We interviewed 42 PCPs from 30 primary care practices affiliated with 6 AMCs and 8 non-academic healthcare organizations. Table 1 describes the characteristics of the respondents including their gender, specialty, affiliation, years in practice, and geographic location.
Across interviewees and states, we characterized four themes related to PCPs’ perspectives about the impact of COVID-19 on primary care teamwork (Table 2): (1) staff members’ roles were repurposed to support telemedicine; (2) PCPs felt disconnected from staff; (3) PCPs had difficulty communicating with staff; and (4) many PCPs were demoralized during the pandemic. Since PCP perspectives were similar regardless of geography and practice setting, we report our findings from MA and OH in the aggregate.
Repurposing of Roles to Support Telemedicine
Physicians relied heavily on telemedicine during the early phases of the pandemic resulting in expanded roles for medical assistants (MAs) and other primary care staff who needed to help patients engage with telemedicine. Interviewees elaborated on the new responsibilities of MAs and nurses in preparing patients for virtual visits, which prior to the COVID-19 pandemic, rarely occurred:
So the medical assistant, what they'll do is call the patient, prime them for the visit, review their medication list with them and then there's a way in the chart that the medical assistant can denote that this patient is ready to begin the visit and then that lets me know, I can shoot them the invitation to the telemedicine visit. (FM, 5 years in practice)
Roles of MAs were repurposed to facilitate the virtual rooming process and to provide technology support to patients. These roles were in addition to existing responsibilities essential to primary care delivery. There was general agreement that this repurposing of staff roles was fundamental to implementing virtual visits while PCPs were working offsite during the early part of the COVID-19 pandemic.
Disconnection from Staff
While stay-at-home orders were in place, physicians were unable to work side-by-side and maintain usual lines of communication with their staff. As one PCP noted: “With virtual health, I’m kind of by myself. We do a lot of sending out messages and stuff but still not that visual contact, we all kind of felt separated from each other.” (FM, 35 years in practice) The physical separation between PCPs and staff also made it difficult to maintain work relationships essential for delivering team-based care. For example, two PCPs explained how being separated from their team made it “incredibly challenging” to know what was going on with patients and made them feel “on [their] own” in the physical absence of staff.
A major drawback of PCP and staff separation was that physicians could not interact or consult with other team members as they did before the pandemic—resulting in a more individualized care experience:
So primarily me and my patient interact really in a different way than having the rest of the care team integrated. I think we went from a really good, robust care team working together to take care of patients and being able to bounce things off people quickly to more of an individualized [manner where] me and my patient [were] working together without the medical assistant, or the nurse, or other folks. (FM, 15 years in practice)
Another physician described how telemedicine altered how healthcare providers engaged with each other: “People realize that this was going to be the system for holding [it] all together because you can’t just run upstairs. You can’t just pick up the phone, we are now dispersed.” (Pediatrics, 6 years in practice)
Electronic modes of communication via electronic health records, voice messages, and/or text messaging replaced synchronous in-person conversations between PCPs and staff. These modes of communication were less useful when team members wanted to interact to respond to emergent patient care needs:
We've had to move to a lot more electronic conversations...with staff. And so it's changed the dynamic of the quick simple conversation as you pass someone [in] the hallway [... it] requires [a] phone call or a text message, which is often more time consuming and challenging, and so [it is] all together harder to make on the fly changes. (GIM, 7 years in practice)
Some physicians noted the disadvantages of not having face-to-face communication and having to switch to virtual platforms to communicate with patients. One PCP described the impact of not having these face-to-face encounters: “...and now that whole chain is kind of broken and so they're missing a lot of those interactions. I miss that too because sometimes I find out [a] bunch of information that I might need because they’ll [the patient] tell the MA something[…] And so sometimes that's really helpful.” (FM, 23 years in practice) Another PCP commented on the difficulties of communicating with staff in their practice: “So there’s something going on with the call with a patient that I need resolved right away, it’s not always immediately obvious to me how to connect to that [staff] person[...].” (FM, 17 years in practice) Despite these challenges, asynchronous communication was reportedly important to help coordinate day-to-day work activities.
Demoralization of PCPs
Physicians remarked about the impact the pandemic had on the morale of their staff. For example, some staff were redeployed to hospital units to help manage the surge of COVID-19 patients and others had to pick up shifts to cover for the redeployed co-workers, as well as co-workers who were sick. One participant explained the potential ramifications of the situation:
And, as people are dropping out sick, as people are struggling one way or another, morale takes [a] really big hit. And so what we are really struggling with now in a pretty profound way is, I think, [a] devastatingly low level of morale, to the point of which my medical director was overheard the other day saying that he feels like this is the end of our practice. (FM, 5 years in practice)
One participant described how staff turnover also increased anxiety within practices, especially for long-serving staff members: “And then you also are losing members of your clinical team and can't really, you know, replace them. And so I think it’s creating just a lot of angst.” (GIM, 10 years in practice) Isolation also contributed to a poorer work environment, such that physicians, staff, and patients could not have simultaneous conversations critical to the delivery of coordinated care: “But definitely the mood was much more negative because…they’re physically isolated from us and from their families and from their patients and from each other because they’re all having to sit far apart from each other so they can't even have that usual conversation.” (GIM, 21 years in practice) Overall, with fewer PCPs working in person, morale decreased as some staff had to work harder to continue providing in-person primary care during the pandemic.