Saturday April 4, 2020

Dr Mark Murphy: The way GPs work has been disrupted and changed forever

A hundred years ago, our population was ravaged by infectious diseases from which death was common. In today‘s world, we have become used to being insulated from waves of infections, but one such wave is hitting us now

22nd March, 2020
In Ireland, however, most doctors rarely encounter the many diseases we now vaccinate against, never mind witness a death

The 1921 annual report of marriages, births and deaths painted an unrecognisable picture of Irish life 100 years ago. With tenements a breeding ground for infection, before the arrival of vaccines and antibiotics, there were 7,651 recorded deaths from tuberculosis in 1920. Almost 11,000 succumbed to influenza over two seasons and measles caused the death of 505 children. It was the cruel normality of Irish life that communities were ravaged by deaths which are now entirely preventable, such as typhus and diphtheria.

As we know, infectious disease remains endemic in some nations and continues to cause suffering globally. In 2018, 1.5 million people died from tuberculosis and 400,000 from malaria. Other countries have suffered catastrophic epidemics, including the death of 2,000 from an outbreak of the Ebola virus in the Democratic Republic of the Congo last year.

In Ireland, however, most doctors rarely encounter the many diseases we now vaccinate against, never mind witness a death. Mortality from infectious disease has precipitously fallen and it is the non-communicable diseases of cancer and cardiovascular disease to which the majority of humans now succumb, due to the parallel successes of socio-economic progress and modern medicine.

Today, our normality has radically and suddenly altered.

For the first time in generations our insulated island is facing the threat of infectious disease which, without public health measures, could reawaken the vital statistics of our past. A wave is hitting us, yet we are uncertain how hard.

On Friday March 13, the model of general practice in Ireland, which had existed for decades, changed overnight. Traditional face-to-face consultations were replaced with phone-consultations, emails and video-calls. Our open doors were closed to all patients with respiratory symptoms. This disruption, which forced GPs and the HSE to innovate and collaborate closely, will change general practice forever.

The same routine care continues, just in a different manner.

Babies are still being vaccinated in our practices, antenatal checks are continuing, and those who really need to see a GP in person will be accommodated. Over the coming weeks, many healthcare contacts will be made over the phone, from mental health problems, to renewing prescriptions. It is a massive credit to the Department of Health, HSE and the representative GP organisations that the software systems and processes to enable this change have been resourced and created so quickly.

There have, of course, been understandable problems. The Covid-19 pandemic has placed enormous strains on supply chains internationally. Accessing protective equipment has been difficult, including masks, gloves, alcohol gel and packs of prophylactic protective equipment (PPE) for assessing symptomatic patients. Many GPs have been frustrated seeing patients in our practices without adequate equipment, exposing us to the potential of getting sick, which could potentially close down an entire practice.

Accessing PPE will be essential to keep front-line community healthcare staff healthy, enabling them to see patients with Covid-19 who may require assessment, but not hospitalisation.

As of March 20, 22 per cent of those infected in Ireland were healthcare workers. Many doctors with symptoms of Covid-19 have met significant delays in getting tested, which has strained front-line capacity, as they remain in self-isolation. Expedient testing of all healthcare workers must be a priority to maintain the system’s capacity and our staff’s morale.

Patients with a new fever or cough, who think they may have Covid-19, have been advised to call their GP who will advise them about self-isolation and can refer them for the diagnostic test for Covid-19, which is with a swab of the nose and throat.

GPs have been able to request this test only since Tuesday March 17. An appointment to get it can take in excess of three days and there are further delays awaiting the result. To put this in context, no patient in our practice had been tested and received a result as of last Friday (March 20), even for those who told us they were symptomatic 10 days previously.

Whilst this is understandable, it means that the statistics which are released to the public may be a considerable underestimate. This point is important, but will just be of academic interest alone, as long as persons who are symptomatic heed the advice of self-isolation from their GPs and the general public abide by social distancing and hygiene measures advocated by public health specialists.

Prevention is undoubtedly the best strategy for this crisis. The “flattening the curve” analogy has struck home, under the leadership of Dr Tony Holohan, the chief medical officer, and Simon Harris, the Minister for Health. We have also seen a cohesion in our profession mirroring that in our society. GPs and hospital doctors have been educating ourselves in our free time on the changing guidelines, models and pathways of providing care.

It can be hard to see any positives in these times of great uncertainty and economic hardship, but it is important that they are acknowledged. Look at the pride in our healthcare services. Look at how we have rallied behind the public health advice on social distancing and workplace closures. Look at the collective support for the vulnerable in our communities. Look at political cohesion behind our existing cabinet, which would have be unimaginable one month ago. We need this hope for the coming weeks.

Whilst most of us who get infected with the Covid-19 virus will be cared for in the community, some will require hospitalisation, especially those with long-standing chronic illnesses and those who are over 60 years old. Some may become very unwell requiring oxygen and ventilation. The limited capacity of intensive care beds and ventilators in our healthcare system has been well-documented. Preventing community transmission is the best hope we have, but we also need to prepare for all eventualities, including a sudden surge of critically-ill patients. Our hospitals are preparing for that wave.

For the first time in generations, our insulated island is facing the threat of infectious disease which, without public health measures, could reawaken the vital statistics of our past. A wave is hitting us, yet we are uncertain how hard it will hit.

Dr Mark Murphy is a Dublin-based GP

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