The United States has now passed the half million mark for deaths resulting from Coronavirus disease 2019 (COVID-19), and the pandemic continues, although at a slower rate than earlier. As described in an earlier commentary,1 I increased my inpatient work schedule to help out with the COVID surge here in Arizona. I am not working on the COVID floors, but attend on the Internal Medicine, Cardiac Care Unit, and Cardiology consult services. During the COVID surges last summer and again recently, approximately 40% of hospital beds were occupied by COVID patients. The remaining 60% of patients were the usual mix of internal medicine conditions, for example, heart failure, chronic obstructive pulmonary disease exacerbations, pneumonia, cellulitis, liver failure, and so forth. However, the current Internal Medicine inpatient population was distinctly different from what I had seen during past decades.
The recent patient population was considerably sicker and much closer to dying than in the past. At times, one-third of our Internal Medicine patients were receiving consultations from the Palliative Care service and were being considered for inpatient or home hospice. This was indeed unusual because in the past the usual situation involved no patient, or only one individual, being considered for hospice. Why had our patient demographics changed? The answer was simple: patients were avoiding the hospital as much as possible because they feared acquiring a lethal COVID infection on top of their chronic illness. For the same reason, many hospitalized patients refused postdischarge physical therapy or inpatient hospice transfer following acute care.
Patients frequently said: “Oh, no, don’t even think of sending me there. I know I will die if you send me there.” Eventually, internet reports and studies in the medical literature documented that fewer patients with acute myocardial infarction or stroke were being seen in emergency departments in the United States and Europe.2, 3, 4, 5, 6 Moreover, hospital mortality was higher than usual, probably the result of delay in implementing evidence-based therapy. Thus, fear of a COVID infection kept patients with potentially lethal conditions from coming to the emergency department and being admitted to the hospital. Patients often stated that they knew it was safer to stay home rather than come to the hospital. In addition, some patients voiced the opinion that the hospital staff would be so involved with COVID patients that they would not have time for them.
I repeatedly told patients that they were safer with us on both our inpatient and outpatient services than they would be shopping for groceries, where they would not know the COVID status of those standing near them. I listed all the things that the hospital and outpatient clinics were doing to avoid transmitting the COVID virus: social distancing, a no-visitor policy, frequent hand washing and use of hand disinfectants, universal masking, constant cleaning of the hospital and waiting areas, measuring body temperatures, and recently, near-universal vaccine coverage for everyone working in the hospital and the outpatient clinics. Unfortunately, much of this information fell on deaf ears. It seems that fear had overcome rational thinking.
What is the solution to this “fear of medical attention?” The airline industry has been dealing with irrational fears of flying for decades. That industry has even established special programs to help prospective passengers overcome their flight anxiety. The answer is likely to be the same for fear of medical attention: medicine needs to use as many avenues of communication as possible to educate the public concerning safe conditions within hospitals and outpatient clinics. The American Heart Association has already placed billboard announcements in many US cities reminding patients that the risk of dying from a late and inadequately managed myocardial infarct or stroke is far greater than the unlikely risk of acquiring a COVID infection in the hospital or outpatient clinic. So, dear colleagues, please spread the word: “If you are sick, do not delay and do not hesitate to call 911 or get someone to bring you to the closest emergency department where you can receive potentially life-saving therapy.”
As always, I am happy to hear from readers at jalpert@shc.arizona.edu. I promise to respond.
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-Joseph S. Alpert, MD
