Which non-covid doctor's visits should you make, keep, postpone or do by telemedicine?

In late March, the Centers for Disease Control and Prevention recommended that non-emergency medical providers delay routine or elective visits from patients to preserve protective equipment such as masks and to mitigate the risk of spreading covid-19, the illness caused by the novel coronavirus.

But there's a gap between what's elective and what's not, with fear and misunderstanding filling the void. And there's growing evidence that patients might not be visiting health care facilities when they need to, avoiding doctor's offices and emergency rooms even in the most urgent cases for fear of being infected with covid-19.

Although the novel coronavirus has dominated the news, other health problems have not disappeared. So, when should you see your doctor? And should you do it through an in-person appointment or telemedicine?

The first person to turn to for guidance is your primary care physician or relevant specialist. You can also check online for advice: Many medical organizations, such as the American Academy of Pediatricians and the American College of Allergy, Asthma, and Immunology have issued recommendations for practitioners and patients on their websites. And keep in mind that some states have rules about which appointments and procedures can proceed. These rules vary and will continue to do so as some states ease restrictions while others maintain shelter in place rules.

In addition to those resources, here are some general guidelines about how to proceed with your health care during the pandemic.

• When should I go to the ER? Doctors across the country have noticed that patients with heart attacks, appendicitis, and mild strokes are arriving later than they should to the emergency room. "We don't want people to delay getting emergency care," said Alyson Goodman, a pediatrician, medical epidemiologist and representative from the CDC's At-Risk Task Force in the COVID-19 Emergency Response.

You should go to the ER if you are experiencing symptoms that could be life-threatening or cause harm if they are not addressed immediately. Examples of these symptoms include "chest pain, difficulty breathing, face drooping, arm weakness or speech difficulty, or acute injury or trauma," said Goodman. Similarly, if you are in immense pain, you should not hesitate to call 9-1-1 or go to an ER.

• When should I call my doctor? Perhaps you've noticed abnormal swelling in one of your limbs, pain in your abdomen, a strange lump or sudden weight gain. According to Goodman, ideally you should call your health care provider for urgent symptoms that don't require an ER visit. If you don't have a primary care physician, you might call or seek out a local urgent care clinic.

Jacqueline Fincher, a practicing internist and president of the American College of Physicians, said she often needs to see patients with preexisting conditions who have developed new, worsening symptoms in her office. These would be patients who have medical issues like hypertension, diabetes, high cholesterol, heart or kidney disease, along with a change in health status such as swelling in legs, shortness of breath, chest pain or a temperature. "With an acute illness on top of chronic, it's really hard to evaluate in an appropriate manner through telehealth," she said. Fincher said she prefers that such patients call the office instead of emailing or using a patient portal, so she can triage over the phone and, likely, have them come in.

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Specialists are also seeing patients for ongoing or urgent issues, so you should not hesitate to call their offices, either. Amie Gupta Sessa, a board-certified dermatologist in Lutherville, Maryland, is still assessing patients in-office. "We call some of our patients 'frequent fliers,' " she said. "They are growing skin cancers every couple months. For those people, we definitely worry that they won't come in, and we'll see them in three months and the growth will be huge. For those cases, I would say, we are available, and we want to take care of you."

• Which in-person appointments should I keep? Certain health issues will require an in-person visit, said Colin Delaney, a colorectal surgeon and chairman of the Digestive Disease and Surgery Institute at Cleveland Clinic. "Some things just don't work well for telehealth," he said. "Anything needing a physical examination, or a formal assessment before treating, needs to be done in person."

Some allergy patients need to maintain appointments, according to Marc Goldstein, director of the Asthma Center in Philadelphia and chief of Allergy and Immunology at Pennsylvania Hospital. "For in-office therapies, allergy immunotherapy [allergy shots] or biologic treatments for asthma, patients need the regular treatments to maintain the benefit of the therapy," he said. For people with allergies and asthma, allergy shots don't just reduce allergy symptoms; they help control asthma flare-ups that can send a patient to the hospital, Goldstein said.

Immunizations for children up to 24 months are also still recommended as usual, according to Goodman. For newborns with immune systems that are not fully developed, who also need consistent weight checks, it's important to continue pediatrician visits on schedule.

Patients receiving cancer treatment or those who are on dialysis also should go to all regular appointments. Other regular health care visits may require careful discussion with your provider. For example, the American Physical Therapy Association is advising physical therapists to carefully consider whether "the risk of exposure to COVID-19 outweighs the benefits of immediate treatment," adjusting treatment plans or rescheduling appointments accordingly.

While some visits for pregnant patients, like supplement counseling, can be accomplished via telehealth, other prenatal care like ultrasounds and labwork must be completed in-office. Talk to your OB/GYN; some women may be placed on a revised prenatal care schedule with a mix of virtual and in-person appointments to decrease potential covid exposure.

If you are unsure whether your appointment qualifies as essential care in your state, call in advance. For instance, time-sensitive fertility treatments were paused right after the pandemic began, but some New York clinics recently resumed in-person care after Gov. Andrew Cuomo, D, designated fertility treatments as essential medicine in an executive order in April.

• Which appointments can be done via telemedicine? Many doctors are still seeing patients face-to-face, but virtually. According to Patrice Harris, a psychiatrist and president of the American Medical Association, while there is "no one-size-fits-all" appointment style, a patient might expect to video conference with their doctor to discuss any new symptoms, medical history, a medication list and all the standard information they might share during a regular visit. "They just can't do the physical examination," she said. "Ultimately, they should expect the typical shared decision-making process and open conversations regarding medical care" that they would have at a standard checkup.

Telehealth is good for managing chronic conditions, especially because some patients with such conditions are in the high-risk group for covid-19. "People still need to have diabetes and hypertension managed," Harris said. "This is a wonderful opportunity for the use of telehealth to make sure care is not interrupted. We want to make sure they have avenues to get care."

For patients with chronic conditions who will be coming in for visits less frequently, Fincher is encouraging them to order blood pressure cuffs, glucometers and scales if they do not already have this equipment at home.

Delaney said virtual appointments are particularly useful for postoperative patients, or those who have conditions such as Crohn's or colitis who might need simple adjustments to their care. Similarly, patients who regularly see a mental health practitioner can usually convert to telemedicine appointments; many psychiatrists are still seeing patients virtually during the covid pandemic.

If you simply have questions for your doctor, telehealth may also be right for you. Goldstein has patients with respiratory issues who are using telemedicine to ask how they should approach the pandemic. "Telemedicine is more about advice, or where they are with their symptoms and concerns they may have," he said. "For many, it's a great way to ask their questions. A lot of my patients with asthma ask about their risk of getting or developing complications with covid, which I can address over the phone."

For nonemergencies that may require in-person care, you may also start with telehealth. "We are trying to triage everything through telederm," said Sessa, the dermatologist. "Say for a rash, we'll want to know how severe it is, if it's blistering, has it been going on for three years or a week - the acuity of it. Are they having other systemic issues, as well? Are they sick?" This helps her determine if a patient needs an in-person visit.

• Which routine appointments should I reschedule? If you are generally healthy, have no imminently concerning symptoms and have an upcoming physical with your primary care provider, it's OK to cancel that appointment for a short duration, Fincher said. "We are trying to give patients options with their regular, routine appointments," she said. "Some patients do not want to do telehealth and have said, 'I will come see you and get my labs when I feel comfortable.' " In these cases, Fincher said, you or your doctor should reconnect in one month to see where you're at or if you have new symptoms.

Non-urgent dental visits and cleanings should be postponed, limiting appointments to emergencies only. Routine cancer screenings for cervix, lung, breast or colon cancer can also be postponed - unless you are having symptoms that may raise a red flag, such as a lump in the breast or bloody stool, for instance. In this case, you should talk to your doctor who may order a screening test. If your screening is canceled, make sure to reschedule it as soon as possible when restrictions in your state ease up.

• What precautions should I see at the doctor's office? If you are going in to see your doctor for a physical visit, Harris said to "definitely call in advance" and ask for guidance. "The doctor's office or hospital can tell you which door to enter, what you should do when you enter, and they can educate you about the check-in process," Harris said. "I recommend everyone wear a face covering. Everyone should continue to wash their hands [frequently]. And always stay six feet apart from the nearest person."

Many doctor's offices are attempting to configure waiting rooms so there's only one person in there at a time, and everyone is at least six feet apart at minimum. "Some doctors' offices are even putting up Xs on their floors as a visual cue to show how far six feet away is," Harris said.

Fincher, the internist, said her office is screening patients. "If they come into the office, they are met at the door by someone who screens them and checks their temperature, and they are asked a handful of covid-related questions they need to respond 'no' to. Then and only then can they come into the office." Whether in the lobby or in a room, patients remain socially distant from others at all time. If anyone is not comfortable coming into the office, patients can also just "drive up in their car and we will come see them in their car if they are more comfortable," Fincher said. She will draw blood for labs and conduct the physical exam there if desired.

For emergency visits, look for guidance upon arrival. "The CDC has some measures in place for patients visiting hospital or ER settings, like visual alerts at entrances with instruction on hygiene, abundant supplies like hand soap, alcohol-based hand sanitizer," Goodman said. Emergency rooms should also be triaging patients with respiratory symptoms separately from those who don't have symptoms.

Wherever you go, health care staff should be monitoring their own potential covid-related symptoms before every shift and wearing appropriate face masks or other relevant personal protective equipment. If you have questions about the measures your doctor or health care provider is taking to protect patients during the pandemic, place a call before you go in.

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