• Rosalind Kaplan, MD

One Worry at a Time

Rosalind Kaplan, MD

I got up on the wrong side of the bed on Monday, after a weekend fraught with a flood of bad news- the continuing saga of the imminent overturn of Roe, the continuing war in the Ukraine, and then another mass shooting by a white supremacist. I was seeing an uptick of covid at work, more than I expected given recent news reports. It all just seems overwhelming and out of control.

As a control freak, I feel like I need to 'do' something, but anything I can imagine doing seems pretty lame.

I've decided that the only way to deal with it all, short of going off the grid or crawling under a rock, is to compartmentalize. After medical training and years of practice, I should be pretty good at that. I decided that I'd worry only about one thing at a time. This is a twisted form of

mindfulness, I guess. If I were really mindful, I'd live completely in the moment, dealing with only what is right in front of me. Sure, that would be the most mentally healthy thing to do, but it's asking too much right now.

So this week, I'm going to worry only about one major existential crisis. I won't completely ignore all else- I mean, I voted, and I'll keep recycling. But my concentrated efforts this week are on figuring out how I, personally, am going to live in our covid-ridden world.

I know, I hate covid too. I'm so sick of it. But it's still here. I've seen a big uptick of cases at work this week. Initially, I felt alarmed, but that got me nowhere. Instead of panicking, I wrote a lot of orders for covid tests, and prescribed a lot of Paxlovid. I think I've finally given up on the idea that the covid crisis will calm down sometime in the near future. It really is going to keep its grip on us for the foreseeable future, and I need to wrap my mind around that.

As a doctor, that means a bunch of things for me. First off, I will be wearing an N-95 mask a lot of the time at work for a long time, maybe forever. I keep trying to get used to it. It's very difficult- it fits tightly (if it is the correct size) and feels very hot. I barely feel human wearing it.

It also means that the medical system is going to continue to be stretched and stressed. It seems like a lot of people who aren't in healthcare don't realize how much strain covid has put on our already fragile health system. Up to 20% of healthcare workers left the system since the beginning of the pandemic, and many more want to or plan to. That means less people to serve those who need medical care- doctors, nurses, techs, pharmacists, and others. In addition, a lot of time, energy and money is still being applied to covid care, leaving less for other issues, and we have a brand-new chronic illness in the form of Long Covid Syndrome, which is affecting a large group of people and will require more research and a multi-disciplinary approach, an expensive proposition. As the government begins to shift the costs related to covid to insurance companies, as it is poised to do, we will also have to contend with a hodgepodge of new rules about payment, which will further complicate the issue.

At urgent care, we are thrilled to see patients with issues that are not covid related. It is so refreshing to manage urinary or gastrointestinal problems, or to suture a laceration! But people with non-covid issues are waiting longer than ever for care, because of the scads of people needing covid testing and care for covid-related symptoms. I also am spending lots of time talking to folks about getting their boosters, wearing masks in crowds or avoiding crowds, and what to do if they are exposed or develop symptoms. Things keep evolving, and people remain confused or unclear about all of this.

The medical system has not even begun to recover from the covid crisis. We never got much of a break between surges, but when the case numbers were way down, we were busy trying to make up for lost time with all the people who had delayed care for other problems. We haven't caught up, and now we may be in another surge. To add to the problems, it is more difficult than ever to get specialist appointments, medications and equipment; understaffing in many facilities and supply chain problems affect medical care at every turn. Pharmacies are very short-staffed and are handling more work than ever before, doing covid testing and administering covid vaccines (unlike flu vaccines, for which there is a 'season', covid vaccines are ongoing), in addition to the usual work of filling prescriptions.

While hospitalizations have not risen nearly as much as case numbers, hospitals are still struggling to keep up with workloads, and in some parts of the country, hospitalizations are, in fact, rising significantly.

I also have to look at the patients' perspective. Trying to get care for anything these days is incredibly frustrating. I have a friend who needs surgery after an injury, an 'elective' but necessary procedure. She is a well-educated, savvy person who, under normal circumstances, can navigate the details of her care. But she's feeling overwhelmed. It was difficult to get scheduled and she had to wait several months because the OR schedule was so busy. That means she was in pain for a longer time than expected. Getting her preoperative labs and EKG was an all-day event, and when she tried to schedule the covid test she needed two days before surgery, the on-line scheduling software kept kicking her off and nobody answered the phone at the number provided.

As a consumer in the healthcare system as well as a provider, I must resign myself to covid's reality. I'm not going to call it the 'new normal' because it's anything but normal, and I hope it doesn't stay this way. But for now I'm adjusting my expectations as a doctor and as a patient. When it took over a week to get a routine prescription for myself, I had to remind myself that it wasn't the doctor's fault or the pharmacist's fault. Nor was it the fault of the person who answered the phone at the CVS Pharmacy. The drug was out of stock initially, and when it finally arrived, it took 48 hours for the pharmacist to get to her pile of backlogged non-urgent prescriptions. It wasn't a life or death situation; had it been, I suspect she wouldn't have put it off.

Most patients have been patient and calm and understanding of how overstretched we all are. I wish that those few who are irritable and angry, the ones who make the assumption that we're not trying hard enough, would read this post and hear what's happening from the other side. Unfortunately, they aren't the people who are reading my blog. But they are making the situation even worse, by putting even more stress on people who are hanging on by a thread.

Those who become blatantly abusive are traumatizing the people who are trying to help them, and likely contributing to even more short-staffing when those traumatized people leave the healthcare workforce.

Some helpful hints:

-If you haven't gotten all the boosters you are eligible for, don't wait any longer.

-Consider masking in public places again, and consider avoiding large gatherings right now.

-Order your covid tests from the government. There is a new round being mailed to those who request them: 8 tests per household.

-Use your tests properly: If you have symptoms and test negative once, repeat the test in 2-3 days. If symptoms persist, consider getting a PCR. If you test positive, assume it is real. False positives are very uncommon, while false negatives are quite common, occurring when the viral load is not high enough to meet the threshold for detecting antigen.

-If you test positive, isolation is at least 7 days from the onset of symptoms (if your asymptomatic, use the day of the positive test as day 1). If you are vaccinated and get exposed, you can continue to go to work, etc. but consider wearing a mask, and do at least 2 serial tests.

-If you are over 50 or have a significant health problems and you test positive for covid, talk to your doctor right away. You may benefit from Paxlovid, and you need to start it within 5 days of developing symptoms.

-You do NOT need to retest if you are positive and get better. You do NOT need a negative test to go back to normal activities.

-Make routine doctor appointments way ahead of time

-Refill prescriptions as early as possible.

-Calmly advocate for yourself if you need an appointment or medication or other services earlier than they are offered to you. If that doesn't work, ask your doctor to advocate for you.

-Advocate and vote for changes in the healthcare structure that may alleviate some of the current barriers (a whole topic of its own).

-Finally, temper your expectations. We've got a long road ahead.

I've gotten all my covid concerns out on paper now. Next week I'll return to the question of the health ramifications of overturning Roe, and the following week I'll address the medical community's thoughts and position on gun control and gun violence.

Have a covid-free week if you possibly can!

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