Living the Covid life in General Practice.

As an urban General Practitioners we were ‘Covid-19 aware’ relatively early on and abandoned tedious local network meetings in physical venues (usually some way away from our workplaces and without parking) for somewhat less tedious but nonetheless difficult Zoom meetings where we floundered about trying to decide strategy amongst the Known:Knowns that were few and the Unknown:Unknowns that were seemingly massive but by their nature invisible. Advice from ‘above’ came down in torrents, largely unhelpful and all the time changing and once we had decided a way forward there would usually be a directive that essentially wasted all the work done previously demanding we do something else entirely. Some things never change, and it remains thus. Fortunately for me as a part-time partner I can let my youngers and betters deal with much of this. Having said that we have been in a new routine for some time now which involves new ways of working. Never in well over 30 years of practicing medicine have I come across a system that satisfies everyone, or in truth even gets close. Maybe once I’m beyond ‘practicing’ and master the subject I’ll have all the answers but until then we’ll all have to struggle along the best we can.

All on-line?

The biggest change has been the way we work or more particularly the way we consult. Before we ‘locked down’ patients had in the main started staying away – Who wants to sit in a waiting room full of patients with a contagious and potentially deadly disease after all? Even then the concern was not with the worried well but the worried unwell, worried but more by Covid-19 than by signs of a heart attack, stroke or cancer. We still don’t know where these patients went but the statistics imply they just didn’t present and thus we GPs didn’t refer nearly so many.

That many patients have not attended any healthcare setting will no doubt come back to haunt us in the NHS, but not nearly so much as for those unfortunates who cross the Treatable:Untreatable threshold because either they were too scared to present or hospitals were essentially closed for normal business. (There was this idea that psychiatrists and surgeons could be repurposed to help in ITU and in truth some were, but most were not and remained underutilised and frustrated as their waiting lists increased exponentially creating another pandemic of sorts.)

Where’s the doctor?

So where are we now? Many hospital departments are finding that with new protocols they remarkably no longer need to follow up some patients and these are discharged back to their GPs. Others have found that online consultations can work for many follow-ups etc. There are obviously some benefits and disadvantages for all concerned but my feeling is there is no turning back and in future hospitals will become the places one attends only if absolutely necessary. Maybe we will not even visit our loved ones there in future?

Where are the patients?

In General Practice we now see very few patients face:face. Most consulting is on-line rather than either a same day ‘urgent’ appointment or a 3-4 week wait for an appointment (when the retort is often, “Well I was ill then but now I’m better but I thought I’d come along anyway as getting an appointment is really difficult!” – Yes, indeed and because you are here it just got longer for everyone else!) We now use software that further distances the patient from their GP but at the same time decreases the time for a response. Still not pleasing anywhere near all the people all the time and upsetting others we can offer a response of sorts in literally a few minutes to a maximum of 48 hours. The replies are in the main in electronic format, either SMS or email. These can contain by their nature much more written information than might be taken away from a normal consultation and can signpost to other services or websites etc. Some patients will obviously need a telephone call for further information gathering etc. Interestingly I have found that after the initial boom in video consulting a request for a photo followed by a telephone call is more useful and allows for the images to be stored in the patient record. Of course, we see patients face:face too but in full PPE and only when deemed clinically necessary. Many patients find on-line consulting far preferable to waiting a long time for an appointment, hanging about in the waiting room and seeing an under-pressure GP trying desperately to wade through the list and keep to time whist not missing anything significant. Many are able to take out a few minutes from work (at the office or increasingly at home) and thus save more time not having to travel to the clinic and back. I’m sure many miss the social interaction and I haven’t yet met a GP who wishes it were not otherwise, many of us feel like call-centre operatives and none of us were trained or feel we signed up for this way of working. There are clearly benefits for many. However, there are risks too. It must be true that it will be easier to miss subtleties when online. One of the great skills of experienced GPs and other medics is our training and ability to pick up on subtleties, some will even say they have the diagnosis before the patient sits down. Patients will also present very differently depending on the situation and context, especially if they know the doctor well. On-line will be factual and bullet pointed or checked boxes. Face:Face there may be hesitation, pause or silence. There can be varying degrees of eye contact and facial expressions and tears communicate a great deal. (However even face:face there are difficulties with masks etc. I recently had a complaint that was at least in part because the patient attended in with what I took to be in a very nervous manner and close to tears and left in seemingly the same condition. What I hadn’t realised was that there was disfunction in the consultation and the non-verbal clues were literally masked and unseen by both parties.) Patients also bring ‘calling cards’ with them. A classic being a depressed overwhelmed mother bringing in a snotty but otherwise well infant. Even if we miss the visual clues she may well say “…whilst I’m here doctor…” bringing up something she didn’t feel ‘worthy’ of a consultation in its own right or likely subjugating her health for that of her child. Where is she now? What resources does she and others have whilst being told to stay at home and see only immediate family? We know Domestic Abuse has increased but it’s visibility decreased, unfortunately it has joined a long list ‘the disappeared and invisible’. There will, mark my words be consequences to Covid-19 well beyond the acute physical. (and now Long-Covid too.) The mental health of the nation has been largely missed in all this. The detrimental effects of unemployment or even the uncertainty and anxiety about redundancy etc. are well known.

Can we do this on-line?

Working from home is just one part of the ‘new normal’ and may seem preferable in the short term but a large part of our human experience gets missed when staring at a screen. For those with spare rooms and a garden it will work better but the flat sharers and high-rise dwellers are likely to fare less well. I wonder how we’ll feel about this in a few years? Avoiding the commute and the stress and the associated ‘wasted’ time of this is good, but missing even the unspoken human connection on the bus or train, that hugely valuable coffee or drink after work and the water cooler chat will diminish our work place camaraderie. Many of us are not even venturing to the shops, restaurants or cinemas but buying on-line, getting take-aways delivered and subscribing to a Netflix account and so have even less human contact. Will it come back or are we forever social distanced even when the Coronavirus departs and if so will we need to adapt to being less human on a social level? The health consequences of that are hard to imagine, except that seeing your GP face:face is likely to be a rarity!

 

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