In March, Marc Price set up a tent outside his primary care practice in Malta, N.Y., where he and his colleagues could don their protective gear to see the daily stream of coronavirus patients. Three weeks ago, the tent was finally upgraded to a shed ahead of snowstorms. But, despite months of constant close contact with Covid-19 patients, staff at the practice have yet to be vaccinated.
“I’m still waiting for my turn,” said Price.
He is not alone among primary care physicians, many of whom are not affiliated with hospitals and so have no direct link to vaccine distribution at this stage. “The rollout so far has been heartbreaking to witness from the standpoint of primary care,” said Emily Maxson, chief medical officer at Aledade, a company that works with more than 7,300 providers across 27 states.
“Many are angry and frustrated and fed up, frankly. They’re absolutely downtrodden,” she said.
Primary care doctors are included with tier 1a, the first group designated to receive vaccines as laid out by federal guidance. These physicians have been severely affected by the pandemic; one study of more than 1,000 health care deaths in May found that primary care doctors made up the highest percentage of physician deaths within that group.
Community doctors also play a crucial role in supporting the health care system overall: Patients who are tested at their family doctor don’t need to burden an already-overwhelmed emergency care system. And while those patients may be in less acute need than ER patients, these visits still create significant contagion risks.
“We feel like we’re the true front line. We see these patients before they go to the hospital or ER,” said Jason Lofton, a primary care doctor in De Queen, Ark., and county health officer for Sevier County, where there is no hospital. “We want to make sure we’re not forgotten. It’s easy when you’re in a small corner of rural America to be left out.”
Only 23% of primary care clinicians know where they’ll get a vaccine from, according to a survey of more than 1,400 such doctors from Dec. 11 to 15 by the Larry A. Green Center with the Primary Care Collaborative. “More than three quarters don’t even know where they’re getting the vaccine,” said Ann Greiner, chief executive of the Primary Care Collaborative. These doctors should be vaccinated to fully support patients, she added: “We really want to keep patients out of the emergency room, for obvious reasons.”
So far, a “stark minority” of the primary care physicians that Maxson works with at Aledade have received their vaccine; most doctors are still waiting, she said.
Federal guidance is subject to interpretation from states, the majority of which are distributing vaccines via major hospitals. And, without any clear state or federal government directive on when primary care doctors should be vaccinated, many independent physicians must rely on the goodwill of hospitals to receive their doses.
The problem is affecting community practices across the United States to varying degrees, said Shawn Martin, chief executive of American Academy of Family Physicians. In the Northeast and West Coast, where there are huge medical centers focused on vaccinating their own staff, it’s “very common” for primary care physicians to be left out. Other states, such as Illinois, North and South Carolina, and Florida, seem to have recognized the problem and are starting to address it.
“I don’t think it’s resolved by any stretch of the imagination,” said Martin.
There’s no question that everyone who works in health care deserves a Covid-19 vaccine quickly. But many primary care physicians feel they aren’t prioritized in line with their risk. Some hospitals are choosing to vaccinate all staff, including those who aren’t involved in patient care or visitor contact, before passing vaccines onto unaffiliated family doctors, said Maxson.
“To be quite frank, for an orthopedic surgeon or urologist, those patients having elective procedures are being tested before going into the operating rooms. The risk of Covid is there, but it’s small,” said Price. Health care systems are naturally incentivized to inoculate their own first, he added: “That probably makes more money for the hospital than someone who’s not their staff.”
States can opt to send vaccines directly to primary care clinics, or via pharmacies, but so far, plans to do so are scattered. In New York, for example, EMS workers and coroners are explicitly prioritized within the first tier, while primary care doctors aren’t specifically mentioned. There’s significant variation in vaccinating primary care physicians even within states, said Maxson. The most important factor for a primary care doctor’s vaccination date is their relationship with a community hospital.
The lack of transparency over distribution plans has added to frustrations. “Part of the fear is not just being excluded right now, but not knowing when your card will come,” she said.
New York state’s health department told Price he’d receive vaccines from Albany Medical Center. But, after repeated calls to the hospital, they said they weren’t responsible and Price’s clinic should instead get their doses from the state. Eventually, after also speaking with local Assemblywoman Carrie Woerner, Price received a mass email from both the Medical Society of the State of New York and New York State Academy of Family Physicians saying primary care doctors could expect to receive a vaccine on Jan. 4. He doesn’t know who will be distributing it, or where he should go to receive his shots.
Failing to include primary care doctors early in the rollout process could have wider ramifications. These physicians are generally well-placed to have close ties with their communities. “I’m spending time with each patient, basically coaching them to say the vaccine’s worth taking,” said Lofton. “They want me to take it first.”
If independent clinics don’t have strong ties to vaccine distribution, they will likely play a more limited role in vaccinating their own patients once doses are available for the wider public.
“I’m really worried about large retail pharmacies’ ability to gain the trust of the population,” said Maxson. Primary care doctors also have the opportunity to offer vaccines to patients who come in for other reasons. “If our PCPs are left out, we miss the opportunity to vaccinate more passively,” she added.
Independent primary care practices are also relatively small clinics, without many backup employees to pick up the workload when staff are sick or quarantining. Price should be on vacation this week, he said, but two of his colleagues are off after being exposed to Covid-19: “We’re just getting run down.”