It is not just another busy working day for Tawhida Yassine AbdelGhaffar, a prominent paediatrician who chairs the Yassine Abdel Ghaffar Charity Center for Liver Diseases and Research.
It is a day where she has to see and examine a number of new patients who have been referred for treatment from several doctors and hospitals. But it is also a day where she has to call upon all her engagement skills to communicate with a number of patients she has been treating but who are not making it to their follow-up visits because of the coronavirus.
“Treating children in general requires a lot of direct communication, a lot of contact and a lot of building confidence and showing care; this is so much more the case for children with acute and chronic problems, especially those with liver diseases who have to go through a very strict routine to maintain a good health condition and who have to follow a long path of medication, which is often against the nature of children, who tend to decline this kind of commitment,” AbdelGhaffar said.
This means that every time she is talking to one of her patients on the phone to follow up on their case, she needs to engage in an excessive exercise of sensibility to compensate for the observations she normally makes when she is with the patient in the examination room, and she also has to ensure her voice is filled with affection and compassion, which she would be otherwise pass on to her patients via smiles and small talk.
This is not always an easy endeavour given that a successful telephone consultation depends not just on the doctor but also on the patient. Very young patients whose parents are not at ease in managing a medical follow-up conversation become a very challenging exercise for this experienced doctor. Most of the patients who depend on the charity service of the centre are not privy to the sophisticated smart phones and fast internet that allows for communication through video-calls that would otherwise make a distance medical consultation easier.
“I spend a thorough half hour revising the file of every patient before starting a telephone call, and I take very detailed notes, but obviously at times it becomes very challenging, especially if children start getting irritated with the long treatment or the many restrictions,” AbdelGhaffar said. Then again, she added, it was an inevitable decision to reduce the medical visits as much as possible and to keep them as far apart as possible, to avoid putting her patients in harm’s way.
Since COVID-19 became established in Egypt, in late February or early March, AbdelGhaffar has been very precise about appling a strict set of guidelines to all the medical staff of the centre. All doctors, nurses and workers are uncompromising about using protective gear and about carefully monitoring their own health to make sure that they do not become carriers of infection. Doctors and nurses have been introduced to the guidelines of safe medical examination and doctors’ offices have been re-arranged in line with the maximum possible degree of distancing, to make sure that patients coming in, always with a parent, are not sitting too close to one another or to the doctor. Patients’ appointments are also managed so as to prevent any large groupings in the waiting rooms.
Still, AbdelGhaffar has requested that all patients who receive medical treatment at the centre be spared from coming to the premises unless absolutely necessary. Patients who do their first check-up are not allowed to do it by phone.
“This is not at all possible; the patient has to be thoroughly examined. We try to do the maximum possible to spare our patients from a commute and direct contact with many people as possible, but there are things that cannot be compromised and those we do under very strict safety measures,” she said.
Patients with liver diseases fall squarely within the high-risk groups. Also, not all the patients who access the charity service at the centre, located in eastern Cairo, are residents of Greater Cairo. Many patients have to travel from far-away governorates to visit the centre, mostly by public transport, which forces them away from the essential requirements of social distancing and puts them at higher infection risk.
“In general care is part of treatment; this is so much the case when we deal with children; we have to sustain the care and keep a rigorous follow-up with the patients to make sure that they are receiving adequate instructions,” she said. This meant that, in addition to the scheduled phone calls, AbdelGhaffar has to make herself accessible to answer queries from patients or parents of patients through WhatsApp or text messages.
Obstetrician and gynaecologist Magued Abou Sea’da has also been counting on the telephone consultations and WhatsApp texting to manage a good part of his patients. Gynaecology patients who are not suffering pressing conditions have been asked to delay their consultations.
“In principle we declined the number of patients who come to the clinic to make sure that there is no overlap at the waiting room and that I don’t have to see a large number of patients on the same day,” he said. Pregnant women were advised to double space the intervals of their check-ups, unless otherwise found necessary, and they are not admitted to hospital for delivery until it is absolutely necessary.
To make up for this, Abou Sea’da agreed to begin something he had previously not thought of: telephone consultations. In general, Abou Sea’da, like many other doctors, is not comfortable managing his cases on the phone. He believes that a patient has to be properly examined to allow a doctor to make a sound judgment on the case. But with the risk of COVID-19, this seasoned doctor had found a way to re-work his management of phone calls with his patients.
Patients with quick questions send messages, and if it is his assessment that they are in a good place to manage written instructions, he texts the instructions. If he worries that the patient might not be comfortable handling texted instructions he answers through a scheduled phone call. Other patients who need a more thorough follow-up to allow the doctor to ask several questions and to take detailed notes are scheduled for a longer telephone chat.
“Quite an exhausting exercise and a very different style of practice of medicine, to be honest,” he said.
Carving out a niche
For doctors working in large private medical centres, the management of distant medical service seems to have been taking a more integral part. Neurologist Ramez Reda, of the neurology and sleep disorder centre NeuroMed, says that his distance-management of cases through video calls is proving quite convenient for many patients who have been too worried to leave their otherwise secure confinement to access medical services.
For patients suffering neurological disorders, Reda said it is often too difficult to count on voice calls to help patients. “I usually observe facial expression, eye and lips movement, body posture and so on; so video calls have proven very useful,” he said. This, he added, also applies for the increasing number of patients who suffer sleep disorders due to the anxiety caused by COVID-19.
Requests for video call visitation are made through the call centre and schedules are decided upon the convenience of both doctors and patients. A tele-medical visitation is usually booked for around 30 minutes. Online medical visitations are designed to allow sufficient intervals to allow time for a possible internet drop.
Mostly, Reda has been resorting to calls via Zoom app, which do not require a very large bandwidth and allow for good quality videos. “And it has been working well,” he said. Other applications that are particularly tailored for a doctor-patient consultation, like Doxy, are also finding their way into the daily work of NeuroMed.
Ramez himself has been exploring the wide range of applications. And while some applications are more tailored for medical services that allow for doctors to send prescriptions and to carefully inspect reports of x-rays and blood tests, he said that the priority now for doctors is to opt for the application that is the easiest for patients to use. To compensate, he added, the doctor would then write a prescription and have it sent by WhatsApp, and if a patient needs some tests, the centre will provide this service at home under strict safety measures.
Plastic surgeon Omar Naggari also has to depend on the video-calls to follow up with his patients. For him, telephone calls serve very little, so if a patient is not coming to the clinic for the check-up, his centre will have to schedule a video call upon the consent and the convenience of the patient.
The telemedicine practice, Naggari said, has found its way slowly but surely. Around late February/early March, patients of the Yes Clinic were receiving phone calls to cancel their appointments – except for the very necessary cases, who were allowed to do their visitation under the strict guidelines of protection and distancing.
In the following weeks, Naggari provided group guidance to his patients through online streaming sessions. And he was managing patients’ very specific queries through brief phone calls or messages. However, six weeks down the road, patients of the Yes Clinic were demanding to make plans.
“To be able to help my patients make plans I have to see them, so we opted for video calls for elementary consultations, and then I have to decide priorities and to schedule visits in line with the strict social distancing regulations,” Naggari said. Once patients receive the required service, then the follow-up is managed as much as possible through the online consultation service that is now available through the centre’s hotline.
Reda and Naggari have both sensed a growing ease on the part of their patients with the online service and they both expect it to continue to be part of medical practice in Egypt over the long-term.
“Ultimately, nothing takes place of the visitation and direct doctor-patient relationship, but if we put the situation of the pandemic aside and consider the case of a patient who lives in Upper Egypt very away from the clinics of our centre in Cairo then he might be more comfortable doing one follow-up consultation online and then comes for the following visitation,” Reda said.
He added that the fact that medical care is now managed in part through insurance companies or through corporate or syndicate subscriptions make it a lot more manageable for medical centres to administer medical fees through these companies and agencies.
Some patients are also finding this growing trend quite useful. Nevine, a 40-year-old depression patient, has been “more comfortable” doing her session with her psychiatrist from home.
“In the beginning of this coronavirus situation we decided to suspend my sessions for two to three weeks and agreed that I would call her once a week instead of going to her for a brief chat,” Nevine said. However, as the concern over COVID-19 was increasing rather than declining and her psychiatrist was not feeling very comfortable depending on the phone calls, the two decided to resort to Zoom.
“It has actually worked quite well. It spares me from having to drive for an hour from where I live to the clinic and another hour back to my home,” she said.
Accessing health care at home has all but completely disappeared from the map of medical services in Egypt for around 30 years. However, during the past few years, with growing demand, some doctors have opted to reintroduce it.
Mahmoud Chanawani is a paediatrician who decided to close down his Maadi clinic and to do only home care over the past five years. The decision, he said, was prompted by growing number of requests for house calls, especially in cases where children are really young and get really ill in the middle of the night, past the working hours of any clinic. Chanawani had also been wanting to cut down on working hours after close to 40 years of practice.
Still, his style of practice has been influenced by the coronavirus. Parents, he said, are as concerned about their children seeing a doctor as they would be concerned to take their children to a clinic, because while the child is spared from any possible contact in the waiting room of a clinic, they would still be seeing a doctor who sees other patients.
“And like doctors who were seeing fewer patients in their clinics to reduce the chance of contamination for themselves and for their patients, doctors working in home care were also worried for their safety and that of their patients, because house visits might reduce the risk a bit but the risk is always there,” he said.
And just as Chanawani opted to reduce the number of visits he makes to keep them in the strictly necessary range, the patients of children “are more and more opting for telephone consultations.”
“For a paediatrician it is not unusual to receive a call from a parent to consult on a sudden illness of a child,” he said.
Chanawani tries to manage as much as possible through the phone and at times he asks parents to send him pictures of the children through WhatsApp, or if it becomes possible, he opts for a video call. He would only opt for a house visit if he finds it “truly necessary and if the parents requested it.”
There is one situation that Chanawani would feel obliged to decline a house visit, he said -- “if I suspected it was COVID-19 – but luckily I have not come across any cases so far.”
Mohamed Khater, a geriatric physician, has decided since the launch of the Seniors Clinic a few years back that home care is simply an integral part of providing medical help to the elderly. With elderly people a particularly high-risk group for the coronavirus, Khater has now decided that his patients would be spared even home visits unless it was found necessary, and that telemedicine would be part of home care.
The resort to online medical consultation is decided, Khater said, upon a set of measures that would allow the doctor to be able to provide the right and timely medical help for the patient.
“If we are talking about a patient that we are already following or a patient who calls with symptoms that are not perceived in any way to be life-threatening, then we ask if the patient is in condition to manage an online consultation,” Khater said.
Otherwise the centre would send a doctor to promptly examine the case at home and decide upon consultation with a more experienced team whether the patient could be treated at home or needs to be taken to a hospital. In some cases, Khater added, the online consultation helps some patients avoid an unnecessary ordeal of going out, or the need to receive a doctor at home. And, he added, in some cases the video call allowed the doctor to promptly instruct the patient not take a medical situation lightly and to head to the nearest hospital.
The experience of the past weeks, Khater argued, is likely to encourage more and more medical facilities, in the private zone, to make room for home care medicine.
“I think there is a practice that is being established now with the home care medicine whereby doctors are acting within a system that allows them to do their job properly and to be spared from any unfortunate situation regarding their medical choices or medical fees, because this is mostly happening through medical centres rather than individual clinics,” he said.
For Samar, who has been delaying regular check-ups for her parents, who both suffer from chronic diabetes and heart conditions, the home care service that she was introduced to through a friend proved very useful. However, she argues, “it is perfectly good and perfectly purposeful but it is also very expensive – I’m not sure how people without sufficient means could benefit from it.”
According to Nabil Meheri, a doctor with long expertise in health insurance systems, the right to home visits when necessary should certainly be incorporated in the health insurance plan that the government has initiated. Today, Meheri added, with the experience of the pandemic, this plan needs to be revisited to consider all possible ways of providing health care for people in challenging situations while keeping the doctors and medical teams safe.
“In general, I think we have some crucial questions to ask today about the impact of the pandemic on the practice of medicine in a way that would be safe for patients and doctors,” Meheri said.