Bengaluru, New Delhi: Medical practitioners across the country are hesitant to return to work, even though lockdown has been eased for them and clinics allowed to function since 4 May.
And it is not just their high-risk jobs. They have also been facing difficulties posed by the lack of guidelines and sparse and uncoordinated supply of protective equipment.
Despite the predicament, however, more and more practitioners are opting to restart their services, given that the pandemic is likely to persist in the coming months.
ThePrint spoke to several of these practitioners who described the challenges they face, their fears with reopening their practices and the precautions they are willing to take.
Emergency services vs other consultations
Some emergency non-Covid medical services remained open through the lockdown, though most operated at reduced capacity for social distancing purposes.
“I work in the neuroanaesthesia department, so my work profile is centered around operation theatres and ICUs,” said Dr. Dhritiman Chakrabarti, neuroanaesthesiologist at NIMHANS, Bengaluru. “Our elective cases had stopped for a while during the lockdown for around two weeks and have now been opened at a reduced capacity.”
“Emergency and ICU services continued as usual,” he added. “The rosters were structured such that half the staff were working at any point of time, to preserve staff in case of an inadvertent contact with a Covid patient necessitating quarantine.”
Other non-essential medical operators and private practitioners have found other ways to provide services.
“We realised we were not an essential service and closed our clinic two days before the lockdown was even announced,” said Dr. Latika Arya, a dermatologist in Delhi.
“For now, we are doing online consultations. We will open on Monday, but it’s not a free walk-in clinic. It will be on selective appointment,” she told ThePrint last week. “We will first understand from patients their concerns. And if it can be managed on tele-dermatology, we will request them to take online or video consultations.”
“I haven’t resumed clinic practice yet,” said Dr. Gowri Kulkarni, a general practitioner based out of urban Bengaluru. “Most of my clinic patients prefer to reach me on call or via messages, as they feel it is safer.”
“Most acute illnesses can be managed with a good history record and frequent follow ups, and need to be referred for physical consultation only if needed,” she explained. “Most of my chronic disease patients, like elderly with diabetes, hypertension, hypothyroidism, etc are all working with me online as it is definitely safer for them.”
For now, the internet has proven to be a blessing across the board.
“Yes, I have started online consultations,” said rural obstetrician Dr. Shantanu Abhyankar, who practices in the small town of Wai, Maharashtra. “Video calling is a better, more efficient system than physical contact, and also saves time.”
But this easy solution isn’t free of problems.
“There’s anxiety for both parties,” said Abhyankar. “I am unsure whether I am supplied with the correct and complete information, and the patient is constantly anxious about whether I have understood everything.”
“The medical legal implications for online consultations is still a grey area, and there are issues with fee structure and payment as well,” Abhyankar added.
Online-only practice also affects business.
“Because I’m not in the clinic, I can’t get new patients,” said Kulkarni.
“There has been a huge economic impact,” said Arya. “We used to see 20-25 patients a day, but with online consultations, I’m seeing 4-5 only. And many procedures have been stopped as well.”
While many practitioners will have to reopen clinics sooner than later, both for their own economic sake as well as for pressing medical needs of patients, starting to do so comes with a lot of uncertainties and worries.
The biggest worry for them all is that hospitals and clinics around the world are primed to become hotspots for newer clusters due to the sheer number of sick people coming in. There have been several hospital-hotspots cropping up across the country for the past couple of months.
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Back to hospitals
According to several healthcare professionals, when it comes to going back to work, there is definitely the fear of the unknown, especially of asymptomatic transmission occurring in their clinics or hospitals.
“The fear factor is definitely the generic emotion among all staff,” said neuroanesthesiologist Chakrabarti. “The main fear was due to lack of appropriate equipment and policy in the beginning. Now that has reduced a lot.”
He added that once a lockdown was imminent, many institutions acted quickly to procure PPE kits for future use.
“Doctors have been and will be at a risk of infection, but services have to go on,” said obstetrician Abhayankar. “We will lose some doctors but there will be others to take their place.”
However, beyond just doctor behaviour, patient behaviour is also a cause for concern.
“As a clinician, my biggest fear is lack of information from my patients,” said GP Kulkarni. “There is so much stigma created around Covid for no reason. I have had patients who have hidden a history of travel and contact, and this can be disastrous.”
Additionally, in many surgical rooms, staff have been trained rigorously and intensively to handle potentially infected patients who might land up on the surgical table.
“Since anaesthesia is centred around ICU care and since we handle the airways as part of general practice, we did an especially intensive training of our residents and faculty in all aspects of handling a potential Covid case,” Chakrabarti said. “The lockdown also gave us time to set standard operating procedures (SOP) such that later confusion can be avoided.”
But despite all preparedness, many institutions are facing a marked shortage of PPE. Additionally, PPE is not prioritised for general practitioners, dermatologists, or dentists.
Earlier this month, the Health Ministry issued guidelines on the rational use of Personal Protective Equipment in non-Covid hospitals and non-Covid treatment areas of a hospital with a Covid block. The guidelines directed practitioners to wear the recommended PPE kits based on their “risk profile”.
For instance dentists, ENT doctors and opthamologists who are at moderate risk, according to the Health Ministry, were advised to wear N-95 masks, goggles and latex examination gloves. Such practitioners have also been directed to wear face shields “when a splash of body fluid is expected”.
Meanwhile, those working from “doctors chambers” with a “mild risk” profile have been advised to just don a triple layer medical mask and latex examination gloves. The ministry’s guidelines disallows them from conducting any “aerosol generating procedures”.
The SARS-CoV-2 virus or novel coronavirus spreads through droplets, but aerosol generating procedures result in a process called aerosolisation, whereby the top layers of liquids and solids are converted to tiny particles that can float in the air — also known as aerosols. The process typically occurs during surgical procedures and autopsies, and poses a risk if the patient hasn’t tested negative.
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Confusing reopening guidelines
Despite the easing of the lockdown on 4 May, medical practitioners faced difficulties in accessing facilities given the curbs on movement between certain states. For instance, it became difficult to travel between Haryana and Delhi as five borders in Faridabad were sealed on 29 April and Gurugram intensified surveillance at state and district borders.
Speaking to ThePrint, Indian Medical Association (IMA) national president Dr. Rajan Sharma said the lack of proper uniform guidelines also meant private clinics and hospitals remained shut.
“We (the IMA) have written three letters pressing for one nation, one set of guidelines because the guidelines were changing district-wise, town-wise and state-wise,” he said “One person was saying if you don’t open up we will penalise you, the other said if you are opening then you cannot see fever, cough and other patients.”
Then, on 11 May, the home ministry wrote to all states advising them to reopen private clinics and nursing homes and allow the removal of restrictions on the movement of medical professionals.
“At many places, private clinics and nursing homes are also reported to have not been allowed to open. The functioning of these medical facilities, which supplement the regular medical infrastructure, and relieve the burden on the hospitals, is also crucial. I would urge all States and UTs to ensure that such clinics and nursing homes continue to function without any hindrances,” the MHA letter reads.
The IMA also held separate video conferences with officials of Maharashtra and Uttar Pradesh. Following the meeting with UP officials, the Yogi Adityanath government on 14 May asked doctors of private hospitals and nursing homes to provide non-Covid health services and gave permission to private hospitals and nursing homes to restart operations.
In Maharashtra, the meeting with the IMA culminated in the setting up of two committees at the state and district levels for the better coordination between public and private hospitals. The panels will also ensure that PPE kits, gloves and masks are made available to medical workers in private hospitals.
“This is an unknown enemy that is teaching us our strategy and making us revise our strategy on a daily basis,” Sharma added.
In the absence of clear guidelines from the Centre and state governments, the IMA, public and private medical bodies have issued their own set of guidelines.
“Although obstetricians usually see healthy women, there is a great risk of asymptomatic transmission,” said Abhayankar. “There are no quick tests or perfectly protective measures. Keeping this in mind, the Federation of Obstetric and Gynaecological Societies of India (FOGSI) has come out with guidelines to offer the best possible care. Currently, we follow these guidelines.”
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Extensive protection measures
Many institutions have finalised a set of standard operating procedures (SOPs) to be able to work as safely as possible with the risk of asymptomatic transmission. Avoiding physical contact, drastically slashing the number of patients walking in, and adoption of biosafety sanitising procedures are likely to be implemented in most medical institutions.
“We will not allow patients who are above 65, children below 10, pregnant women, and people who have any sort of uncontrolled medical illness (like cancer) or are immuno-suppresed,” said Arya about her dermatology clinic. “Regular patients who need routine follow-ups and new patients who need consultation will be treated online unless coming to the clinic is absolutely necessary.”
For those coming in, there are strict physical distancing measures too.
“Those exhibiting Covid symptoms like cough and fever will be screened out over the phone. Patients are given detailed instructions for their appointment before coming in,” Arya added. They have to wear a mask, and get their own water bottles and pens. No papers will be allowed. Medical records will have to be scanned and emailed to us.”
“After they’re here, they will first be made to sign a declaration. Then they’ll be directed to wash their hands for 40 seconds, after which they will be asked to wear a shoe cover and sanitize again,” Arya said. “The waiting area has been rearranged with physical spacing and fewer seats, and we’re avoiding making people wait as much as possible by spacing out appointments.”
Arya says she normally spends 15-20 minutes per patient, but now, each patient is being given a 45-minute slot.
The clinic doesn’t plan to restart any procedures, but whenever it does, the doctors would be wearing PPE, she said.
Neuroanesthesiologist Chakrabarti said, “We have SOPs regarding admission and treatment of every patient, from a Covid detection perspective and treatment perspective. There will be training of ground staff in those SOPs. We have to ensure availability of PPE and availability of testing kits and/or testing centers in close vicinity of the hospital (our neurovirology dept is conducting it now). There will be strict Covid screening and testing of all suspected patients, and I feel this is not being done properly everywhere at the moment.”
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Flattening the curve further
Despite such measures, however, some close-contact medical professionals have decided to hold off on resuming practice for a longer period of time.
“We dentists are in the high-risk category because we directly contact the patients’ mouths and fumes are released whenever we use the rotary tool,” said Dr. Divyangna Chaudhary, a dentist based out of Delhi. “I want to wait for the right time to open my practice because infections are increasing day by day and I don’t want to put myself in danger.”
A doctor or other hospital staff getting infected is usually the first step in a hospital outbreak.
Unless absolutely necessary, Chaudhary said, it is a waste of resources to stock PPE kits in the current climate for non-essential medical practices, and is currently planning to reopen his practice after at least another month.
Dr. Col. Saroj Kumar Ojha, also a dentist practising out of Delhi, said, “Practitioners should not reopen yet. They should wait for at least two months, or even until October. It is difficult to determine who is a carrier, so we must assume everyone is.”
“You are opening and working in people’s mouths, which is highly risky. And the virus passes so fast, it is very difficult to protect one self or others,” he added. “All emergency procedures should be done but no elective procedure should be done. We must first wait for herd immunity to develop.”
Arya echoed the sentiment to an extent.
“Ideally speaking, I would not like to open at this stage, but then you see that patients have real issues such as allergies or hair fall. So they do need care. And on the other hand, we have to open too, because this situation is not going to go away in a month. We know that precautions have to be maintained for six months to a year.”
But many cannot afford to push reopening due to the nature of injuries coming in.
Said Chakrabarti, “During the lockdown, emergency cases reduced as the number of head injuries came down. And we saw an immediate sharp uptick in head injuries the day alcohol shops were allowed to reopen. Most were DUI (driving under influence) accidents.”
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