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Doctors and COVID-19: Why we need to be a wise human first!
*Corresponding author: Gouri Adwaita Gore, Obstetrician and Gynecologist , Dr. Gore’s clinic, 201, Glamcent Premises, Central avenue Road, Chembur, Mumbai - 400071, Maharashtra, India. gourimd@gmail.com
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How to cite this article: Gore GA. Doctors and COVID-19: Why we need to be a wise human first! Indian J Med Sci 2020;72(2):41-3.
DOCTORS AND COVID-19: WHY WE NEED TO BE A WISE HUMAN FIRST!
This new year eve got us a gift of COVID-19. This year will be recorded in history of as a time when the modern world with great technological advances was fighting tooth and nail for survival of mankind. I doubt if any doctor practicing today has ever witnessed such a mayhem. As I write this more than 100 doctors have succumbed to COVID-19 in India. The mortality rate in doctors seems to be higher than that in the general population. Many more have suffered from severe disease and were able to recover.
I have been reading about personal experiences of COVID-19 infection suffered by many doctors around the world. I had a dreadful encounter with COVID in May 2020 when all of my family tested positive. Two of the family members had a stormy course, but they recovered. Some doctors actually called me – when they got positive – just to speak and share their worries too! I have tried to find answers to some questions here with focus on non-medical aspects of a doctors life. Some analysis about doctor’s attitude and behavioral trends in approaching such a disaster might be useful for making us ready for any such event in future.
WHY DO DOCTORS GET INFECTED MORE?
A very simplistic answer is “because they treat infected patients.” It is an obvious fact, but that is an incomplete explanation. It is well accepted that doctors subconsciously train their minds to be emotionally detached from the illness while treating patients and that helps them in making rational decisions. We get convinced that the patient in front of us has got a disease which would not affect us. Even if it does, we will get a better deal (lesser symptoms) than our patients. Too much of this makes some of us think that we are invincible! Early on during the pandemic, the doctors who were not very particular about PPE and other protections were the softest targets. Many senior practitioners – physicians and family physicians, especially in private practice underestimated the infective potential. They were comparing this with yearly influenza epidemic and thought that like every year they will sail through. Many doctors continued with their clinic’s as a routine without PPE, not controlling patient numbers, not particularly paying attention to social distancing or sanitization. Family physicians were the most unarmed and got exposed to infected cases. Family physicians and doctors working in smaller setups could not sustain the escalation in operating cost due to the high cost of PPE/masks/sanitization kits coupled with the reduced earnings. While those were reluctant to spend for protection gear some did not want to lose patients when the next-door doctor shut his clinic. Those who kept hospitals and clinics closed eventually realized that this cannot go on forever and opened the clinics welcoming a swarm of patients. Doctors took pride in telling stories of how so many patients were waiting only for him or her all these days! How, he or she cannot send anyone back because the patients needed THE DOCTOR! At the same time, in some other part of the country few patients lodged consumer complaints with allegations of getting infections from clinics and hospitals. Some of us forgot that we are not superhumans and we can get infected in nonhospital surroundings where we do not wear PPE. The doctor ID could save us from police action during lockdown but not from infection!
WHY DO DOCTORS HAVE A HIGHER MORTALITY?
Delay in testing and delay for hospitalization
Some of the published reports from Europe show the same mortality rates for doctors and the general population. However, one report from Bangladesh categorically stated the mortality rate in doctors from Bangladesh and India to be higher than that for the general population.
This pandemic is proving once again that doctors are bad patients. Doctors generally tend to overlook their own symptoms. Very few of us objectively assess ourselves as we would do for our patients. A common tendency is to give a non-medical reason like too much work or lack of sleep for non-specific symptoms. Symptoms such as fatigue and sore throat will be passed on as a common cold. Many doctors hesitate to test for COVID when they have trivial symptoms or suspected contact due to the fear of getting a positive report. Majority of the infected will remain asymptomatic and recover, but it also means more people will do the test only when the symptoms go beyond their control. Typically doctors test only when they have persistent high-grade fever or significant breathlessness. Once positive, monitoring is the only option – again parameters are one thing and symptoms are another. Everyone does not get a high fever. Lung involvement is often silent. Oxygen saturation monitoring by pulse oximetry may not always correlate accurately with arterial blood gas parameters. Symptomatic doctors delay admission to hospital with the argument “what more can be done in the hospital apart from monitoring which I can do at home? I will get admitted if I experience more symptoms or deterioration.” Some went to the extent of home oxygen therapy as well.
Age and comorbidities
In India, doctors as professionals continue in private practice for many years beyond the average retirement age for other working professionals. All citizens above 60 were at home, except for doctors. Even younger doctors with comorbidities were coming in contact with the infected patients knowingly or unknowingly. The clinic practice was on while all other professionals could do work from home. Although they were exempted from COVID duties and penalty if they decided not to work, they had to go on to earn a daily meal.
It is said that a smart man learns from his mistakes, a wise one learns from the mistakes of others! Some of these strategies will be useful for those who are still in the “safe zone.”
Acknowledge that you are susceptible, even if you do not work in COVID hospital
Asymptomatic COVID infection is a reality! Institutes can debate whether there is community spread or not – as individuals the approach should be “anyone and everyone near me is asymptomatic COVID positive.” All doctors must think about appropriate protective gear, sanitization methods, and testing strategies, which tests to do and how often to do may be decided depending on resources and type of practice. When asymptomatic doctors test and are detected positive they can limit spread to others doctors/families/friends who do not use PPE round the clock. Severity of COVID does not depend on the order in which people get infected, so the index case may remain asymptomatic but others can get a severe form of the disease!
Be within limits
It is high time all doctors have to accept that prevention is the only weapon we have. Even if it means that operating cost for practice will increase by purchasing protection gear and earnings will reduce because one will attend to less number of patients than before. The losses would not be as bad as death due to disease.
Going through the drill of donning- doffing- bathing- sanitizing- changing clothes- washing clothes, and distancing from family members is very monotonous and stressful but that is our survival strategy. There are good doctors and great doctors but we all are mortals. Nobody is indispensable! If a patient cannot get to one doctor, he will surely seek some other medical help if he really needs one, but if the doctor gets infected, none of these patients will be of help.
Accept being a patient
Do not delay hospital admission – even if all investigations can be done on OPD basis and you have all facilities of monitoring at home. There could be a window of only a few minutes or few hours – when someone starts deteriorating. One observation is that ensuring adequate lung oxygenation at all times seems to be the single most important differentiator for outcome! Which means one has to act before significant desaturation and lung damage sets in. Whether one can do that by breathing exercise, nasal oxygenation, high-flow oxygenation in prone position, or ventilatory support is for the experts to decide. Hence, direct supervision of the team is important. Of course, different centers may be following different protocols, so it is best to decide where one would like to go for treatment in case the situation arises. It is definitely better than calling all doctor colleagues around the city when you test positive seeking telephonic advice.
Make provision for hospital payment
The treatment cost in a private hospital can range between 2 lakhs and 20 lakhs or more. This again depends on the severity of disease and supports required. The doctor colleagues are usually very helpful to arrange bed, medicines and expediating investigations but they cannot influence billing of any corporate hospital. As per my knowledge, none of the hospitals offer any special discounts for doctors.
Make assessment of insurance cover and create a contingency fund if the cover is inadequate. All responsible adults should know about insurance policy, cashless process, documents and whether they are signatories to the bank account, etc. Net banking and online transfer facility are a must! If the entire family is quarantined, none will be able to go to the bank and withdraw or transfer money. There has been a situation when in spite of having funds in the bank account, doctors were not able to utilize the money as the account had only one signatory who was admitted in the hospital. In anticipation of such a situation, one could add more joint account holders or keep some blank signed cheques at home at a secure place.
As a long-term measure, extending medical insurance cover will be sensible for those in 40s’ as usually the difference in premium is not much. Make sure there is adequate liquidity in terms of asset allocation at least for next 12 months.
Have a plan B if you do not make it!
Although society assumes that doctors in private practice earn a huge fortune, the reality is otherwise. Like in other professions, there is a small percentage of high earning doctors but the majority of doctors in private practice have a moderate income by which they can lead a reasonably comfortable life till it is going on predictably. Our unpreparedness for an unexpected event can have a deep impact on families beyond repair. For severity of infection including death and age is no bar!
Every death is a loss for someone but dying in the 40’s has severe implications for family members than probably dying in the 80’s. Doctors in their 40’s and 50’s – (who by the way should work for the government COVID duty as well) should have very objective and non-emotional homework about what if the earning member, especially if the single earning member succumbs? Not to go to OPD or OT is not the answer. Having a single earning member in a family is always a risky proposition. When both partners are earning, the liabilities also get divided. This cannot happen overnight, but each couple can find a solution to this in the long run. People in this age group have a maximum proportion of committed liabilities such as insurance premiums, EMIs, investment, and instalments. It will be a good idea to take a broader view of 24 months to decide if all these committed expenses will be manageable with reduced earnings.
Communicate openly with children!
Our children at home are silent sufferers of our professional hazards, COVID is just one of them. We have to tell them the real situation about the possibility of infection, plan of action if both parents have to be hospitalized and some insight about finances too! If we consider them as a responsible teammate, try not to hide things. They cope up well with the situation. Hard times are the best opportunity to make them learn some important life lessons.
The society may call us “COVID warriors,” they may shower flowers on us but there is no one to support the doctor community in this time of crisis. We should stand strong today as we are the soldiers and we are the generals too!
