The physician and mass medical event response: emergency preparedness implications.

To the Editor,

Disaster planning has become a popular media topic in light of some of the national and world events of late including the severe acute respiratory syndrome epidemic, the events of September 11, Hurricane Katrina, and the threat of the H5N1 avian flu. Although much of the literature has focused on strategies for governmental and regional preparedness, very little information is available regarding the local preparedness of the primary care physician and his or her role in the medical management of such a disaster. Most preparedness planning up until this point has centered on hospital emergency departments (EDs) [1]. A recent report focused on emergency health care providers including emergency medical services, ED nurses, and emergency physicians and their intention to work during an infectious pandemic. In this study, the investigators noted that 80% of respondents would report for work if the infectious agent was unknown; less than half, however, would plan on reporting for work if the infectious agent was identified and known to be transmissible. The addition of treatment for the provider and family would, however, increase the number of providers who would report for work [2].

Although the primary care physician has been somewhat overlooked in the literature, it is clear that he or she is not overlooked by the patients who will be affected by such a medical disaster. A 2003 survey from Israel found that only 30% of patients in that nation would choose the hospital ED as their first choice for information in the event of an anthrax attack. Instead, two thirds of those surveyed preferred to seek help and information from their family physician or the health authorities [1]. In the US health care system where EDs are already overcrowded and the primary care physician plays a central role in accessing care, emergency planning must take account of these vital players and their impact on the delivery of care in a mass medical response.

We conducted a cross-sectional survey of 2238 physicians within the northwest hospital region of Virginia from August to November 2006 to determine the anticipated level of local primary care response in the event of a medical disaster. Internists (25%), family practitioners (18%), and pediatricians (14%) comprised a significant proportion of respondents, whereas the category of “other,” including radiologists, anesthesiologists, emergency medicine physicians, as well as a myriad of other specialists, comprised an additional 35% of respondents. More than half of those responding had a clinical practice independent of the hospital. Fig. 1 summarizes other characteristics of the responding physicians, including their capacity and willingness to assist in the community during a medical disaster (this survey used the example of an influenza pandemic), as well as their perceived state of preparedness. In the event of a large-scale, high-mortality influenza pandemic (similar to the 1918 pandemic [3], [4]), only 18% predicted that they would close completely. Thirty-three percent predicted that their clinic would remain open for any patient within the community, whereas 27% said they would remain open for established patients only (Fig. 2 ). Answers regarding a small-scale, low-mortality pandemic (similar to the 1957 or 1968 influenza pandemic [4]) followed the same trend with only 7.3% saying they would close completely, 48% remaining open for all patients, and 29% remaining open for established patients only. The physicians' predicted material requirements for maintenance of clinical operations during a pandemic are summarized in Fig. 3 .

Fig. 1

Characteristics of physician responders.

Fig. 2

Predicted status of independent clinical practices in a large-scale pandemic.

Fig. 3

Physicians' predicted requirements for maintaining clinic in an open status during a pandemic.

There has been much discussion in the ethics literature on infectious disease outbreaks regarding the physician's “duty to treat” in such circumstances [5], [6], [7]. Historical accounts of past epidemics and pandemics reveal the complexity of this issue and the evolving view of the physician's obligations during an infectious disease outbreak. Ethicists describe a peak acceptance of this duty between 1847 and the 1950s and a more recent “professional retrenchment” against it over the past 40 years [5]. The results of our survey, however, reveal that most physicians do accept a certain duty to treat during a medical disaster such as the one described in our study. Only 9% of physicians surveyed said they would turn away patients with influenza (ie, answered that they would either close their clinic or remain open only for established patients without influenza-like symptoms) during a small-scale pandemic and 34% would do so during a large-scale pandemic.

It has been proposed by some authors that the physician's duty to treat contagious patients should be reciprocated by certain societal social obligations, namely, (1) to take all reasonable precautions to prevent illness among health care workers and their families; (2) to provide for the care of those who do become ill; (3) to reduce or eliminate malpractice threats for those working in high-risk emergency situations; and (4) to provide reliable compensation for the families of those who die while fulfilling this duty [5], [6]. With these points in mind, it is interesting to note which requirements for keeping their clinics open ranked most highly among the physicians surveyed: (1) vaccination for self and family (24%); (2) antiviral medications for self and family (22%); and (3) regular delivery of personal protective equipment (20%). Notably, financial reimbursement ranked much lower at only 8%. These findings reinforce the argument that special efforts should be made as part of disaster planning to ensure that health care professionals receive all reasonable preventive and treatment measures in the event of an outbreak [6].

Although the most frequently chosen response in both scenarios of our survey (large-scale and small-scale pandemic) was to “remain open for all patients, established and new, regardless of illness” (33% and 48%, respectively), it must be noted that this leaves a large group of uninsured patients and patients without an established primary care physician with no recourse except the hospital ED. In the event of a small-scale pandemic, 45% of physicians said that they would see established patients only (whether ill with influenza or not) and this number grew to 49% during a large-scale pandemic. This means that nearly half of independent clinics would close their doors to new patients seeking medical treatment during a pandemic, leaving a large number to seek care elsewhere.

A national random-sample physician survey in 2002 showed that 80% of US physicians were willing to care for patients in the event of an outbreak of “an unknown but potentially deadly illness,” but that only about 20% felt prepared to do so [7]. Likewise, a 2001 national survey of family physicians showed similar results with only a quarter of family physicians feeling prepared to respond to a bioterrorist event [8]. The results of our local survey nearly 5 years later were remarkably similar with 71% of physicians reporting a willingness to assist in managing a pandemic but only 20% having a written plan in place. Of the 80% of physicians without a written plan in place, 36.8% said they would need help to develop a plan.

Although small in scope, this regional study has important implications for future disaster preparedness planning. It shows that today's primary care physicians do believe in a duty to treat during a medical disaster and that most would keep their clinics open during such a crisis. The study also shows that despite attempts at continuing medical education on the subject of disaster preparedness, 63% of physicians still do not feel adequately informed and that they desire outside help in developing a specific written emergency plan for their clinic. Further research must be done to determine which methods will be most successful in achieving a higher rate of perceived physician preparedness. In addition, future disaster planning must take into account those factors which are most important to physicians being able to maintain their clinics during a medical disaster, such as vaccination and antiviral medication for self and family and adequate availability of personal protective equipment.