Public Health and Clinical Practice: Working Together
I had the opportunity to speak to a physician colleague from Ohio about the collaboration between private practice physicians and the various public health organizations during the current pandemic. Angela DeJulius, MD, MPH, is a board-certified family physician who is currently a primary care physician in a federally qualified health center in Kent, Ohio and an adjunct faculty member at Kent State University’s College of Public Health. Over the course of her career, Dr. DeJulius has served as the medical director of a county public health department, and as Director and Chief University Physician, University Health Services at Kent State University.
Angela, what are the biggest challenges for a primary care physician in caring for patients during this pandemic?
As physicians, we work with the clinical aspects of disease and focus on what’s best for our patient, but are sometimes less familiar with how to manage disease at the community level. Recommendations that make sense for public health (for example, limiting testing) might not seem helpful for an individual patient encounter. We have to reconcile what we want to do for each patient with what we are able to do, given such constraints.
In the current pandemic, many primary care physicians are working to manage their chronically ill patients via phone or video encounters. We want to keep them stable and out of the hospital, which includes helping them to stay home and avoid unnecessary exposures. This presents financial challenges. Practices that aren’t already set up to bill for telehealth services will anticipate some loss of revenue. We are anticipating some relaxation of the requirements for telehealth encounters, and there is also the possibility of compensation under the relief packages being considered in Congress.
Finally, the pandemic highlights or exacerbates our daily challenges with technology that might not be consistent or compatible between offices, labs, and hospital systems. Mounting a unified response is difficult when something as simple as ordering a test might depend on connectivity with a lab or hospital system outside our usual network. Physicians are problem-solvers, and I’m confident we will all work around this issue (as we always do).
How do you think we assure that vulnerable populations are receiving the same quality of patient-centered care during this pandemic?
It’s essential to keep our safety net Federally Qualified Health Centers open, staffed, and resourced to meet the needs of underserved populations. These patients are some of the most medically fragile, and often the least able to implement recommendations like isolation in the home. Often without health insurance, paid sick leave, reliable transportation, or stable housing, it is easy for them to fall through the cracks. If not thoughtfully implemented, our response to a pandemic is likely to exacerbate existing disparities. Physicians in the community have a duty to advocate for these patients. For example, if you are involved in setting up a testing center at your hospital, make sure that the protocol accommodates patients who lack access to technology for an electronic order, or a vehicle to obtain a drive-thru test.
What advice can you provide to your primary care physician colleagues, many of whom are closely interfacing with the public health system perhaps for the first time, and may not have strong sense of respective roles?
First of all, consider your public health colleagues as you would any other specialist – they have an area of expertise to share, they are in daily contact with your state’s health department, and they will have the most up to date and accurate information. Trust them.
In a pandemic, your local public health department will be involved in the local and regional response along with hospitals, first responders, elected officials, and others. They will have the “big picture.”
Disease reporting to public health officials usually occurs without the physician’s direct involvement – labs typically do it for us when there is a positive result on a reportable disease. However, in suspected cases of COVID-19 disease, the physician must notify the health department immediately. Upon receiving these reports, the work of disease investigation is done by public health nurses. Remember that HIPAA allows the exchange of health information for public health purposed. If possible, designate one person on your staff to be the primary contact for the health department.
How do you provide leadership to the other team members in your clinic at this difficult time?
The specifics of each office practice will differ, but it’s essential that physicians lead by example with hygiene and PPE use. Your team will model your behaviors in this regard. Take the time to educate your team and acknowledge their fears. Have a contingency plan for work arrangements and coverage if a team member is exposed or ill (including yourself); above all, be calm, consistent and flexible.
Anything else you would like to share?
Remember that like physicians, public health professionals must make decisions with incomplete information. As more details about the coronavirus emerge, their approach to the pandemic can change just as your treatment plan for a patient would evolve.
Some doctors and other health professionals want to pitch in and help outside their office setting, but have reservations about liability exposure. This is often addressed when emergency declarations are issued at the state or federal level. For example, licensure could be transferrable between states; hospital privileges might be expedited; and liability protections could be in place. Many county health departments maintain a Medical Reserve Corps registry of diverse health professionals who can be called upon in times of need – look into this locally and sign up now if you’re interested.