Primary care amid the pandemic

James Gaden D.O. and Bridgette Wiefling M.D. are both primary care doctors. Despite their shared profession, they are in some ways on different paths.   

One of a nearly vanished breed, Gaden is an old-fashioned country doctor. He owns a solo practice in Orleans County, where with the help of a nurse and an office manager, he serves roughly 3,000 patients. He is not affiliated with any health system and may be the last local doctor still practicing who does not use an electronic medical records system. Gaden’s telemedicine consults are done with phones, not on Zoom.

By contrast, Wiefling sees patients at a Rochester Regional Health-owned practice that employs two other internists. In addition, she holds senior and executive vice president titles at RRH that put her in charge of the financial and clinical operations of the primary care and medical specialty group operated by RRH, a $3 billion, five-hospital system that spans four counties.

Those differences notwithstanding, since the coronavirus pandemic arrived there are experiences that Gaden and Wieflinghave shared with primary care providers here and nationwide. As COVID-19 cases fill hospitals, doctor-patient relationships in the primary care realm have undergone significant changes, with new protocols and a sharply increased reliance on telemedicine. 

Both Gaden and Wiefling have sent patients with severe cases of COVID-19 to the hospital. Both have seen some of those patients die. Both are similarly frustrated with the way the coronavirus outbreak has eaten into the routine preventive care they would like to give their patients.

And like some other area frontline health care providers, both have themselves contracted the virus.

Gaden showed symptoms early, first noticing them in March. Days were not that bad, he says. Nights were another story. 

“I was like Chris Cuomo,” Gaden says.

After coming down with the virus last spring, Cuomo, a CNN personality, kept broadcasting from his home, describing nightly fevers, weight loss and other effects in real time to an audience of millions.

Wiefling also caught the virus early on.  

“I was really sick,” she says. “At one point I picked up a box of food I’d had delivered and took it upstairs. It was so hard to get up the stairs and when I got there, I wondered: ‘Why do I feel so bad?’ So I grabbed a pulse oximeter, which up to that point I had not used, and I put it on my finger. The reading was 74.”

Pulse oximeters measure levels of blood oxygen. A reading of 74 is some 20 points under a healthy person’s reading. 

“That’s when I really understood that this is what happens,” says Wiefling. “I didn’t feel short of breath.”  

A reading like Wiefling’s can be a worrisome sign for COVID patients, some of whom have been known to suddenly collapse and die for want of oxygen even though they are unaware that they are having any difficulty breathing. 

Lending credence to the adage that doctors make the worst patients, when Wiefling began to experience shortness of breath a few days later, she decided not to check herself into the hospital.

“I probably should have, but I’m stubborn,” she says. “I didn’t want to go. I was thinking: ‘I’m going to be embarrassed. And what are they going to for me, anyway?’”

New protocols

Both physicians recovered and soon were dealing with their patients’ COVID symptoms. Both would send patients to the hospital and both would see some succumb to the virus. Both would sometimes see themselves at times more distant and at times closer to their patients.    

When Jeff Jubenville called Gaden’s office complaining of COVID-like symptoms, Gaden did not ask him come in. Instead, he sent Jubenville to Strong West, the Brockport free-standing emergency department affiliated with the UR Medicine’s Strong Memorial Hospital. Gaden refers patients with less severe COVID systems to a testing site. If they test positive, he follows through with phone consults.

Patients who call the group where Wiefling practices are treated similarly. Following protocols devised by RRH, they speak first with a triage nurse who sends the most severe cases directly to an emergency department. Those with milder symptoms get referred to a drive-through testing site after a telehealth evaluation by a provider. After testing, they are told to go home and isolate until they get a result. 

Those who test positive are enrolled in RRH’s COVID Care Companion program, which sends them daily texts asking them to report symptoms. Those with severe symptoms could be signed up for home oxygen or sent to an urgent care center for X-rays, or sent to a hospital ED.

“We learned very early on in the first surge that this disease is different,” Wiefling says. “People don’t realize how sick they are. They’re dying at home without ever having reached out, or they’re dying in the parking lot trying to get to care.”   

Jubenville started experiencing COVID symptoms in mid-December. He was not surprised to have caught the virus; his wife had it before him. But he was taken by surprise when his case took a more serious turn.

Says Jubenville: “It started out kind of pesky and I thought: ‘If this is as bad as it gets, I’m doing okay.’” 

Even after he lost his sense of taste and smell and an ED doctor told him he would need to be hospitalized, Jubenville “felt like I could drive myself.” Just the same, he accepted an ambulance ride to Highland Hospital, where he spent more than a week. Jubenville was never on a ventilator or in an intensive care unit, but he was on oxygen for much of his stay. 

A changed experience

Jubenville enthusiastically praises the care he received at Strong West and Highland, but confesses to feeling isolated during his hospital stay. No area hospitals have allowed family members to visit during the pandemic. Doctors and nurses kept watch over him, Jubenville says, but spent much of their time in his room “with their faces buried in a computer.”

Cautioned against bringing valuables to the hospital, Jubenville decided not to take his hearing aids. Given that such devices cost thousands of dollars and are not covered by insurance, it was a reasonable decision. But, says Jubenville, “when I told people that I couldn’t hear them, I’m not sure they really understood what I meant.”

Since Jubenville’s discharge from the hospital, Gaden has kept tabs on him by phone. Recovered from the virus, Jubenville, 64, is left with lingering after-effects. His pre-COVID high blood sugar levels are now a full-blown case of type 2 diabetes, which sometimes requires insulin. 

Another COVID patient of Gaden’s who was hospitalized, a retiree in her mid-70s who asked that her name not be used to protect her privacy, said she spent most of a roughly two-week stay at Strong Memorial in an ICU, where she describes her care as “excellent.”

Now at home, she still feels too weak to do much. A neighbor fetches mail from the box at the end of her driveway. Her daughter is caring for her small dog. The animal has been a constant companion since her husband died in 2019, but for the time being, she is too weak to walk it.

As with Jubenville and other recovering COVID patients, Gaden keeps track of the woman’s recovery through phone consults.

“I follow up to see how they’re doing,” he says. “A lot have co-morbidities that need to be watched.”

For some, co-morbidities are a consequence of COVID. Jubenville’s type 2 diabetes was sparked by the steroids that helped him beat back the virus,” Gaden believes.

The push for telehealth

In U.S. health care, high patient-to-doctor ratios in primary care are the rule. Gaden’s 3,000- patient load is not unusual. Added to that is a fee-for-service physician reimbursement system that pays per office visit or service and thus keeps doctors on what many derisively refer to as a “hamster wheel” of endlessly cramming as many patient visits as they can manage into their work days. Both factors were encouraging providers to increasingly rely on telemedicine before COVID hit.

The pandemic has greatly accelerated that trend and is likely to keep doing so, notes a recent Mayo Clinic Proceedings. At Stanford University’s medical center in California, the post notes, telemedicine visits went from 400 a day to 3,000 when the pandemic hit. 

“When all is done, the COVID-19 pandemic will likely be seen as a tipping point for telemedicine in the United States, the point when it was no longer considered a niche service, but an essential piece of care delivery,” state the post’s authors, physicians Steven Lin M.D., Amelia Sattler M.D., and researcher Margaret Smith.

Gaden’s telehealth consults are almost all done by phone. A high percentage of his patients are elderly. Many are not comfortable doing video consults and are not computer savvy. 

Orleans County, where he practices, is one of the area’s poorest, Gaden says. His patients are mostly working class and farm families. Some do not have reliable broadband. Others do not have computers. 

Gaden laments the rise in telehealth. It puts an unfortunate distance between him and his patients, he believes. Voice-only consults do not give him visual cues that can tell him a lot about patients’ general state of health. Video visits are an improvement but still a poor substitute.   

Wiefling is more comfortable making video diagnoses, and even phone consults can yield a trove of valuable data, she says. Doctors can ask if patients are monitoring their blood pressure or taking medications and at least get a verbal picture of their general state of health. 

“When you can see person (in a video visit), you can get a lot of information. In primary care, thank God we’ve had it. If we hadn’t had the ability to use telehealth,” says Wiefling, “we’d be in a much worse situation than we currently are.”

No matter how doctors might feel about it, the Mayo Clinic post’s authors predict, “the longer COVID-19 lasts, the more it will push the envelope on the breadth, depth, and comprehensiveness of care that can be accomplished through virtual visits.” 

For a variety of reasons, not the least of which is fear of COVID infection, some patients are backing away from regular visits to their primary care providers and are postponing or entirely avoiding treatment for acute and chronic non-COVID conditions.

“This is probably the (pandemic’s) biggest impact,” Wiefling says. “People are afraid to come in to get care. They don’t want to be around people. They don’t want to catch the virus. This has been going on now since March. We’re at almost a year of people avoiding regular primary care.” 

For patients who do come in for non-COVID care, Wiefling says, the pandemic has created new barriers.  

“Part of coming to your primary care provider is about your emotional connection,” she says. “You develop a relationship over time. Now you’re in a mask, behind a shield. You’ve got your coat on and gloves. It creates a wall. It creates distance. Sensitive conversation suffers when you’re shouting through your mask and your shield. It doesn’t come across the same way.”

Says Gaden: “Once everything shut down, patients stopped coming. They stayed home. People are putting off prevention.” 

Gaden estimates patient visits to his office to have fallen to half of what they were pre-pandemic. Fear of infection is keeping people home, he believes. The drop in volume means less reimbursement from payers and is hitting his practice in the pocketbook. But Gaden says he is more concerned by the care his patients are missing.

“Primary care is supposed to be about prevention, he says. “We’re responsible for maintenance. For too many people, that’s going by the wayside.”

Putting off care

In a mid-December survey conducted by the Primary Care Collective, 43 percent of primary care doctors polled told the Washington, D.C.-based non-profit that they were seeing fewer patients and that safety concerns were motivating patients to put off care. Sixty percent of respondents said their patients’ health unrelated to COVID has worsened during the pandemic. 

In her primary care practice and across the RRH system, “we’re starting to see in our acute care setting a rise above and beyond our seasonal norm of patients coming in with acute disease that was potentially preventable,” Wiefling says. “We’re seeing a rise in (hospital) admissions that are not COVID and that rise in admissions is out of proportion to what we normally see. But we’re just starting to look at that. We can see the graph, but we haven’t documented the degree of it yet.” 

In other results of the Primary Care Collaborative survey, doctors reported staff shortages and an increase in their own feelings of stress and exhaustion. The local picture is similar. 

“As providers, we’ve been asked to fight a war,” Wiefling says. “And we’ve been somewhat crippled in the tools we have to fight the war. We’ve been working crazy hours for a year now. Everybody’s working crazy hours. It’s definitely taken an emotional toll on everybody.” 

Still, she adds, “there will there be good things that come out of this when we reach the other side. Our altruism, those feelings that moved us to go into medicine, it’s all being pulled out. We’re asked to be doing so much more than any of us thought we’d be asked to do. People are doing it and they’re not complaining about it.” 

The stress, the crazy hours, the emotional distance and patients’ fears, believes Wiefling, have encouraged primary care doctors to “use all of our levers for good communication. It’s made us more acutely aware of the relationship aspect of care. It’s made us more aware of the vulnerabilities of our patients. These are things we knew before. But I think now it’s really hit home.”

Finally, says Wiefling, “I feel closer to my colleagues than I ever have before. You’re going through something together and I love them like family. I loved them before, but, you know, I loved them like friends.” 

Will Astor is Rochester Beacon senior writer.