Coronavirus: Making Primary Care Cool Again

You guys may not know this, but up until this pandemic, primary care has been the runt of the medical litter. Like, if the different branches of medicine were a high school sitcom, outpatient internal medicine would be the dorky intellectual kid who everyone knows is really smart, but no one invites to parties.

We’re the money losers of the hospital, because the bureaucrats behind insurance reimbursement levels decided that procedures pay, and thinking doesn’t. Our gig largely involves cognitive and communication skills, not scalpel or syringe skills. We want to spend time with patients, talking with them, gathering a good history, thinking through problems, developing relationships. But under the current models, our time isn’t considered valuable, and instead we’ve been pressured to see more and more patients: Volume, numbers, productivity. This makes it hard to take good care of people. This also means that no one wants to go into primary care. Who wants to work their ass off doing a crappy job and be paid the least of their colleagues? Medical students and residents coming out of training with hundreds of thousands of dollars in med school debt aim for higher-paying specialties. It’s hard to find a primary care doc, right? This is why.

Yeah, we haven’t been the cool kids, but it’s okay, because we always knew we were worthy. And we’re getting to prove it now.

There’s three really important ways primary care doctors have been stepping up to the pandemic plate: One is front-line clinical care of COVID19 patients, as almost all of us were pulled into duty ahead of other specialists who might be farther away from general medical training. Two is telemedicine, a long-underrated and underutilized method to provide patient care, and that has almost overnight become essential. Three is something called serious illness communication, given that most people will catch this highly contagious and often fatal disease within the next year, before a vaccine is available. This is critically important, and probably the hardest task of all.

Let’s start with the front-line work. COVID19 is a new thing, and there are literally no established management guidelines or proven treatments in existence. There’s no chapter in any medical textbook on this. There’s very recently published data coming out of the areas hit ahead of us, but studies have been problematic. It’s hard to do research when your hospital system is collapsing and your colleagues are dying.

Instead, there’s been learning on the fly, and crowdsourcing. We’ve put together our own clinical guidelines and algorithms. Our hospital website has posted live documents with information, but everything has a disclaimer prominently displayed: “The document is live and is updated daily”. Because with COVID19, things can change on a daily basis depending on what we’re hearing from the folks in Italy or New York or down the hall.

But we have a surge coming, we need to know what to do, and we are on it. My colleagues in internal medicine have stood up fully functional Respiratory Illness clinics in mere days, like this one that was created within in a formerly thriving sports medicine clinic. What you see below is the day’s guidelines and algorithms hanging all around my workspace. Everything about the clinical workflow, like how to order tests, testing criteria (testing still being very limited), how to send a patient to the emergency room, what to do if they collapse and code (and they have), how to file your note and how to bill the visit is visible to us as we work.

It’s my primary care colleagues that have developed these guidelines and are running these clinics, as well as staffing them. But as important as seeing patients in the Respiratory Illness clinic is keeping patients out of it, if they do not need to be there.

That brings me to telemedicine. So, the office where I’ve worked for the past twelve years is usually bustling, fully booked and adding on patients right and left. These days, it’s deathly quiet, and there’s only a skeleton crew seeing a trickle of non-COVID19 urgent cases.

The doctors, NPs and nurses are still wicked busy, though. The phone calls and messages are nonstop. The hospital has hurdled over and through myriad logistical obstacles so that we can provide telephone and video care to patients. Telemedicine is the here and now. We don’t want people to leave their home and come to coronavirus ground zero for care, we want them to stay at home if possible, and we’re asking ALOT of questions to figure it out. And patients love it. It’s easier, faster, more convenient, and cheaper (No parking! No taking the day off of work! No arranging child care!).

It hasn’t been an easy-peasy transition, however. There’s been technical difficulties, programs to learn, bugs to work out. Our heads are spinning as we quickly shift from our longstanding well-ingrained clinical practice based on face-to-face conversation and physical exam to this new, unfamiliar format. There’s still tons of patients who need care, and little time to fiddle with the knobs or experiment with the technology. We’re live.

That brings us to the last and probably most important piece, communicating with our patients about their risk, and preparing them to potentially face illness and death. We’ve all seen the numbers on the news. A lot of people are catching this virus. Many end up in the hospital, and of those, half end up in critical care. The death rate is frightening, and we know that elderly patients and those with chronic medical problems are more at risk.

This is why we need to talk about it. My colleagues wrote an excellent article about the immediate need for some serious conversations that was published in the Boston Globe, explaining:

“As coronavirus cases surge across America and the potential consequences of horrific ventilator shortages loom large in our collective psyche, we doctors should be reaching out to vulnerable patients to proactively have these serious illness conversations.”

We owe it to patients who may or may not realize the grave danger they are in. We need to ensure that they are doing everything possible to stay safe and not get sick in the first place. But they also need to know that now is the time to get their affairs in order, to call the people in their lives and say the things that need to be said, just in case. We need to ask them what their preferences are for their care if they get sick, really sick. It’s a difficult and delicate task. It’s a big ask. But it’s what we in primary care internal medicine have been trained to do for our own patients better than anyone else.

And so this is what we are doing. Our hospital has organized a massive effort in record time, complete with Zoom training sessions, scripts, guidelines, and a support hotline. All so that we can identify our most at-risk patients, reach out to them in the coming weeks, and have these very serious conversations. It’s heavy, it’s hard, and it’s what we need to do, right now.

Whew! Let’s end on a lighter note. Of course, none of these posts is complete without the PPE selfie. I want to point out the ingenuity and generosity of the Patriots’ team owner, Robert Kraft. He worked with our Governor Charlie Baker to bring a million precious N95 masks over from China, which we appreciate very much! Prior to this I was wearing a surgical mask to see coughing patients. N-95’s are MUCH safer. I leave you with this, and some views from the clinic: