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.