Dr. Mary Marshall, a family physician in Grand Blanc, relies more heavily on a small group of specialists.

Dr. Jody Jones, an obstetrician-gynecologist in Canton, sees more at-risk pregnant women through telemedicine.

These are a few ways doctors say that COVID-19 has changed the way they practice medicine.

Now in its fourth surge, coronavirus has mutated into a more contagious form of SARS-CoV-2, the delta strain, causing hospitals and providers to reinstitute restrictions designed to limit the virus’ spread.

While three vaccines have been available since January, only 55 percent of the U.S. population is fully vaccinated, allowing coronavirus to spread mostly among the unvaccinated.

As a result, doctors schedule people differently for visits. People still wait more in their cars than sitting in crowded medical offices. Smaller ambulatory surgery and diagnostic centers are again doing more business than large hospitals. Telemedicine, after dropping somewhat after the third surge, is picking up again.

ENT specialist Dr. Bobby Mukkamala, past president of the Michigan State Medical Society and current chair of the American Medical Association, said COVID-19 continues to limit the number of patients in waiting rooms. It also has led to longer care discussions.

“We want to minimize exposure to aerosolized infectious organisms, because that is how COVID spreads. My wife (ob-gyn Dr. Nita Kulkarni) and I used to have a waiting room with 25 people, sitting shoulder to shoulder. Now, with the reality of having a severe infectious disease pandemic like COVID, we have patients sitting in their cars and calling into the office letting us know that they’ve arrived.”

Mukkamala believes the full office waiting room will be a thing of the past, even if COVID-19 goes down to 1 percent positivity rate in the community from the current 10 percent. Experts say the goal to minimize spread of the virus is a positivity rate of less than 3 percent.

“If we get 80 percent or more people vaccinated, then I could see having more people in the waiting room and not wait in their cars, but it will be awhile,” he said. “Wearing masks is a good thing, even if it is to prevent spread of colds.”

Neurosurgeon Dr. Jay Jagannathan said the biggest clinical changes for his four-physician practice during the pandemic has been ensuring safety of staff when performing surgeries at hospitals and rounding post-operatively with adequate PPE and hospital vaccination requirements.

“When you are on call, it is always an issue in terms of going in to see all kinds of patients. You have to protect yourself and your staff,” said Jagannathan, who owns eight-provider Jagannathan Neurosurgery Institute, a Troy-based neurosurgery group. “Some hospitals are requiring negative COVID tests in order to perform elective surgery. It can affect surgical planning. Patients get tested and the results are positive, so we have to readjust our schedule.”

Marshall, a solo practitioner and former president of the Michigan Academy of Family Physicians, said the most obvious way COVID-19 has changed medicine is the ubiquitous use of personal protective equipment, or PPE, such as masks, gloves and gowns.

“Prior to COVID, there were limited times when full PPE was necessary, and now it is fairly routine,” she said.

Marshall, who conducts hospital rounds on her own patients, said she’s also changed how she communicates with patients and their families.

“Lack of visitors in the hospital has changed the way we communicate with families,” she said. “We spend much more time on the phone discussing patient care with families than prior to the pandemic. We have learned how to use Zoom and FaceTime to improve communication as well.”

Takla said evaluating patients with COVID-19 compared to patients who don’t have the virus was the first change for him. Identifying tell-tale coronavirus symptoms and isolating those patients in the beginning was a challenge, he said.

“The lessons we learned will help us take care of challenging patients in the future who do not have COVID,” Takla said.

Treating what seems to be a never-ending stream of patients with COVID-19 has reinforced the method by which Takla cares for patients.

“I’ve been physically and emotionally drained. But most of the times, given what’s been going on in the world, I actually feel very blessed because (the pandemic) continues to reinforce even more how I approach patients, both with humility and kindness and trying to be nonjudgmental,” he said.

Jones, an obstetrician-gynecologist with the Ann Arbor-based IHA Cares, a 700-provider multispecialty medical group, said initial office visits have changed for pregnant women. For new patients, providers identify those who are at low risk or high risk of contracting COVID-19.

Low-risk patients visiting the office are given increased spacing for their prenatal visits to decrease possible exposure. High-risk patients have even more precautions. They are asked to use blood pressure cuffs at home, do more prenatal visits using telemedicine and double-up on appointments.

For example, when lab work, blood pressure and ultrasound tests are needed, high-risk patients aren’t required to come for in-person follow-up appointments. Instead, telemedicine is used more often.

“Generally speaking, patients were reluctant to come in anyway. A lot of them were very happy to hear that if they went for their ultrasound appointment, then they didn’t have to come back to the office,” Jones said. “A lot of patients don’t want to take any added risks.”

Before the pandemic, only 8 percent of Americans used telemedicine to visit their provider. Most doctors didn’t make the option available because they felt it wasn’t an effective substitute. A recent survey found that 20 percent of patients would change doctors for one that offers telehealth services. Now many doctors offer telemedicine.