Essay: September 20, 2020

With primary care in shambles, the ‘single astute’ clinicians couldn’t respond to Covid-19

By Philip M. Bretsky

I should have been the perfect person to help sound the alarm about Covid-19. I’m an epidemiologist who specialized in infectious diseases and have worked for the last 12 years as an internal medicine physician in California. I know that viruses know no boundaries and can “jump” from animals to humans. If a pandemic ever emerged — and I had a suspicion it would at some point — I expected to be a key part of the response. But I wasn’t, largely because the U.S. health care system has shackled me and other primary care physicians from contributing to the vital work of being a key part of the nation’s early warning system.

During my graduate work, my faculty advisor was Dr. Robert Shope, a preeminent virologist. He was a co-author, along with Stanley C. Oaks and Nobel Laureate Joshua Lederberg, of the Institutes of Medicine’s groundbreaking 1992 publication “Emerging Infections: Microbial Threats to Health in the United States.” At the time of the publication, Shope said, “The medical community and society at large have tended to view acute infectious diseases as a problem of the past. But that assumption is wrong. We claimed victory too soon.”

I had little practical exposure to an infectious disease outbreak until the H1N1 “swine flu” outbreak that began in 2009. At the time, I was so new to being a physician that I assumed flu season was normally that bad. In retrospect, it did strike me as odd that so many of the patients I saw were younger, but my ignorance made this unusual and characteristic feature of H1N1 seem simply, well, usual.

Fast forward a decade. I’m older and grayer, though debatably wiser. I watched as the 2019/2020 flu season followed its usual pattern: flu cases peaking in Los Angeles, where I work, between Christmas and New Year’s Day. In February, however, I began to see a perplexing number of flu-like illnesses in patients testing negative for influenza with our point-of-care testing. Were these Influenza B cases? Was there a problem with the test? Or was it something else?  A recent study of patients seen at a Los Angeles medical center with flu-like illnesses in March suggests this may have been Covid-19, as 5.3% of these patients tested positive for the novel coronavirus.

I began following the coronavirus outbreak in China in earnest beginning in mid-February. I really began paying attention when the CDC’s Dr. Nancy Messonnier said in a White House press briefing that she expected widespread transmission of the virus in the U.S.

Although the CDC lists the first three cases of travel-related Covid-19 occurring on January 14, the first case of community spread in the U.S. was reported February 26. That was the week I stopped seeing patients with any acute illnesses in the office. By mid-March I had closed the office, transitioning patients to telemedicine and a video platform for assessments.

Surveillance systems — preferably global ones — are the first and perhaps most critical bulwark of a health system that can rapidly and definitively respond to a pandemic. As Shope and colleagues wrote in their report, “Surveillance can take many forms, from complex international networks involving sophisticated laboratory and epidemiological investigations, to small, community-based programs or a single astute clinician.”

So what happened in the United States that our own surveillance system failed so miserably? There are many places in which blame can be reasonably placed. One of them is the evolution of a health care system that is too bureaucratic and top heavy to respond to shifting threats.

For the past 12 years, I watched as primary care physicians — our “single astute clinicians” — have been devalued in the medical community. As with all skilled gaslighting, this erosive process began innocently enough at the hospital level, replacing doctors who cared for their own patients with hospitalists. At the same time, mass consolidation of physician practices was underway, with major hospital groups acquiring outpatient practices.

This system has built up regional hospital systems by absorbing community-based, independent primary care practices. It has decimated rural and small town medicine under the guise of higher quality care being available in metropolitan health centers. Health insurance companies then contract with these large hospital entities, creating a massive administrative complex that provides zero direct patient care.

Inherent in these negotiations, brokered by hospital administrators and legal counsel, was the fact that primary care medicine was openly and unabashedly characterized as a “loss leader,” its only value in patient recruitment, retention, and referrals to hospital-owned imaging centers and profitable specialty care. As a result, the profit-driven health care system that valued knee replacements over cardiovascular disease prevention left the citizens of the United States with no surveillance network.

By 2019, for the first time ever, employed physicians exceeded independent physicians. Employed physicians are more likely to refer patients to higher-cost facilities in their employer’s network than solve problems on their own. That means the key components of recognizing an emerging infection, assessing its risk, and sounding the alarm was punted, sometimes to hospital administrators with no formal medical training.

And once the pandemic was on the horizon, what did hospitals do? They pulled inwards, shuttering outpatient clinics, abandoning community outreach, and braced for an inevitable tsunami of critical illness due to Covid-19.

Our ill-prepared system has failed at every turn in its response to the pandemic, from failed testing kits to overlooking asymptomatic carriers, hyping unproven therapies, missing testing dates, and health departments that simply gave up.

A further failure is the massive lack of data sharing in spite of huge expenditures over the years for electronic health records systems (and huge profits reaped by vendors such as Epic). Hospital systems have long touted their “patient portals,” yet haven’t bothered to make electronic connections with their local, regional, or state health departments. In the face of a pandemic, electronic health records are nearly useless. Instead, health care workers are left filling out case report forms and faxing them to local health departments.

Senator Kamala Harris and many others have described a “vacuum of leadership” in Washington DC. There’s also a vacuum in our health care system. The novel coronavirus has swept into this empty space, encountering little resistance as hospital leaders, who only months ago were busy with service lines and maximizing profits, are now nowhere to be seen. Health insurers have provided no guidance, no leadership, no innovation. Is it any wonder that a system that wastes 25% of total health care expenditures would perform any better in the midst of a pandemic?

The United States is harvesting what it has sown. By choosing profits over people, we now have on our hands a massive death toll that could have been largely prevented. We are lucky that Covid-19 generally spares children and young adults, and that it does not have a 100% mortality rate like rabies, a 50% rate like Ebola, or a 35% rate like its coronavirus cousin, Middle Eastern respiratory syndrome (MERS). While nature may abhor a vacuum, this single stranded RNA virus has thrived in ours.

The next outbreak could be worse. To make sure our health care system is up to task when it strikes — and it most assuredly will — we need to listen to what Shope, Lederberg, and Oaks wrote almost 20 years ago: “The emphasis of American health care system has always been on curing rather than prevention … The best way to prepare for the future is by developing and implementing preventive strategies that can meet the challenges offered by emerging and reemerging microbes. It is infinitely less costly, in every dimension, to attack an emerging disease at an early stage and prevent its spread than to rely on treatment to control the disease.”

Philip M. Bretsky is a primary care physician practicing in Santa Monica, California.


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