This winter, COVID-19 is not your only health concern
By Helene M. Epstein
As you read this, COVID-19 may be spiking in your community for the second or third time. Perhaps your hospitals are overwhelmed with patients and have stopped elective surgeries. Restaurants and gyms and all but essential stores may be closing, again. The news is filled with scary headlines. You have every reason to want to limit your exposure.
But when was the last time you saw your doctor? When were you supposed to have a colonoscopy, or a mammogram, or get your cholesterol checked? Even without pre-existing conditions, how you manage — or don’t manage — your health in the midst of a pandemic can cause a wide range of issues.
COVID-19 may be scary but ten more months of avoiding your doctor may be worse.
Why your other health risks need your attention as much as avoiding COVID-19
Jana Ragsdale had every reason to fear COVID-19. She is a single mom of two boys, one in high school and one in college. She had already battled neurological Lyme disease for years which meant her immune system had been badly breached. Although a casual observer couldn’t tell, she was still dealing with the last vestiges of Bell’s Palsy, a common Lyme symptom. Bell’s Palsy is a neurological condition which temporarily atrophies the muscles on one side of your face so your eyes and lips look as though they’re sliding off.
Because of her Lyme experience, Jana had learned to become an empowered patient and to advocate for herself. As a writer/social media consultant, Jana says she prefers to get her health news unfiltered, by following epidemiologists and health experts. She was not only aware that COVID-19 had arrived in her town of Portland, Oregon by late February, Jana had a prescient understanding of what was headed our way. “I did a Costco run for anti-bacterial wipes and flu medicines. I was all set up,” she says. “I knew there was no way we would avoid this.”
Despite her best efforts, on March 9, Jana became one of the first 100 people in Portland Oregon to get coronavirus symptoms. Her son came home from high school four days later with similar symptoms. His school closed to in-person classes that day.
Jana wasn’t alone in being fearful of COVID-19. Healthcare professionals were as concerned as the rest of us. Many primary care practices initially closed and directed patients to hospitals’ emergency departments. “Early on, as all the healthcare systems were trying to figure out what the best protocol is, there was a lot of confusion… and some growing pains,” says Ali Tehrani, MD, Assistant Professor of Neurology at Johns Hopkins Medicine, a neuro-ophthalmologist with a focus on stroke. The uncertainty was pervasive; how does the infection spread, how does coronavirus affect the body, how do we test and diagnose it, and how do we treat the symptoms and prevent others?
Initially, Jana’s symptoms were mild but on March 19 she developed a high fever, and over the next few days delirium, shakes, and loss of taste.
Jana says that her doctors were worried and unprepared. “They didn’t want me to come in.” Her first appointment was a phone call and a few days later, as her symptoms worsened, she had a video visit with a nurse. The nurse told Jana to hold her breath and count to 10, every day. “If I can't do that,” Jana says, “I was told to go to the closest ER.”
In April, she found it hard to know where her Lyme symptoms ended and COVID-19 symptoms began. Then she developed a new symptom, serious pain in her armpits. She thought it was her lymph nodes. Jana reached out to her regular primary care physician (PCP). She says she was very “trepidatious” about visiting her because her PCP's office is on the fourth floor of a hospital that was treating COVID-19 patients. So, they did a telehealth appointment instead.
Jana says she told her doctor, “The pain is mostly in my lymph nodes. The ones under my arms are so inflamed that I cannot wear a bra. I feel constant soreness.” Swollen lymph nodes are usually a sign you’re fighting an infection, which Jana was. But because Jana’s pain was limited to the lymph nodes in her underarms — and not in the lymph nodes in her neck or groin — her doctor wanted to rule out breast cancer. Jana’s doctor urged her to get a mammogram despite her fears of getting COVID-19 again.
Looking back at the first three months since she had contracted COVID-19, Jana admitted, “I had put off getting a mammogram or an in-person visit with my PCP due to COVID. My PCP office and mammogram center are attached to the hospital… and the general infection rates in Oregon were high at the time.” She says she canceled her mammogram, originally scheduled for the end of March. Though she was always diligent in getting all her health screenings, “there was so much misinformation and lack of information,” she had understandable concerns about keeping her mammogram appointment.
Jana was lucky her PCP already had a telehealth system in operation. Some practices took months to get theirs up and running, which meant many patients had to choose among staying home and ignoring their symptoms, finding home-based solutions on the internet, or risk the emergency room during a pandemic. During the first six months of the pandemic, face-to-face doctor visits dropped by 50 percent. Telehealth filled only some of that void.
Dr. Tehrani adds, “A lot has changed since early spring 2020. We had very robust protocols [established] and these protocols work.” Hospitals, testing facilities, and medical practices quickly learned how to protect patients and themselves. Where possible, healthcare facilities of all types scrambled to set up easy-to-access telehealth or video-health appointments so patient care didn’t lapse.
Telehealth can be extremely helpful if you experience coughing and difficulty breathing for the first time. Many medical practices are so hyper-vigilant about COVID-19, that they’ll assume you’ve been infected. However, there are several respiratory diseases whose symptoms are similar to some COVID-19 symptoms. Most medical practices ask you to fill out a questionnaire stating you don’t have any of the listed COVID-19 symptoms before your appointment. If you have these symptoms, you may have difficulty getting seen. Don’t lie but don’t let the questionnaire prevent you from getting diagnosed in a timely fashion. Call ahead to discuss how to handle potential COVID-19 symptoms. Get a free COVID-19 test first or opt for a telehealth visit as soon as possible.
Some diagnoses require being seen and tested in person and those were greatly affected by the pandemic. Cancer screenings dropped precipitously as COVID-19 moved across the country. According to Bill Cance, MD and Chief Medical and Scientific Officer of the American Cancer Society, “Screening facilities in many places were closed.” While it’s difficult to know the total impact these closings had, Dr. Cance notes, “There are models that are predictive if you shut down screenings for three months. So, there were about 19 thousand delayed diagnoses of colorectal cancer, and about 36 thousand delayed diagnoses of breast cancer, based on the model.” Dr. Cance shared that Quest Diagnostics reported a 46 percent drop in the rate of all cancers diagnosed in just the first three months of the pandemic. While cancer screenings are recently back to normal, there’s still a backlog from all of the earlier missed screenings. And with the current surge in COVID cases, we may see a greater gap. That means too many cancers are still not getting diagnosed.
There are lots of reasons to be concerned about these delayed cancer diagnoses. Dr. Cance says, “There is ongoing evidence that these undiagnosed patients will remain undiagnosed for the indefinite future, sadly. Because it’s not just the shutdown [which caused a backlog], it’s also the fear of getting COVID, the denial, and the financial toxicity.”
In addition to COVID fears causing delays in diagnosis, he notes that about 12 million individuals have lost their health insurance coverage during the same period, disproportionately impacting Black and Hispanic people. This will likely get worse with predictive models estimating that 30 million Americans won’t have any health insurance by the end of the year. “About 22 million cancer screenings were canceled or missed, between March and June,” notes Dr. Cance. Over a third of “primary care practices have cut back the number of services offered to patients. There’s the perfect storm. A convergence of factors that’s going to make it a long time to bounce back from the effects of reduced screenings.”
The National Patient and Procedure Volume Tracker estimated that breast health visits dropped by two-thirds in the first two months. During the same time period, cardiology, neurology, pulmonology, rheumatology, vascular, and gastroenterology visits all dropped between 40 to 70 percent. During the first six months of the pandemic, emergency room care initially fell by over 50 percent, and people with the types of potentially serious conditions who often come to the emergency room are still avoiding going.
Experts believe that too many people died unnecessarily at home during the first wave of the COVID-19 pandemic, so afraid to catch COVID-19 that they waited too long to visit their doctor. At the height of the spring crisis in New York City, newspapers were filled with stories of the overwhelming number of people who did call 911 with already fatal or near-fatal heart attacks, heart attacks that might have been avoided had they been able to see a doctor and get a more timely diagnosis. On the other hand, the need for emergency services was so great in New York City that ambulances were unable to respond to everyone in need. That’s no longer true. The Fire Department of New York (FDNY) who oversee emergency ambulances indicate they are well prepared for the next spike.
Dr. Cance urges patients to “be your own advocate to get your [cancer] screenings.” Jana did. She’s a highly proactive patient and paid attention to her still sore underarms. Despite her experience with COVID-19 and her fears of getting it again, in June she called for a mammogram appointment and was surprised to get one almost immediately.
The mammogram detected something on her right breast. Five days later, she had a biopsy. Three days after that, her PCP called and asked her to come in that day. “I knew it wasn’t good news,” Jana says. It was July and infection rates had dropped but Jana was still uncomfortable that her PCP was on the fourth floor of a hospital filled with COVID-19 patients. Jana says, “I took the stairs; I wouldn’t take the elevator.”
The diagnosis was DCIS (Ductal Carcinoma in Situ), a highly curable type of breast cancer. Her doctor told Jana she could wait, a bit, to have the surgery. Her lymph node pain under her arms was just a lucky coincidence that drove her to get screened and checked. She had lumpectomy surgery at the end of August and began radiation treatments in September. Jana is expected to fully recover, cancer-free.
The question remains what might have happened if Jana had allowed her fear of COVID-19 to keep her from getting that mammogram? DCIS is defined as a constellation of cancer cells inside the walls of a milk duct. If undiagnosed, they could break through the walls of the duct and invade other areas of the breast or body. No one knows when that might happen; each woman’s breast cancer behaves differently. Referring to the way untreated cancer can progress in stages from low-risk to life-threatening, Dr. Cance says, “We don’t know how much stage migration of breast cancer will occur with these delays. However, it’s important to get diagnosed as early as possible because we have such wonderful treatments for breast cancers.”
In other words, don’t let fear of COVID-19 keep you from taking care of all the other health risks you may face.
How can I maintain my health and survive this pandemic?
- Trust in the science.
Remember, the medical community has learned a great deal about how to diagnose, treat, and prevent COVID-19. “We are not in the same situation as six, seven months ago,” says Dr. Tehrani. “Health care systems are much better at keeping patients safe.” Your local doctor and hospital know how to protect you –– and themselves –– from COVID-19.
- Don’t ignore any painful or worrisome symptoms.
If you have any preexisting conditions or serious family history, don’t be so afraid of catching COVID-19 that you wait too long to be screened or seen. Dr. Cance says, “There are two things patients, and physicians, need to pay attention to. One is family history. That automatically elevates the urgency for screening. Second are symptoms, particularly colorectal.” Because colorectal cancers are increasing at an alarming rate in people under 50, the recommended age for a colonoscopy is now 45, and younger if you have a family history. Referring to the tragic loss of Chadwick Bosman at just 43, Dr. Cance noted, “Cancers are occurring earlier in life. If you’re having persistent symptoms, go to see your doctor.” That’s true for stroke and heart disease, as well. Never discount your symptoms because you think you’re too young.
- Listen to your body.
Even without family history or preexisting conditions, the most important things to watch for are symptoms of cancers, heart disease, and stroke. Signs of stroke are too often ignored, even without a pandemic. Dr. Tehrani notes the rate of people showing up at the emergency department (ED) with small strokes initially dropped because of fear of COVID. Many of these patients eventually showed up at the ED with evidence of subacute strokes two to three weeks old. “They have a small stroke, they don’t come to the ED, a week or two weeks later they have a huge stroke,” says Dr. Tehrani. “Had the patient sought care we could have potentially prevented that large stroke.” Death isn’t the only issue. There’s no reason to live with that toothache, frequent headache, back pain, or rash. You wouldn’t put off getting a broken leg set.
- Stress affects mental health.
These past ten months have been stressful for many of us. If you don’t have a safe place to work out or walk, or if you’re isolated, or out of work, you’re not alone. In June, just two months after many communities were first affected by COVID-19, over one-fourth of parents reported worsening mental health for themselves. Children are feeling the strain as well. These many months later, how many more of us might be affected? Remember that most mental health resources and professionals are now available via telehealth or video visits. Some are even meeting patients outdoors or available by text.
- Stress affects physical health.
Has the stress of dealing with the pandemic resulted in gaining the dread “COVID 19” pounds? Or is stress causing you to smoke or drink more? While eating, drinking, or smoking might feel good in the moment, they can cause serious medical conditions. Overeating overtaxes your body and can lead to diabetes, high blood pressure, gastrointestinal issues, and heart conditions. Too many cocktail zooms can lead to high blood pressure, heart disease, stroke, and liver disease. Signs your liver is affected include weight loss, digestive issues, swelling of ankles or stomach. Smoking causes respiratory problems.
- Have you lost your health insurance?
Most large communities have at least one Federally Qualified Health Center (FQHC) or other free health clinic which offers healthcare and behavioral healthcare for free or greatly reduced fees based on your income. However, you may have to ask as their resources are stretched to the breaking point. Most offer telehealth services as well as COVID-19 testing. There are approximately 12,400 locations in the U.S.
- Start with a video or telehealth appointment.
No travel is involved, no risk of getting infected, and you get the doctor’s undistracted attention for the whole appointment. Telehealth visits are perfect for initial consultations with primary care doctors and specialists. Dr. Tehrani suggests that if his patient has a $30 blood pressure machine at home, he can learn as much about their risk of stroke on a video-health visit as he can in person. If there is any reason for concern, an in-patient visit can be quickly arranged.
- Know before you go.
If you need to be seen or tested in person, call ahead to ask what their COVID-19 protocol is. Ask if appointments are spaced out, how frequently are waiting areas and exam rooms cleaned, what PPE are the front desk and healthcare professional wearing. Ask how they’re screening patients before each appointment. Keep your mask on the whole time you’re at your appointment.
- As COVID rates continue to rise, don’t let down your guard.
Continue to take the simple precautions that help prevent transmission. Avoid crowded areas. Always wear a mask, indoors and outdoors, unless you’re home. Keep at least six feet between you and other people you don’t live with, 10 feet apart indoors. Wash your hands frequently with hot soapy water, especially after touching door handles, elevator buttons, signing store kiosks for purchases, or anything you don’t clean yourself. Johns Hopkins University of Medicine has a webpage where you can view lots of up-to-date statistics on COVID-19 in your state, and if available, by county. The CDC also has an interactive site that can give you state data and is linked to each state’s department of public health.
- Be choosy about where you get your health screenings.
There are plenty of stand-alone facilities, meaning they’re not in hospitals that treat COVID-19 patients. They’re available to conduct safe in-person appointments for tests like mammograms, MRIs, urine and blood tests.
- Until a safe vaccine is available, get that flu shot as soon as possible.
If you do get flu-like symptoms this winter, doing so helps your doctor rule out the flu. Also, some experts believe that the flu vaccine helps prime your immune system to recognize and fight the COVID-19 virus.
The Society to Improve Diagnosis in Medicine (SIDM) catalyzes and leads change to improve diagnosis and eliminate harm from diagnostic error. We work in partnership with patients, their families, the healthcare community, and every interested stakeholder. SIDM is the only organization focused solely on the problem of diagnostic error and improving the accuracy and timeliness of diagnosis. In 2015, SIDM established the Coalition to Improve Diagnosis, to increase awareness and actions that improve diagnosis. Members of the Coalition represent hundreds of thousands of healthcare providers and patients—and the leading health organizations and government agencies involved in patient care. Together, we work to find solutions that enhance diagnostic safety and quality, reduce harm, and ultimately, ensure better health outcomes for patients. Visit our website at www.improvediagnosis.org, and follow us on Twitter or Facebook.
Helene M. Epstein writes about patient safety and family health. Her goal is to help readers apply important new information to their own lives. Subscribe to her website at www.hmepstein.com and follow her on Twitter, Facebook, and YouTube.
Dx IQ is made possible with funding from the Mont Fund and the Gordon and Betty Moore Foundation.
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