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Unexpected Lessons from COVID-19

Unexpected Lessons from COVID-19

A UK Doctor’s Perspective

Heidi Paine was a resident physician in one of the hardest hit hospitals in London, England during the early days of the COVID pandemic. She was a visiting researcher at CHLPE in 2020–21, where she brought her experiences to bear in thinking about the many facets of COVID's impact on the healthcare system.

Dr. Heidi Paine

Feb 2021

Sitting in our Friday cancer case meeting, the squeal of my pager pierced the discussion for what felt like the hundredth time that morning. An hour later, after coughing my way through that and many more referrals, Emma, our specialist cancer nurse, took me aside. “You should go home. You look absolutely awful!” “I’d love to,” I replied, not sure whether to be offended at her assessment or grateful for her concern, “but I’m on-call and so far no volunteers to cover me on a Friday evening, surprise surprise!” “Okay, well, make sure you get some rest this weekend!” she called, as I headed out to answer yet another page. ‘Chance’d be a fine thing,’ I thought, staring down the barrel of a busy weekend on-call. And with that, I rushed off to the emergency room to see patients who, according to some, felt much better than I looked.

Knowing what we know now, I feel guilty and somewhat embarrassed that I went to work that weekend. I felt lethargic and feverish. But despite never being more than two metres from a thermometer, I never checked my temperature. What number would make me call in sick anyway, knowing that to do so would be to let my team and my patients down—all for what, a ‘bad cold’? Though not unique to those in healthcare, the British mantra of ‘keep calm and carry on’ hits particularly hard when all around you there are ‘really’ sick people.

So there I was in early March, the on-call general surgery resident for a busy London teaching hospital, suffering from what felt like the worst cold of my life… whilst in a sauna, with an elephant sitting on my chest. I didn’t know it then, but COVID-19 was already firmly in the UK, already in London, and apparently already in me. I never got tested—you couldn’t at that stage unless you had travelled from a hotspot—but I believe I must have had COVID, not least because I cannot fathom how I would have made it through the ensuing months without having caught it. But whilst my personal journey with COVID may have been relatively mild, my professional journey was about to begin.

Preparing for battle

The following week was one of the strangest I have experienced as a doctor. We were glued to the surgeons’ lounge TV with its 24-hour panicked reporting of new COVID cases emerging across the UK, worryingly now in people with no travel history. Medical social media groups buzzed with anecdotes of people treating their first COVID patients, as well as rumours of colleagues exposed and themselves ventilated in the ICU. Yet other than being summoned to a donning and doffing class—learning the procedure by which to safely apply and discard PPE—I wasn’t impacted by COVID at all.

Moreover, not only was I not seeing COVID patients, but I wasn’t seeing any surgical patients either. It was as though the threat of COVID alone was enough to somehow scare off appendicitis and bowel obstruction along with, my medical colleagues incredulously informed me, the usual heart attacks and strokes*. By the end of the week our team, now double its usual size in preparation for the promised COVID influx, found ourselves somewhat bemused and relieved. We dared to hope that the apocalyptic predictions had been unfounded. And then, the very next day, the tsunami hit.

* This phenomenon was reflected across the country, and while now thought in part due to patients presenting later due to fears of attending hospital during the early days of the pandemic, there remains an inexplicable drop at the start of the pandemic in the number of some of the usual acute medical and surgical conditions.

The war

It felt how I imagine a battlefield must, only this wasn’t wartime and we hadn’t signed up to make decisions like these, decisions about who could or should receive care. But as COVID swept through our city and our hospital, ravaging all in its path, everything other than COVID care or true emergencies had to be postponed just to keep our heads above the water. Cancer patients, already carrying immense burdens, had their surgeries cancelled due to lack of ICU capacity. Patients unable to walk, just days away from life-changing hip replacements, were told it could now be months. Treating the invisible virus was, and continues to be, everything the media reports: exhausting, terrifying, relentless. But for me personally, postponing or cancelling non-COVID care was one of the most difficult aspects of all. Cancelling an operation is a part of my job I always dread, but to do it by telephone, to a patient already shouldering the stress of a cancer diagnosis, with no assurance of a rescheduling date, is a feeling I truly hope to never have to experience again.

As COVID became the new normal, my job felt anything but. The thing about surgeons is, put simply, we love to operate. Signing on the dotted line of surgical residency unofficially means waiving your rights to attend movie nights, birthdays, weddings (not infrequently the ability to participate in your own), and everything in between. The incentive for this sacrifice is several fold, but never felt quite so intimately as in those quiet moments standing in theatre, scalpel in hand, performing your meticulously learnt craft. It is, perhaps unsurprisingly given the trade-offs we make, hugely fulfilling, technically challenging, and completely and utterly addictive.

Surgery is a craft, and mastering it takes practice. As the pandemic showed no signs of abating, concern for missed training grew within the medical community. It was endemic at every level, from medical students missing crucial rotations, to final year residents unable to take exams to become the next consultants. While this may at first seem insensitive during a pandemic, please consider that once this is all over, you’ll want to know that the doctor delivering your baby or repairing your broken leg has had enough training to do so competently. I’ll admit that I was far from immune to this concern when it came to missed surgeries in my own training.

But as I sat in the cafeteria one day in May lamenting my lack of recent operating, my boss offered a different perspective. “The position you’re in now is unique to your generation of doctors,” Dr. James told me, “and you’d be wise to try to use this experience to your advantage. Not only are you treating COVID, but you’re involved in reorganising services, redesigning working patterns, and participating in record speed drug trials. Six months without operating isn’t going to affect you in the long run, but six months of the experience you’re getting now will stick with you for the rest of your career, if you choose to learn from it.” Feeling the pangs of surgical withdrawal from two months without stepping foot in an operating room, his words fell somewhat on deaf ears. It was only in the brief respite between waves that I realised he was right. Come what may, surgeons will learn how to operate. But to focus on my few lost cases in COVID was to miss the other skills I was developing in adapting to the pandemic.

Lessons Learnt

As history predicted, the brief summer relief was quickly eclipsed by an even more deadly second wave, and re-deployment into areas of the hospital like the ICU and COVID wards again became a reality. It may not have been the kind of operating I was used to—despite the masks and scrubs the whole hospital now wore, I couldn’t trick my brain into thinking I was in an operating room—but I was learning to ‘operate’ all the same, just as Dr. James had told me. As a manager, as a negotiator, as a leader. As I look back on this time, especially the early days of COVID, I see not only these new skills I learned—undoubtedly more useful than performing that 400th appendicectomy—but also new values and perspectives the pandemic has taught me. With many dark times behind us, and sadly many more still to come, I can take a little comfort in reflecting on four surprising lessons that working as a front-line doctor during a once-in-a-century pandemic has taught me.

Lesson #1: You can’t care for others unless you care for yourself

This is perhaps obvious to some, but it took the pandemic for the medical community to accept that, simply put, if you are ill, you shouldn’t come to work. Of course, had I suspected that I had COVID on that March weekend, I would not have gone in. But even in the absence of suspicion of a highly infectious virus, shouldn’t my action have been the same? The conceptions we have of time off work showing weakness, or affecting perceptions of our commitment, are clearly outdated. One of the best things I have witnessed in COVID has been the compassion towards colleagues who are ill and insistence that they take the proper time away to recover. Of course, government-mandated self-isolation for symptomatic individuals had a part to play in this. But I truly believe we’ve seen a long overdue attitude shift in healthcare that will prevail long after the end of track-and-trace alerts. COVID is a marathon, not a sprint, and its effects will be felt by those on the front lines for years to come. Those effects will only add to the high rates of stress and burnout already prevalent prior to the pandemic. Let’s hope that the newfound compassion, understanding, and prioritisation of healthcare workers’ own health are firmly here to stay.

Lesson #2: Rank doesn’t matter in a pandemic

Medicine has always been an incredibly hierarchical profession. While proponents advocate for the clear roles and code of conduct offered by hierarchy, there is evidence that this rigid structure can be detrimental to learning, wellbeing, and patient safety. Deconstructing these entrenched ways of working is undoubtedly complex, but COVID was very quick to show us that, like many things in society necessarily accelerated by the pandemic, it can and must be done. The pioneering surgeon is of no use if operations are cancelled; the professor of oncology cannot treat patients whose chemotherapy is postponed. Doctors across all specialties and levels were re-deployed wherever needed, and often found themselves working under a far more junior doctor, or in a team headed by allied healthcare professionals. In this and many other ways, COVID-19 was a great leveller; you might turn up to handover to find a consultant in the place of an unwell resident, or go to review a patient on ICU being watched over by the anaesthetic trainee relieving an ICU nurse on a much needed break from 13 hours in PPE. You came to work, left your grade at the door, and did what needed to be done.

This exhausting work, these role reversals, the learning of new skills and reprisal of old long-forgotten ones, was done willingly, with a common goal and without complaint. The pulling together and willingness to learn transcended specialty and rank instilled in us a greater level of understanding and compassion towards our colleagues, one that may have taken many years to achieve without the catalyst of COVID. Of course, I don’t expect miracles overnight. OBGYN and Surgery will continue to fight about the source of abdominal pain. Orthopaedics and Plastics will still disagree on who takes hand injuries. But this will be done with a new-found understanding of the pressures and motivations we are all subject to, and I think that’s a very welcome lesson indeed.

Lesson #3: it’s not what you do, it’s the way that you do it

In some senses it was easy to feel helpless as a doctor in the COVID pandemic. I was used to the very instantaneous, tangible results of surgery, yet my skillset was largely useless in the face of a patient gasping for breath. Even for those who specialised in intensive care and respiratory medicine—the specialties most aligned with COVID—there weren’t many treatments for COVID available in the early days, and often it felt as much luck as skill when a critically unwell patient survived. But as the list of effective treatments I could offer patients seemingly shrunk overnight, I found myself focussing more time and effort on making sure that I at least did those few things ‘right’. I’ll never forget the elderly patient who, too frail for emergency bowel surgery, wanted nothing more than to eat her favourite chocolate one last time. Normally I wouldn’t be privy to this level of personal information; her relatives would have been by her bedside, armed no doubt with her favourites. But her son and his family were isolating with COVID at home, and anyway would have been subject to one of the most pronounced cruelties of the pandemic: the rule precluding hospital visitation. I couldn’t operate on her, I couldn’t save her, I couldn’t even buy her time, but I could definitely buy chocolate, and in that moment, she got exactly the care she needed. The old adage goes, surgeons spend the first few years of training learning how and when to operate, and the rest of their career learning when not to. Not being able to ‘do something’ to improve a patient’s condition, especially as a surgeon used to practical solutions, is incredibly difficult. COVID showed me that fixing the pathology is not the only way to treat a patient. The value of learning this lesson at this stage in my career truly cannot be overstated.

Lesson #4: Not all change is bad

‘Telephone clinics? They’ll never work. Patients will hate them.’ This was what we told each other, and ourselves, as we reluctantly transitioned from seeing and examining every patient in our outpatient clinic, to sitting in an office with a list of phone numbers and teleconsultation timeslots. ‘Managers have tried it before, but the patients prefer to come in.’  I’d heard it time and time again, and said it plenty myself. I believed it, or at least I believed that telemedicine couldn’t capture the essence of a face-to-face appointment. I’m surprised and pleased to report that I was wrong.

Of course, those who had their appointments cancelled or postponed due to the pandemic didn’t see the benefits, understandably. But those who experienced the new system, by and large, relished the change. It saved an elderly patient a whole day waiting for hospital transport; a busy parent didn’t have to juggle the school run to make their appointment. What’s more, the benefits weren’t just visible for the patients but for us too. My clinics ran faster, and aside from the odd voicemail I hit, almost everyone ‘attended’, unlike in face-to-face clinics. Anecdotally, patients didn’t feel a dip in quality of consultation. And to my surprise, on the whole neither did I. In-person appointments were still available to the minority who needed them, but by and large the change forced by COVID proved what anecdotally many of us already knew: much of the activity in outpatient clinic, such as ordering investigations or routinely checking progress post-operatively, could be done remotely. But importantly, we learnt that patients not only accepted but embraced this change.

There will always be patients who want or need to be seen in person, and there are areas of the body that the telemedicine medium doesn’t lend itself to working well in. But more broadly speaking, COVID taught us that the inertia against change that is common in healthcare, often out of fear of the unknown, can blind us to helpful innovations. Telemedicine is just one of many new ways of working borne out of the pandemic. Now that the ball is rolling, I’m excited to see where it goes.

Looking to the future

It’s often said that those in healthcare cope with the day-in-day-out suffering we see by distancing ourselves from patients. This is not out of lack of empathy or care—far from it in fact—but out of the need to practice with objectivity and professionalism, and to preserve our own wellbeing in the relentless face of disease and illness. With the pandemic came an overwhelming acute rise in the trauma and suffering witnessed, and as we look tentatively to the future, it will be necessary for those on the front lines to start to distance and move past the horror of COVID if we are to look after our patients and ourselves. But while there is plenty I wish to forget about the past year, the pandemic taught me some lessons that I couldn’t have learnt in twenty years of medical school, and those, I sincerely hope, will live in my memory, and in my practice, for the rest of my career.

All staff names and patient-identifiable details have been changed to preserve confidentiality.