Continuing our series of interviews with doctors about the Covid-19 era, I spoke with a primary care internist who works in Westchester County, just north of New York City. He spoke on the condition that I not use his name.
His work life changed completely — the practice began doing a lot of telemedicine visits, he said, and he was pleasantly surprised to find how much he liked it, how well telemedicine let him connect with his patients. Taking a history from a patient is similar in person or via telemedicine, he said.
He also anticipates that the system will start losing doctors. “Primary care doctors are already in short supply. So now you’re going to have all these groups folding, and who knows where those patients will get decent care,” he said.
He’s concerned that people who are skipping care will miss a diagnosis of a serious issue because they don’t want to go to the doctor for fear of getting infected with Covid-19.
The thing that surprised him most about Covid-19? How badly prepared the nation was for the pandemic.
Here’s our conversation, lightly edited for clarity and brevity.
Jeanne Pinder
What are the biggest changes for you in the era of coronavirus?
New York doctor
I haven’t gone to the office in about five weeks. I went into the office for the first time the other day.
The biggest change for me was that I never did telemedicine before and starting about five weeks ago, I was doing exclusively telemedicine.
I was very skeptical about (it) but I actually liked it. There’s something about the interactions on the video that I think the patients seem to like. There’s a certain intimacy — they see you in your home environment, you see them in their home environment, and the dog is barking in the background.
I also felt less pressed for time because I schedule my telemedicine appointments for 40 minutes each, which is twice as long as my typical office appointment. The suits me fine because I have a deliberate, slower style — I like to think I’m thorough. it’s just different from running around the office like a maniac. Usually I’m given 20 minutes for a regular office visit and 40 for physical. That’s still more than most colleagues in my group, who allow 15 and 30 minutes respectively
Stunned by mismanagement of the crisis
JP
What surprised you most about the coronavirus era?
NYDoc
I’m just stunned by how badly the federal government has managed this. I shouldn’t be surprised because if you look at Trump’s record, his entire life has been one of failure. There isn’t a single thing he’s done that he’s been successful at, other than manipulating people. For instance, he was a horrible businessman — frequent bankruptcies, stiffing contractors repeatedly, etc. Anytime Trump says anything — anything — I assume the opposite is true, automatically. When you take a guy who’s failed at just about everything he’s ever done, and is 70 years old. Of course he’s going to fail at something as complicated as the pandemic. In fact, the degree of failure has been so high that that astonishes me even more.
The same goes for Jared Kushner, who also seems to have failed at everything he’s ever done. There’s this great symmetry that he found the father-in-law who kind of mirrors him. So of course Kushner would screw up the ordering of personal protective equipment and hiring competent people and not know what he was doing. He’s got the greatest deer-in-the-headlights face I’ve ever seen — and so does Trump, by the way.
It’s unbelievable that those two are running things.
But what would you expect? People with a record of lifelong failure will continue to fail? How could it possibly be otherwise?
When you see all the death and fear, though, it’s still astonishing. It’s one thing if you’re a real screw-up in a smaller environment like running what is really a family real estate business. You don’t really affect that many people’s lives. But put Trump and Kushner in charge of something truly big, like running the government’s response to coronavirus, and what would you expect other than utter catastrophe?
JP
I can barely look at the numbers from day to day.
NYDoc
There’s that famous Dunning Kruger effect, the law of competence where people who are highly competent think they are less competent than they are. People who are incompetent think they’re more competent than they are.
I think of this axiom every time I think of Trump, Kushner and the various lackeys and toadies at the White House. At some level I thought, O.K., well, between Fauci and various other legitimate experts, this will go O.K. But it’s still going as badly as it possibly can because the buck stops with Trump.
Acute care sessions for Covid patients
JP
Don’t say that! It could always get worse!
Tell me about your job, your office — is there anything that has really made you proud of the response to the coronavirus in your environment? The doctors, the administrators, the nurses, the staff?
NYDoc
I’m an outpatient physician. I haven’t been to a hospital to round on a patient in probably 10 years. My group is now organized into hospitalists and outpatient physicians and we stay pretty separate. I have a huge amount of admiration for those who are working in the ER and ICU without adequate protective equipment …. And the people who come here from other states to volunteer!
My practice recently started something called the acute care sessions. We’re starting at three o’clock I the afternoon. It’s a session for people either recovering from Covid or who have suspected Covid. In the morning, you have the non-Covid patients with their hypertension, diabetes, heart disease, etc. Those of us who are a little bit older (I’m 66), have stayed away more. And I think this is the first week we all kind of went back to do some morning hours.
But we’re hesitating on coming in for the Covid hours at three, because we feel we’re at risk. Actually, the demand for those slots has been pretty minimal, either because the number of cases is dropping or patients are still afraid to come into the office.
A month ago when I first started doing telemedicine, every single appointment I did was with somebody who had symptoms and was worried about Covid. I had to sort of do the whole triage thing and figure out who could stay home and who should go to the hospital. Fortunately, the great majority could stay home with supportive care: Tylenol, fluids, etc.
You have to screen them by asking certain questions. You ask about shortness of breath, cough, sore throat, body aches, and impaired taste and smell. Some of them would follow up by video a day or two later. Most of them did seemed to be doing well enough for me not to become unduly concerned. However, there were some people who seemed stable but were really worried — I must have done a telemedicine appointment with each of them four or five times while they stayed home in isolation.
Assessing this can be tricky. Some patients would say something like, “My “breathing is off.” I’d have to spend a good while making sure that it was true shortness of breath, rather than something that felt like shortness of breath but really wasn’t, because I didn’t want to send a healthy person to the hospital. I think there were about four or five people who I sent to the hospital based on what they told me on the phone or what I sense on my video monitor. And it turned out they needed to be there.
One guy was at Greenwich Hospital for about two and a half weeks, and he’s recovering slowly. He didn’t get intubated. Another guy just got discharged from White Plains Hospital after five weeks. He also didn’t get intubated. His brother died of the same illness and his sister was hospitalized in the same hospital he was at. He was a guy about 52 years old. I must have spoken with him four or five times over the course of a week and a half. He finally called me one day and I could tell he was huffing and puffing, though I still wasn’t sure because he is a patient with underlying anxiety. Sometimes anxious people huff and puff more. But I had a feeling that he needed to be in the hospital and it turned out he did.
Then there are patients who don’t really feel short of breath but may still have Covid pneumonia. The only way to assess them is to measured their oxygen with a pulse oximeter, one of those finger devices. And that can only be done during a telemedicine visit if they have the device. A few of my patients did; most did not and had trouble getting one due to high demand.
There was one woman who I’ve known a long time who was having a fever and was tired but she just wasn’t giving a specific enough history. Maybe she was short of breath, maybe she wasn’t. Some people are just not able to describe how they’re feeling in a way that helps you figure out what’s going on.
That’s when you really have to press them for details. It’s a bit like sweating somebody in the police station in “NYPD Blue.” This particular patient just could not convince me that she did not require further evaluation and I sent her for an X-ray—the radiologist reported pneumonia on both sides of her lungs “consistent with Covid pneumonia.” I sent her to the hospital. Fortunately, she did well and came how shortly afterwards.
People not going to the doctor
JP
I keep hearing that there are a lot of people who are just not going to the doctor now. I just talked to a cardiologist. He had somebody who called in with signs of a heart attack on Friday and refused to come into the clinic. They circled back with him on Monday and yes, indeed, he had. But he said, I am not going to the hospital. Do you hear that a lot?
NYDoc
I know people who wouldn’t want to leave their house to see a doctor right now for anything but suspected Covid. I typically review their charts and if they have been stable previously and feel OK, I tell them they can skip their 3-month follow-up appointments. Of course, an office visit is always preferable. But I’ve found you can manage patients more effectively than you think without actually examining them. That really shouldn’t surprise me because the mentor I trained with was a major “history is 90% of diagnosis” guru. He taught me that if you take a good history and really, really listen — not always easy— you can get most of the information you need.
I manage a lot of people with hypertension, diabetes and high cholesterol — I jokingly refer to this as “the troika.” When I do a telemedicine appointment with them, many are able to check their blood pressure, pulse, sugar levels and weight at home, and of course, their temperature. Most appear stable. But let’s say their home blood pressure is high — then I will try to convince them to come in so I can recheck them and, if necessary, adjust their medication. The same goes for diabetics with higher sugars.
I saw a guy in the office yesterday who was in for a routine follow-up and said he felt well. But his heart rate on a routine chest exam was extremely rapid. We did an EKG on him he was in this irregular rhythm is called super ventricular tachycardia, or SVT.
He required immediate ER treatment with intravenous medicine to slow his heart rate down. I told him to go in. He was a little leery of getting exposed to possible Covid but he trusted us and went anyway. He did fine and was home the evening. In this case, I would have had no idea he was in trouble without examining him. But he was probably an exception.
I’ve had a couple of patients with very severe back pain, too severe to be treated with pills. One was quite elderly and therefore at high risk for Covid complications. But she was in such severe pain she was willing to come to the office to get a cortisone injection.
Doctor groups closing, and fewer doctors
JP
So out of all of the things that you’ve seen, what do you think is going to survive this era? You talked about telemedicine, but are there changes in patient behavior, changes in administration, at your clinics, changes in reimbursement that will outlast this era?
NYDoc
I think there’s going to be a lot of consolidation. I think a lot of groups will be closing – you have read about this already in the newspaper, and I think there’s going to be a lot more financial pressure.
Patients are going to really get screwed because there’ll be fewer doctors. Primary care doctors are already in short supply. So now you’re going to have all these groups folding, and who knows where those patients will get decent care.
Medical practices are going to have to tighten their wallets, because we’re all hurting. I didn’t get paid last month, I didn’t get a single dollar. In fact, some of us may end up owing money, because of fixed overhead.
But my group is in pretty good shape relative to most. We have a few hundred physicians. We’re multi-specialty–we have an outpatient surgery center, we do our own MRIs and mammograms and stress tests and so on.
So certain subspecialty services and procedures can help us can make up the difference – we’re not just a bunch of primary care folks. But even for us — it’s really been tough financially. Support staff have been furloughed. We’ve had to borrow money.
And on top of all this, Trump is really hyped up about ending Obamacare now, at the worst moment in history to be thinking about this. How will that affect my job? I don’t know.
On the other hand speaking for myself, I’m on the back nine of my career. I was thinking I might retire in two or three years. It’s occurred to me for the first time that maybe I’ll move things up.
All the protective equipment and procedures
I think about risk all the time. I don’t have an N95 mask. I have what’s called the KN95. mask, which I don’t think is as good. I wear shield over it , I wear a disposable gown and I have an ample supply of gloves and Purell.
Every morning I get up and I put on scrubs. I don’t wear my regular clothes. I get in the car to go into the office. I go to a checkpoint where I’m screened, my temperature is taken and I’m given this little sticker that says I’m good to go, and I go upstairs
When I am in the office, I’m always thinking I forgot something protective. What if there’s something on my keyboard as opposed to just being in the air? What if I’m not removing and putting my mask on properly or storing it the right way. I keep thinking that there’s no foolproof system.
When I leave my office around 1 to come home and do my telemedicine for the afternoon, I drive y car while wearing a surgical mask. When I arrive home, go to the back of my house. I let myself into the basement. I leave my shoes, car keys and wallet in paper bags. We don’t have a shower in the basement like some people do, so I go to the laundry sink, I strip off all my clothes, I throw them into the laundry machine and I wash myself as best as I can. Then I dash upstairs to my second floor and shower. Then I apply Purell to my smartphone and scrub my eyeglasses.
I’ve now had to self-quarantine twice, for 14 days each, due to exposure to someone with either Covid or suspected Covid. So in addition to all the above, I’ve spent a month where I had to eat separately from my wife and son, and wipe down every door knob, faucet, microwave console, kettle handle and table I touch.
And you know those masks we have — we’re wearing them for three, four hours at a time. They irritate your face. Occasionally I’ll go into the office where my desk is, close the door and pull the masks off (I wear 2) off for a couple of minutes just because they are so unpleasant. When I practice telemedicine I don’t have to do any of that stuff.
Testing for antibodies
JP
By the way, did I mention? I got tested for antibodies and I was positive. I don’t think I really had symptoms, it was after a hip replacement at Montefiore New Rochelle.
NYDoc
So what did the antibody test do for you?
JP
So here’s the thing: I did it because I wanted to write about it. And now that I have the antibody test, I’m like, does that mean anything? We don’t have any idea whether it means anything.
NYDoc
My group is recommending against antibody tests right now. Some groups are making them available. I don’t know if that’s a money-making thing or what but my understanding, at least as of yesterday, is that the antibody tests were not really helpful because a lot of them are not very specific for coronavirus. So that’s the first thing.
Secondly, we don’t know if the information they provide is helpful, because it’s a qualitative test, not a quantitative test. And even if it was a quantitative test that gave you the exact titers — the amount of antibodies — nobody knows what that means — yet. So other than getting a sense of the prevalence of antibodies in the population, which is an interesting epidemiology issue, we don’t think having a positive test at this moment should give anyone full peace of mind.
JP
I’ve done enough journalism around it to know that it doesn’t mean peace of mind. I signed up for plasma donation and they will test me to see if I qualify.
NYDoc
Do I have the acute antibodies? Do I have the long-term antibodies? Do I have no antibodies? And what it means, but then you got to study people and see Well, O.K., if you stratify people into high antibody, low antibody, medium antibody, and you expose them to the virus, you know, how are they doing in six months?
