• How Our Community Practice Took On COVID ― and Beat It

    September 30, 2021, 10:00 a.m. — First let me say I’m a farmer who practices family medicine in upstate New York. I live on our family farm in Owego, a town of fewer than 20,000 people in Tioga County. So I know a thing or two about community.

    I’ve been with my primary care group practice, Endwell Family Physicians LLP in Broome County, N.Y. ― population 190,000-plus ― for more than 20 years. The practice, which includes nine other board-certified family physicians and has a total staff of 115, cares for about 35,000 patients.

    We view ourselves as trench doctors ― we do everything. We do home visits, hospital care, and we have a great time. We were at the forefront of the medical home, and many of our physicians have been active over the years in our local Academy.

    When COVID came around, we saw that we had an opportunity to do something ― we had little bit more freedom than some of the hospital-affiliated family medicine practice groups. But what we were able to do surprised even us ourselves.

    The project was sparked by intense frustration at watching our patients die of not COVID. This was in spring 2020, when we were on COVID teams in the hospital and we saw what was happening there.

    We were faced with a decision: Are we going to see patients or are we not going to see patients? We decided that we’d like to see patients, but we didn’t want to do that until we had tests to be able to tell them whether they had COVID or not, knowing that we couldn’t tell by looking. 

    Since we couldn’t get testing right away ― although we certainly tried to ― we set off on a different project: educating ourselves about pandemic history. 

    The five partners who headed this endeavor, me and four others, split up the work and started setting up the office, teaching people how to don and doff, keeping up with the history, reading a lot of literature and fighting to get testing.

    In the meantime, we were watching our patients die of not COVID. What I mean by that is I had three patients, I think, in that early spring ― only three ― die of COVID. But I had over 40 die of not COVID. They had all gone to get swabbed and were told they didn’t have COVID, and then they went and died of something else, like pulmonary embolisms and MIs. 

    We were all frustrated and knew we had to do something.

    It seemed that nobody except ERs was taking tests to point of care, and the ERs were mayhem ― too many bodies to control. But we could control our office. We got MERV-13 (air filtration); we got ventilated correctly. We got the equipment to see COVID rule-out patients so the doctor, in full personal protective equipment, was the only person who saw the patient. We even cleaned the rooms.

    The goal was to see high pretest probability patients ― that is, symptomatic patients during surge conditions ― test them, diagnose them, and then either directly admit appropriate patients to the hospital, send them to our own COVID at-home program, send high-risk patients for monoclonal antibody infusions (when that became available), and/or follow up all COVID-positive patients via video every two to three days until they were well.

    We wound up with a case series of 1,146 COVID-19-positive patients during the COVID surge period from Oct. 5, 2020, through Feb. 28, 2021.

    As expected, we diagnosed many other serious illnesses in our clinics. Robust, early  multichannel communication for all staff let us educate them about the pandemic, practice safe work processes, achieve high staff vaccination rates, and rapidly adapt to changing conditions ― all while buoyed by a sense of epic camaraderie at realizing we were making history in our community.

    The results were nothing short of astounding: a nearly 60% reduction in hospitalizations, a sixfold decrease in mortality, zero staff-to-staff, staff-to-patient, and patient-to-staff transmission, and no hospital readmissions.

    The bottom line is that our approach allowed rapid triage and treatment of COVID-19 patients while decreasing the burden on overly taxed hospital systems and simultaneously boosting outpatient volumes in a safe fashion. It’s a “pandemic playbook” that can be replicated in nearly any outpatient setting or nursing facility.

    That last part is particularly important because this pandemic isn’t through with us yet. We’re now seeing 4%-5% positivity in our community, but our office is having days with up to 25% positive COVID patients. And we’re a high vaccination rate county, probably, compared to most places in the South and Midwest. So we’re clearly back at it.

    What we’ve seen this time around is we still have to fight like lions to get testing, although we have PPE, and we’re a little burned out. Trying to celebrate while you’re making history while you’re burning out all at the same time has been a trick ― a real leadership issue. Thankfully, we have good people here, and our staff are protected. As a result of what we went through, we’re now 100% vaccinated. Oddly enough, it was the back-end things, the ripple effects of having seen COVID, that really helped our staff, helped our community.

    We tried to make everyone safe who was on our staff so we had the confidence of our staff and they knew we had their backs, they were covered, and we were using data to drive our decisions ― even when we had no real data. For instance, we went to everyone on our staff wearing N-95s when our case rate went over 2% in the town, and this was last fall. There was no guidance.

    What staff didn’t want to hear is, “Dr. Lazarus thinks we should be in N-95s because he woke up that way and felt it.” There are great sources of help, but they’re just harder to find. If you miss two or three days of COVID news, you’re kind of far behind. It’s like this constant psychotic trail of news, and I found great solace in three sources:

    • One is Eric Topol, M.D., who most people know — the doctor from Scripps.
    • The other’s not even a doctor — Zeynep Tufekci, a sociologist from the Univerity of North Carolina at Chapel Hill who’s recently moved to New York. She’s the one who first said, “This is airborne. You guys are a bunch of idiots; can’t you see?” That wasn’t based on great science at the time ― not yet ― but she was right.
    • And now there’s a company called The Public Health Company, which describes itself as “on a mission to protect businesses and communities from infectious disease.”

    What we’ve found in our area this time is that everybody has seemed to be asleep. The health department was asleep, the hospital systems were asleep, the county executive was asleep … and our office has been poking them, saying if you don’t mitigate now, it’s done. You can forget about it. It’s going to be horrible or more horrible, but if you mitigate now, it could be less horrible as we start school.

    So here we go again. We’re all going to have our COVID degree; it’s going to be four years of this. This time, though, we know what we need to do. COVID-19 is a primary care disease, as are all pandemics.

    We all have blood here; we have bodies in the ground. It’s our town, and we’ll beat this by adapting to the community’s needs ― the essence of family medicine.

    Lazarus Gehring, M.D., is a board-certified family physician who graduated from Israel’s Tel Aviv University and completed his residency at United Health Services Hospitals Family Medicine Program in 2002. He is a partner at Endwell Family Physicians in Endwell, N.Y. He also serves as a clinical assistant professor at the State University of New York Upstate Medical University and is director of the Family Medicine Department at its Binghamton Clinical Campus.