The Next Covid “Surge”

As a primary care physician, I have observed a record number of cases flooding into our clinic system in the past month, and they have nothing to do with the virus. Well, I guess indirectly, they do. It’s a phenomenon I see time and again and it plays out something like this:

A 53 year old patient with several chronic conditions is on my schedule for “physical and follow up.” After I enter the room and greet her, she says, “I’m fully vaccinated now! What a relief! I thought I should come back for my yearly physical.”

Last time I saw her was pre-covid, almost a year and a half ago. “Oh, that colonoscopy you ordered for me? I didn’t get it scheduled before covid hit. And I am overdue for my mammogram, because, well, covid. I also need all of my medications refilled [22, if you include vitamins and supplements] and I have a list for you as well.” I scan her list of concerns and it includes knee pain, back pain, insomnia, increased anxiety, and GI distress among other things. All of this in the time frame of a 30 minute appointment, which in reality is more like 20 minutes with the doctor, the rest is for vital signs, rooming, and check out.

In the end, I took care of the med refills, the immediate symptoms/concerns, and had her reschedule the yearly physical and routine tests. But afterwards, I pondered if this was the right thing to do–after all, her health maintenance was delayed to begin with–and now, I had created two appointments instead of one and my schedule is already booked weeks out. I was also simply flustered and frustrated by the sheer amount of work that fell into this office visit, which is becoming more like every single office visit. All due to, well, covid. A four hour block of clinic is taking me five hours to complete, and there are only so many hours in a day.

After this appointment, I pondered how we are ever going to “catch up” as a health care system. I’ve heard the same thing from my colleagues that are surgeons; they are still in the process of rescheduling elective procedures that have been delayed, postponed, or cancelled. But as I once pointed out to a patient, there really is no such thing as elective surgery, unless you include cosmetic surgery. No one recommends a patient go under the knife unless it is absolutely necessary. That knee surgery or hip replacement or gallbladder removal means we’ve exhausted all conservative measures (including medications, injections and so on) and an operation is needed as a last resort.

To help us offload the system, many approaches could be tried (but sadly I doubt they will.) Each patient appointment could be extended in length to allow extra time for catch up, but administrators won’t like that, because we see fewer patients in a clinic session. We could delegate routine tests such as colonoscopy or mammogram by authorizing standing orders for patients that are due. However that would require system support from a nurse or other clinic staff member to reach out to the patient and get them scheduled; our nursing staff right now are stretched too thin and half are still working from home. There is a similar process called pre-visit planning whereby a patient is contacted prior to any appointment and any health care maintenance that is overdue is ordered ahead of time, including screening tests, immunizations, labs. This was a true godsend that again, went away during the pandemic due to staff reductions and furloughs, and simply never came back. Each time I bring up, “Whither pre-visit planning?” I am met with blank stares.

I don’t have any easy answers, here, but just as the health care system had to “gear up” to take care of covid patients, we now need some new approach to gear up and take care of the rest of the population whose physical health (and mental health) has been neglected for the past 15 months. Just like covid itself, it is going to require investment of time and resources. It is sadly the next covid surge, the 5th Wave if you will, as we see patients of all types rushing in, returning to the system to restore gaps in their care.

I wonder how we could “flatten the curve” in this situation? Ideas welcome.

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