How do German General Practitioners Manage Long-/Post-COVID? A Qualitative Study in Primary Care
Abstract
:1. Introduction
2. Methods
2.1. Study Design and Participants
2.2. Informed Consent
2.3. Interview Guide
2.4. Data Collection
2.5. Data Analysis
2.6. Data Protection
3. Results
Definition and Epidemiology of Long-/Post-COVID Syndrome
No, more like eight weeks. I think you really have to wait eight weeks.(Ms. E)
Well, when they come for the first time, three or four weeks after the infection, then I say everything’s still ok, but when it goes on for a month or two, then I do say that it’s probably Long-COVID.(Ms. I)
And in four or five female patients—after nine months, they still showed nothing: that is to say after nine months there was still no improvement. I would then refer to them as having Long-COVID. And in one case, it was recognized as being an occupational disease.(Mr. K)
Well, of those, I calculated that overall this year I had 190 cases of Corona of which I coded 40 as U099, meaning Long-COVID or Post-COVID. And of those, there were a handful, that is to say about five maybe, right?(Mr. H)
So 10, 20 Long-COVID cases in the practice that I guess I know about. And it’s probably about two of those, meaning about 10 percent.(Ms. I)
4. Diagnosis
4.1. Symptoms and Complaints
And they have dyspnea a lot, when they exert themselves, tightness in the thorax, a cough—those are the complaints that patients have at the moment.(Ms. G)
He’s exhausted and has exertional dyspnea, so when he exerts himself physically, his physical activity is limited and he increasingly experiences shortness of breath—and then often excess mucus and pressure on his chest, so a bit like pulmonary symptoms. That’s on the one hand, and in addition to all the symptoms of exhaustion.(Ms. F)
Well, I’ve experienced patients whose symptoms are mostly respiratory, as well as those that primarily have gastrointestinal issues, but in the end they just feel exhausted all the time, with difficulties in being productive and in concentrating—kind of like being a completely different person that they don’t recognize at all and with illnesses they’ve never experienced before.(Mr. K)
4.2. Diagnostic Procedures
We often carry out general health check-ups, as one does, by measuring blood pressure, listening to sounds in the body, (oxygen) saturation, whereby I normally measure saturation for the patient’s sake, so they can see it’s not too low.(Ms. J)
And we do pulmonary function tests in the practice, the results of which are generally perfectly normal. At the beginning of the Corona pandemic, we used to regularly send patients for an X-ray but stopped because the findings we got back were never remarkable in any way.(Ms. J)
And then, when everything’s normal there as well, if the complaints continue, we send the patient to a cardiologist for a further examination.(Ms. G)
4.3. Problems GPs Experience in Diagnosing Long-/Post-COVID
Well, yes, there is a guideline that’s a bit of a decision aid. But it seems to me, and this is unfortunately in the literature, that there is no specific figure at the moment that would enable you to say for sure—well you know the patients have symptoms, but all the values that we measure are normal. There are none that clearly reflect these Long-COVID symptoms. I think it’s more of a clinical decision.(Ms. G)
You have the impression that many of the patients with Long-COVID, that they were very—how would you say it? Under pressure before their COVID-illness, and very busy, you see? Very performance-oriented. And that makes it a bit difficult, of course, because you think of other things and sometimes wonder if there isn’t a depressive component behind it all. Because I mean all the symptoms clearly can make you depressed when you’re used to doing things but can’t any more.(Ms. G)
The Corona deniers—they always play it down. They come far too late, you see? And they don’t get tested. And then I have a problem proving it and the whole legal side of things. And then of course I have the general problem in family medicine when I have people that have never learned to pay attention to what’s going on in their bodies.(Mr. B)
She has a fever again and again. Now, of course, we don’t know whether the fever comes from the illness or the vaccination—the third she has had—or has she had COVID in the meantime, you see?(Ms. E)
4.4. Methods to Improve Diagnostic Investigations
First of all, it would be good to have an unvarying guideline recommendation that you could rely on. I think what’s available at the moment is a bit weak. It wouldn’t be bad to have a standardized questionnaire either. And then, well the development of a guideline on it would facilitate the whole procedure of making a diagnosis a bit.(Ms. L)
As I said, there’s still no kind of marker that one could rely on because everyone has normal measurements, including those from cardiac tests. And that’s what’s missing a bit.(Ms. G)
Coordination with a kind of COVID outpatient clinic, like it is with the university hospital, but just a better coordinated version, so that they, for example, have the possibility to bill for lab tests, so they don’t have to come under my budget. And, yes, that the whole thing is better coordinated and all the data are immediately used in research.(Mr. K)
4.5. Patient Characteristics Related to Long-/Post-COVID Syndrome
That varies. I’d say that most are between 25 and 55, or 58. I’m not sure how old the female patient was, but about that. We don’t really see older patients, 60, 70.(Ms. G)
No, men that took longer, they all had some kind of a mental disorder such as depression or a kind of … they are what I would call light men, men that are rather sensitive, very sensitive even. Well, kind of stressed out in advance or alcoholics.(Mr. B)
…we sent those whose illness was really severe and whose saturation was really bad for a CT scan directly and then we really saw that severe changes had taken place in their lungs. The interesting thing is that they are not the patients that sit in the consultation room every week because they‘re feeling poorly on account of Long-COVID.(Ms. J)
We have cases that become chronic. That happens. But well, they are mostly those that already have severe underlying diseases, severe COPD where the lung tissue has been significantly damaged, or PAOD, you see? Then you do see that they have problems.(Mr. D)
Those that are in their early fifties, that are in the situation because of their age: Is that really incapacity for work? As I said, they are preschool teachers, most of them are preschool teachers that were probably already saying to themselves, ‘I can’t manage this any longer, with loud children for 40 h, it’s just not going to getting any better’.(Ms. J)
5. Treatment
5.1. Non-Pharmacological Treatment
When the disease is advanced, I try to encourage patients to move so that they increasingly strain themselves, at least twice a day, in order to trigger the revascularization of small blood vessels.(Mr. D)
Forest-bathing is good (…) In Japan, there are even studies on it—if you do it for two hours a week (…) Well it’s like hiking, but you do it without any objective, you take your time and it makes no difference where you end up, otherwise you end up under time pressure. So you shouldn’t take the dog. You just take water with you and when you go in—you’ll need about half an hour to really be properly in there—then you’ll start sensing the forest and concentrating on listening to the birds singing etc.(Mr. B)
5.2. Pharmacological Treatment
Exactly, we often see an obstruction to the function of the lungs, which we then treat. We do that with a combination drug containing Beta 2-sympathomimetics and cortisone.(Ms. G)
They take an ibuprofen, but in case of migraine I have to use high doses, and then I normally manage to stop the attack.(Mr. B)
5.3. Referrals
To a certain extent you can—this sounds a bit silly—occupy patients by saying to those that are in a great hurry, ‘OK, if you want a further diagnosis’ and then giving them a referral to a neurologist or the Post-COVID outpatient clinic, knowing as I do that they will have to wait six months for an appointment.(Ms. J)
5.4. Problems in the Treatment of Long-/Post-COVID
Some patients—the ones that keep coming back—have difficulties accepting that there are no established therapy options.(Mr. C)
…that it’s often women that can’t take time off, for whom it is out of the question when someone says to them, ‘slow down a bit for six months’, you see? They’re just people that can’t do that because they’re so bound up in their professional lives and have families to look after, where it’s just not possible not to give 100%. They also get in a kind of panic when you tell them it may take six months of a whole year until they‘re fully back on their feet again.(Ms. J)
Let’s just say that the illness tends to last longer in people with fairly serious underlying illnesses, or who worry a lot. It would certainly be desirable to provide them with psychotherapy, right? But I can’t afford to do that.(Mr. H)
The problem of psychosomatics. And so I have to look: ‘What is the problem?’ We have problems at work at the moment, financial problems, family problems—see if it’s that. And if it’s not then see if medication works.(Mr. B)
…no time for questionnaires. I’m not prepared to do that for patients with statutory health insurance—you see? We can’t manage that.(Mr. B)
We recently sent a patient to rehab, and it was very good for her. But the health insurance funds strictly limit that, our ability to send people for physiotherapy or ergotherapy or whatever, you see?(Ms. G)
5.5. Factors Positively Affecting the Course of the Disease
When the person has a positive attitude, they’re back on their feet a lot quicker.(Mr. H)
And I also noticed that people with Long-COVID that were still weak after three months but were prepared to be vaccinated. When they were vaccinated, it alleviated the symptoms. I don’t know why. It has been described in the literature, so I do it, and it works somehow.(Mr. D)
5.6. How Do GPs Define Treatment Success?
That they’re healthy again, that they can work again, that they feel well again, that they can tolerate stress again.(Ms. F)
Let’s put it like this. Most people only come back if they still have complaints. It’s rare that anyone says, ‘I feel brilliant now’, right?(Ms. I)
5.7. Necessary Improvements in Treatment
Yes, I think we should collaborate with some kind of center that offers that kind of thing. I think it would make sense if some kind of institute existed where a psychologist or a psychotherapist was available, as well as physiotherapists and ergotherapists, so that they’re all in one place.(Ms. G)
Self-assessment forms, standardized ones that you could give patients to take home with them. They could be useful in monitoring developments—that would certainly be helpful. Family practices often just don’t have the time to run extensive psycho-pathological tests.(Mr. C)
Yes, in my opinion it might be good it patients were to receive more information, perhaps from various media channels, that lifestyle changes are not just good for other illnesses, but that they have a particularly positive influence on the course of Corona and Post-COVID.(Mr. H)
6. Discussion
6.1. Main Results and Comparison to Literature
6.2. Strengths and Limitations
6.3. Recommendations
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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GP and Practice Characteristics | |
---|---|
Sex—N (%) | |
Female | 6 (54.5) |
Male | 5 (45.4) |
Specialization—N (%) | |
GP | 9 (81.8) |
Internal medicine | 2 (18.2) |
Further specialization—N (%) | |
Thorax surgery | 3 (27.3) |
Cardiology & emergency | 1 (9.1) |
Psychotherapy | 1 (9.1) |
Practice type—N (%) | |
Single, without personnel | 4 (36.4) |
Single, with personnel | 2 (18.2) |
Professional association | 3 (27.3) |
Group practice | 2 (18.2) |
Location of practice | |
Large town (>100,000) | 4 (36.4) |
Medium-large town (20,000–100,000) | 3 (27.3) |
Small town (5000–20,000) | 3 (27.3) |
Village (<5000) | 1 (9.1) |
Size of practice—mean/median (range) | 2482/1750 (900–5500) |
<1000 patients | 1 (9.1) |
1000–2000 patients | 5 (45.4) |
2000–4000 patients | 1 (9.1) |
>4000 patients | 2 (18.2) |
Age—mean/median (range) | 47.5/52 (34–61) |
Years of work experience—mean/median (range) | 20.3/19 (8–36) |
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Bachmeier, B.E.; Hölzle, S.; Gasser, M.; van den Akker, M. How do German General Practitioners Manage Long-/Post-COVID? A Qualitative Study in Primary Care. Viruses 2023, 15, 1016. https://doi.org/10.3390/v15041016
Bachmeier BE, Hölzle S, Gasser M, van den Akker M. How do German General Practitioners Manage Long-/Post-COVID? A Qualitative Study in Primary Care. Viruses. 2023; 15(4):1016. https://doi.org/10.3390/v15041016
Chicago/Turabian StyleBachmeier, Beatrice E., Salome Hölzle, Mohamed Gasser, and Marjan van den Akker. 2023. "How do German General Practitioners Manage Long-/Post-COVID? A Qualitative Study in Primary Care" Viruses 15, no. 4: 1016. https://doi.org/10.3390/v15041016