It’s not just what I wear. So much in my pediatric practice has changed so fast because of covid-19. Like a boat on rough seas, the disease caused by the novel coronavirus has forced my colleagues and me to tack rapidly against the waves of infectious surges. And while much has been said and reported about its effect on hospitals, emergency rooms and intensive care units, most Americans still receive health care as outpatients, in clinics like mine.
It’s where we — pediatricians and other primary care doctors — provide the holistic view of their health and make sure they get their preventive needs met. It’s where we tell patients they have asthma, ADHD, cancer and other life-changing diagnoses. Covid-19 continues to upend how we care for this bulk of patients. Sometime, hopefully in 2021, I will be able to offer a vaccine to my small patients. But until then, as we hurtle toward three quarters of a year under the thumb of this pandemic, we need to take stock of all of it and to ask: Are our patients getting the care they need?
An analysis in August by the Commonwealth Fund showed that when we began shutting down in March, office visits to doctors fell by 60 percent. A shutdown was necessary: We simply didn’t know enough about the disease and its transmission; personal protective equipment (PPE) and testing were scarce. If there was a single bright spot to come out of that period, it was that doctors and patients could use telemedicine — particularly video visits — to care for patients as they sheltered in place.
As I told a news reporter at the time, in the absence of medicines or a vaccine, the only prevention is to stay home and socially distance, including from your doctor. In this respect, video — to be able to see a child’s energy level, check their effort of breathing, look at a rash — was a win for patients, pediatricians and the health-care system. It’s sure to endure after this pandemic ends.
It turns out now that with progress in our understanding of and testing for covid, and better PPE supplies, patients have started to come back to their doctors, some specialists even exceeding pre-pandemic levels. But for pediatricians, office visits are still stuck well below that baseline, even as we started a #CallYourPediatrician Campaign to let parents know we were ready to see them.
Parents might still be wary about covid-19, or they may not want to bother us because they think we are inundated with covid-infected or suspected patients. Telehealth also might be meeting their needs exceptionally well. After all, the effort is not a small one to pack up your baby or toddler in the car, stroll them through a parking lot and then sit and wait for the doctor in the office. Finally, the sheltering and schooling at home may actually be keeping kids physically less susceptible to common childhood diseases, the diagnosis and treatment of which are bread-and-butter stuff for pediatricians.
A study in June by researchers in France found an over 70 percent decrease of kids presenting to offices and emergency rooms for acute gastroenteritis, common colds, bronchiolitis and ear infections, relative to historical expectations.
Patients’ staying away has had side effects.
Telehealth, and the pressures of covid, gave doctors and patients an out from prescribing antibiotics only when a patient really needed it, such as for pneumonia or many ear infections.
We could routinely make that determination during an office visit using our stethoscope and otoscope. Now, if a patient has a fever and symptoms of infection, we hesitate to see them unless and until they’ve tested negative for the coronavirus, lest we risk exposing other families, staff or colleagues to the disease. The clock ticks while we wait for that test result against the unknown possibility that a child has a serious bacterial infection. As we know in our profession, kids are not adults. One minute, a child can look just fine; the next, he could be lethargic and toxic as infection spreads across his body via the bloodstream.
Faced with that uncertainty, I’ve seen colleagues lower their threshold for prescribing antibiotics.
I’m guilty of this myself. Each time I do it, it leaves a sinking feeling in the pit of my stomach because I know I may doing more harm than good: The child could experience a significant side effect that could create more confusion and anxiety.
Did I pick the right antibiotic? Is it even really a bacterial infection?
I’m certainly not helping to contain the rise of antibiotic-resistant infections, which the World Health Organization says is one of the top health threats of the century, predicting that by mid-century, 10 million people could die each year from antibiotic resistant disease if we continue to prescribe at our current levels.
Delaying or deferring care has other drawbacks. The real or perceived barriers to an office visit have left children falling behind on their routine childhood vaccines. A review of data from Michigan, for example, showed that compared to 2018 and 2019, vaccination coverage declined between January and April of this year. If this pandemic has taught us anything, it’s that vaccines are critical to keeping society safe and stable. We are already bracing ourselves for a “twindemic” of influenza and covid-19 this winter. Adding an outbreak of a vaccine-preventable disease — measles, pertussis, chickenpox — further threatens that safety and stability.
We’re also forgoing some crucial basics: the chance to weigh and measure a child’s weight, length and head size to track their growth; to screen them for autism or other developmental problems; to test their blood to make sure they are not anemic or exposed to the toxic effects of lead; to make sure a patient’s mother is not experiencing postpartum blues, depression or psychosis; to screen their hearing and vision. We risk losing track of a cohort of kids with under- or undiagnosed physical, developmental or emotional problems and the chance to intervene sooner.
I began my reflection with the discomfort of what it’s like to see a patient in the office. And they do come, often due to motivated parents who want to make sure their kids stay up to date on those aforementioned health needs.
But if access to care were a concern before, we’re now handcuffed by the need to make sure we provide a covid-safe practice. We stick dots and arrows on the floor and remove or tape up seats in our waiting rooms to keep people six feet apart. We screen everyone for the disease before they come in and at the door with a temperature sensor. We scrub, scrub and scrub between patient visits. If we need to send them for an X-ray or lab test, radiologists and phlebotomists who will draw their blood have their own safety procedures to adhere to. These actions are the right thing to do and yet they have the unintended consequences of creating bottlenecks.
Finally, and most personally for me, I miss the social aspect of medicine.
Our engagement with the youngest, more darling population of patients is obscured by the fog on my glasses and glare of my face mask. The necessary barriers widen the gap between pediatrician, patient and parent.
There’s also a growing chasm of collegiality.
I work in a group practice of pediatricians and other specialists. During less turbulent times, our hallways bustled with activity as colleagues and staff members moved around to see patients. I could walk down the hall and chat; ask a question about a complex patient; commiserate about a hard day; sit down and have lunch in the break room with a mash-up of people.
Now, the halls are eerily quiet as we sit in our offices and care for patients via email, phone and video.
All of this has forced us to think differently about how we deliver care. Chief among them is that we can turn cars into clinics. Drive-through coronavirus testing has spawned experiments in drive-through vaccinations for kids and even drive-through blood draws.
Other improvements are afoot as well: Groups of doctors are working together to provide best practices about how to examine patients over a video visit; we are learning how to do developmental screening using video visits or structured questionnaires to have parents answer online. It helps to have Zoom-like video and chat on our computers to maintain our professional and personal connection. We recently celebrated a colleague’s retirement that way as each of us sat in our offices eating cake and roasting him over our webcams.
But to my question: Are children getting the care they need? No. But all of us — doctors, parents and our health-care system — are doing the best we can, as we wait impatiently for a vaccine and better therapeutics.
Covid-19 will not last forever. I’m hopeful that when we come out on the other end of this madness, we will not just be able to catch up. I’m hopeful that we will take what we’ve learned to build better ways of practicing medicine.
Most of all, I’m hopeful for the return of a busy clinic filled with patients, their parents, my colleagues, and looking forward to the day I can take off this anti-covid armor.
Rahul K. Parikh is a physician and writer in the San Francisco Bay area.