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Physicians unaffiliated with healthcare systems continue to have difficulties obtaining COVID-19 vaccinations for themselves and their staffs, but that challenge appears to be fading in some states. Yet, in many places, primary care physicians (PCPs) still aren’t being enlisted in the national vaccination effort, despite their numbers and their relationships with patients.
In the first few weeks after the Pfizer and Moderna vaccines received emergency use authorizations from the US Food and Drug Administration, they were distributed mostly to hospitals, pharmacies, and long-term-care facilities. Naturally, the hospitals and healthcare systems vaccinated their own staffs and employed physicians first.
So, even though the guidelines from the Centers for Disease Control and Prevention specify that all frontline healthcare workers should be included in the first vaccination group, many nonhospital-affiliated private practices have been left out in the cold. Nonpatient-facing hospital staff members in some facilities, as well as first responders such as police officers and firefighters, have taken precedence over independent primary care physicians.
In Florida, residents older than 65 were invited to get vaccinated before some physicians had received shots, said Anders Gilberg, senior vice president of government affairs for the Medical Group Management Association (MGMA), in an interview with Medscape Medical News.
While the US Department of Health and Human Services is now telling states to give vaccinations to everyone over 65, that wasn’t the case back then.
Community doctors in some areas are still finding it hard to get vaccinated or even find out how to get shots. Yul Ejnes, MD, an internist and partner in Coastal Medical, an independent group based in Cranston, Rhode Island, told Medscape Medical News that he and his practice staff haven’t been vaccinated, while the staffs of local hospitals have received their shots.
In response to repeated inquiries from his group, he said, the state health department recently said independent practice staffs will start getting vaccinated the week of January 25.
Ejnes said he understood why hospital personnel went first: hospitals have the necessary infrastructure, “and the staff in the emergency department and the ICU are caring for the sickest of the sick.”
For primary care doctors like himself who don’t work for the hospital, he said, “I don’t think an infrastructure to get us the vaccine in a timely manner was developed — or if it was developed, it hasn’t been communicated to us.”
Nevertheless, Ejnes stressed that primary care physicians in the community are just as vulnerable to the coronavirus as hospital clinicians. “We’re seeing patients who have COVID but don’t know they have it. I’m seeing 15 patients a day, and we screen them — as everyone else does — for symptoms and contact and travel, and check their temp,” he said. “But not a day goes by that one of the clinicians in this office doesn’t get a phone call from a patient who was seen a day or two earlier to tell them it turns out they were COVID-positive. I’m spending 15 minutes in a 100-square-foot room with a patient for a routine visit. And as much as we’re masking and gloving and wearing eye protection, I wouldn’t consider us to be at low risk, especially with the high prevalence of disease.”
In some other states, the situation seems to be improving. Ada Stewart, MD, president of the American Academy of Family Physicians (AAFP), said that she and her colleagues in a community health center in Columbia, South Carolina, are in the process of being vaccinated. She got her own shot January 6 at a local hospital.
Her clinic’s staff hadn’t been vaccinated earlier, she said, because nobody in the practice knew the contact person at the hospital who could help access the vaccine doses. Other independent practices in her state are now getting vaccinated, she said, after South Carolina Governor Henry McMaster ordered that all healthcare providers in the top priority category be inoculated by January 15. “At this point, the issues have been diminished.”
However, Stewart added, independent doctors in some states are still unable to get their shots. AAFP state chapters, as well as the national organization, are trying to persuade governors to ensure all of these physicians are vaccinated. “We’re trying to make sure that the voices of physicians not affiliated with health systems are being heard,” she said.
Lucky Shot for Doctor
David Boles, DO, a family doctor in Clarksville, Tennessee, was able to get his first dose of vaccine just before Christmas, he told Medscape Medical News, because he was medical director of a hospice that had received vaccine doses for first responders. When some firefighters and police officers failed to show up for their appointments, the hospice called him and said he had 45 minutes to get to the site if he wanted to be vaccinated.
In early January, his colleagues and staff were also vaccinated, he said, after they were notified of their eligibility as frontline healthcare workers.
Boles agreed with Ejnes that community physicians and nurses are as much at risk as hospital clinicians, except for those intubating patients in the ICU. They may be even more vulnerable, he added, because they have less personal protective equipment than hospital doctors and nurses.
Jennifer Brull, MD, a family physician in Plainville, Kansas, said there have been plenty of COVID-19 cases in her small rural community, and the local critical access hospital nearly ran out of beds at one point. Through a collaborative relationship among her clinic (the lone one in the area), the hospital, and the county health department, nearly every frontline healthcare worker has been vaccinated, and most clinicians in her group have gotten their second doses.
Both the hospital and the health department received vaccine supplies, she said, and everyone in the high-priority category was offered shots. So far, about 170 healthcare workers have been vaccinated, and only a few declined. More than 300 other people — most of them essential nonhealthcare workers and people older than 65 — have signed up for the next round of shots, she said.
Expanding Vaccination Effort
Brull’s practice is the exception among private medical groups around the country. Gilberg said the MGMA is “concerned that independent practices are playing second fiddle because they’ve been left behind.” Physicians and patient-facing staff in private groups, he said, should be getting vaccinated before hospital information technology workers and other nonpatient-facing staffers.
Medical practices also can and should play a much bigger role in the overall vaccination effort, he said. Gilberg has spoken to leaders of several large primary care groups “that have the freezers [for vaccines] and the capacity but haven’t been folded into the distribution plan, especially if they’re not part of the hospital system.”
While hospitals have the storage, he said, they’re not set up to distribute vaccines throughout their communities. “Most healthcare in this country is delivered outside of the hospital setting. That’s how you’re going to get people vaccinated,'” he said.
Ironically, he added, “the same PCPs that are having trouble getting themselves and their staffs vaccinated would be the physicians who could help with vaccine distribution.”
Brull’s clinic stands ready to help the hospital and health department vaccinate the local population. When sufficient vaccine supplies arrive, she said, she envisioned the doctors and staff administering 200 to 400 shots per day on Saturdays or weekends.
Brull was the exception — the other physicians interviewed for this story hadn’t been invited to participate in vaccination efforts.
Ejnes said his group is capable of vaccinating its patients if it uses the Moderna vaccine, which doesn’t require a super-cold freezer. There are logistical challenges, including social distancing and finding space to observe vaccinated patients for 15 minutes after their shots, he noted. “We’re ready and willing, but realistic about how much we’ll be able to do in this effort,” he said.
The fact that doctors haven’t been enlisted yet in this campaign speaks volumes about “the neglect of the public health infrastructure,” Ejnes said. “We’re not mobilizing as quickly as we should.”
Boles’ group has a refrigerator for pediatric vaccines, which could be used to store the Moderna vaccine, he noted. Shots could be administered to patients in their cars in the parking lot, and they could wait for a while afterward until a nurse came out to verify they were okay.
Mass vaccination sites might also be deployed, as Los Angeles is doing with Dodger Stadium, and physicians could take shifts there in their spare time, Boles said. But for right now, he views pharmacies as the primary venues for community vaccination.
Of course, the number of pharmacists and pharmacy-employed advanced practice nurses is tiny compared with the number of primary care doctors, mid-level practitioners, and nurses in ambulatory care practices. Moreover, Gilberg said, practices know from their electronic health records which patients are most at risk and should be vaccinated first. “Walgreens and CVS don’t know that.”
Physicians should also take the lead in vaccinations because of their patient relationships, he noted. “They can help educate [vaccine-hesitant] patients on why it’s important and dispel some of the rumors and the misinformation that has been politicized. That’s why we should engage physicians in an outpatient setting. And we have to vaccinate them and their staffs. Otherwise, we’re never going to get this rollout underway.”
Stewart, of the AAFP, agreed. “We are really the foundation of how we’re going to accomplish this. Most folks are seen by a primary care physician. We touch millions of lives,” she said. “We’re part of the community. Our patients trust us. We’re out there doing it already. We’re doing prevention, giving flu shots, and we’re trying to encourage people to get the COVID vaccine.”