comment “After the pandemic will we return to our old ways?” DAVID OLIVER “Pride in our colleagues is matched by anger at government failures” HELEN SALISBURY PLUS Family doctors in the US; the human lessons from other crises THE BOTTOM LINE Partha Kar Covid-19: we must keep faith in our experts e live in the age of information In short, as a healthcare professional, ensure that overload. Once you factor in the you’ve given any patients with diabetes the appropriate unregulated world of social media number of testing strips; ensure that they have access to and self-appointed experts, as well telephone support for queries and that they know what W as the urge for people to jump in to do when ill; and reinforce the basics of hand hygiene with their two pennies’ worth and a disregard for real and social distancing, as advocated by Public Health experts, it becomes quite diffi cult to fi nd sources you England. As things stand, it doesn’t matter what your can trust. Then covid-19 appears, and the information age is, what your type is, what your control is if you have world looks like a maze full of pitfalls for anyone diabetes. If it isn’t essential work or travel, stay at home. trying to ascertain the correct information. These are extraordinary times, and we need to have Understandable worries abound, and recent faith in the people leading us, from a healthcare point times have also shown the impact that healthcare of view. It’s perhaps not very modern to say so—but professionals can have, in positive and negative ways. trust the experts. My parents are both in high risk Huge social media followings don’t necessarily mean groups, and they’re here visiting the UK as part of their that account holders have expertise, yet their views are golden wedding anniversary. With those high stakes, seen and taken on board by large numbers of people, I place my faith in Chris Whitty, England’s chief many of whom will be isolating themselves from their medical offi cer and his team. usual, face-to-face social networks. It’s time we all adhered to that principle and let the Misinformation is spreading along with the virus. team do their job. There’s Polarised political views, and the scars of the Brexit a time when we all need to debate, have perhaps made some people forget the learn to follow. This would importance of working together as a nation, and being be it. kind to others in these diffi cult times. Partha Kar, consultant in diabetes When a healthcare professional, or anyone else, and endocrinology , Portsmouth tweets something along the lines of “Many will die— Hospitals NHS Trust especially the elderly,” they need to think about the [email protected] eff ect this has on older people and those who are Twitter @parthaskar vulnerable or whose relatives are. We know that fear Cite this as: BMJ 2020;368:m1143 will exacerbate many mental and physical health issues, but somewhere this knowledge seems to have Social media been lost by some fellow healthcare professionals. In misinformation an eff ort to make a political point, is the ethos of “be is spreading kind” getting lost? along with People with diabetes are at increased risk of the virus illness if they contract covid-19. Thankfully, there is some reliable information around. If you’re a healthcare professional and you’d like to direct your patient to a reliable source, it’s worth looking at the information from Diabetes UK and the Juvenile Diabetes Research Foundation (JDRF UK), which has been developed in conjunction with NHS England and Public Health England. the bmj | 4 April 2020 25 YANKEE DOODLING Douglas Kamerow Don’t forget covid-19’s impact on US primary care There are twice as many family doctors in America as in emergency departments, yet they have received little to no guidance uring the exponential growth The most important thing to understand There are dramatic differences in of covid-19 in parts of the US, about systematic changes in US healthcare how practices have reacted to the we have heard a great deal delivery is, of course, that we have no single coronavirus epidemic in the media about brave, healthcare system. A primary care medical Dexhausted emergency room practice may be a small, self-owned group, authorities. They have reacted in diff erent doctors and staff . Very little that I have seen, part of a larger hospital system, owned by the ways, some suspending routine well-patient however, has focused on a much larger state or federal government, or a community visits in favour of treating only urgent and group of doctors who are also on the front owned non-profi t corporation. symptomatic patients. Others with larger, lines: those who deliver primary care. Family doctors, for example, may own their multi-site practices have routed high risk In the US there are more than twice as practice with full authority to set and change patients to one specifi c location, trying to many family doctors as ER doctors and practice policies or they may be salaried maintain chronic care visits for the rest of their almost three times as many paediatricians, employees who lead the clinical team but patients. most of whom work exclusively in primary have little or no say in management. This Once policies for testing and triage are care. Altogether there are more than fi ve means that there are dramatic diff erences in set, practices’ size and ownership aff ect times more primary care doctors than ER how practices have reacted to the coronavirus implementation of patient communication doctors, and that is not counting general epidemic and in what their doctors think and triage. Doctors in small, independent internists, many of whom in the US are also about those changes. practices report diffi culty reaching all patients primary care doctors. before visiting to appropriately triage them. What is going on in primary care? I Constantly changing guidance Larger practices, with more resources have spoke to friends and colleagues to fi nd out, Every doctor I spoke to reported feeling more staff , online patient portals, apps, even and I heard three main points. Dramatic bewildered by constantly changing guidance outreach workers who can guide patients. changes in practice have come very quickly, from experts and regulators about coronavirus Some doctors have ample supplies of the without much prior preparation. Little testing and triage policies. personal protective equipment that enable assistance, or even clear guidance, has come They were often confused by changing them to see high risk patients, while others from authorities. And the resulting changes recommendations from trusted sources, as report shortages. vary widely by practice organisational well as confl icting recommendations from One doctor told me they were switching structure. local, state, medical specialty, and federal from 90% in-person visits and 10% online BMJ OPINION Mary E Black This too shall pass Serbia, I have been here before. What I have Laughing is a way to build community learned is this: resilience. Let's not make it cruel And so we enter a new world of social • Nothing focuses the mind more than an distancing, people stocking their larders, existential threat. At our core, humans three month supplies of nappies while and limitations on how we can gather. Having want to survive. We will check we have the others can’t fi nd any. Profi teering, pilfering, grown up in Northern Ireland during the fundamentals and learn to live without the and petty theft . Troubles, worked through a war in Bosnia, non-essentials we used to rely on. • We will see cabin fever. The government is and brought up a baby under UN sanctions in • Nudge theory does not encompass what concerned about lockdown for more than will happen next. Social norms will shift 12 weeks. Sarajevo, and other cities under because we will look to those around us siege, did it for four years, and countries and change our behaviour accordingly. like Yemen live with this constantly. Sales • We will see the best of human behaviour, of jigsaws and Jenga will rise, but domestic extreme acts of kindness. Volunteer violence will flare up and children at risk networks will spring up everywhere. We will will be less visible. witness the selflessness of health workers • Those marginalised in society are most who will turn up day aft er day, exhausted at risk. Anything we can do to protect the and exposed. We will owe them our lives. homeless, asylum seekers, the very poor, • We will see the worst of human behaviour. the socially isolated, the frail, and the Absolute greed as families stock up on elderly, we must do now. 26 4 April 2020 | the bmj ACUTE PERSPECTIVE David Oliver Some activities may never return s the saying goes, “necessity also redeploying specialist clinicians to is the mother of invention.” allow more fast-track access to their skills, In the pandemic, we’re away from overcrowded and pressurised seeing scientifi c evidence emergency departments. This is overdue. A evolve quickly, technologies A recent letter sent by the NHS's chief develop, and real time, ever changing plans executive, Simon Stevens, and chief virtual visits to the opposite, reducing for epidemiology, public protection, and operating offi cer, Amanda Pritchard, their in-person visits to 10% of their ensuring that health services remain viable. included a provision to move away from patient encounters. Smaller practices When we’re through this crisis and have “payment by results” tariff s towards had fewer resources to even attempt such time to refl ect, no doubt some practices will block contracts, removing some fi nancial a dramatic change.