Primary care providers often tell patients who feel sick to drop by the office – but not so much if they have the flu.
How does it work during a global pandemic?
“Let's keep people who are sick in their houses,” Dr. Richard Charles said Thursday morning as the volume of phone calls began to quadruple from a typical day in his downtown Buffalo office.
Charles, chief medical officer with General Physician PC, and other primary care providers spend most of their work hours tending to patients recovering from injury or surgery, battling chronic disease and trying to stay on a path to good health.
That changed several weeks ago, with reports COVID-19 had spilled onto cruise ships, then into the Pacific Northwest and, in the last two weeks, into New York State – including Erie County.
As the challenge heads toward those on the front lines of medical care, many believe it is best handled by phone or online for the benefit of patients and providers. Leading primary care providers in the region believe the arrangement will assure more safety, slow the spread of the potentially deadly novel coronavirus and help at the tail end of a hectic influenza season.
The added workload involves easing patient anxieties, determining along with county health department employees who should get COVID-19 testing, and helping arrange hospitalization for the most seriously ill patients.
Regional health care workers have been preparing for the worst, hoping for the best, and bracing for the first confirmed COVID-19 cases in the region.
“People probably are going to react in a panic, when they should react by just taking a step back,” said Dr. Joseph Corigliano, a family doctor and chair of the Primary Care Department with Buffalo Medical Group. “They should realize that this is very similar to the flu in terms of symptoms, and the fact that chances are they're going to recover if they get it.”
A need for more testing
Corigliano said most patients who called his Amherst office before the middle of last week voiced concerns about travel, visiting with older relatives or having kids come back to Western New York from school.
Those calls continue, but a greater percentage now come from patients experiencing flu-like symptoms.
Charles worked closely with the Erie County Department of Health last week to determine which patients should get a novel coronavirus test. They included a traveling nurse practitioner who visited Italy a few weeks ago, came down with an upper respiratory infection and was feeling better. The recommendation was no.
Dr. Roseanne Berger, a physician with UBMD Family Medicine, said she and other providers want to see more test kits made available, and testing parameters expand.
"We wish there would be a way to get rapid and quick testing, which is a concern that many of us have. We don't know what we don't know," said Berger, also senior associate dean for graduate medical education in the University at Buffalo Jacobs School of Medicine and Biomedical Sciences.
Primary, urgent and emergency care staff so far have started with three questions for patients with colds, coughs and stuffiness:
• Do you have a fever of at least 100.4 degrees, a worsening cough or shortness of breath?
• Have you or someone you’re close with traveled within two weeks of feeling sick to COVID-19 hot spots, including China, Italy, South Korea or another region with widespread or sustained community transmission?
• Have you been in close contact with someone who has COVID-19?
“If they check the right boxes, then we’re getting them tested,” said Corigliano, whose practice includes more than 40 primary care doctors and several physician assistants and nurse practitioners in 10 offices in Erie and Niagara counties.
Patients who don't check as many boxes are encouraged to stay home, treat their symptoms and contact the office if they intensify.
State and county officials are working to broaden testing, which will start this week. That could lead to a greater understanding about how COVID-19 is spreading.
“This is a very fluid process,” Corigliano said.
As is the case with many primary care practices, patients with the Buffalo Medical Group and General Physician practices are encouraged to reach their doctors through a web portal. They can ask questions that normally are answered within 24 hours. These days, with health concerns so high, BMG is among providers trying to get back to patients within an hour.
Nursing teams are among those handling calls at General Physician, which has more than 1,200 employees in 22 offices, including specialists, 41 primary care physicians and almost the same number of nurse practitioners and physician assistants.
“Our goal is to keep patients in their home and call your doctor,” Charles said. “Let us know what your symptoms are. Let’s walk through the criteria.”
“The electronic visit gives us a nice opportunity to interact with the patient,” Corigliano added. “We have specific questions embedded within the visit. The patient can give us their symptoms, how long they’ve gone on, etc. We're able to glean a lot of information from that in order to make a decision.”
Tip of the iceberg?
Many providers already are juggling phone calls and swapping work-related text message with patients.
“ ‘I'm going to Utah, doc, and I'm just nervous,’ ‘I'm 90 and I'm in the West Indies. Can I come back?’ These are the kinds of questions I'm getting,” Charles said.
“As this gets bigger, we know we're going to start to have other concerns,” he said. “We're going to have employee concerns. We could have people out of school. How do we take care of our employees? We know that we could be unable to staff all our offices. How do we start figuring that out?”
Those interviewed for this story suspect that the number of cases could grow exponentially as testing becomes widespread. The good news is that an estimated 80% of those who contract the virus can manage it without medical treatment.
The hope is that by recommending people stay close to home, the numbers can be limited. If not, they fear those most at risk – over 60 or with compromised immunity – could overwhelm the regional health care system.
Part of the effort will start with patients – and employees – who try to enter a hospital, nursing home or medical practice with symptoms of a cold or the flu.
Signs have gone up at the General Physician office on Main Street, where Charles works, telling visitors to stay away if they’ve traveled to nations where COVID-19 has been more common, or have come in contact with someone who has, and to call instead. If a patient is ill, they immediately will be given a surgical mask to wear, lowering the prospect of spreading disease to other patients, as well as staff.
“I’ve had the flu twice already this season,” Charles said, “and I got vaccinated.”
Starting Monday, staff at UB School of Dental Medicine will take a three-pronged approach with patients at its dental clinics. When they confirm an appointment, they will be asked if they have flu-like symptoms and have been in coronavirus hotspots. They’ll be asked the same questions when they check in for treatment. They also will have their temperature taken.
A similar process likely will become standard protocol in dental offices across the region, said Dr. Joseph J. Zambon, dean of the UB dental school.
Buffalo Medical Group will handle sick patients in similar fashion to General Physician PC, Corigliano said, and will direct patients with respiratory conditions to an isolation room.
At this stage, primary care practices are not taking samples for COVID-19 testing in their offices. Charles, Corigliano and others are conferring with county health department public health nurses, those specialists are traveling to homes to test patients deemed a priority, and the tests are conducted in a county lab. Patients are quarantined until results are available. They face a mandatory quarantine if they test positive. As of Saturday, nobody had.
It’s key, Charles said, that patients call their primary care provider if they believe they might have contracted the novel coronavirus, get screened properly, and wear a surgical mask if they leave their home.
Vigilance will be important for everyone as health care providers work to reduce coronavirus transmission and focus on the sickest patients, doctors say. Everyone can help by directing coughs into their elbow, washing their hands – especially before arriving and leaving a destination with others – and keeping common surfaces clean. They also should avoid those who are sick and stay away from others if they are ill.
“I'm telling people to live their lives,” Corigliano said, but take far greater precaution if they have serious health conditions.
That collective approach will help those like Hope Planter, 88, who had her left hip joint replaced and visited the General Physician downtown office Thursday for an orthopedic appointment. Afterward, she and her daughter, Zina, 62, stopped to see Charles to talk about COVID-19.
The elder Planter – a clean freak who has arthritis but no chronic heart or lung conditions – plays cards with a small circle of friends on Thursdays and Fridays. Charles told her she was welcome to keep doing so unless one of her friends was sick. She also was encouraged to keep her distance from her grandchildren.
“It’ll be hard to stay away from the grandkids,” her daughter told her, “but you’ll do it.”
The COVID-19 pandemic arrived at the tail end of the flu season, when patient volume already was so high that many doctors spent the last few months with patients beyond regular business hours, Charles said.
He relishes the latest challenge – and the difference he can make as a primary care provider – but said other doctors he’s talked with see the novel coronavirus “as one more thing” in a very demanding career.
“One of the things we’ve talked about,” he said, “is how do we support our colleagues?”
The primary care doctor hopes COVID-19 will fade with the chill of winter. He knows that’s not always the way coronaviruses work.
The regional health care system has emergency plans in place, capable health providers throughout, and top-flight researchers, Charles said – but this is a daunting time.
“You have to be prepared,” he said. “What really reassures me is the leaders and others in the health system are prepared. They are thinking, ‘What if this goes to Def-Con 4? How do you get more ventilators? How do you get more ICU beds? How do you better handle what happened today?’
“Say tomorrow we wake up and COVID-19 is gone. There's going to be a next time, and I think we've learned a lot about how this all works.”