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.
COVID-19 has impacted all medical specialties with an ability to affect any part of our bodies from the top of our heads to the tips of our toes. Being a generalist, I have really enjoyed speaking to some of my friends from medical school on how this virus has affected their specialties and seeing how much overlap there has been with mine. Therefore, I thought I would set these conversations out through pan-specialty mini-series of the through the lenses of different health professionals in the UK. This week, I wanted to pen the thoughts of my dear paediatrician friend, Dr Lucy Pickard (who has previously helped me understand the American health system – link to post here) which is the product of multiple chats over lockdown but also a more formal chat over a cup of socially-distanced tea – how very British.
The effect on paediatric presentations
Apparently, like us in family medicine, paediatrics have had a drop in patient footfall from the start of the pandemic. It is thought that this is due to a reduction in patients presenting with minor illnesses because people are advised to stay away from hospitals and clinics but also because they’re also afraid to expose themselves to the disease. As you can imagine, this has led to more delayed presentations to hospital, resulting in patients with later stage pathology arriving. I’m really not surprised by this because, in my day job, I haven’t seen a single upper respiratory tract infection (URTI) since the beginning of lockdown and I wonder if this is because of the reduction in infections because of the hand-washing public health measures or because parents are having a higher threshold before reaching for medical help. Lucy points out that even if the number of infections reduce, children should still be developing the same rates of diabetes or leukaemias: where have they gone? Lucy is actually doing some fantastic qualitative work where they are trying to identify barriers to access for parents in the current climate. Preliminary results suggest a fear of catching COVID-19 at hospital but also a feeling of guilt that the NHS is overwhelmed at the moment and also a misconception that hospitals and clinics are closed. I’m hardly surprised by this because the public health messaging has been focused on staying away and saving the NHS. When I have had to call another GP or call the hospital, there is a two-minute automated recorded lecture before reaching the receptionist or switchboard telling me to stay away. I am really aware of the painful conversations that I am having with patients with sick children who need coaxing to seek help. One mother comes to mind who had one sick child (who needed medical attention) and another child who was shielding and she couldn’t decide who to protect more – which must have been an agonising decision for someone who was just trying their best with the information that she had. Basically, how do we make patients feel cared for whilst minimising unnecessary consultations? That’s the million-dollar question.
PIMS-TS stands for Paediatric Inflammatory Multisystem Syndrome Temporally associated with COVID-19 (the word “temporally” here is used to mean “association through time”). Some of you may be aware of the wave of fear that swept through UK general practice and paediatrics a month or so ago about a condition that resembled Kawasaki disease after an NHS England letter was “leaked” and was doing the rounds on social media. I promptly forwarded it to Lucy at the time who had already seen it only a few days before. Very little data exists for the condition since it is still rare and, like most COVID-related diseases, we are learning something new about it daily. If you would like some reliable information, RCPCH have very helpful guidance that is updated weekly. What I’ve taken away from my conversations with Lucy is that it may be a condition, like Kawasaki’s, which is an inflammatory response to exposure to the virus, but not a direct effect of the virus itself. We just don’t know enough yet. She feels that family physicians’ highly-tuned sense of spotting who is and who isn’t a sick child in our consultation room has never been more important. She really encourages us to trust this experience and to have a low threshold to call local paediatricians if things don’t add up. In response to this, with others, she has helped develop a service for local GPs where they have open access phones lines and email hotlines as well as the capacity to do video consultations to support their primary care colleagues. I’m sure we’re all hoping that this service would be rolled out worldwide!
We also talked about the importance of checking sources. When I first came across this letter, I thought it was a joke but other doctors were reacting to it as if it was gospel. I’m still not sure if that letter was real but it does give lessons on taking conversations out of context. Given the overwhelming amount that we had to learn in a short time about coronavirus, these social media forums were like a breeding ground for anxiety for health professionals where any new material could trigger a tsunami of panic and fear. The time of covid, for me, was marked by a true belief that verification of facts and using our training to be level-headed before forwarding or posting were needed more than ever.
The effect on doctors
Lucy, being on the cusp of becoming a consultant, has remained in her role as a paediatrician but many of the paediatric junior doctors were re-deployed to ITU as soon as the hospitals started to restructure and are only just now returning to their normal rota. She tells me that some of the conversations that she has had with he juniors since has been heart-breaking. There have been harrowing stories of patients facing illness and death alone; of feelings of medical impotence against the virus; of doctors themselves who have not been able to see their own sick relatives. I think, in general practice, we are relatively spared the direct heart-ache of COVID even though we will be dealing with it indirectly for years to come. Lucy points out that this is the first time for many of us, as doctors, have had to face our own personal frailty and fallibility – even our own mortality. We’ve had to come to terms with a totally new level of caution and a totally new level of self-protection in our practice that we were not used to before. I would even say that we have had to deal with the vulnerability of not knowing anything which is hugely humbling. We have had to go from feeling invincible to feeling incredibly vulnerable (physically, mentally and clinically) in a matter of weeks which is the antithesis to the doctor personality. The repercussions for our patients are predictable but I do wonder how this will play out in our medical community.
Social determinants of health
I love the fact that paediatricians are as clued up about social determinants of health as we are in general practice (in fact, I love the fact that Lucy is a generalist because there is so much overlap in what we do). Particular to this subject, Lucy is quite worried about schools remaining closed. I remember, at the beginning of the pandemic, that many of my parent friends felt that the government should have closed the schools earlier but I’m starting to see the long-term impact of mass closure of education. I don’t think there are any right answers here and I’m certainly not able to say whether keeping schools open or closed was or is the right policy but there has been a few thoughts in my mind that I feel relieved that Lucy has been pondering over too.
Firstly, we know that children from affluent backgrounds are more likely to have internet at home and more devices for home-schooling. The Good Things Foundation state that 1.9 million households do not have internet and they argue that digital inclusion is necessary for social inclusion. When children are being home-schooled whilst schools are closed, digital exclusion will mean educational exclusion. School is to some extent a leveling ground for social disparities and the closure of schools will only widen the education gap. Research conducted by Michael Marmot states that, pre-COVID, there is a noticeable widening of disparities during summer holidays that are only rectified when the children return to school in September but this pandemic is like the perpetual summer holiday with ever increasing gaps. With an impending possible public funding, are community projects and libraries at risk, meaning vulnerable children suffer more?
There is another aspect of school closures that Lucy points out as harrowing. Teachers and staff are trained to look out for signs of safeguarding issues – whether that be neglect or abuse – and we have lost that sentinel during school closures. Households being locked down for over two months with all the heightened emotions around COVID and the frustrations of lockdown is a perfect storm for domestic violence and child abuse. I haven’t seen any safeguarding issues yet but this has made me really think about the cohort of children who are not being seen by their GPs or teachers, especially as remote work becomes the norm. I don’t have any answers here and neither does Lucy but it is the grim reality of COVID-19.
New ways of working
On a slightly brighter note, we talk about new ways of working and the positives that COVID has brought the NHS. It is certainly a time of innovation and working together. As mentioned before, there have been new phone-lines and email hotlines set up and her department have moved over to remote consultations with only a select few who are seen face-to-face. She kindly says that she has learnt much from her GP colleagues about remote consultations although I have also pointed out to her that this has been patchy for us too pre-pandemic. The positives for us in primary care are that we have universally and collectively been allowed to update to the 21st century.
Will this be the future of paediatrics? Lucy misses the face-to-face consultations and we talk about how just laying a hand on patients, both for clinical diagnosis but also as part of the doctor-patient relationship, is so necessary. Given the current restrictions, Lucy says that video consultations have been great for building rapport as she doesn’t have to wear PPE so children and parents can see her face. She also points out that there is a flatter hierarchy between herself and the patients’s family as they are both consulting from their own natural environments and not exclusively on her turf (i.e. the hospital outpatient clinic). When so much of our work centres around compassion and rapport-building, I do wonder what long-term impact wearing masks and remote consulting will have. Certainly, in GP, we can have several mundane consultations to build rapport for the time we are really needed; for Lucy, her patients have waited months to see her and this is the one time they get to speak to the specialist. We will have to see and decide what innovations to keep and what to give back.
I generally love putting the world to rights with Lucy but this has been a fascinating foray into the paediatric world for me. I feel that we have the same concerns about the future of our patients and our services even though the size of our patients may differ. I feel that we both have been dealing with the indirect effects of COVID-19 but will be picking up the pieces for years to come from the mental health and public health fallout. I know that Lucy has dedicated herself to integrating primary and secondary care more than your average specialist and I really hope that this sentiment continues and becomes widespread as I feel that we have a lot to learn from each other.
You can follow Lucy on her twitter account @Lucy_SSP