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A Piece of My Mind
April 27, 2020

Lost Space

Author Affiliations
  • 1Department of Medicine, Division of General Internal Medicine, Harborview Medical Center, University of Washington, Seattle
JAMA. 2020;323(20):2019-2020. doi:10.1001/jama.2020.7237

In early April, we learned that the prior month’s death toll in New York City had been more than twice the normal total. Deaths attributed to coronavirus infections only accounted for a portion of the shocking excess.1 Tragically, the only surprise in this devastating statistic is how quickly it became apparent.

During the period of intense preparation for inpatient surges across the country, primary care physicians have been steeped in a rising anxiety that fills the emptiness of once-bustling offices. At its worst, we feel a helpless dread. In easier moments, we still experience a premonitory exhaustion—knowing that the proverbial “marathon” ahead is insufficiently long and costly to describe what is coming to primary care clinics. Long after the last patient in the United States recovers from the coronavirus disease 2019 (COVID-19), many others will still be afflicted. They will have lost their jobs, and with them, their health insurance. They will have missed office visits and screening tests that might have prevented or delayed illness or even death. They will have suffered emotionally from the stress of isolation, and they will have become fearful of clinics and hospitals. They will have lost access to care in unexpected ways, like the undocumented couple who didn’t come to their appointments last week. When the pair encountered the symptom screening station at the hospital entrance, they left, assuming they would be turned away.

Among the many reasons I became a primary care physician is the power of a shared space. I refer literally to the clinic examination room, wherein exists a type of intimacy specific to the relationship between a single patient and their physician. Because of that intimacy, built over many visits spent huddled together in a quiet room, we perceive just how much an individual patient can be affected by social circumstances. I care for a patient whose hemoglobin A1c and Patient Health Questionnaire (PHQ-9) track so closely that I once graphed them in parallel to show my students. Less obvious is the shift in her glycemic control in response to her seasonal employment or the change in her blood glucose when her abusive partner moved back in with her after being released from jail, but the correlation is certainly there. Now, the effects of the global pandemic on this patient are already evident—her work hours have been cut, and she’s behind on getting the medications she can barely afford. She recently asked me for a letter declaring her fit to work as a cleaner, which I reluctantly wrote after imploring her to wear the personal protective equipment that I hope she’ll be given. Even if she escapes infection, the coronavirus will still harm her. Any primary care physician reading this will think immediately of their own vulnerable patients; although we are seeing less of them, they occupy our minds more than ever.

When our community was at the brink of the COVID-19 crisis, there were plans to use the footprint of our clinic for inpatient and emergency department overflow. Despite the obvious rationale, repurposing this space felt like a further displacement of ambulatory patients, already driven away out of fear of the virus but in no less need of care. This past week, the inpatient swell has been manageable, the clinic is still a clinic, but outpatient physicians and nurses have been diverted to off-load other strained services. Depleted of its human resources, a tide of distress occupies the quiet workroom. Those who remain struggle to keep up with outreach, patch up problems over the phone, and convince patients that they should seek in-person care if they need it. As we all gain space in unexpected ways—lanes to choose from on empty highways, abundant parking spots in the hospital garage, 6 feet between each person—I miss the intimate quarters of the examination room, and I fear the consequences of its loss.

No primary care career would be long without optimism, however, and there is cautious hope to be found. Local and regional governments have taken dramatic measures to limit movement and gatherings, and that has curbed the potential devastation of this pandemic. Medical students, temporarily excluded from clerkships, are volunteering as health care navigators for the most vulnerable patients. The clinic has rapidly adapted to virtual visits for those with the necessary technology, preserving uncrowded physical space for those without. There has been a loosening of the reimbursement structures, an overdue change that, if it persists, will increase remote care for patients who cannot always come to the office. As many lose their jobs and business owners struggle to provide the benefits that the government does not, perhaps our country will take lasting action against the inequity and dysfunction of shackling health insurance to employment.

There is reason to hope, and to trust. I trust my neighbors. They trust their doctors. We must continue to earn their confidence by giving as much attention to the outpatient surge as we have given to preparing our intensive care units. We should take cues from leaders who demonstrate good judgment, compassion, and decisive action to protect the most vulnerable. Last week, I was on the phone with a man who can blame the pandemic for the loss of his income as a day laborer. He told me he hoped his landlord will understand, and I was finally able to give some good news: the local government has halted evictions during the crisis. “In that case,” he said, “I think I’ll be fine. I’ll see you in the clinic when this is all over, doctor.”

We must do everything we can to make that true.

Section Editor: Preeti Malani, MD, MSJ, Associate Editor.
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Article Information

Corresponding Author: Renata Thronson, MD, Department of Medicine, Division of General Internal Medicine, Harborview Medical Center, 425 Ninth Ave, Box 359892, Seattle, WA 98104 (lrenata@uw.edu)

Published Online: April 27, 2020. doi:10.1001/jama.2020.7237

Conflict of Interest Disclosures: None reported.

Additional Contributions: I thank my patients for letting me share their stories. I thank John Choe, MD, MPH, Ruth Emerson, MD, and John Sheffield, MD, for their editorial feedback. None were compensated for their contributions.

References
1.
Katz  J, Sanger-Katz  M. Deaths in New York City are more than double the usual total. New York Times. April 10, 2020. Accessed April 17, 2020. https://www.nytimes.com/interactive/2020/04/10/upshot/coronavirus-deaths-new-york-city.html
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