the world, we really are living the same experience right now. I have, like everyone else, found myself connecting in video chats with family members and dear friends and asking ourselves, "Why were we not doing this before?"
Difficulties for Patients
Many of our patients are dealing with the challenge of preexisting mental health issues. This is compounded by job loss, added financial stress, increased social isolation, and fears about their health and physical safety. Other patients face the added stresses of working from home, trying to balance child care and home-schooling and, often, without the support of grandparents, who are themselves in isolation.
Our elderly patients face the added stress of adapting to telemedicine and isolation, something that may be very foreign to them. Getting the elderly patient on a telemedicine platform can be daunting and stressful for all involved.
Many of our patients have been in isolation for weeks now. They are fearful and often without their normal family interactions and supports. The elderly realize they are at very high risk in the event they become infected by the novel coronavirus. They often do not fully understand the mode of transmission or the best practices for social isolation. They fear being without care for other medical problems if those should arise and of being without needed medications or health care as the systems become overloaded with the care of COVID-19 patients. Patients are terrified of needing to show up in an ER or the need to be hospitalized for any reason.
Part of our outreach primary care role is to attempt to help triage, support and maintain patients in their homes in order to lessen the risk of disease transmission. My advice for people who need medical care is:
- Use virtual triage with telemedicine when possible.
- Avoid hospitals and in-person doctor’s offices as they are becoming petri dishes for infection.
- Know that much more can be accomplished with telemedicine than doctors may have thought possible prior to the pandemic. In my experience, patients are enjoying telemedicine, and I do too, surprisingly. I think it is one element of healthcare delivery that will endure in some form after this is all over.
My advice to people who are NOT in need of medical care is:
- Do everything you can to keep it that way. Reasonably avoid high-risk activities — don’t put yourself in a situation where you could fall off a horse, break a leg, etc. Stay healthy.
- If you have the good fortune of excellent health and perhaps extra time on your hands, give thought to reach out to more vulnerable friends, neighbors and family members who may be in need and isolated at this time. I encourage all of us to consciously think of those who are isolated and in need, and to reach out, even if virtually.
This will be the most challenging thing most Americans, and the entire human race for that matter, will ever face in our lifetime. We are in this together and must do this together. We are, as a society, only as weak as our weakest link, and in this, I speak to the moral imperative for proper social distancing. None of us is without risk, but the vulnerable among us, in particular, rely on us doing this together and following medical guidance.
I implore our government leaders to listen to scientific and medical experts and clearly communicate and mandate what is needed from all of us. I implore them to find a way to provide adequate protection and support to the frontline soldiers — our clinicians — in this war (and it is a war).
I honestly believe that on the other side of this horrible ordeal, the world in some ways will be a better, gentler place. We have been forced to stop and reevaluate everything. Our common humanity is on full display as every nation on earth is living this pandemic together — black white, yellow, Christian, Muslim, Jew. We are being given a chance to reconsider our priorities, the meaning and purpose for our lives, the value of relationships, even our very relationship with our planet.
The best of humanity is already on clear display in the generosity, compassion and bravery seen on the front lines and in our communities. My plea is for all of us to do all we can to beat this together. Hope to see you on the other side.