Practicing Family Medicine in a Pandemic World: Lessons for Telemedicine, Health Care Delivery, and Mental Health Care

Telemedicine

During the COVID-19 pandemic, most practices were forced to implement telemedicine. Several articles in this issue focused on various forms of telemedicine. Frehn et al¹ present a qualitative study looking at how telemedicine was implemented in the unique environment of Federally Qualified Health Centers. The results revealed opportunities for strengthening telemedicine services. Petrilli et al² compared telemedicine visits during the pandemic to in person visits for musculoskeletal complaints. In particular, the authors looked at differences in radiographic ordering trends and results. Results indicate some natural limitations of telemedicine’s capabilities. A report from Texas³ looks at telemedicine patterns during the early and late phases of the pandemic. Findings highlight the need to address inequities in telemedicine delivery. Patients experiencing intimate partner abuse have unique challenges and experiences using telemedicine.⁴

Billings et al⁵ conducted a secondary analysis to understand how 5 previously described clinical decision rules for diagnosing influenza would perform when applied to the telemedicine setting. PCR results were used to calculate accuracy of the rules. Interestingly, the authors also looked at the effect of symptoms being reported by the patient versus the clinician. Elberg and Adashi⁶ communicate a recent Special Fraud Alert from the Department of Health and Human Services, Office of Inspector General, concerning telemedicine companies. This is a must read for family physicians working with telemedicine companies.

Health Care Delivery

One of the potential benefits of the electronic health record (EHR) is to help identifying opportunities to make better medical decisions. A cluster-randomized trial of a clinical decision support tool that makes recommendations targeting cardiovascular disease risk factors put that promise to the test.⁷ Identifying ways to make it easier to get patients with opioid use disorder proper treatment is becoming increasingly important. One mechanism is to create standing orders that can be quickly implemented by nursing staff. A longitudinal study of clinician and nurse perceptions in 1 urban clinic evaluated the acceptability and perceived effectiveness of a protocol of nurse standing orders.⁸

Survival rates of patients with cancer continue to increase. The 5-year relative survival rate in the US is now more than 65%. This means primary care physicians, who provide the majority of survivorship care,⁹ will continue to care for more and more cancer survivors. Guidelines for the long-term care of cancer survivors exist, but do primary care physicians use them? Are they receiving appropriate training about these guidelines?¹⁰

Another article¹¹ reports on the experience of leaders and staff at 4 community health centers with screening for social determinants of health (SDoH) and loneliness. Their experiences suggest key processes and resources necessary to adequately meet patient needs in these areas. A separate report¹² on SDoH screening used mixed methods using clinician and staff interviews plus EHR data. Findings highlight barriers to addressing needs when clinicians uncover them. Inequities in screening patterns are also clear in their findings.

The Pandemic and Mental Health

Data from the 2020 to 2021 and 2018 to 2019 versions of the National Survey of Children’s Health were analyzed to evaluate the physical and mental health outcomes of the COVID-19 pandemic on caregivers of children with and without special needs.¹³ Ladner et al¹⁴ explored the mental health implications of COVID-19 hospitalizations for Latinx and Spanish-speaking patients in Massachusetts early in the pandemic. This study details how social circumstances and culture influenced their hospital experience.

Current Issues in Family Medicine

Huguet et al¹⁵ sought to understand how insurance patterns (gaining, losing, or maintaining) around the age of Medicare eligibility impacted chronic disease diagnoses. The large EHR-based study included more than 45,000 patients across 25 states. Several of their findings reveal care delivery gaps both before and after the age of Medicare eligibility.

Sanders et al¹⁶ studied early career family physicians’ salaries using responses to the 2016 to 2020 American Board of Family Medicine National Graduate Surveys. There were some reasons to celebrate and some reasons for continued concern about compensation within the specialty.

LeFevre et al¹⁷ discuss the implications, positive and negative, of the recent elimination of the “X-waiver” requirement to prescribe buprenorphine for opioid use disorder. This thoughtful commentary explores the implications of this sudden change and points out the need for further advocacy on the part of family physicians. Dr. Rabinowitz¹⁸ shares his unusual pathway to becoming a family physician soon after the official birth of the specialty.