Teachings After COVID-19 Outbreak From a Survey of Family Physicians ==================================================================== * Marco Toselli * Ignazio Palazzi * Martina Lambertini * Andrea Maurizzi * Alberto Cereda * Arif Khokhar * Stefano Landi * Fabrizio Toscano * Giovanni Marasco ## Abstract *Background:* Since December 2019, the dramatic escalation in coronavirus (COVID-19) cases worldwide has had a significant impact on health care systems. Family physicians (FPs) have played a critical role in the coordination of care. *Materials and Methods:* In April 2020, we performed an online prospective survey to assess the impact of the pandemic on FPs’ practices. *Results:* Three hundred FPs were included. Mean age was 53.6 ± 13.5 years. Before the pandemic, 60.2% reported >75 outpatient visits/week, which reduced down to an average of <20/week for 79.8% of FPs; 24.2% of FPs discontinued home visits, while for 94.7% of FPs there was a >50% increase in the number of telephone consultations. Concern related to the risk of contagion was elevated (≥3/5 in 74.6%) and even higher to the risk of infecting relatives and patients (≥3/5 in 93.3%). The majority of FPs (87%) supported the role of telemedicine in the near future. Satisfaction regarding the network with hospitals/COVID-19-dedicated wards received a score ≤2/5 in 46.9% of cases. *Conclusions:* The COVID-19 pandemic has had a significant impact on the working practices of FPs. A collaboration is needed with well-established networks between FPs and referral centers to provide new insights and opportunities to inform future working practices. * COVID-19 * Delivery of Health Care * Family Medicine * Pandemics * Personal Satisfaction * Physicians * Prospective Studies * Surveys and Questionnaires * Telemedicine The coronavirus disease (COVID-19) pandemic has significantly impacted health care systems.1,2 Family physicians (FPs) faced significant challenges and demands to meet the clinical and logistic needs of the population3 as well as to coordinate health care between patients and hospitals/new COVID-19 units. The impact on family physicians and their working practices has been poorly investigated.4 We performed an online prospective survey to assess the impact of the pandemic on FPs. It was delivered by the Local Association of Physicians of Forli-Cesena and Rimini, Emilia Romagna, Italy, from April 16 through 30, 2020, to all FPs of these districts; Forli-Cesena and Rimini districts belong to the Emilia-Romagna region, which is 1 of the 3 Northern Italy regions mostly affected by the COVID-19 pandemic. Italian FPs are part of the territorial primary care system and take care to up to 1500 patients for health issues not requiring a specialist consultation, with outpatients and home visits. The questionnaire consisted of 29 multiple-choice questions (Table 1). A scale from 0 (not satisfied at all) to 5 (extremely satisfied) was used. Three hundred FPs were included (response rate 56%). All the participants expressed their consent for publication. View this table: [Table 1.](http://www.jabfm.org/content/34/Supplement/S222/T1) Table 1. Summary of Main Data of the Survey ## Demographics and Professional Information The mean age was 53.6 ± 13.5 years, and 55.9% were males. The majority of FPs worked as solo practitioners (47.7%), followed by those working as group practitioners with other physicians (42%) and in multispecialty groups (6.5%). Only 27.8% of FPs were tested for COVID-19; 6.5% of them were positive. ### Perceived Personal Safety Of FPs, 67.3% felt they did not receive adequate information regarding the use of personal protective equipment (PPE). It is noteworthy that only 29.7% of participants were provided with official protocols and only 18.7% felt satisfied (score ≥3) with the information they received. The perception of safety was extremely low, with a reported score of 0 or 1 in 40.7%. ### Activities, Concerns, and Perspectives for the Next 6 Months The number of visits before the pandemic was >75/week in 60.2% cases, but 79.8% of the FPs reported a subsequent average of <20 patients/week. The usual home visits for the evaluation of older/fragile patients were discontinued by 24.2% of FPs, while in 94.7% of cases there was a >50% increase in the number of telephone consultations. FPs’ satisfaction regarding the network with hospitals/COVID-19-dedicated wards received a score ≥3 (satisfied) in 53.1% of the cases. Resource distribution was considered unequal by the vast majority of the participants; 86.3% were not or a little satisfied (score ≤2), of whom 41.4% of the participants were completely unsatisfied. Concern related to risk of contagious was elevated (≥3 in 74.6%), and concerns about infecting relatives and patients were even higher (score ≥3, high concern in 93.3%). Eighty-seven percent of the participants favored the use of telemedicine in the near future, including electronic/online prescriptions to avoid overcrowding. This survey highlights some of the challenges that FPs have had to face during the pandemic. Clinical activity underwent a deep reorganization to balance the health care to patients with the lack of PPE and necessary information. Indeed, the decrease in the number of outpatient and home visits was mirrored by an increase in telephone consultations. Telemedicine has been the main modality to provide care assistance and will have a greater role in the future.5 Finally, this survey highlighted the lack of specific training on the infective risk of COVID-19 and on the use of PPE, especially as FPs were faced with new unfamiliar tasks such as quarantine regulation and psychological support. The limitations of this study are the small sample size and the data collection from only 2 Emilia-Romagna areas. However, this region was significantly affected by the pandemic, and our data confirms prior findings from another Italian report.4 Health systems are going to experience further changes: FPs will represent the first line of fight against the pandemic, being required to detect, isolate, and treat new cases. Improvements in the collaboration between FPs and hospitals/COVID-19-dedicated wards is needed. These institutions have the duty to provide physical/psychological protection to FPs, who represent the outpost of citizens’ health. ## Notes * This article was externally peer reviewed. * *Funding:* None. * *Conflicts of interest:* None declared. * To see this article online, please go to: [http://jabfm.org/content/34/Supplement/S222.full](http://jabfm.org/content/34/Supplement/S222.full). * Received for publication May 31, 2020. * Revision received June 13, 2020. * Accepted for publication July 31, 2020. ## References 1. 1.Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020;395:1054–62. doi: 10.1016/S0140-6736(20)30566-3. [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1016/S0140-6736(20)30566-3&link_type=DOI) [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fjabfp%2F34%2FSupplement%2FS222.atom) 2. 2.Ahn D-G, Shin H-J, Kim M-H, et al. Current status of epidemiology, diagnosis, therapeutics, and vaccines for novel coronavirus disease 2019 (COVID-19). J Microbiol Biotechnol 2020;30:313–24. doi: 10.4014/jmb.2003.03011. [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fjabfp%2F34%2FSupplement%2FS222.atom) 3. 3.Thornton J. Covid-19: how coronavirus will change the face of general practice forever. BMJ. 2020;368:m1279. doi: 10.1136/bmj.m1279. [FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiYm1qIjtzOjU6InJlc2lkIjtzOjE3OiIzNjgvbWFyMzBfNC9tMTI3OSI7czo0OiJhdG9tIjtzOjMwOiIvamFiZnAvMzQvU3VwcGxlbWVudC9TMjIyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 4. 4.Fiorino G, Colombo M, Natale C, Azzolini E, Lagioia M, Danese S. Clinician education and adoption of preventive measures for COVID-19: a survey of a convenience sample of general practitioners in Lombardy, Italy. Ann Intern Med. 2020. Published online April 15. doi: 10.7326/M20-1447. 5. 5.Ingravallo F. Death in the era of the COVID-19 pandemic. Lancet Public Health 2020;5:e258. doi: 10.1016/S2468-2667(20)30079-7.