Covid-19: Don’t forget the impact on US family physicians

Dear Editor

The crucial role of the General Practitioners (GP) in the global COVID-19 pandemic (1) has received relatively less attention (1). A significant daily load of GP in most countries comprises patients with upper respiratory symptoms. The first case of COVID-19 in Singapore was an imported case from Wuhan. The primary healthcare system was fully prepared because of previous experience in managing SARS (severe acute respiratory syndrome) in 2003 and H1N1 pandemic in 2009. The Public Health Preparedness Clinics (PHPC ) were activated, government subsidy was given for patients with respiratory symptoms at these clinics, and all healthcare workers followed the World Health Organisation recommendations to wear a surgical mask at work and to don full Personal Protective Equipment (PPE) of N95, gown, gloves and goggles when engaging COVID-19 suspects.

All patients who returned from Wuhan were quarantined, and those from other parts of China had to serve a 14 days Leave of Absence (LOA) from work. Some of these efforts and the low number of new COVID-19 patients earned Singapore international praise for its “near-perfect” system, due to her ”strong epidemiological surveillance and contact-tracing capacity” according to a Harvard study (2).

As more countries got affected by COVID-19, Singapore encouraged her citizens to return home from United Kingdom, Europe and America etc and that’s when we saw our second wave of infections. These returnees were not allowed to leave home for 14 days under a Stay-Home Notice (SHN). Singapore had an efficient ring-fencing strategy with case contact tracing for every infected patient, and close contacts were put under SHN for 14 days. Almost daily, criteria for definition of suspect cases changed. All at-risk cases were sent by a dedicated ambulance to the National Centre of Infectious Diseases (NCID) for diagnostic swab. When these patients were diagnosed to be positive for COVID-19, the clinics assisted in the contact tracing of patients who had visited the clinic within 30 minutes of the confirmed patients’ visit to that clinic. As early COVID-19 cannot be distinguished from common cold or influenza, GPs issued 5 days of medical leave for all patients with respiratory symptoms. Teleconsultation at the clinic premises became more popular despite limitations such as risk of diagnostic errors.

Despite these measures, we saw our third phase where cases surged (from hundreds to a few thousand) exponentially over a period of one week with foreign worker dormitories forming clusters of infected patients, and evidence of widespread community transmission led to an escalation of swabbing for diagnosis, with the primary care clinics roped in to conduct swabs, and setting up of large scale isolation/recovery centres outside the hospitals. The evidence for presymptomatic spread increases the difficulty of early diagnosis of COVID-19 for the GP, while Singapore launched widespread use of masks for all and focussed on safety distancing.

Throughout this short evolving period of challenges, GPs had to adapt quickly to the rapidly changing criteria for case definition for action through the real time constant updates via the National Task Force various communication channels. With energy sapping preparation, GPs invariably spent less time with patients even for those affected by psychological problems as a result of COVID-19. The information overload from social media (some were Fake news) led to many time-consuming queries from patients (such as use of hydroxychloroquine). GPs were also affected by “COVID fatigue” and burnout including closure of clinics for disinfection or manpower difficulties. Single GP clinics with limited resources faced triage problems. There were also limited management guidelines for GPs dealing with vulnerable groups such as paediatric and obstetric patients with conditions aggravated by the direct or indirect impact of COVID-19.

COVID-19 will invariably lead to a new norm for GPs with paradigm changes in clinical pathways (such as site of testing and referral system), and governmental changes in policy, primary healthcare delivery and support systems. Solo practice GP may potentially be more affected. The optimal use of telemedicine in primary care has not been systematically studied and not yet widely accepted by the population and even many doctors are not familiar with it, especially the medico legal risk, and the difficulty in delivering a holistic care without face to face contacts. These are the challenges GPs globally have to face regardless of geographical locations and cultural differences. Guidelines taking into account local issues will need to be swiftly revised as well with the evolving landscape changes in COVID-19 (3).

Philip Kheng-Keah Koh, MBBS, MMed (Family Medicine ), Eng-King Tan, MBBS, FRCP (UK)

References

1. Kamerow D. Covid-19: Don't Forget the Impact on US Family Physicians
BMJ. 2020 Mar 26;368:m1260. doi: 10.1136/bmj.m1260
2. R Niehus, PM De Salazar, A Taylor, M Lipsitch. Quantifying bias of COVID-19 prevalence and severity estimates in Wuhan, China that depend on reported cases in international travellers. MEDRxIV doi: https://doi.org/10.1101/2020.02.13.20022707.
3. Razai MS, Doerholt K, Ladhani S, Oakeshott P. Coronavirus disease 2019 (covid-19): a guide for UK GPs. BMJ. 2020;368:m800. doi: 10.1136/bmj.m800.