Bridging the Gap in Long COVID Care: Identifying Core Competencies for Primary Care Curriculum Development and Evaluation

Bridging the Gap in Long COVID Care: Identifying Core Competencies for Primary Care Curriculum Development and Evaluation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Bridging the Gap in Long COVID Care: Identifying Core Competencies for Primary Care Curriculum Development and Evaluation Rachel Geyer, Kristen O’Loughlin, Cassie Theobald, Donovan Rivera, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9098407/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background There is an unmet need for Long COVID care within our healthcare system. Primary care clinicians (PCPs) face challenges in providing effective care due to limited relevant Long COVID training and lack of standardized clinical resources. Pre-CME (continuing medical education) survey data indicates that 62% of clinicians experience difficulty diagnosing and managing Long COVID. There is a need for competency-based curricula to equip PCPs with tools for interdisciplinary, patient-centered care. Methods A mixed-methods Delphi needs assessment process was designed to gather stakeholder input to guide the development of Long COVID core competencies. Participants were recruited through word of mouth and completed a 30-minute survey on barriers and facilitators for Long COVID care, case scenarios, and topic preferences. They also participated in a 1-hour Zoom focus group using an unstructured question guide to review survey responses, which were then analyzed with summary templates and a matrix analysis. Results The study enrolled 26 participants, 21 of whom also participated in focus groups. Areas of convergence and divergence in participant perspectives were used to inform development of core competencies that ultimately could be categorized in alignment with the six competency-based domains defined by the Accreditation Council for Graduate Medical Education (ACGME). Conclusions This study establishes a consensus-based framework of competencies for PCPs managing Long COVID, reflecting the condition’s evolving nature and the importance of continuous, relationship-centered care. Implementing these competencies in training and professional development can enhance care quality, standardize practices, and improve outcomes for patients facing complex, multisystem health challenges. Long COVID education primary care medical education mixed methods delphi needs assessment patient perspectives COVID-19 core competencies Introduction Long COVID represents a significant and multifaceted healthcare challenge, affecting up to 30% of the population who have recovered from the acute phase of COVID-19. 1–3 Patients often experience a diverse range of symptoms, including fatigue, cognitive dysfunction, and respiratory issues, which can severely impact their quality of life. 4 Primary care clinicians (PCPs) face challenges managing these complex symptom presentations, highlighting the need for coordinated care strategies and supportive resources. Despite the growing prevalence of Long COVID, a notable gap exists in specialized training for clinicians focused on the comprehensive management of this condition. 5 Existing educational programs often do not incorporate the necessary interdisciplinary and biopsychosocial approaches required for effective Long COVID care. 6,7 Furthermore, there is no established set of "core competencies" for managing Long COVID, which can create confusion among clinicians about critical elements of care. PCPs - often the first point of contact for these patients - would benefit from a skills-based framework that emphasizes evidence-based diagnostic and management strategies and brings together multidisciplinary expertise. Targeted needs assessments are a foundational element of curriculum development 8 and help ensure that training aligns closely with the real-world needs of both clinicians and patients. Additionally, core competencies provide a framework for targeting outcomes at the level of both clinician behaviors and health system needs. 8 Integrating core competencies into curricula ensures that training is outcomes-defined and competency-based, aligning with best practices in medical education. To date, no consensus-driven competency framework exists to guide PCP training in Long COVID care, and stakeholder-informed evidence to shape such training is lacking. Addressing this gap is essential to ensure that future educational initiatives are relevant, comprehensive, and grounded in the realities of primary care practice. Thus, as an initial step in developing a Long COVID certificate course for PCPs to address critical gaps in clinician training, this mixed-methods study aimed to (1) conduct a targeted needs assessment through surveys and focus groups with key stakeholders using a Delphi process to identify knowledge gaps and define essential learning priorities; and (2) establish core competencies for Long COVID care to guide future education and training. Methods Study Design This mixed-methods study employed Delphi methodology to systematically gather and synthesize input from Long COVID stakeholders through surveys and focus groups. Stakeholders included PCPs, individuals with Long COVID (IWLC), national Long COVID experts (e.g., clinicians in dedicated Long COVID clinics), family and community members. Demographic data collection was intentionally limited due to the anonymity inherent in the Delphi method. The study team is affiliated with a Long COVID clinic within an academic medical center, which provided clinical and research expertise that informed the study design and stakeholder engagement process. This project was approved by the University of Washington Human Subjects Division (STUDY00022894). Recruitment We recruited PCPs and Long COVID experts through convenience sampling based on recommendations from members of this study team and word-of-mouth. Many of the Long COVID experts came from the AHRQ Long COVID Collaborative that the UW Long COVID Clinic is also a member. A Long COVID clinic staff member, not affiliated with the study, contacted individuals with Long COVID, including those on the waitlist who were not officially patients of the clinic. Interested individuals provided their contact information for follow-up by the study coordinator. We also recruited family members using snowball sampling by asking patients to share the study contact details with their family members if they were interested in participating. All participants completed an online informed consent process before taking part. Data Collection Quantitative Participants initially completed a 30-minute survey to rate or rank barriers, facilitators, skillsets, and training topics they believed should be included in a Long COVID training program (Appendix 1). The survey was created by the study team with input from the clinicians and staff within the UW Long COVID Clinic. Surveys were tailored to minimize jargon, with specialized questions for clinicians on topics like laboratory testing, interdisciplinary collaboration, and patient scenarios. Clinicians were also asked to provide their specialty, type of practice, and years in practice. Participants were asked to complete a second survey after the study team drafted core competencies to rate agreement, disagreement, or suggested revisions of a draft list of core competencies. At the conclusion of the study, participants had the option to provide demographic information, including their age, sex, gender, and race. Data was securely collected and stored using REDCap (Research Electronic Data Capture). 9 Qualitative Participants were invited to one-hour Zoom-based focus groups facilitated by a trained qualitative researcher (REG). Each focus group included participants from the same stakeholder type (e.g., PCPs). These unstructured discussions explored survey findings and addressed areas of disagreement among stakeholder types. Key findings from focus groups were analyzed by the study team and informed the drafting of core competencies. Participants also responded to open-text items in the initial and follow-up surveys. Analysis Quantitative Survey data was exported into Excel 10 and analyzed using descriptive statistics and means to identify trends and prioritize key topics across stakeholder types (Appendix 2). Differences of means were calculated to highlight key disagreements between stakeholder types. Qualitative Open-text responses to surveys were reviewed by REG and CT and summarized based on participant groups. Following each qualitative focus group, REG and CT created summary templates of each discussion. These were drafted based on notes from the focus group and then reviewed against the recording to ensure they comprehensively captured all key takeaways. The templates were reviewed and discussed with REG, CT, and KOL. This method is well suited for projects that require fast data extraction and analysis. The focus group audio was transcribed via Zoom to provide additional quotes and references for the analysis. Using the summary templates, the research team completed a matrix analysis (Appendix 3). 11 This method allows for rapid analysis and interpretation of qualitative data and aligned well with our study design, as each focus group represented a distinct stakeholder type, allowing for structured cross-group comparisons across domains. We added a final row capturing researcher reflections on each domain, informed by our understanding of Long COVID and the broader healthcare system. Initial participant feedback on the draft core competencies was reviewed by the project team and assessed for (1) alignment with the project goal of PCP training and (2) feasibility of implementation. This was followed by an iterative review process incorporating additional participant suggestions and edits. The cumulation of these steps was a finalized set of 13 core competencies, outlined in the results section. Results Participants The project recruited 26 participants across all the groups (Table 1). PCPs included a mix of internal and family medicine; two were from community practices. Long COVID experts varied in specialties including pulmonary care, critical care, and integrative medicine. Both PCPs and Long COVID experts had similar years in practice with a combined average of 15 years (range 1-36 years). The participants were primarily white (69%) and ranged in age from 35 to 54 years old. We had 14 (64%) participants identify as women, 6 (27%) as men, and 2 (9%) as nonbinary. Core Competencies Competencies aligned with the six Accreditation Council for Graduate Medical Education (ACGME) 12 domains were developed in response to stakeholder input. Complete competency statements and stakeholder perspectives with supporting quotes are presented in Table 2. Below, we summarize cross-group perspectives relevant to each domain. Patient Care Diagnose Long COVID, recognize its common and atypical presentations, manage co-occurring conditions, and develop individualized treatment plans using pharmacologic and non-pharmacologic strategies with appropriate referral when needed. Stakeholders emphasized the importance of early recognition and diagnostic confidence as foundational challenges. IWLC highlighted the importance of clinicians who take symptoms seriously and can identify atypical presentations, whereas PCPs expressed uncertainty due to the absence of objective diagnostic criteria. Managing co-occurring conditions and coordinating care across specialties were viewed as central roles for PCPs. All groups endorsed individualized, multimodal care plans that integrate pharmacologic and non-pharmacologic strategies, with careful consideration of PEM (Post-Exertional Malaise). Medical Knowledge Understand current evidence on Long COVID pathophysiology and proposed mechanisms and apply this knowledge to inform patient care and clinical decision-making. Family members wanted clinicians to understand the pathophysiology so they could better support their loved ones. IWLC prioritized practical diagnosis and treatment over mechanism-focused explanations. PCPs requested concise updates on mechanisms and emerging science to strengthen patient education. Systems-Based Practice Deliver coordinated, patient-centered care through thoughtful referral stewardship and provide thorough documentation for work, school, and disability needs in collaboration with other professionals. PCPs and experts emphasized the importance of transparent communication regarding referrals, including realistic wait times and the rationale for specialist involvement. IWLC stressed the importance of accurate documentation for disability and accommodation needs. Experts recommended coordinated, interdisciplinary documentation processes. Interpersonal and Communication Skills Use affirming, patient- and caregiver-centered communication, address prognostic uncertainty clearly, and apply trauma-informed care that validates physical symptoms and acknowledges emotional impacts. Validation, empathy, and shared decision-making were central themes across groups. PCPs sought Long COVID–specific examples for validating symptoms, addressing emotional needs, and involving family members. Experts noted the importance of discussing prognosis uncertainty while maintaining realistic hope. Trauma-informed approaches, such as avoiding psychogenic attributions, were viewed as essential. Practice-Based Learning and Improvement Identify trusted resources and critically evaluate emerging Long COVID evidence to guide shared decision-making, especially when findings are limited, conflicting, or inconclusive. PCPs reported that patients frequently bring emerging research and treatment ideas to appointments. Both PCPs and Experts emphasized the need for training in critical appraisal, navigating limited or conflicting evidence, and discussing negative findings within shared decision-making conversations. Professionalism Reflect on personal biases and promote equitable, consistent, high-quality Long COVID care across clinicians and healthcare settings. Stakeholders stressed the importance of addressing personal biases about COVID-19 and Long COVID to ensure equitable care. PCPs endorsed reflective practice tools and expressed interest in standardized clinical resources to promote consistent care across clinicians. Discussion This mixed-methods study identified core competencies for Long COVID care in primary care settings through a targeted needs assessment that engaged PCPs, IWLC, family and community members, and interdisciplinary Long COVID experts. Using surveys, focus groups, and a modified Delphi process, we identified key knowledge gaps and educational priorities to inform future training initiatives. Findings underscored the complexities associated with diagnosing and managing Long COVID amid clinical uncertainty, heterogeneous symptom presentations, and limited evidence-based guidance. Stakeholders strongly agreed that PCPs must be able to recognize and validate diverse symptom presentations, develop individualized and coordinated care plans, and communicate effectively about prognosis and care expectations. Participants further emphasized that trauma-informed and patient-centered approaches are critical for building therapeutic alliances, supporting shared decision-making, and addressing the psychosocial impact of Long COVID. Diagnostic Uncertainty and Symptom Recognition Ambiguity around Long COVID diagnosis has been a persistent challenge since the condition first emerged in 2020. 13,14 Despite the release of the 2024 NASEM (National Academies of Sciences, Engineering, and Medicine) working definition 15 many PCPs in this study expressed discomfort diagnosing a condition without objective criteria. Experts emphasized the need to apply the NASEM definition flexibly, using clinical judgement to validate patients’ experiences and guide care in the absence of confirmatory tests. This view is consistent with international guidelines, which uniformly note that Long COVID is often characterized by unremarkable, and frequently costly, diagnostic work-ups, and recommend patient-centered evaluation and shared decision-making as central to diagnostic practice. 16 Across stakeholder groups, recognizing both common and atypical symptom presentations emerged as a core competency. IWLC particularly emphasized the importance of being believed when describing less visible or poorly understood symptoms -an insight reinforced by qualitative studies demonstrating that supportive, validating clinical encounters are essential for those navigating Long COVID. 17 This aligns with guidelines that advocate a holistic assessment approach – integrating symptom monitoring, functional evaluation, and clinical judgement, while avoiding over-reliance on conventional testing. 16,18 The American Academy of Physical Medicine and Rehabilitation (AAPM&R) further emphasizes the importance of a comprehensive, multidisciplinary approach tailored to the complex and individualized needs of people with Long COVID. 18 Individualized Treatment Planning and Risk Management Competencies also reflected the importance of tailoring management to the heterogeneity of Long COVID. While clinicians often prioritized pharmacologic interventions, IWLC emphasized non-pharmacologic strategies, patient education, and minimizing potential risks such as polypharmacy. A cross-sectional study found that 11.7% of people with Long COVID experienced polypharmacy and 25% were at risk of drug–drug interactions, reinforcing the need for vigilant symptom management and medication oversight. 19 There was strong consensus on the importance of identifying PEM, which affects approximately 25% of people with Long COVID, and on ensuring cautious use of exercise-based therapies, as these may be contraindicated for some patients. 20 These results highlight the need for competency development not only in treatment selection but also in risk identification and mitigation to ensure individualized and safe care. Communication and Evidence Appraisal The psychological toll of Long COVID was a recurring theme and is consistent with previous literature; many people with Long COVID reported experiences of stigma, dismissal, or medical trauma. 21 As a result, communication competencies emphasize empathy, transparency, and acknowledgement of uncertainty, shared decision-making, and a commitment to health equity. The American Academy of Family Physicians (AAFP) guidance supports this approach, recommending alignment with patient values, openness about uncertainty, and use of the Agency for Healthcare Research and Quality (AHRQ) SHARE model. 22,23 Participants also noted that patients often arrive with their own research or treatment ideas, underscoring the need for PCPs to critically evaluate emerging evidence. Engaging patients in collaborative interpretation was viewed as an essential skill for maintaining trust in the context of evolving and sometimes conflicting guidance and is consistent with practice guidelines from the National Institute for Health and Care Excellence. 24 Implications for Education, Curriculum, and Practice This study presents a consensus-driven competency framework to guide education and training for PCPs in Long COVID care. Alignment with ACGME domains facilitate integration into curricula and professional development initiatives, while also providing a foundation for clinical leaders and policymakers to develop tools and resources. Given the ongoing evolving science surrounding Long COVID, training should emphasize flexibility, collaborative learning with patients and caregivers, and relational care. Importantly, the study engaged multiple stakeholder groups, including PCPs, Long COVID specialists, IWLC, and family and community members, through the Delphi process, ensuring that the competencies were shaped by both clinical expertise and lived experience. This diverse input strengthened their relevance and positioned the framework to support models of care that extend beyond a purely biomedical focus. Limitations and Future Directions This study represents the first systematic investigation into key knowledge gaps and educational priorities to guide future training initiatives in Long COVID care. A notable strength was the high level of engagement across methods, with 80% of survey respondents also participating in focus groups, enhancing consistency of input across phases. However, limitations should be noted. Although the sample size met Delphi standards, it may not fully capture all regional, cultural, or practice-setting variations in Long COVID care. Stakeholders were predominantly white, limiting racial and ethnic diversity, and few PCPs were from community practices, reducing perspectives from rural or non-academic settings. In addition, because Long COVID clinics are primarily affiliated with academic centers, the Long COVID specialists in our sample were drawn mainly from these settings, potentially skewing perspectives toward academic practice norms. The range of specialties represented was intentionally narrow, reflecting our primary focus on primary care clinicians and Long COVID specialists, along with other key stakeholder groups identified by design; however, this may have excluded perspectives from additional relevant disciplines. Future research should evaluate the real-world implementation of these competencies through formal curricula and their impact on clinician confidence, care coordination, and patient outcomes. Additional studies are also needed to assess adaptability of the competencies across diverse primary care settings and to rigorously evaluate educational initiatives - such as the planned Long COVID certificate course - at the clinician, patient, and system levels. Conclusion This study presents a structured, consensus-driven framework of competencies for PCPs caring for individuals with Long COVID, developed through a modified Delphi process that incorporated various lived and clinician perspectives. The competencies reflect both the evolving nature of Long COVID and the central role of primary care in delivering longitudinal, relationship-based care. Embedding these competencies in Long COVID education and professional development initiatives can ensure training remains competency-based, outcomes-focused, aligned with best practices in medical education and considers key stakeholder opinions. Ultimately, this standardized framework offers practical direction for improving primary care quality and patient outcomes for this emerging multisystem health challenge. Abbreviations AAPM&R American Academy of Physical Medicine and Rehabilitation AAFP American Academy of Family Physicians ACGME Accreditation Council for Graduate Medical Education AHRQ Agency for Healthcare Research and Quality COVID-19 Coronavirus Disease 2019 IWLC Individuals with Long COVID LC Long COVID NAPCRG North American Primary Care Research Group NASEM National Academies of Sciences, Engineering, and Medicine PCPs Primary Care Clinicians PEM Post-Exertional Malaise REDCap Research Electronic Data Capture UW University of Washington Declarations Ethics Approval and Consent to Participate This project was conducted in accordance with the Declaration of Helsinki and approved by the University of Washington Human Subjects Division (STUDY00022894). All participants reviewed and signed an informed consent form prior to any study procedures occurring. Consent for Publication Not applicable. Availability of Data The datasets generated and/or analyzed during the current study are not publicly available due to potentially personal identifying information included in qualitative and quantitative datasets but are available from the corresponding author on reasonable request. Competing Interests The authors declare no competing interests. Funding This project was funded in part under grant number 1U18HS029905-01 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services (HHS). Authors Contributions REG, KMO, CT, DR, JB, AC, JF, and NLG conceptualized and designed the project and interpreted the data. REG, KMO, and CT analyzed the data and drafted the manuscript. DR, JB, AC, JF, and NLG revised the manuscript. Acknowledgements This project was funded in part under grant number 1U18HS029905-01 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services (HHS). The authors are solely responsible for this document's contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of HHS. Authors’ Information The authors included on this manuscript are current clinicians or staff working in the UW Medicine Long COVID Clinic. References Long COVID. February 7, 2025. Accessed March 19, 2025. https://www.cdc.gov/nchs/covid19/pulse/long-covid.htm O’Mahoney LL, Routen A, Gillies C, et al. The prevalence and long-term health effects of Long Covid among hospitalised and non-hospitalised populations: A systematic review and meta-analysis. 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Multidisciplinary collaborative guidance on the assessment and treatment of patients with Long COVID: A compendium statement. PM R . 2025;17(6):684-708. doi:10.1002/pmrj.13397 Michael HU, Brouillette MJ, Fellows LK, Mayo NE. Medication utilization patterns in patients with post-COVID syndrome (PCS): Implications for polypharmacy and drug-drug interactions. J Am Pharm Assoc (2003) . 2024;64(4):102083. doi:10.1016/j.japh.2024.102083 Pouliopoulou DV, Hawthorne M, MacDermid JC, et al. Prevalence and impact of postexertional malaise on recovery in adults with post-COVID-19 condition: A systematic review with meta-analysis. Arch Phys Med Rehabil . 2025;106(8):1267-1278. doi:10.1016/j.apmr.2025.01.471 Eberhardt J, Gibson B, Portman RM, et al. Psychosocial aspects of the lived experience of long COVID: A systematic review and thematic synthesis of qualitative studies. Health Expect . 2024;27(5):e70071. doi:10.1111/hex.70071 Agency for Healthcare Research and Quality. The SHARE Approach. October 2024. Accessed September 2025. https://www.ahrq.gov/sdm/share-approach/index.html American Academy of Family Physicians. Talking to Patients About Long COVID: Guidance on Shared Decision Making. Published online 2025. https://www.aafp.org/dam/AAFP/documents/patient_care/covid19/long-covid-discussion.pdf Raleigh MF, Nelson MD, Nguyen DR. Shared decision-making: Guidelines from the national institute for health and care excellence. Am Fam Physician . 2022;106(2):205-207. https://www.ncbi.nlm.nih.gov/pubmed/35977119 Tables Table 1. Participant demographics Table 1a. Stakeholder type breakdown Group Survey Focus Group Individuals with long COVID 8 6 (75%) Family members 2 2 (100%) Community member 1 1 (100%) Primary Care Clinicians 9 7 (78%) Long COVID expert 6 5 (83%) Totals 26 21 (80%) Table 1b. Participant optional self-reported demographics n % Age (years) 18-24 1 3.8 25-34 3 11.5 35-44 5 19.2 45-54 8 30.8 55-65 3 11.5 65+ 2 7.7 Missing/Not reported 4 15.4 Gender identity Woman 14 53.8 Man 6 23.1 Nonbinary 2 7.7 Missing/Not reported 4 15.4 Race/ethnicity African American/Black 2 7.7 Asian 5 19.2 White 18 69.2 Other 2 7.7 Missing/Not reported 4 15.4 Types of clinical practice* Academic 13 86.7 Community 2 13.3 Years in practice* Mean 15 Ranges 1-36 Specialties*^ Internal medicine 4 26.6 Family medicine 4 26.6 Pulmonology 3 20.0 Critical care 2 13.3 Integrative medicine 2 13.3 Other 3 20.0 *only asked of PCPs and Long COVID experts; n=15 ^more than one specialty could be indicated; total will be over 100% Table 2. Core Competencies for Primary Care Management of Long COVID ACGME Domain: Patient Care Core Competencies Stakeholder Perspectives Quotes Diagnose Long COVID using current diagnostic criteria and evidence-based approaches. PCPs expressed uncertainty in diagnosing Long COVID due to the lack of objective criteria, despite its importance for insurance and accommodation purposes. Long COVID experts warned against strict diagnostic criteria, highlighting the usefulness of tools like the National Academies of Sciences, Engineering, and Medicine (NASEM) 12 definition and symptom recognition to improve diagnostic confidence. “Having familiarity with the diagnostic criteria, I think sometimes in primary care, patients come to us with so many different symptoms. And so, when can we feel comfortable labeling and feeling like we're adding this diagnosis to a patient's problem list... having, the clear kind of diagnostic criteria helps [me] feel more comfortable.” (PCP) “I think the doctors who don't treat [Long COVID] are looking for really clear concrete, like ‘I am looking for this. These are my criteria. It's all cut and dry. And then I know.’ And in reality we don't always have that available to us, patients may not know if or when they got COVID, and it's based on clinical pattern recognition... if they over rely on a diagnostic criteria, they're going to miss a lot of people.” (Long COVID Expert) Recognize and evaluate the common symptoms and clinical presentations associated with Long COVID. Given the lack of diagnostic criteria available, all participant groups reported symptom recognition as important for identifying Long COVID. One PCP stated that education priority should be based on the “timeline of a treatment program instead of relative importance. As such, recognizing symptoms of Long COVID should be the first step before moving to other topics. IWLC specifically emphasized wanting to see PCPs who would not dismiss their symptoms and who are able to recognize both common and less typical presentations of Long COVID. “I might look fine from the outside and what I'm telling you are still problems that I deal with and I'm trying to come see you at a time when I feel okay and so when I feel terrible I'm at home.... I think that part of the education for a doctor is important for me to feel heard and understood.” (Individual with LC) “Examine the patient's symptoms and list them off categorically (CFS, PEM, ME, MCAS)...it's important to know which symptoms are the most severe and helping them construct a routine that would help them take steps towards their recovery.” (Individual with LC) Identify and provide first-line management for co-occurring conditions and complications often associated with Long COVID, including recognizing when to refer to or co-manage care with subspecialists. IWLC felt that managing conditions associated with Long COVID was relevant at all levels of care and should therefore be a priority in clinician education. However, although some PCPs expressed uncertainty about how to determine which conditions are directly attributable to Long COVID, they ultimately recognized they would manage the condition similarly regardless of the etiology. Another group of PCPs acknowledged the importance of recognizing co-occurring conditions (e.g., menstrual changes or atrial fibrillation), particularly those that are less frequently seen in the general population but occur more frequently among IWLC. Experts said PCPs should be a “home base” for patients in managing care and providing support. “There's just a set of syndromes that are maybe again, either causally or not, at least associated, related to a certain condition… It's a little bit like retinopathy and diabetes kind of a thing. We know how to treat retinopathy, but we should probably be on the lookout for that given that the patient has diabetes.” (PCP) “I think that understanding that there are these parallel conditions that may be associated or triggered as part of the picture of Long COVID is really important... like people having menstrual irregularities, people suddenly having AFib, who didn't have those other problems before, and even thinking to ask somebody who is not suffering from a lot of Long COVID symptoms... I think that it's really important for PCPs to have an understanding what the associated conditions are, and that even if they're not the ones who are going to manage those things... they're all part of a bigger picture.” (PCP) Develop and implement a comprehensive, individualized management plan for Long COVID that incorporates both pharmacologic and non-pharmacologic treatment strategies, recognizing when and where to refer patients for escalated or specialized care when needed. IWLC prioritized non-pharmacological treatments, noting that many medications addressed only some symptoms and often resulted in polypharmacy, adverse side effects, and high costs. They also emphasized that exercise-related treatments should be approached cautiously, and that any recommendations or referrals to specialists (e.g., physical therapists) should include explicit notice of the presence of post exertional malaise (PEM) and suggestions to consider during treatment to avoid worsening symptoms and impeding recovery. While PCPs and experts agreed that non-pharmacologic treatments should be the initial approach, they felt that education should place greater emphasis on pharmacologic options, as PCPs are less familiar with available medications, their off-label uses, and associated risks and benefits. PCPs are familiar with non-pharmacological options but would benefit from guidance on how these should be adapted for Long COVID. An education program should address both pharmacologic and non-pharmacological strategies to best meet the needs of patients with Long COVID. “Part of my issues with that is, it's almost always you need to go for walks. You need to start doing some sort of exercise. And at physical therapy that I go to, or vestibular therapy, we're doing physical activities and the second we go just a little too far, it sets me back weeks... be careful when you send people off to change their lifestyles, especially for the ones with severe Long COVID” (Individual with LC) “I was prescribed an amphetamine to help me because there was research showing that it worked. But what I chose to do with that was of course take more because... I could be this false sense of higher functioning that never really was real...the next thing I knew I was buying amphetamine pills, I ended up going to rehab, so I had some slew of secondary issues that came from my diagnosis of post COVID syndrome.” (Individual with LC) “As people who treat [LC], you're going to have to use pharmaceuticals for a lot of the pieces of it. And so it's not sort of an ‘if’ it's a ‘in what situations,’ whereas I would think the patients would hope to do everything without pharmaceuticals, if at all possible.” (Expert) “I feel like there's not a lot of familiarity or comfort with some of the medications that are used, and maybe feeling like there may be more limited data at this point. But I wonder... maybe there's more data out there than I am aware of and so, maybe having more knowledge of that would be helpful... some of the pharmaceuticals that are used are not necessarily things that as a PCP I would commonly prescribe.” (PCP) ACGME Domain: Medical Knowledge Core Competencies Stakeholder Perspectives Quotes Demonstrate an understanding of the current evidence regarding the pathophysiology and proposed mechanisms of Long COVID, and recognize how these factors impact patient care and may contribute to limitations in the clinical setting. IWLC were less interested in ensuring that clinicians understand the underlying mechanisms of the condition, preferring to focus on diagnosis and treatment. In contrast, caregivers and community members wanted this education prioritized to better understand what their loved ones were experiencing. They emphasized that PCPs should also educate caregivers about the causes of Long COVID, alongside symptom management, so they feel better equipped to provide ongoing support. “If I asked my friend right now, who's diagnosed with Long COVID like, would you want to know what causes Long COVID. Is that important to you? I know he would be like, ‘I really don't care… I want to figure out what to do with the symptoms I'm experiencing.' I know it's real but for me, as somebody who is not diagnosed and who's watching it, that is top of my list. I would love to know, like what is causing it. I'm seeing and witnessing so much suffering.” (Family member) ACGME Domain: Systems-Based Practice Core Competencies Stakeholder Perspectives Quotes Deliver coordinated, patient-centered multidisciplinary care through thoughtful referral stewardship, while providing a patient-centered medical home that serves as the hub of care for patients with Long COVID and minimizes reliance on fragmented specialty care. Both PCPs and experts emphasized the importance of setting clear expectations with patients regarding referral timelines and the role of specialists in a transparent and patient-focused way. They suggested training that equips PCPs with strategies and tools to ask patients about their reasons for wanting a specialist referral, followed by open communication to ensure referral or consultation with the most appropriate specialist when needed. IWLC would like their PCPs to know which specialists have experience treating the condition. However, PCPs and experts acknowledged that many specialists lack this training and would likely manage symptoms the same regardless of origin. While PCPs are familiar with treating symptoms themselves, they expressed interest in identifying the most relevant specialists for referrals and understanding the rationale for these referrals (e.g., cardiology for palpitations). “I tend to try to be very upfront with patients when I know they're going to have a wait for something that I know is really important and impacting their life… I will often like schedule some telehealth clinics in between. Just so we can connect, I can make sure [there are] no dramatic changes again, allowing them to be heard and feel like they're not just being dropped into nowhere for 4 to 5 to 6 months.” (PCP) “What's the reason for the referral or for the referring question, and I think it's good to pose that both to the PCP and the patient, what's your motivation for the referral? And that's not to challenge a patient. But just say, is it because you want a second opinion? Is it because you're anxious that something's being missed? And then same thing for the PCP - rather than just referring for Long COVID, I would pose having a specific question in mind. ...and they might have different reasons for referring also.” (Expert) “It feels like to me anytime I talk to a specialist, since my symptoms aren't off the charts, then they don't take it quite as seriously and then it's dismissed. And so, how do I get the care in between somebody who has severe heart failure versus somebody who's gotten POTS or really has a high heart rate because of Long COVID.” (Individual with LC) Provide guidance and appropriate documentation for work, school accommodations, and disability evaluations, collaborating with other healthcare professionals as needed to deliver comprehensive and effective support for patients. IWLC understood thorough documentation to be critical to their disability claims and accommodation requests, as it is “one of the only things patients cannot do on their own.” While PCPs are experienced in completing these requests, they noted that examples of recommended language and objective criteria specific to Long COVID would be helpful, particularly given symptom uncertainty and the absence of definitive diagnostic tools. Experts further advised collaborating with other healthcare professionals (e.g., physical therapy, occupational therapy, speech-language pathology, vocational rehabilitation) to deliver comprehensive guidance, documentation, and accommodation as an interprofessional team. “Some of these other things I could research on my own… but [SSDI documentation] is something I can't do on my own. There's nobody else who can do it if your medical provider isn't willing to do it.” (Individual with LC) “The kind of disability paperwork process can be one that you feel like you want to be able to advocate for your patients. And it's also like this kind of sort of to me a little bit opaque process. ... the challenge with Long COVID is some of the uncertainty and the lack of diagnostic tools that we have in filling out some of the paperwork where there's a lot of requests sometimes for like very specific information and diagnostic information.” (PCP) ACGME Domain: Interpersonal and Communication Skills Core Competencies Stakeholder Perspectives Quotes Foster patient- and caregiver-centered, affirming communication that supports shared decision-making and builds a positive therapeutic relationship. Community and family members acknowledged that “caring” communication can take different forms depending on the audience, so PCPs must use their judgment to determine how best to provide information and validation in each individual case. PCPs use patient-centered communication skills in all aspects of care they provide, but they would appreciate Long COVID-specific examples of how to validate patients, respond to emotions, and discuss pathophysiology to build rapport. Such examples could also help PCPs reflect on their own emotions and convey to patients that they are fully prioritizing their care within the constraints of primary care (e.g., limited visit time). Family members expressed a desire to be included in treatment discussions so they can provide consistent, long-term support. While patient self-management of symptoms is ideal, the complexities of Long COVID make it challenging to navigate alone. As with other chronic illnesses, community and caregiver involvement can be critical for treatment adherence and improved health outcomes. “I recall one of the learnings I've had through this really trying to support patients, or helping them not feel guilty that they can't train their fatigue away and actually tell them … Don't push it too hard… And just that reassurance helps them with, you know, that can come with that as if they're not trying hard enough.” (PCP) “I think having a family member or some sort of guardian communication tool would be helpful... And I think both this is like the care team themselves are learning and then communicating it to the person impacted. That's a lot of information. I'm also just a fan of having somebody to support me with all of the information I get, because I'm like, wait, what did they say?” (Family member) “The better the support system that exists, the better. That you know family, friends, whoever the support system is, can help reinforce support. you know, following doctor's orders and dealing with a chronic condition successfully. So I do think that universally dealing with chronic illness is more successful when it's a team sport.” (Community member) Acknowledge uncertainties surrounding Long COVID prognosis while providing clear communication and ongoing support to patients and their families. Experts felt that PCPs need strategies for discussing the uncertain prognosis of Long COVID with patients in ways that preserve hope without creating unrealistic expectations, and to help patients understand realistic treatment goals (e.g., 5-10% improvement) within the broader journey of living with a chronic illness. Per PCPs, part of providing clear communication is explaining the referral process and setting realistic expectations for specialist wait times. PCPs recommend scheduling follow-up visits during this waiting period to ensure patients continue to feel supported where possible. “I think it's also okay to say to the patient ‘we're all learning about this as we go. Even the experts are learning right now about this.’ And just sort of an acknowledgement of, you know, we don't know everything yet. We're doing our best. We're trying to work with the information that we have, and we will keep communicating that as we go.” (PCP) “One thing that I still struggle with is prognosis... And if anyone has any magic language of how to tell someone that I have no idea how long this is gonna last for you, it could be a month or 6 years, and you know that's really hard. But I think that PCPs are going to be asked that, and they need to have some sort of a strategy to respond that doesn't either crush the patient's hope, or give them unrealistic expectations.” (Expert) Strengthen the therapeutic relationship through trauma-informed care that emphasizes shared-decision making, validation of physical symptoms, and recognition of the emotional impact of Long COVID. PCPs reported receiving training on trauma-informed care, usually integrated into other educational contexts. A Long COVID-specific application of this approach would help them listen actively and demonstrate compassion through targeted verbal and nonverbal cues that patients find reassuring. PCPs and experts agreed that validating physical symptoms can support rapport and trust building. This can also open the door to a discussion on how emotions and mental health can influence physical symptoms, without attributing symptoms to psychogenic origins. This is a critical distinction as many IWLCs and PCPs describe prior experiences in which healthcare providers dismissed patients’ physical symptoms as purely psychological, leaving them feeling invalidated and reluctant to discuss less “visible” symptoms with their PCPs. “And it's [Long COVID] often dismissed, as it's a mental health problem. And so...to make sure that there is this validation is first, and then that understanding that things are very related to each other and that physical symptoms, it's not that it's all in your head, but that it's aggravated or triggered by what's happening with our emotions and our mental health... it's easier to begin to have that conversation when you have started by validating their symptoms and recognizing that these are real, and these are a lot of physical symptoms, and then beginning to educate and assess even more about mental health needs… but as a PCP, it's my role to be able to identify [mental health]...I would just say that I think it's easier to prioritize the mental health support if one has communicated and validated symptoms first.” (PCP) “This is all sort of trauma informed care... And so from a PCP perspective, I think that trauma informed care sort of gets mentioned. And but I think that actually being trained in how do you address that? ...the value of saying, ‘I'm so sorry that you're feeling so unwell’ is a tremendous value to a patient. And so I think that those kinds of skills that you know… I've found that to be very valuable in my basic PCP interactions with people, and especially with people with Long COVID,” (PCP) “I actually come to that mental health component of things last after their long list of symptoms...I think I try to focus on the other symptoms first as a way to build trust and validation, but also still circle back to mental health. But I tend to do that later on in the conversation. And I think that's just something small that I've learned through experience to build trust. ” (Expert) ACGME Domain: Practice-based Learning and Improvement Core Competencies Stakeholder Perspectives Quotes Identify trusted resources—such as consensus statements, clinical practice guidelines, and evidence-based recommendations—and critically appraise the literature to guide shared decision-making discussions, especially in areas where medical evidence is conflicting, inconclusive, or limited. PCPs reported that patients often bring information on Long COVID (e.g., treatments) to appointments, prompting them to conduct their own research to prepare for productive discussions about risks, typical use of treatments, and potential publishing biases – ultimately helping patients decide whether to proceed with an intervention. They expressed interest in training on how to discuss negative or null findings when patients request certain treatments, as well as guidance on locating the most current and reliable Long COVID research. Access to accurate, timely data would enhance shared decision-making and increase PCPs’ comfort with prescribing. “I've had multiple patients present a lot of that information and be like, ‘Hey, I really want to try XY, or Z. I've read about this or the news,’ so I always ask them to send those things to me so I can read over them and maybe do some of my own research. And then we have a discussion about that... what would the risk be? Whether you know the medication might be typically used for? ... I feel like I as long as I'm having that discussion with them, and they would like to try it. It doesn't seem, you know, harmful. ” (PCP) ACGME Domain: Professionalism Core Competencies Stakeholder Perspectives Quotes Reflect on and address personal biases to ensure equitable, compassionate, and patient-centered care for individuals with Long COVID. Family and community members voiced concern about the current public health issue involving clinicians and patients in some geographic areas of the United States not recognizing the existence of Long COVID, leading to gaps in necessary care. PCPs requested that training incorporate time or tools for reflecting on personal emotions and/or biases about COVID-19 and Long COVID to help ensure equitable and appropriate care for all patients. “I think it is helpful that sometimes, too, to have space or toolkits to kind of like remind providers to kind of like, reflect on their own emotions, and maybe biases that might come in and so I don't know if there are specific toolkits kind of for that, too.” (PCP) “I'm a caregiver for my mother, who has been grappling with long covid symptoms for the last like 3 years. …It's hard to be a caregiver when both the person experiencing these symptoms doesn't believe that they have the illness...Her doctor's like ‘Long COVID is not real. You have depression, or you're going through menopause. So that's why you're having these muscle spasms.’ But it's really challenging. Because I will try to have a conversation with [the] physician. and it's just like I'm shut down as a caregiver, and so it makes it hard to advocate.” (Family member) Support equitable standards of care to ensure patients with Long COVID receive consistent and high-quality management, regardless of a clinician's specialized training or experience in Long COVID, advocating on an individual patient level and within the healthcare system as appropriate. Family and community members stated that information on Long COVID should be readily accessible to all clinicians, not just those specifically trained to manage the condition. Providing a toolkit or “cheat sheet” for clinicians and their clinics may help disseminate information on current research, symptoms, and treatments to a broader audience, particularly if clinics display patient-friendly infographics for patients and caregivers. PCPs expressed interest in having local resource lists they could use to connect patients with Long COVID to holistic care options. “I think that there are providers out there who have very best intentions and it's not that they don't believe in long covid. They certainly do, but maybe don't have a full toolkit, or are totally up on all the evidence-based research to be able to really tackle symptoms and side effects from Long COVID with a full arsenal...I think that's where the equity piece comes in is if someone seeks care in a clinic where the provider is doing nothing but Long COVID visits all day their toolkit and their experience level is going to be completely different than potentially a primary care provider who is seeing patients for all kinds of things at all ages all day long, and then has to suddenly pivot, and all of a sudden become a Long COVID expert...I think my greatest concern is making sure that patients receive the same level of care.” (Community member) Additional Declarations No competing interests reported. Supplementary Files Appendix1NeedsAssessmentSurvey.pdf GAPManuscriptV2FINALMar2026SupplementaryMaterials.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 07 May, 2026 Reviews received at journal 14 Apr, 2026 Reviewers agreed at journal 30 Mar, 2026 Reviewers invited by journal 27 Mar, 2026 Editor assigned by journal 25 Mar, 2026 Editor invited by journal 20 Mar, 2026 Submission checks completed at journal 19 Mar, 2026 First submitted to journal 19 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9098407","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":614839928,"identity":"76934ceb-4c9d-4c2f-9076-e4480d2b8a8b","order_by":0,"name":"Rachel Geyer","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAApUlEQVRIiWNgGAWjYPACGzApQYqWNNK1HCZBi7x7j+Hjyj3nEzccYD54m4cYLYZnzhgbnnl2G6iFLdmaOC0zcswkGw7cTtx2gMdMmjgt89+Y/2w4cA6ohf8bcVrkJXjMGBsOHADZwkacFgOetGKgw5KN9x9mM7acQ5Qt7Yc3fmw4YCc7s7354Y03RNlygMMAwmImRjnYlgb2B8SqHQWjYBSMgpEKANkpNAg1baucAAAAAElFTkSuQmCC","orcid":"","institution":"University of Washington","correspondingAuthor":true,"prefix":"","firstName":"Rachel","middleName":"","lastName":"Geyer","suffix":""},{"id":614839933,"identity":"5ac167b4-c5fc-4f3f-9c62-dfe6d6c7386b","order_by":1,"name":"Kristen O’Loughlin","email":"","orcid":"","institution":"University of Washington","correspondingAuthor":false,"prefix":"","firstName":"Kristen","middleName":"","lastName":"O’Loughlin","suffix":""},{"id":614839934,"identity":"bc9c0332-9723-4eda-84a1-90959a898fbb","order_by":2,"name":"Cassie Theobald","email":"","orcid":"","institution":"University of 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22:53:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9098407/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9098407/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105904807,"identity":"02d449fc-61fd-452a-bb59-ebf081eee687","added_by":"auto","created_at":"2026-04-01 10:10:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1069419,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9098407/v1/985e95c2-23e6-460f-962f-b1032ab0068e.pdf"},{"id":105852362,"identity":"83832b98-c6dc-4663-a57c-272ccd6e4384","added_by":"auto","created_at":"2026-03-31 20:14:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":160885,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1NeedsAssessmentSurvey.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9098407/v1/04aeea52911be7df50f15757.pdf"},{"id":105852363,"identity":"8c5c6511-4d48-47d9-8c74-9a9690343692","added_by":"auto","created_at":"2026-03-31 20:14:36","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":87727,"visible":true,"origin":"","legend":"","description":"","filename":"GAPManuscriptV2FINALMar2026SupplementaryMaterials.docx","url":"https://assets-eu.researchsquare.com/files/rs-9098407/v1/30a4e008d12c106265756880.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Bridging the Gap in Long COVID Care: Identifying Core Competencies for Primary Care Curriculum Development and Evaluation","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLong COVID represents a significant and multifaceted healthcare challenge, affecting up to 30% of the population who have recovered from the acute phase of COVID-19.\u003csup\u003e1\u0026ndash;3\u003c/sup\u003e Patients often experience a diverse range of symptoms, including fatigue, cognitive dysfunction, and respiratory issues, which can severely impact their quality of life.\u003csup\u003e4\u003c/sup\u003e Primary care clinicians (PCPs) face challenges managing these complex symptom presentations, highlighting the need for coordinated care strategies and supportive resources.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDespite the growing prevalence of Long COVID, a notable gap exists in specialized training for clinicians focused on the comprehensive management of this condition.\u003csup\u003e5\u003c/sup\u003e Existing educational programs often do not incorporate the necessary interdisciplinary and biopsychosocial approaches required for effective Long COVID care.\u003csup\u003e6,7\u003c/sup\u003e Furthermore, there is no established set of \u0026quot;core competencies\u0026quot; for managing Long COVID, which can create confusion among clinicians about critical elements of care. PCPs - often the first point of contact for these patients - would benefit from a skills-based framework that emphasizes evidence-based diagnostic and management strategies and brings together multidisciplinary expertise.\u003c/p\u003e\n\u003cp\u003eTargeted needs assessments are a\u0026nbsp;foundational element of curriculum development\u003csup\u003e8\u003c/sup\u003e and help ensure that training aligns closely with the real-world needs of both clinicians and patients. Additionally, core competencies provide a framework for targeting outcomes at the level of both clinician behaviors and health system needs.\u003csup\u003e8\u003c/sup\u003e Integrating core competencies into curricula ensures that training is outcomes-defined and competency-based, aligning with best practices in medical education.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo date, no consensus-driven competency framework exists to guide PCP training in Long COVID care, and stakeholder-informed evidence to shape such training is lacking. Addressing this gap is essential to ensure that future educational initiatives are relevant, comprehensive, and grounded in the realities of primary care practice. Thus, as an initial step in developing a Long COVID certificate course for PCPs to address critical gaps in clinician training, this mixed-methods study aimed to (1) conduct a targeted needs assessment through surveys and focus groups with key stakeholders using a Delphi process to identify knowledge gaps and define essential learning priorities; and (2) establish core competencies for Long COVID care to guide future education and training.\u003c/p\u003e"},{"header":"Methods","content":"\u003ch2\u003eStudy Design\u003c/h2\u003e\n\u003cp\u003eThis mixed-methods study employed Delphi methodology to systematically gather and synthesize input from Long COVID stakeholders through surveys and focus groups. Stakeholders included PCPs, individuals with Long COVID (IWLC), national Long COVID experts (e.g., clinicians in dedicated Long COVID clinics), family and community members. Demographic data collection was intentionally limited due to the anonymity inherent in the Delphi method. The study team is affiliated with a Long COVID clinic within an academic medical center, which provided clinical and research expertise that informed the study design and stakeholder engagement process.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis project was approved by the University of Washington Human Subjects Division (STUDY00022894).\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eRecruitment\u003c/h2\u003e\n\u003cp\u003eWe recruited PCPs and Long COVID experts through convenience sampling based on recommendations from members of this study team and word-of-mouth. Many of the Long COVID experts came from the AHRQ Long COVID Collaborative that the UW Long COVID Clinic is also a member. A Long COVID clinic staff member, not affiliated with the study, contacted individuals with Long COVID, including those on the waitlist who were not officially patients of the clinic. Interested individuals provided their contact information for follow-up by the study coordinator. We also recruited family members using snowball sampling by asking patients to share the study contact details with their family members if they were interested in participating. All participants completed an online informed consent process before taking part.\u003c/p\u003e\n\u003ch2\u003eData Collection\u003c/h2\u003e\n\u003ch4\u003eQuantitative\u003c/h4\u003e\n\u003cp\u003eParticipants initially completed a 30-minute survey to rate or rank barriers, facilitators, skillsets, and training topics they believed should be included in a Long COVID training program (Appendix 1). The survey was created by the study team with input from the clinicians and staff within the UW Long COVID Clinic. Surveys were tailored to minimize jargon, with specialized questions for clinicians on topics like laboratory testing, interdisciplinary collaboration, and patient scenarios. Clinicians were also asked to provide their specialty, type of practice, and years in practice. Participants were asked to complete a second survey after the study team drafted core competencies to rate agreement, disagreement, or suggested revisions of a draft list of core competencies.\u003c/p\u003e\n\u003cp\u003eAt the conclusion of the study, participants had the option to provide demographic information, including their age, sex, gender, and race. \u0026nbsp;Data was securely collected and stored using REDCap (Research Electronic Data Capture).\u003csup\u003e9\u003c/sup\u003e\u003c/p\u003e\n\u003ch4\u003eQualitative\u003c/h4\u003e\n\u003cp\u003eParticipants were invited to one-hour Zoom-based focus groups facilitated by a trained qualitative researcher (REG). Each focus group included participants from the same stakeholder type (e.g., PCPs). These unstructured discussions explored survey findings and addressed areas of disagreement among stakeholder types. Key findings from focus groups were analyzed by the study team and informed the drafting of core competencies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants also responded to open-text items in the initial and follow-up surveys.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAnalysis\u003c/h2\u003e\n\u003ch4\u003eQuantitative\u003c/h4\u003e\n\u003cp\u003eSurvey data was exported into Excel\u003csup\u003e10\u003c/sup\u003e and analyzed using descriptive statistics and means to identify trends and prioritize key topics across stakeholder types (Appendix 2). Differences of means were calculated to highlight key disagreements between stakeholder types. \u0026nbsp;\u003c/p\u003e\n\u003ch4\u003eQualitative\u003c/h4\u003e\n\u003cp\u003eOpen-text responses to surveys were reviewed by REG and CT and summarized based on participant groups.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFollowing each qualitative focus group, REG and CT created summary templates of each discussion. These were drafted based on notes from the focus group and then reviewed against the recording to ensure they comprehensively captured all key takeaways. The templates were reviewed and discussed with REG, CT, and KOL. This method is well suited for projects that require fast data extraction and analysis. The focus group audio was transcribed via Zoom to provide additional quotes and references for the analysis.\u003c/p\u003e\n\u003cp\u003eUsing the summary templates, the research team completed a matrix analysis (Appendix 3).\u003csup\u003e11\u003c/sup\u003e This method allows for rapid analysis and interpretation of qualitative data and aligned well with our study design, as each focus group represented a distinct stakeholder type, allowing for structured cross-group comparisons across domains. We added a final row capturing researcher reflections on each domain, informed by our understanding of Long COVID and the broader healthcare system. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInitial participant feedback on the draft core competencies was reviewed by the project team and assessed for (1) alignment with the project goal of PCP training and (2) feasibility of implementation. This was followed by an iterative review process incorporating additional participant suggestions and edits. The cumulation of these steps was a finalized set of 13 core competencies, outlined in the results section.\u003c/p\u003e"},{"header":"Results","content":"\u003ch2\u003eParticipants\u003c/h2\u003e\n\u003cp\u003eThe project recruited 26 participants across all the groups (Table 1). PCPs included a mix of internal and family medicine; two were from community practices. Long COVID experts varied in specialties including pulmonary care, critical care, and integrative medicine. Both PCPs and Long COVID experts had similar years in practice with a combined average of 15 years (range 1-36 years). The participants were primarily white (69%) and ranged in age from 35 to 54 years old. We had 14 (64%) participants identify as women, 6 (27%) as men, and 2 (9%) as nonbinary.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eCore Competencies\u003c/h2\u003e\n\u003cp\u003eCompetencies aligned with the six Accreditation Council for Graduate Medical Education (ACGME)\u003csup\u003e12\u003c/sup\u003e domains were developed in response to stakeholder input. Complete competency statements and stakeholder perspectives with supporting quotes are presented in Table 2. Below, we summarize cross-group perspectives relevant to each domain.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003ePatient Care \u0026nbsp;\u003c/h3\u003e\n\u003cp\u003e\u003cem\u003eDiagnose Long COVID, recognize its common and atypical presentations, manage co-occurring conditions, and develop individualized treatment plans using pharmacologic and non-pharmacologic strategies with\u0026nbsp;appropriate referral\u0026nbsp;when needed.\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eStakeholders emphasized the importance of early recognition and diagnostic confidence as foundational challenges. IWLC highlighted the importance of clinicians who take symptoms seriously and can identify atypical presentations, whereas PCPs expressed uncertainty due to the absence of objective diagnostic criteria. Managing co-occurring conditions and coordinating care across specialties were viewed as central roles for PCPs. All groups endorsed individualized, multimodal care plans that integrate pharmacologic and non-pharmacologic strategies, with careful consideration of PEM (Post-Exertional Malaise).\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eMedical Knowledge\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003e\u003cem\u003eUnderstand current evidence on Long COVID pathophysiology and proposed mechanisms and apply this knowledge to inform patient care and clinical decision-making.\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFamily members wanted clinicians to understand the pathophysiology so they could better support their loved ones. IWLC prioritized practical diagnosis and treatment over mechanism-focused explanations. PCPs requested concise updates on mechanisms and emerging science to strengthen patient education.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eSystems-Based Practice\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003e\u003cem\u003eDeliver coordinated, patient-centered care through thoughtful referral stewardship and provide thorough documentation for work, school, and disability needs in collaboration with other professionals.\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePCPs and experts emphasized the importance of transparent communication regarding referrals, including realistic wait times and the rationale for specialist involvement. IWLC stressed the importance of accurate documentation for disability and accommodation needs. Experts recommended coordinated, interdisciplinary documentation processes.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eInterpersonal and Communication Skills\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003e\u003cem\u003eUse affirming, patient- and caregiver-centered communication, address prognostic uncertainty clearly, and apply trauma-informed care that\u0026nbsp;validates\u0026nbsp;physical symptoms and acknowledges emotional impacts.\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eValidation, empathy, and shared decision-making were central themes across groups. PCPs sought Long COVID\u0026ndash;specific examples for validating symptoms, addressing emotional needs, and involving family members. Experts noted the importance of discussing prognosis uncertainty while maintaining realistic hope. Trauma-informed approaches, such as avoiding psychogenic attributions, were viewed as essential.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003ePractice-Based Learning and Improvement\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003e\u003cem\u003eIdentify\u0026nbsp;trusted resources and critically evaluate emerging Long COVID evidence to guide shared decision-making, especially when findings are limited, conflicting, or inconclusive.\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePCPs reported that patients frequently bring emerging research and treatment ideas to appointments. Both PCPs and Experts emphasized the need for training in critical appraisal, navigating limited or conflicting evidence, and discussing negative findings within shared decision-making conversations.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eProfessionalism\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003e\u003cem\u003eReflect on personal biases and promote\u0026nbsp;equitable, consistent, high-quality Long COVID care across clinicians and healthcare settings.\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eStakeholders stressed the importance of addressing personal biases about COVID-19 and Long COVID to ensure equitable care. PCPs endorsed reflective practice tools and expressed interest in standardized clinical resources to promote consistent care across clinicians. \u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis mixed-methods study identified core competencies for Long COVID care in primary care settings through a targeted needs assessment that engaged PCPs, IWLC, family and community members, and interdisciplinary Long COVID experts. Using surveys, focus groups, and a modified Delphi process, we identified key knowledge gaps and educational priorities to inform future training initiatives. Findings underscored the complexities associated with diagnosing and managing Long COVID amid clinical uncertainty, heterogeneous symptom presentations, and limited evidence-based guidance. Stakeholders strongly agreed that PCPs must be able to recognize and validate diverse symptom presentations, develop individualized and coordinated care plans, and communicate effectively about prognosis and care expectations. Participants further emphasized that trauma-informed and patient-centered approaches are critical for building therapeutic alliances, supporting shared decision-making, and addressing the psychosocial impact of Long COVID.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiagnostic Uncertainty and Symptom Recognition\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmbiguity around Long COVID diagnosis has been a persistent challenge since the condition first emerged in 2020.\u003csup\u003e13,14\u003c/sup\u003e Despite the release of the 2024 NASEM (National Academies of Sciences, Engineering, and Medicine) working definition\u003csup\u003e15\u003c/sup\u003e many PCPs in this study expressed discomfort diagnosing a condition without objective criteria. Experts emphasized the need to apply the NASEM definition flexibly, using clinical judgement to validate patients\u0026rsquo; experiences and guide care in the absence of confirmatory tests. This view is consistent with international guidelines, which uniformly note that Long COVID is often characterized by unremarkable, and frequently costly, diagnostic work-ups, and recommend patient-centered evaluation and shared decision-making as central to diagnostic practice.\u003csup\u003e16\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eAcross stakeholder groups, recognizing both common and atypical symptom presentations emerged as a core competency. IWLC particularly emphasized the importance of being believed when describing less visible or poorly understood symptoms -an insight reinforced by qualitative studies demonstrating that supportive, validating clinical encounters are essential for those navigating Long COVID.\u003csup\u003e17\u003c/sup\u003e This aligns with guidelines that advocate a holistic assessment approach \u0026ndash; integrating symptom monitoring, functional evaluation, and clinical judgement, while avoiding over-reliance on conventional testing.\u003csup\u003e16,18\u003c/sup\u003e The\u0026nbsp;American Academy of Physical Medicine and Rehabilitation (AAPM\u0026amp;R) further emphasizes the importance of a comprehensive, multidisciplinary approach tailored to the complex and individualized needs of people with Long COVID.\u003csup\u003e18\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIndividualized Treatment Planning and Risk Management\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCompetencies also reflected the importance of tailoring management to the heterogeneity of Long COVID. While clinicians often prioritized pharmacologic interventions, IWLC emphasized non-pharmacologic strategies, patient education, and minimizing potential risks such as polypharmacy.\u0026nbsp;A cross-sectional study found that 11.7% of people with Long COVID experienced polypharmacy and 25% were at risk of drug\u0026ndash;drug interactions, reinforcing the need for vigilant symptom management and medication oversight.\u003csup\u003e19\u003c/sup\u003e There was\u0026nbsp;strong consensus on the importance of identifying PEM, which affects approximately 25% of people with Long COVID, and on ensuring cautious use of exercise-based therapies, as these may be contraindicated for some patients.\u003csup\u003e20\u003c/sup\u003e These results highlight the need for competency development not only in treatment selection but also in risk identification and mitigation to ensure individualized and safe care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCommunication and Evidence Appraisal\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe psychological toll of Long COVID was a recurring theme and is consistent with previous literature; many people with Long COVID reported experiences of stigma, dismissal, or medical trauma.\u003csup\u003e21\u003c/sup\u003e As a result, communication competencies emphasize empathy, transparency, and acknowledgement of uncertainty, shared decision-making, and a commitment to health equity. The American Academy of Family Physicians (AAFP) guidance supports this approach, recommending alignment with patient values, openness about uncertainty, and use of the Agency for Healthcare Research and Quality (AHRQ) SHARE model.\u003csup\u003e22,23\u003c/sup\u003e Participants also noted that patients often arrive with their own research or treatment ideas, underscoring the need for PCPs to critically evaluate emerging evidence. Engaging patients in collaborative interpretation was viewed as an essential skill for maintaining trust in the context of evolving and sometimes conflicting guidance and is consistent with practice guidelines from the National Institute for Health and Care Excellence.\u003csup\u003e24\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplications for Education, Curriculum, and Practice\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study presents a consensus-driven competency framework to guide education and training for PCPs in Long COVID care. Alignment with ACGME domains facilitate integration into curricula and professional development initiatives, while also providing a foundation for clinical leaders and policymakers to develop tools and resources. Given the ongoing\u0026nbsp;evolving science surrounding Long COVID, training should emphasize flexibility, collaborative learning with patients and caregivers, and relational care. Importantly, the study engaged multiple stakeholder groups, including PCPs, Long COVID specialists, IWLC, and family and community members, through the Delphi process, ensuring that the competencies were shaped by both clinical expertise and lived experience. This diverse input strengthened their relevance and positioned the framework to support models of care that extend beyond a purely biomedical focus.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations and Future Directions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study represents the first systematic investigation into key knowledge gaps and educational priorities to guide future training initiatives in Long COVID care. A notable strength was the high level of engagement across methods, with 80% of survey respondents also participating in focus groups, enhancing consistency of input across phases. However, limitations should be noted. Although the sample size met Delphi standards, it may not fully capture all regional, cultural, or practice-setting variations in Long COVID care. Stakeholders were predominantly white, limiting racial and ethnic diversity, and few PCPs were from community practices, reducing perspectives from rural or non-academic settings. In addition, because Long COVID clinics are primarily affiliated with academic centers, the Long COVID specialists in our sample were drawn mainly from these settings, potentially skewing perspectives toward academic practice norms. The range of specialties represented was intentionally narrow, reflecting our primary focus on primary care clinicians and Long COVID specialists, along with other key stakeholder groups identified by design; however, this may have excluded perspectives from additional relevant disciplines.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFuture research should evaluate the real-world implementation of these competencies through formal curricula and their impact on clinician confidence, care coordination, and patient outcomes. Additional studies are also needed to assess adaptability of the competencies across diverse primary care settings and to rigorously evaluate educational initiatives - such as the planned Long COVID certificate course - at the clinician, patient, and system levels.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study presents a structured, consensus-driven framework of competencies for PCPs caring for individuals with Long COVID, developed through a modified Delphi process that incorporated various lived and clinician perspectives. The competencies reflect both the evolving nature of Long COVID and the central role of primary care in delivering longitudinal, relationship-based care. Embedding these competencies in Long COVID education and professional development initiatives can ensure training remains competency-based, outcomes-focused, aligned with best practices in medical education and considers key stakeholder opinions. Ultimately, this standardized framework offers practical direction for improving primary care quality and patient outcomes for this emerging multisystem health challenge.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAAPM\u0026amp;R American Academy of Physical Medicine and Rehabilitation\u003c/p\u003e\n\u003cp\u003eAAFP American Academy of Family Physicians\u003c/p\u003e\n\u003cp\u003eACGME Accreditation Council for Graduate Medical Education\u003c/p\u003e\n\u003cp\u003eAHRQ Agency for Healthcare Research and Quality\u003c/p\u003e\n\u003cp\u003eCOVID-19 Coronavirus Disease 2019\u003c/p\u003e\n\u003cp\u003eIWLC Individuals with Long COVID\u003c/p\u003e\n\u003cp\u003eLC Long COVID\u003c/p\u003e\n\u003cp\u003eNAPCRG North American Primary Care Research Group\u003c/p\u003e\n\u003cp\u003eNASEM National Academies of Sciences, Engineering, and Medicine\u003c/p\u003e\n\u003cp\u003ePCPs Primary Care Clinicians\u003c/p\u003e\n\u003cp\u003ePEM Post-Exertional Malaise\u003c/p\u003e\n\u003cp\u003eREDCap Research Electronic Data Capture\u003c/p\u003e\n\u003cp\u003eUW University of Washington\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics Approval and Consent to Participate\u003c/h2\u003e\n\u003cp\u003eThis project was conducted in accordance with the Declaration of Helsinki and approved by the University of Washington Human Subjects Division (STUDY00022894). All participants reviewed and signed an informed consent form prior to any study procedures occurring.\u003c/p\u003e\n\u003ch2\u003eConsent for Publication\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003eAvailability of Data\u003c/h2\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to potentially personal identifying information included in qualitative and quantitative datasets but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch2\u003eCompeting Interests\u003c/h2\u003e\n\u003ch2\u003eThe authors declare no competing interests.\u003c/h2\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis project was funded in part under grant number 1U18HS029905-01 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services (HHS).\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAuthors Contributions\u003c/h2\u003e\n\u003cp\u003eREG, KMO, CT, DR, JB, AC, JF, and NLG conceptualized and designed the project and interpreted the data. REG, KMO, and CT analyzed the data and drafted the manuscript. DR, JB, AC, JF, and NLG revised the manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThis project was funded in part under grant number 1U18HS029905-01 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services (HHS). The authors are solely responsible for this document\u0026apos;s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of HHS.\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026rsquo; Information\u003c/h2\u003e\n\u003cp\u003eThe authors included on this manuscript are current clinicians or staff working in the UW Medicine Long COVID Clinic.\u0026nbsp;\u003cbr clear=\"all\"\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLong COVID. 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A multidisciplinary review of long COVID to address the challenges in diagnosis and updated management guidelines. \u003cem\u003eAnn Med Surg (Lond)\u003c/em\u003e. 2025;87(4):2105-2117. doi:10.1097/MS9.0000000000003066\u003c/li\u003e\n\u003cli\u003eNational Academies of Sciences, Engineering, and Medicine. A long COVID definition: A chronic, systemic disease state with profound consequences. Published online July 9, 2024. doi:10.17226/27768\u003c/li\u003e\n\u003cli\u003e\u003cem\u003eCOVID-19 Rapid Guideline: Managing the Long-Term Effects of COVID-19\u003c/em\u003e. National Institute for Health and Care Excellence; 2024.\u003c/li\u003e\n\u003cli\u003eHawke LD, Nguyen ATP, Sheikhan NY, et al. Swept under the carpet: a qualitative study of patient perspectives on Long COVID, treatments, services, and mental health. \u003cem\u003eBMC Health Serv Res\u003c/em\u003e. 2023;23(1):1088. doi:10.1186/s12913-023-10091-9\u003c/li\u003e\n\u003cli\u003eCheng AL, Herman E, Abramoff B, et al. Multidisciplinary collaborative guidance on the assessment and treatment of patients with Long COVID: A compendium statement. \u003cem\u003ePM R\u003c/em\u003e. 2025;17(6):684-708. doi:10.1002/pmrj.13397\u003c/li\u003e\n\u003cli\u003eMichael HU, Brouillette MJ, Fellows LK, Mayo NE. Medication utilization patterns in patients with post-COVID syndrome (PCS): Implications for polypharmacy and drug-drug interactions. \u003cem\u003eJ Am Pharm Assoc (2003)\u003c/em\u003e. 2024;64(4):102083. doi:10.1016/j.japh.2024.102083\u003c/li\u003e\n\u003cli\u003ePouliopoulou DV, Hawthorne M, MacDermid JC, et al. Prevalence and impact of postexertional malaise on recovery in adults with post-COVID-19 condition: A systematic review with meta-analysis. \u003cem\u003eArch Phys Med Rehabil\u003c/em\u003e. 2025;106(8):1267-1278. doi:10.1016/j.apmr.2025.01.471\u003c/li\u003e\n\u003cli\u003eEberhardt J, Gibson B, Portman RM, et al. Psychosocial aspects of the lived experience of long COVID: A systematic review and thematic synthesis of qualitative studies. \u003cem\u003eHealth Expect\u003c/em\u003e. 2024;27(5):e70071. doi:10.1111/hex.70071\u003c/li\u003e\n\u003cli\u003eAgency for Healthcare Research and Quality. The SHARE Approach. October 2024. Accessed September 2025. https://www.ahrq.gov/sdm/share-approach/index.html\u003c/li\u003e\n\u003cli\u003eAmerican Academy of Family Physicians. Talking to Patients About Long COVID: Guidance on Shared Decision Making. Published online 2025. https://www.aafp.org/dam/AAFP/documents/patient_care/covid19/long-covid-discussion.pdf\u003c/li\u003e\n\u003cli\u003eRaleigh MF, Nelson MD, Nguyen DR. Shared decision-making: Guidelines from the national institute for health and care excellence. \u003cem\u003eAm Fam Physician\u003c/em\u003e. 2022;106(2):205-207. https://www.ncbi.nlm.nih.gov/pubmed/35977119 \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1. Participant demographics\u003c/p\u003e\n\u003cp\u003eTable 1a. Stakeholder type breakdown\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\u003cstrong\u003eSurvey\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\u003cstrong\u003eFocus Group\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003eIndividuals with long COVID\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e8\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e6 (75%)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003eFamily members\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e2\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e2 (100%)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003eCommunity member\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e1\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e1 (100%)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003ePrimary Care Clinicians\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e9\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e7 (78%)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003eLong COVID expert\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e6\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e5 (83%)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\u003cstrong\u003eTotals \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\u003cstrong\u003e26\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\u003cstrong\u003e21 (80%)\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 1b. Participant optional self-reported demographics\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003en\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e%\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e18-24\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e1\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e3.8\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e25-34\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e3\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e11.5\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e35-44\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e5\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e19.2\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e45-54\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e8\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e30.8\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e55-65\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e3\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e11.5\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e65+\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e2\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e7.7\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003eMissing/Not reported\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e4\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e15.4\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\u003cstrong\u003eGender identity\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003eWoman\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e14\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e53.8\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003eMan\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e6\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e23.1\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003eNonbinary\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e2\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e7.7\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003eMissing/Not reported\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e4\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e15.4\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\u003cstrong\u003eRace/ethnicity\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003eAfrican American/Black\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e2\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e7.7\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003eAsian\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e5\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e19.2\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003eWhite\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e18\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e69.2\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003eOther\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e2\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e7.7\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003eMissing/Not reported\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e4\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e15.4\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\u003cstrong\u003eTypes of clinical practice*\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003eAcademic\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e13\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e86.7\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003eCommunity\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e2\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e13.3\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\u003cstrong\u003eYears in practice*\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003eMean\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e15\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003eRanges\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e1-36\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\u003cstrong\u003eSpecialties*^\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003eInternal medicine\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e4\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e26.6\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003eFamily medicine\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e4\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e26.6\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003ePulmonology\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e3\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e20.0\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003eCritical care\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e2\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e13.3\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003eIntegrative medicine\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e2\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e13.3\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003eOther\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e3\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e20.0\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*only asked of PCPs and Long COVID experts; n=15\u003c/p\u003e\n\u003cp\u003e^more than one specialty could be indicated; total will be over 100%\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2. Core Competencies for Primary Care Management of Long COVID\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"899\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 899px;\"\u003e\u003cstrong\u003eACGME Domain:\u0026nbsp;Patient Care\u003c/strong\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003eCore Competencies\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 318px;\"\u003eStakeholder Perspectives\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003eQuotes\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\u003cem\u003eDiagnose Long COVID using current diagnostic criteria and\u0026nbsp;evidence-based approaches.\u003c/em\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 318px;\"\u003ePCPs expressed uncertainty in diagnosing Long COVID due to the lack of objective criteria, despite its importance for insurance and accommodation purposes. Long COVID experts warned against strict diagnostic criteria, highlighting the usefulness of tools like the National Academies of Sciences, Engineering, and Medicine (NASEM)\u003csup\u003e12\u003c/sup\u003e definition and symptom recognition to improve diagnostic confidence.\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u0026ldquo;Having familiarity with the diagnostic criteria, I think sometimes in primary care, patients come to us with so many different symptoms. And so, when can we feel comfortable labeling and feeling like we\u0026apos;re adding this diagnosis to a patient\u0026apos;s problem list... having, the clear kind of diagnostic criteria helps [me] feel more comfortable.\u0026rdquo; (PCP)\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;I think the doctors who don\u0026apos;t treat [Long COVID] are looking for really clear concrete, like \u0026lsquo;I am looking for this. These are my criteria. It\u0026apos;s all cut and dry. And then I know.\u0026rsquo; And in reality we don\u0026apos;t always have that available to us, patients may not know if or when they got COVID, and it\u0026apos;s based on clinical pattern recognition... if they over rely on a diagnostic criteria, they\u0026apos;re going to miss a lot of people.\u0026rdquo; (Long COVID Expert)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\u003cem\u003eRecognize and evaluate the common symptoms and clinical presentations associated with Long COVID.\u003c/em\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 318px;\"\u003eGiven the lack of diagnostic criteria available, all participant groups reported symptom recognition as important for identifying Long COVID. One PCP stated that education priority should be based on the \u0026ldquo;timeline of a treatment program instead of relative importance. As such, recognizing symptoms of Long COVID should be the first step before moving to other topics. IWLC specifically emphasized wanting to see PCPs who would not dismiss their symptoms and who are able to recognize both common and less typical presentations of Long COVID.\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u0026ldquo;I might look fine from the outside and what I\u0026apos;m telling you are still problems that I deal with and I\u0026apos;m trying to come see you at a time when I feel okay and so when I feel terrible I\u0026apos;m at home.... I think that part of the education for a doctor is important for me to feel heard and understood.\u0026rdquo; (Individual with LC)\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;Examine the patient\u0026apos;s symptoms and list them off categorically (CFS, PEM, ME, MCAS)...it\u0026apos;s important to know which symptoms are the most severe and helping them construct a routine that would help them take steps towards their recovery.\u0026rdquo; (Individual with LC)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\u003cem\u003eIdentify\u0026nbsp;and provide first-line management for co-occurring conditions and complications often associated with Long COVID, including recognizing when to refer to or co-manage care with subspecialists.\u003c/em\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 318px;\"\u003eIWLC felt that managing conditions associated with Long COVID was relevant at all levels of care and should therefore be a priority in clinician education. However, although some PCPs expressed uncertainty about how to determine which conditions are directly attributable to Long COVID, they ultimately recognized they would manage the condition similarly regardless of the etiology. Another group of PCPs acknowledged the importance of recognizing co-occurring conditions (e.g., menstrual changes or atrial fibrillation), particularly those that are less frequently seen in the general population but occur more frequently among IWLC. Experts said PCPs should be a \u0026ldquo;home base\u0026rdquo; for patients in managing care and providing support. \u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u0026ldquo;There\u0026apos;s just a set of syndromes that are maybe again, either causally or not, at least associated, related to a certain condition\u0026hellip; It\u0026apos;s a little bit like retinopathy and diabetes kind of a thing. We know how to treat retinopathy, but we should probably be on the lookout for that given that the patient has diabetes.\u0026rdquo; (PCP)\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;I think that understanding that there are these parallel conditions that may be associated or triggered as part of the picture of Long COVID is really important... like people having menstrual irregularities, people suddenly having AFib, who didn\u0026apos;t have those other problems before, and even thinking to ask somebody who is not suffering from a lot of Long COVID symptoms... I think that it\u0026apos;s really important for PCPs to have an understanding what the associated conditions are, and that even if they\u0026apos;re not the ones who are going to manage those things... they\u0026apos;re all part of a bigger picture.\u0026rdquo; (PCP)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\u003cem\u003eDevelop and implement a comprehensive, individualized management plan for\u0026nbsp;Long COVID that incorporates both pharmacologic and non-pharmacologic treatment strategies, recognizing when and where to refer patients for escalated or specialized care when needed.\u003c/em\u003e\u003cem\u003e \u003c/em\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 318px;\"\u003eIWLC prioritized non-pharmacological treatments, noting that many medications addressed only some symptoms and often resulted in polypharmacy, adverse side effects, and high costs. They also emphasized that exercise-related treatments should be approached cautiously, and that any recommendations or referrals to specialists (e.g., physical therapists) should include explicit notice of the presence of post exertional malaise (PEM) and suggestions to consider during treatment to avoid worsening symptoms and impeding recovery.\u0026nbsp;\u003cbr\u003eWhile PCPs and experts agreed that non-pharmacologic treatments should be the initial approach, they felt that education should place greater emphasis on pharmacologic options, as PCPs are less familiar with available medications, their off-label uses, and associated risks and benefits. PCPs are familiar with non-pharmacological options but would benefit from guidance on how these should be adapted for Long COVID. An education program should address both pharmacologic and non-pharmacological strategies to best meet the needs of patients with Long COVID.\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u0026ldquo;Part of my issues with that is, it\u0026apos;s almost always you need to go for walks. You need to start doing some sort of exercise. And at physical therapy that I go to, or vestibular therapy, we\u0026apos;re doing physical activities and the second we go just a little too far, it sets me back weeks... be careful when you send people off to change their lifestyles, especially for the ones with severe Long COVID\u0026rdquo; (Individual with LC)\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;I was prescribed an amphetamine to help me because there was research showing that it worked. But what I chose to do with that was of course take more because... I could be this false sense of higher functioning that never really was real...the next thing I knew I was buying amphetamine pills, I ended up going to rehab, so I had some slew of secondary issues that came from my diagnosis of post COVID syndrome.\u0026rdquo; (Individual with LC)\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;As people who treat [LC], you\u0026apos;re going to have to use pharmaceuticals for a lot of the pieces of it. And so it\u0026apos;s not sort of an \u0026lsquo;if\u0026rsquo; it\u0026apos;s a \u0026lsquo;in what situations,\u0026rsquo; whereas I would think the patients would hope to do everything without pharmaceuticals, if at all possible.\u0026rdquo; (Expert)\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;I feel like there\u0026apos;s not a lot of familiarity or comfort with some of the medications that are used, and maybe feeling like there may be more limited data at this point. But I wonder... maybe there\u0026apos;s more data out there than I am aware of and so, maybe having more knowledge of that would be helpful... some of the pharmaceuticals that are used are not necessarily things that as a PCP I would commonly prescribe.\u0026rdquo; (PCP)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 899px;\"\u003e\u003cstrong\u003eACGME Domain: Medical Knowledge\u003c/strong\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003eCore Competencies\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 318px;\"\u003eStakeholder Perspectives\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003eQuotes\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\u003cem\u003eDemonstrate an understanding of the current evidence regarding the pathophysiology and proposed mechanisms of Long COVID, and recognize how these factors impact patient care and may contribute to limitations in the clinical setting.\u0026nbsp;\u003c/em\u003e \u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 318px;\"\u003eIWLC were less interested in ensuring that clinicians understand the underlying mechanisms of the condition, preferring to focus on diagnosis and treatment. In contrast, caregivers and community members wanted this education prioritized to better understand what their loved ones were experiencing. They emphasized that PCPs should also educate caregivers about the causes of Long COVID, alongside symptom management, so they feel better equipped to provide ongoing support. \u0026nbsp;\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u0026ldquo;If I asked my friend right now, who\u0026apos;s diagnosed with Long COVID like, would you want to know what causes Long COVID. Is that important to you? I know he would be like, \u0026lsquo;I really don\u0026apos;t care\u0026hellip; I want to figure out what to do with the symptoms I\u0026apos;m experiencing.\u0026apos; I know it\u0026apos;s real but for me, as somebody who is not diagnosed and who\u0026apos;s watching it, that is top of my list. I would love to know, like what is causing it. I\u0026apos;m seeing and witnessing so much suffering.\u0026rdquo; (Family member)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 899px;\"\u003e\u003cstrong\u003eACGME Domain: Systems-Based Practice\u003c/strong\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003eCore Competencies\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 318px;\"\u003eStakeholder Perspectives\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003eQuotes\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\u003cem\u003eDeliver coordinated, patient-centered multidisciplinary care through thoughtful referral stewardship, while providing a patient-centered medical home that serves as the hub of care for patients with\u0026nbsp;Long COVID and minimizes reliance on fragmented specialty care.\u003c/em\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 318px;\"\u003eBoth PCPs and experts emphasized the importance of setting clear expectations with patients regarding referral timelines and the role of specialists in a transparent and patient-focused way. They suggested training that equips PCPs with strategies and tools to ask patients about their reasons for wanting a specialist referral, followed by open communication to ensure referral or consultation with the most appropriate specialist when needed. \u0026nbsp;\u0026nbsp;\u003cbr\u003eIWLC would like their PCPs to know which specialists have experience treating the condition. However, PCPs and experts acknowledged that many specialists lack this training and would likely manage symptoms the same regardless of origin. While PCPs are familiar with treating symptoms themselves, they expressed interest in identifying the most relevant specialists for referrals and understanding the rationale for these referrals (e.g., cardiology for palpitations). \u0026nbsp;\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u0026ldquo;I tend to try to be very upfront with patients when I know they\u0026apos;re going to have a wait for something that I know is really important and impacting their life\u0026hellip; I will often like schedule some telehealth clinics in between. Just so we can connect, I can make sure [there are] no dramatic changes again, allowing them to be heard and feel like they\u0026apos;re not just being dropped into nowhere for 4 to 5 to 6 months.\u0026rdquo; (PCP)\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;What\u0026apos;s the reason for the referral or for the referring question, and I think it\u0026apos;s good to pose that both to the PCP and the patient, what\u0026apos;s your motivation for the referral? And that\u0026apos;s not to challenge a patient. But just say, is it because you want a second opinion? Is it because you\u0026apos;re anxious that something\u0026apos;s being missed? And then same thing for the PCP - rather than just referring for Long COVID, I would pose having a specific question in mind. ...and they might have different reasons for referring also.\u0026rdquo; (Expert)\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;It feels like to me anytime I talk to a specialist, since my symptoms aren\u0026apos;t off the charts, then they don\u0026apos;t take it quite as seriously and then it\u0026apos;s dismissed. And so, how do I get the care in between somebody who has severe heart failure versus somebody who\u0026apos;s gotten POTS or really has a high heart rate because of Long COVID.\u0026rdquo; (Individual with LC)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\u003cem\u003eProvide guidance and\u0026nbsp;appropriate documentation\u0026nbsp;for work, school accommodations, and disability evaluations, collaborating with other healthcare professionals as needed to deliver comprehensive and effective support for patients.\u003c/em\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 318px;\"\u003eIWLC understood thorough documentation to be critical to their disability claims and accommodation requests, as it is \u0026ldquo;one of the only things patients cannot do on their own.\u0026rdquo; While PCPs are experienced in completing these requests, they noted that examples of recommended language and objective criteria specific to Long COVID would be helpful, particularly given symptom uncertainty and the absence of definitive diagnostic tools. Experts further advised collaborating with other healthcare professionals (e.g., physical therapy, occupational therapy, speech-language pathology, vocational rehabilitation) to deliver comprehensive guidance, documentation, and accommodation as an interprofessional team.\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u0026ldquo;Some of these other things I could research on my own\u0026hellip; but [SSDI documentation] is something I can\u0026apos;t do on my own. There\u0026apos;s nobody else who can do it if your medical provider isn\u0026apos;t willing to do it.\u0026rdquo; (Individual with LC)\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;The kind of disability paperwork process can be one that you feel like you want to be able to advocate for your patients. And it\u0026apos;s also like this kind of sort of to me a little bit opaque process. ... the challenge with Long COVID is some of the uncertainty and the lack of diagnostic tools that we have in filling out some of the paperwork where there\u0026apos;s a lot of requests sometimes for like very specific information and diagnostic information.\u0026rdquo; (PCP)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 899px;\"\u003e\u003cstrong\u003eACGME Domain: Interpersonal and Communication Skills\u003c/strong\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003eCore Competencies\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 318px;\"\u003eStakeholder Perspectives\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003eQuotes\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\u003cem\u003eFoster patient- and caregiver-centered, affirming communication that supports shared decision-making and builds a positive therapeutic relationship.\u003c/em\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 318px;\"\u003eCommunity and family members acknowledged that \u0026ldquo;caring\u0026rdquo; communication can take different forms depending on the audience, so PCPs must use their judgment to determine how best to provide information and validation in each individual case. PCPs use patient-centered communication skills in all aspects of care they provide, but they would appreciate Long COVID-specific examples of how to validate patients, respond to emotions, and discuss pathophysiology to build rapport. Such examples could also help PCPs reflect on their own emotions and convey to patients that they are fully prioritizing their care within the constraints of primary care (e.g., limited visit time). Family members expressed a desire to be included in treatment discussions so they can provide consistent, long-term support. While patient self-management of symptoms is ideal, the complexities of Long COVID make it challenging to navigate alone. As with other chronic illnesses, community and caregiver involvement can be critical for treatment adherence and improved health outcomes.\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u0026ldquo;I recall one of the learnings I\u0026apos;ve had through this really trying to support patients, or helping them not feel guilty that they can\u0026apos;t train their fatigue away and actually tell them \u0026hellip; Don\u0026apos;t push it too hard\u0026hellip; And just that reassurance helps them with, you know, that can come with that as if they\u0026apos;re not trying hard enough.\u0026rdquo; (PCP)\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;I think having a family member or some sort of guardian communication tool would be helpful... And I think both this is like the care team themselves are learning and then communicating it to the person impacted. That\u0026apos;s a lot of information. I\u0026apos;m also just a fan of having somebody to support me with all of the information I get, because I\u0026apos;m like, wait, what did they say?\u0026rdquo; (Family member)\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;The better the support system that exists, the better. That you know family, friends, whoever the support system is, can help reinforce support. you know, following doctor\u0026apos;s orders and dealing with a chronic condition successfully. So I do think that universally dealing with chronic illness is more successful when it\u0026apos;s a team sport.\u0026rdquo; (Community member)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\u003cem\u003eAcknowledge uncertainties surrounding\u0026nbsp;Long COVID prognosis while providing clear communication and ongoing support to patients and their families.\u003c/em\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 318px;\"\u003eExperts felt that PCPs need strategies for discussing the uncertain prognosis of Long COVID with patients in ways that preserve hope without creating unrealistic expectations, and to help patients understand realistic treatment goals (e.g., 5-10% improvement) within the broader journey of living with a chronic illness. Per PCPs, part of providing clear communication is explaining the referral process and setting realistic expectations for specialist wait times. PCPs recommend scheduling follow-up visits during this waiting period to ensure patients continue to feel supported where possible.\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u0026ldquo;I think it\u0026apos;s also okay to say to the patient \u0026lsquo;we\u0026apos;re all learning about this as we go. Even the experts are learning right now about this.\u0026rsquo; And just sort of an acknowledgement of, you know, we don\u0026apos;t know everything yet. We\u0026apos;re doing our best. We\u0026apos;re trying to work with the information that we have, and we will keep communicating that as we go.\u0026rdquo; (PCP)\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;One thing that I still struggle with is prognosis... And if anyone has any magic language of how to tell someone that I have no idea how long this is gonna last for you, it could be a month or 6 years, and you know that\u0026apos;s really hard. But I think that PCPs are going to be asked that, and they need to have some sort of a strategy to respond that doesn\u0026apos;t either crush the patient\u0026apos;s hope, or give them unrealistic expectations.\u0026rdquo; (Expert)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\u003cem\u003eStrengthen\u0026nbsp;the therapeutic\u0026nbsp;relationship through trauma-informed care that emphasizes shared-decision making, validation of physical symptoms, and recognition of the emotional impact of\u0026nbsp;Long COVID.\u003c/em\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 318px;\"\u003ePCPs reported receiving training on trauma-informed care, usually integrated into other educational contexts. A Long COVID-specific application of this approach would help them listen actively and demonstrate compassion through targeted verbal and nonverbal cues that patients find reassuring. PCPs and experts agreed that validating physical symptoms can support rapport and trust building. This can also open the door to a discussion on how emotions and mental health can influence physical symptoms, without attributing symptoms to psychogenic origins. \u0026nbsp;This is a critical distinction as many IWLCs and PCPs describe prior experiences in which healthcare providers dismissed patients\u0026rsquo; physical symptoms as purely psychological, leaving them feeling invalidated and reluctant to discuss less \u0026ldquo;visible\u0026rdquo; symptoms with their PCPs.\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u0026ldquo;And it\u0026apos;s [Long COVID] often dismissed, as it\u0026apos;s a mental health problem. And so...to make sure that there is this validation is first, and then that understanding that things are very related to each other and that physical symptoms, it\u0026apos;s not that it\u0026apos;s all in your head, but that it\u0026apos;s aggravated or triggered by what\u0026apos;s happening with our emotions and our mental health... it\u0026apos;s easier to begin to have that conversation when you have started by validating their symptoms and recognizing that these are real, and these are a lot of physical symptoms, and then beginning to educate and assess even more about mental health needs\u0026hellip; but as a PCP, it\u0026apos;s my role to be able to identify [mental health]...I would just say that I think it\u0026apos;s easier to prioritize the mental health support if one has communicated and validated symptoms first.\u0026rdquo; (PCP)\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;This is all sort of trauma informed care... And so from a PCP perspective, I think that trauma informed care sort of gets mentioned. And but I think that actually being trained in how do you address that? ...the value of saying, \u0026lsquo;I\u0026apos;m so sorry that you\u0026apos;re feeling so unwell\u0026rsquo; is a tremendous value to a patient. And so I think that those kinds of skills that you know\u0026hellip; I\u0026apos;ve found that to be very valuable in my basic PCP interactions with people, and especially with people with Long COVID,\u0026rdquo; (PCP)\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;I actually come to that mental health component of things last after their long list of symptoms...I think I try to focus on the other symptoms first as a way to build trust and validation, but also still circle back to mental health. But I tend to do that later on in the conversation. And I think that\u0026apos;s just something small that I\u0026apos;ve learned through experience to build trust. \u0026rdquo; (Expert)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 899px;\"\u003e\u003cstrong\u003eACGME Domain: Practice-based Learning and Improvement\u003c/strong\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003eCore Competencies\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 318px;\"\u003eStakeholder Perspectives\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003eQuotes\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\u003cem\u003eIdentify\u0026nbsp;trusted resources\u0026mdash;such as consensus statements, clinical practice guidelines, and evidence-based recommendations\u0026mdash;and critically appraise the literature to guide shared decision-making discussions, especially in areas where medical evidence is conflicting, inconclusive, or limited.\u003c/em\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 318px;\"\u003ePCPs reported that patients often bring information on Long COVID (e.g., treatments) to appointments, prompting them to conduct their own research to prepare for productive discussions about risks, typical use of treatments, and potential publishing biases \u0026ndash; ultimately helping patients decide whether to proceed with an intervention. They expressed interest in training on how to discuss negative or null findings when patients request certain treatments, as well as guidance on locating the most current and reliable Long COVID research. Access to accurate, timely data would enhance shared decision-making and increase PCPs\u0026rsquo; comfort with prescribing. \u0026nbsp;\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u0026ldquo;I\u0026apos;ve had multiple patients present a lot of that information and be like, \u0026lsquo;Hey, I really want to try XY, or Z. I\u0026apos;ve read about this or the news,\u0026rsquo; so I always ask them to send those things to me so I can read over them and maybe do some of my own research. And then we have a discussion about that... what would the risk be? Whether you know the medication might be typically used for? ... I feel like I as long as I\u0026apos;m having that discussion with them, and they would like to try it. It doesn\u0026apos;t seem, you know, harmful. \u0026rdquo; (PCP)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 899px;\"\u003e\u003cstrong\u003eACGME Domain: Professionalism\u003c/strong\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003eCore Competencies\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 318px;\"\u003eStakeholder Perspectives\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003eQuotes\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\u003cem\u003eReflect on and address personal biases to ensure\u0026nbsp;equitable, compassionate, and patient-centered care for individuals with\u0026nbsp;Long COVID.\u003c/em\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 318px;\"\u003eFamily and community members voiced concern about the current public health issue involving clinicians and patients in some geographic areas of the United States not recognizing the existence of Long COVID, leading to gaps in necessary care. PCPs requested that training incorporate time or tools for reflecting on personal emotions and/or biases about COVID-19 and Long COVID to help ensure equitable and appropriate care for all patients. \u0026nbsp;\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u0026ldquo;I think it is helpful that sometimes, too, to have space or toolkits to kind of like remind providers to kind of like, reflect on their own emotions, and maybe biases that might come in and so I don\u0026apos;t know if there are specific toolkits kind of for that, too.\u0026rdquo; (PCP)\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;I\u0026apos;m a caregiver for my mother, who has been grappling with long covid symptoms for the last like 3 years. \u0026hellip;It\u0026apos;s hard to be a caregiver when both the person experiencing these symptoms doesn\u0026apos;t believe that they have \u0026nbsp;the illness...Her doctor\u0026apos;s like \u0026lsquo;Long COVID is not real. You have depression, or you\u0026apos;re going through menopause. So that\u0026apos;s why you\u0026apos;re having these muscle spasms.\u0026rsquo; But it\u0026apos;s really challenging. Because I will try to have a conversation with [the] physician. and it\u0026apos;s just like I\u0026apos;m shut down as a caregiver, and so it makes it hard to advocate.\u0026rdquo; (Family member)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 155px;\"\u003e\u003cem\u003eSupport equitable standards of care to ensure patients with Long COVID receive consistent and high-quality management, regardless of a clinician\u0026apos;s specialized training or experience in Long COVID, advocating on an individual patient level and within the healthcare system as appropriate.\u0026nbsp;\u003c/em\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 318px;\"\u003eFamily and community members stated that information on Long COVID should be readily accessible to all clinicians, not just those specifically trained to manage the condition. Providing a toolkit or \u0026ldquo;cheat sheet\u0026rdquo; for clinicians and their clinics may help disseminate information on current research, symptoms, and treatments to a broader audience, particularly if clinics display patient-friendly infographics for patients and caregivers. PCPs expressed interest in having local resource lists they could use to connect patients with Long COVID to holistic care options.\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u0026ldquo;I think that there are providers out there who have very best intentions and it\u0026apos;s not that they don\u0026apos;t believe in long covid. They certainly do, but maybe don\u0026apos;t have a full toolkit, or are totally up on all the evidence-based research to be able to really tackle symptoms and side effects from Long COVID with a full arsenal...I think that\u0026apos;s where the equity piece comes in is if someone seeks care in a clinic where the provider is doing nothing but Long COVID visits all day their toolkit and their experience level is going to be completely different than potentially a primary care provider who is seeing patients for all kinds of things at all ages all day long, and then has to suddenly pivot, and all of a sudden become a Long COVID expert...I think my greatest concern is making sure that patients receive the same level of care.\u0026rdquo; (Community member)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Long COVID, education, primary care, medical education, mixed methods, delphi needs assessment, patient perspectives, COVID-19, core competencies","lastPublishedDoi":"10.21203/rs.3.rs-9098407/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9098407/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThere is an unmet need for Long COVID care within our healthcare system. Primary care clinicians (PCPs) face challenges in providing effective care due to limited relevant Long COVID training and lack of standardized clinical resources. Pre-CME (continuing medical education) survey data indicates that 62% of clinicians experience difficulty diagnosing and managing Long COVID. There is a need for competency-based curricula to equip PCPs with tools for interdisciplinary, patient-centered care.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA mixed-methods Delphi needs assessment process was designed to gather stakeholder input to guide the development of Long COVID core competencies. Participants were recruited through word of mouth and completed a 30-minute survey on barriers and facilitators for Long COVID care, case scenarios, and topic preferences. They also participated in a 1-hour Zoom focus group using an unstructured question guide to review survey responses, which were then analyzed with summary templates and a matrix analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe study enrolled 26 participants, 21 of whom also participated in focus groups. Areas of convergence and divergence in participant perspectives were used to inform development of core competencies that ultimately could be categorized in alignment with the six competency-based domains defined by the Accreditation Council for Graduate Medical Education (ACGME).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis study establishes a consensus-based framework of competencies for PCPs managing Long COVID, reflecting the condition\u0026rsquo;s evolving nature and the importance of continuous, relationship-centered care. Implementing these competencies in training and professional development can enhance care quality, standardize practices, and improve outcomes for patients facing complex, multisystem health challenges.\u003c/p\u003e","manuscriptTitle":"Bridging the Gap in Long COVID Care: Identifying Core Competencies for Primary Care Curriculum Development and Evaluation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-31 20:14:30","doi":"10.21203/rs.3.rs-9098407/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"236717708743971584619595637464781973843","date":"2026-05-07T09:01:20+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-14T16:57:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"159926717228490764802398960311114885084","date":"2026-03-30T20:21:25+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-27T10:08:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-25T06:10:11+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-20T05:25:46+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-19T18:51:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2026-03-19T18:37:26+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d9f0eaf7-1f62-46db-8d7f-17255e6826a4","owner":[],"postedDate":"March 31st, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"236717708743971584619595637464781973843","date":"2026-05-07T09:01:20+00:00","index":39,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-31T20:14:30+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-31 20:14:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9098407","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9098407","identity":"rs-9098407","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}