Long COVID and the Doctor-Patient Relationship

Dr. Karnik, who works in the University of Chicago's Post-COVID Recovery Clinic, talks about taking care of patients with persistent symptoms after COVID infections and reflects on the doctor-patient relationship in this setting.

What is The Clinical Excellence Podcast?

The Clinical Excellent Podcast, sponsored by the Bucksbaum Institute for Clinical Excellence is a biweekly podcast hosted by Drs. Adam Cifu and Matthew Sorrentino. The podcast has three formats: discussions between doctors and patients, discussions with authors of research pertinent to improving clinical care and the doctor-patient relationship and discussions with physicians about challenges in the doctor-patient relationship or in the life of a physician.

[00:00:00] Dr. Cifu: On today's episode of The Clinical Excellence Podcast, we have Dr. Rasika Karnik talking about long COVID.

[00:00:10] Dr. Karnik: The patients that we see are in a tremendous amount of distress, which is why they have sought out care with us. So that makes it challenging because, you know, imagine the first time you see a patient and they maybe have four or five symptoms, and even if it is long COVID, there is no diagnostic and there's barely a definition.

[00:00:30] Dr. Cifu: We're back with another episode of The Clinical Excellence Podcast sponsored by the Bucksbaum Institute. During this podcast we discuss, dissect and promote clinical excellence. We review research pertinent to clinical excellence. We invite experts to discuss topics that often challenge the physician-patient relationship, and we host conversations between patients and doctors.

I'm Adam Cifu, and today I'm joined by Dr. Rasika Karnik. Rasika is a general internist at the University of Chicago who has developed an interest in and expertise in long COVID. Rasika is originally from Michigan, but spent her high school years in India. She got her MD from Wayne State University School of Medicine and came to us at UFC after practicing for several years in Dallas and then St. Louis.

Soon after her arrival, she started seeing patients in our post-COVID Recovery Clinic. Rasika, thanks so much for joining me today.

[00:01:23] Dr. Karnik: Thanks for having me.

[00:01:24] Dr. Cifu: So first, a really general question. You've been seeing patients with prolonged symptoms of COVID since like, very early in the pandemic. Um, and I'm just interested in kind of the medicine so far, like what do you come upon most? What do people... What are people suffering from the most? What are people most interested in having treated?

[00:01:45] Dr. Karnik: Sure. That's a big question. We sort of, we see, or I see a large variety of patients and complaints, but I would say that the most common complaint does match up with the literature, which is a fatigue aspect of persistent symptoms after COVID. So I certainly see a lot of fatigue and brain fog. And so those are the two that I truly see and they're very debilitating symptoms. And it's hard for people to accomplish the tasks that they want to do which is infuriating to patients. Hmm.

[00:02:22] Dr. Cifu: Maybe this is an obvious question, but you know, does it feel different to you than your sort of regular internal medicine, seeing people who have difficult to diagnose troublesome symptoms? Or is there something different in the presentation, in the relationship? What do you think?

[00:02:40] Dr. Karnik: It certainly is different and there are a couple of reasons for it. So one, you know, as an internist with a primary care panel, I get to know the patients and most of the time I'm meeting them and they're not in distress.

Whereas with the long COVID clinic, the patients that we see are in a tremendous amount of distress, which is why they've sought out care with us. So that makes it a bit challenging because, you know, imagine the first time you see a patient and they maybe have four or five symptoms, if not more, and they're all challenging to diagnose and even if it is long COVID, there is no diagnostic that I can give them. There's barely a definition. So it is very challenging from a physician-patient standpoint. But something that I realized a few months into it is that just listening to the patient was therapeutic and making sure that they understood that I did not think they were crazy.

[00:03:33] Dr. Cifu: Yeah.

[00:03:34] Dr. Karnik: So that proved to be very valuable to our patient population.

[00:03:38] Dr. Cifu: They sound like the kind of clinics that you go home and need to have a beer afterwards. Right?

[00:03:42] Dr. Karnik: Funny you say that, there was certainly, when I first started seeing patients, I would see them in these 40-minute visit chunks.

[00:03:49] Dr. Cifu: Yeah, yeah.

[00:03:50] Dr. Karnik: And I would see maybe four or five in a half day. And by lunchtime, my mind was spinning . I mean, I needed to take a walk. I needed to decompress.

[00:04:00] Dr. Cifu: Um, so there's a question that I feel like we discuss a lot these days and I'd love to sort of get your thoughts and I think probably nobody knows this and, you know, you are primarily a clinician with an expertise rather than like, you know, a scientist with an expertise in this, but do you think long COVID is something specific to COVID, or do you think it's kind of a post-illness syndrome? Um, and we're only kind of recognizing it now just because so many people were sickened in a short period of time, you know, at the beginning, let's say first year and a half of COVID.

[00:04:32] Dr. Karnik: Mm-hmm. Yeah. That's a great question. I actually think it's a combination of both. So I think that COVID in the beginning was a new virus, right? To the human body was very pathogenic. The rates of death and very severe illness were high. So I do think that partially it's because it is just the virus itself, but I also think because it was so contagious that so many people had it. So I think you're seeing more of it because of that too. And I don't think it's, you know, it's this idea of having a postviral sequelae is not new. Just, you know, the numbers are so high because so many people were infected.

[00:05:07] Dr. Cifu: Yeah. I'm interested because people with whatever we want to call it, you know, long COVID, post COVID, you know, ongoing symptoms, who I've seen, you know, outside of your group, you know, there's sort of symptoms that I'm used to seeing in those patients who have unexplained symptoms that you have difficulty with, and whether it's the non-specific things like you talked about, like the brain fog or fatigue, or whether it's maybe more specific thing like PoTS and stuff. And when I try to be optimistic about this, I sort of think like, huh, you know, maybe because of long COVID, we're going to figure out some of these things that have been torturing people for decades or probably forever that we've never been able to figure out.

[00:05:52] Dr. Karnik: Yep. Absolutely. No, I totally agree with you on that. And I think because of the sheer number of people and also the power of the patient. Patients organizing together, their voice is very clearly heard by people in charge and they've organized themselves very well, which I think will only help with these non-specific symptoms that a lot of patients have had in the past. Right? Like your chronic fatigue is not new.

[00:06:14] Dr. Cifu: Right. Right.

[00:06:15] Dr. Karnik: The brain fog associated with chronic fatigue is not necessarily new, but I do think that you're right, much more attention will be given to these and hopefully more information will be...

[00:06:28] Dr. Cifu: Yeah. The voices of the patients will be louder just because there are more of them.

[00:06:32] Dr. Karnik: There's more, plus there's also social media, I think, and like, the internet has made it very easy for people all over the world to congregate. I mean, the first group that actually came up with long COVID, I mean this was patient led research collaboratives, so they are the first ones that shed light onto this disease process and named it. So the long haulers.

[00:06:51] Dr. Cifu: Right. So this podcast obviously focuses on the physician-patient relationship since that's sort of the Bucksbaum Institute's focus.

[00:07:00] Dr. Karnik: Mm-hmm.

[00:07:00] Dr. Cifu: You're a primary care general internist, but your role with long COVID, you know, is somewhat different, and you alluded to that, right? You're seeing patients in consultation, you're seeing patients with these poorly understood, poorly defined syndromes.

You talked about just sort of listening to people and, you know, I guess believing people, um, has been therapeutic for them, but has your, I don't know, has your experience with the patient-doctor relationship been different in this setting than it has been for the rest of your career and your experience?

[00:07:33] Dr. Karnik: I think so, and part of it is because they are in such distress and I've never known them normally, right? Like what they were at at their best. Oftentimes, you know, for me I have to, you know, take a step back and think like this, you know, this is not them at their normal. Right? You know, and I believe them for what they tell me, because frankly it's, you know, just how I approach life. It's easier to believe people, and I kind of go forward. But yes, it is, it is different because, you know, they mostly come to me with a thousand complaints or, you know, a hundred not a thousand, I'm exaggerating, but many, and so in that sense, it's a little different because I think there's more need. Right? There's a little bit more of, you know, counseling, grieving, right? Some of them are grieving their past self and there's more emotion behind it.

[00:08:28] Dr. Cifu: I hadn't thought about that difference of, you know, knowing people well and then watching them become sick. I think it's something that you and I probably previous to that have experienced, you know, when we're on the inpatient service and you're sort of faced with all these people who, right, you know, you can see pictures in the room of them well, but you just know them as sick, but I always sort of think about it as that, as you grow up, you know, being a doctor, you don't just know people who are always healthy, you just know people who are always sick, but you have that long experience with people where you know people who are healthy, you see them get sick. Hopefully you then see them get better, but you're almost going back to where like, okay, I'm just seeing sick people who are sick when I meet them, and you know, it hasn't been that long. Probably a lot of them are staying sick.

[00:09:13] Dr. Karnik: Yep, and they're kind of chronically low-grade sick and sort of, you know, they are not able to just... It's almost a disability, right? So they're able to kind of make it through life, but it's frustrating from my standpoint because oftentimes I feel like I can't help them.

[00:09:29] Dr. Cifu: Yeah.

[00:09:29] Dr. Karnik: Right? I don't know what to do for them. Um, I wish I could do more. I, as you mentioned, I'm not a scientist, so it's harder for me to, you know, it's not my mindset to just experiment on patients either. Right? Say, well, let's throw this at you and let's order of these labs that I don't know what to do with. So, in that sense it is challenging to just sort of see these chronically ill patients.

[00:09:50] Dr. Cifu: Yeah, yeah, or chronically suffering people.

[00:09:52] Dr. Karnik: Yeah. Chronically suffering, and you know, the other thing too that I think seeing post-COVID patients has really solidified in my head is that, you know, a lot of these people were like young and didn't have any chronic medical issues, so they didn't really have a primary care doctor. Right? So like they didn't have somebody that they could go to, and that's distressing, you know, because I think it is easy to write patients off when they come in to you, you know, and seemingly they're very well-appearing and like they have all the resources in the world and they should be able to recover, and this is, you know, "all in their head." So I do think it underscores the importance of having a primary care doctor.

[00:10:29] Dr. Cifu: So my last question is probably totally unfair, because I'm going to ask you to kind of look into the future. COVID's obviously changed a ton. It's not there yet, but it is getting closer and closer to like, you know, being just another respiratory virus.

We rarely see COVID pneumonia anymore in the hospital, thankfully. What do you sort of expect to see as far as, you know, newly diagnosed people? Um, what have you seen with kind of new people coming into the practice or the people you've been following for a while? Is there like reason for optimism or a reason for pessimism or a little bit of both?

[00:11:06] Dr. Karnik: I think there's reason for optimism. I think, you know, as you mentioned, it's becoming more and more just like your run-of-the-mill respiratory virus. You know, personally speaking of just having the flu, I felt much worse, you know, than I think some of my patients did, or some of the patients that I've treated, you know, as part of the primary care practice for COVID, to me, you know, there are other viruses that make you feel a lot worse.

[00:11:29] Dr. Cifu: Yeah.

[00:11:30] Dr. Karnik: So I do think that it will decrease as it just becomes more and more of a virus that we commonly encounter and deal with just like most other coronaviruses. So I think people will get better. I do think that there is, you know, I certainly see patients, a subset of the post-COVID patients that get better with time and they kind of fall off, right? They don't come back to me. And then you just have the patients that are persistently chronically ill, and to me a lot of them have a lot of comorbidities and it's hard to sometimes tease out which is causing what.

[00:12:01] Dr. Cifu: Right.

[00:12:02] Dr. Karnik: So, and the other thing too is that I personally, I just think a lot of people pay attention to their bodies more actually, if they have COVID because it's this major new virus and you know, you kind of wonder what it could be doing to you. Yeah.

[00:12:16] Dr. Cifu: I wonder if the fact that, you know, the COVID we are getting now is less severe and people are recovering, you know, more quickly, more easily, may actually make it harder for some of these people from the past, you know, who are dealing with worse symptoms and they may face more and more people that are like, you know, "What's the big deal?" You know, it's...

[00:12:40] Dr. Karnik: Yeah, but you know, the other part to your question I didn't necessarily answer. So I do think that, um, I think that people that have, you know, post-infectious sequelae, like I think that as an entity will stay and be more recognized.

And I do think that as long as there's, you know, research funding and people that are interested in this, we will get some more answers in the future.

[00:13:01] Dr. Cifu: Yeah, that's a great point. And it's a field that's sort of already there when we talk about hospital-associated disability and such, it's not a big jump to broaden that out, right? To include, you know, this entire population of people.

[00:13:17] Dr. Karnik: Yep. Yeah, so I do think people will... There'll still be more attention given to post-infectious sequelae.

[00:13:24] Dr. Cifu: Yeah. Yeah.

[00:13:25] Dr. Karnik: And also fatigue, I think. You know, just the debility and being able to function at your normal ability and there's more and more diagnostics that are out there, but we are not quite sure what to do with it, but I think I'm hopeful that that will change.

[00:13:40] Dr. Cifu: Well, thank you so much for taking time out to talk to me. It was a great discussion, and I think we touched on a lot of, you know, questions that people have.

We're going to put this up right away because COVID changes so much that I sort of didn't want to like leave this sitting in the can for six months, because we may be talking about something completely different.

[00:13:59] Dr. Karnik: Sure.

[00:14:00] Dr. Cifu: And I'm hoping more than ever that people sort of reach out with comments. So thanks for joining us for this episode of The Clinical Excellence Podcast.

We're sponsored by the Bucksbaum Institute for Clinical Excellence at the University of Chicago. Please again, feel free to reach out to us with your thoughts and ideas on the Bucksbaum Institute Twitter page. The music for The Clinical Excellence Podcast is courtesy of Dr. Maylyn Martinez.