Welcome to The Plague Pit – issue number 14

For this issue, I’m delighted to introduce Dr Chris Villiers – a GP Senior Partner and an Honorary Lecturer in the Department of Community Medicine at Barts and The London Medical School. Here is his account of how COVID-19 has affected his working life.

Everybody knows what it’s like to make a GP appointment. You’ve got that niggling cough, or that achy shoulder that just won’t go away. You ignore it for a decent amount of time until either your better half, or your anxiety levels, decide it’s time to take action. You ring up your local GP surgery to arrange to be seen.

You’ll speak to a very nice receptionist who will sympathise with your plight and offer you the very next routine appointment, which will most likely be in two to three weeks time. If you manage to convince her it’s a very urgent problem you’ll be squeezed in to a same-day appointment to see a harassed GP. She’s most likely running around an hour behind time, sitting on a bladder the size of a melon due to lack of opportunities for toilet breaks.

The coming of COVID-19 has thrown that model out of the window. Now the surgery, which is normally bursting at the seams with people booking appointments, waiting to see the nurse or GP or collecting prescriptions, is eerily quiet. The doors are shut and anyone entering has to reveal themselves via an intercom ,which has been hastily fitted, to make sure they are expected and have been vetted for symptoms of the deadly virus.

All patients ringing with a request to be seen are now given a triage telephone appointment with a GP who will ring them back within the hour. If the problem cannot be sorted via a phone call (and it’s amazing how many can given access to the patient’s detailed computer records), then a video consultation can be arranged via the patient’s smartphone. This is particularly useful for dermatology problems which can be quickly assessed and diagnosed. It’s certainly better than the alternatives.

One patient with a worrying mole on his abdomen was asked to email in a photo of it. By the time it arrived and was scanned onto the computer it looked like a forest scene by Bruegel the Elder (he was a particularly hirsute gentleman). Luckily a video consult provided clarity.  Video consultations are also useful for assessing sick children. Mum’s protestations that little Johnny has never been so unwell and that he hasn’t stirred out of bed for a week can be weighed up against the sight of Johnny in the background, doing star jumps to a Joe Wicks workout on the telly.

If a prescription is required it is computer generated and sent electronically to the pharmacy of the patient’s choice, thus robbing the patient of the pleasure of gazing at the doctor’s hieroglyphics and wondering how anyone could possible read such scrawl.

Some patients, however, cannot be dealt with by phone or video, so a face to face appointment is required. One doctor per day is providing these in the afternoons. This requires them to don gloves, apron, face mask and visor . The patient is asked to cover their mouth and nose. The history has already been taken by phone so the the patient is just in the room long enough for a physical exam to be accomplished. Any further conversation regarding management is also conducted by phone after the examination.

 Such lengths may seem draconian but the fact that up to 80% of patients with Coronavirus are asymptomatic means they are necessary for the protection of medical staff and patients alike.

Care homes are a particularly vulnerable area should Coronavirus strike. In the ‘before times’, GP visits to our care homes were a daily occurrence. Now, however, they are strictly limited due to the potential for visitors to unwittingly bring the virus in with them. Consequently we have just adopted a practice of video ward rounds. One of our GP registrars (GPs in training) arranges a video consult each day with a carer on one of the care home units via their smart phone. The carer then goes from room to room allowing the GP to ‘see’ and discuss the heath needs of each resident.

This both gives the GP the opportunity to be proactive in their management and (on a more sombre note), should the patient pass away, it allows the GP to complete the death certificate without referring the case to the coroner. Previously a doctor would have had to see the patient within 14 days of death to complete the certificate. Emergency legislation recently changed this to 28 days and allows a video assessment to suffice.

Other changes to our work pattern include GPs working one day per week at home. This has been necessitated by the need for social distancing from each other at work to decrease the risk of virus transmission in the surgery (we have already had a number of staff off sick with typical Corona symptoms). We have also given up two consulting rooms per day to the community midwives. They have had to vacate the local Community Hospital, which  as it is being used as a step-down facility for Corona patients being discharged from the local acute hospital.

Working from home is a mixed blessing. On the one hand I have a lovely view of the garden from my study window. On the other hand I can see all those gardening jobs I have been studiously avoiding for the last year.

Technology is also changing the way GPs are communicating with each other. Our GP practice has had a partners WhatsApp group for some time. In the last 8 weeks, though, it has been an invaluable way of sharing guidance and advice in dealing with the outbreak, Pandemic-related  documents arrive on a regular basis and need disseminating and absorbing.

I have, however,  been caught out in the past with WhatsApp. I once shared an article about how hormone tablets women can take to delay their period when they are on holiday are now available without prescription at Superdrug. I thought I had shared it with the surgery group but instead I sent it to my cycling club group. I got a lot of puzzled responses, mainly along the lines of: ‘Will this make me go up hills quicker?’

Because partners are regularly away from the surgery now, our practice meetings are done by a video conferencing service called StarLeaf (Think Zoom for doctors). Another app called Pando is being used to send clinical queries to ‘Teams’ of hospital specialists (WhatsApp for doctors).

Conversation at the practice has already started turning to how we will go back to consulting when the epidemic is over. Consensus is that we should keep all the best bits such as instant phone consults for patients, video consultations and maybe the occasional work from home day.

Hopefully we can get rid of the face masks at some point and see our patients smile again.

Dr Chris Villiers