Extending lessons learned to a post pandemic world

Since COVID-19, the way that we practice medicine has changed. Every patient we see, test we order, and treatment we prescribe is under closer scrutiny. Direct patient interaction has been cut to the bare minimum. This has proved to be a challenge in many ways, forcing us to adapt to a new model of medicine. Counterintuitively, this model may lead to better training, utilization of testing, and increased access to care. While it has been difficult to completely change our practice during my last year in neurology residency, I have firsthand seen these positive changes that can potentially lead to improved training and patient care once the pandemic is over.

As a neurologist, I often order multiple brain and spine CTs, MRIs, and PET scans daily. However, we are now working in a resource-limited environment, and the stakes for imaging and testing have become much higher. One CT or MRI scan opens up nurses, transport staff, radiology technicians, radiologists, and environmental services to potential exposure. Likewise, the patient is also exposed. All the equipment needs to be decontaminated, which sometimes can mean hours before the scanners are operational again, delaying care for others. This has required me to practice medicine without the safety net of having additional testing. It has been a return to the fundamentals of medicine, with increased emphasis on the history and physical examination to guide diagnosis and treatment. Now, I am doubly conscious about ordering potentially unnecessary laboratory testing or imaging, which is a dangerous practice in itself. Unexpected incidental findings occur in as much as 10% of patients. For a large percentage of patients, these findings are benign but cause unnecessary, worry, stress, and further testing. While this has required us to prioritize and triage testing, this higher threshold will ultimately help to address and lower these incidentalomas.

COVID-19 is also shifting our normal inpatient model of care to an outpatient model. Normally we would admit patients to the hospital for transient ischemic attacks or small strokes. Now, as we are consciously minimizing exposure for our patients, we are sending them home with expedited outpatient workup and follow up. Other institutions have recently implemented these measures before COVID-19, without any significant decline in care. It was previously harder to expedite rapid follow up because of physical limitations and time constraints. Now those obstacles are easier to overcome with virtual visits. While virtual visits cannot fully replace in-person interactions, they are helping to increase access to care. Certain specialists, such as neurologists, are in limited supply in the United States. However, there are certain areas with clusters of specialists, especially in cities with large academic medical centers. This disparate proportion of specialists ultimately contributes to health inequities, especially in poorer urban or rural communities. Even where I practice in Boston, patients with limited means often miss appointments because of lack of transportation or inconvenient scheduling. It can also take up to three months to schedule an initial visit with our neurology clinic. As many providers have switched to a virtual format, the availability of appointments has increased dramatically. I was able to see one of my patients on a Sunday evening via a virtual visit because it worked better for both of our schedules. Previous virtual visits before the pandemic usually required some type of computer or expensive equipment. Now, as care has expanded, and technology has been streamlined, patients can use their cellphones for these visits. Continuing to expand virtual visits after COVID-19 can immeasurably help provide better access to care.

COVID-19 has meant many things for the health care system. However, not all of them have to be detrimental. There are lessons and silver linings to take away. As a resident, I have been reminded of the importance of history taking and a good physical examination. It has forced me to hone my clinical skills and think critically about ordering further tests or treatments. For our profession, it has made us adapt to a more outpatient and virtual model. While we may lose some of the personal interaction of a face to face visit, this is mitigated by the improved access to care for all. As we return to a state of normalcy, we should not be so quick to revert back to our old models, but rather we should integrate some of the new adaptations we have made.

Josh Budhu is a neurology resident and can be reached on Twitter @joshuabudhu.

Image credit: Shutterstock.com

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