Post-pandemic pediatrics

In the April 2020 issue of Contemporary Pediatrics, I authored a brief “Your Voice” missive entitled “COVID-19: Thoughts while circling the wagons.” At that time my practice was in lockdown, as were most medical practices in the country, and I was doing only virtual visits from home. We positioned 1 brave, young, and healthy colleague in the office, along with a nurse and secretary to evaluate and treat patients who needed to be seen in the office. Our practice was cautious, heeding advice from the Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP), and saw children (without COVID-19 symptoms) with injuries, rashes, or exacerbations of chronic problems. We only saw well young babies who needed vaccines and distributed infant scales so babies with feeding issues could be monitored via virtual visits. We continued to do so for 2 months until we all returned to the office. During the lockdown, many pediatricians took advantage of assistance provided via the CARES act to keep their offices afloat financially, and quickly learned new skills to provide virtual visits at home. We all implemented new workflows to use parking lots as waiting rooms, reuse personal protective equipment (PPE) that was suddenly in short supply - and tried to avoid furloughing staff when revenue dropped precipitously.

Now, over a year later we find that millions of adults in the United States have been vaccinated, and children aged 12 years and older are being vaccinated as well. As of this writing, the CDC has recommended that if you are fully vaccinated:

“You can resume activities without wearing a mask or staying 6 feet apart, except where required by federal, state, local, tribal, or territorial laws, rules, and regulations, including local business and workplace guidance”

It would seem that we are nearing the end of a movie where science has defeated an evil scourge, the clouds are parting, and the sun is shining through….

It has been a year and half that will long be remembered. We have learned so much about COVID-19, public health, and how resilient families, teachers, and healthcare providers can be.

Here are some things we have learned along the way:

• We were darn lucky that researchers began developing vaccines based on messenger RNA and Adenovirus vector technologies following outbreaks from SARS in 2003, and MERS in 2012. These were quickly adapted to target SARS-CoV-2. A COVID-19 vaccine was developed and released for Emergency Use in under a year!
• The FDA can and did indeed change their onerous process for approving pharmaceuticals and vaccines when faced with a crisis. Certainly, they should be able to modify their pre-pandemic rules and regulations to safely expedite new medical diagnostics and therapeutics.
• In the early days of the pandemic, many pediatricians learned how to do virtual visits, but now that we are back in our offices, fewer pediatricians are doing these. Virtual visits are a huge convenience for patients and will help re-establish confidence in the medical home. They should be a routine part of pediatric practice. We need to assure that insurance will continue to pay for Telehealth visits at parity for in office visits.
• Many children could not learn effectively via remote learning, and many will need significant assistance to make up for a “lost” year.
• Our mental health healthcare system - which was inadequate in the pre-pandemic period- was nearly non-existent during the pandemic and many pediatric providers rose to the challenge of treating children with depression and anxiety. We need to find new ways to provide mental health services to children and their families. One way is to expand the workforce by motivating interested individuals to become mental health providers by paying for their education and training.
• Even now pediatric practices are seeing fewer patients now than they did pre-pandemic. The result: revenues are down (by at least 25% by my estimate). The reason, with social distancing and PPE use, fewer kids are getting routine illnesses such as influenza, strep, respiratory syncytial virus (RSV) etc., that we use to see with great frequency in the office. Once more Americans are vaccinated, and children return to school, we will likely return to “pediatric practice as usual”, but it may take time for this to happen.

Most importantly, the COVID-19 has exposed glaring flaws in our health care system. It no longer makes sense for insurance companies to dictate policy for our patients via their control over healthcare purse strings. There needs to be a more efficient way to authorize medications, diagnostic tests, and other services for our patients. The FDA needs to expedite the introduction of vaccines, medical devices and pharmaceuticals. The CDC needs to be apolitical in making its recommendations. These need to be evidence based, and crystal clear.

The way forward may be a bit precarious, but and as COVID-19 variants emerge we will need to routinely vaccinate children and families probably on a yearly basis, and we will likely be able to prescribe new anti-virals that will effectively treat SARS-CoV-2. Hopefully, pediatricians, public health officials and politicians will have learned lessons from the COVID-19 pandemic of 2020/2021. Only time will tell.