For MedPage Today‘s “After the Pandemic” series, we asked our editorial board members to discuss what significant and lasting effects the COVID-19 pandemic will have on medicine and the delivery of healthcare.
Here, we interview Bob Doherty, Senior Vice President of Governmental Affairs and Public Policy for the American College of Physicians (ACP).
Check out some of our other articles in the series here.
How will internal medicine change as a result of the pandemic?
Doherty: One result is that people have discovered how important internal medicine is in our healthcare system. The value that internal medicine physicians bring to healthcare was greatly illustrated during the pandemic, not only in the sense that internal medicine physicians were on the front lines treating COVID-19 patients — whether as primary care physicians or infectious disease specialists — [but] they were leading the evidence-based response to COVID-19. And the simple fact was that the most trusted spokespersons on COVID-19 have been internal medicine physicians such as Dr. [Anthony] Fauci, [Surgeon General] Dr. [Vivek] Murthy, and [CDC Director] Dr. [Rochelle] Walensky. If you turn on the news every night, chances are the person speaking truth to science about COVID-19 is an internal medicine physician.
Overall, the pandemic has changed this specialty just like it has affected other specialties. Video-enabled telehealth with smartphones and audio-only consults with patients have become a major element of the care provided to patients. For many months, most care was delivered remotely because internal medicine physicians heeded the call to suspend elective visits, when COVID was spreading so rapidly and hospitals were overwhelmed — during that time, most care was provided by telehealth. We fully expect that to continue, although obviously, most internal medicine practices returned to seeing patients, it was probably fewer than pre-pandemic, and with precautions of course. Patients have come to expect doctors to be available by phone or notebook computer, and I think that’s going to continue. I think physicians found it a valuable way to interact with patients.
A lot of what else will have to change is payment structures and regulations relating to telehealth. The easing of regulatory restrictions on telehealth were only authorized for the duration of the public health emergency, but without support and flexibility, physicians will not be able to provide telehealth. That’s a major focus for ACP. There needs to be sufficient payment to physicians for providing those visits, and there needs to be support for them for their systems, including access to technology. The downside to telehealth is that it can exacerbate healthcare inequities — those with a cellphone or notebook computer can see physicians virtually, but patients in rural areas or who are not computer-savvy or only have flip phones may not have access — so there is that worry. If telehealth is going to reach its promise, we need to address broadband access, so people in rural and underserved communities have access to these services. That’s going to need to be part of policy going forward.
How will the pandemic affect the way internists are paid?
Doherty: The pandemic showed how vulnerable physicians are if they’re only paid via fee-for-service. If you’re a primary care internist, you get paid by how many patients you see in the office, and suddenly, they had no patients coming into the office — no fee generated, no payment to keep the practice open. Although they were able to shift to telemedicine, to a considerable extent, the payment they were getting for those encounters was not sufficient to offset the loss in revenues. Because of that, many physicians had to apply for loans. Many practices had to lay off staff, and many physicians stopped taking salaries themselves.
So it was a struggle. I think practices are coming back now, but many are still struggling, and not coming back from the losses they experienced. And many doctors who were working for large healthcare systems took pay cuts, because their revenues were down also. Practices also had to incur a lot of expenses in terms of redesigning waiting rooms so people weren’t crowded together, putting in online scheduling systems, and erecting plexiglass to create barriers between staff members and patients, for controlling infections. And there was PPE [personal protective equipment] — N95 masks are not cheap.
What about burnout?
Doherty: It’s a huge concern. Even before the pandemic, there was growing evidence of burnout among physicians, including high suicide rates; some dealt with it by substance use. It’s a real problem, but it got worse during the pandemic, and still is. Physicians have been scarred to some degree with the challenges of being frontline physicians taking care of patients who were very sick, and not being able to get PPE themselves. They had to worry about bringing the disease back to their families if they’re exposed to a patient with COVID.
There are the worries about keeping the doors of their practice open, but then I think there’s another element, of frustration: They’re doing everything they can, even putting their lives on the line — and then they’re seeing talking heads on TV and politicians on social media platforms saying that it’s not necessary that you wear a mask; it’s an infringement on your freedom. And now they’re saying don’t get vaccinated; there is all this misinformation out there, and the peddling of fake therapies that have no effectiveness. That frustrates physicians — they’re doing everything they can to keep their patients well, and at the same time, those things we know to be effective are being undermined in the public sphere by politicians, talking heads, anti-maskers, and governors in states that were prematurely lifting mask requirements. It is dispiriting to physicians — it just makes their job so much harder.
Most struggle to continue what they’re doing, but the harm is there. ACP is supporting the Lorna Breen Act, which will provide resources to clinicians who’re experiencing symptoms of burnout in a non-stigmatized way. And that’s the other thing — the stigma needs to be removed. Many physicians are reluctant to go for help because of the stigma associated with reaching out and saying, “I am suffering psychological harm”; physicians are worried if that became known, it could be harmful to them in their employment or their practice. There is so much that needs to be done … We need to change the environment in which they practice so they don’t feel disrespected, so they feel they’re getting the support they need — from their employers, from practices, from payers, and from politicians. Then I think you’re going to see the opportunity to begin to turn this around so fewer and fewer physicians feel they’re kind of lost.
Is internal medicine still a desirable specialty?
Doherty: Internal medicine is the largest specialty in the U.S., with the largest percentage of frontline physicians in the U.S., and the internal medicine match a couple of months ago was the highest ever. People are going into internal medicine in droves, and I’ve seen some reports that medical school applications are at historic highs.
So even though there are certainly many established physicians who are dispirited … It’s a range, not every physician is burned out; many physicians have found helpful ways of dealing with these stresses. I don’t want to generalize and say that every doctor is unhappy. Many physicians feel a sense of pride in what they’ve done to help patients through this horrific public health emergency, to meet the highest aspiration that comes with being an MD or DO physician. There’s that positive side. I think a lot of people going to medical school are seeing these doctors on TV speaking the truth, and seeing them being heroic in providing care to patients under historically difficult circumstances, so there is some positivity out there as well.
Also, I think more and more physicians are beginning to challenge the status quo that’s not working, and saying that we need big changes in the healthcare system; that’s what we hope to see happen. That still drives our advocacy.
For example, in this pandemic, one thing that’s lacking is communication between [vaccination sites] and the patient’s own physician. It’s not just getting shots to give to patients — it’s making sure that patients get their shots, where they get them, and that that information is communicated back to the physician. This shows the problems with our EHRs [electronic health records] … after decades of saying we need interoperable EHRs, it’s not a given that if you get a vaccination at a mass vaccination center — or Walgreens or CVS — that that’s going to be on the physician’s EHR; in all likelihood it’s not … In a better world, no matter where you got it, it would automatically have been entered into the electronic health record and showed up on the doctor’s EHR as well. It has shown how fragmented our system is. Hopefully we’ll learn from this pandemic to make our healthcare system better overall and be ready for the next public health emergency, because there will be another one.