A “Deep Breath In” for GPs

Rebooting general practice

Before anyone in Wuhan fell ill, GPs had already been feeling the strain. In the UK, despite government promises of 5000 new practising GPs by 2020, there were 6.2% fewer full time equivalent GPs in 2019 than in 2015.1 Similarly, physicians in the US have been compensating for an estimated shortfall of some 14 500 primary care doctors since 2017.2 Recent attempts to take the strain off GPs in England by funding allied health professionals have faltered because of onerous new demands on fledgling primary care networks.3 Turning it off and switching it back on again is often the only thing that works when your computer grinds to a halt. Perhaps coronavirus will do the same for primary care.

In the first quarter of 2020, covid-19 abruptly and dramatically changed clinical practice for GPs around the world. For many of us, routine appointments, chronic disease monitoring, health promotion activities, and face-to-face consultations have all but ceased. Health technologies, including apps to remotely monitor disease, patient access to online medical records, mobile health messaging, and telemedicine consultations had already started to change primary care and its delivery fundamentally,4 but video consultations were yet to become widely available. If the biggest obstacles to broader use of telemedicine before covid-19 were related to patient privacy and our stubborn sentimentality for face-to-face consultations, the pandemic has forced us to stop deliberating and get online. The first episode of Deep Breath In discusses video consultations, their use in the pandemic, and the extent to which they may redefine the future of primary care.

As our guest Trisha Greenhalgh notes, the effect of covid-19 on medical care in the UK is the single greatest change to occur in medicine since the inception of the NHS. And yet, the essential role(s) of a GP and the expectations patients had of us were already in flux.5 A qualitative study of GPs in southwest England from 2018 found that a lack of personal-professional boundaries and “unrealistic expectations about what general practice can and should deliver” were key reasons why GPs left their clinical practice.6 As covid-19 stresses the already flimsy boundary between our personal and professional lives, GPs are questioning the part we play in our health systems while confronting the fear, anxiety, and uncertainty of practising in the time of covid-19.

Abscess of fear

The emotional challenge of adjusting to these changes amid so much suffering is hard to overstate: not since the early AIDS epidemic have we as doctors so universally encountered death we cannot prevent while worrying about the health risks we personally take in the course of doing our jobs. In addition to the familiar fear of missed diagnoses, we fear for our own health as well as that of our families and our colleagues. For Danielle Ofri, physician at Bellevue Hospital in New York and author of the book When We Do Harm, fear isn’t necessarily a bad thing. In our second episode, she describes fear as a soft walled, left lower quadrant abscess that we carry around with us, helping us to avoid cavalier decisions and reckless mistakes. We just need to find ways to stop the abscess from bursting.

Keep breathing

There may be more abscesses lurking within us besides fear. Doctors on the front lines face an unusually high risk of burnout and post-traumatic stress disorder from covid-19, while others may struggle with “bystander’s guilt.”7 Now, more than ever, GPs need connection with other GPs, a sounding board to explore the unprecedented challenges we’re facing, and some headspace to process our emotions. Deep Breath In will try to offer at least a small dose of these, to help GPs feel a bit more connected, a bit more heard, and a bit more supported. In our first season, we will explore the ways in which covid-19 has upended our normal practice. In each fortnightly episode, we interview leading experts to shed some light on the issues we face each day that cannot be reduced to another guideline or flow diagram. We get a few things out in the open (that fear, guilt, and uncertainty) in order to get at the value and meaning of our work.

Exhale.