Pickup truck medicine: saving primary care during Covid-19

As the Covid-19 pandemic burned through Chicago, New York, Detroit, and other large U.S. cities this spring, residents serenaded and applauded hospital health care workers. Rightly so: They were doing amazing, high-risk, and innovative work. We should also have been celebrating primary care physicians, who kept finding new ways to continue caring for their patients during times of lockdown and hardship, often putting themselves at risk of being infected with the coronavirus.

I interviewed several primary care doctors about how they cared for their patients, themselves, and their families during the first few months of the Covid-19 outbreak in the United States. All of them work in New York state, which was one of the hardest-hit regions in the country during the March, April, and May course of the pandemic. As a standard part of my research, I always use pseudonyms when telling the stories of the people I interview.

There is Maddie, the mother of two young children who works for a rural safety net clinic in upstate New York, garbed from head to toe in personal protective equipment jumping into the backs of patients’ pickup trucks parked in the clinic lot to perform clinical examinations because the patients aren’t allowed inside with their symptoms. Delivering difficult care, like helping patients with opioid addiction, through telehealth visits. Washing her work clothes in a separate laundry each night to keep her family safe. Mad at herself for making an extra stop at the grocery store to get a gallon of milk since it added extra risk on top of the risk she was exposing herself to at work each day.

There is Ben, who works with Maddie, a 60-something father of two young doctors, suiting up and sliding into the back seats of patients’ cars to draw blood and take vital signs. During a telehealth visit with a 92-year-old patient with congestive heart failure, Ben diagnoses him as having excess fluid in his lungs and increases the patient’s dose of Lasix dose, which solves the problem, convincing Ben that “he could do this.”

There is Ben and Maddie’s clinic, which installs a Wi-Fi hotspot in the parking lot so patients with poor or no internet access in their homes — which in their rural area is pretty much everyone — can drive to the clinic, park, and then use their phones or other devices to do telehealth visits with the doctors and nurses stationed inside the clinic, steps from where their cars are parked. Doctors act like information technology experts, working out the bugs of Wi-Fi log-ons and smartphone screen freezes for their patients.

There is Keith, a 78-year-old grandfather and highly vulnerable to Covid-19 who could retire tomorrow but instead keeps his small family practice in western New York open, treating his patients by phone and computer. Seeing two-thirds of the revenue from his practice disappear overnight, he reduces his salary to zero, gets a federal paycheck protection loan to cover his staff so he doesn’t have to lay them off, and generally practices medicine in ways he was never taught to do and which he doesn’t feel particularly comfortable doing. But doing it anyway.

There is Mika, mother of two young children and two teenagers, who teaches young family doctors as part of her work in an urban, hospital-based, primary care office filled with underserved patients. She’s trying to balance her full-time job with what quickly becomes an even more hectic home life when the schools close. Delivering babies in layers of gowning, trying to lower the anxieties of medical residents who still need to learn many skills, and doing telehealth for half of her patient visits. Jumping immediately into the shower each night upon arriving home to shed any contagion she may have brought home and lower the risk to her family. Telling me about some of her physician colleagues who sleep in their garages to lower that risk.

There is Chloe, mother of three, a leader of her suburban family practice, whose office is caring for 17,000 patients with half the staff they had a week before the shutdown. Who takes on basic nursing duties because her nurses had to take on receptionist duties due to several staff furloughs. Who, among other diagnostic feats, correctly diagnoses a fractured hip in one of her elderly patients during a telehealth visit.

Some of these doctors felt guilty, at least initially, that they didn’t go to New York City at the height of its Covid-19 caseload to help out in hospitals and emergency rooms. But they realized they were doing good and important work in their own backyards, because many people around them still needed care, even those who didn’t have Covid-19.

These doctors stepped up. They kept the delivery of primary care going in their communities despite offices that were physically closed, fewer staff and resources, and harder-to-reach patients. They learned new ways to deliver patient care quickly, using tools they were not necessarily ready to embrace, but did anyway. They innovated to create workarounds in finding and getting care to their patients they would have never dreamed of trying before. They took risks by coming into contact with patients who potentially had Covid-19. They were empathetic to those around them, co-workers and patients alike. Several had to care for and occupy the time of younger children now at home all day. All the while they also had to acknowledge and manage their own fluid psychological states — burnout, anxiety, and job dissatisfaction among them.

A well-functioning system for delivering primary care is essential for keeping people healthy. How best to structure and staff that system are topics of ongoing debate. For decades, primary care physicians and the model of the physician-owned practice remained the de facto way to bring essential diagnostic and treatment services, chronic disease management, and prevention and wellness to patients. That’s changed over the past couple decades as primary care physician shortages, and the rise of specialty medicine, retail health care, and the modern quality movement with its hyper focus on cookbook medicine have conspired to undermine a physician-centric primary care delivery system.

A new narrative now focuses less on the central role of the primary care physician and more on the roles of technology, non-physician staff, standardization, and corporate medicine in getting primary care to people on time and at lower cost.

What I learned from Maddie, Ben, Keith, Mika, Chloe, and many other primary care doctors I have interviewed over the years is that, even when this pandemic has faded away, we will still need people like them at the center of an effective primary care system. How can we keep them engaged and working in sustainable ways?

Let them use technology as they see fit. Trust them to decide the types of innovation they need. Take care of their emotional and psychological needs so they have the will and energy to do their jobs. Pay them like the dedicated, well-trained experts they are.

Let these health care professionals and their patients decide how to get things done. During a pandemic, that produces heroic behavior. During normal times, it means managing a primary care system that is more responsive, accommodating, effective, and satisfying for all of us.

Timothy J. Hoff is a professor of management, health care systems, and health policy at Northeastern University in Boston, a visiting associate fellow at the University of Oxford, and the author of “Next in Line: Lowered Care Expectations in the Age of Retail- and Value-Based Health” (Oxford University Press, 2017).