Q&A: How Physicians Should Adjust Practice to Cope with Coronavirus
MARCH 12, 2020
Robert McLean, MD
While more and more is being learned about this novel disease at an incredible pace, many clinicians outside of the Centers for Disease Control and government organizations may find themselves playing catch-up when it comes to practice recommendations for this unique and delicate situation.
To learn more about how the coronavirus pandemic might impact how clinicians practice and what steps clinicians should be taking, HCPLive® caught up with Robert McLean, MD, a practicing rheumatologist and incoming president of the American College of Physicians, who took part in a Q&A on that very topic.
HCPLive: How concerned are physicians and how concerned should they be that somebody may come into their clinic with something like this?
McLean: I think given the uncertainty around the coronavirus, the data seems to be telling us that it is quite contagious, much more contagious than flu in terms of closeness of contact and how many people seem to be getting it from relatively casual contact in the community, although without adequate testing, we really don't know the denominator yet.
The extent of spread still remains and the uncertainty, which I think is one of the factors contribute to a lot of anxiety around it. With that in mind, I think there's a lot of concern that a lot of public health measures and societal cultural measures need to be put in place to try to minimize contact in different areas to try to decrease the possible spread.
Part of the problem is it seems people might be relatively asymptomatic and still contagious for several days—maybe even 4 or 5 before they are actually very sick. So, that raises a concern of some sort. I think in doctors’ offices we clearly have to be more worried about a potentially sick patient:
A. Being contagious to other patients in our office,
B. Being contagious to our medical staff, and
C. Being contagious to us.
So, there is a lot of concern about patients coming in. One of the problems is that the symptoms are, quite frankly very similar to the flu. So, whereas in the past people have had flu like symptoms and we brought him in to the office—we felt comfortable putting a mask on them and keeping them out in a safe way in the waiting room.
It's not clear that's adequate for the coronavirus and—on the basis of that and some of the recommendations from the CDC that testing be done in negative pressure rooms and all these kinds of things—most of the recommendations are to not bring people into the office. Even for flu vaccines because, quite frankly, they might be having coronavirus and we don't have the testing for that.
HCPLive: Are any specific precautions clinicians should be taking outside of normal care?
McLean: Not doing testing for influenza in the office to decrease the potential contagious nature of it is a real paradigm shift that I think a lot of people are coming to grips with.
I think the most important things is to try to reassure patients who call with different types of respiratory symptoms that there are some appropriate questions asked and there probably needs to be a low threshold for a clinician who can ask some more detailed questions with some clinical experience and judgment to get on the call, potentially the doctor, to decide does this person seem to be at risk for influenza or COVID-19?
They should not be coming into the office, but also gauging are they sick enough that maybe they need to be hospitalized. if that's the case, that would be a reason to send them to the emergency department. If in fact, they just seem sick, but not so sick that they seem they need to be hospitalized and I think we are moving to where we need to be giving people reassurance and instructions on how to manage themselves for what is likely a viral illness of some sort—whether it's COVID, whether it's influenza, or some other of the many respiratory viruses in the following days to make sure that people aren't going the wrong direction.
I think it’s moving to a paradigm of care where we are comfortable with either telephone or telemedicine. In some places, groups set up the possibility of video visits and I think that this epidemic crisis of concern is going to lead to the use of the modality to really expand greatly, and that's a significant change.
HCPLive: Is there any reason to discontinue any sort of therapy or treatment if your patient develops COVID-19?
McLean: There are 2 answers to that. From a primary care perspective, primary care perspective probably not depending on where you are practicing and how much specialty care they have in their community.
As a rheumatologist, I have a lot of people on different immunosuppressive medicines for autoimmune rheumatologic conditions. When they get sick, and especially now with the uncertainty here, I have a very low threshold to tell them to not take their immunosuppressive medication for their rheumatoid arthritis or other conditions for the next week or more. Fortunately, a lot of the conditions that we have that are autoimmune, people can hold these medicines for a week or 2 when they're sick and their underlying conditions are usually not going to flair.
I think the primary care doctors need to, and they typically do, know their patients well enough and know if they are on these medicines then they need to make sure that the patients contact a specialist or tell them themselves you probably need to consider holding your immunosuppressive medicine for the next week or 2 while this is going on.
In terms of the standard medications for blood pressure or diabetes medicines—typically, there's no reason they need to be stopped. I think for a number of those medicines—if people are really getting sick and dehydrated because they're so sick, things like diuretic medicines and things that might be contributing—maybe people should not be taking medicines that might further make them worse.