This is the eighth in a series of posts made in preparation for a presentation I will be making for physicians in fellowship training at an upcoming ACCP meeting. In...
In March 2020, outpatient medicine as we previously knew it changed, perhaps forever. The COVID-19 outbreak was accelerating in the United States and by the beginning of June, it would kill more than 100,000 Americans. People self-isolated in their homes, businesses shut down, and hospitals prohibited visitors. Patients were scared to go to their doctor’s offices and doctors were scared to be in their offices with patients.
In Ohio, the Governor and the Director of the Department of Health issues orders to stop elective medical testing and procedures. Medicare eased restrictions on telemedicine so that patients could still see their physicians without risking exposure to the virus in the doctors’ offices. All of a sudden, it wasn’t safe to go just about anywhere.
Today, our state’s medical practices and hospitals are opening back up for regular medical care and procedures. But the virus is still in our communities and is still causing hundreds of deaths per day. So, is it safe to go to your doctor’s office or to your hospital for an elective surgery? As usual, the answer is… it depends.
In the era of COVID-19, the moment we step outside of our homes, everything we do is a calculated risk. Going to the grocery store for on-line ordering with curbside pick-up is relatively low risk. Going to a sold-out concert and spending 4 hours in a mosh pit is relatively high risk. In our community, many people have died because they got infected with COVID-19 but many others have died because they stayed home in fear of the virus rather than going out to get needed medical care. So, how do you know if it is safe to go to your doctor’s office? Fortunately, there are several things that you and your doctor’s office can do that will improve the safety of patients coming in for medical care.
- Limit visitors. The risk of getting infected with COVID-19 increases with the more people you have close contact with. By limiting visitors, there will be fewer people in the building and statistics will be in your favor. Ideally, there should be no visitors except for those necessary to accompany patients with impairments.
- Screen everyone entering the building. This means asking if people have had contact with persons known to be infected with COVID-19, if they have fever, or if they have cough. Ideally, everyone entering the building should have their temperature checked at the entrance.
- Provide masks. The main reason for non-medical people to wear a mask is to prevent them from infecting others – wearing a mask does less to help keep you from getting infected yourself. When I go to a store, I wear a mask to protect everyone else from me, not to protect myself from everyone else. Buildings where everyone else is wearing a mask are buildings that are safer for you to enter.
- Improve throughput efficiency. The less time that a person is in the building, the lower their potential exposure risk. Strategies can include pre-visit registration on-line, reducing time spent in waiting areas, and minimizing time between tests and the doctor’s appointments (for example, the time between a doctor’s appointment and getting an x-ray in the same building).
- Safe waiting rooms. Most doctors’ offices and hospitals have waiting rooms that are designed to fit the largest number of people comfortably in the smallest space possible. In the era of COVID-19, there should ideally be 6 feet between people in the waiting areas. This means that most waiting areas should only hold about a quarter of the number of people that the same waiting areas held in the pre-COVID-19 era. Waiting areas can be restructured by removing chairs and by putting up plexiglass or other barriers between chairs.
- Don’t shake hands. Almost overnight, the handshake has gone from a welcoming greeting to a threatening gesture.
- Go before you go. The fewer doorknobs, handles, and buttons that you have to open, press, or push, the lower your risk of acquiring the COVID-19 virus if the person before you opened that door, pressed that toilet handle, or pushed that elevator button. Use the restroom before you leave home.
- The smell of disinfectant is perfume to your nose. If the exam rooms smells like fresh bleach or alcohol-based disinfectants, then the office staff are likely sanitizing that room between patients. That will make chair hand rests, examination tables, and counter tops safer for you to touch.
- Use telemedicine. Sometimes, an in-person visit with the doctor is necessary. A physical examination may be required. Maybe you need a vaccination, a blood draw, or an EKG. However, many (and maybe most) doctor’s visits can be done by video visits or even telephone visits. Currently, Medicare and many insurance companies are relaxing restrictions on telemedicine so that doctors can get paid to do telemedicine visits whereas in the past, those insurance companies would only pay for face-to-face office visits. If you can get everything accomplished by a telemedicine visit from the safety of your own home, then do so. A side benefit of telemedicine is that if the doctor is doing two thirds of the visits by telemedicine, then there will be fewer patents in the waiting area and fewer patients in the building thus making it safer for those patients who do require an in-person visit. Because I care for patients with COVID-19 in our hospital’s ICU, I am sensitive to the fact that many of my outpatients would rather not be in the same room as I am on the outside chance that I could have picked up the virus and either be asymptomatically shedding it or be in the incubation period before full-blown infection. Therefore, even if my patients have to come in for pulmonary function tests or x-rays, I will still offer them a telemedicine visit so that they can come in, get their tests, go home, and then have a telemedicine visit with me later.
- Schedule acutely sick patients for the end of the day. In the past, I often used the last appointment of the afternoon for those patients who I anticipated would need extra time for counseling – that way, if I spent 30 minutes for a 15 minute appointment, I wouldn’t be behind on my schedule for all of the subsequent patients. Now, I’d rather have that last patient of the day be the one who has more acute respiratory symptoms so that most of the other patients are out of the building and the waiting area when a patient who could potentially have COVID-19 shows up.
- Show up on time but not too early. If your appointment with your doctor is at 11:00, don’t come to the office at 10:00 or you will have to wait in the waiting area for an hour. But don’t be late either since you might then have to wait an hour or two until the doctor has another opening on his/her schedule to fit you in.
- Hand sanitizer everywhere. Ideally, there should be alcohol-based hand sanitizer in waiting areas, hallways, offices, and exam rooms so that office staff and patients can sanitize their hands as often as possible.
- Keep COVID-19 patients away from other patients. Most patients with COVID-19 are treated as outpatients but they still need regular medical care. Our medical center has drive-up swabbing stations to safely test patients for COVID-19 infection in their own cars and we also can do blood draws at these sites so that patients with known COVID-19 infection can get regular blood tests, such as INR levels if they are on anticoagulants. This keeps patients with COVID-19 pneumonia from having to go to the clinic lab to get those blood draws and thus keeps them away from healthy people.
- Don’t touch your face. One of the side benefits of wearing a face mask is that it will keep you from subconsciously touching your mouth or nose after you have touched a surface that harbors the virus. If you need to blow your nose or sneeze, use hand sanitizer both before and after you use a tissue.
Most hospitals and physician offices are actually fairly safe, as far as COVID-19 is concerned. There is heightened attention to infection control, hand sanitizing, and masking that is not as universally practiced at other venues such as stores, gas stations, and public spaces. That being said, there are steps that both the doctors and the patients can take that can make outpatient visits even safer.
June 6, 2020