How Family Physicians Can Better Diagnose and Treat Long COVID
April 1, 2025, Matt LaMar — Five years after the COVID-19 public health emergency began, the pandemic is now an endemic — and those suffering from long COVID continue to feel the disease’s effects.
The family physicians who were on the pandemic’s front line are now leading the fight against long COVID. AAFP News spoke with Eric Herman, M.D., assistant professor of family medicine at Oregon Health & Science University, to discuss how family physicians can best diagnose and manage long COVID.
What Is Long COVID, and How Long Does It Last?
Long COVID, an infection-associated chronic condition, is diagnosed after symptoms persist beyond the typical four-week period of acute COVID infection symptoms.
While the vast majority of COVID infections do not result in long COVID, Herman explains, every COVID infection is a risk for long COVID. “For everyone who gets tested positive for COVID or has a positive diagnosis, usually somewhere about 7% of those people can persist having long COVID for over three months,” he says.
There are wide variations in the length of long COVID. “It depends on the person,” Herman says. “Some people can recover from long COVID over time, but many people, as we're learning, have symptoms that persist for years.” Some of Herman’s patients with severe and complex long-COVID symptoms — such as dysautonomia or postural orthostatic tachycardia syndrome — report having had symptoms since the beginning of the pandemic.
Herman points out some key statistics vital to understanding the condition:
- 85% of patients with long COVID say symptoms have persisted 12 months.
- 25% of patients with long COVID report significant limitations in their activity.
- 13% of patients with long COVID are unable to return to their normal daily activities at 18 months.
Accompanying the highly variable nature of the length of long COVID, more than 200 symptoms have been ascribed to the condition, complicating diagnosis.
What Are the Symptoms of Long COVID?
As a chronic condition, long COVID can sometimes include symptoms similar to those of acute infection, including fatigue, headache and shortness of breath. But in many cases, more complex symptoms can present.
Herman says one of the most common indicators of long COVID is post-exertional malaise, which often presents itself in a disproportionate and delayed manner to a patient’s activity.
“People that have post-exertional malaise, even with a minimal amount of effort, like walking to the mailbox or walking the dog or cleaning up the kitchen, can find themselves experiencing profound fatigue,” Herman says. “But the main difference is that the onset of that fatigue is delayed. They can do something in the morning, and then they pay the price, crashing physically the next day. Post-exertional malaise has this delayed onset of fatigue that is completely disproportionate to the exertion they did.
“Some people have many other challenging symptoms that just persist, including orthostatic intolerance, cognitive impairment, body aches and anxiety. But if there really seems to be a strong association with just the minimal amount of exertion or activity and a flourishing of multiple symptoms, that helps me put it together, too.”
Why Are Family Physicians Important in Diagnosing Long COVID?
With variable timelines, a wide range of symptoms and a declining initial rate of acute COVID diagnoses, properly diagnosing long COVID can be tricky. Understanding a patient’s baseline health is key. This is where family medicine shines.
“They didn't have these symptoms before they had COVID, right?” Herman says. “They used to go to work, they used to go to school, they used to take care of their grandkids — and now they can't.
“In family medicine, one of the beautiful things about our profession is, we get to have trusted relationships with the patient in continuity of care. So we know them, we know this person, we know who they were and how they acted and how they thought and what their hopes and dreams were before they had this acute infection… And you can see that and feel that and hear that when you talk to patients.”
Long COVID can be confusing to patients, especially those who were previously healthy, without chronic pain or symptoms. Patients often demonstrate bewilderment and a sense of fear that they can’t live their life how they used to. Family physicians are well-positioned to identify changes to the baseline physical and mental health of their patients and to help them understand, deal with and overcome long COVID.
Preventing and Treating Long COVID
“The best way to prevent long COVID is to prevent COVID,” Herman explains. “Anything you can do to prevent COVID prevents long COVID. We also know that people that get multiple COVID infections are more likely to develop long COVID. Someone who's had one COVID infection is less likely to get long COVID compared to somebody that's had three or four or five or six acute episodes of COVID.”
One vital step toward that prevention is to advise patients to stay up to date with COVID vaccinations. Additionally, some studies indicate that treatment with nirmatrelvir/ritonavir (Paxlovid) during an acute COVID infection can prevent some patients from ending up with long COVID.
Herman says the best way to help patients who have long COVID recover is to help them avoid post-exertional malaise and build stamina through pacing. The first step is to stop post-exertional malaise by working with patients to establish an understanding of their “body battery.” From there, they can work to build stamina and rebuild the basic mitochondrial capabilities of their cells. For individuals with other comorbidities, such as POTS (postural orthostatic tachycardia syndrome) ensuring proper salt and fluid intake, as well as using medicines to treat other symptoms, can be important tools.
Long-COVID Resources
One of the key ways to more accurately diagnose and treat long COVID is to be aware that it is a possibility. “When people present with fatigue or headache or confusion or brain fog, that really should be higher in the differential diagnosis,” Herman says. “Just have it in your mind.”
For additional long COVID resources, visit the AAFP long COVID resource guide. In it, you’ll find guidance, printable handouts and long-COVID CME for auxiliary study.