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How the COVID Pandemic is Changing Medical Practice: A Q&A with Steven H. Richeimer, MD

PPM spoke with Steven H. Richeimer, MD, chief of pain medicine at USC’s Keck School of Medicine, about the impact of the COVID pandemic on pain practitioners, both those in clinical practice and those pursuing pain fellowships.

The COVID pandemic has changed the practice of medicine in numerous ways, and its effects are experienced not only in the day-to-day critical care and emergency medicine settings but also in the area of pain management. In Steven H. Richeimer’s clinical practice, for example, which is a tertiary care center, patient care has been significantly altered. The biggest change in his practice is the use of telemedicine, especially now that reimbursement is equivalent to that for in-person visits – at least in his state of California and most others to date.

Here’s how he views things changing in the short- and long-term.

Image: iStock (BsWei)Practitioners and seeing a sea change in the pandemic's effects, not only in day-to-day critical care and emergency medicine settings but also in the area of chronic pain management.

Telemedicine is the New Standard, Especially for Specialty Care

As telemedicine and virtual consultations have become readily available, both doctors and patients recognize how beneficial they are. “The changes we’ve seen with telemedicine and phone visits shouldn’t be undone once we get back to normal,” said Dr. Richeimer. “There are times we need to see patients in person, but not always. Of course, if the clinician is worried about someone, they’ll want to lay eyes on the patient,” he added. Patients may also need to come in for urine testing or other assessments that must be done in person.

One of the biggest advantages to telehealth is that it increases access to specialty care, particularly in more rural areas. “In small towns and rural areas, there are often no pain medicine doctors. In general, seeing a specialist is difficult in these areas, and having access to a pain specialist can really be helpful,” said Dr. Richeimer. (More clinical considerations for telemedicine, including troubleshooting tips from a behavioral pain specialist.)

Patients Understand the Scope of Care

As the stresses of coping with chronic pain during the COVID pandemic multiply, one would expect patients to be reaching out more to their healthcare providers for support. In fact, according to Dr. Richeimer, more patients in his multispecialty practice are reporting increases in pain and stress, coupled with decreases in physical activity, access to physical therapy, and the availability of interventional procedures. “They say they’re feeling worse, but they understand why, so they’re being patient, and we haven’t seen an increase in demand for opioids,” he noted.  

“As always, and not just during the COVID pandemic, we prescribe the lowest doses of opioids possible for our patients or try not to use them at all.” There has been an increase in naloxone prescribing over the past year, primarily because in California, this opioid overdose reversal drug must be offered to patients taking higher doses of opioids, or to those with other risk factors, because of their increased risk of overdose.

Elective Procedures Are Slowly Resuming, as Alternative Therapies Grow

Dr. Richeimer noted that because of the COVID pandemic, all elective procedures generally used for pain management (eg, injections) have stopped in his institution but will resume again gradually for patients in need. Practices in other states, like New York, are already starting to reschedule these procedures, starting with treating the most severe cases.

Currently, Dr. Richeimer’s group offers an array of pain management strategies as alternatives. Physical therapy sessions have been taken online, with therapists able to watch patients move, assess their needs, and guide them through exercises. Psychologists are available for online mental health sessions. Ketamine infusions have restarted, and other procedures will be resuming in a few weeks or so. “We will want to make sure, however, that patients are healthy and under 65 years of age, with no other immunosuppression.”

“While we’re reluctant to perform a procedure on anyone who might be at increased risk for COVID-19, we will discuss the risk with the patient and determine if the patient feels miserable enough to want to proceed,” he said. “Pain, by itself, is immunosuppressive, and adding an immunosuppressive agent, such as with a steroid joint injection, may put the patient at increased risk for viral infection,” noted Dr. Richeimer. 

Young Healthcare Providers Are Missing Out

In Los Angeles, where Dr. Richeimer practices, care for patients has been altered, but the COVID pandemic has not hit the area as hard as in other areas, such as in the northeast. This also means that the emotional impact on providers has been less. “There may be some soul searching among young doctors, but we are not seeing them question their choice of careers,” said Dr. Richeimer, who directs the pain medicine master’s degree and certificate program at USC Keck School of Medicine. 

There is an impact, however, on the education of pain medicine fellows that is causing concern among students, fellowship program directors, and accreditors alike. The fear is that with only 1 year of training in this new era of distance medicine, upcoming fellows will not be exposed to the level of practical experience that is needed. “With fewer in-person visits, fellows are no longer seeing patients in person. The team must be sure to include them in telemedicine visits, for example, so they are gaining necessary patient care experience,” said Dr. Richeimer.

According to Dr. Richeimer, fellowship program directors are wondering if programs should be extended to be sure students receive adequate experience, or whether board examination dates should change. This would, of course, be up to national credentialing organizations, such as the Accreditation Council for Graduate Medical Education (ACGME).

In the meantime, with procedures delayed and office visits decreased, Dr. Richeimer hopes that practicing clinicians will use the extra time to educate themselves on pain management to boost their knowledge. “Using this time to learn about pain medicine and perhaps having an impact on the epidemic of opioid misuse would be a great outcome for this pandemic. And changes in the practice of medicine, such as telemedicine, will help take us into a brighter future.” 

See also, how the pandemic is changing physical therapy practices.

Last updated on: May 28, 2020
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