U.S. FP Shares COVID-19 Insights From Practice in China

Laura Jordhen, M.D., has already experienced it.

Since 2016, Jordhen has been practicing in Shanghai's United Family Xincheng Hospital and was chair of infection control for the hospital before becoming chief of its family medicine department in December. She also is a preceptor for a family medicine fellowship.

After weathering the worst of the epidemic in China -- about 520 miles from where it started in Wuhan -- Jordhen came home this month to visit her family in Vancouver, Wash., just as the number of confirmed cases in the United States was starting to climb.

Jordhen said she was discouraged by what she witnessed in her own country. She spoke with AAFP News on March 16 about lessons U.S. physicians could learn from China's experience and what she would like her American colleagues to know as they prepare for the pandemic.

Q: What was your experience like as a physician in Shanghai?

A: After Wuhan was locked down on Jan. 23, we actually were directed not to see any patients with fevers. The Shanghai Center for Disease Control takes a citywide approach to care, and all patients with fever were directed to special clinics for testing for COVID-19. Since the second week of January, we have been triaging people first by phone and again at the door for travel history, presence of family members from epidemic areas, presence of fever and any respiratory symptoms during the last two weeks.

Q: What else changed at your hospital?

A: We're not seeing high-risk patients for nonemergent care. Restrictions have become more and more strict. Our dental clinic was closed except for emergencies. Our ear, nose and throat clinic closed. Non-urgent endoscopy was closed. Our number of visits went down quite a bit. We've been discouraging people from scheduling their annual exams and preventive exams until the epidemic subsides.

Q: Shanghai had special clinics you referred people with fevers to. How did that work?

A: In public hospitals they had areas that were separated from all other care. They would be seen by people wearing full protective equipment. The public hospital also has the ability to have labor and delivery in a negative-pressure room for women with respiratory symptoms who are going into labor. At our private hospital, we see patients with cough and colds (but no fever) in a separate area of the hospital with a separate entrance. Between pediatrics, internal medicine and family medicine, we send all the people with cough, cold, runny nose, sore throat -- anything that could be a viral URI -- to a dedicated family physician in this totally separated area. So, we're keeping all that potential cross-contamination out of our waiting room, away from kids getting vaccinated, away from OB. We're wearing full face shields or goggles, N95 masks and gowns in that area.

Q: What about people doing your triage? What kind of gear are they wearing?

A: We have a nurse and a security guard outside. They're wearing N95s, eye protection, gowns and gloves. We're basically assuming anyone with respiratory symptoms could be ill. You don't know. We're also triaging visitors.

Q: What are things like in China now?

A: Things are slowly getting back to normal. Our ear, nose and throat clinic is reopening. Dental is reopening. The number of new confirmed cases is low. People in Wuhan are still basically isolated in their homes, but throughout the rest of China schools are starting to open up. With still a few cases reported every several days in Shanghai, schools have still not reopened. It's still very strict social isolation. Massage, hair cut -- any kind of business that involved physical contact or having people close together -- was shut down around Chinese New Year, which started Jan 25.

Q: How is this outbreak similar or different from the SARS outbreak in 2003?

A: The main difference between this and SARS is that with SARS, people were either really sick or they were not. You didn't seem to have the asymptomatic or minimally symptomatic patients in a community not knowing they were sick and continuing to spread it. SARS could be controlled by isolation of cases and contact tracing. It petered out in June, but it wasn't because of the weather. It was (because of) really aggressive contact tracing and isolation.

Q: You returned to the United States March 4 to visit your family. Are you surprised by what you are seeing here? What can the U.S. health system learn from what other countries are doing?

A: I was shocked. I assumed the United States was prepared for the inevitability of COVID-19 coming here. We saw from what happened around the world that it is so contagious. I remember reading in January about a taxi driver in Thailand who was infected after driving a Chinese tourist. There was a tour guide in Japan who was infected after guiding some tourists from Wuhan. These were not household contacts. It's publicly available data. That gave me a real sense of how contagious this was. I figured people in the U.S. would be on top of this. But when I arrived, I talked to Dr. Dave Carsten, chief of infection control for the Washington State Department of Health. Dr. Carsten was way ahead of his colleagues in addressing the impact this pandemic could have on dental teams. This wasn't really on their radar yet. It seemed remote to a lot of Americans.

Q: You joined the discussion in the AAFP's COVID-19 online member community. What did you find there?

A: What I found was practices didn't have enough personal protective equipment and were struggling to respond to this. I didn't expect that. In Shanghai, we have enough PPE to meet our needs. My message to U.S. family physicians has been that you can't combat this alone. It needs regional coordination. It needs planning for what if -- for example -- your rural care team is ill? If you're in a physician shortage area and your physician has been exposed and is out for 14 days, what is your contingency plan? This crisis requires groups and health systems to come together. They can say, "We're not seeing cough and cold patients at clinics A, B and C; they all go to clinic D because it has all the masks." That's how you can be good stewards of your resources. It's a really different way of organizing care.

Q: What should family physicians be doing outside their exam rooms?

A: It's time for family physicians to be leaders -- to say, "We have to be prepared. There could be more sick people than we have beds. How are we going to allocate resources? How do we keep physicians safe? How do we have cough and cold patients either stay home or be in the hospital and not anywhere else?"

Q: What could the United States be doing better?

A: There's no role for early treatment. You can't go to your physician early in the course of the infection and get medication to keep you well. There's not Tamiflu for this. I would much rather see patients with mild symptoms not enter the health care system at all because they could expose their doctor and waste PPE. I'd love for those patients to get cared for without contact and for patients who do need care -- if they're sick enough to need oxygen or IV fluids -- to skip clinic and go right into a hospital with a designated ward for COVID-19 and not enter through the same doors and waiting rooms and sitting around with everyone else who is sick with something else.

We need drive-through testing so you can keep COVID-19 patients separated from others. Can you have triage outside? Can you separate patients with respiratory symptoms right away? Can you test for COVID-19? You can't put everyone in the one negative-pressure room. You'll need to cohort patients and (have) a dedicated team to take care of that cohort. You'll need to prepare for delivery and care of newborns born to mothers ill with COVID-19. All those protocols need to be in place now.

Q: What concerns do you have for your physician colleagues?

A: I talked to an ER physician colleague in Shanghai about triaging hospital admissions early on before protocols were in place. If he admits a patient with possible COVID-19, then our staff is at risk. If he sends them out, it's hard on the patient. He was really struggling, feeling he has to make that decision alone each time. For our physicians who work in hospitals, if they have to make critical decisions alone about who to treat when there are more patients than beds -- who to take in and who to send away -- it's excruciating. I want people to be talking to their ethics committees, pulmonologists and critical care teams now. What are ways to decide objectively who we can treat? Plan now. I hope it never happens here, but it is happening in Italy. It's going to be exhausting. We should expect that there's going to be a lot of physicians and nurses on the front lines who are traumatized when this is over.

Q: What should we not be doing?

A: Physicians are notorious for working when ill. You're going to be thinking, "I have a common cold. I'm the only doctor in my county, so I have to work." In this scenario, you may be seriously harming patients by going to work ill. If you're not there, there's no physician. That's better than bringing COVID-19 to your elderly patients. It's going to take a different understanding of what's safe for physicians and patients. This is not the time to gut it out and keep working.

I also want physicians to be advocates for putting off elective care. If a patient is going for knee surgery, the orthopedist may not be the one to say, "Let's not do it." Family physicians need to say, "You know, your knee surgery should wait until the epidemic is over because I don't want you to have complications and be in the ICU and not have a bed." We need to be champions of slowing down anything not urgent. We want to refer people for colonoscopy because they're turning 50, but not right now. Let's not bring people in for screening. Let's refill our patient's diabetes medication without them coming in. We're supposed to check all the boxes for things like a patient's A1c. Not right now.

Physician leaders need to realize this is a different time. Nothing is normal. All the focus should be on building capacity. How do physicians do that in a way that's viable? Do telemedicine. Do phone calls to keep people out of the office. If you are following up on a patient's cholesterol or bone density, you don't need a physical exam to do that, but you don't get paid if you don't do that. How do we keep practices open in safe and economically viable ways? This takes high-level problem-solving.

Q: Many Americans seem resistant to the idea of social distancing. They think, "It's not going to happen to me. I'm healthy." How do you break through that?

A: There's a false sense of security that there's something about our lifestyle that will protect us. "We live in houses, not apartments. We drive cars instead of riding a subway." What's happening in Italy should be a real wakeup call. I'm not seeing urgency. I'm especially worried rural counties aren't going to be prepared.

You have people on social media saying, "I had it and it's not that bad." People are underestimating it because most people who get infected recover, but the volume of ill patients is going to be overwhelming. 

Q: How does this end?

A: It's like fire. It will burn as long there's fuel. In this case, the fuel is people who are not immune. Right now, we think that's everybody. Until you either have everyone isolated from each other and the fire goes out or a subgroup of people are immune, it will keep burning. We're still so interconnected, even if we don't live in multistory apartment buildings. We're all still at risk.

Unfortunately, it became a political issue in the United States. There was a lot of downplaying it initially. It's really important for family physicians to look at the data and not follow the lead of politicians if they're not acting according to evidence. We love evidence-based medicine. I wish there were evidence-based politics.