Opinion: The race to where? A primary care session during the pandemic

The green dots on the schedule screen in my primary care office light up in rapid succession. All of my patients are arriving.

“Don’t look too hard at the board, it will just stress you more about the busy schedule,” I think to myself. Still, I note that one patient arrived early and will be waiting for a long time before he sees me. And one mom brought her newborn baby. I don’t want them to sit too long in the waiting room, particularly when we are trying to socially distance patients during Covid-19.

Another patient’s transportation home is likely to arrive before she has a chance to go to the lab. Since half of our clinic visits are telemedicine, who knows when she will come back?

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The session started late. My first patient wasn’t ready for me until well after the assigned time for her physical exam, a visit that always takes longer than the allotted time because patients often come in with a multitude of concerns. Since it is even harder to get an appointment for a physical during the pandemic, I try to address all of my patients’ questions rather than making them reschedule.

I gradually fall further behind. Everyone wants to share their story. Patients have been waiting for months during the pandemic for a 20-minute in-person appointment. And all the issues and concerns that built up during the months our primary care office had canceled all non-urgent appointments come flooding out.

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My patients share news of new jobs, losing jobs due to pandemic furloughs, children growing and the difficulty of remote learning, new grandchildren, and sad reality of loved ones passing from Covid-19. They have been isolated and alone for long pandemic months. But today they are out and about, talking with their doctor in person!

Hungry for social interaction, they linger more than they did in the past. They inquire about my safety during the pandemic. I have missed seeing them and am worried about them; I want to hear about them, too. But connecting to our shared humanity slows down my clinical work.

Despite my careful pre-planning for the session, surprises pop up. The pandemic is making people feel more anxious and depressed, so we take the time to refer some to behavioral health. For patients who are out of work and struggling financially, we connect them with our community health worker. Some have used the Family and Medical Leave Act to care for loved ones with Covid-19, so we fill out paperwork. Pre-pandemic referrals to specialists have expired, so new ones are placed.

So many clicks of the mouse as I navigate through the electronic medical record; so many ticks of the clock as I run past each allotment of time per appointment.

I try to use each moment to the fullest, maximizing my efficiency — the e-word health care providers dread. The patient is changing back into their clothes — I am charting. The computer is warming up — I am establishing rapport and gathering the patient’s history. A letter is printing — I am reviewing with the patient how to take a new medication. I feel like the Looney Toons’ Road Runner. Meep meep.

During the day, I get a text from my at-home daughter who is doing remote schooling. Later, my daughter at college calls me via FaceTime. Both times my mind flashes to the worst-case scenario. I can’t help it — I worry: Is my daughter at home having trouble with our internet? Is my daughter at college calling because she has been exposed to or tested positive for Covid-19? So I text back or answer the call, just in case.

As I pass exam rooms where my patients wait, I peek in through my smudged face shield, flash my biggest smile under my mask, and cheerfully say my mantra, “I’ll be right with you. Thank you for waiting.” They reply compassionately, “You’re busy today, doc!” “Always,” I respond.

“You don’t even know,” I think.

A medical assistant asks me, “How much longer until you get to room 13?” This question means that a patient is frustrated with waiting. “Five minutes,” I chirp calmly. Inside I’m am tense and anxious, working hard to avoid losing it.

I have felt emotionally depleted during the pandemic. The work of the initial surge took so much out of me. My mask suffocates me. My face shield makes my head hurt. I am perpetually moving, constantly talking, always hand sanitizing, plowing forward. The adrenaline coursing through my veins leaves me breathless and my heart races. It feels like aerobic exercise, but without the endorphin high.

I make my way through the session. I sneak a glance at how many green dots remain, and compare them to the time. I quickly calculate how late I’ll be for the in-person work meeting scheduled for soon after the session is supposed to end.

After seeing my final patient of the morning, I can relax, not to mention pee, eat, and drink. In the privacy of my tiny office, it feels so good to take off my face shield and mask. But the race isn’t over. Now I need to complete my notes, order labs, and manage paperwork, as well as answer my messages. During the pandemic, patients ask their questions with new urgency. Everything is top priority. Clinicians like me are working more on our “off time” to meet these needs. This increased responsiveness comes at a cost to our well-being.

As I multitask — shoving down lunch, managing the post-session chores — I reflect on the session. Did I provide excellent care to my patients today? Did I miss anything? Did I rush and confuse someone? Are they complaining to friends or family right now that their doctor did not listen to them?

I feel like I am in a perpetual race. Every work day I show up to the starting gate, wishing for this day’s race to be different. A leisurely stroll, perhaps, where I could gaze at the scenery, pace myself to be in sync with each patient, take time for my bodily needs, not keep anyone waiting, and not disappoint anyone.

In the race of the primary care session, there is no finish line, there are no medals, and there are certainly no T-shirts for the first 500 entrants. The evidence concurs: Health care providers are burned out, spend too much time on administrative tasks, and work too much — and that was before the pandemic. Covid-19 has made it worse.

I worry about my mental and emotional health, and that of my colleagues.

Still, primary care providers show up every day, hoping something systemic will shift to make that day different.

Pamela Adelstein works as a family physician at the Codman Square Health Center in Dorchester, Mass.

Source: STAT