How will the COVID crisis affect our practice?
Carlos G. Naval, MD, MBA
Correspondence: Carlos G. Naval, MD, MBA
Galileo SurgiCenter, Mandaluyong City
271 EDSA, Mandaluyong City
e-mail Address: firstname.lastname@example.org
Disclosures: The opinions expressed in this editorial are those of the author and do not reflect the views or opinions of the PJO editorial staff.
The lockdown is unsustainable. Eventually, the government will have to allow establishments to open and the flow of goods and people to resume. That life will simply revert to what it was before the lockdown as if nothing happened is a fantasy.
The SARS-CoV-2 virus will not disappear and cannot be eradicated unless an effective vaccine is found. Just like influenza, an equilibrium will develop with the human race co-existing with the virus. At that point, SARS-CoV-2 may circulate among a portion of the population with mild or no symptoms and be transmitted from person to person until a “seasonal” outbreak occurs when a bunch of susceptible people get infected and display severe symptoms. Then, the person-to-person transmission will be broken as the virus encounters people who have developed antibodies to it, the so-called herd immunity effect. Hopefully, future outbreaks will be small, uncommon, and quickly over.
The fear of the highly contagious nature of this disease and the complication known as acute respiratory distress syndrome often followed by intubation and death, stoked to a frenzied hysteria by 24/7 media coverage, motivate most to stay indoors. This fear will outlast the epidemic for sure.
When the lockdown and the enhanced quarantine policies are relaxed, the persistence of the virus and the trepidation for an invisible enemy will change our patients’ behavior and would alter our clinic procedures in several ways.
More clinics will probably convert to strict appointment systems to ensure adequate physical distancing between patients and less crowding. The number of companions will be limited to one, if a companion is necessary at all.
At first, clinic hours will be reduced and appointments will be restricted to urgent or semiurgent cases for two reasons. On the supply side, health care providers including the doctors will want to reduce their exposure to patients. On the demand side, patients who are not very symptomatic will most likely postpone their appointments. Budgetary constraints will also affect the demand side because of the economic slowdown brought about by the lockdown.
Air purifiers in the waiting rooms and clinics may become standard appliances. Seating will be arranged to put a distance of 1-2 meters between patients. Wiping down clinic furniture and other surfaces will have to be done periodically and often.
Social distancing will be the norm and certain habits, such as hugging, patting the shoulders, and other means of close contact, will be consciously minimized and replaced by gloved-hand gestures and smiles unseen behind our masks. Wearing masks may become very common for patients stepping out of their houses and we would not be surprised for these masks to become transformed to fashion accessories in due time. Healthcare personnel will be expected to wear surgical or N95 masks, replacing blazers and white coats as embellishments of the health profession. Perhaps some will wear caps, goggles, and face shields but impracticality will possibly limit this set-up to procedures that require close contact with a patient such as fluorescein angiography, biometry, and intubation and extubation for general anesthesia.
Bottled sanitizers will make a huge comeback and everyone will be more aware of the need to wash and sanitize their hands after touching objects. The paranoid will be even more paranoid bringing sterilizing sprays in handbags to clean anything they touch or sit on. Eye instruments will have to be sterilized, particularly the chin and forehead rests of the slit-lamp in an almost theatrical manner demonstrating to patients that they are sterile prior to use.
Examining patients will present with some difficulty. Disinfecting or washing our hands will be an alternative to wearing gloves which we would have to be changed for each patient. Breath shields will be a standard feature of slit-lamps. Talking will probably be restrained and done at a safe distance. Sterilization will be absolutely necessary for lenses, instrument tips or probes for examinations requiring contact and these procedures will probably lose favor for noncontact equivalents when possible.
Telemedicine systems have come to fore. Previously planned for the future or not at all, many doctors are now suddenly looking at this as an alternative to face-to-face consultations for non-urgent cases. Monetizing these online consultations and recognizing the limitations, the ethical implications and the medicolegal repercussions of online consultations have not been addressed completely.
Elective surgeries will resume but not at the same pace as before the lockdown. On the one hand, the fear of the patients to exposure especially to hospital environments will make patients hesitant to schedule surgery. On the other hand, PhilHealth will lag in processing pre-surgical approvals, claims, and payments, shifting their manpower and other resources to the COVID-19 response.
The effect of the COVID-19 crisis on the economy will be felt by most. Revenues of medical facilities will go down with reduced patient load and clinic hours. Costs will increase with extra measures to ensure sanitation of the facilities and equipment, to sterilize instruments, and to provide protective equipment for all personnel.
There will have to be adjustments to the “new normal.” How long before we get back to our comfort zone of face-to-face personalized patient care? Much will depend on the perception of how much risk that another epidemic erupts and another lockdown is triggered, and of our confidence in having mitigated that effects of that.
In short, like in all crises, after some time, an equilibrium will be reached. A balance will be realized between the patients’ needs for eye care and their fear of the virus, between the doctors’ desire to prevent spreading the infection and the necessity to resume working, and between the constraints of consumers’ finance and the business needs of the healthcare industry. But, unlike past crises, where the effects are acute and temporary so that recovery is quick, the pandemic will produce longer lasting repercussions. Prices for health care will go up for sure. The cost of keeping the virus at bay will certainly add to overhead costs and to the contingency funds for mitigating complications and liability of infection, which will be passed on to the patients and their payers. Yet, revenue shortfalls are expected due to the diminution in demand. Seemingly, the only way for us to cope will be partly to sacrifice and live in an environment with less income or try to bridge the gap by charging more.
Another way is to innovate to provide the same quality of service safely and contain costs by being more efficient and effective. This crisis has exposed our vulnerabilities. It would be a fantasy to think that we can go back to what we were doing before the pandemic; it is an opportunity for us to scrutinize those vulnerabilities and transform our practice to something that is more crisis-proof. So, with the additional free time we now have, take a few hours to face the new reality and plan to adapt, or perish as an indirect fatality from the COVID-19 pandemic. Good luck to us!