6 Snags Docs Hit When Seeing Patients Again

Liz Seegert

July 08, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Sachin Dave, MD, an internist in Greenwood, Indiana, never thought he'd tell his patients to avoid coming into the office. But these days, he must balance the need for face-to-face visits with the risk for COVID-19 transmission. Although he connects with most patients by telehealth, some patients still demand in-office care.

"My older patients actually insist on coming to see me in person," said Dave, who is part of Indiana Internal Medicine Consultants, a large group practice near Indianapolis. "I have to tell them it's not safe."

It's a minor hitch as his practice ramps up again — but one of those things you can't overlook, he says. "We need to educate our patients and communicate the risk to them."

As practices across the United States start reopening, physicians frequently hit bumps in the road, according to Kerin Bashaw, senior vice president of patient safety and risk management for The Doctors Company, a physician-owned malpractice insurer. "It's about minimizing risk."

As practices increase patient volume, physicians are juggling a desire for a return to patient care and increased revenue with a need to maximize patient and staff safety. Avoiding some of these common snags may help make the transition smoother.

1. Unclear or nonexistent polices and protocols

Some physicians know what general rules they want to follow, but they haven't conveyed them in a readily available document. Although you and your staff may have have a sense of what they are, patients may be less aware of how mandatory you consider them. It's important to develop a formal framework that you will follow and to make sure patients and staff know it.

Dave and his colleagues have stringent safety protocols in place for the small percentage of patients he does feel a need to be seen in person. Masks are mandatory for staff and patients. The waiting room is set up for social distancing. If it begins getting crowded, patients are asked to wait in their cars until an exam room is ready.

"I'm not going to see a patient who refuses to put a mask on, because when I put a mask on, I'm trying to protect my patients," said Dave. He makes it clear that he expects the same from his patients; they must wear a mask to protect his staff and himself.

"I am going to let them in with the caveat that they don't have qualms about wearing a mask. If they have qualms about wearing a mask, then I have qualms about seeing them in person," he said.

Be sure that all patients understand and will adhere to your protocols before they come to the office. Patients should be triaged over the phone before arriving, according to CDC recommendations. (Remember that refusing assessment or care could lead to issues of patient abandonment.)

When you don't really have a framework to follow, you don't really know what the structure is going to be and how your practice is going to provide care. The question is, how do you build a framework for right now? says Ron Holder, COO of Medical Group Management Association (MGMA). "The first step is do no harm."

2. Trying to see too many patients too soon

On average, practices report a 55% decrease in revenue and a 60% decrease in patient volume since the beginning of the COVID-19 crisis, according to MGMA. It's natural that many want to ramp up immediately and go back to their prior patient volume. But they need to take it slow and ensure that the correct safety protocols are in place, says Holder.

For example, telehealth is still reimbursable at parity, so physicians should keep taking advantage of that. MGMA's practice reopening checklist has links to additional resources and considerations.

Some doctors want to see an overload of patients and want to get back to how they practiced before the pandemic, says orthopedic surgeon Charles Ruotolo, MD, president of Total Orthopedics and Sports Medicine in Massapequa, New York, and chairman of the Department of Orthopedics, Nassau University Medical Center, "but at the same time, you know we still have to limit how many people are coming into the office."

It's not fair if some doctors in your practice are seeing 45 patients daily as they did previously whereas others are seeing half that many, he explains. "We must remain cognizant and constantly review schedules and remember we have to still keep the numbers down."

"COVID is not going to be completely over in our lifetime," says Evan Levine, MD, a cardiologist in Ridgefield, Connecticut. Taking advantage of technologies is one way to reduce risk.

He predicts that the demand will continue to increase as patients become more comfortable with virtual visits. Using Bluetooth and WiFi devices to assess patients is no longer futuristic and can help reduce the number of people in the waiting room, according to Levine, a solo practitioner and author of What Your Doctor Won't (or Can't) Tell You . "That's a very good thing, especially as we look to fall and to flu season."

3. Undercommunicating with patients and staff

Don't assume patients know that you've opened back up and are seeing people in the office, says Holder. Update your practice website, send letters or newsletters to patients' homes, maintain telephone and email contact, and post signs at the facility explaining your reopening process. CDC has an excellent phone script that practices can adapt. Everyone should know what to expect and what's expected of them.

He advises overcommunicating ― more than you think is necessary ― to your staff and patients. Tell them about the extra steps you're taking. Let them know that their safety and health are the most important thing and that you are taking all these extra measures to make sure that they feel comfortable.

Keep staff appraised of policy changes. Stress what you're doing to ensure the safety of your team members. "Even though you could be doing all those things, if you're not communicating, then no one knows it," said Holder.

Holder predicts the practices that emerge stronger from this crisis will be those with great patient education that have built up a lot of goodwill. Patients should know they can go to this practice's patient portal as a trusted resource about COVID and safety-related measures. This approach will pay dividends over the long term.

4. Giving inadequate staff training and holding too-high expectations

Staff members are scared, really scared, says Bashaw. Some may not return because they're unsure what to expect; others may have to stay home to care for children or older relatives. Clear guidance on what is being done to ensure everyone's safety, what is expected from staff, and flexibility with scheduling can help address these issues.

Most practices' staff are not used to donning and removing PPE, and they're not used to wearing masks when working with patients. Expect some mistakes.

"We had a scenario where a provider was in a room with an older patient, and the provider pulled his mask down so the patient could hear him better. He then kept the mask down while giving the patient an injection. When the family found out, they were very upset," Bashaw related. "It was done with good intentions, to improve communication, but it's a slip-up that could have found him liable if she became ill."

Ruotolo had to implement new policies throughout his practice's multiple locations in the New York metro area. They encompassed everything from staggering appointments and staff to establishing designated employee eating areas so front desk staff weren't taking their masks off to snack.

Having specific guidelines for staff helps reassure patients that safety protocols are being adhered to. "Patients want to see we're all doing the right thing," he said.

Have those policies clearly written so everyone's on the same page, Ruotolo advises. Also make sure staff knows what the rules are for patients.

Ruotolo's reception staff hand every patient a disinfectant wipe when they arrive. They are asked to wipe down the check-in kiosk before and after using it. Assistants know not to cut corners when disinfecting exam rooms, equipment, or tables. "It's the little things you have to think about, and make sure it's reiterated with your staff so they're doing it."

If your practice isn't back up to full staffing volume, it's a good idea to cross train staff members so some jobs overlap, suggests Holder. Although smaller practices may already do this, at larger practices, staff members' roles may be more specific. "You may be able to pull employees from other positions in the practice, but it's a good idea to have some redundancy."

5. Neglecting to document everything — even more so than before

The standard of care is changing every day, and so are the regulations, says Bashaw. Many physicians who work in larger practices or for health systems don't take advantage of internal risk management departments, which can help them keep tabs on all of these changes.

Writing down simple protocols and having a consistent workflow are extremely important right now. What have you told staff and patients? Are they comfortable with how you're minimizing their risk? Physicians can find a seven-page checklist that helps practitioners organize and methodically go through reopening process at The Doctors Company website.

Implementing state and local statutes or public health requirements and keeping track of when things stop and start can be complex, says Bashaw. Take a look at your pre-COVID policies and procedures, and make sure you're on top of the current standards for your office, including staff education. The most important step is connecting with your local public health authority and taking direction from them.

Bashaw strongly encourages physicians to conduct huddles with their staff; it's an evidence-based leadership practice that's important from a medical malpractice perspective. Review the day's game plan, then conduct a debriefing at the end of the day, she advises.

Discuss what worked well, what didn't, and what tomorrow looks like. And be sure to document it all. "A standard routine and debrief gets everyone on the same page and shows due diligence," she said.

Keep an administrative file so 2 years down the road, you remember what you did and when. That way, if there's a problem or a breach or the standard isn't adhered to, it's documented in the file. Note what happened and when and what was done to mitigate it or what corrective action was taken.

All practices need to stay on top of regulatory changes. Smaller practices don't have full-time staff dedicated to monitoring what's happening in Washington. Associations such as Medical Group Management Association can help target what's important and actionable.

6. Forgetting about your own and your staff's physical and mental health

Physicians need to be worried about burnout and mental health problems from their team members, from their colleagues, from their patients, and from themselves, according to Holder.

"There's a mental exhaustion that is just pervasive in the world and the United States right now about all this COVID stuff and stress, not to mention all the other things that are going on," he said.

That's going to carry over, so physicians must make sure there's a positive culture at the practice, where everyone's taking care of and watching out for each other.

Liz Seegert is a freelance healthcare writer in Little Neck, NY

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