Michael Niederman, MD, on How I Practice Now: How COVID-19 Has Changed the Outpatient Experience

In part 1 of 3 of this video series, Pulmonology Consultant Advisory Board Member Michael Niederman, MD, from Weill Cornell Medicine, discusses the long-lasting impacts that the COVID-19 pandemic will have on the outpatient experience.

Additional Resources:

Schenck EJ, Turetz ML, Niederman MS. Letter from the United States: a New York experience with COVID-19. Respirology. 2020;25(8):900-902. doi:10.1111/resp.13893

Watch Part 2: The Inpatient Experience.

Watch Part 3: The Education Experience.

Michael S. Niederman, MD, is associate division chief and the clinical director of the Pulmonary and Critical Care Medicine at the NewYork Presbyterian-Weill Cornell Medical Center. He is also a professor of clinical medicine at Weill Cornell Medical College.

TRANSCRIPT:

Michael Niederman:  Hello. I’m Dr Michael Niederman. I am professor of clinical medicine at Weill Cornell Medical College and associate chief and clinical director of Pulmonary and Critical Care Medicine at NewYork‑Presbyterian Weill Cornell Medical Center.

I’d like to talk to you today about my perspective as to how COVID has changed the practice of pulmonary and critical care medicine. I believe, based on our experience in New York, that COVID has had a profound impact on the practice of medicine and an impact that in the end is likely to continue for many years to come.

This is much more than just a viral infection. But this is a change in the entire practice of our specialty in pulmonary and critical care. This change is evident in multiple areas.

It’s evident in our outpatient practice of pulmonary medicine, in our inpatient practice of pulmonary and critical care, and it’s particularly evident as well in our role as educators and in our teaching of residents and fellows throughout the medical center. I’d like to go through each of these areas quickly to try to give you a flavor or how much things have changed.

In the outpatient practice of medicine, one of the obvious refinements that has resulted from COVID and likely to continue long after COVID is gone is an enhanced reliability on telemedicine. We have changed our paradigm in outpatient practice from doing almost all of our visits face‑to‑face to now a formula where about half of our visits are face‑to‑face, and the other half are being done by telemedicine.

That has advantages and disadvantages. The advent of telemedicine makes us much more accessible to patients. It shortens the wait time for appointments. It makes it easy to follow up with patients and to see them very quickly at a minimal hassle to them, and frankly at a minimal health risk to them, because many of them are afraid to travel to and from the doctor’s office.

On the other hand, telemedicine has some limitations. When we do our video visits with patients, we are of course unable to do certain physical exams. We can't do pulmonary function testing. We can’t do 6‑minute walk testing. And we’re limited in some of the assessments.

We’re evolving to a point where some of our visits are face‑to‑face, and some of them are video. We’re trying to figure out the ultimate best blend of combining these 2 different modalities. I think patients also are trying to feel this through. And when we surveyed our patients, although many are very satisfied with the video visit experience, a large number of our patients say, “This was fine, but for my next visit, I’d like to see the doctor face‑to‑face.” I think that we definitely are learning how to incorporate telemedicine into our practice, and we’re doing this much more rapidly than I think we ever would if COVID hadn’t come.

On the other hand, we’re concerned about COVID for a number of reasons. There are many patients who have post‑COVID respiratory symptoms, and we’re learning a lot about these patients. They’re, to some extent, taking up a large part of our outpatient practice. We have patients with symptoms of bronchospasm, dyspnea, organizing pneumonia. We have patients with extreme and unexplained fatigue with dyspnea when we’re trying to understand the natural history of COVID and particularly the natural history of patients who’ve recovered from COVID.

At the same time, patients who don’t have COVID are a little reluctant to visit doctors. And we’re worried that patients with other lung diseases, patients with lung nodules, lung cancer, COPD, asthma may be neglecting some of their care because of fear of going to the doctor. And to some extent, the advent of video medicine gives them some access to medical care without them having to go directly to a medical center. 

So I think that we are certainly changing our outpatient practice with an increased reliance on telemedicine but also changing our outpatient practice by tackling problems that didn't exist before. We’re also challenged in the outpatient setting to figure out how to do certain testing. We have not yet, for example, completely resolved the issue of how do we safely do pulmonary function testing without contaminating the environment? How do we do overnight sleep studies. And so all of this is an evolving area of interest but still part of the changes in medicine that are occurring as a result of our experience with COVID.