What is routine? Preventative care in the age of COVID.

Since the arrival of COVID-19 in America, most health care systems have adopted a policy delaying non-essential or non-urgent procedures and appointments in the hopes of preserving PPE and minimizing interpersonal exposure. Despite resultant furloughs, frustrations, and massive financial losses, the practice remains relatively non-controversial as the safest course for patients and staff. Numerous professional societies have subsequently released guidelines defining what kinds of conditions can and should be deferred. However, it remains unclear how long such delayed care will be necessary, what procedures will be included, and who will ultimately decide what care is and is not allowed.

Experts estimate efforts to contain COVID-19 will last months, if not years, with subsequent waves being even more severe. Consequently, we cannot reasonably assume a return to post-COVID standards anytime soon. As America’s health care system faces this unprecedented new normal, returning to financial solvency and the delivery of evidence-based, comprehensive care will require the development of flexible and creative policies that we have barely begun to explore.

I first witnessed the precarious position in which our patients are put by delaying care with a man who needed endoscopy for acute, relatively severe dysphagia. For better or worse, the hospital’s policy was a near-total prohibition on non-emergent aerosolizing procedures like endoscopy. No one was willing or able to step in, so he was sent home with a modified diet and a great deal of uncertainty about when his workup could continue. Sending that patient home without a clear plan felt like the medical equivalent of stepping away from a stove without setting a timer. While his condition will be monitored through a telemedicine clinic, that will be of little comfort to him or his family if his symptoms continue to worsen. Across specialties, providers have written about similar issues from missed myocardial infarctions to cancer patients facing delayed tumor resections. Just today, I saw a patient with brain lesions that we don’t know how to treat because our surgeons do not feel safe doing a biopsy until he tests COVID-negative. Unfortunately, he has been sent home to wait with persistently positive tests for over five weeks now.

After only a few months, our ability to provide preventative medicine and early, aggressive treatments has radically deteriorated. Many hospitals and clinics are still struggling to cope with the initial phases of a pandemic, such as acquiring adequate PPE. As stay-at-home orders are rolled back, many remain wary of a second infectious peak that would push our system further into default. Even in the unlikely best-case scenario, development, and distribution of an effective vaccine within the year, we are facing enormous socioeconomic consequences of what has already come to pass.

Besides well-intentioned concerns of draining resources from COVID patients, many people harbor a deep fear of virus exposure in a clinic or hospital. To further compound issues, unemployment rates continue to rise, leaving vast swaths of the population suddenly without health insurance and hesitant to present for care they cannot afford. For example, despite evidence of hypercoagulability in COVID sufferers, neurologists are actually reporting an overall decrease in patients presenting with stroke. It is unlikely that people have miraculously stopped having strokes and much more likely that people with minor or transient symptoms, which may herald an impending catastrophic infarction, are not presenting for evaluation. On the other end of the age spectrum, rates of childhood vaccinations have plummeted despite reassurance as to the safety and importance of staying on schedule.

In the coming years, we may expect an increase in complications from chronic conditions like diabetes and hypertension, more advanced presentations of progressive diseases like cancer, and a potential resurgence of preventable diseases like measles. And, of course, minority and low-income communities will continue to be hit the hardest.  We cannot presume to know when patients will again feel comfortable seeking early evaluation, and we certainly cannot assume that our system will have the capacity to manage them once they do.

Needless to say, the resultant increase in morbidity and mortality is an unacceptable disservice to patients. How long can we ask people to wait for care we have dubbed elective, even though all care, at its core, is essential? How long can we stall before preventable harm reaches a critical mass? At what point does routine become urgent? Patients and providers alike understand that sacrifice is necessary, but sacrifice alone is not a long term solution.

Those of us not caring directly for COVID patients need to start considering how we can minimize the catastrophic impact on our ability to provide primary and chronic care. Delaying care, even for an excellent reason, will eventually catch up with us. The more we plan now, the more likely we will be to find solutions that adequately mitigate harm for patients and us. If we hope to reopen society, providers are in the best position to lead the push for better access to PPE, testing kits, telemedicine reimbursement, and health care coverage for all. COVID is on track to catalyze a total overhaul of how we provide and pay for health care; if our country can come together to embrace change, we may even be able to improve access in the long term. Whatever happens, we cannot wait long. We must continue to fight for our patients’ needs in both sickness and health.

Kaci McCleary is a neurology resident.

Image credit: Shutterstock.com

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