No single individual or branch of medicine has been untouched by the pandemic and our governments’ responses to it.
In general practice, the opening of the telehealth sluice gates has fundamentally changed how GPs are treating patients. It has also affected how many patients they are seeing over the threshold of their surgeries.
And while, in the short-term, telehealth has been a safer way of at least triaging patients with flu-like symptoms, it is raising concerns in the GP ranks, given its limitations and the fear the pandemic has created in the community, that there will be a dangerous spike of unmanaged chronic disease symptoms in a few short months.
It is a message that now needs to be heard from the chief medical officers and politicians during their daily media briefings.
Infectious diseases clinician Dr Nick Coatsworth (who also happens to be a UWA medical graduate) was the first to highlight the issue when he was on media duty over the Easter weekend. He reassured the public that there was an extremely low chance of COVID-19 infection for those requiring a doctor or pathology visit for their chronic conditions. He urged people not to neglect their general health.
It is an issue that worries Armadale GP Dr Ramya Raman.
“There is a lack of chronic disease management right now because patients aren’t coming to us for their follow-ups as they normally would. We must brace ourselves for a spike of poorly managed diabetes, COPD, polypharmacy issues in elderly patients, falls, hip fractures to all sorts of cardiovascular health,” she told Medical Forum.
“All of which, may, of course, lead to many more people occupying a lot of hospital beds.
“We are grateful for the introduction of telehealth but there are challenges and, I can tell you, that I am certainly missing my face-to-face consults with patients.”
While fear of COVID-19 keeps some people from visiting their doctor, despite surgeries taking pains to limit numbers in waiting rooms, it is a complex reality facing GPs and practice owners and it may take some time to reel in.
With so much media talk, speculation and the all-too-real financial and social impacts of the tough public health measures, the science of treatments and vaccine may be the few things that are able to cut through.
However, in the meantime, there must be some semblance of business as usual for general practice.
Ramya said the practice for which she works, Skye Medical Armadale, has started outdoor flu vaccination clinics, which are giving her and her colleagues a chance to eyeball some of their patients they hadn’t seen in a while.
“We’re minimising patient contact and maintaining the social distancing rules but still having a consultation per se, making sure we are recording all the essential vitals, administering the vaccine and monitoring post vaccine administration. The response from our patients has been overwhelmingly positive with this set up,” she said.
“With this current pandemic and the dynamic changes our health system has seen, I think my colleagues would agree that general practice is not going to be the same moving forward.”
As a GP with special interest in women’s health, Ramya is aware of the potential impact of family domestic violence (FDV), especially in this current environment of social isolation, job losses, financial stresses and health concerns.
It would be a sad reflection of society’s failure to stamp on FDV if it were to be considered a chronic disease, but like mismanaged diabetes in the time of COVID, there is great fear that it is increasing and going unreported.
Because of the subtleties of presentation to GPs, it is hard to prove that isolation, fear and mounting tensions alleviated by alcohol and substance abuse has caused a spike in FDV incidents in WA. Though some reports from China, during its severe lockdown, indicated that FDV had increased by 30%.
“It is a complex area because people don’t tend to come in with FDV as the presenting symptom. Certainly, mental health concerns like anxiety and depression, have spiked in general practice in the past four weeks.” Ramya said.
“Self-isolation, stresses around finances and job losses, restrictions in movement, worries about children and elderly parents are some of the challenges. It’s all about the anxiety and stress that generate these concerns and the aftermath of these.
“There is also an increase in alcohol and substance abuse because people are staying at home and it adds up to family and domestic violence, particularly when there are already predisposing factors.”
Ramya says some of the flags for possible FDV is a person presenting with multiple physical symptoms and symptoms of anxiety and depression or poor sleep.
“What the RACGP is advocating so strongly for is to keep FDV in the back of GPs minds when they are seeing patients. The conversation is subtle and may start with an update on what is happening at home. Or noticing a bruise and inquiring what had happened, these gentle probes may help a patient to open up.
“Family medicine is complex and dynamic. GPs are often dealing not just with one family member; we are usually are seeing the entire family.
“Certainly, women don’t present these things symptoms initially. It’s up to me to keep a log of the emotional, physical or financial concerns that they have, the relationships that they are holding with their families, identifying any potential risks the kids may have. I usually document how old the kids are, what is the relationship within the family; is it a mixed family dynamic? Who else is living at home?
“And importantly, it’s ensuring that I make a follow-up plan with them because it is a safety measure. This is by far the most important thing, for women to feel safe, and we must work with patients to ensure they have a safety plan in place in case things go bad.
“Knowing how to manage these situations; how to refer a patient to the right place using the right resources, is essential. That is the message the RACGP wants heard. The College’s White Book is an excellent resource and it is regularly updated, and 1800 Respect is also an excellent resource.”
“There are some incredible resources alongside the White Book and 1800 Respect – Relationships Australia and Lifeline and there is a 24-hour FDV helpline for both men and women (https://mccwa.org.au/fdv.html). I also see a role for safety apps and frequently recommend the Daisy, Sunny and Girls Gotta Know apps to my patients.”
For Ramya, her role as the trusted family doctor is what makes her get out of bed every day and go to work.
“Listening to your patient, giving time to your patient and validating their disclosures and protecting their privacy is a responsibility but it is also privilege and the foundation of general practice.”
ED: Dr Ramya is a GP with special interest in women’s and children’s health. She is a medical educator at WAGPET and the School of Medicine, University of Notre Dame, Fremantle. Ramya is also an elected council member on the RACGP WA Faculty.