Author's note to fellow clinicians

1/4/2020

Dear colleague,

In the interest of full transparency, two things about me; as one of the clinical leads for the AGP service I was very stressed by the forecasts of the Covid pandemic; and I ran around shouting 'Fire!' or its equivalent in a bid to adapt services rapidly. I say this because (1) clinician mental health needs to be spoken about more openly and (2) the below comes as self reflection, but if it helps me, it may help others. The quotes are the linchpin sentiments of the Covid response I see around me, across primary and secondary care, and my take on the potential repercussions of them. This page represents my personal view solely, and not that of the Acute GP service or CPFT or RCH.

Under the current circumstances and the stark warnings and adaptations both on this website and elsewhere, it is a deeply stressful time to our healthcare systems, our community and our clinicians. I would like to write informally and without accusation about concerns of the unintended consequences of that systemic pressure in a bid to acknowledge it and protect the care we provide.

This website is intended as a quick reference to local system processes around acute medical management of community patients. It's a portal to communicate and coordinate practices among us for the better care of our community, rather than a source of authority in itself. As is always the case with any clinical guideline, those we receive and publicise are based on an unavoidable mix of evidence quality. This includes blends of empirical evidence, observational studies, national guidelines, local specialist interpretation, resource availability and clinician opinion. We've always tried to be explicit where this is the case.

"It is better to act quickly and err than to hesitate until the time of action has passed" Clausewitz

The Covid-19 pandemic, by its sheer speed, poorly-evidenced uncertainty but well-promulgated predictions, is presenting a significant challenge to all healthcare and resource infrastructure. This pandemic is an unprecedented threat to our patient's health and our healthcare system's effectiveness. We must work at speed, but be as sure as we can be that those changes do not inadvertently introduce additional excess risk to our community. This pressure pushes the foundation of any new Covid-response guidelines away from robust evidence to a generally less conclusive evidence base as we await better data evolving from the pandemic. There simply aren't the studies of significant rigor or size or local relevance yet, particularly in primary care or epidemiology. It is therefore imperative to explicitly assess the quality of the data that is driving the pace of change and that which underpins our newly developed guidelines. As you'll know, as well as being part of our GMC responsibility this also has direct relevance to our discussions with the patients in front of us. There will be a time when, with the cool fully-informed clarity of retrospection, our collective decisions in this era will be reflected upon and every colleague wants to make them the best we can in the shortest period of time.

"Drowning in information but starved of knowledge" John Naisbitt

We need information, even of the scale of the uncertainty, in order to act and we are currently flooded with Covid information. From news outlets, emails, journal updates, webinars, government, patients, colleagues, family and friends, clinical decision groups, social (and increasingly professional real-time) media...the list goes on. Even if our own established, trusted lines of information remain intact and up to date, in this global societal issue those lines may be drowned by the clamour of the others and offer precious little directly applicable. You may have heard the WHO talk about the pandemic of misinformation being equally concerning as the viral pandemic. So where do we look? At the two extremes of response to such an info flood, do we hunker down and practice as we always have in the faith that that was at least certain or of known unknowns; or do we as clinicians try to rapidly adapt, engage widespread pragmatism and it's unknown unknowns? Of course, we try to tread the line between cautiously but rapidly adapting, but it is difficult. The same routes of information overload chastise inaction, biasing us toward change of practice in any form.

There is evidence that as human beings our drive in such rapid, high consequence, uncertain circumstances promotes our intuitive, more emotionally-triggered subconscious brain processes. They are valuable in rapid decision making when we don't have full clarity of detail; the intuitive spot diagnosis, moments of clinical gestalt, initiation of CPR, etc. Great for focus, terrible for tunnel vision. Our training and repetition can inform these reflexes, but they happen without deliberation and only with any real analysis post-hoc. This processing is not a unique characteristic of the individual clinician alone, but can also impact the resultant new health service structure that such thinking in a crisis can produce. Not only is it less robustly evidence-based, it is naturally more intuition-led and reflexic. Under a banner of dynamic system responsiveness, pandemic anxiety, common focus and group think can relegate our deliberative objective logic to a later post-mortem of what we are currently adopting.

It's a widespread problem. Major journals, esteemed pillars of robust appraisal, have published and subsequently retracted high profile erroneous Covid-19 articles, the pressurised peer response process risking polarising rather than deliberating response to new information. Our media is capitalising on the curiosity and tragedy of the pandemic, while intensity of global tracking is unprecedented. What the most robust data available does tell us is that the infection fatality rate (note, not case fatality rate) is far from determined but is highly likely to be tending to ~1% (with the wide variation reported in large part relating to how testing was performed). What isn't yet clear is what proportion of the population will become infected and at what rate, and hence what healthcare will be available to them. 

"Hope for the best but expect the worst"

Given the mortality risk, the surge potential of the new coronavirus causing thousands of simultaneous cases becomes the main concern to address urgently, potentially overwhelming the health resources we have. It's important we're explicit about this, as, given our ingrained intuitive and social pressure for change, we may be tempted to take immediate extreme measures under these alarming circumstances in preparation to fully mitigate the expected risk. But this approach, with its draw of resources, simultaneously erodes our care of the well known, well established risks of the illnesses we were already managing.  The best response here then must be phased planning, with consideration of monitoring resources and the time/effort needed to escalate between phases, becoming increasingly stringent in our prioritisation of dwindling resources as demand increases. If we employ extreme measures too early, we risk neglecting the care of our patients for little societal benefit and significant harm.

Our guidelines must then be as evidenced as possible and explicit where not, open to critical multidisciplinary debate and widely agreed, and calibrated against demand so as not to ignore our patients non-Covid problems. Equally, now more than ever, the phased responsive guidelines must inform and not dictate individualised care. The Coronavirus Act 2020 acknowledges that lack of resource availability will inevitably cause an impact on clinical decision-making, but we are duty-bound to offer individualised, defensible care to our patients.

This is the reason that local Covid-relevant guidelines are slow to appear, incomplete or frequently revised. Please bear with us. In their absence, or even in their presence where they are not in the patient's best interest, we should ensure we operate in as objective and deliberative a way as possible for the best care of our patients. Primary care clinicians are highly adept at operating in uncertainty. That levelheaded, tailored pragmatism is bring called upon like never before. All the while sharing decisions with colleagues and recognising our own stress. I hope the Acute GP service can support you and your patients at this difficult time.

Many thanks for reading.

Chris Ireland

Addendum 15/6/2020

We now have in place the rapidly implemented changes in our delivery of health across Cornwall in response to the predicted Covid pandemic, but the surge has not materialised. It's important to note the rate of new cases (R number) is less than 1, possibly thanks to some of the social measures enacted, and that the predictability of any surge has improved from the initiation of these system changes. Our resources have not dwindled under rate of demand. Instead, given the magnitude of response first envisioned, and the hard work put into transforming the health service into something more adaptive, resilient and capacitous to the predicted onslaught, we are in a state of health lockdown. There is a palpable inertia to opening back up, to losing the resilience to a sudden surge. This too is a sign of the human emotional processing in the design of the systems we work in. Once our neurohormonal sympathetic survival reactions are triggered, we need greater evidence to the contrary to recalibrate risk perception. But there is now good evidence; our systems now have capacity like rarely before; impaired chronic illness management has caused many excess deaths; acute exacerbations of chronic health and psychology are increasingly common acute presentations; there is no excess risk of Covid-19 to healthcare workers with correct PPE procedures (away from AGP, with increased stringency for BAME colleagues); access to primary care has declined; those most suffering from this are the most vulnerable in the community, the inverse care law evident.

 

As shops and travel open back up, we need a robust plan to reinstate routine care countywide, while limiting iatrogenic risk of cohorting ?Covid cases away from those patients with background risk. As before, we still await clarification of what the background risk is. Critical to the interpretation of Covid testing, and hence the interpretation of risk exposure to all healthcare workers, the prevalence remains under huge debate. It is an indictment that health cannot publicly pioneer an approach to risk mitigation in this, but rather retail and travel tolerate that uncertainty first and we play catch up.

Royal Cornwall Hospital

Truro

Cornwall TR1 3LJ

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