• DPC and COVID: Looking Back as We Move Forward

    The COVID-19 pandemic isn’t over ― not by a long shot ― but we nonetheless seem to have eased back into the pre-pandemic rhythm of working, seeing family and cautiously exploring public spaces. In the initial shock of being so close to others, I wonder, as I smile politely at strangers and see their reflexive, unmasked smiles in return, if those around me really are vaccinated, or if ― like 53% of eligible people in my community who are not ― they’ve simply abandoned their masks, tossing aside the latest public health guidance right along with them.

    The moment still doesn’t quite feel right ― like putting a shoe on the wrong foot ― but we all seem to want to force COVID to be over. As a society, we want to be past it. We want to move on. So, it seems only natural to take a step back and reflect on what the past year and a half have brought us. Specifically, it’s worth reflecting on how our little direct primary care clinic is doing.

    The short answer: We’re doing well.

    When most of the health care world closed its doors to in-person visits in March 2020, we flung open all of our modes of communication. We sent out routine emails updating our patients on what was happening. We invited them to continue to schedule phone and video appointments, just like they had always been able to. We encouraged them to send us messages and connect via email.

    And our patients stuck around; our revenues remained remarkably stable. We didn’t have to cut back on staffing, and we were able to keep everyone employed at the same level they’d always been.

    But as time wore on, everyone started losing patience. Our patients were frustrated, and we could see their emotional resilience fraying. We had always invited open communication and unlimited visits, and we watched patients who didn’t usually suffer from anxiety or depression schedule visits to just talk through their exhaustion, insomnia, fatigue and the like. The line between work hours and personal time began to blur for clinicians and staff, and boundaries that we had worked so hard to establish melted away, disregarded in the stress and anxiety of responding to COVID.

    By the time the vaccine was released ― with the unfortunate politicization surrounding it ― we were acutely aware that our patients had reached the limits of their endurance and their resilience was all but gone. They were at their wits’ end. And so were we. Although we pride ourselves on customer service, we began to feel the strain, too. A significant portion of our patients were less forgiving, and they let us know. We apologized time and time again for the frustrations that COVID was imposing on everyone’s day to day routines, but even we wore thin.

    As of February 2021, all of our staff had been fully vaccinated. But by then it had already become abundantly clear that everyone was in need of a vacation, so when our nurse asked off for a long weekend in January, I insisted she take the whole week.

    As winter thawed into spring, and now with the full-throated blaze of summer setting in, we’ve started to reestablish those oh-so-important boundaries. No work or responding to patients on the weekends; we need to recharge. Appointments must be scheduled ― no impromptu calls or pop-ins; we have to be able to give our full attention to those already in front of us. No more catering to those who have been verbally abusive or who have taken their exhaustion out on us; given that we all only have so much energy, we need to focus on providing excellent care to those who value what we do and who work in partnership with us to achieve the best health possible. No more delaying vacations; we’ve stepped up our hiring so that each employee can get a well-deserved break to take time fully away from work.

    As a result of this reset, we’ve seen ― for the first time since the onset of COVID ― a decline in our revenue and patient population as some of those patients have suggested that they are getting less from us. And actually, that’s OK. Those who are still around are those who are committed to their health and to the model in which we practice. Excellent primary care is based on longitudinal relationships, and as we see members leave our practice, we’re reminded that those who are still with us are here because they get the value of primary care. Moreover, we’re still strong enough that everyone on our staff, including the new additions, continues to have job security and full pay, just like before COVID.

    This past year has been hard on everyone. But given the flexibility inherent in the small size of our clinic, our ability to adapt, and our commitment to an economic model that incentivizes long-term relationships, our experience was much smoother than what I’m seeing with my peers in the traditional, insurance-based system. As we all move forward, with our polite exchanges of unmasked smiles, it may be worth considering whether primary care, as a whole, would benefit from moving toward a system a bit more like direct primary care.

    Allison Edwards, M.D., founded and cares for patients at Kansas City Direct Primary Care; provides locums coverage at rural hospitals in Missouri, Kansas and Colorado; and is volunteer faculty at the University of Colorado and the University of Kansas. You can follow her on Twitter @Dr_A_Edwards.

    Read other Fresh Perspectives posts by this blogger.



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