COVID-19 has barely hit South Africa and already our over-extended healthcare professionals are coming under enormous pressure from fearful and abusive patients, as well as ill-informed criticism over remote consultations, writes, MedicalBrief. Neither the SA media, nor the Health Professions Council nor the national Health Department appear to be aware of international best practice encouraging GPs to avoid face-to-face consultations.
Acting on what it describes as “tip-offs”, Daily Maverick’s Rebecca Davis writes the publication “has confirmed that at least five GPs in Cape Town and Johannesburg have stopped allowing patients to come into their practices in person, allowing only telephonic consultations”. “Anecdotal reports suggest that the total number … is likely higher” and questions whether this is ethical.
Davis writes: “We are not naming the GPs due to a desire not to stigmatise healthcare workers at an already fraught time – but the question of whether this behaviour is ethically acceptable is an open debate.”
She says that a Health Professions Council of SA memo to healthcare workers on 18 March supplied a link to clinical guidelines from the National Institute for Communicable Diseases stipulate the best practice for GPs when dealing with potential coronavirus cases, which include isolating the patient in a separate room and donning protective gear while consulting with them. “The guidelines do not offer telephonic consultations as an alternative.”
The report quotes Health Department spokesperson Lwazi Manzi as saying that it “is aware of this situation” and that the department’s position is that “a standard operating procedure has been circulated to doctors about how to handle potential COVID-19 cases, and as such there should be no reason for a healthy GP not to offer treatment in person. But Manzi nonetheless expressed some sympathy, saying: “We understand that people panic, even healthcare workers. We are engaging (them) on this.”
The report says that a dialogue between the SA Medical Association and Health Minister Zweli Mkhize, as well as doctors from both the public and private sectors, practitioners told Mkhize of the strain they were under, “with patients flooding their facilities demanding to be tested for coronavirus”.
The report says more than one doctor asked Mkhize to permit the widespread use of telephonic or virtual consultations to treat patients instead of seeing them in person. The Health Minister committed to engaging with the HPCSA on the matter.
Daily Maverick writes that while there have been reports of a shortage of protective gear (masks and gloves) in some of South Africa’s public health facilities, it is unlikely that private-sector doctors would be unable to obtain the necessary gear.
Daily Maverick put the question to Professor Ames Dhai, director of the Steve Biko Centre for Bioethics at the University of the Witwatersrand: is it ethical for GPs in private practice to refuse to see patients in person due to COVID-19 concerns?
Dhai said: “Doctors cannot refuse to manage patients. We all take oaths, and inherent in these oaths are that we understand the gravity of this calling. We are all aware of the coronavirus problem, and we are aware of the preventative measures we should be employing.”
But Dhai said that a doctor refusing to treat a patient was quite a different kettle of fish, ethically speaking, from a doctor making alternative arrangements for the patient. The latter, Dhai suggested, might well be acceptable. She said this could include both telephonic consultations and supplying patients with the Covid-19 hotline number to call.
“Others aren’t convinced. A local health activist … considered the issue to be morally analogous to doctors in the early days of the HIV pandemic refusing to allow potentially HIV-positive patients into their practices,” continues the report. “Some GPs who are seeing patients as normal have expressed disappointment with colleagues who have shut their doors on in-person consultations.” One asked Daily Maverick: ‘Why would someone practise as a doctor and not want to see patients when they most need you?”
The HPCSA response to Daily Maverick comes down firmly in favour of face-to-face consultations:
“One of the ethical values and standards in the practice of health professions is that healthcare practitioners should act in the best interests of patients even when the interests of the latter conflict with their own personal self-interest. As professionals, health practitioners have a “moral obligation” to provide healthcare to patients requiring such care. Generally, telephonic consultations are discouraged. Practitioners should adhere to the safety precautions instead of avoiding to see patients who need their professional services.”
MedicalBrief notes that the HPCSA and national Health Department responses are out of touch with frontline realities elsewhere in the world. As reported in MedicalBrief last week, the UK’s National Health Service, in a significant policy change, has instructed England’s 7,000 GP surgeries to start conducting as many remote consultations as soon as possible, replacing patient visits with phone, video, online or text contact. They want to reduce the risk of someone infected with COVID-19 turning up at a surgery and to free GPs to deal with the extra workload created by the virus.
In an analysis by the Medical Protection Society, published this week in MedicalBrief, Dr Graham Howarth, head of medical services, Africa, notes that the use of telemedicine has been advocated as one of the ways of delivering healthcare during the crisis.
“Where face-to-face consultations are not feasible, you need to be satisfied that proceeding in this way is in the patient’s best interests and that you can adequately assess the patient remotely. cases of emergency, patients should be encouraged to seek assistance via the recommended route, in accordance with the most recent government and/or public health guidance.”
Howarth also addresses an increasingly likely dilemma: doctors being asked to undertake duties outside their speciality or expertise. “Many state-employed doctors may also have an employment contract stipulating they are obliged to follow reasonable instructions, which could extend to seeing emergency patients even if outside the scope of their speciality.
“If a doctor is asked to perform a duty they would not normally undertake, they need to assess whether they feel they have the skills and competence to proceed. This will include considering what is in the best interests of the patient. If they do not feel it is safe to proceed and that to do so will place the patient at greater risk of harm than not undertaking the duty requested, then they should advise whoever has asked them to do so and explain their concerns,” advises Howarth.
See alsoNICD's guidelines for SA's GPs in treating COVID-19 COVID-19 medico-legal dilemmas for South African practitioners