The Pandemic Determinants of Health

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Today my clinic began with a young adult coming in for follow-up for depression and needing paperwork completed for mental health–related medical leave. This was followed by an older adult whose visit notes read “annual visit, last seen 2019.” Next was another patient scheduled for an annual examination, who left with a diagnosis of complicated grief following a family member’s recent death from COVID-19, someone they had begged to get vaccinated. Then I switched gears to a telemedicine video visit with a new patient establishing care. This patient had been undergoing a long, inconclusive workup for chronic dyspnea. Since then they had rarely left their home, aside from essential activities.

A woman in her 60s was then seen for long-standing depression and complicated grief, exacerbated by recent COVID-19 infection and her granddaughter’s hospitalization for a new diagnosis of metastatic cancer of an unknown primary. Due to the pandemic restrictions, she was unable to visit her grandchild in the hospital. Then came a patient for posthospitalization follow-up for a recent fall causing a large skin tear that had now developed into an exquisitely tender, warm, red, swollen shin. Next, a man with multiple chronic conditions who still had not met his grandchild born during the pandemic. Lastly, a 58-year-old woman being seen via telemedicine video following a visit to the emergency department for typical chest pain. She had been discharged from the emergency department with steroids and nitroglycerin for possible inflamed chest wall but continued to experience daily chest pain and was taking multiple nitroglycerin tablets a day.

During each visit I am able to cross the 11-second physician interruption checkpoint effortlessly because I am often at a loss for words. I share many of their concerns but have very little in my toolbox aside from providing a chance to talk candidly about how they are doing and listening closely. The heavy burdens they are all carrying these days, which profoundly impact their health and well-being, can barely be brushed over in our allotted time.

My usual medical advice of “eat mostly whole foods, avoid anything processed, exercise at least 150 minutes a week, get at least 7 hours of sleep a night, and reduce your stress levels” has been replaced by “it is at baseline hard to be a human right now…with any additional stressors on top of the pandemic alone it’s appropriate to feel [fill in the blank]...so be gentle with yourself…I’m sorry for your suffering.”

I want to tell my patients to focus on taking care of themselves and getting through each day. Still, the world has never afforded anyone that luxury. Their blood pressure, diabetes, heart failure, pulmonary disease, cancer, have not taken a hiatus to allow them time to focus on constantly adapting to the changing pandemic. In fact, many of their chronic conditions took advantage of recent unsupervised time to run amok; hemoglobin Avalues that were previously well-controlled were now in the double digits due to stress-induced changes in eating habits and cholesterol levels spiked because of newfound skepticism of medicine or simply not wanting to take so many medications anymore.

In the final moments with each patient, I cram in and check off what was a routine visit in the prepandemic world. Except now, even when their faces are fully revealed during the examination, mine remains hidden.

I remain fulfilled in my work as a primary care physician and am honored to be a part of each patient’s life and journey in health, but increasingly over the past 2 years each clinic session seems filled with tragedy on an unprecedented scale. Prepandemic, we had an interminable list of things to accomplish each visit. Just as our patients’ days and capacities have not extended to accommodate the increased load neither has our allotted time to care for them, and we are tasked to address more and more pandemic determinants of health. I wish I could wave a magic wand and alleviate their pain and suffering or at least bring it down to a level where they might have the mental space to make or keep their health and well-being a priority.

I offer what I can, a safe space to share openly about how they are doing, followed by commendations to highlight all they have managed to accomplish or maintain during these extraordinary times. At the end of the visit, I carry a simultaneously empty yet full cup, and the patients are sent back into this uncertain world to care for themselves.

Corresponding Author: Jennifer Shiroky-Kochavi, MD, MPH, University of South Florida, 13330 USF Laurel Dr, Fifth Floor, Tampa, FL 33612 (jshirokykochavi@usf.edu).

Additional Contributions: I thank the patients for granting permission in allowing me to share their stories.