The other long COVID: impacts on health systems and clinicians

AS Australia moves through the current Omicron wave of the COVID-19 pandemic, attention in both mainstream media and medical literature has begun to turn towards the impacts of long COVID. This is the name given to the long term impacts of SARS-CoV-2 infection, which in its most severe form can affect multiple organ systems and lead to debilitating levels of fatigue and cognitive impairment. Although to date there is a scarcity of advice around the management of COVID-19 symptoms in the long term, this conceptual shift recognises that the impacts of the pandemic will likely remain with our patients for many years and will require new and complex multidisciplinary care models.

Less considered, however, have been the long term impacts of COVID-19 on our health systems and medical workforce. In hardest hit states such as Victoria and New South Wales, hospitals have struggled to fill shifts for doctors working in intensive care settings secondary to requirements for en masse furloughing of staff, while Victoria activated a Code Brown across the state for the first time in its history.

We argue that the systemic impacts of COVID-19 may be even longer lasting than the illness itself, taking a toll on our profession that might require years or even decades of recovery.

These impacts are evident across the career cycle, intersecting the work lives of medical students, prevocational doctors, registrars and consultants in similar but also unique ways. Prior to COVID-19, discussions were being held to plan for a workforce that would best match medical graduate numbers to future workforce projections, ensuring that registrar training places aligned with both training requirements and areas of geographical and skills-based community need. Addressing the workforce maldistribution was a major body of work for many specialist training colleges in collaboration with health departments, and much of that work will need to be reinvented and reimagined in a post-crisis era where the long term impacts of the pandemic on the training pipeline are yet to be seen.

This unprecedented global crisis has created substantial challenges for medical education. Jasmine Davis, President of the Australian Medical Students’ Association (AMSA), recently discussed the impacts of the COVID-19 pandemic from a medical student perspective, noting that while the pandemic had born some early positives in the form of online learning, many of the impacts of COVID-19 on medical students have been negative. With reduced clinical exposure in some states, many medical students are experiencing decreased confidence in their clinical skills and existential questions around what it means to be a doctor.

The COVID-19 pandemic has also exacerbated the poor mental health and wellbeing of medical students, junior doctors and senior doctors alike. Uncertainty about educational opportunities, training pathways and academic stressors, alongside the impacts of the pandemic more generally, such as economic pressures, social isolation, and caring responsibilities, are all factors contributing to the incidence of mental illness in our future and current workforce. Even prior to the pandemic, medical student and doctor suicide was far too commonplace, and this must urgently be addressed.

The potential and real impacts of COVID-19 on health system reviews such as the Royal Commission into Victoria’s Mental Health System need to be considered, with the resources, staffing models and feasibility of mental health reform potentially requiring significant reworking in light of the emerging long term impacts of COVID-19 on the health system landscape.

Of course, the aforementioned stressors at the student level flow directly into the prevocational space, with a new cohort of interns beginning their careers in hospitals across the country this month. Internship is a learning curve at the best of times, but starting in an environment plagued by staff shortages, extreme levels of burnout, and uncertainty around supervision – not to mention in a work environment which exposes them to personal risk – needs particular consideration. Many prevocational doctors have expressed concerns that the past 2 years of disjointed clinical experiences have left them with subjective knowledge gaps, and they are joining the profession at a time when the availability for further teaching, modelling and mentorship by senior staff is at a low.

Our registrars, both unaccredited and accredited, have been at the frontline of the public health system pandemic response for the past 2 years, and this too has come at a significant cost. Many specialist trainees have been moved to different parts of the health system, which has impacted upon their completion of mandatory rotations, and international studies have shown the progression of some surgical trainees has been impacted by the cancellation of surgical lists. Psychiatry trainees have been increasingly required to make decisions on patient care from a distance, with limited resources and reduced access to both inpatient and community care. Emergency department registrars have experienced significant pressure following an increase in presentations by 6.9% between 2019–20 and 2020–21, and although welcome, the introduction of surge medical staff from other fields requires additional supervision from critical care registrars.

Amid these increasing service demands for registrars, there have additionally been substantial COVID-19-related impacts on exam preparation across all specialty areas. Few specialist colleges have adequately addressed the fundamental paradox whereby pandemic-affected trainees are working harder, in a more challenging context than ever before, with fewer opportunities for bedside clinical teaching, and less overall time and energy to study. Accommodating major changes to exam delivery, or as we have seen recently, the failure of some colleges to deliver examinations, is extremely stressful for an already stressed cohort of junior doctors. In response, many trainees have ultimately chosen to decrease their hours to part-time work or locums, change training pathways, or leave health care altogether.

Indeed, our health systems were simply not adequately prepared and resourced to coordinate service delivery for the current phase of the pandemic, and this brunt has been felt markedly by senior medical staff. Many hospitals have lost clinicians from senior roles, anecdotally citing a growing distance and disconnect of understanding between those at the frontline and those who manage them from afar. The loss of such clinical leadership has a profound effect on staff morale, and on the safety and quality of patient care, reducing the availability of clinical expertise. Finding staff to take on critical leadership roles amid the ongoing crisis presents even more challenges.

Outside of the hospitals, GP clinics have been similarly inundated and overwhelmed. Again, staff shortages, supply shortages and inadequate funding models have put substantial stress onto an already busy and demanding career – and this does not even begin to speak to the challenges of the vaccine rollout. The Royal Australian College of General Practitioners has emphasised that the current circumstances are absolutely not business as usual, with many GP practices having to triage patient care to an extent that has never been seen before.

There have been some positives amidst the COVID-19 pandemic. Never before have we had a population so engaged in public health. We have seen an increase in the awareness of the general public about funding and workforce supply limitations, and an improved understanding of the need for surge capacity in healthcare. We have seen recognition that the provision of health care, during COVID-19 or otherwise, is an enormously challenging task and that those working within these systems may suffer from their own mental and physical health issues, just like everyone else.

Articles have been written in Insight+ calling for health system reform, and these calls have grown louder as the public is urged to #RememberHowItFeels to create political impetus for change. The desire to ensure that we have a health care system that is robust, supported, accessible, equitable and safe has perhaps never been greater.

So, what is next?

We are hopeful that Omicron will subside, and that we will move into the next phase of COVID-19 pandemic management. However, the broader impacts of the pandemic will require a new focus, a unity and an energy that we will have to tap into, even though our reserves are low. It is clear that the pandemic has affected the entire medical workforce from medical students to consultants, and if there is ever a time for solidarity of purpose, it will be in the coming months and years.

As medical students and doctors, we need to begin preparing for the impacts of long COVID on our health system – a disease with many variants and victims, some seen, many unseen, and others that may remain a mystery for a while to come. And we need to do this together.

Dr Simon Judkins is an emergency physician and the Director of Emergency Medicine at Echuca Health. He is a Board member of the International Federation of Emergency Medicine and AMA Victoria. He is the Chair of Mental Health committees at ACEM and RDAV. The views in this article are shared with the other authors and not specific to any of these organisations.

Dr Skye Kinder is a psychiatry registrar and the 2019 VIC Young Australian of the Year. She is an Australian Financial Review 100 Women of Influence listee and was recently recognised by Forbes 30 Under 30 for social impact in the Asia–Pacific region.

Dr Laksmi Govindasamy is a public health physician and emergency medicine registrar. She was the AFPHM Sue Morey Medalist in 2020 and is undertaking a PhD exploring leadership development and gender in emergency medicine.

Dr Geoffrey Toogood is a cardiologist and a long-time advocate for mental health. He has swum the English Channel. He came up with the idea of crazysocks4docs day, and was the recipient of the AMA President’s Award in 2019.

Jasmine Davis is the current President of the Australian Medical Students’ Association. She is also a medical student at the University of Melbourne studying the intercalated Doctor of Medicine and Master of Public Health.

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.