A German family doctor in COVID-19 – can a decentralised system centralise a pandemic response?

DISCLAIMER: I do not intend for these blogs to be seen as giving clinical advice nor as judging public health policy but rather to recount the lived experiences of family medicine physicians from across the world. I recommend you still follow your local guidance but this goes without saying.

Date of interview 15th March 2020

Number of confirmed cases at time of interview: 3062

Number of deaths at time of interview: 6

Population of Germany: 82.8 million people

Today, I am interviewing Dr Christian Rechtenwald who lives near Wurzburg in Germany. The first case was diagnosed at the end of the January in Bavaria and the rapid spread is alleged to be due to a couple who had attended multiple large events before developing symptoms. Germany, the well-respected economic powerhouse of Europe, has only just now been overtaken by Spain and France for number of confirmed cases but has a surprisingly small proportion of deaths secondary to COVID-19. Christian is not entirely sure why this is so small but suspects that it is most likely just because of a time lag and that this will increase rapidly soon too.

Germany is split into 16 federated States which means that there is variation in how law is manifested across the country. Because of this it is virtually impossible to implement a top-down system that would control the whole country. The Health Minister can only suggest recommendations but not enforce them. Christian says that some regions are on lock-down and some aren’t; the numbers allowed to gather at one event are also different (as a side note, I’m wondering how Berlin’s famous nightlife is going to manage!); schools are closed in some places and some are not and so forth. So we are only able to focus on Christian’s local area in this blog post.

All the regular consultations get triaged by phone initially before allowing the patient to come to the clinic and sick notes for a week can now be written without seeing the patient. They try to see any patients with fevers towards the end of the clinic too to avoid mixing the well and possibly sick patients. Something I find very interesting from this conversation is how referrals for testing are done. So far, in all the interviews I have conducted so far (Hong Kong, Italy, Japan and UK), there is a centralised telephone number that the patient calls directly. In Christian’s area, the patient would call their local doctor who would triage and it would be the doctor who would call the special phone number to refer the patient for testing if high-risk. I can see the benefits immediately as it would alleviate the pressures on the people receiving the phone calls as the worried well would be filtered out (NHS 111 can have a waiting time of up to an hour). It does mean that tests are rationed to those who have been assessed by a clinician (albeit by phone) rather than questions from a protocol. However, although Christian is in favour of this system, he does feel that it is a bit complicated and also I wonder how much of the family doctor’s time must be used to manage the worried well. Clinicians in community clinics do not routinely wear Personal Protection Equipment (PPE) and an order that they made four weeks ago for some masks still hasn’t arrived. Christian is pretty relaxed about this at the moment and is currently using a simple surgical mask when required.

Another interesting point is that if there is a suspected positive case, the clinic has to close down until the test results come back. If positive, the clinic needs to remain closed for the full two weeks of quarantine and, if negative, it returns to business-as-usual. I can imagine that this must drop the workforce considerably when clinics are quarantining and I wonder if this will have to change if the virus gets more prevalent.

Schools will be closed as of next week in most regions in Germany which will affect Christian as he has a young son. He says that most people have been discussing whether they should really be allowing grandparents to look after them but, thankfully for “critical staff” (healthcare workers etc), special daycare institutions will be opened. However, this will pose other problems because a smaller number of children will be attending from a larger area and we wonder if this might somewhat defeat the purpose of closing the schools in the first place.

We recognise that there is much clinical uncertainty and misinformation, even amongst medical circles, and we can only imagine how confusing it must be for patients. One of the things I find interesting in my own circle of friends is that, although my peer group seem to be fairly clued up, we are all having a hard time convincing our parent generation. Christian has also noticed that the older patients are more resistant. Even when he is going for a walk in his village and chatting to the local community, he is surprised at the fact that they are not very well-informed. He had a meeting with his local mayor today and they have jointly agreed to post flyers through all the letterboxes of their village to give useful information to its citizens on how to stay safe and how to look after their loved ones. I think this is a really excellent initiative that Christian is starting and reflects the role he has in his community as a family doctor. He thinks that once the death rate increases, the awareness will increase and the seriousness of the situation will finally be understood.

I ask him how the medical workforce are holding up in Germany. He said that the mood changed for the worse last week. He also saw on Facebook several of his nursing colleagues posting about Personal Protection Equipment and hand sanitisers being stolen from hospitals by members of the public. This is also happening in the UK which is obviously very disappointing news and Makoto did describe some masks being taken home by students in Japan (taking something that’s not yours in Japan is hugely frowned upon so this is a big deal).

What I find interesting about the COVID-19 response that Christian describes is that it reflects the decentralisation of the government. Each German state has their own way of containing the virus and, within that, the clinics are doing their own thing. There appears to be so much variation. This must be a nightmare to co-ordinate as a Health Minister and it must be quite challenging as a front-line clinician. Christian does think that it would be useful to have one singular guideline rather than nuggets of information from lots of different sources but I guess that’s the same with everywhere. I don’t think we had much guidance until last week in the UK. Regardless, this is not quite I had imagined of Germany which is a country that has an international reputation of being so together.

A UK friend said to me yesterday that he thinks that the COVID-19 epidemic is accentuating a lot of his friend’s underlying personalities – borderline anxious friends are cancelling everything and pragmatic friends are getting even more practical. I feel the same about cultural differences. Christian feels that the German system is “typically German'” and on the complicated side. We, in the UK, obviously do have this central government but not everyone agrees with their policy and this is played out on social media (to me, this feels like the equivalent to everyone at the pub talking about their strategies on football matches). However, one of the things I love about the British is the ability to pull their socks up when we need to do it. The preparation that the hospitals are doing in the UK is as organised as major incident planning. Having helped out as a student at the 7/7 bombings, I have full faith that they will be ready and we as GPs should be ready to look after the less sick to take the pressure off them.

Christian jokes saying that the only way we will know what works is by seeing who is still standing at the end. Dark jokes aside, I really don’t think he’s wrong! There is so little information out there and so little outcomes that can be reliably predicted that who knows what is the right answer. Until then, we should work together and support each other internationally where we can.

I wish everyone to be strong and have faith. Stay well, stay safe x

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