Conversations On Coping with Corona

 Dr.S.Subramanian, Director,Smrthi Healthcare, Chennai 

in conversation with

Mrs. Chitra, Health Communicator.

Here is a free transcript of the conversation.

Mrs C: 

Hello Dr, your patients to are eager to hear your views on the pandemic situation and this the context of our conversation.

Let me begin by asking  as to how you are  doing as a medical professional also as a member of the society?

Dr S:

Just like anybody else in the society, we are also taken aback by the kind of changes we need to adapt to, as  result of the pandemic. It has thrown all our plans and comfort zones out of the place and we are really adapting to situations every day. It is very tiring. With medical profession being on the forefront of the struggle of COVID, we must bear the brunt. Our elders, our senior members of our society have faced such problems earlier too and if we look back and take from their experiences, we will be able to come through this very well.

Mrs C: 

How has Smrthi Healthcare adapted as a healthcare system?

Dr S:

Unlike many other entities, we were not able to completely shut down our work during COVID. Instead we continued to provide our services in the best possible manner. So, given the fact that we have a medical background and we had a responsibility towards the community, right through the lockdown,  we decided to provide our best possible services, whatever it takes, in the best possible manner. Through God’s grace and lot of support from community we were functional.  Manu parents and lot of children and pregnant women came to us through the pandemic. I would not call it an achievement. But I feel that we have been able to live up to the commitment given at the beginning. 

Mrs C: 

We are evolving in our response. Do you think the changes are here to stay?

Dr S:

The changes are here to stay yes and we have learnt certain things and we have adapted to them. Because we are forced to learn, we learnt it very quickly and having learnt that we can have the comfort of certain services at the comfort of home, we would not want to go back on certain aspects of care back to olden methods. For example, certain review visits may not happen at all because we will be able to provide near adequate care online. Through this, we  will be able to cut short lot of effort, time and money for the patient and the healthcare.  These changes are removing lot of pressure on the healthcare system. These changes are here to stay. But this will also evolve over a period.

Mrs C: 

In this context, how do we access healthcare system, like do we restrict it to sickness visits or do we consult even  if we see  challenges like red flags?

Dr S:

When you look at access to healthcare system, during the time immediately following the outbreak, it was relevant to say that it was better to stay back at home and to avoid unnecessary visits. Restrict to immediate care needs only. But with prolonged lockdown, what was emergency care has now been extended to care which cannot be postponed any further. For example, we did postpone vaccinations for the first 10 -15 days of lockdown. IAP and other associations recommended that postponing vaccines would mean return of vaccine preventable diseases. Especially the initial ones like DTP, MMR etc if skipped would create an outbreak of these diseases over and above COVID which would be a catastrophe. Given that fact, now many pediatricians have started with it. So, what was not considered emergency earlier, has now become essential. So, we have transitioned from emergency to essential care services.

Mrs C: 

For children undergoing therapies, what does this break, or shift mean?

Dr S:

For children undergoing therapy  due to issues with developmental progress not being age appropriate, we need to look at it not just from medical but also social context. When we look at the child, the parents, family, siblings, and people around the child have to put that much effort on the child than the previous state of the child prior to break of therapy. The longer they do not have care they are going to slip back as far their progress is concerned. Their goals are not going to be reached. It is going to be more and more difficult to provide care for these kids. Breakage of continuity of care is a major issue in rehab. In rehab you do not see immediate effect, you do not administer therapy and see change the next day. In therapy many a times you need to put in sustained effort, faith in therapy over a period  of time to see the results coming out. When you are not able to provide that care for more than  two three months, this is definitely  going to be a big problem for these kids.

Mrs C: 

Do you mean to say that we need to move forward and get in tandem with therapy schedule?

Dr S:

Definitely. It is not just about therapy it is about everything in life. We know that COVID is here to stay we have many authorities stating that it is going to be a pandemic and slowly it is going to be an endemic like Swine flu or other illness. We are going to live with it. Whether we have vaccines or not, this is not going to go away from the community. Given that fact ,we must look forward as to how we are going to handle this. We cannot expect the pre-pandemic situation to return. We need to start looking at other options.

Mrs C: 

Do you mean to say that ultimately, we need to come onsite as the situation is not going to go away?

Dr S:

Our response must be according to local community spread. It cannot be same for every state, community, or city. We must provide care based on the situation in the society. Depending on this we  have to provide onsite or a distant or online therapy where the parent becomes the provider  and the therapist/specialist  trains the parent to deliver it. The therapist here provides therapy through the parental mode. In fact, I would go a step further and we should probably think of providing a hybrid mode, ready to shift from one mode to another depending on the situation in community. We need to continue to provide care. It may not be the optimal mode of providing care, but it is better than not providing care at all.

Mrs C: 

How safe is the onsite therapy?

Dr S:

Being a medical system which was running through the pandemic, our adaption has been according to the recommendations and to  to the needs of the challenges, Whatever needs to be done in the form of screening patients  who come to the system or in the form of providing only one to one therapy, stopping group therapy, ensuring  safety of provider to ensure continuity of therapy is being done. We are ensuring that the place is sanitized. We make sure the rooms are sanitized before therapy, just before therapy starts, all materials are sanitized, then therapy is administered. Once the therapy ends, the entire place is again sanitized, and the items are sanitized too. Though the recent evidence does say that fomite borne infections is low, we still ensure that kids are safe. We are also ensuring that the parents are there with the child and most of the handling of the child is done by the parents so that physical touch by others is avoided as far as possible. Enough amount of social distancing is ensured between the child and the therapist.

Mrs C: 

The escalated costs, time, and stress on the system as a result of this. How have you coped up with that?

Dr S:

It is all part of the game and if we are to ensure sustained therapy, we need to sustain in every other aspect as well. It is not the time to look at cost now. The other point is about time. Yes, it is taking away lot of our time. You can imagine, literally mopping down the entire space and cleansing every material  after every therapy is taking a lot of time. But I feel that this is going to be essential . With time, as we get better evidence on maintenance, we may probably scale down this amount of precautionary measures. As of now we are taking all precautions as we still cannot take such evidence as final word.

Mrs C: 

Doctor, in this context, I would like to know as to how you have managed with cost? Have you transferred it to patients?
Dr S:
Cost has escalated. But it has not been transferred to the patients. We are bearing it. As of now, we are able to manage. In fact we have packaged our costs for therapies at 10% lower than the pre-pandemic costs.

Mrs C: 

How would you assess/ elaborate your online interventions ?

Dr S:

As I mentioned earlier, to measure any outcome of an intervention, you should allow sufficient time for the intervention to act. There is a time lag between  providing therapy and outcome being manifest. In rehab we know it is going to take a long time  before we can  have a definitive outcome. This is where we stand as far as evidence is concerned. We only started in April and with the kind of numbers we have, I do not think that I can clam that I have evidence for or against the online therapy. There have been  previous papers about online settings and those are in different community settings, time etc. We cannot extrapolate those data in our system. We will be able to gauge this only with time. But what I can say is that by not providing therapy, these children are going to  slip. But I can say that by providing online or hybrid therapy and by studies in other organizations where parent directed therapy have been effective, I am confident that this will be a good mode to provide therapy during these Corona times.

Mrs C: 

Thank you, as we carry forward this confidence that you have,  I  would want you to give this a finishing touch with a two liner for every parent.

Dr S:

We are challenged by the present situation and we need to look forward and start adapting. We cannot continue to say that the previous setting would come back,  and we would only work around such setting. We should start looking for options, other modalities of providing care, education, and stimulation for children. In this setting we can spend the time to communicate appropriately with children and we should realize that we are the role models in showing strength, resilience, and patience. I am sure that children will grow up  watching this and as they grow up, they will realize that they have learnt a very important lesson in life when they face adverse situations.

Thank you!