Practicing Medicine in COVID Times

Being available to one’s patients, whatever be the circumstances, is a physician’s key attribute

When the COVID pandemic struck in the early months of this year, there was a sense of unrest, apprehension, and panic amongst the doctors and patients alike.

While the healthcare sector was suddenly hit by a virus, which forced it to “lock its doors” to all others and focus single-mindedly on the COVID patients, the patients with other chronic ailments felt abandoned. As the lockdown was implemented across the nation as a desperate measure to prevent the spread of the infection, travelling to hospitals and getting their regular reviews done, became almost impossible.  

The key to optimum management of chronic lifestyle diseases includes regular follow up and monitoring of control with drug dose titration along with surveillance for complications. While most of these patients require monthly to quarterly follow up, with better patient education and empowerment, this could well be achieved by even less frequent visits in most cases.

Telemedicine became the new buzzword and doctors and patients started finding new ways to regain access to each other and carry on with healthcare. An abrupt change in practices to incorporate such methods, ensuring greater accessibility to patients, and use of telemedicine to circumvent physical consultation is not as easy as it appears. It requires a major change in the way doctor-patient relationship is perceived by both the sides, and what each other’s expectations are out of this interaction.

For me, this change happened almost seamlessly. Interacting freely with patients through telephone and emails and being accessible to them has been a practice I have always followed. Practicing in a healthcare delivery system that is free of cost to the patients, it helped me render round the clock accessibility to my patients without worrying about losing out on my “consultation fee”. Despite the recent legal perspective against tele-consultation, I have always maintained that well-meaning advice given telephonically to help the patients, with no material benefits in mind, would rarely be misconstrued.

On the flipside of it, calls during unearthly hours and some patients being unduly bothersome with their queries are often disliked by the family. But when handled with patience and tolerance, the benefits of such a practice far outweighs these negatives. The number of unnecessary OPD visits and hospitalizations that can be prevented by such tele-follow ups, makes it extremely worthwhile for both patients and the doctor. It has also helped me maintain contact with patients in various cities and continuity of follow up despite the periodic relocations to other cities.  

As the hospitals started restricting non-COVID “cold” cases and non-life-threatening super-speciality OPDs, I started receiving distress messages from some of my patients regarding their future follow up. As they were already on my contact list, all it required was some reassurance, advice regarding dose modification and asking them to stay home and buy their medicines locally. Most of them didn’t mind spending money to buy medicines in return for safety and comfort of being at home and getting proper advice. Many of them even sought medical advice for their relatives and friends who were not as fortunate with their own doctors.

To feel wanted and not abandoned, in these times of crisis was universally appreciated by them.

The most vulnerable to deterioration and life-threatening complication on drug-default are the patients of type 1 diabetes who are dependent on insulin for survival. Without waiting for them to raise the alarm, my staff was tasked to promptly contact them individually on phone for status-check and enquiries were made if they had their stock of insulin available with them. Issue of Insulin from their nearest military hospital was arranged for those who were unable to get it due to lockdown in cities even as distant as Meerut and Shillong. Most of them who could not get their usual brand/molecule were assisted in buying a proper substitute after a call with their local chemist shop was arranged. Those on Insulin pumps, were provided the much-needed disposables (accessories) for 2-3 months replenishment, to avoid visits. After this call from our centre, even those who were not in regular touch on phone till now, became more sincere in their monitoring and providing timely updates.

Thanks to the regular follow up on the virtual basis, none of them deteriorated in their glucose control to warrant hospitalization due to hypoglycemia or ketoacisosis, a fear that always hounds these patients and their caregivers. This, in my view, was one of the many positive fall-outs of being in touch with the patients not just during this crisis, but always as a regular practice.

The most encouraging aspect of this practice was some of its many success stories. A pregnant lady with type 1 DM, now on Insulin pump since Jan 2020, could manage her glucose control with regular feedback, and sail through the crucial months of her pregnancy despite the lockdown restrictions. A young boy, first diagnosed to be type 1 diabetic during the early days of lockdown, completed his first 3 months of follow up almost fully telephonically, and improving from HbA1c of 12.4 to 6.3% with an uncomplicated course. Similarly, many elderly patients in Delhi and various other cities, on my contact list, were advised to remain at home and avoid hospital visits. Talking to them and clearing their doubts helped a great deal in reducing their anxiety while monitoring their treatment simultaneously.  It also helped in a couple of patients presenting for the first time, with a scary looking pituitary tumor (prolactinoma) who could be counseled in their first visit and later followed up telephonically with serial tests to monitor therapy without letting the COVID restrictions impact their management.  

Meanwhile, a few in the doctor fraternity were busy doing webinars on medical topics mostly related to COVID. While few of them were relevant to the times, most were sorting out their pangs of withdrawal due to lack of conferences and CMEs and some falling prey to the commercial requirements.

I felt that it was the patients who needed this virtual communication platform the most in these times. Taking a leaf out of these, I could organize a virtual meet with my patients. More than 40 patients of type 1 Diabetes, with their next of kin, sharing the platform to discuss their concerns, and just feeling happy to see each other after a long break, was a refreshing experience. This also helped them feel being reached out to by the medical fraternity.

Over the last few weeks, the hospitals have re-opened gradually and cautiously let the OPDs function. But most patients have remained apprehensive and continued with the convenience of remote follow up. Considering the high-risk group of the aged and diabetic that I was dealing with, I felt that it remained worthwhile doing so.

Many lessons were learnt in these few months of changing the way I worked. Most of the patients who were on regular follow up through the telephone before the crisis, continued to reap its benefits, more so in times that it became the sole way of doctor-patient communication. Those at high-risk of COVID disease could be dealt with optimally being in the safely of their homes. The number of patients who needed to visit the hospitals was curtailed without impacting their follow up and metabolic control. This helped the healthcare system to focus on COVID management.  As most of these conditions are amenable to tele-consults and follow up, in the way forward, it would be prudent to follow these practices and curtail physical visits to the extent possible.

While this has become the “new-normal” for the times we live in, for me as a physician and to my numerous patients over the years, this has always been the “old-reliable” and will continue to be so. Of course, now with universal validation.