By early March, it became clear to Andy Fine, MD, FACP, that even the precautionary policies his practice had already implemented couldn't guard against COVID-19. The staff was screening patients by phone before they came in, asking about any cough and fever. They also posted a sign at the office door, requesting that any patients with those symptoms use a secondary entrance.
“But we'd have patients come in that had abdominal pain or a sore shoulder and then they'd start coughing,” said Dr. Fine, an internist in Littleton, Colo. “And we'd say, ‘Wait a second, you said that you didn't have a cough.’ And they'd say, ‘It's no big deal. It's minor.’”
Physicians interviewed this spring said they frequently circled back to the day when they realized that their practice life was about to dramatically shift. They talked about their first patients with potential coronavirus symptoms, when they knew that they would have to close their physical doors, and the rapid-fire move to treating most patients through a video screen.
Several months out, it's still uncertain to what degree the pandemic will reshape the practice of medicine in the near term, and perhaps much longer. Temporary changes in reimbursement by federal officials have enabled physicians to treat patients through telemedicine or even with a phone consultation at similar rates to an in-office visit. As small businesses, physician practices have also been eligible for loan relief through the Payroll Protection Program (PPP), under which a loan can be forgiven if employees are kept on the payroll for eight weeks.
But the pandemic, depending on how long it persists, could potentially threaten the health of some patients if they leave chronic or other medical ills untreated for too long, in addition to threatening the longer-term financial viability of practices. Outpatient clinical visits, which had declined nearly 60% by late March, had rebounded somewhat by mid-May but remained roughly one-third lower than prepandemic days, according to an analysis published May 19 by The Commonwealth Fund. Declines in health care revenue started impacting jobs from the start, with 1.4 million jobs shed between March and April.
As of mid-May, Dr. Fine said that his patient volume was down about 50% compared with January and February despite offering telemedicine visits. His practice, which numbers 25 employees including six clinicians, did receive a PPP loan. But that just buys two months, said Dr. Fine, who also noted that payroll costs only comprise roughly two-thirds of the total cost of running his practice.
Yul Ejnes, MD, MACP, a Rhode Island internist who works in a five-physician office that is part of a larger multisite practice, reported in late April that his patient visits had dropped by roughly one-third. That financial strain, particularly for independent practices, may unfortunately accelerate the ongoing trend toward acquisition by larger health systems, he said. “We are not talking about an environment where practices were awash with revenues to begin with, at least in primary care—this is a really big hit.”
Plus, simply opening the practice doors won't prove to be a financial panacea, given initial public health guidance to continue to foster social distancing, Dr. Ejnes noted. “You can't have wall-to-wall people sitting next to each other waiting for whatever periods of time when you reopen,” he said.
In March, as people were encouraged to shelter at home and only venture out for essentials, preventive services plummeted. By late April, the number of people getting screened each week for breast, colon, and cervical cancer dropped by 86% to 94% compared with the rates prior to Jan. 20, according to an analysis that health information technology company EPIC conducted of its own data. Orders for measles and other pediatric vaccines nearly evaporated from mid-March through April, according to a Morbidity and Mortality Weekly Report article published May 15.
As stay-at-home orders were issued across the country, physicians reported a swift transition to nearly all telemedicine, a relatively new way of practicing for some. In early March, Priya Tandon, MD, FACP, quickly read up on televisits and ordered a camera for her office computer in Colchester, Conn.
As she watched the news reports, the internist and solo practitioner became increasingly edgy that she couldn't keep her patients and staff safe. On March 19, Dr. Tandon asked her staff to call all the patients scheduled for that day and tell them that the practice was immediately converting to telemedicine. She sent an email to her panel of patients, which also directed them to her website, where she posted video updates for more information.
Alice Fuisz, MD, MACP, a Washington, D.C., internist, said that she also moved quickly to telemedicine starting in mid-March and halted all in-person visits by month's end.
As of mid-May, she could only recall a few patients she had examined in the office, including a woman with rectal bleeding. Since the patient was immunocompromised, she preferred to get her lab work done at Dr. Fuisz's office rather than at a community lab. While she was there, Dr. Fuisz performed a quick exam to confirm her tentative diagnosis that the bleeding was caused by hemorrhoids.
But Dr. Fuisz worried about the patients who were pushing back annual physicals or follow-up visits, preferring to conduct them in person once the office doors reopened. While the vast majority of diagnoses can be made with a detailed medical history, she described a few instances—such as feeling a mass that proves to be thyroid cancer—where an exam can make the difference.
“I worry that if this goes on indefinitely with the trickiness and the risk of bringing people into the office, we are going to miss the potential to diagnose things because we're not seeing people in person,” Dr. Fuisz said.
Sorting out COVID-19
It had already been a bad influenza season, one of the worst that ACP Member Leslie Murphy, MD, had seen. Then reports of COVID-19 appeared first in China, followed by other regions of the world, including the U.S. Dr. Murphy, who practices in Pinehurst, N.C., near Raleigh, said that she and her staff became increasingly vigilant starting in mid-February.
They removed the magazines and puzzles from the waiting room. They designated one room as the sick room and asked anyone with flu or respiratory symptoms to wait in their car until that room became available. Staff took their own temperatures before coming into the office each day.
“We just would become more paranoid all of the time about who would come in, what they could have, what we could be exposing them to by having them in our office,” Dr. Murphy said. “I had never thought of my office as a dangerous place.”
In early March, a patient who had recently returned from a month-long stay in Vietnam called Dr. Murphy's office reporting respiratory symptoms. After confirming that the virus had been detected in regions where the man had traveled, Dr. Murphy and her nurse reviewed a webinar about personal protective equipment before dressing in multiple layers, including double gloves and masks. They asked the man to stay in his car and collected the swab for the influenza test through a window. (Read more about primary care visits conducted in practice parking lots.)
“When I went out, he was very nice about it because anybody else might have thought I was insane,” Dr. Murphy said, laughing. The flu test proved to be negative. Ultimately, public health officials decided that the patient didn't need to be tested for COVID-19 but recommended that he self-quarantine, she said.
Once it became clear that the virus was circulating, Dr. Ejnes said that the multisite practice he's part of decided to convert some of the clinics typically used for after-hours care to treat patients whose symptoms couldn't be addressed virtually. Because fewer patients were seeking out medical care overall, in the end they designated one site for patients with respiratory symptoms that might be COVID-19. Clinicians at a second site provided other types of in-person care, such as abdominal pain that needed a physical exam, he said.
As of late May, Dr. Ejnes said that four of his patients diagnosed with the virus had needed to be hospitalized, but the care of most of his patients with COVID-19 could be managed at home. The multisite practice had organized a COVID-19 team in which staffers, such as medical assistants or care navigators, touched base daily with patients who had tested positive. If there were any red flags or concerns, a physician would get involved, he said. “The majority of patients have not had to set foot in a health care facility.”
Reopening amid uncertainty
The duration of the pandemic could alter the extent to which patients seek out care, according to a viewpoint piece published online May 1 by JAMA. Will some patients, the authors asked, decide that certain services are not essential and no longer return for them? Or, they added, “Will the rush of patients who do seek services lead to delays in scheduling and the rationing of capacity, both of which may lead patients to abandon valuable treatment out of frustration?”
Dr. Fuisz has established a process for no-touch lab work and created an online video with her staff to educate patients on how it works. This spring, she also started to work back through appointments to determine which patients were due for their annual physical or a follow-up visit. The patients were then contacted through the patient portal to alert them that the visit could be completed virtually.
Dr. Ejnes's practice has been sorting through the electronic health record to flag and call vulnerable patients, such as elderly individuals with diabetes and chronic obstructive pulmonary disease, “to check in to make sure that they're OK, and to let them know that we're still there,” he said. “We don't want to have to deal with a second wave of chronic illness that's out of control after the first wave of coronavirus.”
Resuming in-person visits raises challenges not only in terms of keeping patients and staff safe but also in how to remain financially viable if practices operate below their prior capacity, Dr. Ejnes said. To limit the number of patients in the waiting room, they could be moved more often directly to the exam rooms, he said. But if there aren't sufficient exam rooms, what then?
One option would be to extend office hours to treat a similar number of patients as previously, Dr. Ejnes said. But then practices would have to pay for the additional staff time. Another approach would be to keep the same number of hours, but treat some patients by telemedicine, an option that's only feasible if reimbursement remains on par with in-person visits, he noted: “A lot of different permutations that aren't pleasant no matter how you look at it, in terms of being able to get back to what we've been doing.”
As of late May, Dr. Ejnes hadn't yet started seeing patients in the office, and his immediate group of five physicians hadn't settled on a precise time and approach to reopening, although they hoped it would be some time in June, he said. Dr. Fuisz didn't foresee bringing in patients routinely for in-person exams until at least September, although the no-touch lab work will continue. By September, she might pursue an approach that offers a telemedicine visit first, followed by an in-person exam if needed, she said.
Dr. Tandon also extolled the usefulness of telemedicine visits, which she intends to continue to some degree if federal officials don't reduce reimbursement. Some video visits can be quite efficient, such as the diagnosis of a rash, and save patients the aggravation and risk of making a trip to the office, she said. “We live in the Northeast; we sometimes have six feet of snow outside, a lot of ice.”
But Dr. Tandon, who as of late May was still using about 90% virtual appointments, echoed other physicians who worried about how late 2020 might shape up, with a potential second surge of COVID-19. “What are we going to do in the fall when there's flu season overlapping all of this too? That's a huge question,” she said, adding that she hopes that reliable rapid-fire diagnostic testing will be available by then.
Even when practices restart in-office care, it's unclear how many patients will return, Dr. Fine said. Some might continue to delay getting any care until they require emergency treatment beyond what an outpatient practice can provide, he said.
“The internist is trained in having expertise in complex medical management of patients that are older and have multiple medical illnesses,” Dr. Fine said. “Those are the same exact people that are at highest risk of not only getting the disease [COVID-19], but getting a severe form of it. So how could you feel comfortable going to your internist, knowing that you're actually putting yourself potentially in harm's way?”