It’s suddenly getting really crowded again.
Since early March, when the pandemic really took hold and started to overwhelm our health systems, we canceled or rescheduled most if not all of the regularly scheduled appointments, and for the most part our practice has been pretty empty.
As the practice site for 30 clinician educators, full-time faculty members seeing their own patients and supervising residents, and for the 130 internal medicine residents doing outpatient ambulatory block rotations and continuity clinic, we usually had about 250 to 300 patients a day come through our practice. But during the COVID-19 pandemic, in-person visits for anything other than this disease slowed to a trickle.
We converted most of our routine care to video visits or telephone care, helping our patients stay in home isolation, managing hypertension and asthma and diabetes and migraines and depression and anxiety and low back pain over the phone or on a video visit, refilling 3 months of medicines at a time to keep patients from even having to travel to the pharmacy, and putting off labs and routine healthcare maintenance and physical examinations as much as possible. We were even diagnosing and managing milder COVID-19 at home, getting scores of patients through their illnesses without them ever coming to the hospital.
Office Visits Only When Necessary
In the peak of the pandemic, we occasionally grudgingly had to bring a patient into the office, if they absolutely positively needed to be seen in person. Sometimes a video visit wasn’t enough, and we really needed to do a physical and see it with our own eyes, feel it with our own hands, hear it with our own ears. Sometimes we needed a lab, an EKG, a chest x-ray — or more. But mostly our schedules were empty, our waiting rooms quiet.
For these past few months our cough, cold, and fever (CCF) clinic, where we were seeing and triaging suspected COVID-19 patients, was the only busy part of our practice. Most of the rest of our providers were redeployed to telephone care and video visits, with a few folks standing by for CCF clinic, and to see any necessary in-person visits for other medical issues.
At the peak of the crisis, we had established a busy video visit practice far exceeding our expectations, and were seemingly very safely and effectively remotely taking care of the needs of so many of our patients. Then, as COVID-19 tapered off in New York City, and we initiated the process of restarting our practices, we began to offer limited appointments in an effort to bring patients in who needed to be seen, while still maintaining social distancing and avoiding overwhelming our facility.
Lines Snaking Down the Hallway
As I described before, we spread out and staggered scheduled appointment times, eliminated seats in the waiting room, created no-touch pre-registration, all in an effort to minimize contact between patients and staff as well as patients and each other. All our care is now provided primarily in the exam room, from soup to nuts, from vitals to taking the history to the physical examination to phlebotomy to EKG’s to vaccinations and other needed treatments. But as we’ve started to open our doors again, it seems the pent-up demand has proven to be a little too much.
The other day, the line at our registration window snaked all the way down the hallway, curled back on itself again and again, until everyone was really pretty much on top of each other. Our waiting room, even with most of the chairs removed, was way too packed, with a number of people standing around waiting for their appointments. Our providers were also having trouble with the new system, with getting the hang of the new efficiencies, coordinating labs and vaccines and EKG’s in the room, as well as taking some extra time to catch up with their patients.
Everybody has described that much of the visit is spent exploring how people have fared through the pandemic, how their family is doing, how they’ve been affected, what it’s been like for them. So much anxiety, so much depression, so much PTSD. Quarantine fever. Twenty-minute visits have stretched into 30 minutes have stretched into 40 minutes, and more.
And strangely — or maybe not so strangely — the demand for video visits seems to have plummeted. As much as our patients have told us that they liked doing video visits during the pandemic, and that the providers similarly felt they were providing good care for the most part, selling patients on these visits now, with in-person visits possible, has become harder and harder. During the peak of the pandemic, many of our providers were completely full up for a practice session with video visit after video visit, but now this seems to have slowed back to a trickle.
We’ve also been making an effort to bring our sickest and highest-risk patients back to the practice as quickly as possible, doing outreach to each provider’s most needy patients, and this has only added to the volume of complex patients that need to be brought into the practice, seen and evaluated and taken care of, before sending them back home.
More Space, More Time
So what’s the solution? How are we going to be able to maintain social distancing, keep our patients safe, keep our staff and providers safe, and still efficiently take care of everybody we need to take care of?
We need more space, we need more time, we need more exam rooms, we need more resources, and we need more people convincing patients that a video visit may be enough at this particular time, that maybe this isn’t the time or place for them to come in — not just yet.
Instead of cutting back on resources, we need to build them up, add them on, rent some space, add on members of the team to help provide patient-centered continuous care beyond the need for coming into the office and for physically being here in the practice.
Because if we return to normal, if we go back to doing things the same old way, I fear that this virus is going to creep back into our midst, and start once again to spread like wildfire through our communities. Now is the time to do it better and smarter — not wait until things get bad again before we have to slam on the brakes and need to close our doors once more.
Fred N. Pelzman, MD, of Weill Cornell Internal Medicine Associates and weekly blogger for MedPage Today, follows what’s going on in the world of primary care medicine from the perspective of his own practice.
Last Updated July 13, 2020