Après the Pandemic, the Deluge

If it’s not COVID-19, what else could it be?

There’s an old joke in internal medicine about a large team rounding on an inpatient cardiology service, consisting of multiple medical students, interns, residents, fellows, and an elderly senior attending. After a long and detailed presentation of an overnight admission by the post-call intern, the attending turns to the medical students and says, “So, what do you think it is?”

Most of the medical students look at the papers in their hands, or stare at their shoes, or look far off like they are thinking deeply about some other critical issue. But one brave medical student chimes in and replies, “Aortic dissection secondary to relapsing polychondritis.” The wise old attending’s jaw drops, amazed that the medical student was able to come up with this diagnosis, a puzzle that had eluded everyone else on the team. “How could you possibly know that?” To which the medical student replies, “What else causes chest pain?”

Since the start of the terrible pandemic over a year and a half ago, our lives have been taken over by COVID-19. When, in the peak of New York’s surge last year, we closed our practice to in-person visits for everything except emergencies, we tried our best to manage most everybody’s diseases over the phone. We made do with portal messages, emails, texts, phone calls, and video visits, but it felt like there was an enormous amount of healthcare that we were just not getting to. All we saw in the office was COVID-19 patients sick enough to need care, but not sick enough to be admitted.

But we all started to wonder where all of the rest of these diseases had gone. What happened to the heart attacks, the strokes, the diverticulitis, the appendicitis, the cellulitis, the asthma flares?

While the rest of the country, especially in places with low vaccination rates, have been having yet another terrifying surge of COVID-19 cases, here in New York City we have inactivated our COVID-19 practice (which we euphemistically named the “cough, cold, and fever clinic”), and are just doing occasional swabs when people have some mild symptoms, or are planning travel, or need clearance for work. But we’re just not seeing that much of that terrible disease right now.

Trust me, we know it’s probably out there, and it’ll probably come raging back in New York, right around the time that influenza and the other fall respiratory viruses rear their ugly heads. But right now our emergency room, local urgent care centers, and even our own practice have all been overwhelmed by the dam that has burst for all the pent-up care that got put off, exacerbated by everything else that has been going on in this country.

Each day our providers tell us they are swamped with patients who have questions and concerns, new symptoms, an urgent need for attention, and everyone has been pushed yet again to another breaking point. Add to that the question about boosters, and we’re ready to cry.

This is what we’re here for, this is what we love, but after the 18 months that we’ve just been through, everyone is feeling the stress and strain in a whole new way. Everybody I know is answering portal messages till 11:30 at night, finishing their notes on the weekends, trying to keep up with the deluge of in-basket messages. Everybody has had to get creative in finding ways to fit patients in, scheduling them for telephone calls and video visits, adding on extra sessions, and using multiple members of our team to try to satisfy the need when patients say that they just can’t wait for 2 or 3 more weeks, let alone for 2 or 3 more months, to be seen.

I’ve come to the conclusion (once again, no surprise), that the answer isn’t to make everyone here work harder, especially with fewer and fewer resources. The answer has to be a bold, forward-thinking commitment to strengthen primary care, to build up a huge base of people willing to do what we do, taking care of people and all of their myriad needs. We need to free our specialists up so that they can handle the complex cases that we can’t, but we also need more of us to do the basics, the fundamentals, the nuts and bolts, the bread-and-butter.

As we look at our broken healthcare system, and try and reimagine a better public health infrastructure that would help us handle pandemics like we’ve just been through, we also need to recognize that the overflow from these systems always falls onto the primary care providers, be they in pediatrics, family medicine, internal medicine, or obstetrics and gynecology.

And not just them. We need massive reinforcements in our ability to provide mental healthcare for our patients, as well as near-endless resources in the community.

The burden this pandemic has placed on everybody has been unfair across the board, and it is grossly imbalanced in who it has affected. We need to provide our patients, from every community, with all the healthcare they need, so that there’s always someone there answering the phone, listening to them, helping them overcome barriers to care, and getting them the things they need to be as healthy as they possibly can.

If we can’t rise up to this challenge, it’s not going to take another pandemic to wipe us out.

Fred N. Pelzman, MD, of Weill Cornell Internal Medicine Associates and weekly blogger for MedPage Today, follows what’s going on in the world of primary care medicine from the perspective of his own practice.