By EDSEL MAURICE SALVANA, MD, DTM&H, FPCP, FIDSA
Respirator, face cover, gown, gloves, shoe covers. One would think I was preparing for surgery or a chemical weapon attack. But no, this is me in the clinic about to examine one of mypatients. She looks at me suspiciously. “She” is Mrs. Cruz (name and details changed to protect her privacy), a 70-year-old lady whom I have taken care of for years. She has beginning dementia, but she always has a big smile for me whenever shevisits. Now she looks at me with increasing alarm. I belatedlyrealize the problem—she cannot see my face, and I am scaring her.
The art of medicine is almost as old as civilization itself. Advances in science have increased the reliability of treatments we use to help our patients feel better. The way we deliver care, however, has remained the same. A doctor still needs to examinea patient.
Aside from the data gathering that happens when interviewing the patient and doing a physical examination, the foundation of a good doctor-patient relationship is established during the encounter. A doctor who listens and understands what a patient is going through is much more effective and more likely to get the patient to take medication. The relationship starts when the doctor introduces himself to the patient, and progresses when the warmth of a smile and the firmness of a handshake are perceived by the patient. Sympathetic comments help patients cope, and body language and facial expressions bring home the message that the physician is there to help.
When Covid-19 hit, almost all our outpatient clinics were closed. Care in clinics prevents many, many diseases from developing into full-blown dangerous conditions that may end up needing admission to the hospital. When the lockdown was extended, more and more patients were unable to seek their usual care. Some clinics adapted with telemedicine, buttelemedicine has its limits. Doctors are unable to do physical examinations or administer treatments in the same manner as a clinic visit. When Manila shifted back to MECQ, some doctors including myself gradually restarted our practices.
Hospitals are understandably cautious. The number of patients a doctor can see are limited, and all patients are screened for fever and other Covid-19 symptoms before being allowed to proceed to clinic. Doctors have acrylic windows on their desks, and gargantuan filters clean the air. Alcohol and bleach spray are readily on hand, and a stack of PPE gowns is folded neatly nearby in case the doctor needs to examine a patient. Patients are requested to follow the rules—they have to fill in a health declaration, they are limited to one companion each, and all are required to wear masks.
Aside from being unable to communicate with our patients properly with our facial expressions, the masks muffle our voices, necessitating a near–shout in order to be heard. We are also unable to take visual cues from our patient’s expressions—avital part of listening and gauging if our patients are holding back on what they are feeling.
As the pandemic continues to wreak havoc in the world, nations are beginning to learn to live with the virus. The lockdowns were meant to help us catch our breath and to protect our healthcare system from becoming overwhelmed. Some countries did better than others.
Looking at the United States, where lockdowns were late and far too short, two million cases and over 100,000 deaths show the effect of not taking COVID-19 seriously enough. Places that acted early and comprehensively like Taiwan, Vietnam, and New Zealand, have done well but remain vulnerable.
The Philippine lockdown was earlier than most, and this proved critical in keeping deaths at bay. Mexico locked down 10 days later than the Philippines, resulting in over 5,000 cases a day. This shows that every single day counts when you are dealing with an exponentially growing foe. While our death toll recently exceeded 1,000, it could have been much, much worse.
With case numbers increasing anew, we need to be proactive and work harder if we are to avoid another shutdown. ECQs are not sustainable and take a tremendous economic and societal toll, including an adverse impact on the proper delivery of healthcare.
Universal masks, physical distancing, handwashing, and disinfection can substantially decrease the risk of Covid-19 transmission and should be meticulously implemented. The government needs to step up testing and aggressive contact tracing to isolate clusters. We need to keep numbers manageable until better treatment and a vaccine are developed.
Filipino doctors are now much better at keeping Covid-19 patients alive, but this will be all for naught if hospitals are overwhelmed by a sudden surge.
Some colleagues refuse to call all these a new normal. Indeed, there is nothing normal about this. But it is better than not being able to provide care to our patients. Personal protective equipment keep doctors safe and prevent us from bringing Covid-19 home to our families. This is okay for now, I tell myself, as I complete my clinical exam on Mrs. Cruz. No smile for me today. But I hope it isn’t for very long, for all our sakes.
About Dr. Salvana:
Edsel Maurice T. Salvana, MD, DTM&H, FPCP, FIDSA is an internationally recognized infectious diseases specialist and molecular biologist at the University of the Philippines and the Philippine General Hospital. He is the director of the Institute of Molecular Biology and Biotechnology at the National Institutes of Health at UP Manila. He has spoken and written extensively on the Covid-19 outbreak, and serves on the Technical Advisory Group of the Inter-Agency Task Force for the Management of Emerging Infectious Diseases (IATF-EID).