"There is no shine without the grind. Champions are made when the stands are empty. Make sure you understand that."
-- Clemson University football coach Dabo Swinney
We are in the dog days of summer. This is the period in July and August when Sirius, the Dog Star, appears to rise just before the sun. The ancient Greeks thought this hottest part of the summer was a time likely to bring fever or catastrophe.
Earlier this year, many were confident that COVID-19 would meet its match in the intense heat and humidity here in the south. Those hopes have since evaporated like the morning dew.
In addition to providing outpatient care, our family medicine clinic in southwest Alabama also serves the local nursing home and hospital. Another nursing home in the rural county south of us was hit early in the pandemic when one of its employees contracted COVID-19 and died. The virus swept through that nursing home like a wildfire, leaving death and destruction. Knowing that the nursing home in our own county was our point of greatest vulnerability, the family physicians and nursing home staff quickly put a firewall around it, limiting contacts and visitors, screening employees and patients early, and aggressively social distancing as much as possible. These measures have served us well. Not a single patient has tested positive for or died from COVID-19.
However, now that the number of positive cases is increasing astronomically in the community, we are beginning to have employees test positive. We are realizing we can keep the nursing home out of the community, but it is very difficult to keep the community out of the nursing home.
I cannot imagine what would've happened in this area if our small rural hospital, which has struggled financially to survive for all of the 36 years I have practiced here, was not serving the community. Its impact is felt not only in this town of 5,000 souls but also in the rest of the county and in surrounding counties. Early on, we aggressively protected our employees with personal protective equipment and screened patients. When the national reference lab timeframe for testing results extended up to five days, we found a regional lab that could continue to give us a 48-hour turnaround. Now we are even doing the rapid test in situations when it is critical that we know that information immediately.
Closing our family medicine clinic was never even a consideration. We have been open every weekday during the shutdown and reopening. Not a single employee at our office missed an hour of work because of layoffs. Everyone received their normal paychecks. Closing our office would have funneled more patients into the emergency room. We felt like we were better prepared to protect our patients and practice social distancing in our office than they could in a crowded emergency room.
Telemedicine sounds like a perfect solution for this situation, but in a rural area where you can still hear the question "What is the internet?" the number of patients for which the service is helpful is limited.
However, we have found our early investment in chronic care management to be a lifesaver both for our patients and our practice. These CCM patients are the ones who most need to be monitored to make sure they are getting their requirements met, including drug refills, food and social interaction with our office nurses. In addition, it has brought in thousands of dollars every month to our practice. It would've been hard to keep our doors open without that reliable source of income. Chronic care management gives us a financial floor month after month, which is important to the survival of our practice even in the good times.
These are unusual times. I have had the opportunity to do short-term mission work in a hospital in Kenya and in prisons of Zimbabwe. I saw everything from tuberculosis to measles to tetanus to malaria. During my time in those countries, I took prophylaxis to keep from getting malaria. But now, in addition to the normal, overwhelming concerns we face every day -- including the financial strain on my practice -- I wonder if I will be the vector to spread COVID-19 and bring potential death to my loved ones, coworkers and patients.
Now that things have opened back up, patients seem to have little hesitation about coming back into the office – even though the number of COVID-19 cases continues to skyrocket. In the past month, I have diagnosed two patients with colon adenocarcinoma who were completely asymptomatic but able to come in for their screening colonoscopy. One of them, during the workup for their cancer, recently was found to have a pulmonary embolus, so I started him on anticoagulation. We will never know how many people we lost during the time when office visits decreased and patients failed to come in even when they were symptomatic. Primary care and prevention remain essential even in this unusual time. That also means taking a little extra time during sick visits to look at routine preventive care, especially immunizations.
COVID-19 is novel. It is new. We've not seen anything like this before. But in the dog days of summer, it's starting to seem really old. What we once hoped would be a sprint, or maybe an intermediate jog, has become a marathon. Most of the "heroes" signs have disappeared. It feels like the stands are empty. It's starting to become a grind. But nobody is better at grinding it out than family physicians. We ground our way through college, then medical school and residency. And we did that knowing there would be a day when the sun would shine again.
Steven Furr, M.D., is a member of the AAFP Board of Directors.