We may have stumbled our way through preventative care in covid, but now the upsides could go far beyond.
It’s been a strange old couple of years. Now that things superficially appear back to what could be interpreted as normal, it seems remarkable to look back and think how we’ve skated through the last few years. We went from one rapid challenge to the next without having time, until now, to reflect on the logistical challenges it encompassed.
We scrambled to take action, in extraordinary ways that we felt were the best response to the – dare I say – unprecedented circumstances. We may barely have had time to buy bread before but, all of a sudden, found ourselves making far too much sourdough. We decided we would close the borders and not let anyone into the country. We abandoned our in-person shopping habits for boxes dropped off on our doorstep – and some of us even took on multiple ministries without telling our colleagues.
Until the facts are laid out for us, it’s clearly very easy to forget that we did any of that (especially the last one), as we haven’t been afforded the luxury of time to reflect. Challenge after challenge has been thrown at us as a society, and we did whatever it took to get it done, but it’s only now that we are starting to dust ourselves off and reflect on it all over a cup of tea (and maybe some of that sourdough which has been occupying space in the freezer).
We would prefer never to live through those times again, but like a mother lifting up a car to get to her newborn baby underneath (or perhaps a little less impressively), we did some things that we did not think we were capable of. Of course, it really is in medicine where that is the most true.
For our patients, the fact that we have broadly been able to protect most (but not all) of them from the most severe consequences of infection is something to be proud of. After having struggled for years to vaccinate our patients – and a quick look at our influenza and herpes zoster vaccination rates prior to covid is embarrassingly telling – we managed to get the vast majority of our patient population vaccinated, multiple times over.
More than that, when new advice was issued (as it frequently was), or new developments occurred (as they frequently did), we were able to let a lot of our patients know. That relative success was partially because of the flurry of activity that consumed society in general, but we did get it done. Now that we sit back and the flurry is gone, it is time to realise how chaotic it was, and to think about what worked and what we could do better.
Ideally, we should learn how to do this better, as we reflect on our covid experience – so we can deliver preventative care consistently, across our patient population, across all of our patients and in a rapid manner. If we keep on doing what we did before covid, though, we will get what we got before covid, which really wasn’t good enough then. I think we can do better, and this is what Phil Robinson and I argue in an editorial just out now.
The temptation here is to blame individual clinicians, that we should do better as physicians. I will admit I am as guilty as anyone of not counselling all my patients about what they should know about – not just regarding covid, but also other infections, cardiovascular risks, cancer, fertility, and more, even though that’s standard of care. There is only so much that you can fit into a review appointment though, and it’s already enough of a struggle in the 15 minutes to convince my patients to have blood tests. Even then, just like their blood tests – will they actually follow through on the long list of things I’ve talked to them about? And what happens when new developments happen between appointments, what do we do then?
Of course, we should be cognisant of our patients’ risks, and advocate to them for their holistic care. When there’s a workforce shortage, though, it’s hard to argue that we should be regularly spending extra appointments with these patients covering this ground.
I’d suggest there are three things that need to be targeted, systems that need to be changed if we are going to make real progress – action that goes beyond individual responsibility.
First, maybe we need to think about how we can improve workflows with effective clinician networks. We are already delegating some responsibilities, or at least often do – blood tests in stable patients between follow-up appointments, for example. We sometimes try to do the same for vaccinations and cardiovascular risk factor management to our general practitioner colleagues, but we’re very bad at doing it, at least compared to others – our instructions are vague and not enforced in the psyche we imprint on medical students.
Wouldn’t it be better if generalists knew that rheumatoid arthritis conferred similar cardiovascular risk to diabetes, and had clear and accessible guidance as to what monitoring was required? If they knew the influenza risk that RA conferred as a medical student, they probably would be proactive in making this happen – because they are masters at preventative medicine. If we could empower them with consistent, standardised guidance, we would likely find willing friends.
It might be that we find it too complicated ourselves, or outside our standard scope. Should we be like the orthopaedic surgeons, who recognised what they were good at, knew they would always be valued for that, and (in orthogeriatricians) found others who could embrace the rest? They empowered an oversupplied speciality, for mutual benefit. In the covid-normal world, maybe a yearly referral to an immunosuppression infection disease physician for vaccinations, formal action plans in the case of infections (both covid and general), and occupational infectious diseases advice might be a correlate? As physicians, we want to do everything a physician can do, but maybe pragmatically we might be better to co-opt in help – help that would not replace us, but that would enhance us. While my instinct resists this, there is a strong logical argument for it.
Secondly, patient engagement is critical. Not infrequently I find that patients who I have spent time discussing the critical utility of blood tests to, and have walked to the neighbouring pathology collection centre myself, still do not have those blood tests done. Our patients will not always do exactly as they are told, especially when diverse backgrounds are in play. As we have seen in the wake of Shane Warne’s death and the flood of cardiovascular checks that have flowed on, patients often need the right motivation to act. Our patients, who frequently believe their arthritis stops at their joints, rarely appreciate their cardiovascular risks, even as the general population gets engaged by effective health promotion with simple and consistent messaging. Perhaps we need our own campaigns, using all the tools of health promotion.
Finally, our information systems, their linkages, and our capacity to communicate with them are failing. When the winter booster was announced by the government in the face of a covid wave, how did you generate a list of all the patients eligible, and let them know rapidly that they were? How did you message those eligible for antivirals to tell them that they were, without spamming others? I had no easy way at all, and most of us would have been limited to getting a list of patients on a certain medicine – no real capacity to filter on the basis of their vaccination status, or laboratory tests, or comorbidities. In an era where my supermarket, bank and telco have me profiled in excruciating detail and have no difficulty in targeting communications to me, we theoretically have access to far more intimate detail but have no way of harnessing it. Systems can do better.
Individual responsibility might be part of it, but pragmatically we can’t navigate a rapidly changing, complex world without better systems, built on the lessons of covid. If we fail to take this opportunity that covid has opened up, then the fallibilities of our stretched workflows will mean we accept worse for our patients.
