Physicians continuously challenged in delivering high-quality patient care 

BY Ruwan Laknath Jayakody 

Physicians have to continuously adapt to rapidly changing circumstances, and remain committed to patient care despite increased personal risk, as they continue to face challenges in delivering high quality care to all patients.

This observation was made in an editorial on the “Physicians’ response to the Covid-19 pandemic: A view from Sri Lanka” which was authored by Sri Jayewardenepura University’s Medical Faculty Chair Professor of Medicine K. Wanigasuriya, Colombo North Teaching Hospital Consultant Physician S. Dassanayake, Kelaniya University’s Medical Faculty Professor in Medicine S. De Silva and Sabaragamuwa University’s Medicine Department Consultant S. Jayasinghe and published in the Ceylon College of Physicians Journal 52 (2) in December 2021.

With the rapid increase in Covid-19 cases and the emergence of new variants, Sri Lanka continues to face numerous challenges in the battle against Covid-19 and its waves. 

The pandemic had a series of complex impacts on the healthcare system. The primary battle fronts were in the hospitals and at their frontline were physicians. They had to face an unseen enemy with meagre resources, a slow and delayed response by the administration, and scepticism by other colleagues who were not convinced of an emerging catastrophe. 

The crushing of the first wave gave a respite which was accompanied by a degree of complacency. 

The subsequent waves were therefore able to almost overwhelm the treatment facilities and hospitals. There were shortages in intensive care beds, ventilators, oxygen supplies and other necessities required in order to care for critically ill Covid-19 patients. 

The challenge was to quickly transform the existing infrastructure in order to accommodate the rapidly increasing numbers of critically ill patients. Physicians made dramatic changes to their work schedules and effectively staved off a collapse of the health system. They identified the requirements necessary to quickly upgrade their wards to make them Covid-19-ready. The Ceylon College of Physicians (CCP) and the Sri Lanka College of Internal Medicine (SLCIM), co-ordinated and mobilised financial, technical and procurement support to institutions and members. 

The CCP Covid-19 aid fund was established in May 2021 with the aim of gathering donations in terms of infrastructure, equipment, and money. A policy statement was issued by the CCP President and was circulated among the members and published on the CCP website. A special sub-committee was appointed by the CCP for the smooth functioning of this process. The CCP Covid-19 aid fund received many donations from both local and foreign donors and many community organisations. These donations were utilised to support state sector treatment centres across the country for the management of Covid-19 patients. A similar process was undertaken by the SLCIM.

A scientifically informed, multidisciplinary effort is essential to beat the severe acute respiratory syndrome-related coronavirus two (SARS-CoV-2) pandemic. The physicians led the initiative to develop guidelines and conducted several online webinars and seminars to educate peers and other staff. The Health Ministry, according to C. Undugodage, U. Dissanayake, H. Tissera and A. Wijewickrama’s “National Covid-19 clinical practice guidelines: How it all began,” relied on physicians in internal medicine and related specialties to develop clinical guidelines concerning Covid-19. Peer consultations were provided through social media and regular webinar-related updates. The CCP and the SLCIM conducted approximately 20 webinars during 2020 and 2021 on a range of topics related to Covid-19.

The physicians’ community had to shoulder the major burden in the provision of care for the Covid-19 patients. Their services evolved with the pandemic. Initially, all polymerase chain reaction (PCR) test positive persons were admitted to hospitals for care while first contacts were quarantined in institutions, in order to limit the spread of the disease. As a result, the workload of physicians increased and the care of patients with other illnesses, which included those having chronic diseases, was compromised. Most patients were provided their medications via post by the hospitals and they lacked the close clinical supervision as patients became reluctant to visit hospitals. Acutely ill non-Covid-19 patients were probably the worst affected due to delays in obtaining PCR reports and the lack of appropriate protocols.

After a period of adjustment, the healthcare system responded in an increasingly structured manner. Many physicians continued to work well beyond their call of duty in order to cope with large influxes of patients. They effectively manned several hospitals and provided consultant cover to many intermediate care centres. This difficult phase eased when the Government policy changed to admit only those with pre-defined criteria, while others were managed at home using the network of preventive services and voluntary services using telephone and mobile calling facilities.

Physicians also provided leadership to the medical teams of junior doctors who provided care to the many thousands of patients with Covid-19 who were admitted to hospitals and intermediate care centres. They re-learnt skills such as the use of non-invasive ventilators and high flow oxygen therapy and taught these skills and much more to their junior staff, so that the first line of defence against Covid-19 pneumonia in hospitals were well trained and informed. Physicians also provided support, both morale-wise, and clinical, when healthcare staff themselves and their family members developed Covid-19.

An advocacy role was played by the physicians to provide correct information to the public and to counter misinformation regarding Covid-19. False information on various treatment strategies to conspiracy theories on vaccines abounded, thus leading to the dismissal of proven public health measures. Physicians teamed up with the CCP and the SLCIM in order to conduct public webinars and media conferences. They also took steps to create and distribute information to combat the spread of misinformation through various communication campaigns. 

The pandemic also saw a surge in research on the topic by physicians which included clinical trials in accepted treatments, indigenous preparations, several case studies, and contributions to modelling and conceptual issues.

A pandemic of this nature will challenge, devastate, and engulf some members of the profession. Physicians had to face exhaustion, ethical dilemmas, and moral injury as they had to sometimes decide who was to live and who would die due to the lack of resources. The direct impact was when several physicians were affected with Covid-19. A handful of healthcare workers sacrificed their lives, thus making the ultimate sacrifice.