Junior Doctors and the COVID-19 Pandemic - What did the Real FrontlineWarriors Go through: A Qualitative Exploration

Introduction

The impact of COVID-19 pandemic on doctors is of tremendous importance. Since doctors are the most important component of the healthcare system, the functioning of the system is affected by the state of doctors. Several studies have focused on the perceived stress among doctors during the pandemic.^1-4 However, it is important to understand various issues on how the junior doctors were impacted. Adequate measures can be taken accordingly to make our healthcare system more doctor-friendly, thereby increasing the delivery output. Therefore, this study was conducted to understand how the junior doctors were impacted during the COVID-19 pandemic and to explore the steps to be taken to make junior doctors more secure and comfortable during pandemics in future.

Material and Methods

A qualitative study was done by obtaining inputs from doctors regarding the experiences and impact of doctors in this pandemic. The study was done for over one month. Junior doctors like Interns and Junior Residents (JRs) were included in the study. Doctors from both public and private sectors were involved in this study. Data was obtained by Focused Group Discussions (FGDs).

The study participants were selected by purposive and snowball sampling. They were selected from government and private tertiary hospitals in coastal Andhra Pradesh.

Approach to Data Collection

After an initial pilot study, it was decided that deductive approach of data collection would be suitable. As this method was new to almost all the study participants, it would be more helpful to prepare a few themes in advance and lead the FGD based on those themes. However, the FGD was not confined to those themes. Any new areas explored in course of the discussion were explored and discussion was encouraged.^5,6

Initial themes prepared for FGD Guide were:

1. Issues with treatment protocols

2. Impact due to infrastructure and logistics

3. Attitude of patients and society due to doctors

4. Positive notes from the pandemic

Notes during FGD were taken by two recorders separately. Audio recording was also done for later transcription.

Coding and Analysis

The entire audio recording of the FGD was transcribed in verbatim. The transcription was gone through repeatedly to identify various codes. These codes were gathered under various pre-set themes. Any new themes arising were also generated. Coding was manually done, and cross checked with two other investigators who were simultaneously recording during the FGD.

Thematic analysis was done to code the data. The themes initially used in the FGD guide were listed. Any new themes generated from the transcripts were also added. All the transcripts were collated. Information was coded and grouped under various themes.⁷

Results

A total of five FGDs were conducted, three for interns and two for junior residents. Twenty interns and eight junior residents participated in these FGDs. Each FGD had 6-8 participants. The average duration of FGDs was 32 minutes, the shortest being 19 minutes and longest being 49 minutes.

In course of the FGDs analysis, two more themes were generated based on the inputs received:

1. Social, Psychological and Family issues

2. Steps to be taken by the government

Theme 1: Attitude of patients and public towards the doctors

The study obtained mixed responses from the participants regarding the attitude of the patients, their relatives, and the general public towards doctors.

Their responses reflected their work setting and whether the patients were stable or critical.

“Most of the patients were stable and comfortable in the wards. They were chatting or seeing something in mobiles.” – Intern 2

“Some patients were constantly troubling about seeing doctors. Even for minor issues like stomach ache, they are complaining doctors were not doing anything.”– Intern 5

“Some patients are not recognizing doctors in PPE kits. So, they complain doctors are not visiting and doing rounds” – Intern 1

“If they can’t recognize us in PPE kits, what can we do. We can’t wear stethoscope and go and how will it be disinfected...they tell us to wear colour bands and all... but these are all not easy practically” – JR 2

Overanxiety on behalf of the patients’ relatives was found to adversely affect the doctors

“Most relatives are not convinced. They were insisting on getting visitor’s pass even if not necessary, coming into wards and disturbing the staff, they don’t wear PPE properly” – JR 6

In case of critical patients, the pressure from relatives was worse.

“Relatives behave rashly with doctors” – Intern 6

“There was lot of pressure and influence at different levels to shift the patients to ICUs and oxygen beds, even though there was no need or much worse patients waiting. Even if the saturation is 90, they were calling to shift the patient to ICU when there are patients in 50s and 60s waiting” – JR 5

In general, all the participants felt that general public is appreciative of doctors.

“Everywhere we are appreciated as frontline COVID warriors. But only till any of their family members gets infected. Then they start blaming us.” – Intern 3

Theme 2: Treatment Protocols

The participants observed that there was lot of confusion on treatment protocols.

“WHO says one thing. ICMR says one thing. The central institutes issued their own protocols. No clarity about which patients should be put into which category” – Intern 6

“We can’t rely fully on protocols. We need to use our own experience. But the number of physicians and pulmonologists and anesthetists was not sufficient, and many other specialists had to be recruited” – JR 4

“Much more confusion about drugs like hydroxy chloroquine, ivermectin, remdesivir. Sometimes they say they are good and sometimes they say they are not helpful” – Intern 5

“General management of the patients was also problematic, as we did not have enough experience” – Intern 8

“People were taking treatment on their own based on social media and some non-medical ‘experts’. Then they are landing up with more dangerous complications” – JR 3

Impact of COVID-19 on regular health care also added to the burden.

“Regular health care has been badly affected. Many people stopped taking medicines for diabetes and hypertension due to fear of going outside. These people added to the already complicated clinical picture” – JR 6

Theme 4: Infrastructure, Logistics and Manpower

The participants felt that during the first wave, there was shortage of almost everything, but slowly things improved.

“Severe scarcity of masks and sanitizers was there in the first wave.” – Intern 2

But with the second wave there were totally different issues.

“During second wave, there should have been proper planning and preparation which failed badly at all stages” – JR 7

“In second wave, even though PPE kits and ventilators supply increased, there was no proper distribution and maintenance. There was difficulty in fitting them. So many ventilators were locked up in some rooms in hospitals.” – Intern 7

Lack of standardized Personal Protective Equipment (PPE) was another major issue.

“There are no common standards for PPE. Many duplicate PPE were also sold. No clarity over this, even during the second wave.” – Intern 14

“But PPE was provided adequately throughout the second wave, and we should appreciate it” – JR 4

Doctors also felt that shortage of manpower not just among doctors, but also among nurses and support staff affected them. The participants were very appreciative of the work done by nursing staff.

“The nurses had to work continuously in the ward for 12 hours in PPE. So, they were so exhausted, and some didn’t even come on rounds with us. So, it became difficult to complete rounds.” – JR 4

“In ICU, one nurse looking after 10-12 critically ill patients on assisted ventilation was practically impossible” – JR 8

“Nurses did a really wonderful job during the pandemic. They were very supportive. But due to shortage, they posted so many student nurses who were not well versed, and that was problematic” – JR 6

Theme 5: Social and Psychological Impact

Uncertainty in managing patients was said to cause a lot of psychological distress to doctors.

“I started feeling what am I good for? Can’t I make a small clinical judgement?

Can’t I categorize a patient as mild, moderate or severe?” – Intern 4

“During entire under graduation, we hardly saw any deaths. Even as an intern, we didn’t have much to do with deaths. But here daily we had to deal with several deaths. Examine, confirm, declare deaths and deal with patients’ relatives completely on our own. Its very distressing” – Intern 6

Most of the participants highlighted the social stigma towards doctors doing COVID duties.

“Many of the neighbors nearly ostracized doctors” – Intern 11

“Even today that feeling persists, even after so many people got infected and recovered almost everywhere.” - Intern 2

“The stigma towards doctors gradually subsided by second wave, as more awareness came to people” – JR5

The biggest fear among doctors expressed by the participants was transmitting the virus to their family members.

“Biggest worry was our family” – Intern 13

“Always had the fear that our parents or children would be affected. So, we had to stay away from them most of the time. That was very distressing.” – PG 4

“There was so much hopelessness in treating patients. So, we were very worried what if our own parents got infected” – PG 5

Participants also explored the sense of security of treatment if they are infected.

“Luckily the managements are taking care of us and providing special rooms. But that’s it. Again, we have to rely on our friends for treatment. Otherwise, we are not sure what will happen to us” – JR 4

Theme 7: Measures to be taken by the government

The participants listed several measures that can be taken by the government to boost the morale of doctors.

They are mostly related to care of COVID-affected doctors and providing financial security.

“In some hospitals there is good treatment, and some hospitals don’t bother. So, there should be a centralized mechanism to monitor the health of all COVID-affected doctors” – Intern 7

“Doctors with high-risk should be exempted from frontline COVID duties” – JR 8

“There is lot of bureaucracy in getting the 50 lakhs if any doctor dies. It should be simplified”

“Some doctors needing lung transplant or getting severe mucormycosis need over one crore. Such people are rarely getting help from government, that too only if it goes viral on social media” – Intern 11

The study participants felt that strict regulation of the fees and charges by the government was not good.

“If a doctor charges money, people should not think he is eating too much money. He is risking his life, getting all equipment at higher costs, and running the hospital, getting nurses and support staff when there is so much shortage and they are demanding more. All these things are very hard work for doctors; and they can earn money. They should not be blamed for this” – JR 7

Another aspect of tight regulation by government is excessive bureaucratic and political interference in patient management.

“Main problem was with government policy of taking over hospitals as COVID hospitals or otherwise shutting them down. Routine healthcare got badly affected” – Intern 7

“There was constant interference from government nodal officers. Updating patient status and details frequently was very tiresome. We could not focus on patient care” – JR 8

Theme 8: Positive notes for junior doctors from the pandemic

The study participants brought out several positive aspects for the medical profession in general and junior doctors in course of the pandemic.

Most important of them was recognition and appreciation from their near and dear.

“Many friends and relatives started consulting us about their health and illnesses” – Intern 1

People consulting doctors was also found to increase since the pandemic.

“Previously people used to rely on quacks and pharmacists for common illnesses. Now everyone started approaching doctors.” – JR 8

“Teleconsultation became totally acceptable and making it easy for both doctors and patients” – JR 1

Though overwhelmed by excessive burden, it was an opportunity for junior doctors to get a perspective of entire patient care.

The participants felt that working during pandemic helped enhance their clinical skills.

“Previously interns were confined to certain tasks like investigations, case sheets etc. Now we could get involved and get the whole picture.” – Intern 6

“Things like ventilator settings, ICU management etc., which we used to learn much later, we could learn in first year itself very well” – JR 4

“Even for those doctors not directly dealing with direct clinical management of pneumonias and critical cases, these duties were like a refresher and we brushed up all those skills” – JR1

Discussion

The present study identified several areas where junior doctors were impacted during COVID-19 pandemic. The most important ones being uncertainty in treatment protocols, overwhelmed by the huge mortality, lack of proper resources. Social support, though extended well in general, was lacking when it came to individual doctors attending COVID duties.

Similar findings were reported by Banerjee et al⁸ and Zafra E.⁹ Fear of infection, uncertainty, stigma, guilt, and social isolation emerged as the main challenges in those studies. Unmet needs identified were also like those highlighted in the present study.

Flexible working hours, security of treatment and financial assistance for affected doctors will go a long way in increasing the morale of doctors working against COVID-19 pandemic.

Even though the Government of India has brought in social security for doctors fighting the pandemic,¹⁰ the participants were skeptical about its full implementation.

The participants observed that though the first wave was unexpected, the health system was grossly underprepared for the second wave. This added to the burden of the doctors.

Conclusion

The present study helps to convey the challenges faced by junior doctors during the pandemic. It also conveys the message to public that doctors are doing their best among very limited resources and incentives, braving huge risks to themselves and their families.

The government needs to devise immediate plans to provide sense of financial and health security for doctors in a centralized way, so that they will be a much formidable force in future.

Conflict of Interest

None.