This survey provides an insight into the concerns of rheumatologists’ health and well-being and the challenges they faced in delivering rheumatology care during the pandemic and prospects for future rheumatology care.
Although the majority of clinicians in our study reported that they had moderate to severe anxiety about the implications of coronavirus on their health (graded anxiety over 3 with 5 being severely anxious), only a small proportion (1.3%) sought medical help. Clinicians appear to have been concerned about general ill-effects of the pandemic on their health and well-being and the risk of contracting the virus whilst being redeployed to the medical wards. Also, up to half of the clinicians in our study were over 50, just over 25% were BAME (Black, Asian, and Minority Ethnic) group and majority were men. These have noted to be independent risk factors for contracting coronavirus SARS-Cov-2 in various studies, and this could have been the reason for concern in our responders. However, the response suggests that many clinicians had no anxieties in engaging with face-to-face consultations.
Initial studies from China [6] established that HCP suffered psychological consequences such as anxiety and depression when directly engaged in managing the patients with COVID-19. Redeployment, staff shielding, and isolation seemed to be two main reasons for short staffing and reduced clinical capacity in our study, which must have contributed to increased workload and anxiety. Many studies so far have evaluated how the COVID-19 pandemic has adversely affected clinicians’ health and well-being. Vindegaard et al., in their systematic review, reported that HCP in many observational studies suffered from mental health ailments such as anxiety and depression during the COVID-19 pandemic [7]. Although we did not explore why clinicians did not seek help for mental health issues, recent studies have highlighted that HCP generally avoid seeking help for mental health ailments due to fear of stigma and discrimination [8].
Telemedicine has revolutionised the way we deliver out-patient care [9]. Tele-rheumatology had been sporadically used in a small proportion of rheumatology patients in the pre-COVID era [10]. However, available data suggest that clinicians have adapted to this new way of consulting their patients and telemedicine is now widely used in rheumatology practice in many parts of the world [11, 12]. Majority of clinicians in our study reported that they had access to telephone and video consultations; however, it appears that they were underutilised particularly for new patient consultations. This pattern was also observed in veteran affairs study from the USA [12]. Nevertheless, telephone consultations were the preferred choice for follow-up consultations in our study. There seems to be a difference of opinion in what patients and rheumatologists want to choose telemedicine or face-to-face consultations for rheumatology conditions. In an Italian study, over 60% of patients with connective tissue diseases (CTD) preferred teleconsultations over face-to-face appointments [11]. On the contrary, over 50% of clinicians in the veteran affairs study believed that their preferred mode of consultation for CTD patients was face-to-face consultations. Although further research is required to establish the safe delivery of tele-rheumatology in various rheumatology conditions such as rheumatoid arthritis (RA) and CTD, the recent promotion of video consultations by NICE [13] might help in the evaluation of rheumatology patients, for example the nature of skin rashes in CTD or joint swellings in RA.
Contrary to the studies [14] forecasting the rise of tele-rheumatology, the majority of clinicians in our survey predicted that teleconsultations would be perhaps the least preferred mode of future consultations. Exact reasons for underuse of telemedicine in future are unclear, but this could be due to several factors including elderly patients who may not have good hearing, lack of internet access, poor quality of the image in video consultations, and network issues. Lack of access to the physical examination could have been another potential reason for the reluctance of tele-rheumatology in future, particularly when consulting new patients. As discussed above, most clinicians were not anxious or concerned about the adverse effects of coronavirus during face-to-face consultations which could have influenced their views on the future use of tele-rheumatology. As promoted by NHS England, we feel that a teleconsultation is a useful tool and this should be considered for new patient consultations either to triage or for an initial consultation where appropriate to minimise viral transmission [15]. It is acknowledged that telemedicine technology should be applied in appropriate settings and situations. However, suitable training, enhanced documentation, and applying information governance will go a long way in avoiding pitfalls associated with remote consultations [16].
To our knowledge, our study is the first national survey evaluating the views of clinicians about their choice of rheumatology treatment use during the pandemic and post-pandemic rheumatology practice. Most clinicians’ decision to stop IV biologic drugs during the pandemic’s peak is understandable due to the requirement for these patients to attend hospitals for their infusions. In most cases, patients were given the option to change their treatment to SC form to allow self-administration. This was probably to protect vulnerable patients from hospital exposure, simultaneously reducing patient foot-fall in hospitals allowing for more effective social distancing measures. Early in the pandemic, there was lack of evidence whether immunosuppressive drugs could be continued safely although NICE guidelines advised continuing patients on their biologic therapy. The risk of infections was thought to be slightly raised when patients with chronic inflammatory arthritis are treated with biologic anti-rheumatic drugs, particularly in elderly patients with co-morbidities [17]. The rationale to continue biologic drugs is mainly based on expert opinion and their clinical experience with the notion that the continuation of immunosuppressive drugs would minimise the disease flares and subsequent hospital admissions during the pandemic [5, 18]. Although we did not specifically ask whether clinicians continued other forms of biologics, over 60% of clinicians favoured switching IV to SC biologics which is in line with NICE recommendation [4]; therefore, we can assume that most clinicians continued SC or oral forms of biologics for their patients. Majority of rheumatologists (N = 80, 58%) indicated that their recommendation for patients’ rheumatic drug choice would change due to the risk of COVID-19 infection. 64% of clinicians prefer to use either SC biologics or oral Janus kinase inhibitors/phosphodiesterase inhibitors (JAK/PDE4) over IV biologics to minimise the hospital visits. Therefore, we envisage that rheumatology care pathways will adapt according to the evolving evidence, patients’ requirements, and ongoing risk of COVID-19 infection. One in two clinicians preferred to use oral steroids over IM or IV forms, although long-term corticosteroids are thought to adversely affect rheumatology patients’ outcome during the pandemic [19].
Limitations of the study
Our survey has some inherent limitations due to its nature. The response rate was low, and therefore, the data may not be generalisable to a wider community. As with any survey, responders may have misinterpreted and skipped some of the questions with inaccurate responses.
Speciality trainees (20; 11%) and clinicians from black ethnicity were under-represented. The majority of responders were rheumatology consultants which may slightly reduce the applicability of the data to other team members. We did not have a breakdown of the four regional rheumatology society subscribers where the survey weblink was sent. Therefore, we are unable to compare responses between responders and non-responders. Although consultant rheumatologists usually lead the clinical management decisions, poor representation of the trainees and low response rate might have skewed the results, particularly for future rheumatology care. Despite this, we believe results will help derive meaningful conclusions about the challenges faced in the current practice and future directions. Even though patients might have equally concerned about continuing of synthetic DMRDs during the first peak of the pandemic, we did not evaluate this in our survey.