Thinking (fantasizing?) about the slow return to in-person care in the office when it becomes safe to do so in this #COVID19 #pandemic. While I can't imagine it happening for me until June at the earliest, I think about how many things will need to change, perhaps permanently...

Is this the end of the waiting room as we know it? Having people wait in their cars until they get a text message when their room is ready makes sense, but what about people who didn't come in a private car? What about very hot or cold weather, when sitting in a car is unsafe?

Physical distancing in existing waiting rooms is part of the solution, but how many of us have waiting rooms so expansive that we can keep people far enough apart while being able to accomodate all? Perhaps a hybrid of car/waiting room, but what about that weather?

Then there's the actual visit. Masks/gloves would be minimum protection, but will full #PPE be needed? It would help to segregate resp and non-resp visits with PPE for the resp, but what about those "by the way, while I'm here" late complaints? Careful screening will be a must.

This would require a redesign of schedules, including respiratory and non-respiratory sessions and a more rigorous pre-scheduling process. Plus, if we have people sitting in their cars waiting to be seen, it might compel some of us to do a better job of running on time .

Before suspending live visits, we were already heading in this direction: exam room management will closely resemble turning around an OR between cases, with vigorous wiping down of all surfaces and equipment. Will scribes/voice recognition to document hands-free be mandatory?

Stethoscopes, BP cuffs, ophthalmoscopes, reflex hammers, other equipment that is handled during a visit will need cleaning between patients, or transitioned to disposables. That could be costly, but it may also make us rethink how we do the "physical" part of the visit.

One observation from caring for patients exclusively via #telehealth or phone for the past 6 weeks is how often the exam is not critical to management. Not surprising, but we were afraid to say it out loud, because it challenges what we were taught and patient expectations.

If the "laying of hands" can increase the risk of infection, we should be more judicious about doing it, examining when necessary, while listening and thinking for all patients - treating the exam as a procedure with potential benefits and harms. (I know that seems strange).

Another piece of the "reopening" is the role of #telehealth. Will @CMSGov and the health plans continue current policy or revert to the old restrictions? Continued coverage will let us be selective about who needs to come to the office and who can be managed more safely remotely.

This may reduce office visit volume and facilitate managing the waiting room, exam rooms, and all the other potential hazards of "live" visits. Long term, it may drive office design. I'm sure innovators and entrepreneurs are already thinking about and preparing for much of this.

These are just a few of my thoughts. We don't have a specific timeline as of yet, but as a group practice, we'll develop a plan that will allow us to continue our work for patients while keeping them safe.

Are others in practice making plans, and if so, what are you thinking?