My clinic patient asked me: Should primary care continue in a time like this?
My reflexive answer was “yes,” and my reflective answer was “definitely.”
I work as a primary care physician in a clinic that predominately receives patients who are on Medicaid. Our clinic is not associated with any hospital system. Most of our patients have chronic medical conditions.
Many of my patients are unable to sustain economic fluctuations in their lives. These economic fluctuations become more evident when they are unable to receive healthcare. Despite the coronavirus outbreak, many patients still require primary care.
As I am writing this article, the Maryland governor has taken appropriate public health measures to limit public gatherings. Anxiety among the public is high and some emergency rooms around the country are seeing a surge in patients. I have also observed a decrease in patients who need primary care in my clinic. Unfortunately, such a trend may lead to a rise in non-coronavirus related visits to emergency rooms.
As part of the health care system, primary care keeps patients healthy so that they do not have to visit emergency rooms and hospitals. Primary care is the backbone of any health care system. However, unusual times call for different measures.
Screening protocols and personal protective equipment need to be made available in clinics to protect medical professionals if a patient exhibits symptoms of COVID-19. Additionally, as we practice social distancing, in-person visits are decreasing and many clinics are transitioning toward telemedicine. This includes virtual consults and talking to patients on the phone on how best to approach their care. These conversations with providers who have known their patients for many years are vital to help decrease the burden on emergency rooms and hospitals.
As a primary care physician, I am approaching the coronavirus outbreak using four key questions to determine the right decision. Is my decision medically appropriate? Is my decision appropriate from a public health perspective? Does my decision prevent an economic burden on patients and emergency rooms? Is my decision morally defensible?
In my view, the last question is perhaps the most important one. In Italy, many intensive care unit doctors had to decide who should be placed on a few ventilators when many patients needed the devices. No level of medical training can prepare a doctor for this, and yet the moral distress felt by such doctors is a burden they often carry alone.
U.S. doctors already facing testing kit shortages may face ethical dilemmas when deciding on ventilator care. Should the life of a young individual be preferred over an older person who has pre-existing conditions? Should pregnant women be favored over patients who are not? Should COVID-19 patients get priority over patients who are equally sick but don’t have the virus?
A natural response is: All lives are worth saving. Yes, absolutely. However, it still leaves doctors with tough choices to make. The decision on what ought to be done should be made using moral reasoning and not moral intuitions. Moral intuition means using your “gut feeling” to decide what is right. However, gut feelings may vary from person to person.
The concept of moral “taste buds” explains why. We all have the same taste buds, but our degree of use, perception and emotional association with different tastes varies. Therefore, our likes and dislikes of foods vary. Similarly, two equally trained doctors may use moral principles at their disposal to varying degrees based on their experiences, beliefs and emotional associations with those moral principles.
Arriving at the same decision should not be the criteria for the “right” decision. Instead, using a transparent and standardized process to arrive at a determination will ensure consistency in determining the “right” decision.
Rather than potentially forcing medical professionals to make morally challenging decisions downstream in ICUs, hospital wards and emergency rooms, we need to share this moral responsibility upstream — by continuing to provide primary care and at a public level by socially distancing ourselves.
Embracing this responsibility should be our collective honor and privilege.
Dr. Ali Thaver (email@example.com) is a primary care physician at Jai Medical Center in Baltimore.