Running Through Mud in COVID-19
Adventures in tele-health without a telephone
Posted Apr 30, 2020
by Martha Ward, MD on behalf of the Atlanta Behavioral Health Advocates
Rrrring. Rrrring. Rrrring. “The voicemail for this number has not been set up. Goodbye.”
“The number you are calling is no longer in service. Please check your number and try again.”
“Hello Ms. J! This is Dr. Ward calling. I’m trying to reach your brother but the numbers I have in the chart don’t seem to work. Do you know how I can reach him?” “Well, he calls me from so many different numbers.” “Do you happen to have any of them on hand?” “No, I don’t. Sorry Dr. Ward.”
It’s Monday morning and I’m trying to do my job. Seven years ago, I finished my residency training program and became board certified in both Internal Medicine and Psychiatry. I started a primary care practice located in the outpatient behavioral health clinic of our busy, urban safety net hospital and began treating the medical and psychiatric needs of our most disorganized, disenfranchised patients. All of my patients suffer from severe mental illness (SMI) that impacts their lives such that they previously did not receive any continuity of medical care. Many are homeless. Nearly all are uninsured or are supported with monthly disability checks. I made myself say “yes” to walk-ins, to late arrivals, to phone calls outside of my clinical days. I saw patients as frequently as needed, often with their family members and caregivers, combining psychotherapy with education, and antipsychotics with antihypertensives. Slowly but surely, many improved. Trust was formed. We made a medical home for our patient population.
When COVID-19 hit, our clinic, in line with CDC recommendations, transitioned to tele-health. I tried to give anticipatory guidance. Stay inside as much as possible. Wash your hands. Stay away from people who are coughing. As we all know, the ability to follow this advice is a luxury. What about those living in homeless shelters, or on the street? Or in a car because they escaped an abusive partner? What about those who need to take public transportation to get their food? Or those that eat in soup kitchens? How do you do a tele-health visit if you don’t have a telephone?
We have seen convincing data that social determinants impact health enormously. At baseline, my patients with SMI experience poverty, severe psychological stress, social exclusion, unemployment, poor social support networks, lack of availability of healthy food, high rates of addiction, and decreased access to safe transportation. Such adverse social determinants contribute heavily to the early mortality of individuals with SMI; multiple studies show that persons with SMI treated in the public sector die, on average, 25 years earlier than those in the general population. Such adverse determinants are amplified in the time of COVID-19, particularly for those with SMI. Without the ability to talk with, examine, and effectively treat my patients, I fear for their medical as well as psychiatric outcomes, particularly as addressing chronic medical conditions and routine screening fall to the wayside in this global pandemic.
I drove to clinic last week, in case anyone arrived in person for an appointment. No one did. I passed the stretch of my drive where there are several homeless shelters, soup kitchens, and tent villages. I slowed to see if I could recognize my patients among those gathered in groups. I didn’t. I felt temporary relief—perhaps some have been able to find a place to stay, a spare couch, and are sheltering in place? Yet my relief is short-lived, as other possibilities mount. Maybe some are desperately ill but scared of seeking care. Maybe some are already hospitalized at one of the many Atlanta hospitals outside of our network, or worse, have succumbed to COVID-19 or another underlying medical problem.
I feel quite grateful for my health and safety during this time period. We have more bedrooms than family members in my home, and plenty of soap and hot water. But when asked how work is going, I have to say that I often feel like I’m running through mud.
Ok, back to my phone calls.