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The following article is an excerpt from an interview conducted on March 23, 2020 between J. Kevin Tucker, MD, chief of nephrology at Brigham and Women's/Faulkner Hospital, faculty director of accreditation and maintenance of certification for Harvard Medical School Postgraduate Medical Education and assistant professor of medicine at HMS and Allan Goroll, MD, a primary care physician at Massachusetts General Hospital and professor of medicine at Harvard Medical School, discussing office management and primary care of patients with upper-respiratory infections who might be at risk for developing COVID-19. The interview has been condensed and edited for clarity and accuracy.
How has your office practice changed? Have you gone to virtual visits or are you still seeing patients in the office?
It has changed dramatically. We have canceled all scheduled visits and are now doing essentially 100 percent of our visits by telephone. Although many of these are regularly scheduled visits for chronic care management or annual reviews, we find that patients are grateful for having this telephone contact. Many of our patients are elderly with multiple comorbidities, and the anxiety level either in them or their family members is obviously very high.
By reaching out, we’re sending a message that we’re not abandoning them because times are tough. We’re there to help them get through this period, both with advice and management. A lot of what we do in chronic care management is patient education. If they need to do laboratory tests, that’s a separate issue that has to be done independently. Often, we’re doing that through satellite laboratory facilities so people don’t have to come to a setting where it might be crowded and scary to them.
When a patient calls your office, what symptoms indicate that this may be something other than the common cold?
We’ve developed a triage system that could be implemented by nurse practitioners, physicians or RNs. It focuses on two symptoms—first, shortness of breath and second, lightheadedness or syncope. We look at their problem list to see if they have comorbidities that put them at increased risk. If they report being short of breath or having lightheadedness or syncope, we go to a second phase. Do they have fever? Do they have other symptoms suggestive of pneumonitis? If those symptoms are severe, we immediately triage them to the ER. If not, we offer them what we have set up in lieu of our office practice—a respiratory clinic setting where members of our practice will meet them to evaluate and decide what is best, including whether to test for coronavirus.
Do you have a geographically separate area for those patients who need to be evaluated in the office setting?
We took one of our office clusters and modified it so that we have the proper precautions, protective equipment and facilities where patients will be comfortable. So that they will not be crowded, we give them scheduled appointments. One of their concerns is that they are afraid they will get sick from coming in, so they err on the side of “I would rather not come in.”
Should a patient who has upper respiratory symptoms but has not been coronavirus tested be separated from the rest of the family? And if so, for how long?
So, let’s pick that up in terms of our triage strategy. We have three groups. One group includes those people who do not need to come in. We tell them: self-quarantine, stay out of the kitchen, wear a mask (which we give them) and go to the CDC website because things are changing quickly on the timing of self-quarantine. We don’t forbid them from going outside to get a little exercise. On the other hand, we do want them to wear a mask when they go out. And, we tell them about practicing good hygiene measures regarding other members of the family.
When a patient is at home and getting worse, do you recommend that he or she go to the emergency department, a walk-in clinic or to your special respiratory clinic?
We follow up with a telephone call to be proactive. We have a huge number of patients whom we send home or advise to stay home, but we try to call them on days two, five and eight. We triage them according to our criteria—a decision support tool for the nurses and medical assistants—so that they can have a triage decision made for them based on asking a few questions about risk factors, age, comorbidities and their actual symptoms.
Depending on the reassessment, we’ll send them to the appropriate place. It ranges from “stay home” to “we would like to see you” to “it’s time to go to the emergency room”—and then, we make a referral to the ER. The doctor knows that they’re coming, so they’re handled with good dispatch.
Does the triage algorithm take into account age so that your advice is somewhat different for elderly patients compared to someone who’s much younger?
Anybody over 60 is automatically triaged up into one higher category. So, somebody who has typical URI symptoms but is over the age of 65, especially if they have comorbidities, will be moved up to be evaluated in our respiratory unit.
Are you referring those patients who are not ill enough to be hospitalized for testing, or is that changing daily based on the guidance you’re getting from various public health entities?
That’s been a challenge for all of us and actually very frightening to patients when they’re used to getting all the testing that is absolutely necessary. In the past week with the shortage of testing available, we’ve had to limit testing to those people whose results would greatly affect their treatment. A lot of patients are sitting in specialized respiratory units waiting for their COVID result. Those are the people whom we will try to make sure get tested as early as possible.
We basically tell the other folks that it’s not going to make a difference in the management. We have to assume you are positive and take the appropriate precautions that you don’t infect anyone else. You may be like the other 80 percent with a mild illness, so don’t be fearful as we’ll keep an eye on you.
As one of the thought leaders in primary care, where do you think primary care is going once we’re past this crisis? In a year from now, what will look different when patients come in for an annual visit?
Those who have been claiming that annual visits to the doctor are a waste of time will likely try to promote elimination of annual visits. That would be a lesson we don’t want to learn from this particular event. The most important thing in a doctor-patient relationship is the relationship, and the healing and trusting elements are extraordinarily important. As every healer from the dawn of time knows and as every patient knows, laying on of hands and face-to-face live contact are incredibly important tools for both therapy and the development of trust.
So, therapeutic relationships based on trust are potentially at risk as people see that, at least technically, they can be handled without having had an in-person visit. I think a lot of unnecessary visits can be eliminated, but the core visits that solidify the doctor-patient relationship become even more important at times like this, because patients need somebody they can trust. If all you have is telemedicine, it will be much harder to develop that relationship.
Are there any final thoughts you want to share about how to evaluate patients in the office if they have upper respiratory symptoms?
I think practices need to systematically reorganize at this time. They can’t just conduct business as usual on the fly. Fortunately, insurance companies are now instructed to pay for telemedicine. We need electronic medical records that will facilitate the recording of information. Use of our decision tool actually results in a pre-populated note to ensure efficient documentation and volume handling.
But, I think that a specific reorganization is absolutely essential. And, it’s also very good for the staff, who will feel much more confident and much more comfortable. If we narrow the focus of what they need to do and the advice that they can give, they will feel much more effective.
- J. Kevin Tucker, MD, chief of nephrology at Brigham and Women's/Faulkner Hospital, faculty director of accreditation and maintenance of certification for Harvard Medical School Postgraduate Medical Education, assistant professor of medicine at HMS
- Allan Goroll, MD, primary care physician at Massachusetts General Hospital, professor of medicine at Harvard Medical School