A longitudinal qualitative study on physician experience in managing multimorbidity across the COVID-19 pandemic in Odisha, India

While many studies have documented adverse impact of multiple chronic conditions or multimorbidity on COVID-19 outcomes in patients, there is scarcity of report on how physicians managed these patients. We investigated the experiences and challenges of clinicians in managing patients with multimorbidity throughout the COVID-19 pandemic in Odisha state, India. To understand the factors influencing illness management and the adaptive responses of physicians alongside the evolving pandemic, we followed a longitudinal qualitative study design. Twenty-three physicians comprising general practitioners, specialists, and intensivists, were telephonically interviewed in-depth. Saldana’s longitudinal qualitative data analysis method was employed for data analysis. COVID-19 pandemic initially diverted the attention of health systems, resulting in reduced care. With time, the physicians overcame fear, anxiety, and feelings of vulnerability to COVID-19 and started prioritising patients with multimorbidity for treatment and vaccination. All physicians recommended teleconsultation and digital health records to benefit chronic illness care during future public health crises. The findings underscore the transformative potential of physician resilience and adaptation during the COVID-19 pandemic, emphasizing the importance of prioritizing patients with multimorbidity, incorporating teleconsultation, and implementing digital health records in healthcare systems to enhance chronic illness care and preparedness for future public health crises.


Study design, settings, and participants recruitment
We undertook a qualitative study in Odisha, India, during the COVID-19 pandemic to explore physicians' personal experiences while managing chronic illness and multiple long-term conditions, their challenges, and how they delivered care.General practitioners, specialists in Internal Medicine, and physicians of other specialities who managed patients with chronic illnesses in their usual practice settings were invited to participate in the study.Most of these physicians had managed COVID-19 patients, while a few were afflicted with the virus themselves, needing treatment with isolation, with one participant passing away due to COVID-19.These participants represented a variety of specialities, practice settings, and experience levels.
To ensure the inclusion of physicians from various specialties, we used a purposive selection method with a maximum variation sampling approach.These healthcare professionals were chosen from a variety of step-down care facilities, including primary, secondary, and tertiary settings, to provide a comprehensive representation of Odisha's national healthcare network.The selection process included clinicians from the public and private sectors, as well as from rural and urban areas.General physicians were chosen from primary healthcare centres in both rural and urban areas, while specialists were drawn primarily from urban tertiary healthcare facilities, with one specialist representing a district hospital.All the participants voluntarily participated.PM, the first author, is a clinician (psychiatrist) based at a private medical college hospital in the capital city, while SP, another author, serves as the director of the National Medical Research Centre situated in the capital city of the state.All authors actively participated in managing the COVID-19 pandemic within the state.The recruitment of participants was facilitated through the authors' personal and institutional networks.Their average age was fifty, seven participants were women, and they all had an average of twenty-four years of experience.The details of the physicians interviewed are provided in Table 1.
The first series of semi-structured interviews were conducted in June 2020, coinciding with the first COVID-19 wave, when healthcare services were most strained.We contacted twenty-three physicians, and all agreed to participate in the first series of interviews conducted over the telephone at their convenience.As the pandemic continued, two more surges in the number of cases, the second and third waves, were experienced.These waves led to a return of all COVID-19-related precautionary measures, like personal protection measures and movement restrictions affecting healthcare services.In this context, the research team decided opportunistically to extend the initial study by reaching out to the participating physicians for interviews in the second wave (August 2021) and the third wave (January 2022).Eighteen physicians were available for interview in the second wave and sixteen in the third wave.The subsequent interviews examined how their clinical practice and healthcare

Data analysis
Transcripts from the first series of physician interviews were analysed and thematically coded with Miles and Huberman's approach 22 .The transcripts were coded using the MAXQDA-2022 software 23 .The preliminary codes were grouped using pattern coding and further organised into categories and themes.The codings were carried out initially by PM and KCS in successive steps, they were continuously discussed with SP.Themes and categories were reassessed until a consensus was reached on the final coding structure.Data from the second and third waves were then analysed in sequence, following the previous coding structure.The longitudinal qualitative data analysis approach of Saldaña (2003) was used to examine the data.The "Framing questions" identified the changes that appeared from the previous wave.(e.g., What has changed and when and why it happened).The "descriptive questions" noted what increases or is cumulative across time and the 'surges' or ' epiphanies' that occurred.Forming and exploring the "Analytic/interpretive questions" later helped form the study's findings 21 .
The study was reported according to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist criteria for reporting qualitative research 24 .

Ethical considerations
The study was approved by the Institutional Ethical Committee of the ICMR-Regional Medical Research Centre, Bhubaneswar (ICMR-RMRCB/IHEC-2020/027).All study participants were briefed on the study's objectives and invited for a telephonic or face-to-face interview at a time and place convenient for them, ensuring adherence to standard COVID-19 guidelines during the interview.It was emphasized that participation in the study is entirely voluntary, and all provided information would be treated confidentially.Informed consent was obtained before digitally recording the interview.The study adhered to the Declaration of Helsinki and later amendments.All research was performed in accordance with the ICMR National Ethical Guidlines for Biomedical and Health Research involving human partcipants.

Results
The findings are presented under four major themes: (1)   4.

Theme 1: adapting clinical practice to ensure continuity of care
Delivering care with fear and uncertainty Physicians faced stressful conditions during the COVID-19 pandemic.In the early weeks of the pandemic, they reported feeling vulnerable, feared getting COVID-19, and taking the virus home to elderly family members with chronic illnesses.Many experienced symptoms of anxiety, depression, post-traumatic stress, disturbed sleep, isolation and even alienation from their community while working in the hospital.Nevertheless, most physicians continued work in public and private settings with precautions like wearing protective masks, face shields, and gloves or setting up a transparent barrier from the patient.They reported that these reduced the quality of patient examination and removed the personal touch.Most consultations included "seeing patients from a distance," where physicians could talk and see patients from far and prescribe.Consultation times were kept brief, exploring the essential aspects of the disease.Every incoming patient appeared as a carrier of the untreatable virus.The fear and uncertainty reduced over time as health care evolved to adjust to the pandemic.
"The treating physicians are going through much stress.'Kichi loka hari galeni, kichi loka dari galeni' (some doctors have given up, others live in dread).Some have become so tired of maintaining these precautions that they do not want to continue working this way." [P17, Nephrologist, June 2020]

Evolving patient care
With added efforts against COVID-19, the chronic disease services were sometimes overwhelmed.Primary care and general physicians adapted their practices well to the evolving pandemic.They were at the forefront of the efforts against COVID-19, updating themselves on the latest treatment protocols and adopting them quickly.

Theme 2: appreciation of the multifaceted vulnerability of multimorbidity and need for attention
Shifting priorities in healthcare During the pandemic, physicians revealed many shifts in the illness priorities among health administrators, health workers and patients.At the onset, healthcare systems were reorganised, and all resources were diverted for screening, isolating and treating COVID-19 patients.Health facilities created isolation areas and dedicated hospital beds for COVID-19.Other illnesses, particularly chronic conditions, were overlooked.During the statewide lockdown and transport restrictions, few patients with chronic illnesses visited hospitals.Physicians maintained treatment-continuity informal consultations through phones and WhatsApp.Doctors in specialities like nephrology and oncology reported that emergency care and specialised daycare services like dialysis, blood transfusion, radiotherapy, and chemotherapy continued amid strict COVID-19 related precautions.After the vulnerability of patients with chronic illness to COVID-19 was established, these patients received renewed attention.Physicians started looking proactively for diabetes, hypertension, and other chronic illnesses in all patients, ensuring heightened COVID-19-precautions and care for them.Patients with stable chronic illnesses were encouraged to avoid hospital visits.Hence, towards the later phases of the pandemic (August 2020 onwards), physicians noticed a surge in the return of patients who had not consulted for long periods.
"There is no disruption of service for dialysis or transplant follow-ups.Many who initially dropped out have somehow managed to come by private vehicles and ambulances." [P9, Nephrology, June 2020]

Multimorbidity care-overcoming the complexities
As chronic illnesses received renewed attention, many physicians became aware that patients with multimorbidity were most vulnerable to COVID-19 and its complications.They took extra COVID-19 related precautions for such patients.Their routine consultations were deferred with a provisional treatment plan, prioritising the more severe ailments.Interdepartmental referrals became few, and a collaborative and coordinated approach to treatment planning and care was not always possible.Whenever a referral was not possible, physicians always consulted their colleagues or professional friends and started treatment for comorbid illnesses.Holistic care could not be possible.Some physicians, particularly primary care physicians, revealed that with a long therapeutic relationship, they were familiar with their patient's illnesses and could guide their treatment and referrals when illnesses worsened.The physicians ' familiarity with their patients complemented the limitations of remote consultations. Vol

Remote consultation
Most physicians praised the role of widespread mobile and internet connectivity in keeping them connected to their patients.They used mobile phones, social media, WhatsApp or teleconsultation platforms, with hospitals starting formal telemedicine facilities.There were exchanges of patient treatment information, investigation reports and prescriptions.Physicians sometimes referred patients to their nearest point of care for treatment, investigations, or medicines.Physicians and specialists also used similar remote consultation methods to manage COVID-19 patients in isolation, within the hospital or at home.Those centres managing chronic illness, having a database of treatment records, like dialysis and chemotherapy units, found the information helpful in contacting the patients and facilitating their remote consultations.At the pandemic's beginning (March 2020), remote consultations were considered a temporary solution for health emergencies.Consequently, it was hailed as an indispensable element in healthcare delivery.Nevertheless, as the COVID-19 pandemic waned and travel restrictions lifted, teleconsultation became less used.
"We must sensitise the patients regarding the availability of telemedicine as an option during normal times, and can become more and more familiar with the facility." [P4, Psychiatrist, April 2021] Encouraging self-management Most physicians encouraged self-management practices in patients by giving instructions on managing their chronic illnesses at home.They guided patients on medicines, diet, and exercise, and they taught patients and caregivers to identify symptoms of illnesses and carry out essential examinations like measuring blood pressure and blood glucose levels.They observed that illness self-management was not possible in frail elderly patients or those with dementia, depression, or other psychotic disorders, thereby increasing their care demand on family members.
"Many patients in isolation could follow instructions and manage their illnesses.Older patients and ones with psychiatric illnesses needed help." [P7, Pulmonologist, April 2021]

Theme 4: aligning with rapidly changing public health guidelines and health system interventions
The Government's initial response to the pandemic was to reduce viral transmission through lockdowns, prevention of gatherings, and restrictions on people's movement.Teleconsultation facilities were set up in all parts of the state, with consultants of various specialities.The rapid establishment of COVID-19 diagnostic laboratories also helped identify and separate COVID-19-infected patients from these vulnerable persons.Those COVID-19 patients with chronic illness were telephonically monitored by health workers and guided to the nearest COVID-19 hospital for better care.The pandemic initially disrupted NCD programs, affecting the active door-to-door campaigns to identify people with chronic illness, coordinate and deliver their treatment, and distribute medicines.With the rising importance of chronic illness care, there was a greater emphasis on these efforts and on keeping meticulous digital records of these patients.The Government encouraged the development of COVID-19 vaccines, first introduced among the older populations and those with a single chronic illness or multimorbidity.Eventually, COVID-19 vaccinations brought about a feeling of normalcy among patients with chronic illnesses and the physicians treating them.

Discussion
The COVID-19 pandemic continued for an extended period, affecting chronic illness care.Our present study explored how physicians and health systems adapted to ensure continuity of care in patients with chronic illness and multimorbidity.During the first wave, physicians were hesitant to carry out routine consultations as they felt vulnerable and feared getting COVID-19.They conducted consultations by observing patients from a distance or with a barrier between them.Their familiarity with the patient compensated for the disadvantages of remote consultations.By providing instructions, they encouraged patients to manage their illnesses at home and on their own.Remote consultations were initially carried out informally over the phone.These were viewed as temporary solutions for medical emergencies and were aimed to provide continuity in care.Immediately after the first wave, teleconsultation facilities were set up across the state.The speedy establishment of COVID-19 diagnostic laboratories aided a gradual resumption of physical consultations.The RT-PCR test for COVID-19 was the gold standard for diagnosis, and doctors dealing with patients who tested negative felt more confident and less fearful of getting COVID-19 infection.The subsequent introduction of rapid antigen tests and serum antibody measurement further reduced physicians' sense of vulnerability.Vaccinated physicians could now treat patients without fear of getting infected with COVID-19.At the conclusion of the third wave, COVID-19 was less feared, and chronic disease care services were near normal.
Patients with chronic diseases and multimorbidity need care continuity to prevent complications, avoid emergencies, and maintain a better quality of life 7 .With a steady rise in the burden of chronic illnesses, the health systems in India are evolving to address these conditions through person-centred and collaborative care 8 .However, at the onset of the COVID-19 pandemic, physicians gave lesser priority to patients with chronic illnesses and multimorbidity.Nevertheless, their concerns increased when the vulnerability of these patients to COVID-19 became well-established 17,25,26 .This vulnerability is worsened by ageing and comorbid mental illness 27 .As evident from other studies, the emphasis on chronic illness care increased as the pandemic progressed, and this group of people were given heightened infection preventive measures at all levels 11,17 .These measures ranged from suggesting restricted social interactions, extra protection, and care in hospitals to being identified as the first group to receive the COVID-19 vaccine in India on the 16th of January 2021 28 .An emphasis on routine adult vaccination was also suggested for other infectious diseases 29,30 .The overhauled health system during the COVID-19 pandemic, like the added laboratory facilities and increased hospital and ICU beds, and the sensitised health providers provided a significant change in chronic illness and multimorbidity care and a relook at the government programs for NCDs.
Our study found physicians from diverse fields adapting and innovating to deliver patient care.However, the primary care physicians and general physicians stood out in the versatility of their role during the COVID-19 pandemic in addressing the health needs of patients with a chronic illness or multimorbidity.Their efforts were multifaceted and expanded beyond the scope of their routine work.These included identifying possible COVID-19 cases in these vulnerable groups, reaching out through remote consultations, educating patients about the virus and its prevention, providing mental health support, coordinating government interventions, and promoting and delivering vaccination.This immense adaptability and resilience while delivering care are also observed in other studies [31][32][33] .This crucial role of general physicians has also been noticed in the past during disasters like earthquakes, floods, cyclones, and other large-scale medical emergencies [34][35][36][37] .Though these medical emergencies and the current COVID-19 pandemic underline the importance of general physicians and family physicians as essential elements of a health system, their role is understated in medical education, and they are yet to develop as a discipline in India 38,39 General physicians' familiarity with the place of work, the people they treat and their therapeutic relationships have a crucial role to play in managing chronic illnesses during large-scale health emergencies.
Primary physicians with strong therapeutic relationships knew about the patient's illness and provided support and guidance during remote consultations.These elements of care were crucial for holistic care in patients with multimorbidity by coordinating referrals to specialists and allied healthcare workers.As multimorbidity management calls for a realignment of healthcare through a framework of patient-centred medicine 40,41 , primary care physicians or family physicians form the crux of such restructuring.Patients can be down-referred from tertiary and secondary to primary care wherever possible 42,43 .Hence, primary care physicians are better positioned to coordinate health care delivery in chronic illnesses and multimorbidity.This study indicates that there is a need to foster collaborative efforts and effective communication among medical specialists and primary care physicians, as well as the sharing of treatment plans.Focusing on all aspects of a patient's multiple health conditions, this approach is essential for comprehensive and coordinated care.
During the pandemic, most physicians communicated with their patients through WhatsApp and mobile phones for remote consultations.These consultations provided an alternative to in-person clinical visits for chronic illness 44,45 .In these consultations, they encouraged patients to measure basic health parameters like blood pressure, temperature, oxygen saturation, and glucose levels to monitor treatment progress.Patients were taught to identify illness exacerbation and drug side effects besides informing on diet and exercises.Such remote consultations made patients more responsible for their illnesses.Such Patient activation and self-management practices found beneficial for chronic illnesses were encouraged during the COVID-19 pandemic 15,16,46,47 .These informal physician-patient remote consultations became more structured over time, and ethical and practice guidelines for teleconsultation were in place in the post-pandemic period.Telemedicine evolved as a method of healthcare delivery for providing treatment instructions, improving patients' and caregivers' health literacy and self-care practices.The erstwhile Medical Council of India issued guidelines on telemedicine consultations in March 2020 48 .From the experiences of remote consultations during the COVID-19 Pandemic and instances of its use during other natural disasters, telemedicine can be an alternative mode of consultation during calamities when healthcare is disrupted 49 .Remote consultations for chronic diseases can also be done routinely to ensure care continuity and limit physical consultations to only those needing them, thereby ensuring health and reducing the burden on healthcare systems.The availability of electronic medical records can further the effectiveness of telemedicine in providing appropriate guidance for chronic illnesses and multimorbidity management.The Government of India introduced the Ayushman Bharat Digital Mission (ABDM), wherein a Health ID and Personal Health Records (PHR) can be created and linked with both public and private healthcare facilities 50 .With healthcare professionals across disciplines having better access to the patient's medical records, we can look forward to coordinated care for multiple chronic conditions.
Physicians play a pivotal role in guiding the self-management of illnesses, particularly among individuals with frailty or chronic conditions.This involves educating and sharing information with patients, developing personalized self-management plans, and encouraging patients to actively monitor their health.General Practitioners (GPs) are particularly vital in community healthcare, taking charge of direct care, decision-making, and referrals, and adapting their approaches during crises such as disasters.To fortify the healthcare system's resilience, it is crucial to invest in training programs for GPs and other healthcare professionals, focusing on enhancing comprehensive care and communication skills.The study underscores the importance of policymakers providing clearer guidance and support to clinicians during public health crises, especially when dealing with patients with multiple health issues.Standardized protocols, resource allocation strategies, and effective communication channels can facilitate decision-making.Additionally, both general physicians and specialists should be briefed on adapting their roles in crises.Addressing the increasing prevalence of multimorbidity requires a health delivery system that prioritizes patient-centred, holistic care, leveraging digital technology for telemedicine and shareable health records to enhance accessibility, particularly in underserved or remote areas.
In the context of public health crises, managing patients with multimorbidity requires a keen consideration of temporality-factors related to time such as disease progression, intervention timing, and changing patient needs.This becomes particularly complex when dealing with individuals having multiple concurrent health conditions.During events like pandemics, understanding the temporal dimension is crucial for prioritizing interventions, adapting healthcare resources, and addressing evolving patient needs.Clinicians play a pivotal role in navigating the temporal aspects of multimorbidity to optimize patient outcomes.The knowledge gained from managing temporality in one crisis can be invaluable for future public health emergencies, enabling healthcare systems to enhance preparedness and responsiveness.This learning process empowers clinicians to develop flexible and adaptive strategies, contributing to the creation of more resilient healthcare systems capable of effectively addressing unexpected challenges.

Conclusions
The COVID-19 pandemic disrupted health systems affecting care for NCDs and multiple chronic conditions.However, physicians overcame their fears and found ways to deliver care amidst the chaos.Later, when chronic illnesses and multimorbidity emerged as conditions of vulnerability, there was a renewed focus on these conditions.To ensure care continuity, physicians leveraged their therapeutic relationships, used remote consultations and promoted disease self-management among patients.Health administrators and policymakers also initiated measures to protect persons with multiple chronic conditions, prioritising their healthcare and vaccination.This priority change and the added healthcare infrastructure and laboratory facilities may also boost chronic illness care.With the Government moving towards digital healthcare, teleconsultations can be essential during calamities and regular times for treating long-term conditions.The COVID-19 pandemic may be a watershed moment in the care for chronic conditions.The findings underscore the transformative potential of physician resilience and adaptation during the COVID-19 pandemic, emphasizing the importance of prioritizing patients with multimorbidity, incorporating teleconsultation, and implementing digital health records in healthcare systems to enhance chronic illness care and preparedness for future public health crises.
They felt unquestioned liberty to use whatever available resources to treat their patients.The RTPCR (Real-Time Reverse Transcription-Polymerase Chain) test for COVID-19 was the mainstay for diagnosis, and physicians were more confident and less fearful when managing patients who tested negative.Patients suspected of having COVID-19 were isolated till the results came in.The introduction of Rapid antigen tests for COVID-19 and measuring serum antibodies further reduced feelings of vulnerability in physicians.Optimistic treatment guidelines and convalescent plasma therapy for COVID-19 aided their confidence.Nevertheless, all physicians acknowledged the advent of the COVID-19 vaccine as the turning point in the fight against the pandemic.Vaccinated physicians could see their patients without fear of getting infected.By the end of the third wave, COVID-19 was less discussed with dread."We are not afraid of COVID-19.It is a viral fever.It will not disappear; we must adapt and live with it.COVID-19 is now just a simple flu".[P22, Internal Medicine physician, January 2022] https://doi.org/10.1038/s41598-024-60473-0www.nature.com/scientificreports/

Table 1 .
Details of physicians interviewed.+ indicates participated in interview and × indicate did not participate in the interview.a Passed away due to COVID-19.
The chronic care model adopted from Wagner, 1998.