Q&A: How should PCPs approach routine checkups amid COVID-19?
Since the emergence of COVID-19 in the United States, many patients have forgone routine medical visits out of fear of being exposed to the virus.
Primary care practices, in particular, have observed a significant drop in in-person visits. Results of a survey conducted by the Primary Care Collaborative and the Larry A. Green Center showed that 81% of 736 primary care clinicians reported that they have limited their wellness and chronic care visits, and 70% reported that the patients themselves postponed these visits.
The survey also revealed that preventive services are down among primary care practices, with just 5% reporting cancer screenings, 10% reporting adult vaccinations, 12% monitoring cancer survivors, 14% reporting childhood vaccinations and 25% screening for violence and neglect.
Healio Primary Care spoke with Thomas Murphy, MD, chief medical officer of community-based clinics at UT Physicians, the clinical practice of McGovern Medical School at UTHealth in Houston, to learn more about the importance of scheduling in-person visits during the COVID-19 pandemic and the health implications of delaying these visits. – by Erin Michael
Q: How should PCPs approach routine checkups during the COVID-19 pandemic?
A: What’s happened across America and across the world since COVID-19 is that many patients have delayed their care, even for what many would consider routine care. It’s hard to imagine that there are any routine visits nowadays with the multiple comorbidities and complexities of diseases that patients have, so even something as simple as what would be characterized as routine allows the provider — whether it’s a physician or an advanced care practitioner — to review the patient as a whole, not simply one issue that may or may not be particularly relevant during that day. It also provides a great opportunity to fill in gaps of preventive care such as arranging routine screening mammography, colonoscopy, labs and evaluations that seem to have been really minor at the time, but over the 3 months that we’ve been in lockdown, potentially developed into other things. Really, care delayed is care denied, so we need to encourage patients that it’s safe to come into clinics. Physicians are taking more than adequate safety precautions to protect the patient — social distancing, screening patients when they come into the clinics, rapid triage to exam rooms, protective equipment among staff, and providing necessary personal protective equipment (PPE) to the patients. That’s being done routinely across the entire country. It is important that the message gets out that patients need to come in.
The CDC and other centers have issued some preliminary data last week before suggesting that one-third of all Americans have delayed care due to fear of the coronavirus. There’s probably somewhere, at this point, an excess 20,000 to 30,000 deaths in America because of delayed care. We’re seeing all sorts of complications in patients who have arbitrarily stayed home because they’re afraid [of COVID-19]. I was speaking to a surgeon last week, and he said in a normal 6- to 12-month period, he normally does perhaps one or two open cholecystectomies because it’s a very difficult case or the patient has significant or even gangrenous cholecystitis. The week that I spoke to him, he said he’s done three because these patients had not come in; they were minimizing their symptoms and by the time they came in, they ended up with an open cholecystectomy, and obviously a significantly increased stay in the hospital and subsequent risk of complications. We’re seeing the same thing with appendectomies, ruptured appendices, in patients who have stayed home too long. Although that’s not a routine visit, per say, it perhaps could’ve been characterized early on as a routine but more urgent visit.
Q: Which patients should PCPs prioritize for in-person visits, rather than telehealth visits?
A: Although telehealth has been a really nice tool, it’s really better designed for people with nonacute symptoms. Certainly patients with onset of new pain, new significant fevers, shortness of breath, cough, chest pain, and all of those things that really require a hands-on, physical diagnosis, should come in. For patients who are very stable and are scheduled or could be scheduled for monitoring for things such as BP or blood sugar, a weekly, biweekly or monthly telehealth visit to inquire as to the status of their overall health is fine. Some rashes are perfectly OK to deal with over the phone. And certainly, patients who you’ve established a long-term relationship with and know their overall health status can at least be preliminarily managed by telehealth. The video link is critically important in assessing whether they should come in for a visit. Prioritization is not something that will have a defined algorithm for some time. Someone will undoubtedly try to develop one, but it’s going to require a little bit of the art of medicine, more so than the strict cookbook type of approach. [Telehealth] is a very important part of our future in medicine going forward. We’ve been using it here at the Texas Medical Center to follow-up on pediatric surgery cases. When the patient has had surgery, we can gather significant amounts of information from a video inspection with a laptop or cellphone [visit] of the patient remotely, rather than making them potentially have to drive 75 to 100 miles.
Q: Why are in-person routine visits particularly important for children?
A: Unfortunately, Texas is a hotbed for the anti-vaccination movement, and the more children are kept out of clinics for routine visits, the lower the immunization rate becomes. For diseases that have, in general, been in good control in the country — measles, mumps, rubella, rubeola — we can’t afford to allow herd immunity to drop across the nation and have these viruses re-emerge. Measles is a deadly virus; we can prevent it with vaccination. The critical importance, particularly for children, is to eliminate or potentially eliminate the emergence of these diseases that were almost pandemics in and of themselves 50 to 60 years ago.
Q: What safety precautions should PCPs take for in-person visits during the COVID-19 pandemic?
A: We need to potentially assume that all patients who we see could be asymptomatic carriers, and protect both the patient and the health care provider. We know that perhaps 35% to 40% of patients who develop COVID-19 have no symptoms or minimal symptoms that they’re not aware of. I think there should be a task of assumption from the health care provider’s standpoint that they may be seeing a significant number of patients who have been infected. So, A: Protect the patient, and B: Protect the provider. This includes wearing masks, social distancing, wearing gloves and sterilization of equipment between patient uses. Here in our community-based clinics for UT Physicians, if we see a patient with potential symptoms of COVID-19, or a fever, or we’re just uncertain, the provider is in full PPE, the exam room is completely cleaned at the end or the visit and the room is left open, unused, for 1 hour. That is not always possible in many of the smaller sites, but certainly, housekeeping practices — cleaning the rooms between use and wearing either full or modified PPE when you’re seeing patients — is reassuring both to the patient as well as to the health care provider.
Q: What are the long-term implications of patients forgoing routine in-person visits during the COVID-19 pandemic?
A: Many of the virologists and epidemiologists are clearly anticipating a second wave of infections of coronavirus at some point later this year. What not many people are talking about, but have started discussing in smaller groups, is the effect of delay of care and the excess death rate that’s occurring — the women who have put off having mammograms and patients who have put off having colonoscopies and for whatever reason, never get around to having it done again, possibly because they’re one of the 30 million people who lost their jobs and subsequently lost their insurance. If you look at that entire cohort of 30 million people, there’s a huge number who are going to get cancer who potentially could have been screened. There’s also a massive backlog of individuals who have cancer at this point in time, that by the time screening does occur — whether that’s 3, 6 or 9 months down the road — instead of being in a position where it is relatively easily treatable, it becomes a much more seriously aggressive problem that potentially is going to have a very unfavorable or even fatal outcome. Really, delayed care in the 21st century is denied care.
PCPCC. Quick COVID-19 primary care survey. https://www.pcpcc.org/sites/default/files/news_files/C19%20Series%2010%20National%20Executive%20Summary%20with%20comments.pdf. Accessed May 26, 2020.
Disclosure: Murphy reports no relevant financial disclosures.