GPs are used to dealing with uncertainty, but this pandemic is serving up an unprecedented amount and we need community and government support for our efforts
I dreamed a dream of time gone by
When hope was high and life worth living
Les Miserables (Musical)
The words from this famous musical have no doubt haunted many of us over the last few months as our lives in isolation have been turned upside down.
We spent time dreaming of how good the past really was compared with the present. We revisited our past, connecting electronically with friends and family, acknowledging that this is a poor substitute for touching, hugging and kissing, to mention but a few forms of tactile engagement.
We live in hope that such contact will soon be resumed as we watch the daily horrors emerging from the US, in particular, where a failed medical system has been swamped by an avalanche of critically ill patients. We in Australia are fortunate so far, which gives us in the medical profession, in particular those like me in general practice, an opportunity to reflect, to imagine the future taking on board lessons from the past, noting that in a rapidly changing environment today is tomorrow’s past.
While we still have much to learn about the behaviour of COVID-19, a few certainties have emerged: The virus is unlikely to go away and we may experience a second wave of infections, but even if we don’t it may remain in the community and continue to infect vulnerable people, just as the influenza viruses have done for many years.
We have come a long way in managing bacterial infections, but the same cannot be said for viral infections, apart from the use of vaccines in preventing such infections. We still seem at least 12 months away from a reliable vaccine against COVID-19. Then there is always the possibility of new mutations of the coronavirus, which creates even more challenges going forward.
Our recent experience has shown that cities with high population densities, especially those with high-rise buildings such as New York, have been worst affected. Social distancing and the quarter-acre block during lockdown have helped us in Australia.
So what are the challenges facing GPs now and into the future in regard to the pandemic?
Until now, GPs have been following guidelines from federal and state health departments as well as their professional bodies designed to protect themselves, clinic staff and patients from this coronavirus. This included the use of PPE where available, screening and referring suspect cases to testing centres or local pathology facilities or hospital.
They have spent much time answering questions from worried and anxious patients and many have moved to telehealth consults.
Because the number of confirmed cases in Australia so far has not exceeded 8000, it is likely that many practices have not detected a single case, but complaints about the lack of facemasks and other forms of PPE have been ubiquitous. It seems we have not learned from the 2008-9 H1N1 epidemic.The arrival of influenza vaccines has meant that many patients who have stayed away from the clinic for fear of COVID19 are now turning up for flu shots, some being administered in clinic car parks for safety reasons.
Many GPs, in particular older and those at risk, including myself, have moved to telehealth consults and while we await research of the efficacy and effectiveness of this form of communication with patients, questions are being raised about its sustainability. In my view it has limited value and may be a short-term measure for managing some psychological problems, identifying clinical problems that need management, managing some visible dermatological problems, repeating medications or investigations for known patients, but there is no substitute for face-to-face contact and for physical examination or for something as simple as a blood pressure check.
This raises a serious problem. Patients with chronic diseases, including heart disease, diabetes and cancers, have not been attending GPs or hospital clinics for fear of contracting the virus, when the risk of developing a complication from their chronic illness or having a cancer not detected is far greater than the risk of succumbing to COVID-19.
With restrictions easing, we may see clinics overwhelmed by these patients with stress on investigative and specialist services far greater than the stress from an influx of COVID-19 patients.
Those of us in the southern hemisphere are soon to be exposed to winter with its accompanying colds and flu infections. Patients with symptoms will fear that they may have COVID-19, which was never a contender in the past. It is likely that there will be an even greater number of clinic visits than before, when patients were told to stay home and phone the COVID-19 hotline if they had symptoms. So, will these coronavirus strategies continue, and are we resourced to maintain them until at least October?
There are a number of potential medicolegal and OHS issues which loom in the background. Should a staff member in a clinic contact COVID19 in the future in the absence of proper PPE, they may have case against the clinic for being exposed to an unsafe work environment. The problem may be exacerbated if a staff member is a carrier and infects a host of patients. It is therefore essential that all clinic staff be tested as a matter of priority now that testing is readily available.
In general practice we apply the biopsychosocial model to patient care. COVID-19 has had devastating effect on the economy. We face massive unemployment, in particular youth unemployment with its social and psychological consequences, compounded by a prolonged period of social isolation which is having its own traumatic consequences, especially in already fragile family relations.
It is likely that GPs will have an influx of patients with a variety of psychosocial problems, ranging from insomnia, anxiety disorders, adjustment disorder, through to major depression and PTSD. Domestic violence and its consequences are also looming, which is likely to increase the incidence of behavioural disorders in children.
We are witnessing the greatest pandemic of our time and its impact on every aspect of our lives has been, and continues to be, profound. It has provided, and will continue to provide, challenges for us as GPs, some of which, like the virus itself, are unforeseeable and unpredictable.
In general practice, perhaps more so than in most other medical disciplines, we are used to dealing with uncertainty. We need to prepare to meet these challenges with confidence and with community and government support.
Dr Leon Piterman is Professor of General Practice at Monash University and has been in clinical practice for 40 years
