you only have five minutes with a patient, what questions do you ask and what physical exam maneuvers do you perform? If you can only order one laboratory test, what should it be? If the MRI or CT scanner is unavailable, are you still confident in your diagnosis?
These are questions that we resident physicians ask ourselves daily as part of a critical thinking exercise. They help us stay grounded and able to practice medicine without relying on the luxuries of expensive or advanced testing.
Theory becomes reality
When Covid-19 engulfed our state and hospital, this critical thinking exercise took on new meaning by becoming a daily reality. I found myself increasingly working in a resource-limited environment, in which every patient encounter and test was scrutinized for necessity. It wasn’t easy to completely upend my usual practice — yet I suspect that facing constant limitations may have made me a better physician.
Coronavirus has prompted me to relearn the fundamentals of medicine, triage appropriately, and adapt to a virtual visit model — all of which may mean I’m providing increased care.
Because covid precautions demand limited patient encounters, I am forced to think carefully through the minimum necessary steps, exam findings, and testing to clinch the diagnosis.
I recently saw a 23-year-old woman in the emergency department for a severe headache. She was in significant pain and could not provide much of a history, which meant we were unable to rule her out for Covid-19. She also had a low-grade fever, flagging concern about meningitis, a deadly brain infection.
I abbreviated my exam to look for two things: neck stiffness and trouble with eye movements. She had both, indicating a likely deadly infection, with early signs of increased intracranial pressure. The patient needed prompt antibiotics, urgent head imaging, and a spinal puncture. This type of “emergency neurology” workup is normally frowned upon, as there may be subtle things that are missed in a rapid encounter. However, because Covid precautions demand limited patient encounters, I am forced to think carefully through the minimum necessary steps, exam findings, and testing to clinch the diagnosis.
Tests become risks
In today’s climate, the stakes are higher for any scan I might order. A brain MRI, for instance, will potentially expose the patient’s nurse, emergency room physician, transport team, radiology technologist, radiologist, environmental services team, and administrative staff to the virus — if the patient has it. Likewise, the patient will also be exposed to all of these individuals who might be carrying it.
With this in mind, I am frequently forced to reconsider my recommendations. Obtaining unnecessary imaging is a dangerous practice. Incidentalomas, unexpected incidental findings, occur in as much as 10% of patients. These findings can lead to increased worry, stress, and unnecessary interventions. This is in addition to the harmful radiation or intravenous contrast, which may cause anaphylaxis or kidney damage, that a scan might entail.
We now have to be absolutely sure about every test we order.
Because of this particular patient’s abnormal eye movements and neck stiffness, she needed imaging despite the risks of exposure.While at times it has been daunting to practice medicine without the guaranteed safety net of advanced testing, it has been refreshing to place new emphasis on our clinical skills and knowledge.
Caring for patients at home
This type of risk-averse thinking and triage has impacted our outpatient management as well. We now ask ourselves on a regular basis: Does this patient need to be in the hospital? We have started to triage small strokes for expedited follow-up, completing the work-up over a few days in an outpatient setting. Likewise, we have been doing our best to keep our immunocompromised patients, including those with brain tumors on chemotherapy or with multiple sclerosis on immunosuppression, out of the hospital. We have done this by increasing our number of virtual visits.
Initially, I was hesitant to move toward telemedicine. My training has always prioritized physically seeing patients and testing all parts of their nervous system — including strength, sensation, and coordination. However, while virtual visits are not perfect substitutes for in-person interactions, they offer tremendous value when it comes to increasing access to care.
Many neurologists are clustered in certain regions of the country. This has led to disparate access, particularly in rural and urban areas. Someone in rural Alaska or Maine may live hundreds of miles away from the nearest medical facility. Even living in a city with an abundance of medical specialists does not guarantee access to care. Transportation costs may be prohibitive and time consuming, ultimately contributing to health care disparities.
This pandemic has provided us with the unique opportunity to improve our telehealth system. Previously, these systems were clunky and outdated — requiring expensive technology or complex interfaces. Now, most virtual visits can be conducted using a cell phone. Even though these systems are still in their infancy, there is untold potential in increasing access to care, particularly to our most vulnerable populations. While telemedicine is not perfect and cannot fully substitute for a face-to-face visit, possibilities abound when it comes to providing medical care via telemedicine to traditionally underserved communities.
Covid-19 has undoubtedly changed the practice of medicine. And not all of these changes are negative. When this pandemic is finally over, we should not be so quick to revert back to the status quo, but rather try to integrate these changes to continue to improve health care for all.