“Robert?” I said during a routine telemedicine encounter. “What’s going on?”
Robert said into the phone, “Oh, not much, Dr. M., I just wanted to get my hydrochlorothiazide refilled.”
“Oh, I see,” I said as I reviewed his list of medications in the EMR. “Actually, you’re not supposed to be on hydrochlorothiazide. Remember, we reviewed your meds at your last appointment? I switched it to chlorthalidone, that other medication we talked about.”
“Do you have any symptoms that are concerning you? How has your health been?” I asked.
He began listing his concerns. “My blood pressure has been high. I don’t remember the top number, but the bottom number is 105.”
“Are you short of breath? Do you have chest pain or any headaches?” I asked.
Robert nodded. “I’m short of breath, and there is a headache at the back of my neck. It feels like a weight. I can ‘hear’ my blood pressure.”
Taken aback, I said, “What do you mean by that? You can hear your blood pressure?”
“Well, it’s like a whooshing sound in my ear. But I feel like if I just take the water pill, I’ll be fine. I just need that hydrochlorothiazide refilled. I’ve gained 40 pounds. That’s what this pandemic has done with all the quarantine stuff,” he said.
I began to outline a potential plan of care. “I actually think you need to be seen in person. I’m worried about the symptoms you’re telling me about. If you’ve gained weight and you notice swelling, it might not be just because of a change in your eating. It might explain why your blood pressure is high, and all of the other symptoms too.” I paused. “Can you come into the ER or the clinic for an urgent care appointment?”
“Oh no,” Robert vehemently declined. “No, I can’t come in. I’m too worried about that virus. I don’t want to get it. I’m not coming in until the virus is gone. I’ll wait!”
“But the virus isn’t necessarily going away any time soon. It will still be around. We are all doing our best to minimize its spread and effects, but we can’t actually get rid of it completely for now. Please let me know what I can do to help with an appointment. Would you like me to arrange transportation?” I asked.
Robert shook his head. “No. I’m just not coming in. I appreciate what you’re telling me, but I won’t come in now.”
I urged him to reconsider. “Please, I’m worried about your health. Your symptoms could indicate something else that’s going on, and you’re at risk from the uncontrolled blood pressure. You’re at risk for things like heart failure, a stroke, or a heart attack. If you need me to arrange for an ambulance, I will.” The conversation continued like this for a few more minutes. He then respectfully thanked me for my time, said he hoped I’ll stay safe during the pandemic, and ended the phone call.
The pandemic has raised concerns I never imagined I would face in my lifetime. How do we balance the fear of COVID-19 and the detrimental effects untreated medical conditions will have on our patients? How do we alleviate concerns when the virus remains in our communities, invisible and spreading? These are questions we will have to consider as we reopen and reengage with our patients.
Yesterday, in a conversation with a patient, we discussed how to safely have her come back into the office for evaluation while balancing the very real risk of her being exposed to COVID-19 and transmitting it to her 88-year-old father, whom she cares for. I offered her an appointment at 8 a.m., so she could be the first patient of the day after the overnight deep sanitation of the clinic. For another patient, the solution we devised was to obtain blood work at the local lab near her house, titrate her blood pressure medication at home, use her own blood pressure cuff, and then come in for a follow-up appointment several weeks later, thus minimizing the overall number of appointments needed.
As we gradually reopen our clinic capacity, the patients I see are suffering from untreated or undertreated health conditions that have accumulated in the last few months. Delaying care even further not only puts patients at risk but also frequently requires escalation of care and increased utilization of health care resources. Something that could be managed in the primary care office last week may now require the emergency room or admission to the hospital.
I find myself explaining to patients that very few activities are zero risk. COVID-19 is here to stay, but so are heart disease, diabetes, cancer, and a myriad of other conditions. As we have these conversations with our patients, trust, mutual engagement, and shared decision-making between the physician and the patient remain of utmost importance.
Dr. Manasa Mouli is an attending internal medicine physician in Boston. She has an MD/MBA from Tufts University School of Medicine. She is interested in the future of the healthcare system, and the intersection of medicine with patient stories. She does not have any conflicts of interest to report.
Illustration by April Brust
All information pertaining to patients has been altered. Any similarities in name, age, or health information are purely coincidental.
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