Family Medicine in time of COVID
February 28, 2021
I haven’t read much about family doctors since the pandemic began. I have regularly consumed news items that recognize intensivists, pulmonologists, hospitalists and ER physicians. I have been pleased to see spontaneous efforts that express gratitude for heroic nurses, emergency medical technicians and respiratory therapists. I have appreciated minor nods to delivery workers, morticians, checkout clerks, waiters and several other occupations. But I haven’t seen or heard a word about family doctors in the popular press. I do not wish to diminish recognition of the above workers who have toiled close to the virus with courage and determination. But I have wondered about my colleagues in family practice.
After I retired in 2013 I stayed in touch with my specialty by teaching medical students and attending some family medicine conferences. I backed away from those activities as I began writing a biography of my inspiring mentor in 2018. When the pandemic began, visitors were discouraged from dropping-by the residency program due to viral transmission concerns. So everything that I heard about my specialty was via the national media. And I heard nothing.
Because I know the character of the people in the specialty, I assumed their work was continuing and likely increased. So I interviewed a few family doctors working in diverse practice types and locations planning to report their experiences in a blog. After a very few interviews I realized that one brief essay could not adequately relate this story. I heard about their work, their stress, their education, their suffering and their ongoing challenges. I heard so many compelling stories and themes that I now begin a series of short articles to continue my chronicle of family medicine.
I start with their current work environment. Family doctors and their staffs are very busy. We have heard much about the sick and dying people who have maximally strained the healthcare system. But we gloss over the reality that only about 2.5% of people with COVID 19 infections die and only about 20% of the afflicted go to hospitals. Most people who survive hospitalization continue to need significant medical services. Those who do not require hospitalization may still seek a good deal of medical attention even if they have no symptoms. Others who are not infected suffer with fear when minor symptoms rouse their suspicions and fears. Even those who have little risks and no symptoms are struggling with isolation, anxiety and depression. Thus there is a great caseload that is left to workers who do not make headlines.
Many types of doctors and health workers have contributed to the care of this cohort. But primary care doctors have the most versatility and dedication to care for the wide range of problems that persist after the celebrated hospital discharges. I heard several compelling stories including some that I had not imagined as I listened to working doctors. The novel disease encompasses a broad spectrum. People with suggestive symptoms need a diagnosis. Newly diagnosed patients require a good deal of support, guidance and monitoring. Symptomatic patients require careful reassessments to determine if hospital care is indicated. People discharged from hospitals are far sicker than met criteria for hospital discharge prior to the pandemic. Doctors stationed in hospitals generally do not provide follow-up care after their patients leave the hospital. Almost all of the outpatient doctors that I interviewed told me of patients who were still requiring a very high flow of oxygen when they were deemed well enough to go home. One said, “We used to wean most patients off oxygen prior to discharge. Now I am managing patients who still need 10-15 liters of oxygen per minute to maintain an acceptable blood oxygen level (SpO2 above 90%)”. Much of this roughly outlined work is done by telephone with or without visual telehealth connections. Some remote decisions are difficult and home visits (house calls) are needed. In larger healthcare organizations, some family doctors and their staff members have been redeployed to toil in the overwhelmed highly publicized areas of health services. The downsized provider pool is left to handle the workload that has persisted despite the person power reductions. A number of new primary care problems have arisen while others have exacerbated. Doctors are working hard recommending vaccinations, mask wearing and social distancing to their skeptical patients. One blessing is that influenza and other minor respiratory infections have magically disappeared. One of my selected contacts exclaimed, “We haven’t just seen less flu, we have seen NO flu!” Despite that one side benefit, family doctors and their like are very busy!