Wednesday Apr 22, 2020
The Immeasurable, Cascading Effects of Primary Care
About a month ago, one of my 90-year-old, bedbound patients came to our practice for leg swelling and general malaise. She was brought in by her daughter, who had long been fighting for my patient's survival.
The threat of COVID-19 loomed, and our practice was recommending that all at-risk patients stay home. I wore a mask and gloves and stood on the other side of the room from my patient. There was a chance I had already been exposed to COVID-19, and I was going to try my hardest to prevent the spread of it.
I was concerned about my patient's leg swelling. However, I knew it would be difficult to get any imaging or specialist appointment quickly and safely because COVID-19 was going to drastically change access to health care. My patient and I had discussed advance directives before, but her daughter hesitated to support a "do not resuscitate" order. That day, I pulled the daughter out of the room and asked her directly: "I'm sure you've heard of this virus. We're going to try to get your mom the best care, but in case she gets the virus, do you know what she wants?"
"She's ready to go," my patient's daughter admitted with tears in her eyes. "I'm the one who is trying to hold on."
Two weeks later, my patient was unresponsive. Her daughter took her to the emergency department. She was intubated and later tested positive for COVID-19.
Because of our previous conversation, my patient's daughter didn't hesitate when she found out about the positive COVID-19 result. She decided to extubate immediately, and my patient passed away peacefully a day later.
The patient's daughter, granddaughter and great-granddaughter are also my patients. I took time that day to speak with each of them individually. We talked about their need to quarantine because they had been exposed to the virus. We grieved together over the trauma of how my patient -- their loved one -- died alone in the hospital because of isolation precautions. We braced ourselves for the coming weeks, preparing for the number of lives that would be lost. I refilled their medications, discussed their own health concerns, and wrote them (and their partners) letters for work to document their exposure.
I know I played a significant role in this family's experience with COVID-19. And yet there are moments when I question whether I am essential in this pandemic. It is an insecurity that weighs heavily on me, because I know it isn't true.
Similar to many other outpatient primary care physicians, I work hard every day to keep people out of the hospital. I am available to my patients on a daily basis, monitoring chronic conditions and checking in with patients presumed to have COVID-19. Our organization, like others, remarkably rolled out telehealth services for medical visits and behavioral health within weeks of the first recorded COVID-19 case in New York City. I see patients almost exclusively through video visits and phone calls, with a few necessary visits in person, to make sure that my patients will not overburden emergency rooms with nonemergent health needs.
However, I hear about my colleagues and friends at the hospital, working in the ICUs and ERs, risking their lives daily with insufficient protective equipment. I fear for them and also applaud them as they try to save the lives of those who are battling the most severe form of the virus. Despite my fear of being exposed to the virus -- or worse, of bringing it home -- there is still a desire to be in the hospital, to use my family medicine training to answer the call to serve in a time of need.
Compared to their work, my effectiveness in keeping people out of the hospital sometimes seems negligible. It seemed negligible when a patient of mine, against his better judgement, and against my advice, left his house and came to the office for a mundane reason like an ear irrigation (without any ear wax on exam). Or worse, when a patient, despite my frequent check-ins and online availability, went to the ER for something as simple as a UTI.
I've realized the reason behind my feelings of uselessness. The moments of failure are tangible, measurable moments where my attempt at intervention didn't work.
What I don't see, and can't measure on my own, is the impact of stopping the spread of the virus by telling a mildly symptomatic patient (who clearly doesn't understand what isolation means) to stop going to the grocery store.
I can't comprehend the stroke-prevention impact of waiting patiently during a telemedicine visit for a patient to change the batteries in their blood pressure cuff so I can make sure their medication dose is effective.
I don't see the outcomes of bringing an anxious patient with muscular chest pain to the clinic for an EKG to prevent a visit to the ER.
And while I see it on their faces, there's no numerical way to record a patient's relief when they know that I'm going to monitor their symptoms of suspected COVID-19 on a daily basis and that I will help them decide if and when it is time to head to the ER.
It is always difficult to measure the impact of prevention because it is the measure of something that never happened.
As we get deeper into this crisis, the acuity of patients we see with and without COVID-19 in an outpatient (telemedicine) setting is going to increase. Hospitals in New York are already at capacity, and patients are relying more heavily on primary care practices to manage their exacerbated health conditions. Ironically, our role will likely feel more meaningful because, in addition to prevention work, we will be able to measure the effect of our management for things like severe heart failure, COPD exacerbations and acute hyperglycemia -- things that people usually get hospitalized for.
It means that in addition to ensuring that hospitals have the clinical resources to care for patients with COVID-19, there is an urgency to strengthen and support primary care through appropriate reimbursement and resources. Smaller practices throughout the country are closing altogether because they lack the financial cushion to continue caring for their patients. Larger practices are needing to furlough staff, decrease salaries and halt essential services to keep their doors open and maintain basic access for patients. Instead of avoiding emergency and hospital visits for the millions of individuals who do not have COVID-19, we as a country are systematically choosing to overburden our ERs and hospitals by refusing to adequately support primary care.
We have to find a way to give patients access for all their health concerns, from the most mundane to the highest need. I can't do it alone. Moving forward from this crisis, keeping people out of the hospital is something that we have to commit to as a country. I need insurance companies to prioritize the tools I need, like blood pressure cuffs and glucometers, to make it easier for me to care for patients from home. I need my patients to have access to coaches and educators, physical therapy, exercise and better nutrition so we can prevent the comorbid conditions that complicate recovery from COVID-19. I also need outpatient specialist support for patients who need evaluation for cancer, bleeding and other acute but nonemergent care, even if these specialists are now working in the hospital to care for patients with COVID-19.
Providing access to preventive and primary care has an immeasurable, cascading effect. Even before COVID-19, primary care prevented heart attacks and strokes and improved diabetes control. In the context of a pandemic, primary care via telephone and video visits is vital, not only for routine care, but to keep people from flooding the hospitals. Without a focus on primary care, we are neglecting the health of our people.
Although it may seem at times like our contribution is a small drop in the bucket, when the bucket is about to overflow, it is vital to keep every additional drop out.
Lalita Abhyankar, M.D., M.H.S., is a family physician practicing in New York City. You can follow her on Twitter @L_Abhyankar.(twitter.com)
Posted at 01:08PM Apr 22, 2020 by Lalita Abhyankar, MD, MHS