Not all COVID-19 superheroes wear capes

I WROTE this article after reading Tim Elliott’s article published in the Fairfax press on 20 June 2020 about the intensive care unit (ICU) team at St Vincent’s Hospital. They deserve their accolades, of course, but we also need to acknowledge the equally critical role of the uniformly under-recognised non-hospital workers. GPs, public health physicians, practice nurses, community pharmacists, practice managers, pathology collectors, receptionists – we salute you, too.

While St Vincent’s story highlights five doctors, a Principal GP has five jobs. That’s reality as a practice owner, principal doctor, supervisor, business operator, and employer. It’s not that a single GP could do the work of all five at a major tertiary centre; it’s just that GPs need to have a skill set that can cover all those roles at the scale of one (or a few) medical centres. Ms Kara Zor-El*, our Practice Manager, also has multiple jobs, as does our Nurse Manager Ms Leia Organa*. And yes, 75% of this primary care dream team is female (ably supported by our community pharmacy Superman), because that’s exactly how it is. Here are our stories.:

Dr Kate Manderson Principal GP

Across our four practices, we have 75 000 patient visits per year – at least 100 a week across 15 full-time equivalent (FTE) clinicians. We have around 40 staff, from medical to nursing and clerical. All the early COVID-19 information was focused on inpatient care at government facilities, so we had to translate it for our practices. We couldn’t just close our practices and wait; we had to get on with it. Tertiary hospitals had their aerosol personal protective equipment (PPE), negative pressure rooms and point-of-care testing; we had marking tape from Bunnings, PVC screens, and wipes. It worked. In my opinion, the hospitals didn’t have to manage nearly as many cases as they would have if we hadn’t done our jobs properly.

It is not likely that tertiary hospitals were required to manage their COVID-19 response up with a 50% revenue cut, or personally guarantee their staff’s wages. We don’t have the resources of the state government behind us, with management, logistics, governance and staff and, of course, funding. At one stage we had an executive meeting to see which staff had to cut hours, so we could afford the wages bill, but still make sure the clinics stayed open for our patients. JobKeeper and the telehealth items have helped, but those aren’t a long term solution. I fear for the future and sustainability of quality GP services once those programs end in September.

One major concern I discussed with my GPs and nursing staff is how we would respond to a nursing home outbreak – we only have eight FTE doctors and five FTE nurses to stretch across eight local facilities. It’s incredibly challenging for an aged-care home in a rural area – no major hospital, no after-hours agency, no urban workforce to deploy. Our concern would be that COVID-19-affected residents die in distress, but there are very few syringe drivers or nurses to administer them. The facility nurses would do absolutely everything they could, but it’s hard with only one registered nurse (RN) for over 100 residents in some facilities, and often none at all after hours.

We were just recovering from the summer bushfire crisis when COVID-19 really hit. Personally, it was a challenging and trying few months. There was so much to think about that I found it hard to sleep, constantly ruminating on the guidelines, workflows and setup, trying to keep my team safe at work. We found two rooms across four practices we could use for separate fever clinics, which we set up overnight. We wrote scripts for the receptionists to be able to explain the process, triage people and make sure they could wait for the session. We allocated GPs (only those at low risk), put up signs on the doors so sick patients didn’t come into the main clinic, and arranged the PPE and medical gear and the swab process. It was good to be able to keep seeing our patients rather than sending them all to the emergency department, even with just a mildest cough. Then we carved off half of an entire practice for a GP-led COVID-19 clinic. Getting all of this set up, and keeping it going, has been non-stop. The team rallied to make all of that happen and I’m so proud.

We’ve spoken at practice meetings about how we would manage serious presentations. We can’t get clear video connections because our internet is too unreliable around here, for the practices and the patients, so we have to find ways to do it all on the phone. How do you ask a patient to examine themselves? If they have abdominal pain, you arrange bloods; if they have abnormal liver function tests, we need to ask them – is your skin yellow? Yes – you need to go to hospital now! If we’d seen them face-to-face, we would have seen that 3 days earlier at the first consultation.

The flow of COVID-19 information was relentless, and chaotic. It was sometimes contradictory; other times, it was hard to find, hidden in links or unreferenced media statements. I had to synthesise it, interpret it for general practice, and use it to make decisions on a daily basis. All the infection control protocols were designed with hospitals in mind, so setting up the testing clinic was an exercise in being agile and innovative in a crisis. The public health team have been awesome, they are unsung heroes.

It’s important not to let every thought you have be about COVID-19, because the usual work of the practices keeps going. With the sudden closure of outpatient clinics, hospital specialist rooms and theatres, the primary care specialist (GP) is left holding the baby, especially for vulnerable and isolated patients, elderly people, and those with mental health or drug and alcohol problems. We are lucky we don’t need to be open 24/7, because we have the safety net of an amazing team of ambulance officers and of course the local hospital. There aren’t a lot of after-hours GP services in our area though, so we cover that too. We are never really switched off.

Ms Leia Organa*

Our Clinical Services Manager has been with our GP team for a few years, and has been in practice nursing for a decade. She runs all the clinical services, from the emergency responses and equipment to procedure lists and accreditation. We have four practices with 25 consulting rooms and 40 staff – doctors, nurses, administration and allied health. It’s all about logistics and communication. A big part of her work is also just being present, take feedback on what we could improve, asking if they have everything they need to do their job and how are they feeling. We are so glad our nursing staff have not lost their jobs, but their workload has been huge. And at the same time, they still had to home-school, fight for toilet paper, and hope that they weren’t bringing COVID-19 home to their families.

It is so important to keep general practices open and keep people out of hospitals. The last thing hospitals need is to look after people with preventable complications such as wound infections. We had ex-hospital practice nurses willing and able to step back to the ICU, but then who would look after the patients out in the community? The primary care nurses are doing just as big a job as the hospital ones.

With the GP-led COVID-19 clinic, cramming a busy general practice from seven rooms into three has been a huge challenge. The whole thing, including building, training, equipment, protocols and recruiting, took just a few weeks. That’s got to be a record for a GP practice start-up. Leia arranged the team of nurses to work with the GPs to do the swabbing, but we didn’t have enough, and it’s pretty hard to bring on new staff in a rural area with GP provider number restrictions and limited workforce. We didn’t have enough clerical staff, either, so Leia also helped in training up our doctors and nurses to be able to do that themselves. Everyone just had to do more shifts and help each other out.

Ms Kara Zor-El*

Kara has been a practice manager for years. I love her approach to teamwork and the connection she has with patients. When COVID-19 hit, the practices all got incredibly busy, really quickly. The extra triage and counselling on the phone balanced the drop-off in appointments, in busyness but not in revenue. There was a stream of 50 extra calls every day, and at 5–10 minutes each, that’s a full-time workload itself but with no extra staff. Our business manager was worried about how we would pay the wages because the number of people who’d normally show up completely dropped off. We dropped close to 50% of our revenue in the first few weeks. I think people thought they had a risk of getting COVID-19, so they stayed away. But we have an obligation to our patients and our community to be there for them, no matter what, because COVID-19 doesn’t mean all the other diseases go away.

COVID-19 is still this unknown entity and it’s not enough to say “it’s probably not”, you have to prove it with a swab. We still have people downplaying their symptoms, or just not telling us at all, even while they are at the desk coughing and sniffling! But we can’t afford for people to come in with symptoms, they could be in the waiting room for half an hour, and then again with the RN or GP before they declare they are unwell. Then we will lose staff for a couple of weeks if they need to isolate – the idea of that was a real eye-opener, and that’s why Kara and her team work so hard on triage and screening. Kara also had to rearrange the admin roster and even their seating arrangements, to make it COVID-safe.

Our cleaning contractors are fantastic. We have four different sites with a total of 25 consulting rooms, waiting rooms, staff rooms and offices, so cleaning them is a massive job. During the day, the practice staff do a wipe-down of equipment and surfaces in the respiratory clinic, so overall the risk to the cleaners is low when they come in after hours. That’s another job our doctors, nurses and receptionists need to do: if there is someone who is really sick or a likely case, we have to clean everything and get it back online, right then. Multitasking is a GP superpower.

Mr Clark Kent*

Clark is a local community pharmacist. They do everything once people are out of hospital, and back at home, for heart and lung transplants, rare diseases, trauma, palliation … you name it. They teach patients about their medication and what they have to do with them. Some of the medications are specialised, or the patients have many conditions that all need treatment: some of the patients are taking 20 different medications.

When COVID-19 came, Clark saw a huge increase in his workload. GPs were trying to keep patients safe by doing more reviews by telehealth, but we still don’t have a connected GP-patient-pharmacy system in Australia. Clark works closely with the local GPs, that relationship is so critical to patient care. I get frustrated when I see corporate pharmacies take advantage of telehealth and try to divert patients from their usual GP, when I can see the benefits of GP and Pharmacy working together, like we do with Clark.

* not their real names

Dr Kate Manderson is a GP in the Shoalhaven region on the South Coast of NSW, managing four general practices (five with the bonus respiratory clinic). She was already in awe of the amazing team of administrative staff, nurses and doctors she works with after the summer fire season, but now their response to the COVID-19 emergency has truly brought them to light as genuine community-based health care superheroes.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.