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Managing Difficult Patient Expectations in the Era of COVID

Michael A. Sharma, PA-C

Disclosures

June 09, 2022

"Well," I said to the patient after I completed my exam, "I think it's important that we draw some labs to see if we can better figure out your abdominal pain today."

"Can I get a really good nurse? I'm a hard stick," the patient said. I exchanged a quick, knowing glance with Stephanie, an experienced emergency department RN, and then scanned the patient. A San Diego Padres jersey… okay, a baseball analogy, then.

"The only nurses we hire here are really good nurses," I reassured the patient. "I know Stephanie's going to do a great job, but sometimes things happen with blood draws. Batting .333 gets you into the Hall of Fame… you know what I mean?"

The patient laughed. "Okay, I get it." We all smiled and, after I told him when to expect results, I left the room.

Later that week, a nurse briefed me about a patient I was about to see. "Young lady, COVID positive, symptoms for over 10 days. No health issues, no meds, improved in every way. Just a lingering cough. She's here for a COVID test to return to work."

I frowned. I couldn't believe this was still happening in 2022. A debate continues about the shortened isolation guidelines recommended in December 2021, suggesting that some with COVID can leave isolation after 5 days as long as they "wear a mask" for the remainder of their 10 days. (This is not specific-enough guidance, in my opinion.) 

However, for over a year, it has been well accepted that someone with COVID that did not require hospitalization for the disease and was not "moderately or severely immunocompromised" could exit their isolation after day 10 without testing

Organizations have an important responsibility to stay current on public health recommendations to avoid overburdening employees. Otherwise, in addition to possibly losing pay for missing work during their illness, employees have to bear the cost of a clinic or emergency department visit for a test. And if they test positive, they may lose more wages from being away from work longer.

Furthermore, clinics lose appointment slots that can no longer be used by others who have actual medical needs, and the emergency departments the patients might visit would probably become further overrun.

After printing out the current CDC recommendations for returning to work, I went to see the patient. We exchanged the typical greetings and I confirmed the circumstances of her visit.

"Right, my job needs me to take a COVID test so I can go back to work," she said.

My response: "So here's the good news. The CDC has said for a long time that people in your situation don't need to test to go back to work. People can still test positive after 10 days or have an improving cough like yours, but it doesn't mean they're contagious. Here," I said, handing her the sheet of recommendations. "Maybe you can show this to your supervisor?"

"Oh, I am a supervisor. It's our policy. People need a test before going back to work," she said, business-like. She accepted the paper and neatly folded it twice without a glance at its content.

A supervisor! Perhaps this was an opportunity for me to affect several people. It was her policy or the policy of her colleagues, perhaps her supervisor. She didn't seem to be too upset by it. How would I appeal to her? 

"Okay, obviously you're here for a test. I'm worried about what could happen here. You might test positive and have to stay out of work even longer. I mean, I'm sure the people you work with are missing your leadership," I suggested. "Wouldn't it be awful if you had to stay out of work for no reason?"

"I really do want to get back to work," she mused. "But I need a test. And it has to be a PCR test."

I hoped my sour expression was not visible through my mask. "We've known for a long time that a PCR test can be positive for months after someone's been infected for COVID-19. Months," I emphasized. "You may not end up being with your people for 60-90 days if we do a PCR test." 

"It's policy," she said, all business again.

"Alright," I said, forcing a smile. "We'll get you tested."

Eighteen hours later, the patient's test result came back: negative. I almost wanted it to be positive, not because I wanted the patient to be sicker (because that's not what it would indicate), but because it might help illustrate the problem more clearly. I called her with the news.

"I'm happy it's negative. I can only imagine how much this policy has affected your workplace. Listen, I know some people who do COVID business consulting. They'd be happy to check out your policies, maybe see where they can be updated so everyone's safe but not missing as much work," I offered.

"I appreciate the call," she said, answering by not answering. We exchanged a few more pleasantries and mutually ended the call.

Even though she was going to do great, I felt tremendously frustrated. Her situation was just one of many examples nationwide. A Miami private pre-K–through–8th-grade school quarantined students after they got COVID vaccinations. A 20-year-old college student faced disenrollment from her university for not wanting to comply with a booster mandate after she claimed an adverse reaction to her first COVID vaccination and got a medical exemption.

What was American public health doing if it could not protect students and employees from being victimized by onerous policies? What was I doing with my life if I couldn't even convince someone of one of the most agreed-upon aspects of this pandemic? 

Interrupting my mid-shift crisis, a nurse walked up. "Ready to hear about the next patient?" she asked. I cleared my mind of my doubts and prepared to step up to the plate for my next swing.

Disclaimer: Identifying details of referenced patients or healthcare workers have been changed and composited from multiple encounters.

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About Michael Sharma
Michael A. Sharma, PA-C, is a practicing emergency medicine and urgent care PA in the Dallas, Texas, area. He is the co-host of The 2 View: Emergency Medicine PAs & NPs podcast with NP Martha Roberts. Mike is a US Army veteran, including a deployment to Afghanistan as a trauma team leader at a NATO Role 1 aid station. He has lectured and taught hands-on workshops internationally and nationally on emergency medicine topics to a variety of clinicians. Follow Mike on Twitter, Facebook, and Instagram.

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