Routine Healthcare Is Falling Through The COVID-19 Cracks

IRA FLATOW: This is Science Friday. I’m Ira Flatow. Our health care system is straining under the weight of the coronavirus epidemic. Shortages of masks, ventilators, hospital beds, medical staff, you know the story. But the epidemic is also upsetting parts of the health care system that are not directly treating COVID patients. In the coming weeks, we’ll be looking at some of these ripple effects. So let’s start today with a question about how the pandemic is affecting your access to basic health care. On our Science Friday VoxPop app, we asked for your recent health care experiences. And you gave us a range of responses.

SPEAKER 1: Howdy. I chipped a tooth. The filling is still in place and the tooth is still holding so my dentist decided that we should hold off any major repair until after this epidemic. Hope the rest of the tooth doesn’t fall out.

SPEAKER 2: I’m on antidepressants. And today I’ve been trying to schedule a routine psychiatric appointment so I can keep getting them. My medical practice, however, is so busy that they just took my number and said they’d call back. And I’ve been literally waiting all day just to make one appointment.

SPEAKER 3: I had to go to the emergency room because I had a couple of puncture wounds in my hand. And you could see my adipose tissue. I went to one that was not downtown. It looked like a scene out of I am Legend. There was like maybe five cars in the parking lot.

It was all employees. They scanned me as soon as I got in to make sure I didn’t have a temperature. I didn’t sign any paperwork. I did it all over my phone. Everybody it pretty far away from me.

IRA FLATOW: One person delaying care, one with longer wait times, and one with a strange, but relatively streamlined experience. Joining me now to talk about access to care and navigating the medical system in these stay-at-home times is Michael Barnett. He’s assistant professor at the Harvard TH Chan School of Public Health, also a primary care physician at Brigham and Women’s Hospital in Massachusetts. Thanks for joining me today, Dr. Barnett.

MICHAEL BARNETT: Thank you for having me.

IRA FLATOW: You’ve written about events that are, quote, “shock to the health care system,” things like natural disasters. How similar is this to a natural disaster?

MICHAEL BARNETT: So there are a number of ways, from a health care system perspective, that this resembles a natural disaster. What we know from experience with hurricanes, like say Hurricane Sandy or Hurricane Maria, is that when a natural disaster comes in, there is, of course, the effect on population health from the disaster itself, from people’s homes being flooded and being exposed to natural elements that can harm them, of course. But also natural disasters shut down the health care system. Hospitals can’t work. Power is out. Doctor’s offices are closed.

And with the coronavirus, there isn’t the physical damage of a natural disaster like a hurricane. But in many ways, the health care system is shutting down, both because they may be too busy in some situations, like some of your listeners explained around the emergency room, but also we have health care systems that are shutting down because they don’t want to expose their staff or patients to the coronavirus and they’re trying to postpone, basically, anything that’s not an absolute emergency for several weeks or months until the coast is more clear and they feel safer having patients come to their facility.

IRA FLATOW: But sometimes they have a very difficult problem, like this woman was saying she had a puncture wound in her hand. If you have a toothache and you need to go see your dentist, you need to go. That’s something you can’t put off. Are doctor’s offices or emergency rooms, you know, prepared for this kind of walk-in or semi-emergency that has nothing to do with the virus.

MICHAEL BARNETT: It’s a tough question. You know, I think part of what the challenge is it’s really a cliche almost now to talk about how unprecedented the current situation is. And the truth is that a lot of doctors and health care facilities are really figuring this out as we go. You know, one challenge is the idea of what is and isn’t a quote, unquote, “elective problem” or “non-emergent” problem is not so cut and dry, necessarily.

You know, sometimes a toothache is a toothache that maybe can be nursed along for a month or two. And sometimes a toothache could turn into an abscess, which if not treated, could actually result in somebody getting very sick or losing more teeth or having damage to their mouth that actually could be irreversible. There’s a big fuzzy boundary between what needs to be treated in the next two weeks versus what can wait three months.

And both doctors and patients, I think, are kind of groping around to figure out how can we balance the competing interests of getting people care they need soon versus trying to limit the exposure of health care personnel and people as much as we can. Because that and also, you know, health facilities are going to be such a nexus to spread coronavirus throughout a community if we’re not careful.

IRA FLATOW: How much of a standard checkup, let’s say it’s your time to have a standard checkup or an appointment, can be delivered over telemedicine?

MICHAEL BARNETT: Telemedicine is one of the saving graces, I think, of the situation right now. Telemedicine was really not embraced in a broad way prior to coronavirus epidemic. And now the entire health care system is basically having a crash course in how to deliver telemedicine. Because we have no other option.

The good news is that for routine health care issues such as just a routine checkup to the extent that people are still doing those or maybe, more importantly, managing common chronic illnesses like diabetes or high blood pressure or, say, weight loss, I say most medical care can be delivered just as effectively over telemedicine, even over just the telephone as you could get through an in-person visit. Because so much of what we do in medicine is really just communication. It’s talking with patients.

It’s checking in on how they feel, what they’ve done. We do need some biological information, some physiologic information like weight or blood pressure or, say, blood sugar for people who have diabetes. And many people have the devices at home they can use, many of which are available just at the pharmacy to buy over the counter to measure a lot of that information. But even without it, we can do a lot by phone.

IRA FLATOW: I’ve seen this going through the internet now of doctors telling patients to buy a little fingertip blood pressure and oxygen level meter. Are you familiar with that?

MICHAEL BARNETT: Yes, and those are– they’re actually quite cheap. There are those oxygen meters that will also tell you your heart rate. Sometimes they could be $20, $30. And at least in my experience, they seem to be relatively reliable. Though I think it’s going to depend, of course, on the device.

IRA FLATOW: They’re impossible to get out, I’ll tell you. I tried to buy one.

MICHAEL BARNETT: Are they? Yeah, I’m not– I’m not surprised.

IRA FLATOW: Yeah, but we are all going to have to, I guess, adapt to this new telemedicine idea and learn as we go along with it.

MICHAEL BARNETT: You know, I think that’s what everyone is doing, including doctors, because the medical system in the US has been very cozy with the idea of delivering basically almost every ounce of health care through an in-person visit where a patient and a physician are in the same room at the same time. And there have been calls for years, including by folks like myself, to try to transition our health care system away from one which is based fundamentally on having an office visit as the way that we deliver all health.

When we have so many other technologies and so many other ways that we can interact with patients and connect with people who have a hard time coming to the office or for whom it’s extremely inconvenient. And now we’re all thrust into it. And doctors need to learn a new way of communicating and a new way of being proactive with their patient to help manage illness even if people aren’t– even when people are outside the routine of walking into the physician office once, twice, three times a year.

IRA FLATOW: Can you actually show a doctor something on your body through telemedicine?

MICHAEL BARNETT: You can. And I think there are situations where actually seeing the patient in person or maybe seeing a rash on somebody’s leg, a doctor might be able to get a sense of what’s going on through video. It’s, of course, going to be somewhat limited. Because the resolution is not that great. So if you need to, for instance, look at something on the skin, it may not really be possible to tell for certain whether it’s one kind of rash versus another.

On the other hand, there are things that are probably easier to assess by video. Like, for instance, how somebody’s breathing is doing. You can get a sense by hearing someone talk on the phone. But if you’re trying to clinically assess to someone who potentially has coronavirus, are they getting sick enough that they might need to go to the emergency room, sometimes it can be extremely valuable just to watch how somebody is breathing and just to see how much they– how hard they have to work just to have a conversation with you on the phone.

IRA FLATOW: That’s very interesting. Let’s talk a bit about drug shortages. Are there ripple effects of the crisis on the availability of medications you’d need for regular care?

MICHAEL BARNETT: Yeah, there are increasing reports of drug shortages. There isn’t a lot of systematic data that I’m aware of at the moment to really report on them. Part of what’s interesting about this pandemic is that information and the situation is moving so quickly that basically the only way to keep up to date on what’s going on sometimes is to follow reputable sources on social media and to get a feeling of what reports are circulating out there.

What I am seeing that it seems like some basic medications are starting to become in short supply. And these are things that we actually need in the hospital and potentially in the ICU as well. So, for instance, drugs that you need to sedate patients or keep their muscle paralyzed from moving if they’re on a ventilator.

Also there are reports of shortages of antibiotics, in particular, an antibiotic called azithromycin, which has been widely promoted despite the lack of evidence as effective or potentially treating or preventing coronavirus in combination with hydroxychloroquine. Hydroxychloroquine is another drug that is in short supply. There’s been a lot of discussion about how there’s actually very little evidence to support whether hydroxychloroquine is effective, but it’s been widely promoted by a variety of people, including the president.

And that has prompted a surge of interest in acquiring that medication, often by doctors themselves prescribing it for themselves. Unfortunately, these are medications that people with other diseases need to treat their ailments like lupus or rheumatoid arthritis. And there are reports of them being in short supply and worrying about running out of those and risking a disease flare.

Another set of medications that I also worry about that are in short supply are inhaled medications to help breathing. So one of these medications is called albuterol. And it’s a very basic inhaled mist, basically, that is essential to treat folks with asthma or with smoking-related lung disease like emphysema. And hospitals are using it quite a bit in treating patients with coronavirus as well. And so if that becomes in short supply, it’s also going to be a major problem.

IRA FLATOW: I thought it was interesting from hearing in the VoxPop app from one of our listeners who said that basically she went to an emergency room and the parking lot was empty and no one was in it and she got service very quickly and efficiently. Is that common now, do you think?

MICHAEL BARNETT: Well, it’s interesting because, I guess, the emergency room, there I’m a little bit surprised. But there’s a complex mix of changes in the health care system. On the one hand, you have places like New York City where the emergency room and the hospitals are overflowing. They’re completely packed with people who are sick with coronavirus as well as every other reason why people would be sick.

And let’s not forget that before the coronavirus showed up on the scene, most American hospitals run very close to capacity. And we have a lot of folks who are sick in the US. And it’s not like the health care system had a ton of empty capacity at baseline just to treat people who need to be treated on any given day. Now, double or triple that volume with coronavirus patients, and we run into a really significant problem.

Now one way that the health care system can make capacity is by basically canceling as many quote, unquote, “elective procedures” or not purely emergency-based procedures and other admissions that they can. And this includes things that folks in the public might not think of as necessarily elective or non-emergent. So, for instance, sometimes people are admitted to the hospital to get chemotherapy for cancer.

You know, no one thinks that chemotherapy is something that should wait around for a few months. But it’s not strictly an emergency. And sometimes that might be able to safely wait for a little time, particularly if you’re in an extremely unprecedented situation like now. And, of course, there are lots of other surgeries that can easily wait a few months.

So that’s opened up a bunch of hospital beds. And also clinics like mine have canceled practically every appointment that they can, every routine or prior scheduled appointment. Because we wanted to avoid exposing patients to health care settings and having people come in who don’t otherwise, you know, absolutely require care.

What this means is that while emergency rooms and hospitals are filled to the brim and overflowing, you have surgical centers and physician offices and maybe some community emergency rooms which are ghost towns. They’re empty. Because physicians have canceled their schedules and cleared out as much as possible.

They’re transitioning everything to telemedicine. And also patients are scared. They don’t want to come into health care settings. And a lot of health care, I think, is not happening right now, which probably should be happening on some kind of timely manner. But people are basically sheltering at home. And health care issues are very likely to accumulate over this period. And there could be a second wave of, basically, under treated illness not related to COVID that we’re going to have to manage in the next few months.

IRA FLATOW: I’m Ira Flatow and this is Science Friday from WNYC Studios. People are basically fearful of coming in.

MICHAEL BARNETT: Correct, well, I think the fear combined with the deliberate canceling and people getting the message from their physician, “we’re canceling your appointment because of COVID and we’re going to wait until we can see you.” And that’s a powerful message for patients.

No one’s being told, “We don’t like you, we don’t want you to come in.” But they’re being told, “We’re canceling your appointment for now because it’s not safe for you to come in.” And I think patients get the message that I need to wait.

One unnerving set of reports that I have also been reading about is that a lot of cardiologists, for example, are recording that volumes of heart attack in their hospital are way down. And this is really concerning and a bit mysterious because they’re even reporting decreased volumes of the most serious kind of heart attack, which physicians call a semi for short. These are emergencies that really shouldn’t be elective.

If you have one of these heart attacks called a semi, most people will be in extreme pain or discomfort. And it’s obvious that something very terrible is happening. And to see a greatly decreased volume of those heart attacks makes me extremely worried that maybe people are actually suffering with quite severe symptoms at home and aren’t showing up because they think that basically nothing is going to be as important as a coronavirus patient in the hospital right now. It’s possible there’s something else going on that maybe somehow social distancing and people basically staying at home are suppressing these kinds of emergencies. But there are a number of reports like this that concern me.

IRA FLATOW: What do patients need to be thinking now beyond staying healthy?

MICHAEL BARNETT: I think it’s really important right now to recognize that your health concerns are not less important now than they were before and that it could be really hard for someone without medical training to assess whether or not a medical worry you have right now that may or may not be related to coronavirus needs attention in the next few days or if it can wait a few weeks. Because that’s actually a very tough call to make.

But I worry that patients are trying to make the call themselves because they don’t want to inconvenience their doctors and they don’t want to try to make the busyness in the current situation worse. But actually, that’s a very difficult call to make. And, you know, doctors like myself, we are here for patients.

In fact, many of us, our offices are quieter and emptier than they have ever been before. And so we have the capacity and time to take care of concerns that come up. And I want to encourage people to reach out to their doctor if they have concerns beyond standard, you know, beyond their standard keeping up with health and routine checkup.

IRA FLATOW: Dr. Barnett, we have run out of time. This has been very, very informative. I want to thank you very much for taking the time to be with us today.

MICHAEL BARNETT: Thank you very much, pleasure.

IRA FLATOW: Michael Barnett is an assistant professor in the Department of Health Policy and Management at the Harvard TH Chan School of Public Health and a primary care physician at Brigham and Women’s Hospital in Boston.

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