Engagement in minimizing the spread of COVID-19.

None of our interviewees seemed to question the need to participate in minimizing the spread of COVID-19. They stated that the situation was urgent and serious, and they had to act to protect their patients and themselves and to avoid a collapse of the health care system. As one GP said

“Now with this COVID (..) it was very serious, if we did not act properly concerning ourselves, our staff and our patients (…) it could have fatal consequences” (GP1-interview 1).

Some of the GPs said that they had felt a sense of team spirit among health professionals, and that collaboration in the health care system on COVID-19 had been unusually well functioning. The GPs’ statements concerning the seriousness of the situation were also reflected in the number of precautions taken to prevent spreading of COVID-19, especially following the national lockdown. These included keeping up to date with the guidelines and following their recommendations, e.g. regarding increased hygiene, removing chairs from the waiting area, transferring as many consultations as possible to video and telephone, and not seeing patients with symptoms that could be caused by corona virus. Apart from the seriousness of the situation, some of the GPs stressed that an important pre-requisite for their engagement with video- and telephone consultations and, thereby, for their possibilities of participating in disease prevention, was the agreement made regarding remuneration of video and extended telephone consultations, which helped to secure their income.

Keeping up-to-date with new guidelines and information.

The GPs said that keeping up to date with the pandemic-related guidelines and information was challenging. First, the guidelines and the associated information were sent out by several organizations and on many platforms. They mentioned the NBH, DSAM, PLO, and the regional departments of PLO as their primary sources of knowledge. Guidelines from NBH came by e-mail, whereas DSAM and PLO sent out newsletters and posted information on their web pages and in their Facebook groups. As one GP said: "Hails are fired from five shotguns over your head at once" (GP 7-interview 1). In addition to the channels of information on guidelines aimed directly at general practice, the GPs also mentioned following news media, including government press conferences. This was out of general interest, but some of the GPs also mentioned that it was necessary as changes in pandemic-related strategies, initiatives, and restrictions were sometimes introduced at these conferences before they were communicated to health professionals. This is a point we will return to below.

A second challenge to staying up-to-date, especially in March and April 2020, was that guidelines concerning COVID-19 changed daily, and that information on these updates came at diverse times during the day. Furthermore, each time a change was made to a NBH guideline, the full guideline was distributed again, at the time of the first interview this was done without highlighting the changes. Thus, the GPs spent a lot of time trying to figure out what was new each time a guideline arrived:

“What they did in the end was that they highlighted the changes, but they did not even do that to begin with. So, you had to read the whole guideline to find out, what was new, what is changed, what is it I have to relate to now, what does my staff need to know, what do I need to know?” (GP4-interview 2)

As explained by this GP, at the time of the second interview, such changes to existing guidelines were highlighted, and that made the GPs’ work a lot easier.

At the same time, however, quite a few of the GPs said that politicians and authorities generally did well, and that some confusion is inevitable in such an unknown and chaotic situation as in the beginning of the pandemic with insufficient knowledge.

"There is always new information and thus constantly new corrections, so I also feel that you have to be a little large and say that it is the art of the possible." (GP6-interview 1)

Individual and collective work with guidelines and information.

The frequency with which guidelines changed meant that the GPs’ workday became longer because they used evenings and early mornings to read new, immediately applicable, guidelines and the associated information. When describing how they navigated in the flow of updates, all the GPs mentioned paying specific attention to their professional societies. The GPs explained that the guidelines coming from health authorities lacked descriptions of how they should be implemented, but their professional societies had done an excellent job of translating them into concrete suggestions for general practice. However, the suggestions for implementation from the professional societies necessarily came after the updated guidelines had been sent out, so while waiting for these, the GPs also had to keep an eye on the updates coming directly from the health authorities and find out how to act accordingly. As one GP explained:

”First of all, we try to see when the emails from PLO or DSAM come, then we know, then it’s something final. The problem is when it is not there, when we have a morning meeting at 10 minutes to eight. Then the evening before, you have to read the Danish Agency for Patient Safety’s website, Statens Serum Institut’s website, the National Board of Health’s website, and try to see, well, what are the announcements written here and what can we use them for. So, clearly our focus has been on, when announcement from the societies comes, then it is definitive, because there is someone who has tried to filter the information and made it much more targeted at us.” (GP2-interview 1)

The GP further explained that in order to know exactly how guidelines could be implemented locally, they had to pay attention to the region-specific information from the regional PLO departments e.g. on testing capacity and availability of PPE.

Apart from their individual work with reading new guidelines and information, the GPs described that deciding and planning how to implement the guidelines required collective work in the clinics, and thus internal communication had intensified profoundly in the first couple of months of the pandemic. Extra meetings were held both between the GP-owners of the clinic and with the entire staff. For example, in most of the clinics, the GPs had introduced morning meetings where they discussed the latest news and decided how to respond to these:

”We have a day structure where we all meet, all those who have to be at work, we meet 10 minutes to eight for a mini-morning meeting, where we update each other on the current status, who is sick and how do we approach the day. And there we have tried to start the meeting with what the latest recommendations are? What, related to who should be sent where?” (GP3-interview 1).

Key topics at these meetings were for instance making sure everyone had the same perception of who could be tested for COVID-19 (as we will return to later, this was not always clear), and figuring out which patients to see in the clinic and whom to talk to on the phone or in a video consultation. The GPs explained that they highly appreciated the list made by DSAM on who to see in the clinic. However, the list had to be interpreted according to specific patient needs. As one GP explained, it was an issue of constant internal discussion how to make this interpretation.

“We talk about it every single day, every single hour. And in the morning, we have a doctor’s telephone hour from eight to nine, and there we typically sit five or six doctors on the phone, and the four of us can sit in the same room. So there we have the opportunity to talk together about what to do in a specific situation, and continuously reassess, and we typically also talk about it during the lunch break or during the day. And our staff is constantly asking for guidelines for what to do. And we try to give it to them in relation to what is being distributed from our societies, and then say that they should allocate the patients accordingly and confer with us, if they are in doubt.” (GP6-interview 1).

In general, the GPs were able to make sense of the guidelines. However, when reflecting on the flow of guidelines and information in the first few months of the pandemic, the GPs said that the many sources of information, the constant revisions of guidelines and the difficulties with locating what exactly had been changed in new guidelines made it almost impossible to keep up-to-date, and trying to do so left them tired and often frustrated. In the second interview, some of the GPs were fed up with reading guidelines. One said:

“We do not bother any more. Well, I think that most GPs are totally exhausted by now. We read and read and read in the beginning, and all of a sudden, you reach the point: “No, now we can no longer bear it. Now, we have to take it when we get the question. Then we look it up.” (GP5-interview 2)

The GPs also said that the flow of changing guidelines had diminished, as had the work needed to keep up- to -date. At this point (at the end of June 2020), the pandemic was generally well-controlled in Denmark; the incidence and prevalence of COVID-19 were low, as was the number of patients hospitalized with COVID-19 [11]. Correspondingly, large parts of the Danish society had been reopened.

Giving advice to patients about risk groups.

Following the first phase of the reopening of society in April 2020, the GPs received many calls from patients who wanted to know if they belonged to one of the so-called risk groups, e.g. people who are in increased risk of getting severely ill if infected with COVID-19, and how they should act if they did. Patients were especially concerned about going to work. The GPs said that giving advice regarding risk groups was challenged by the often-changing guidelines.

”Again, there have been changing instructions, right? And when the guidelines have been changed, it has been difficult, because then we have had a few weeks before where it said: ‘Now you are in the risk group. You must not, and then, next week, a new guide said: ‘that actually you could if you did not have contact with directly ill people, and that sort of thing”. So that part has been difficult, because it changed”. (GP 3-interview 2).

Most of the GPs said that, knowing their patients’ medical situations, they could assess if they were in a risk group. However, at times it could be complicated to give advice on appropriate implications of being in a risk group for a specific patient’s everyday behavior. The GPs stressed that deciding whether a patient could go to work was not their responsibility, as that depended on the possibilities of keeping a distance to other people and the risk of infection at the workplace in general. If needed, the GPs could write a medical statement describing a patient’s risk status, but it was up to the patient and his or her employer to figure out if and how the patient could show up at work. This was in line with a statement from DSAM [12]. However, a few of the GPs had talked to patients or employers who expected more direct guidance from GPs regarding which work tasks patients in risk could safely manage.

The GPs also received calls from patients who had spouses or family members who belonged to a risk group and were unsure if they should go to work or to social events. The GPs differed with respect to how manageable they found such questions. Some found them too specific to answer, while others said that they usually found some solution with the patient. Some of the GPs also found that answering such questions should not be the task of the GP; the patients should call the national corona hotline established by the authorities.

Managing patients with symptoms of COVID-19.

The task of managing patients with symptoms of COVID-19 changed in accordance with the development in knowledge concerning these symptoms and the testing capacity. In the beginning of the pandemic in Denmark, criteria for suspecting COVID-19 were primarily focused on having visited other countries with widespread infection or having been close to someone who had been diagnosed with COVID-19. As the pandemic spread, however, everyone was advised to stay at home if they had any illness symptoms. Until the end of March, patients could only be tested if they were so ill that they needed to be admitted to the hospital. At that time, GPs had to assess the severity of the patient’s illness, which most of the interviewed GPs found manageable. However, some of them mentioned that in the very beginning of the pandemic, when knowledge was scarce about exactly which symptoms indicated COVID-19, they often conferred with the infection department at the local hospital.

From the beginning of April 2020, testing capacity gradually expanded. Across all the interviews and the daily notes, the GPs highlighted that communication regarding this expansion had been problematic. One problem was that the authorities informed the public about expansions in testing capacity during press conferences, before any specific guidelines had been issued to general practitioners about who exactly could be tested and how. Furthermore, some press conferences were held during the day, when GPs did not have the opportunity to watch them. As a result, patients started calling their GPs requesting tests before their GPs had been informed about the expansion or knew exactly what it entailed. In relation to this, the interviewed GPs found that the general statements made at the press conferences sometimes did not correspond to the actual guidelines, leading some patients to think that they could get a test when, in fact, they could not:

“So, we are a little frustrated that now, for example, the current announcement in the press is that now everyone can be tested with mild symptoms, right. It then gets blown across the entire broadcast area, and that’s actually not what the guidelines are. People hear about the guidelines in the press. They do not see what the National Board of Health announce to us, and they do not see everything that is written in small print, right. So we have to sit all the time and say: ‘yes, but it’s not quite like what you read in the newspaper or what you heard in the news. There are these and these limitations. And it becomes a frustration among the citizens at the other end, and we become the target for it. From the patients’ viewpoint it looks as if it is something we decide, and it is not something we decide, but we try to navigate according to what we are told to do” (GP6-interview 1).

A second problem in relation to testing capacity was that the statements concerning expansions of testing capacity were made before the local possibilities for testing more people were in place. This meant some referrals to tests were rejected, and that figuring out who could be tested was complicated. For example, on 20 April 2020 the authorities announced that now anyone who had symptoms could get a test. This was not the case in Region Zealand, however, where the test centers did not have the capacity to test people with mild symptoms. The case in Box 1 shows how one GP had to make several phone calls in the days from 20–24 April, to find out which patients he could refer to a test.

In addition to the problems related to testing, the GPs also described how unclear announcements concerning a rollout of pneumococcal vaccine had given them extra work. In the beginning of April 2020, the government announced that specific groups would be offered pneumococcal vaccine in order to prevent a high number of lung infections in addition to COVID-19. However, it was not made clear exactly who could get a vaccination and when. As a result, many patients started calling their GPs asking if they could get the vaccination, but since the GPs had not received a guideline with a plan for who to vaccinate, they had no answers for these patients. Such a plan was in place a couple of weeks later [13].

The GPs were very frustrated with the discrepancies between announcements, guidelines, and practical reality, as they resulted in extra work for them. Accordingly, there was a very strong plea from the GPs that they were briefed first before announcements were made to the general population, and that specific guidelines for general practice came before or at least at the same time as the announcements:

Well, it’s always nice to be ahead of things that happen, instead of being behind. So if one was to wish for anything, then it would definitely be that, before any official announcements, a briefing was planned of the groups in the health system it involved. It does not have to be several hours before, but at least at the same time. The moment that for instance a news broadcast starts, then a guideline should be distributed to healthcare staff who is affected by it. ‘This is the new announcement, it will mean such and such for you. We recommend that you approach it in this way’. So, I do not want say a roadmap, but at least reflections on how they could presume it would affect our workday, and how they think we could solve it in the easiest way possible. (GP2-interview 1)