Understanding the changes in practice patterns in ophthalmology following COVID-19 lockdown.

PURPOSE: Severe acute respiratory syndrome-Coronavirus 2 pandemic has brought the world to a halt. We performed a questionnaire-based survey to know more about these issues which affected them due to this pandemic and resultant lockdown.
METHODS: A questionnaire-based survey (53 questions) was conducted online among Indian ophthalmologists with a 2-week response time. The invitation to participate was also circulated widely among various ophthalmologists as members on different social media platforms and emails. It was mandatory to answer all the questions in the questionnaire to make it a valid response.
RESULTS: A total of 903 responses were received across the country. A majority of these responses, 403 (44.6%), were from private practitioners. Almost 876 (97%) of the responders had either kept the daily working hours as same as pre-COVID-19 era or had reduced the actual working hours. Overall, 547 (60.6%) responders did not downsize their staff and 569 (63%) did not reduce the staff salary. Consultation charges were not revised by a majority (659, 73%) of responders. Total of 663 (73.4%) were following the appointment system and 702 (77.7%) responders had reduced the number of patients to less than 6 an hour. Only 106 (11.7%) were doing a mandatory RT-PCR test before surgery, whereas 567 (62.8%) did on the basis of suspicious symptoms.
CONCLUSION: Our survey gives valuable inputs regarding the changes made by different ophthalmologist groups during the times of COVID-19 and lockdown.

Severe acute respiratory syndrome-Coronavirus 2, also called COVID-19, was declared a pandemic by World Health Organization with more than 213 countries affected by it.[1] The lockdown in India was started on March 25, 2020 with a view to flatten the curve. The lockdown has severely impacted the Indian Gross Domestic product (GDP). The Indian GDP growth rate fell from 8.2% in January–March 2018 to 3.1% in January–March 2020, and this further fell by a huge drop of 23.9% in the first quarter of 2021. As per the statistics released, the GDP of April–June 2021 fell by 23.9% in comparison to the same quarter in 2020.[23] The initial reports from the western world did suggest that ophthalmology was among the specialties with the highest proportion of residents with confirmed COVID-19 across all residency programs in New York.[4] As of now, India is firmly in grip of this global pandemic with India reporting a total of 28.4 million patients of confirmed COIVD 19 and around 1.7 million active cases.[5] The lockdown, together with the fear of transmission of the disease, has severely affected routine ophthalmology practices including cataract surgery and subspecialties.[678] Apart from the actual loss of practice, the mental health of ophthalmologists and public at large has been affected due to anxiety, depression, and fear psychosis.[91011] We performed an online survey with a preformatted questionnaire to evaluate the effect of COVID-19-related lockdown on social and economic aspects and the impact on the ophthalmic practices in India. Guidelines have been issued by professional societies and organizations as to how to manage ophthalmology practices in the COVID-19 era, during and post lockdown. However, it may not be practically possible to adhere to all the guidelines in our individual practices. This online survey was performed to understand the changes in practice patterns post COVID-19 lockdown (from June 1, 2020).

Methods

An online survey using secure Google form was circulated among Indian ophthalmologists on June 7, 2020 with a 2-week response time. The invitation to participate was also circulated among various social media platforms of ophthalmologists as members and by email. The survey consisted of 53 questions. It was mandatory to answer all the questions. The survey was anonymous and did not collect any personal and identifying information [Annexure 1].

Results

All the data was tabulated in a datasheet. Data were described as frequencies, percentages, and means. A total of 903 responses were received across the country. A majority of these responses, (403, 44.6%), were from the private practitioners followed by 152 (16.8%) from ophthalmologists working in private or public Institutes [Fig. 1]. Majority of our respondents were between the age of 35 and 55 years (480, 53.8%), while 186 (20.8%) were <35 years, and 227 (25.4%) were >55 years of age.

Figure 1

Distribution of various responders in terms of the type of practice they have in this survey

Working hours

Almost 876 (97%) of the responders had either kept the daily working hours as same as pre-COVID-19 era or had reduced the actual working hours. Only 27 (3%) had expanded their working hours. More than half the responders (512, 56.7%) worked between 4 and 8 h in a day and 286 (31.7%) worked for <4 h. Overall, 798 responders (88.4%) worked for less than 8 h a day. Only 105 (11.6%) worked for more than 8 h. Out of the 403 private practitioners, 59 were continuing to work with the same working hours whereas four had expanded their time and the rest had shortened their working hours. The respondents who had expanded their working hours were working between 4 and 8 h, and the age was between 35 and 55 years of age. Of the 340 respondents who said they had reduced their working hours, 179 (52.6%) were working for less than 4 h a day and 9 were working for more than 8 h per day. The rest were working between 4 and 8 h per day. Of those in group or family practice (n = 88), 54 (61.4%) were in group practice and 34 (38.6%) were in family practice. Of these, only two had expanded their working hours but were working for less than 8 h per day. Sixty-nine (78.4%) had reduced their working hours, while 17 (19.3%) had maintained the same.

Staff downsizing and salary cuts

Overall, 547 (60.6%) responders did not downsize their staff. Almost a similar number 569 (63%) did not reduce the staff salary. In individual practices, out of the 403 responses, 267 (66.3%) did not downsize the staff. However, out of these, 48 did reduce the salary with a maximum of 30% (n = 25). Similarly, 55 (62.5%) of the group/family practice group did not reduce the staff. Out of the total 63 responses from trust hospital eye surgeons, 37 (58.7%) retained the staff. In the Ophthalmic Institutes, 95 (46.3%) retained their staff. This suggests that private practitioners, group/family practice surgeons, institutes, and trust hospitals were able to retain most of their staff [Fig. 2a].

Figure 2

(a) Majority of responders (63%) did not reduce the salary of staff post lockdown. (b) Distribution of percentage of the total reduction in salary in the 37% of responders who did reduce or downsize the salary with majority (30%) of responders reduced the salary between 21 and 50% of the actual salary

Only 347 (37%) eye surgeons or hospitals reduced the salary, of which only 85 (24.5%) reduced it by less than 20%, 109 (31.4%) reduced by 21–30%, 105 (30.3%) reduced by 31–50%, and 48 (13.8%) reduced it by more than 50% as compared to the pre-COVID-19 era [Fig. 2b].

Consultation charges

Consultation charges were not revised by a majority (659, 73%) of responders. Charges were increased by 239 (26.4%) respondents [Fig. 3a and b]. A majority of surgeons (727, 80.5%) have kept their surgical charges the same as before, while 151 (16.7%) had increased the charges with a maximum increase by 98 (61.6%) by around 10% [Fig. 3c and d].

Figure 3

(a) Pie chart with majority 73% (in blue) who did not increase the charges pre and post lockdown in OPD. (b) Distribution of responders who increased the charges. Maximum responders increased the charges by 10% (n = 91) (c) Distribution of percentage of responders who changed or increased the surgical charges. Majority in blue (80.5%) kept the surgical charge the same as before. (d) Distribution of responders who increased the surgical charges and most of them increased the charges by 10% (n = 98)

Surgical work

A majority of the responders (630, 69.8%) had started performing elective surgeries at the time of the survey with around 83.8% (n = 559) of the responders showed reduced the number of surgeries, whereas the others had maintained their pre-COVID-19 surgical volume.

Change in practice pattern

A total of 663 (73.4%) were following the appointment system. Four hundred and fifty (50.4%) had started using teleophthalmology in their practice, but only 204 (22.6%) of the total responders were promoting teleophthalmology over actual physical consultation. Out of the total 403 private practitioners, almost 328 (81.4%) were promoting actual physical examination.

In all, 479 (53%) of the total responders had altered the hospital infrastructure for the COVID-19-times practice. Of 403 responses by private practitioners, 212 (52.6%) said made infrastructure changes. Majority of the responders had got an air purifier installed in their outpatient department (OPD); 34.7% had installed an ultraviolet (UV) light. This shows more and more acceptance of UV light in the clinical practice. In the OPD, 124 (28.8%) had got a UV Light; 53 (12.3%) had a UV air sterilizer; 52 (12.1%) had a high-efficiency particulate absorbing (HEPA) filter air purifier and 15 (3.5%) had a plasma air sterilizer. For the operation theater, of the 354 responses, a majority of respondents 166 (46.8%) had installed a UV light or a UV-based air sterilizer; 87 (24.6%) had started using an HEPA filter air purifier and 29 (8.2%) had got AHU alterations.

Majority of the responders (510, 56.5%) did not have any change the mode of payment; however, 387 (42.9%) did shifted to digital payment. In the subgroup of solo practitioners, 239 (59.3%) had not implemented any change in the mode of payment. Out of the total 88 responses in group practice, 41 (46.6%) had no change in the mode of payment.

Most of the respondents (661, 73.2%) suggested that they are getting a COVID-19 self-declaration/screening form signed by the patient and relatives.

Overall, 892 (98.8%) responders were following some sort of social distancing between the staff and patients in their hospital. A total of 542 (60%) were using soap and water for the disinfection of the patients hands on arrival at the hospital, while 821 (90.9%) responders were using a disinfectant dispenser at the point of entry and 780 (86.4%) were insisting on cleaning of the patients’ hands by the sanitizer.

Majority of the responders (651, 72.1%) were themselves using N95 mask or equivalent, whereas only 268 (29.7%) responders said that their staff was using N95 masks. For patients, 523 (57.9%) were using a cloth stitched mask.

On arrival at the clinic, only 707 (78.3%) of the responders were using noncontact infrared thermometers for measuring the temperature of the patient. Four hundred (44.3%) responders stated that their staff was wearing gloves, mask, and face shield at the entry point of the hospital, while 613 (67.9%) of responders were having staff use a face shield while in contact with the patients and 747 (82.7%) were having staff to wear gloves while in contact with the patients.

Overall, 418 (46.3%) ophthalmologists/optometrists were wearing a washable gown along with gloves and face shield, 355 (39.3%) were wearing only gloves and face shield, 76 (8.4%) were wearing full personal protective equipment, but 54 (6%) are using none of the above precautions when examining a patient in the OPD. Six hundred and eighty-one (75.4%) responded as above OPD precautions are being used by both, ophthalmologists and optometrist, 186 (20.6%) by ophthalmologists alone, and 16 (1.8%) by optometrist alone. Post lockdown, 410 (45.4%) were still continuing with the paper-based medical record system and only 23 (2.5%) had incorporated an EMR system.

Despite COVID-19, 380 (42.1%) responders were still continuing with the system of filing the demographic details of the patients on arrival at the registration counter conventionally by paper and pen; 385 (42.6%) were doing so by oral information by the patient; 87 (9.6%) were using a registration kiosk; and 51 (5.6%) were using WhatsApp or a patient registration app [Fig. 4a].

Figure 4

(a) Changes made for recording the patient details when they arrive at the clinic. (b) Different ways used by ophthalmologists to clean the trial frame and refraction set. (c) Frequency of cleaning of examination lenses. (d) Distribution of ways of disinfecting or cleaning used by the ophthalmologists

A total of 702 (77.7%) responders had reduced the number of patients to less than six an hour. Majority of the responders (485, 53.7%) had stopped doing routine refraction in all the patients. Only patients who needed the refraction or seemed to have a change in refraction were subjected to refraction. Majority of the responders (532, 58.9%) were cleaning the refraction set with the help of an alcohol-based sterilizer or a sanitizer [Fig. 4b]; 790 (87.5%) were cleaning their slit lamps after each patient; 561 (62.1%)) were cleaning their examining lenses [Fig. 4c]; and 359 (40.9%) of the 97.1% responders who were cleaning these lenses were doing it with alcohol-based swabs [Fig. 4d].

In all, 264 (29.2%) of the responders were postponing dilated fundus examination and 731 (81%) of responders had stopped doing lacrimal sac syringing.

Only 106 (11.7%) were doing a mandatory RT-PCT test before surgery, whereas 567 (62.8%) did on the basis of suspicious symptoms. Four hundred and fifty (49.8%) responders had started for the practice of mandatory physician reference for preoperative fitness. Only 243 (26.9%) of the responders were doing a mandatory chest X-ray for all the patients before surgery. A total of 568 (62.9%) of the responders had reduced the number of postoperative follow-ups. In all, 804 (89%) believed that the expenses of the practice have increased post lockdown.

Other issues

Only 78 (8.6%) believe that the post lockdown had improved their mental peace, 504 (55.8%) said it was worse, and 321 (35.5%) said that mental peace remained the same.

Only 125 (13.8%) believed that their income has remained the same, whereas the rest felt that the income has reduced [Fig. 5a]. Most of the respondents 746 (82.6%) believed that practice would recover in a year’s time [Fig. 5b].

Figure 5

(a) Current income status of the various ophthalmologists. Only 13.8% feel that the incomes status is still the same as before. (b) Overall outlook of ophthalmologists about recovery in ophthalmic practice

Discussion

The effect of COVID-19 on the Indian economy seems long lasting. Nair et al.[6] presented a short survey-based study to show the impact on the practice of ophthalmology. They reported that the ophthalmologists indeed perceive themselves at a higher risk. Sanjay et al.[12] also described various challenges that eye surgeons face along with their paramedical staff. The reduction in the number of OPD and the surgeries was felt to be because the patients are afraid of coming to the clinic and eye surgeons are afraid in operating the bulk of patients.[71112] The overheads and the cost remained constant, while the volumes reduced, causing a crunch in cash flow.[12] This created a difficult situation for private practitioners. In a previous survey by Khanna et al.[13] on the psychological impact of COVID-19, out of the total 2350 responses, 869 (37%) respondents felt that either it was difficult to meet the expenses or they were barely able to meet the expenses. A critical one-third of respondents did feel a serious reduction in the practice and felt the economic crunch. This is especially true for solo private practitioners who are dependent on their individual practice for their income. Another survey by Nair et al.[6] showed that almost half of the Institutes and medical colleges were working during the lockdown, whereas almost three-fourths of private practitioners had a complete shutdown of their practices.

A large majority of private practitioners have actually reduced the number of working hours in ophthalmology practice. Our study clearly indicates the most of the respondents have reduced their working hours to less than 4 h. This is mainly because ophthalmology is perceived to be a high risk branch for the spread of COVID-19 virus.[14] With the limited and evolving knowledge and a myriad of literature on the spread of the virus, the guidelines are also evolving both in terms of prevention and treatment.[612141516] Shetty et al.[17] provided relief by showing that phacoemulsification is indeed safe for eye surgeons if adequate precautions are taken.

Almost a third of private practice eye surgeons did not remove or downsize their staff. The salary cut was less than 30% in most of these private practices. It is possible that individual practitioners had comparatively less day to day running expenses, because of which they could pay/retain their staff despite a reduced income [Fig. 2a and b].

Another important aspect of COVID-19 is the cost to the care giver. Various articles suggest that the cost of treatment has increased mainly due to the precautionary changes and increased disposables that have been advocated in routine ophthalmic practice. As the cost of treatment increases, the volume of patients actually has gone down both due the lockdown and also due to the widespread fear of spread of the disease on closer contact. Ophthalmologists, therefore, have to logically compensate by increasing the charges in the OPD. It was surprising that almost 70% did not increase their consultation fees even in private practice [Fig. 3a-d]. This could mainly be on the humanitarian grounds that the already suffering population should not be forced to pay even when the surgeon had increased overheads for the protective gear and to implement precautionary measures to prevent any spread of disease.[691213] It is very important to understand that most of the eye surgeons felt that there is indeed an increase in the cost of running expenses; however, this was seen more in the private practice group than the institutes and medical college respondents. This could be because the solo practice owners to being personally responsible for their expenses and may have been more prudent.

Telemedicine and telehealth has been encouraged in the early management of patients during the outbreak of COVID-19.[18] Tele ophthalmology for management of patients in the presence of lockdown was taken as a viable option for both health care providers and patients. Sharma et al.[19] in their small survey (n = 58) done on ophthalmologist in India showed that 17.5% were using teleophthalmology in their practice. In our own survey, we saw 22.6% of the respondents were promoting it in their practice. Some of the barriers for incorporating teleophthalmology in practice have been ethical, legal, financial, technical, and of course most important scientific.[181920] Ethical and scientific barriers including data privacy and inaccuracy may lead to legal problems.

Mental health has also become one of the most important part of human life. The lockdown stress has severely impaired a large section of population.[391013] The various reasons for this stress are

Economic problems including the reduction in practice

Fear of getting the infection similar to previous outbreaks.[2122]

Fear of family members getting infection due to their involvement.

Only 78 (8.6%) believe that the post lockdown has improved mental peace. This could be a very small subset of eye surgeons who felt that they were at peace when they were in the lockdown and therefore felt better once they forced to stop working. Majority believed that either it has remained the same or has worsened post lockdown in terms of mental peace. It is understandable that the most vulnerable group would be the private practice group with solo practice owners having most of the stress. Rightly, almost half of them felt that the mental peace had worsened. An interesting cross analysis was that all the private practice responders who were less than 35 years of age felt that the mental peace has worsened. The young ones who had probably just started their career or may have just settled in the practice were all feeling a worsening in the mental peace. Since this particular group is more fragile, it is important for the policy makers to look into the well-being of young entrepreneurs. A small subset of respondents was the resident doctors, but a bulk of them felt that the mental peace had indeed worsened.

The silver lining of the whole survey came in the end with most of the respondents feeling that there was light at the end of the dark tunnel and believed that practice would recover in a year’s time [Fig. 5b]. The respondents in the medical college group seemed more hopeful compared to the private practice counterparts, but overall it was believed that the picture would be better within a year’s time. It is quite optimistic to believe that the patients, economy, and payments would come back to normal in a year. The older age group respondents, the more experienced ones, were more hopeful of practice coming back to order in a year’s time. Although the economists believe that with the GDP and economy taking a strong beating, it is unlikely to happen in near future.[23] However, this economic down-growth probably does not mimic the health sector growth as predicted by ophthalmic surgeons. With some predicting a growth of 20% in financial year 2022, others predicting a better future in ophthalmology with more consolidation in the coming 6–12 months.[2425] This forecast seems similar to the positive thoughts of the respondents of this survey, which is indeed inspiring hope.

Conclusion

The survey gives important insights into the practice patterns of ophthalmologist in general in India. The charges were almost similar to pre-COVID-19 times. Most of the practitioners were following the norms of protection from COVID-19, although telemedicine was not very well embraced. The COVID-19 situation, lockdown and resultant stress mainly due to the financial losses, has an effect on mental health of significant number of practitioners. The best part is that we hope that this would recover in a year’s time.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.