Our modern era has witnessed the explosion of electronic health record (EHR) use, hospital mergers resulting in large sprawling, multi-campus health systems, and mounting productivity pressures. As a result, primary care practitioners (PCP) commonly report feeling like cogs in a large, impersonal machine and express a sense of disconnection with colleagues. Increasing reliance on business models without fully engaging front line staff, and the push to maintain access are among the contributors to widespread reports of burnout; a growing shortage of PCP compounds the problem.1,2 Southwick and Southwick recently opined in JAMA Psychiatry that while social support is strongly associated with both enhanced mental and physical health, clinicians are now experiencing a reduced sense of belonging and loss of social connection that has both created unprecedented isolation and fueled widespread burnout.3 They attributed this to excessive time devoted to EHR use at both work and home along with growth in online learning and increased social media use.3 In response, they called for building community and “development of longitudinal relationships through peer support and provision of space and time for staff and students to congregate and share their experiences.”3 We applaud this call for enhanced social support in primary care settings, but dispute that increased online learning and social media engagement promote isolation; we believe that the opposite is true. Since publication of this piece, the COVID-19 pandemic has hit the United States in full force bringing with it unprecedented levels of healthcare social distancing, rapid conversion to virtual education, and widespread use of telemedicine.4 While these are designed to enhance both survival and healthcare capability, they may exacerbate clinician isolation.
In August 2019, our group of practicing and aspiring general internists and geriatricians launched a novel Twitter-based Primary Care Chat (PCC) (https://twitter.com/primarycarechat) with the goal of cultivating a supportive learning community for those practicing in primary care. During PCC, we bring together PCP to share the challenges and joys of primary care and engage in discussion and learning around common topics. Twitter chats are scheduled online gatherings in which pre-formulated questions and discussion points are posed to the virtual audience who sign on to the platform at a specified time and respond to each posted topic in threads. The chat format allows those participating to read and respond to one another’s answers. Those not available during the scheduled chat time may also read the conversations and respond at their convenience. Using the twitter handle @PrimaryCareChat and mission statement, “deep dives into the art and joy of great adult primary care, as well as the evidence behind it,” we have hosted bimonthly twitter chats on a variety of topics.
During our chats, we have held discussions around medical education and challenges in primary care (how to enhance interest in primary care careers, how we manage our time, humanism in primary care), presented knowledge-based topics (managing sleep disorders, rheumatologic conditions, dermatology, LGBTQ+ care in primary care) and covered special focus topics like trauma-informed primary care. Each one-hour chat is followed by a summary of teaching “pearls” and interesting ideas (see figure). We use Twitter Analytics to measure impressions and engagement and tweet a post-chat poll to measure benefit. Both impressions (averaging over 35,000 per chat) and the quantitative poll data we have collected demonstrate high utility and value of PCC.
Understandably, much focus during the pandemic has been on hospital capacity, ICU capability, and emergency department management; less attention has been directed toward primary care experiences. PCP have found our patients frightened, unwell, alone and in search of guidance through the uncertainty; we have had to provide reassurance and care while rapidly adopting virtual care modalities. As the teams responsible for ensuring continuity, we have significant concerns about our patients’—especially our older adults’—wellbeing. Additionally, mounting concerns about the potential need to ration care and supplies to maximize societal benefits weigh heavily on PCP who have cultivated deep and meaningful relationships with patients over the years. In response to these mounting concerns, the PCC team posted a poll in mid-March 2020 asking our followers whether they would prefer a week off from our Twitter chats or a chat focused on the COVID-19 response in primary care. The response was resoundingly affirmative: PCPs wanted to gather online and discuss primary care during COVID-19 with a community of colleagues.
Our March 19, 2020 chat included the following questions:
- “What role are PCPs playing at your institution on the COVID frontlines?”
- ”What is your approach to your outpatient patient panel? (example: Telehealth)
- “How will (and should) the role of the PCP/primary care team evolve during this crisis and beyond?”
- “What are you doing to stay sane/take care of yourself?”
Responses generated during the chat support our assertion that online learning and engagement need not increase isolation, but in fact can be structured to create a collaborative learning community and foster collegial social support which is especially critical during this unprecedented time.
To illustrate this, here is a sampling of tweets from the community during the COVID-19 Primary Care chat:
“I am feeling tremendous gratitude for this community tonight more than ever.” (general internist)
“The #primarycarechat community is fantastic and so supportive. I’m so thankful for you all.” (internal medicine resident)
""Hi my friends! Was so looking forward to this after a very long and stressful week.” (geriatrician)
What roles are PCPs playing at your institution on the COVID frontlines?
“triage triage triage. Navigating day to day changes for patients while taking symptom, exposure and risk history. Daily check ins for all on home isolation log. Helping 2keep pts out of urgent cares and ERs…. Overseeing concerned residents.” (general internist)
“We are the frontline...We are trying to help people stay home, meet their medical needs and keep them out of the ED.” (general internist)
“I’m starting now with goals conversations to make sure I know [what patients want done] and document wishes. But I haven’t yet touched the ‘what if they can’t/won’t do what you are hoping for at the hospital.’” (geriatrician)
What is your approach to your outpatient patient panel?
“The whole thing is bizarre, moving target/info every 12 hours. Heuristics/thought process constantly in flux.” (general internist)
“The whole team needs to work at their top skill, flexible. Avoid...underutilizing the skill of other professions, clinical pharmacist and integrated behavioral health.”
(Re lack of testing) “the asymptomatic person who will have minimal clinical manifestations but will be COVID + will lose their minds. But could also provide some serious peace for others.” (medical student)
“I’ve been thinking a lot about this...phone and video visits can play a much bigger role, not just in a pandemic. Once people come out of isolation, I wonder what other disease processes we’ll see. Depression & others?” (family medicine physician)
“I had not thought about this enough (before COVID-19)—virtual care such potential to address social isolation.” (general internist)
What are you doing to stay sane/take care of yourself?
“I’m cooking, staying in touch with friends/ family, and burning some anxious energy in the name of acquiring PPE and other needed initiatives to help my [resident] friends. Also trying to sleep as much as I can, which has been tough. Oh, and exercise. EVERY. DAY.” (medical student)
“Off next week...guilty a bit” (general internist)
“Take that vacation/week off without guilt. Your patients, learners & family all need you to take care of yourself. Plus, you’ll charge back in refreshed just when someone else needs a break. This is going to last a while. In other words, what would you tell your learners to do?” (general internist)
“I have been seriously feeling it. Like how I felt after 9/11. I’m trying to find ways to be productive, because that always feels soothing. Exercising every day is unbelievably helpful to me. And honestly, I could not wait to connect with you all tonight.” (geriatrician)
“Writing and reflecting a lot, watching lots of comedy, enjoying more home cooked meals!” (general internist)
“This chat has truly been valuable to me. This community...means alot for my #wellness.” (general internist)
In summary, the COVID-19 pandemic is imposing the urgent need for social distancing and decentralization of care which is superimposed on pre-existing widespread feelings of isolation, disaffection and burnout among clinicians. We believe that carefully cultivated online learning and social media use that intentionally encourages engagement can increase social support and the feeling of belonging among PCP, which in turn, can bolster morale and lessen burnout.
Primary Care Chat takes place two Thursday nights per month (9:30 ET/6:30 pm PT), all are welcome https://twitter.com/primarycarechat