Anticipating Overworked Health Workers During Covid-19
The administrative process needs a breakthrough to perform beyond "procedural normality" to enable medical empowerment. Remember, we are in an emergency. Don\'t sit back with plainly normal thinking and procedures.
Covid-19 is raging out of control. The emergency public activity restrictions (PPKM Darurat) was imposed on Java and Bali over 3-20 July, only to be extended twice, the first time to 25 July and the second time to 2 Aug..
The health service has collapsed. A total of 23 patients self-isolating at home reportedly died before they could be taken to a hospital. Others died while desperately going from hospital to hospital seeking treatment. Various foreign news agencies ran the headline, “Indonesian health system close to collapse”.
The sound of wailing sirens, images of hospital rooms overwhelmed with patients, long queues for funerals and burials, as well as the escalating COVID-19 caseload and death toll in Indonesia are heart-wrenching and sad.
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It has been over 1.5 years that the nation has been struggling against the COVID-19 pandemic. Lessons must be learned from other countries that have succeeded in controlling the coronavirus.
One thing that needs heightened vigilance is exhaustion (burnout) among health workers. Many global studies have been conducted on the adverse effects of the pandemic on health workers.
Fatigue is caused by increased workload, anxiety over increased virus exposure while tending to COVID-19 patients, discomfort from continuous use of personal protective equipment (PPE), and personal anxiety over their families’ due to the restrictions in place at medical facilities.
The ongoing COVID-19 emergency has resulted in an increase of 36,973 hospital beds since 17 May, but not in the number of health workers. Without a massive addition of health workers, doctors who are exhausted from fighting the pandemic for 1.5 years will be more vulnerable to contracting the virus due to their excessive workload.
Moreover, a total of 545 doctors have died of COVID-19 as of July 17. This has further reduced hospital treatment capacity in the face of the surge in COVID-19 cases.
Exhaustion has also hit medical workers at community health centers (puskesmas). With their limited number of doctors, puskesmas receive a considerable number of patients. In addition to handling an influx of patients, both COVID-19 and non-coronavirus, puskesmas are also tasked with contact tracing and vaccination.
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Puskesmas must also monitor both asymptomatic patients and patients with mild symptoms self-isolating at designated facilities or at home. The Health Ministry has launched a telemedicine outreach program but people in the outlying regions might have problems accessing the application, either because they are unfamiliar with the technology or because of limited internet access. Thus, health workers remain integral to the government’s monitoring efforts.
Nearly 1,000 doctors raised their concerns over the threat to fatigued and overwhelmed doctors, whether generalists or specialists, who provided patient care during the Covid-19 pandemic over the past 1.5 years. They voiced their concerns at a webinar titled “Emergency Rescue of Medical Doctors and Health Workers”, held on 11 July by the IDI Communication Forum of regional chapters and branches, as well as other health associations.
Emergency situation
The government first implemented the PPKM Darurat from 3 to 20 July, and has now extended the policy twice. In this state of emergency, it is necessary to think and act with urgency. It requires immediate and massive increase in the number of medical personnel over a short time. What can be done? We should push for the employment of general practitioners.
There are three types of general practitioners that can be utilized, namely those who have completed their hospital internships (residencies), those who are currently doing their internships, and those who are waiting to take their national exams.
Doctors who have completed their residencies are scattered throughout Indonesia and can be recruited immediately by local health offices and distributed to assist with puskesmas services.
Those still doing their residencies can be placed at COVID-19 referral hospitals or puskesmas to assist with services for one year.
“Retakers” are physician candidates who are waiting to take the national exam. They are medical students who have completed the academic curriculum and fulfilled all requirements, consisting of various assessments and exams at their medical schools.
Medical school takes 5.5 to seven years to complete, which is longer than other undergraduate and professional programs. Medical students must complete a total of more than 200 academic credits (SKS).
The Indonesian Doctor Competency Standards, issued in 2012, notes that medical students must study 736 diseases and fully master 144 of them, meaning that medical school graduates are required to be able to treat these diseases at primary health care facilities.
A medical graduate should be able to diagnose and prescribe treatment for 261 diseases. Medical graduates are equipped with 275 types of clinical skills necessary for formal practice during their education.
Indonesia’s medical education has adopted a competency-based curriculum and complies with the accreditation process in accordance with the Independent Accreditation Agency for Health Higher Education (LAMPTKes).
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Accreditation is part of the External Quality Assurance System, and the accrediting agency ensures that medical school programs follow the required educational standard.
Only accredited higher education institutes have the authority to offer a medical program and certify and inaugurate their graduates as stipulated in Law No. 20/2003 on National Education and Law No. 12/2012 on Higher Education.
Meanwhile, LAMPTKes is recognized by the World Federation for Medical Education (WFME) as a credible accreditation agency.
Utilizing ‘retakers’
Primary health care facilities (FKTP), which make up an integral part in providing health services, have been incapacitated due to the increase in COVID-19 patients with either mild or severe symptoms.
Hospitals have reached maximum capacity in serving COVID-19 patients, with capacity overstretched at several hospitals. Patients with mild symptoms who go to a hospital will be turned away and advised to self-isolate at home.
However, in self-isolating at home, a patient’s mild symptoms may potentially develop into moderate or severe symptoms in a short time due to the current shortage of medical personnel conducting direct patient monitoring.
Upon completing all curricular requirements at medical school, “retakers” deserve to be certified by their universities as their academic authority, as guaranteed in the National Education and the Higher Education Laws.
While they are still unlicensed but permitted to practice clinically, these retakers can be recruited as medical volunteers and seconded at puskesmas under the direction and supervision of the puskesmas medical authorities.
Their main task is to assist puskesmas doctors in tracing contacts and providing care for patients with zero to mild symptoms who are self-isolating at government centers, community facilities or home, and help with the vaccination rollout, as well as public education through public health campaigns and Covid-19 prevention programs.
Remember, we are in an emergency. Don\'t sit back with plainly normal thinking and procedures. Take an emergency-oriented approach.
To help ease the burden of hospitals and curb the number of patients with either severe or critical symptoms seeking hospitalization, it is necessary to optimize efforts in running public health campaigns and COVID-19 prevention programs at the grassroots.
Currently, 70 percent of hospitalized patients have moderate, severe or critical Covid-19 symptoms. Many puskesmas doctors have also died in the line of duty. Intensified efforts are urgent to curb transmission and prevent patient symptoms from potentially worsening from mild to moderate, moderate to severe, or severe to critical.
The symptoms of COVID-19 patients are prone to aggravating over a matter of days. Puskesmas across the country should step up their outreach role, for instance by employing post-internship medical graduates, medical interns, and the “retakers” who have completed their medical studies as described above.
Titi Savitri Prihatiningsih
Of course, the administrative process needs a breakthrough to perform beyond "procedural normality" to enable medical empowerment. Remember, we are in an emergency. Don\'t sit back with plainly normal thinking and procedures. Take an emergency-oriented approach.
Titi Savitri Prihatiningsih, President of South East Asia Regional Association for Medical Education (SEARAME); 2018-2021 Education Head of Indonesian Medical Association (IDI)
This article was translated by Musthofid.
