My
friend Mina had a stroke at home while an infectious disease pandemic
raged around her. As a physician, I was blindsided. Not just by her
stroke, but by the collateral damage of this pandemic: delayed diagnosis
and treatment for severe medical illnesses at the cost of trying to
prevent exposure to the virus that causes Covid-19.
Part of the problem is seeing everything through a coronavirus lens.
There are catastrophic risks when doctors and patients wear Covid-19
blinders.
Mina is at high risk for developing complications from Covid-19
because she is 70 years old and has multiple sclerosis and heart
disease. One day her left leg suddenly became weak and she fell twice.
Alarmed, she phoned her neurologist, who told her that her multiple
sclerosis was likely becoming more symptomatic.
Normally, symptoms like sudden weakness in a leg or arm would be
evaluated in a doctor’s office or emergency department with a physical
exam and brain MRI to see if they were due to a stroke or seizure.
Mina’s medical center, however, had recently reported new Covid-19
cases. To avoid exposing her to the virus, her neurologist advised her
to stay home and to monitor her symptoms.
Two days later she developed difficulty speaking and smiling on one
side of her face. With the new symptoms and another call to her
neurologist, we all agreed that she needed an MRI.
It revealed that Mina had experienced a stroke. Instead of getting
treatment right away, which is the standard of care for stroke — “time
is brain” stroke specialists often say — it was only days later that she
received the vital medications, referrals to physical and speech
therapy, and evaluations of her neck and brain.
There are
widespread reports
of fewer visits in emergency departments and doctors’ offices for
strokes, heart attacks, and routine medical care. Across the U.S., 911
calls have fallen by
20% to
35%. Spain has seen a nearly
40% reduction
in emergency procedures for heart attacks during the Covid-19 crisis.
Outside of emergency care, overall outpatient visits for routine medical
conditions are down by
30%, including virtual visits. And in a survey across 49 states, only
7% of primary care physician practices reported scheduling preventive visits as a high priority.
Stroke, heart disease, cancer, and lung diseases — among the
leading causes of death
in the U.S. — have not gone away just because Covid-19 has emerged.
Patients and doctors are potentially missing or ignoring worrisome
symptoms unrelated to Covid-19 and not addressing them. Interrupting
care for patients with chronic conditions can lead to disastrous
outcomes.
While the nation understandably focuses its hospitals’ preparedness
for the surge of Covid-19 patients, much of the pandemic response occurs
in outpatient settings and increasingly through
telemedicine.
Efforts by doctors and nurses to triage patients to the safest settings
to reduce risk of Covid-19 transmission is more important now than ever
before. Many primary care practices have transitioned more than
60% of in-person visits to telemedicine, with
40% of doctors and staff mostly using telephones and
23% using video visits.
Mina’s story, however, reveals an overwhelming unpreparedness of our
nation’s outpatient centers to care for high-risk patients during this
pandemic. Doctors are struggling to decide if our patients’ chances of
surviving are better if they stay home or go to the hospital.
Physicians have been given limited guidance for making the nuanced
decisions required to treat patients who don’t have Covid-19 but who are
both clinically complex and at high-risk for complications if they
developed the infection. The absence of standardized guidelines for
using telemedicine or the infrastructure to deliver care at home can
lead to delayed diagnosis and treatment. Even though Mina had help to
navigate the medical system, she experienced this delay. For others
without such assistance, delays of care can be damaging — even deadly.
Patients’ fears compound these complex decisions. My colleagues and I
weekly receive calls from patients with symptoms that would normally
require an emergency department or office visit. Take Craig, a
67-year-old with a history of heart attacks, who called me to report
that he was experiencing chest pain and was worried about another heart
attack. Under normal circumstances, I would have told him to go to the
closest emergency department. But he refused to go to a hospital under
any circumstances after his friend was diagnosed with coronavirus. These
fears are real, common, and affect patients and their doctors. While
Craig is an engaged patient who proactively called me, giving me a
chance to intervene, I know that there are many others who avoid
communicating symptoms with their doctors out of fear.
Along with uncertainty about deciding whether to risk the possibility of exposing patients to the coronavirus, doctors’
fear of becoming infected themselves
can change how they practice medicine. This anxiety is fueled by not
knowing if their teams can prevent them from becoming ill. In early
April,
58% of doctors and staff in primary care practices lacked personal protective equipment, and
more than 30%
of them expressed frustration with constantly changing or conflicting
guidelines. With little access to protective gear, confusion about who
needs it, and stories of health care workers
getting sicker due to
higher exposure, doctors are becoming more willing to implement telemedicine.
We urgently need strategies for the complex scenarios that doctors
now face to balance care for non-Covid-19 conditions with the desire to
protect their patients from being exposed to the virus that causes it.
Developing new approaches to care for patients in the time of Covid-19
may reduce future waves of collateral damage with losses that could be
as significant those from the virus itself.
Virtual care can help reach many patients, but most medical centers
do not yet have the infrastructure in place to fully support highly
efficient telemedicine. In addition to providing telemedicine-enabled
devices, medical centers must have systems to identify and prioritize
which patients will benefit from them the most. For example, they can
distinguish their patients who are at high risk of becoming sick using
predictive analytic models, may engage in using technology, and could be
taught how to use telemedicine tools.
Even though some
new clinical guidelines
are being released during the pandemic, medical teams require more
guidance on how to implement telemedicine. Doctors can benefit from help
deciding which scenarios warrant a video, phone, or in-person visit.
Remote visits also could be supplemented using home-based lab collection
and home monitoring devices to provide information on blood pressure,
blood oxygen levels, blood sugar, heart rhythms, and perform audible
lung and heart exams.
Even with advanced remote monitoring, some patients will still need
in-person evaluation. Emergency care is essential for patients who are
critically ill, even with the risk of Covid-19 exposure. That is
especially true for patients who face challenges accessing telemedicine.
In a survey of primary care physicians, 72% said they have patients who
are
unable to access telehealth
because they do not have access to a computer, smartphone, or the
internet. These patients may need help learning how to use telemedicine
devices or in-person evaluations such as those available through
hospital-at-home and home-based primary care programs.
Fully connecting with patients who live with chronic conditions will
require the U.S. to bolster its ambulatory infrastructure and financing.
Primary care stimulus packages could help support the expansion of the
hospital-at-home approach, along with home-based primary care and remote
monitoring services. Similarly, an expansion of Medicaid would cover
broad medical care for the newly uninsured and those with pre-existing
conditions.
While it will take time to develop deliberate guidance, the nation
needs urgent action to mitigate patients’ and doctors’ anxiety and hep
remove the Covid-19 blinders to prepare for the collateral damage of
non-Covid-19 medical conditions.
Reshma Gupta, M.D., is an internal medicine physician and medical
director for value and population care with University of California
Health in Sacramento, Calif. She thanks Dr. Reena Gupta for her input on
this essay.
Collateral damage occurs when doctors and patients wear ‘Covid-19 blinders’
