In This Wave of Respiratory Illness, Primary Care Is Drowning
By Eric Last, DO
Entering our fourth year of COVID, it's hard to believe some of the conversations I'm still having with patients. Last week in a telemedicine evaluation, a patient dealing with COVID for the first time lamented that he did not understand why so many people were sick or fathom how he even got COVID.
When I asked when he'd received his last vaccine dose, he replied: "Never, I don't believe in it." He's a patient I've known for 20 years.
Another patient with COVID called and said, "The commercial says, 'If it's COVID....Paxlovid', so can't you just prescribe it?" She's currently on 10 different medications, so I explained to her that four of them would either need to be adjusted or held so that I could prescribe nirmatrelvir-ritonavir (Paxlovid). "I never thought it was so complicated," she responded.
We are awash in illness, with COVID, influenza, and RSV spearheading the attack. Multiple other illnesses bereft of formal names are circulating as well. It seems that everyone we know is either sick, was recently sick, or has family who is ill. The headline-grabbing worry is that hospitals will again be overrun, a real potential in a world where simple public health measures are seen as infringements on our rights; where vaccine uptake is pathetically low; and where it is as easy to be exposed to misinformation as it is to contract a respiratory-borne illness.
None of us ever want to see a return to the nightmare days of lines of waiting ambulances and refrigerator trucks laden with the dead outside our hospitals. At Northwell, we had more than 3,400 hospitalized patients with COVID at the height of the pandemic in April 2020. Today, while it's higher than it's been for a while, it's at a more manageable number, just below 500.
However, there is a real crisis: Primary care is buckling under the strain of this season of illness.
Already bearing the burden of retirements, staffing shortages, and daily administrative demands, primary care is the front line of not just epidemics, but of healthcare itself. Because of that, the added stress of this influx of patients will push many practices to the breaking point. No amount of scheduling can add hours to the day, and our workload only becomes more burdensome as we and our office staffs become ill too.
Ironically, at the start of the COVID pandemic, there wasn't much primary care physicians could do for our patients. We would evaluate them (often by phone, occasionally by video), and try to determine who would benefit most from difficult-to-obtain testing. And once a patient was diagnosed with COVID, our major decision point was to determine who was sick enough to go to the emergency department (and pray we hadn't waited too long). The major burden was on the inpatient side.
Now? We have outpatient treatment options, accompanied by a panoply of recommendations so fluid that professional societies publish them as "living documents." These are wonderful developments that let us help patients, prevent them from getting sicker, and keep them out of the hospital...rather than sit helplessly by.
Still, the complexity of this care, the multitude of circulating infections, and the sheer number of patients is mind-numbing.
The vignettes at the beginning of this piece aren't fictional -- they're my interactions with real people, variations of which are replicated multiple times a day. The refusal by some to acknowledge science has made this all worse. The vaccine is safe and often limits the severity of the illness -- particularly in those most at risk for complications -- and can minimize the risk of long COVID.
The lack of trust in experts who really do know better about the effectiveness of vaccines is worsened by the ongoing opposition to masking, and while some hospitals have implemented a mask mandate, many others have not.
It has also impacted our ability to take care of patients who need care for their regular issues, to diagnose new and complex medical conditions, and to conduct routine annual physicals. That's where our current situation quickly becomes unsustainable.
There is no desire among primary care practitioners to avoid caring for patients -- caring is our role. And because our specialty, our "secret sauce," is to foster sincere relationships with patients, we can explain and empathize, encourage and prescribe, usually at the same time. While high-tension medical drama takes place in operating rooms and ICUs, the daily work of primary care is what will sustain most of our patients.
Eventually, springtime will come, waves of illness will run their course, and we will return to a baseline of illness and wellness.
In the meantime, we all hope that emergency departments, general hospital beds, and ICUs will stand the strain. But remember that the foundation of the system, primary care, is in danger.