Ep. 46 - LiveWell Talk On...What UnityPoint Clinic Patients Need to Know during COVID-19 (Dr. Clayton Schuett) April 29, 2020

Ep. 46 - LiveWell Talk On...What UnityPoint Clinic Patients Need to Know during COVID-19

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Host: Dr. Dustin Arnold, chief medical officer, UnityPoint Health - St. Luke's Hospital

Guest: Dr. Clayton Schuett, regional medical director for primary care, UnityPoint Clinic

Dr. Arnold (00:09):
This is a LiveWell Talk On.. What UnityPoint Clinic patients need to know during the COVID-19 pandemic. I'm Dr. Dustin Arnold, chief medical officer at St. Luke's hospital and joining me today is Dr. Clayton Schuett who among other things is a friend and colleague, but also a physician leader at Jones Regional and also for UnityPoint Clinic. Welcome. I wanted to sit down and talk today. One is to I have this fear that we'll get a little surge from COVID. We'll get moderate surge from chronic medical conditions that haven't been addressed for six weeks and then amplified on that. 

We'll start doing postoperative surgeries and we're going to really stress the system because I'm really worried about those patients that, you know, nationally we're seeing heart attacks are down, strokes are down, people are still having heart attacks and strokes. Those don't stop. You always see a little slowdown around Christmas, but December 26, it picked right back up. Right? So I'm really worried about that and I want to kind of talk about your perspective on that today and what we should be doing. I mean first things first, the clinics are open, right? Tell me about that.

Dr. Schuett (01:18):

Yes. All of our primary care clinics are open family medicine, internal medicine, pediatrics are all operating during the normal business hours. Our specialty clinics are  open as well. Normal hours there. We did close our Hiawatha Urgent Care Clinic. We did that on purpose so that we could help use those providers at a different clinic to help better staff for what we call our respiratory clinic. Those patients that have fever, sore throat, cough. We're trying to keep them separate from our other patients, but the rest of our urgent care clinics are open. Our new UnityPoint Clinic Express is open and functioning under normal business hours.

Dr. Arnold (01:52):

How is UnityPoint Clinic Express doing?

Dr. Schuett (01:55):

It’s doing very well. Great access there. It's a little bit quicker care is kind of the idea there than some of our traditional urgent care clinics that can sometimes take care of some more complex problems.

Dr. Arnold (02:06):

And that, started in March?

Dr. Schuett (02:08):

March right before all this or right at this time and started just at the, the very early portion of that. So right in the middle of March,

Dr. Arnold (02:16):

The respiratory clinics, they've done a fantastic job. If you asked me, I think that was one of the, I've said this before, I think there's two things that we'll look back that were great decisions. One is the formation of the respiratory clinic and also Dr. Clete Younger’s work with the nursing home patients in establishing ahead of time some boundaries of care. And what to do in the event that I think those two things right there, we'll look back and say were two of the best decisions we made in this pandemic.

Dr. Schuett (02:46):

And I agree with you. The respiratory clinic really was one of those things to try and keep risk down. People are afraid to come in and be seen. We didn't really necessarily have enough PPE or protective equipment for our providers, so being able to have that respiratory clinic, we were able to become more efficient. We just put our providers in their protective gear and essentially for the day. You're able to take care of as many patients as possible and we were all just centralize that as one way of trying to do things. Standardized and operations. Some people seem like they're a little bit afraid to go into the respiratory clinic. We really don't want patients to be afraid to go there either. We're watching and we're following very specific protocols to make sure that the patients are staying safe, our staff are staying safe, our providers are staying safe. We don't want anybody else to get ill that doesn’t have to.

Dr. Arnold (03:29):

I think it was Napoleon that said men are motivated by fear if people are scared because one, it's the sensationalism of the reports, the numbers that we're finding out the pathogen of the contagions not as virulent as we thought. The question that I think patients are going to have is, is it safe? Is it safe to go?

Dr. Schuett (03:52):

Yeah, without a doubt. Our clinics are actually safer now than they ever have been. Again, by having those respiratory clinics, any patients that really have much for any type of fever, sore throat, cough, we're sending them to a whole different location. We've also done things a little bit different in our protocols as well. So when patients come, they stay in their car and they send us a text message if they're there when we're ready for them, our nurses go out and meet them in the parking lot or the front door, they bring them back, take them directly to the patient room. All of our staff is wearing masks, we expect all of our patients to be wearing masks or something to cover their mouth and nose. When you see the nurses and our providers in addition to their masks, they wear a face shield as well to help treat and try and keep down that risk of transmission. And again, when the visits done, we wipe down or clean the entire room, so that it's safe for the next patient to come in as well. So we really think they're as safe as they've ever been.

Dr. Arnold
Really, and correct me if I'm wrong, but a patient should call ahead if they're coming in for appointment, if they're concerned, they may have it.

Dr. Schuett (04:53):
What we really want patients to do is  call their primary care provider's office first and really start with either a telephonic or a virtual visit. Our virtual visits are visits that have a video component to it as well. Talking through the symptoms and whether they're concerned that it's possible that it's COVID or some other type of illness, it could be allergies. If the patient's really sick and we really feel like they need to have an in person visit, that's what we're going to schedule them over at that respiratory clinic so they can have an in person to visit by somebody wearing the appropriate PPE, following the appropriate procedures. If they seem like they meet the specific criteria for testing for COVID, we can send some of those patients toward what we call our sample acquisition clinic. It's a separate location where patients go, they actually stay in their cars in the parking lot. We come out and meet them there, obtain the sample and send of the patient on their way. So keeps them that risk of transmission for both of us as well as the patients.

Dr. Arnold (05:43):

Speaking of sampling and testing, that's a big talking point. At the, at the state level, the governor, there's a lot of pressure on politicians to get tested. As a clinician. The testing more for me is help determinea disposition from a patient that I don't know whether or not they have COVID or reduction in personal protective equipment. Oh, this patient's negative, therefore we don't have to do that. So  that's a big thing. But yesterday they announced that this might spill over into the pharmacies testing. You know, I'm concerned about that because what are they going to do with the positive or what are they going to do with the false negative? What, what's your opinion on that? How do you see that playing out?

Dr. Schuett
You know, it's a real question, a concern. We've talked through every situation that we have so far about how those test results are going to flow through. Who puts the order in, who follows up on that, who makes sure that we're getting the information back to the patient and then helping try to reach out to that patient then kind of follow their symptoms that they're positive and if they're negative, still trying to take care of those things as well.

Dr. Schuett (06:47):

I'd have real concerns about a pharmacy that doesn't have that ability, that capability of a primary care team that can really follow that patient through the course of their illness.

Dr. Arnold
Yeah, I've always supported pharmacy giving vaccinations, a pneumonia shot influenza because that's a public health measure, you know, that's, that's very protocolized and it's public health. I wasn't happy about them doing the shingles, the zoster because, I've seen patients go to that they have a breakout of shingles and they go to get the shot. Well, that breakout of shingles was a shot that stimulated our immune system. They don't need the shot, you know, and pharmacists don't know that or I presume they don't know that, there's a clinical decision making there. So yeah, I'm kind of concerned about that. And, and I think that leads to my next question as far as patients when they call, who are you testing?
I mean, you're not testing asymptomatic people.

Dr. Schuett

No, we're really looking for patients that have simple. So versus me that have seen symptoms. We want people that meet specific criteria that were set down by our department of public health. Patients that have chronic conditions are over age 60 or 65. Or they have more severe symptoms. Patients that are working in essential health care or some other field that's really necessary for the public good. Those people, we really want to make sure that we know where they're at, tracking them and try not to expose anybody else unnecessarily.

Dr. Arnold

I don't think it's changed from this. A contact of a contact is not an exposure. Correct. So, my neighbor cousin works at a packing plant and I, he had a conversation with a neighbor that was not an exposure. Correct.

Dr. Schuett (08:31):

No it has to be direct contact.  

Dr. Arnold

How have patients reacted to the information technology that telephonic and the virtual visits?

Dr. Schuett

You know, really surprisingly well. Even some of our patients we're a little older, more mature that we were a little bit concerned with. They're really seem like they've gotten to this very well. They've enjoyed not necessarily having to take time off of work or take come out into the areas that they feel are unsafe, that they can be able to have that visit remotely been able to dial in. They're able to do it a little bit more convenient. We had one farmer who wasn't going to come in for his visit. I said, honestly, we can do this virtually. And so we were actually able to have the visit with him in his tractor while he was still farming.

Dr. Schuett (09:10):

So just kind of nice, simple some of our patients really as they've been isolated, they haven't been keeping themselves up quite as much. They may not be doing their hair regularly taking the showers as regularly. We started doing some of our early virtual visits, patients saying yes it’s the first time I washed my hair in a week. So I just got dressed up. I put earrings on because I knew that we were going to see each other. And so it's really been, you know, kind of a nice thing.

Dr. Arnold
I get it. My youngest is doing some zoom for a high for high school and she said one of the kids who's a farmer was in his tractor with Zoom. Yeah, he did it from the tractor. You can do it anywhere and it's one of the great things about it. So, yeah, it is so cool.

Dr. Schuett (09:48):
Yeah, I think it sped up the introduction of telemedicine. You know, I really expected us to be here probably in five to 10 years, but that's exactly right. It's just allowed us to just kind of accelerate that pace. I don't think virtual care, I don't think these visits are going to go away. We're going to have to redefine them a little bit over the course of time. Patients still need to be seen in person both now as well as in the future or specific types of visits. There's some times in between visits that can be done virtually, so we don't always necessarily have to have a physical examination component or quite as in depth of physical examination component to be able to help some of these patients. So one of the bigger things that we're kind of seeing right now is with COVID patients are socially isolated, which can increase their depression.

Dr. Schuett (10:29):

People are anxious, they're worried, they're not sure what the future is going to go ahead and hold. So as we're dealing with depression, with anxiety, a lot of that we can do virtually. We don't necessarily have to have a person. That's just a very easy, nice visit to be able to try and do those things, simplifies it for the patient, simplifies drive time, keeps people safer. I think in the long run that's going to keep down as a lot of our illnesses. So cold and flu season I think will be less because we're able to do more of these types of visits.

Dr. Arnold

A patient may from a mental health standpoint, be a little bit more transparent with you because they're not worried about being overheard. They're not worried about telling the nurse the story then having to tell it to you again.

Dr. Schuett (11:10):

Correct. So the nurse still goes through their portion of things where they will ask for the reason for visit in general terms, it goes through their medications and allergies like you would, I'm going to turn it over. And then the, there are providers that are back in their offices and they're having that separate visit with just the provider. There's people with just the patient, be able to keep that simple. It is just very close between them. It still has a real intimate feel to it, which is kind of strange. But we're able to do a lot with it now.

Dr. Arnold
Is it 50, 50 the, the virtual visual and 50% telephone or we're really trying to move over to the virtual business. I think that those are better.

Dr. Schuett (11:49):

As we first got this started, we didn't have enough familiarity with the technology to do the virtual visits. So we started off with the telephonic visits over a month ago and we got very comfortable with those very early on. The patients did well with those, but there's just sometimes you just need to be able to look at something, see a skin lesion, a rash to be able to look and see if they have swelling or how bad it looks now compared to previously. Sometimes you have to be able to assess their breathing, which you can sometimes do just by looking at how somebody is talking with you in a visit. And I think it does add that extra intimacy of the visit. I think that there's still something important about being able to see the provider.
See faces for us to be able as providers to be able to see their eyes, how they answer a question, still certainly have a very important thing to be able to try and do.

 The virtual visits really enhanced that. So as we get better with those, I think we'll continue to try and do more of those. And less of the telephonic visits interestingly and clinicians, how they responded to this, honestly, they've done really well with it as well. So some of our more mature, experienced physicians who I was most worried about with technology have been some of the earliest ones to really adapt to this. So it's been nice. They've really kind of taken off with this. They're comfortable with it as well, so it can kind of keep the whole process just a little bit shorter for everybody and still have those nice interactions. It's been good for everybody involved.

Dr. Arnold
But that's interesting. I'm not resistant to change. I guess as I've gotten older it's harder to change. It's just harder to change as you get older. That's a given. But, so I, I don't know how I would handle it, you know, I really don't. It'd be interesting, you know, I have my home ventilator patients I take care of. And we do a lot of stuff over the phone. You know, cause they're very intense care and you get good at talking to the families about it and you know, you trust them. So I can imagine that it takes things to the next level where it is more intimate because as physicians we get curb side all the time.

I've certainly been friends, but you're just kind of taken to the next level. That's it. That's interesting. It's going to be interesting to see how that influenced the structure of clinics and care going forward.

Dr. Schuett (13:45):

You know, and it's one of those things that really the virtual care, that telehealth component of things, it has been going across different areas of the country out of necessity. As we get into North Dakota, South Dakota patients, providers are so separated that we just can't drive to everything. So they've been doing these types of visits. We just haven't been pushed to do them and we haven't had need
Dr. Arnold
That's a great observation that there's the need necessity, rural Montana know particularly mental health psychiatry because there's not a lot of psychiatry providers in rural States here in Iowa. But then now we're getting it. We're going beyond necessity to enhancement of care.
Which is that. That's exciting.

Dr. Schuett (14:33):

So it is convenience. It's simple. Moving forward, you know, as a patient myself, sometimes I'm on the other side. I don't like taking time off of work. I don't like to have to essentially give up two to three hours of my day to get out of what I'm doing, drive to my, my provider's office, sit and wait, see the provider, get done, go pick up a prescription and get back to work. So this just simplifies things. Again, you never even have to leave work necessarily. You can just have your associate or your specific time. We contact you. We have our visit for 15 to 30 minutes. You go back with the rest of your day? It simplifies things for everybody. I'm hoping it actually improves our patients coming in or having contact with us so we can make it more convenient for them.

Dr. Arnold

I think doctors have always though in the back of their mind or in the front of their mindset, there's got to be a more efficient way to do what I'm doing rather than this person checking in, sit in the waiting room, sitting in the room, checking out, you know, there has to be a better way. And sometimes events like this push us forward.

Dr. Schuett

You bet. And one of the things that's really an I, I hate to put it on insurance comes, it really has been some of the barriers that insurance companies have put out there that we haven't been able to be reimbursed for these types of visits in the past. So many requirements on how many vitals had to be seen or had to be drawn at or done at every visit. How many things had to be done and that they just simply required to be an in person visit.

This was kind of pushing it that actually I think this is going to keep people safer and healthier in the long run. It'll be less expensive for the insurance companies. It's better for the patient. We as providers don't want our patients sick. We want them to be healthy so we can do those things. Again, we do need to see it in the office over the course of time. Blood pressure is very important to make sure we're watching and monitoring. If you are sick, I do want to know where your temperature is and respiratory rate. There's a lot of times if patients are coming in for chronic conditions, a lot of the stuff I don't necessarily have to have at least with every visit, so it kind of depends on how stable they've been over the course of time.

Dr. Arnold

But those visits are important even if it's an annual checkup. I think it was, it was a VA study and they found that the patients that had antireflux procedures, more of them were dead at 10 years and the ones that took the medicine and you think, well is there something with that surgery that made those patients? No, what it was is the ones that had the, still on the proton pump manner, we're coming to visits and so they would come to the visit to get their drug refill and their blood pressure be high and the doctor would say, wow, you know, you got, we've got to treat your blood pressure. Look how high it is. Oh, okay. YepSo this doesn't replace that contact you need to have with your physician?

Dr. Schuett (17:15):

No, I really see in the, in the future that we're going to want to see patients in the office a minimum of once a year, possibly twice a year at least, depending on the complexity and other things going on.
But some of those rechecks might be able to be done virtually. I think that's really where it kind of fits in. I see you in person, we talk about your depression, your anxiety, whatever those things are, your reflux. But then if we need to recheck again in six months just to make sure things are continuing to go well, having that touch point, that one we could probably do more remotely and stuff overall.

 Diabetics, again, we're going to want to see every three to four months, but if they've been really well controlled, we might be able to cut one of those two or one to two of those visits out per year in person and make it more of a virtual visit. So, each person's going to be a little bit different and unique and really must trust our providers to make those decisions about going back in the office. We need to draw some blood the next time you've really been under good control. I just want to make sure we continue to talk about your diet, your exercise, that you're checking your blood sugar is doing the right things. We're not missing something. So sometimes patients just need to have that reminder, that touch point more so than having that integration frozen.

Dr. Arnold (18:06):

And if it, you know, if it allows you more time to spend with those complex patients. Yep. Then a 15 minute visit you can spend 30 45 minutes with them. That'll keep them out of the hospital. And that's always good. So one last question, why family practice? What led you to what you're doing?

Dr. Schuett (18:25):

Wow. It's such a complex question. You know, growing up, you know as, as you're trying to figure out a job medicine and what a lot of people that go into medicine will say is really kind of wanting to help people. And that's where it really kind of started. So you started into medical school, I'm assuming you get accepted and you kind of have to figure your path. And family practice was great from a couple of different things.

 One, it let me have my hands into a whole wide array of problems. It wasn't such a narrow focus on just one thing. The other thing, having come from a small town, I really like being able to take care of multiple generations. It's one of the cool things that you really get to do, where you get to take care of patients from birth to death. You go ahead and take care of three to four generations of patients. And really that gives you a lot more information on patients as well when you know their grandma or their mother personally because you have them as a patient, you gain so much more and you really understand family dynamics And how that influences everything else.

Dr. Arnold (19:15):

I know that's a hard question to ask and I've come to appreciate it as I've gotten older that you know what you do, you know how you do it. But sometimes it can take decades to figure out why. What's my why. You know? In times like this we find our why, we find why, why do I do what I do? Well, you know, cause I have this inner drive to help people, right? Yeah. You know? And so sometimes people go their whole life with only knowing what and how, and they never had the opportunity to learn the why. And you know, I think there's pandemics opportunity for a lot of clinicians to learn their why, to learn why they do this. And, and there'll be better clinicians once they, once they have that under their belt.

Dr. Schuett (19:53):

without a doubt, you know, and everybody has their, their job has that role in society where things go. And this is where healthcare work is really a chance to step up and say, Oh, we can do this. We can really pull together, we can do this better, efficiently, safer, and really get through this together as a team.

Dr. Arnold (20:08):

Well this has been great information. I, and I know you're busy and thank you for taking time to talk about this. Once again, this Dr. Clayton Schuett.