• Margaret Curtis, MD

Relative Value

One week ago the first case of SARS-COVID 19 was diagnosed in my state, at my hospital. The next day, I sat in my office looking out the window at the bright yellow tent erected outside the ER entrance to triage and test potential new cases. I wore scrubs and a face mask at work for the first time in years. Like the rest of you, I thought about the wave that was about to break over all of us.


Practice since then has felt like running, tripping and stumbling, on a treadmill that keeps accelerating. The pace of change has been breathtaking and it still isn't fast enough, because our opponent got a head start on us. We are hobbled by our lack of knowledge, equipment, foresight, and by the the very business of healthcare.


As hospitals have pivoted to a wartime model, they have had to stop all elective procedures and outpatient visits. Suspending elective care saves resources and protects our patients (and ourselves) from exposure. This has been absolutely essential, and financially devastating, especially for smaller and rural hospitals that already exist on a knife edge of financial viability.


Ideally we would also furlough essential workers - not just doctors and nurses but respiratory therapists, rad techs, support staff - to keep teams healthy and ready to fill in when front-line teams are exposed and quarantined. We haven't seen our way clear to doing this. Instead, staff are going without pay, hours cut, redeployed or losing their jobs.


I consider myself incredibly fortunate to have a job when so many don't. Many physicians in private practice are wondering how they will keep their clinics open. They have lost their livelihoods. I also am fortunate that I can be of use, and like many others I want to do more.


They also serve who only stand and wait. Like many other outpatient physicians, my clinic days are now filled with answering phone calls, managing my own and my colleagues' overflowing inboxes, strategizing with staff and learning everything I can about COVID - including brushing up on my vent management skills (1). There is not CPT or E/M code for any of this.


I also try to fill an even more essential function: I keep my patients out of the Emergency Department. I manage their acute infections, their mental health crises, their minor traumas so they don't spiral and require admission to the hospital. I am not on the front line, but I am supporting the flank. According to the system we use to pay for physician care, none of this has any value. This was evident even before this viral pandemic: we pay for action, intervention, risk and Hail-Marys. We don't pay for patience, wisdom and prevention.


I am here. Send me. While we in the outpatient clinics watch our practices dwindle, there are physicians and practitioners in EDs and ICUs who are busier than they ever wanted to be. They are also risking their own and their families' health. No amount of compensation could be enough. What is the Relative Value of an anesthesiologist who volunteers for a hospital "intubation team", knowing she will be tasked with the procedure that puts her at highest risk of contracting SARS-CoVID19? Or every single healthcare provider who reports to work with inadequate protective gear? Or the hourly-wage employee who cleans the room where a COVID-19 patient has died? There is no metric that applies.


This experience has been entirely transformative, on every level. I hope and believe we will emerge with a new appreciation for community, connection, health and freedom. I hope we also learn a new appreciation for what is most valuable in doctoring, and is beyond measure.

(1). I have now read two references (in the New York Times and our local paper) to "pediatricians might be pressed into service in the ICU!" as if a. we aren't already busy taking care of sick people and b. we aren't actual physicians. But that is a rant for another time.

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