One Year Later: Delayed care, missed visits put crushing demands on doctors

It didn't seem like that long ago I was filled with boundless energy, fueled by fear of an unknown virus facing an ill-equipped nation. Fear that kept me up at 2 a.m. reading preprint articles on COVID-19 and scrolling through Twitter. Three months into the pandemic, fear transformed itself into unfocused anxiety coupled with anger over the police killings of unarmed Black men. It galvanized me to march for justice and demand that health care institutions work harder to undo racism. 

COVID-19 doesn't evoke the same fear in me as it did a year ago. Now it merely makes me impatient, restless, and often just weary. Let's get this over with. It is a feeling one can experience only from a place of privilege in a pandemic — protected by a well-oiled health care institution with command centers, drive-through testing, PPE protocols, and policies 2.0, 3.0 and 4.0. An institution that kept its promise of no layoffs and offered work-from-home accommodations for those of us providing virtual care. 

But even here, we in primary care are exhausted. I know I am.

At the beginning of the pandemic, we prioritized safety for our patients and our staff and radically changed our clinic to provide telehealth services. We could replace many of our office visits with a safer alternative and still help solve our patients' medical problems. Many patients were grateful for our flexibility and ability to treat depression through the phone, diagnose skin rashes through photos, and provide answers about a frightening virus. 

For clinicians, the learning curve was steep. We had to figure out new technologies, master coding systems and follow new documentation requirements. I stumbled through video visits in which the delay between what the patient said and what I heard made conversation incomprehensible. I had to make decisions and develop treatment plans based on incomplete and inadequate information. Virtual medicine was not the kind of medicine I had learned in medical school. I had to learn it now, isolated from my peers. 

Amidst the ceaseless work demands, I greeted a newborn baby at home. The experience wasn’t what my wife and I had imagined. For our safety, our families made the tough decision to cancel their trips to invite their grandson into the world. My wife and I were our own, clinging to those precious moments of love and joy as we persevered through the sleepless nights and constant demands of a newborn.

“You’re hard to get hold of, doc!”

I gained proficiency in providing care by doing it day after day. But it soon became apparent that we could not solve many problems through telehealth. Abscesses needed to be drained, refractory shoulder pain had to be injected, and blurred vision could not be easily explained. Complaints like this required an in-person visit with a physical exam. We needed to change our strategy to keep telehealth accessible and slowly open the clinic to more and more patients.

By December, we had converted a significant portion of our visits to in-person care while doing our best to continue providing telehealth. Then one of my patients casually said, “You’re hard to get a hold off, doc!" I thought it was a comment on our initial, unsuccessful attempt to deliver all care through telehealth. But as the weeks went on, I heard similar words from more patients. I realized that the wait for an appointment had stretched from a couple of weeks to a month. My schedule was filled with the names of patients I hadn't seen in nearly a year, sometimes more. 

 I was used to working 12-hour days, but this felt different. While my workload increased, what struck me was the impact of the delayed care. Some patients had missed necessary care due to lockdowns and other restrictions. Acute pain had turned to chronic pain from delayed surgeries. Sobriety was lost to lonely nights at home. Heroin relapses occurred as support groups evaporated.

Other patients had skipped care because they underestimated the risk of delay. I saw patients whose hemoglobin A1c levels, a measure of blood sugar over time, had skyrocketed as they stopped exercising, reverted to unhealthy nutrition and became less diligent in taking their medication. I saw a patient who had severe gout that led to such large lumps of accumulated uric acid under the skin that he could no longer wear shoes.

While many patients were coming in for urgent care, others showed up for delayed preventive visits. Even though I had seen the harsh prediction that delayed cancer screening might lead to an additional 10,000 deaths, I became frustrated seeing patients who were well while I struggled to find time to care for people with acute and uncontrolled chronic conditions. I started overbooking myself, squeezing in patients at lunch, between other patients and at the end of the day.

The surge in demand seemed untenable. But the pandemic had taken its toll on our institution, as it had with many others. We had decreased revenue as patients lost their insurance, and increased costs from all the COVID-related care, including multimillion-dollar investments in testing sites and vaccination clinics. While some other organizations had laid off and furloughed staff as cost-cutting measures, our organization had not. In primary care we had to do more without more resources.

The vaccines arrived as we were addressing our backlogged demand. My enthusiasm was tempered by our organization’s request for volunteers to vaccinate our patients at weekends clinics. The messages that we were "heroes" for giving our time to help end the pandemic felt surprisingly hard for me to internalize. We had been waiting for this moment for nearly a year, but the mounting demands had drained me. Nevertheless, I pushed through it and signed up to give vaccines — shake, clean, load, vaccinate, repeat.

There's guilt in exhaustion. I wasn't in the ER or the hospitals with ICUs filled with COVID-19 patients. Nor did I lose family members to COVID-19. At one point, more than half the deaths among physicians were in primary care, but I had made it safely through to the other end. I was vaccinated weeks after the first shots were authorized for emergency use. 

I know I should be grateful for my safety and thankful that we have vaccines. I am. But I am also exhausted. We all are running on fumes.  

With more than 2 million vaccine does administered daily in the US, I see the end is nearer. I hope we all can reward ourselves with rest when this nightmare is over. Then let’s not simply go back to the way things were in health care, where physician burnout was rampant and too many patients didn’t get care when they needed it.  I hope we rebuild a health care system that prioritizes equity and serves the needs of all patients with compassion and dignity — a system that fills me with purpose, energy, and even joy as I show up at work every day.