The biggest challenges facing physicians

Thomas Ely, DO, a family physician and president of the American Osteopathic Association, has seen a lot during his medical career, including two combat tours in Vietnam as a medical evacuation pilot, but 2020 is challenging physicians like never before.

A global pandemic is creating two extremes for many doctors—either they are swamped with COVID-related patients in a hot spot or are struggling financially because patients are afraid to come in for appointments. The pandemic fallout is exacerbating a growing burnout problem in the profession, and doctors have become the targets of politicians looking to shift blame.

Medical Economics spoke with Ely about these challenges and other changes in medicine.

The transcript has been edited for clarity and brevity.

Medical Economics: What are the biggest challenges facing physicians during the COVID crisis?

Ely: I think that the challenges are multiple and they vary significantly depending on how individual physicians provide care for their patients. For intensivist, emergency medicine physicians, and other hospital-based physicians, the onslaught of a seemingly never-ending flow of new patients who now require extended hospitalization in a critical care state creates a challenge of endurance. Doctors are coping with medication shortages, and most significantly, coping with the physical, mental and emotional pressures. The mandated reduction or pauses in elective surgery can decimate a practice’s ability to financially survive. And for primary care specialists, especially in rural or underserved areas, it is truly a matter of financial survival.

Recently, the American Osteopathic Information Association and American Osteopathic Association conducted a nationwide survey of practicing physicians, and the purpose was to gauge the financial toll that COVID-19 has taken on their small and mid-sized practices. It revealed that 95% of osteopathic physicians have experienced a decline in physician revenue and more than 40% anticipate that their practice revenue will be cut in half or more as a result of COVID-19. Three-quarters of these physicians said that they will need additional financial support to be able to continue providing quality patient care.

ME: Do you see the advances in telehealth that have come from COVID as a positive for medicine?

Ely: If there's a silver lining to this pandemic, it's the advances made in telehealth. But this is a two-edged sword. Incorporating telehealth into medical practice allows a patient safe access and probably 25 to 30% of primary care patients can be evaluated using telehealth with totally satisfactory clinical outcomes. Physicians are going to have to develop best practices for using this technology. And the use of technology must be incorporated into medical education. And what is still needed, however, is to ensure compensation is commensurate with the type of service provided. If a physician in his practice, invests in new technology services, training his staff and changing the way that they were routinely seeing patients, they must be compensated for this new type and level of care. This is something we continue to advocate for. The big question that I have is, will compensation for telehealth be limited to pandemic legislation? It has been included in payment processes right now. What's going to happen when the pandemic finally evolves? Because it wasn't compensated in the same manner prior.

ME: In what ways has the COVID pandemic contributed to the problem of physician burnout?

Ely: Health care practitioners are showing significant rates of post-traumatic stress, anxiety, insomnia and depression, according to research. So not only are physicians faced with unprecedented levels of death and suffering, but many are also losing their colleagues and family members. It's a devastating time for the health care community. Now, there are some resources available and I would encourage anyone on the front lines, if they're feeling that they need support to reach out for something like the physician support line (www.physiciansupportline.com). This is a free and confidential service to support the mental health of doctors and medical students. One thing that I tell every medical student that I have the opportunity to speak to and osteopathic physicians on an ongoing basis is that they must remember to take care of themselves. Significant numbers of physicians will at some time in their practice life, and especially during this pandemic, have a down period. I advise them that if that ever occurs, if nothing else, reach out to another physician, because there is a strong likelihood that that physician has encountered that same thing in his or her life, and can give some good sound advice on initial steps.

ME: How will practicing medicine change long term due to what we've learned or been affected by during the COVID pandemic?

Ely: I strongly believe that the impact of this pandemic will modify how we practice medicine. In our clinical lives, we get educated, trained and go into practice. And the way that we go into practice is greatly impacted initially on how the physicians who taught us practice. When I was a resident, I learned from every clinical rotation, things that I wanted to emulate, and things that I swore I would never do in my practice. That's part of clinical education. And when I went into practice, I continually learned from every patient I cared for on a daily basis. So when this pandemic is over, we will take new lessons, and we have to modify how we will practice in the future. Osteopathic medicine is centered on the idea of a whole person approach, to care that the body is a unit and the person is a unit of body, mind and spirit. The rational treatment, we believe, is based on an understanding of basic principles of body unity, self-regulation and interrelationship for structure and function. This means we look at the whole person, the health of the community, and how social determinants will factor in. And it is my great hope that this crisis will change our approach to the way we practice medicine, so that we can move toward a focus on prevention and wellness rather than acute traumatic care.

ME: Do you worry about the long-term viability of independent practices, and what needs to be done to save them?

Ely: I absolutely do worry about that. Independent practices, especially primary care practices, have been particularly vulnerable to the devastating economic effects of this pandemic. The established parameters of physician compensation, I believe, must be addressed and possibly adjusted. Physicians should be compensated on their judgment and their outcomes. Payers must recognize that physician practices differ depending on their specialty practice, and most importantly, the types of patients that they are treating. A physician practicing in a rural area, perhaps even without a local hospital, like there are many here in Tennessee, will have to adjust how they provide care and how they treat their patients.

ME: What do physicians need to do to fight the misinformation about things like vaccinations or effective COVID treatments that regularly appear on social media platforms?

Ely: I strongly am concerned about that. The AOA conducted a survey on vaccine hesitancy in June 2019 and found that more than two in five of American adults—45%— say that something has caused them to doubt vaccine safety. This is a staggering number. Vaccines are safe, they are effective and they save lives. So this fall, AOA will actively engage our members and the public about the value of vaccines and routine immunizations. Everyone should get the flu shot vaccine this fall. We cannot take—and people cannot take the chance—of having two concurrent viral illnesses, both of which can kill them. We must work together to encourage families to continue to access routine care and immunizations that protect people from disease. And when there is a vaccine ready to treat COVID-19 we will and must support widespread adoption and usage.

ME: How can a better understanding of social determinants help doctors get better outcomes for their patients?

Ely: In today's fast-paced world, it can be difficult to take time to develop rapport with patients. This is further complicated during this pandemic because of social isolation, decreased personal interaction and the use of telehealth. The osteopathic emphasis on total patient care allows an osteopathic physician to fully evaluate the complete patient and understand why a patient is struggling to improve, and social determinants absolutely directly influence successful medical care. Medicine is based on science, but there is the art of medicine. The relationship between a doctor and a patient starts to mature and grow over time as trust develops. When a patient pushes back, there's always an underlying factor at play that the physician is probably not immediately aware of. But once it's understood, a more successful treatment plan will be put into place.

ME: What changes need to happen in medical school to better prepare future doctors for a post-COVID world?

Ely: Many of our schools are now integrating telemedicine into their training, which is good, and it will position those students as our nation adapts to not only quarantine and limits on travel, but even the future routine practice of medicine. That's just one modality to assist in patient care. We need to ensure that clinical education educates students completely about fully needing to know their patient: who they are, where they come from, their socio-economic situation, and their family history. They must understand how that information might impact their patient care, and this must be an integral component, not only of medical school training, but integrated into our postgraduate training. Remember, for physicians, that's how we learn the art of medicine. So we as physicians need to learn from our experiences in this pandemic. We must take the lessons learned and incorporate these lessons. That I believe is the most significant way to prepare future doctors for a post-COVID world.