The COVID-19
coronavirus is in the U.S., and what it will do here has yet to fully
be seen. I suspect it will not have a high lethality among otherwise
healthy individuals. But I’m no virologist and time will tell.
I do have a couple of observations.
First, we are already working with a shortage of physicians. We don’t
have enough primary care physicians or specialists. Until Medicare
(which funds residency training) agrees to increase the number of
physicians trained after medical school, we will continue to have a
shortage. Sadly, we have a fair number of young physicians who invested
money and time in medical school but who can’t find residency slots. We
refer to them as “graduate physicians,” and we should find ways to use
them as we use nurse practitioners (NPs) and physician assistants (PAs).
They have more didactic and clinical education on graduation than new
NP and PA graduates have.
This matters not only because we already have too few physicians, but
because an epidemic could leave us short of more physicians, who become
afflicted with the disease. Reports out of the People’s Republic of
China suggest that it has been hard on physicians, who are not only
getting infected and sometimes dying but also completely exhausted from their work. (Additionally rendering them more susceptible to infection.)
Another issue we have is that it can take months for a physician to
work in a hospital (to be “credentialed”). Having done some
credentialing lately for a new job, I can attest. A physician has mounds
of paperwork to fill out and has to send copies of every kind of
certification and verification imaginable, even if they’re already on
file from a previous period of employment. Said physician may have to
get a new state license, which is often as daunting (or more so) than
what hospitals require.
Further, he or she must send driver’s licenses, passports, reports of
previous lawsuits (already available online), references, sometimes
fingerprints, and even explanations of more than 1 month without
consistent work in medicine. While that may seem like a good idea to
some, it can make it very difficult to move physicians to new locations
in a pinch. Or in an epidemic.
We need a better way to do this in times of crisis, and I suggest
that there should be a central emergency credentialing system maintained
by each state, which could be agreed upon and shared. Thus, if (for
example) all the physicians in a small hospital in Alabama were stricken
ill, physicians from Pennsylvania could be allowed to come and work,
and this could be accomplished with a click and a file transfer.
States are already working on interstate licensing; that’s great. We
also need inter-hospital credentialing, so that physicians who have the
time off, or who are semi-retired (or fully retired) can get into the
fray.
As an aside, we should develop a better, more uniform way to use
those graduate physicians I mentioned above who would be more than
willing to fill in and learn, and get paid, in times of crisis.
Second, hospitals during flu season are already at capacity. If we
have an outbreak from the novel coronavirus, patients from primary care
offices, clinics, and urgent care facilities, as well as self-triaged
concerned citizens, will show up in hospital emergency departments in
large numbers, potentially serving as hubs for spread of infection.
The answer to every question in an office or clinic, on a
phone-triage line or telemedicine site simply can’t be “just go to the
emergency room,” because the ER will be beyond capacity, as will the
inpatient side of the hospital. Furthermore, what might be a simple head
cold could well become worse if exposed to the sicker patients in the
ER waiting room and treatment areas.
This might require some modification of the Emergency Medical Treatment and Labor Act (EMTALA),
the “anti-dumping” law that mandates that everyone be seen regardless
of ability to pay. Not in order to extract money but in order to
sometimes say “you aren’t dangerously ill, we don’t have time or space
to see you, go home and avoid crowds, and come back if you’re worse.”
Finally, we need to support America’s small and medium hospitals
outside urban areas. They could serve as a relief in times of great
national distress. Rest assured, in a pandemic, the big hospital
teaching centers will be full and more than full. Strategically, America
needs the option of vibrant, well-staffed smaller hospitals in suburban
and rural communities. Not only for epidemics but for natural
disasters, terrorism, or open warfare. (No, I’m not paranoid. Peace and
safety are rarities in history.)
I pray the COVID-19 coronavirus dies a rapid death. But if it
doesn’t, we have work to do. We just don’t have the staff or capacity
we’ll need in case it continues its inaugural journey around the world.
Edwin Leap is an emergency physician who blogs at edwinleap.com and is the author of The Practice Test and Life in Emergistan.
https://www.medpagetoday.com/blogs/kevinmd/85210
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