Surviving general practice in 2020

North Perth GP Dr Jenny Fay looks over the past year of stress, fear, worry and new connections and friends.

2020 has been, without doubt, the most challenging year of my professional life as a GP. What started as a year of planned work, concerts and holidays has dissolved in a time of world crisis. My little part of the world is my family, both immediate and extended, friends and musical colleagues, and my general medical practice at 435 Fitzgerald St, North Perth.

We are a large general practice. We were hearing about a virus in China in January 2020, and then more obviously in February. At that time, it was confined to China, and then, soon after, a cruise ship in Japan.

My son had a planned holiday to Japan on February 16. There was some concern and discussion about whether this was a good idea to go or not. Over the next two weeks there was mounting anxiety and some hysteria in Perth and the rest of Australia, even though there had been no COVID-19 cases here.

Panic buying of toilet paper, liquid soap, gloves and masks happened
almost overnight with supermarket shelves and chemists depleted. As a medical practice, we had no forewarning. We had masks – but only 50 or so. We had a few containers of liquid alcohol gel. Happily, we had industrial rolls of loo paper!

I was really concerned at seeing queues of people outside Coles North Perth, well before 8am opening, and then people running to the toilet paper aisle. Shelves were depleted by 8:15 and the supermarket staff were beside themselves.

Staff at the practice were anxious, like the rest of our community. Decisions were being rapidly made, and then unmade as rules came and then were changed without warning. Hours of planning was undone when a new announcement was made. Patients had extremes of anxiety – fearful of catching disease, not going to work, possibly losing work, wanting to be seen while unwell, not wanting to come to the surgery, feeling vulnerable, caring for vulnerable relatives, travelling here from overseas, and later from interstate.

Simple and clear

Creating a consistent message for reception to give to patients was immensely stressful.

My email feed was increasing exponentially, and it was giving us multiple sources of advice – WHO, RACGP, Department of Health (Federal), Department Health (WA), Medical defence, AMA, Primary Health Network, HealthEd, local hospitals.

Everyone had their view of how GPs should best handle every aspect of general practice – from personal protective gear, swabs, concern for medical litigation, finance, Medicare changes, further Medicare changes, and then more Medicare changes. It was very disturbing and provoked a lot more angst when different messages were being given.

I was one of only a few people visiting local aged care facilities. My patients there were scared. Some were blissfully unaware.

I asked my own father-in-law if he had heard anything about a virus going around. His reply, “No. No. I don’t think so”. Lucky him. Some were only too aware, and very upset at restrictions that banned family members from visiting. I tried to take my time to chat with them, and to ring relatives to reassure them.

When I visited, there were always a couple of aged residents on the inside of a glass door, trying to talk to relatives outside the glass on a phone or iPad. Facility staff had to schedule appointments for phone calls. This was no way to spend your last days on earth and was very upsetting to witness.

Anxious times

I saw a lot more anxiety in my practice. I was becoming anxious myself. The responsibility I felt for our staff and for our patients was immense. It was a struggle to balance keeping my staff safe and well, and the need to see sick patients. I never expected to feel that illness might be risky to see, but that was how it came to feel.
I felt I was a risk to my own family. Several specialists and doctors consulted me as patients. They were anxious, tired and worried.

Travel and hospitality and the arts businesses have been particularly devastated. It was disheartening to hear of longstanding businesses that collapsed and highly respected people losing their jobs. I found it difficult to console when the future seemed very uncertain.

My friends know it was hard for us in general practice. I had two friends who offered to make me cloth masks. I would never normally think these adequate, but since we were very short of personal protective equipment, I accepted gratefully.

In March, we didn’t have more than a dozen gowns and were short on alcohol gel. We ordered a dispenser (even by August, it hadn’t arrived). Quite early, we had to remove face masks from the front reception desk as they were being taken by patients inappropriately. We ordered plastic barrier screens for the reception desk – they eventually arrived in mid-July.

We put in distancing measures, removing most of the chairs from the waiting room, and all the toys and magazines. Those patients who did come in were asked to hand sanitise and some had to wait outside on the footpath.

In March, we decided to triage those who wanted to come to the surgery. This didn’t sit well with any of us. We see sick patients. Not letting them in was unthinkable and worrying for us all. Patients were asked to call us from their car in the car park when they arrived. A doctor then spoke to them and decided how to proceed – ‘can come in’, ‘can’t come in’, or ‘doctor will go to them in the car park’.

There was chaos around COVID testing (throat and nose swabs). Initially we could do testing, then suddenly we weren’t allowed to, with all patients identifying as at risk having to attend a COVID clinic. After a while, testing returned to us in GP. As it stands now, I’m swabbing patients but that was only feeling safe to do here in Perth.

Empty surgeries

For a few weeks, we had almost no patients in the surgery. I worried about having enough business to keep our staff employed. No one knew how long this was going to last or even if general practice would survive. We reassigned other tasks to our nursing staff, including cleaning duties.

Federal Government introduced telephone and video consultation numbers for the first time under Medicare (previously only available in rural and remote areas of Australia). This was introduced almost overnight on Monday, 16 March. With the sudden introduction, we changed the information given at reception. Initially, only vulnerable patients were able to have access to telephone consultations – patients over 70 years old; pregnant; or those with a child under 12 months; patients with chronic health conditions and those who identify as ATSI. The rules changed – thankfully – to allow everyone access to phone consults.

Every time there was a change (about fortnightly) the Medicare announcement would come with no notice (e.g. starting tomorrow). This was a scramble every time as the software providers were caught by surprise and had to provide an upgrade for each change. A lot of hours were needed to keep everything and everyone up to date.

It was curious to have a consultation on the phone. Some things were very simple but I was surprised by what patients thought I could consult about on the phone. I came to realise that my clinical skills of examining and the visual cues I take from a patient were very important. Consults on the phone seemed superficial and I really hated sitting in a room with no social contact. They were also a medicolegal nightmare, fearing I would miss something. I missed shaking hands and hugging my patients.

On one day, I was so pleased to find a patient of mine having a blood test. I’d known her for years. I knew she had cancer. We sat and talked, and she, too, was pleased to see someone face to face. Two weeks later and we had a have a phone consultation as she was now terminal. I tried to convince her it was OK to let her family in to visit, but she wouldn’t have it. Her family felt they were a risk to her. I tried to say that this time was important, and short.

Another two weeks later and I was completing her certificates, those that marked her passing. Her funeral took place with only eight family members plus celebrant and funeral attendant under the new COVID rules. This, for a long life well lived, and for a person so greatly loved. We heard many tales of sorrow like this. It was gruelling and very sad.

Survival kit

I made a decision to do a few things to help myself at this time:

  1. Stop reading social media feeds. Facebook has a million opinions, very few of them expert. I simultaneously decided not to comment on anything.
  2. Only read from a few sources that are reliable – WHO, Department of Health – Federal and WA. I limited where I get my information.
  3. Listen to podcasts when I can. Those by the RACGP president were brilliant as they were based in general practice. One came out every week, beginning in March. I was so grateful for sound and sane information that was relevant to me. In August we heard that our lovely President of RACGP, Dr Harry Nespolon, who so valiantly put a webcast every week for GPs, had just died of pancreatic cancer. He knew he was sick. He kept working for us as he thought it was important. It was.
  4. If I can help, I will. I started a Zoom group for friends on Friday afternoon. Most were retired and therefore having no contact with anyone outside their home. Those over 70 were considered to be especially high risk. I found my friends, a loving, but slightly desperate crowd, and together we learnt how to use Zoom for meetings, have a chat, sometimes a sing or watch a recording of something nice and just generally catch up.

A couple of times we did some physical exercise, dancing to a song, in the isolation of our own homes! That was the other thing – no one was doing any exercise. Those with dogs were doing lots of dog walks. Bike sales were going through the roof as gyms and exercise classes closed. Besides, everyone was too anxious to go out. This “Friday at 5” session became particularly important to me as a circuit breaker. They were worried about me and
it helped to have other people to talk to.

My son came home safely from Japan, prior to mandatory home confinement. But, as he lived with a nurse, the hospitals had already mandated that hospital staff could have no contact with overseas travellers. He came back home to us. But he was a risk to us, to me, to my practice. It was a bonus to have two weeks with him in our home, but I was fearful of a possible source of infection being nearby.

Scrambling home

A staff member (doctor) was close to being caught overseas and scraped in before the deadline of international arrivals closed (also announced suddenly). Some were unwell and had to take longer than usual sick leave so as not to bring any illnesses to work. All had to be tested. One who was older decided the risk was too great at work and took temporary leave. The doctors, nurses, managers and reception pulled together and it was certainly one of our strongest times as a team. I was very proud of them.

My lovely street decided to start driveway drinks on Sunday at 5pm. Take your choice of drink to the edge of your driveway and chat. As the year went on, we started to congregate at a street corner, suitably distanced. Even now in November, we all meet and catch up every week at a local place. Very casual, but it has been a wonderful connection through this year and stronger bonds have been made in our community.

Perth, of course, has survived very well and I’m grateful to our public health and government officials who have listened and worked cooperatively. Their leadership has been outstanding. Similarly, our staff came together. We created better systems of communications and updates. We had ignored a section of pandemic planning in our accreditation (“never going to need that”).

We now have every possible contingency recorded and know well how to manage in a pandemic. We have learned a bundle of new tech options. Zoom is great, with limitations. Family have now heard me singing as I took part in Zoom rehearsals from the privacy of our study. I’ve taken part in and coordinated some concerts. We’re all seeing patients again but are grateful for telephone consulting being another option.

Nothing beats meeting with people face to face, in work and in play. At heart, we are social creatures and this strange time has proven that we need contact with other human beings.