Coronavirus (Covid-19) and the primary care doctor: The view from Kansas

Filed Under: Costs, Health plans, Patients

Continuing our series of interviews with doctors and other medical personnel in the era of Covid-19: Dr. Ryan Neuhofel is a direct primary care doctor -– meaning that his primary care practice runs on a subscription model, where patients pay a set fee monthly for all their primary care. Primary care practices also often arrange low-priced MRI’s, lab tests, medication purchases and the like. Read more about direct primary care (DPC) at Dpcalliance.org. Doc Neu, as his patients call him, practices in Lawrence, Kan., west of Kansas City. He and I speak about health care semi-regularly. I wanted to get his opinion on the current state of affairs. Here’s a transcript of our conversation, lightly edited for length and clarity.

Jeanne Pinder 
What has most surprised you about the Covid era?

Ryan Neuhofel 
I knew it would not happen overnight. But I’m still a little bit surprised at how long it’s taken to mobilize a cohesive response.

There are so many bottlenecks in in dealing with this type of situation. Even something seemingly simple like [personal protective equipment] is a huge problem. We’re much better off right now than we were a month or two ago; after a lot of work and backroom deals.

Also , a bigger time suck has been figuring out how do we best interact with people? Part of that is how do we further adapt telemedicine? But, it’s just part of rethinking our workflows. So it’s been just a mad scramble for us for a month or two, to try to figure out how to do a lot of this stuff.

Part of the challenge is finding our level of comfort — as a physician who’s a practice owner, and then my nurses. There are not precise guidelines or perfect ways to do many of these things. You have to figure out what your level of comfort is. And that’s different for different people. I talk to doctors all around the country, and I’m doing things that maybe other doctors aren’t comfortable with. I think I have a scientific backing and that comfort level with that and other doctors are not. That’s not to say that I’m right, or they’re right. It’s just there’s no there’s no guidebook or perfect plan for a lot of these challenges.

Testing, testing and more testing

JP 
Let’s talk about testing.

RN
Like a lot of people, doctors are doing a ton of reading and learning about some of these topics — some of the complexities of even just basic lab testing concepts, specimen collection, keeping the specimens protected from contamination, many other logistics..

There’s been this learning curve about things like what is the best way to get a sample from the back of the nose, or the oropharynx, or deep in the lungs? There’s not one right answer. Before, if you had asked me what do you think about the proper way to collect a PCR sample for a respiratory viral illness? My answer would have been about 15 seconds long. And now it’s like 15 minutes. Because then when you get into it, you realize, “Oh, my God, this is actually a super complex topic!”

I spent a ton of time in the first couple of weeks just like trying to refresh or learn the ins and outs of lab testing and specimen collection and handling. Maybe that means I was not educated as much as I should have been on that topic. But I think a lot of us were in the same place. With respect to analyzing studies and data, I have a degree in Public Health I think that helps me dig deeper in literature than your average physician. But, even with that, I’ve often felt lost.

A specific example: So very early on, February-ish, there was some confusion and debate about what type of swabs or specimens were best or appropriate for Covid-19 PCR testing. Testing people for an active respiratory infection is not a new topic–we do it routinely for other pathogens, such as influenza, RSV, and pertussis. But when it came to Covid-19, it seemed as much of this was completely new. A So in February when were no swabs to be found, I remember reviewing basic concepts and literature and thinking, “Well, why don’t we just squirt saltwater up their nose and out the other side because I’ve done that before with pertussis?” It’s called nasopharyngeal aspirate and a very proven way of collecting a specimen for upper respiratory infections. I remember telling people this in February, “Hey guys, maybe we don’t need the swabs at all?!”

But the media and the medical community were saying, “well, but you have to have the swabs and VCM medium and if you don’t have it, then you just can’t do the testing.” I believe it was just a state of paralysis for many of us.

Even the labs themselves seemed to be at a loss of giving guidance on many topics. I just said, I’m gonna do the nasopharyngeal aspirate because it’s what I had and trusted the basic science and precedent . Then two or four weeks go by and then my lab finally says, “Oh, yeah, you could just nasopharyngeal aspirate with saline..”

That is just one example of how a simple topic took weeks or months to become clear for physicians.

Fear and confusion

JP
I know here people are terrified. It clouds your ability to think.

RN
Most definitely. Obviously, doctors are humans. I have seen my physician and healthcare friends doing things that I thought were probably overly cautious. Every doctor goes to training knowing we’re put in a little bit of risk. In some ways like being a firefighter or being a police officer, but I’d contend we’re way less brave than those professionals. But,  there’s an inherent danger in being a healthcare worker.

So, there’s reasonable caution for safety or respecting regulations, and there’s paralysis. And I think just because of the global fear, we have sided with the latter too often.

Also, the goalposts and guidelines changing frequently haven’t helped. Physicians, by their nature, are rule-followers. And so, whenever there are not clear rules, even if, in retrospect, those rules make no sense, physicians just don’t want to do anything.

How doctors make a diagnosis

JP
So the all of the tests are, shall we say less than reliable?

RN
This is another thing that is not unique to coronavirus. I would consider myself a medical conservative in the respect of not relying too much on tests, because they’re not perfect. Interpreting diagnostic testing is always complex. The public definitely doesn’t understand that. Far too many people think a doctor doing a careful history and physical exam to reach a diagnosis is “just guessing.” We should get the test to confirm things when needed and feasible. But that is not straightforward in many circumstances — often there is not a definitive 100% test. It’s a combination of factors that lead to a doctor making a diagnosis.

The first thing that we all recognized was, that PCR tests looking for the active virus definitely don’t detect 100% of the time.I It is somewhere between 40-80 percent accurate in detecting Covid-19 cases.

If the test is negative, Is it possible they still have it? Absolutely. Maybe you could test them again, in three days, it would be positive! This is kind of like a mind-blowing concept to the public. This is not unique to coronavirus. This has been true of influenza. And this is where we have to make a somewhat of a preliminary or clinical diagnosis.

And more recently has been the antibody thing and that one is even more complex to wrap your head around. Everyone’s super excited about these antibody tests– like they’re the holy grail for us to get back to normal. And the truth is that antibodies are even more complex than PCR testing for active virus.

What is somewhat scary to me is labs selling Covid-19 testing to patients with very poor explanations of how to interpret them and no professional counseling. If people are making decisions based upon these things, it could potentially be harmful.

We all want a return to normalcy

JP
We talked a lot more about testing than I wanted to. I don’t know why.

RN
I think it’s because people are desperate for a way out of this mess. My wife and I talk about this all the time. We just want some type of solution that lets us go back to normalcy.

I could just see patients’ faces when I go into an explanation of how lab testing is imperfect. I had someone email me this morning and said, “I want to go visit my 93-year-old grandma in Oklahoma, and I had a cough in January and I want an antibody test so I can be comfortable going and seeing her.” I gave her a one-paragraph explanation of “I’m not going to give you an all clear that you’re not going to infect your grandma. I can give you some advice on that. But there’s no certainty in lab testing here.” I doubt she liked my waffling on this issue but it’s just the truth right now.

Direct primary care and the pandemic

JP
So what has changed most for you in the Covid era professionally speaking?

RN
My practice, model, direct primary care, was so much better suited for this type of thing. And that’s not something I considered.

I started a DPC practice a decade ago for lots of reasons — I hate red tape, I hate bureaucracy, I hate lack of transparency, all those things. But I certainly didn’t like envision that my business model or my practice model will work well in the middle of a global pandemic.

As it turns out, having a practice like this has made this much easier for us and patients.
So my business model, my clinical model, and my relationships with patients, were already partially geared to this. And I can’t say that’s true of most doctors or practices.

I’ve been hearing horror stories from other doctors. I They’re already laying off people. They’re truly frightened. I recognize how lucky I am — my practice has been challenging in some respects, but I’m not worried about the fundamental existence of my practice.

Perhaps the most fascinating aspect of the pandemic is the psychological component — how it affects my patients. The weirdest thing I’ve seen is actually, overall our volume of inquiries and communications is less. I would have predicted the opposite because people are trapped at home, and anxious, that we would have an increase in people calling us. But it’s actually been way down. We’re seeing that people are just avoiding the doctor at all costs.

My best theory is because the whole world is worried about one single thing. And, if you don’t think you have Covid, then you don’t call me with lesser concerns–when you stub your toe, or because you have a dry patch of skin or some other kind of minor, trivial thing.

So, we’ve had to tell our patients, “Yyes, Covid is bad. It’s scary. But you also have diabetes. I want you to continue to communicate with us like you normally do about your diabetes, especially because you’re trapped at home and probably eating not so well.”

People don’t want to go to the doctor’s office

JP
A girlfriend called me the other day, saying, she has a dermatological issue and she doesn’t want to go to the doctor. I’m like, you know what? They’re all doing telemedicine. Just take a picture and send it and she was good.

RN
I’ve been saying this for years about remote care. I don’t like the term “telemedicine” because it has so many weird connotations., Care outside of an exam room can take many forms. I like asynchronous communications because they’re more efficient, but “virtual” care shouldn’t be thought of as just videoconferencing for a doctor’s visit in my opinion.

I’ve been text messaging and emailing my patients for years. I don’t have to worry about the business of that because I get paid a different way. But also, I just developed a certain comfort level. Of course I would like to get to know my patients in person first. I think there’s huge value in that physical interaction in the same room to get to know each other. But, then, you can call or text me when it is appropriate; often I can solve the problem quickly without an office visit.

I was telling all my friends who weren’t in DPC or doing a lot of remote care, “it’s not that complex, right? If somebody text messaged you and says I think I have poison ivy, they are usually right. But ask them a couple questions, get a picture and then prescribe a treatment. it’s not rocket science or dangerous. But historically many of my doctor friends w will often say , “Wow, it just seems really risky. I would never do that without a clinic visit.”

Now, after a month of pandemic, “Oh, yeah, we’re 100% telemedicine now.”

Well, what changed? They didn’t all of a sudden to develop like a clinical comfort with diagnosing a rash by picture over a phone. It was out of necessity.

The finances of how it’s paid for kind of dictate what people do. So if insurance companies and governments and all the third parties continue not to pay for it, then yeah, people are going to go back to whatever pays them money. But I do think we’re getting enough evidence that clinically speaking, we’re much more capable of caring for someone remotely than what we maybe thought.

The threat to independent practices

JP
What other things do you think are going to stick with us after this is over — whatever you define is over?

RN
I’m very distrustful of big health systems in general. So it’ll be really interesting to see how that plays out with all the changes happening now. Smaller independent practices, which I know are perhaps a dying breed anyway – can adapt more quickly but also have less cushion to absorb financial losses.

I fear that this is only going to speed up the extinction of a smaller independent practice. Large health systems will get bailed out. Smaller, independent practices are going to be left hanging, and eventually forced to close or get absorbed.

JP
Do you have coronavirus where you are?

RN
There are only 150,000 people in my county, west of Kansas City. it’s been only 50 cases confirmed. So there’s probably more like 500 or 1,000 or more in my county. But Kansas City’s had its fair share of cases. And, yeah, I think that’s the challenge is that this will be community dependent.

Most communities haven’t even really seen that many cases; and certainly have not yet gone through the worst of it. And that’s frightening. You’re in New York – you know how bad it can potentially get. And also the way that this spreads in New York is going to be a lot different than a rural area.

This issue is just not going to be slow steady improvement and one direction. The reality is it’s going to be an ebb and flow for several years at a regional and community level.

There’s going to be a lot of judgment about “Should we rein it back in or open it back up?” Unfortunately, there is a very simplistic national, increasingly political, debate on this. It doesn’t need to be a choice of “stay at home for the next one to two years until we have a vaccine,” or “just go back to normal.” That’s a false choice.

As a public health person, as a scientific person. I want to stress that hundreds of thousands of people could die or are likely to die. But, we should not be discounting the fact that we’re paying a very heavy cost for much of what we’re doing to fight this disease. And it’s not an all or nothing thing. No matter what we do, there’s gonna be a lot of people suffer and die from Covid-19 and other effects of this pandemic.

Balance is really hard to find in America. because everything is so polarized by politics. It’s like, “are you A or B”? Well, perhaps there’s some middle ground that looks different in every place, right?

But that’s complex. It is easier and more entertaining to get on social media and say “these people suck, and they want everyone to die,” or “these people suck and don’t care about people’s livelihoods.”  We are way too quick to demonize people. That’s disheartening to me. I think I think most rational people care about both. Maybe I’m foolish to think that we can somehow as a country find some way forward that doesn’t rip us apart — but we must.

A wakeup call: Prepare better

JP
What are the biggest lessons that can be taken away from this?

RN
The most obvious one is that we were unprepared at multiple levels for any type of pandemic type infectious disease outbreak. This may be foolishly optimistic, but hopefully, after we get through this, we will have a much better public health system in place.

So hopefully this will serve as some type of wake-up call; so we can be better prepared for something else that’s an even  bigger threat.

JP
So we’ve learned that we weren’t that prepared. In fact, we weren’t prepared at all. What else have we learned?

RN
One other big takeaway — the public has such low scientific literacy. These conversations are really, really hard to have even for those with backgrounds in medicine and science. There is a lot of context and nuance. So, without a baseline understanding of basic scientific topics, confusion, false information and conspiracies spread like wildfire.

When everything’s going well, it doesn’t seem like you need to understand science or the world that well. But when things get murky with lots of opinions flying around, it really helps to have a baseline level of interpreting scientific matters. If you’re just going with your gut, or listening to some dude on Facebook who calls himself doctor, there is a real danger of reaching a false conclusion or being mislead.

And, although I’m really upset when I see false information on social media, I don’t think they are bad people. Mostly, they are inclined to distrust authority and “experts.” I sympathize with them in some respects, because there is a reason to distrust some of our institutions — they have done some terrible things. We should remain skeptical; while not succumbing to snake oil salesmen or conspiracy theories.

JP
That was very smart. Do you have any parting thoughts?

RN
It’s a beautiful day out here in Kansas. So I’m going to leave the clinic a bit early. I’ve been building a fence at home. It’s become my weird pandemic project. I’ve worked way harder than I thought on this.I should have trust entrusted it to a professional. . But the experts would have charged me $10,000 to build the fence!