Most patients can be managed by their GP and local network of other specialists and allied health.
While working on a covid ward at St Vincent’s hospital in Sydney, Dr James Zhang regularly dropped in on the new long covid clinic after it opened early this year.
He saw that much of the treatment that most long covid patients needed was well within the remit of GPs.
The clinic had a waiting list many months long, and a team that was “stretched thin” from the overwhelming demand. This bothered Dr Zhang.
“My wife tells me that I’m a very bothered person. But what usually bothers me also happens to bothers a lot of other people. I just have a bit more drive to at least try and deal with that issue,” he tells The Medical Republic.
To address this big gap, Dr Zhang opened a long covid clinic in June at Shire Family Medical in Sydney alongside practice owner Dr Gary Franks. He says GPs are especially well suited to treat the nebulous condition due to its high need for compassion throughout treatment.
“We know our patient’s story, we know their history, we can journey with them through a long period of time. And we’re a lot more readily accessible than the hospital,” he says.
His experiment has given him insights to share with other GPs seeking to manage the condition.
Diagnosis and assessment
Dr Zhang kicks off a quick initial assessment via telehealth to assess the patient’s eligibility under the World Health Organisation definition for long covid. If patients qualify, they then complete a Yorkshire Covid-19 Rehabilitation Screening Questionnaire for quantifying the severity and impact of a patient’s symptoms.
“We use that as a starting point that we can then review it in three to six months to see what their progress is like,” Dr Zhang says.
The telehealth call and Yorkshire screening questionnaire are all done prior to an in-person consultation, where a proper assessment is undertaken. Dr Zhang says this usually lasts 30-45 minutes and aims to exclude any other serious ongoing complications and comorbidities.
Dr Zhang leans on the St. Vincent’s long covid clinic website to guide his choice of blood tests and investigations. He also highly recommends the Clinical Practice Guide for Assessment and Management of Adults with Post-acute Sequelae of Covid-19.
Treatment
Dr Zhang says there is no one-size-fits-all treatment for long covid. A literature review published in Journal of the Royal Society of Medicine identified two main symptom clusters associated with long covid. The first was fatigue, headache and upper respiratory complaints. The second cluster was multisystem complaints such as ongoing fever and gastroenterological symptoms.
The Lancet published research showing in 2021 that showed 203 long covid symptoms recorded across 10 organ systems. These include neurological dysfunction, hair loss, brain fog, itchiness, menstrual cycle changes, bladder control issues and sexual dysfunction.
According to another article in the BMJ, patients with long covid greatly value input from their primary care clinician. Dr Zhang agrees and says treatment requires “a very personalised” approach.
“There’s no one magic pill or single treatment that can make everyone better but the least we can do is handle all the cases that can genuinely be managed by GPs and maybe leave more complex cases to the hospital clinic. Even if it’s to just get the ball rolling, to get the coordination of care happening, to work up the investigations,” he says.
Case study
Dr Zhang cites a case study of an asthma patient who had covid in January this year. Following the infection the female patient had worsening dyspnoea and fatigue and was using more puffers than normal.
“At face value, one could easily just increase the puffers and monitor. But our role is to do a long list of investigations to exclude any other pathology. When we did the patient’s blood tests it turned out that she had a whopping big D-dimer as a result,” Dr Zhang says.
They did a CT pulmonary angiogram and identified that she actually had two very small peripheral pulmonary emboli in her lungs.
The patient was referred to a respiratory physician and is now on anticoagulants.
Long covid clinic DIY
Shire Family Medical has initially opened the long covid clinic only to existing patients. The most prevalent symptoms experienced have been fatigue, dyspnea, worsening of asthma symptoms, and brain fog. Mental health issues are also common.
Dr Zhang encourages other GPs to start a long covid clinic but to “manage expectations and be compassionate”, as the disease can follow a path similar to that of other challenging chronic conditions such as chronic fatigue or fibromyalgia.
He also says it’s essential to reach out to local allied health and specialists to create a referral network.
“You never know what you’re going to get, so you want to take a very broad approach, with a very holistic mindset on what’s going on with the patient. Ask ‘what is affecting them the most? What other serious pathologies do I need to exclude? What other general health measures can I optimise with their lifestyle or exercise or their diet and diabetes?’”
The long covid clinic is mixed billing factoring in the patient’s circumstances including if long covid has impacted their finances and capacity to work. Subsequent appointments then may require a mental health care plan or a GP management plan which “allows the reimbursement to be somewhat worthwhile”.
“If you’ve done the 30-45 minute consultation, with proper workup, taking the full history and really taking the time to work out what their issues are, then subsequent appointments to do the mental health care plan and GP management plan usually don’t take long at all,” Dr Zhang says.
Overwhelming demand for treatment
Recent modelling by the Menzies Institute indicates that there may be up to half a million people with long covid in Australia. Despite the numbers, there hasn’t been much of a drive for GPs to take ownership of treating long covid.
“It’s perhaps one more symptom of how the federal government maybe undervalues GPs and fails to adequately reimburse GPs for the time spent in holistic care that we’re capable of providing. There’s clearly a crying need for it,” he says.
Dr Zhang hopes the long covid clinic at Shire Family Medical will inspire other GPs but he isn’t putting himself on any pedestal.
“At the end of the day it’s just something I’m humbly doing as a GP, like everyone else. We’re just giving it a go and letting the patients know that we’re here for them through thick or thin,” he says.
