EDIT 5/13/20: I think the oringal title of this article “Reopening Phases” made it seem like we were closed at some point. To be clear, we have not closed during the pandemic. Myself and at least 1 staff member have been here every day and seeing patients since this started. Its been a lot different of a day for us than it was in January and February, being in Phase 1/2 (see below), but still mostly full days of work. I changed the title to avoid confusion.
At some point the Governor’s stay at home order will expire. Assuming that it does expire and is not renewed, and that legally we are able to do such things, below I will outline how our office will enter into a phased reopening. I expect over the next 2 years we will have at least a few times that we will reenter quarantine conditions as the number of cases of COVID-19 will rise as soon as we stop our physical distancing. I hope that measures like contact tracing (potentially using an app) and mask wearing, will slow that rise and keep our hospitals from being overwhelmed.
A few things apply to multiple phases.
Cleaning is being done in between patients, especially of all high touch surfaces. This is especially important in phases 0-1 but will continue to some degree in phase 2-3.
Toys have been put away and will be put away until Phase 3
Magazines are still out, but are now one time use. We get a ton - take the one you touch - its yours now… (phase 0-2)
I’m going to use the State of MI’s phases because its too confusing for me to make up my own phases, and its not necessary for me to do so - the important part here is naming/defining the phases and then coming up with plans (both for our office and for society more broadly)
Phase 1 (Uncontrolled Growth) and 2 (Persistent Spread)
The stay at home order reflects that fact that the number of cases in Michigan is too high to allow non-essential travel. For the times when patients do come to the office, we ask them to call us when in the parking lot, we bring things out to them if they’re picking something up, and we generally only have one patient in the office at a time. No waiting in the waiting room. We ask everyone to wear masks.
We are utilizing doxy.me/machadomd for secure video visits. This encompasses all of our follow up visits, chronic disease visits, and most of our acute visits, including those with upper respiratory symptoms (fever and cough etc). This works amazingly well. When I was in medical school, my attendings would tell us how much of the diagnosis is in the patients history much more than the physical, and they were right - a lot can be done without being physically present. I do prefer video over phone, so I can pick up on the unspoken, but for those of my patients who are unable to use a video method we will use the phone. If you are an established patient and need an appointment, please call us to schedule.
The video service works pretty slick, but you do have to read and follow the prompts to allow the website access to your camera and microphone. After that its very simple. No download needed, its works entirely within the browser of your smartphone or laptop.
Wellness visits - the screening and preventative visit done for those on medicare, are being performed via telemedicine.
Well child visits - we are deciding to see these in person on a case by case basis - basically, if you are a child due for shots, or are a baby, we will see you in person. Otherwise we will postpone the visit.
Physicals - by this I mean the screening and preventative visits done for those NOT on medicare. I don’t see this being covered via telemed by insurance, and because these patients are at less overall risk than my medicare (65&up) patients, we are postponing these.
We are still seeing some patients in person, for things that can only be done in person, such as procedures that are not able to be postponed.
Phases 3 (Flattening) and 4 (Improving)
This is the time just after the stay at home order has been lifted. This might roughly begin after at least a 2 week decline in new cases. At this point we will start to allow more in-person visits but certainly not deny any requests for telemedicine for visits that we can do remotely. In-person visits will be spread out more to try to avoid patients contacting other patients. We will still prefer waiting in-car, but in this phase will allow waiting in the waiting room, which has far less chairs in it than it used to. We will ask everyone who does come in, to wear a mask.
URI (upper respiratory infection) visits - cough and cold symptoms - for the vast majority of these we will continue to do these via telemedicine
Wellness visits - the screening and preventative visit done for those on medicare, will be performed via telemedicine.
Well child visits - preferring in-person, but if healthy and not due for shots, may be deferred
Physicals - In office as requested. Not yet seeking out those who are not due for screenings/vaccinations.
Phase 5 (Containing)
This is the phase just before things are “normal” (whatever that is). This probably won’t happen until we’re seeing at least a 4 week decline in new cases. I suspect this will be a difficult phase to get to due to our desire to break quarantine. During phase 5, we will increase in-person visits but not deny any requests for telemedicine that we can do remotely. In-person visits will still be somewhat spread out more to try to avoid patients contacting other patients, and patients can decide to waitin-car or in the distanced waiting room. We will still ask everyone who does come in, to wear a mask.
URI (upper respiratory infection) visits - cough and cold symptoms - for the vast majority of these we will continue to do these via telemedicine
Other non-URI sick visits - we will give the patient the option of in person or via telemedicine.
Wellness visits - the screening and preventative visit done for those on medicare, will be performed via telemedicine (preferred) or in-person.
Well child visits and non-Medicare physical - Will resume fairly normal in-person physicals as requested and seeking out to those who are overdue for certain screenings and preventative services..
Phase 6 (Post Pandemic)
This is the time when we start to get back to the normal levels of illness in the population. This might not be until 2022 and potentially later. We will still see season variation of viruses (both the old and the new) This phase is similar to the old normal, but with a few twists. I don’t think we’ll ever go back to a time where a mild to moderately “sick” patient with upper respiratory symptoms (cough, etc) will come to the office in-person (they are miserable and don’t want to come in anyway, and we don’t want to get sick, so its a win-win). We will do these via telemedicine - we’ve already seen this can work. Those who are sick with respiratory symptoms who need to be seen in person will wait in their car and go straight to a room, and will be asked to wear a mask. Other non-respiratory visits will be at times performed via telemedicine , as requested by patients, when covered by insurance.
Closing Thoughts
We will spend a lot of time in the coming months and years going up and down the phases, from 1 to 5. It will take a long time to get to 6. At the very least it will take longer than any of us wants.
This is the montage part of the movie. The music has started and now we’re shown clips of whats happening to the main character, while time goes by quickly. This is when the rag-tag band of misfits learns how to work together and become a team. Its when the work gets put in to make the weak character stronger for the 2nd half of the movie. Its when the character grows from a child to an adult and you see why they are the way they are. Sometimes montages tell us why that character is so great, and sometimes they explain why they’re not so great. The point of the montage is that these changes don’t happen overnight. They are boring. They take time. But they’re crucial.
How is your montage going? Who will you be after intermission?