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The practice of rheumatology during the covid-19 pandemic

By : Estefanía Fajardo
Periodista científica de Global Rheumatology by PANLAR.



02 June, 2021

https://doi.org/10.46856/grp.26.et087

"The COVID-19 pandemic has imposed many challenges that have ranged from migrating to new technologies to returning to an ICU or intermediate care ward. In the Pan-American Day of Rheumatology framework, we look at the challenges faced and at what is to come regarding patient care in this specialty."

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This is an open-access article distributed by the terms of the Creative Common Attribution License (CC-BY NC-4). The use, distribution or reproduction in other forms is permitted, provided the original author(a) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with this terms.

Tradition dictates that physical contact generates greater trust. Or, at least, that is what many health professionals learned during their undergraduate studies. But what to do when physical contact becomes a risk? This question arose in the wake of the health crisis generated by a tiny virus that came to change dynamics, routines, and doctor-patient encounters. SARS-CoV-2 came wearing a crown, a crown of spicules that "reigns" over most of our day-to-day conversations and actions. 

Rescheduled appointments, patients in doubt, doctors backing ICU rooms, and a virus that move forward unabated, leaving no time to adapt to the new reality -or new normality, as many have decided to call it- was the general picture around the world during 2020 and so far in 2021. Undoubtedly, these have been difficult times that required a reorganization of the medical practice and technological support that we kept at a distance for many years, but which has turned into our ally. 

Indeed, technology has been an ally for developing vaccines, sharing findings between countries, holding conferences, congresses, and virtual seminars. However, the most crucial partnership has been that amid the most significant health crisis of the second decade of the 21st century, physicians and patients could keep in contact. So, how can we stop feeling like we are "abandoning" our patients by moving our encounters to the virtual world?

In this regard, the Pan-American Health Organization (PAHO) maintains that for the COVID-19 pandemic, “health facilities may become overwhelmed and have insufficient capacity to provide adequate treatment to those most in need of care. Teleconsultations are a safe and effective way to assess suspected cases and guide the patient's diagnosis and treatment, minimizing the risk of disease transmission. These teleconsultations enable many of the key clinical services to continue to operate regularly and uninterrupted, both in preparation for and in the course of a public health emergency.” (1)

The PAHO also notes that “teleconsultations are a useful approach for triaging patients and reducing unnecessary visits to emergency departments. Scheduled teleconsultations allow the evaluation, monitoring, and follow-up of outpatients who do not require face-to-face assessment. However, according to the technological infrastructure available, there might still be services that cannot be replaced by telepresence, so it is important to determine when telepresence is an option and when is not” (1)

Patients’ acceptance of the new situation has generally been positive, although it depends on different variables. In a study led by rheumatologist Michael George, assistant professor of medicine at the Hospital of the University of Pennsylvania, a survey was conducted on 1517 patients with autoimmune rheumatic diseases from the United States' Arthritis Power registry. Diagnoses included rheumatoid arthritis, psoriatic arthritis, axial spondyloarthritis, and systemic lupus erythematosus. The survey results show that, during the highest peak of the pandemic, 57% of patients reported avoiding a visit to the physician's office, 42% avoided laboratory testing, and 30% reported having a teleconsultation. In addition, they found that patients in urban areas used telehealth more frequently during this study period than those in rural areas. (2)

In Latin America published data is still scarce, but we know that in some countries records are kept; in Colombia, for example, the Ministry of Health and Social Protection reported that 63.1 million telephone and virtual consultations were carried out between March 2020 and March 31, 2021. Of the total, 20.7 million were telephone consultations, while 42.4 million were teleconsultations. (3)

Of over 42.4 million teleconsultations made, 30% were for medical specialists; between 40 and 50% were for patients with common illnesses, and between 20 and 30% were for chronic patients.

In the context of a pandemic such as the current COVID-19 pandemic, surrounded by multiple technological tools, medical centers are now responding to the virus through the rapid adoption of digital applications and technologies such as telemedicine and virtual care, “which refer to the delivery of digital or remote health services through the use of information and communications technologies (ICT) for the treatment of patients. Telemedicine is expected to provide timely care while minimizing exposure to protect physicians and patients.”

Priscila Torres, journalist and president of the Pan-American Association of Patients with Rheumatic Diseases (Asopan), points out that in the care process “we can talk about patients linked to the public health systems. When the pandemic began, there were difficulties in locating them, because their data was outdated or because there was no contact by phone, mail or even via WhatsApp. There, the patients' associations helped us thanks to the network we have”.

As for older patients, “when talking about telemedicine, we had to address issues such as Internet access, infrastructure and, above all, patient education in technology”, says the Asopan representative. 

The above consideration indicates the need to educate people in the use of these digital tools, but also to understand that the presence for many is necessary due to the context in which some patients live. 

Considering that one of the characteristics of PANLAR is diversity, for the preparation of this article we interviewed different specialists, and took as selection criteria the representation of different geographical regions, age and type of practice. In this way, we present below a broad overview of the process of adaptation to virtuality in patient care, research and teaching during the context of the pandemic.

Teleconsultation came as a support for medical practice. It arrived because there is a risk in face-to-face attendance for both the physician and the patient; it arrived because it was necessary to comply with confinement measures; it arrived because the healthcare systems were subjected to stressful situations. It arrived and stayed. 

Given this panorama, how complex was to deal with the new communication technologies within the practice of rheumatology? To answer this and other questions, Global Rheumatology decided to inquire about the present, the adaptation and what will come for the future of this specialty in an environment of virtualization, knowing that rheumatology professionals in our region have as a differential element the close care of each patient.

Bearing in mind that one of the characteristics of PANLAR is diversity, for the preparation of this article we interviewed different specialists, and took as selection criteria the representation of different geographical regions, age and type of practice. In this way, we present below a broad overview of the process of adaptation to virtuality in patient care, research and teaching during the context of the pandemic.

 

What challenges did the COVID-19 pandemic pose to the practice of rheumatology?

 

Dr. Miguel Albanese, Uruguayan rheumatologist, former president of the Uruguayan Society of Rheumatology, elected president of PANLAR and member of its Executive Committee

Rheumatology is a medical science based on the human doctor-patient relationship. We were suddenly threatened by an epidemic with a great increase in mortality and transmissibility, and in which the great vector is the human being. Faced with this, the first thing one feels is the alteration of the human doctor-patient relationship. The first thing I felt as a rheumatologist, as a practical physician, are communication disorders, empathy disorders. So we suddenly had to rethink how to relate to each other in the pandemic, isolating ourselves, and from there came the whole methodology on how to accommodate ourselves to this reality. 

 

Dr. Deshiré Alpízar Rodríguez, MD-PhD, coordinator of the Research Unit, Mexican College of Rheumatology

Challenges in public and private practice were raised. In the public sector, many hospitals were converted and rheumatology consultations were cancelled for months. In the private sector, patient visits had to be spaced out and consultations had to be reduced in number and frequency. 

 

Dr. Carlos Toro, internist and rheumatologist, master in Autoimmunity, secretary general of PANLAR and general director of the Osteoporosis, Rheumatology and Dermatology Reference Center, Cali, Colombia

The biggest challenge was to continue patient care through teleconsultations. Adapting to this, not only in terms of handling the technology, but also in the development of skills to replace the information obtained from the physical examination. 

 

Dr. Vianna Khoury, Dominican internist, rheumatologist, university professor and specialist at Clínica Unión Médica.

The first challenge was to think about how I could protect my patients in the best possible way to prevent them from contracting the virus and, then, to find a way to follow up their pathology with the least possible exposure.

 

Dr. Annelise Goecke, rheumatologist, MSc, associate professor at the University of Chile, head of the Rheumatology Section of the Hospital Clínico Universidad de Chile, past president of the Chilean Society of Rheumatology. 

During the height of the pandemic, in 2020, some patients were not controlled for a long time and then arrived with severe decompensation of their underlying diseases. At that time they migrated to remote care, with limitations in the ability to perform a complete physical examination. Many patients have had long periods of isolation and sedentary lifestyle. A high rate of depression, anxiety and diffuse pain has been associated, which add to the usual demand for rheumatologic consultation and severely impact quality of life. In older patients, sarcopenia and depression are difficult problems to reverse, even more so when there is still fear of catching the disease.

 

What has been the main change in your relationship with your patients?

 

Dr. Miguel Albanese

I have a career practice of about 40 years. One of the things that was forbidden during my medical training was telephone contact; you could not care for patients by telephone. This obeyed the rules established by the culture where I come from; dogmatically, in the medical school where I was trained, it was stated that only in the face-to-face consultation should I obtain information first-hand and from the patient's point of view. Face-to-face attendance was almost obligatory in the practice of my career.

Today, the practice of medicine includes other methods that allow care from a distance and the use of teleconsultations. Due to the pandemic, we had to distance ourselves and maintain contact with patients; one of the things that was implemented was the use of technology in the service of communication. That is to say, we were able to break that first gap, the insecurity produced by the encounter mediated by technology, and we tried to disguise that insecurity and find elements that could provide the opportunity to be able to correct or orient the patient in the best possible way, through electronic media.

In this pandemic, one of the things that happened to me was that I had to see only 10% of my patients in person; the remaining 90% I had to see by other means.

 

Dr. Deshiré Alpízar 

In relation to the activity of the disease, several patients had no control, since their appointments were spaced out, or they themselves did not attend for fear of contagion. There was also a shortage of treatments. 

Another important aspect, both for the doctor-patient relationship and for medical research and the education of patients, is the use of social networks. Patients are adapting and are attentive to the information they find on these networks, and there is also a notable increase in the presence on networks of health professionals specializing in rheumatology, who individually, or through the different associations, provide information for patients, patient societies and general practitioners.

 

Dr. Carlos Toro

The lack of physical examination leads you to broaden the interrogation, to develop skills to replace that tangible review, through teleconsultation, and also – unfortunately– to the need to request more laboratory tests or imaging. Another aspect that I have been noticing, and which I consider to be somewhat negative, is that at the beginning of the pandemic patients were very grateful to the medical staff and to the development of teleconsultation, but now the situation is different: many of them feel exhausted by the prolongation of the current situation and are less pleased with the non-face-to-face consultations.

 

Dr. Vianna Khoury

A close relationship with patients has been usual in my practice; treating them with that affective warmth that characterizes us Latinos is no longer possible... at least at this time. Having to maintain that affective distance makes the doctor-patient relationship colder.

 

Dr. Annelise Goecke

In my practice, we have been returning to face-to-face service for some time now, maintaining only remote service for document management. Therefore, in my case, the change refers specifically to the loss of the usual physical proximity in greetings and similar instances.

 

How has the management of technology and the process of acceptance of health professionals and patients to this new form of consultation been?

 

Dr. Miguel Albanese

Obviously, technology is the new thing. I come from a place where the use of communication technologies was forbidden in my medical training; but “necessity is the mother of invention”. Today I say that, fortunately, we have technological tools that allow us to communicate. My patients, in general, are elderly and during the pandemic they partially adapted to technology; some did very well, and the use of cell phones and video calls gave me good results. Others were wary of technology, but I was able to adapt to all of them.

 

Dr. Deshiré Alpízar 

Patients and physicians are open to using online platforms for consultations in Mexico. However, platforms and approaches vary widely.

 

Dr. Carlos Toro

In my case, I adapted quickly to the teleconsultation process, and managed to maintain the same volume of patient care that I had before the pandemic, but I definitely noticed the difficulties of adaptation that the patients, and even the work teams, had. We realized, from one day to the next, that as health work teams we had to have a better infrastructure to connect and be able to perform our work optimally.

 

Dr. Vianna Khoury

For me, the process has been a bit difficult. Some patients request teleconsultations and feel comfortable being attended in this way, since they feel more protected; however, others ask for a virtual consultation the first time, but then go on to a face-to-face consultation; and others definitely do not feel comfortable with virtuality, so they request a face-to-face appointment. Regarding my perception as a health professional, I see the use of technology as an option due to the current situation of the virus. However, I do not find it a very satisfactory practice, since as rheumatologists we not only have to listen to our patients, but we also have to palpate their joints, their painful points, among other things.

 

Dr. Annelise Goecke

In my hospital we have already returned to face-to-face care. Technology is used for support, but solely for consultation related to exam controls or document requests. We had this system in place prior to the pandemic and it has been useful, but the usual consultation is currently face-to-face.

 

Do you think that after the pandemic everything will go back to the way it was before, or will these changes remain in the practice of medicine?

 

Dr. Miguel Albanese

We had a traumatic event. Thanks to technology we were able to maintain that baseline activity; I had contact with patients, although in a deferred manner; my work was maintained at 80% and I lost 20% of my face-to-face attendance. In other words, technology was the tool that allowed me to remain active, both in teaching and in assistance, so long live technology! I must also recognize that the use of technology allowed me to participate in annual scientific events and to develop the work in PANLAR. Although clearly nothing replaces the personal meeting.

I believe that, from now on, our professional practice will be a hybrid model. Many consultations will be face-to-face, because it will continue to be important to meet face-to-face with the patient. Personally, I am planning that the odd consultations, i.e., the first and third, will be face-to-face consultations, but the even numbered consultation can be mediated by technology. This is because in the first one I meet the patient, examine him, request the analysis; in the second one, I can talk and give feedback over the phone, the technology is implemented; in the third one, I control him, look at him and so on.

I feel comfortable and I think the patients also feel comfortable; they save trips, waits in the office and there is a fluid communication. Technology is here to stay.

 

Dr. Deshiré Alpízar 

I think we will continue with this system for several years. We will probably set up a hybrid model, with follow-up appointments by teleconsultations and first-time face-to-face consultations.

 

Dr. Carlos Toro

I do not believe that everything will go back to the way it was. At present, and in the future, we must adapt to consultations in which face-to-face and non-face-to-face consultations are mixed. There are many advantages of teleconsultation, because if it is applied with clear parameters and selection criteria that always respect the patient's wishes, it will bring many benefits to society and to the doctor-patient relationship. To cite a few benefits: 1) Greater access and possibility of monitoring the population, 2) Lower cost of travel to medical consultations, and 3) Optimization of time.

 

Dr. Vianna Khoury

I have the impression that as soon as the virus and its degree of contagion are brought under control, everything will go back to the way it was before. Without going any further, we are already seeing it: at the beginning of the pandemic, at the end of 2019 and the beginning of 2020, my patients were fearful and 70% preferred the virtual consultation. At the present time, 2 or 3 months ago, the number of patients attending face-to-face for consultation is almost the same as before the pandemic and very few are asking for virtual consultation, i.e., less than 5%.

 

Dr. Annelise Goecke

I believe that telemedicine has a key supporting role in certain occasions in which the physical examination is not so important, such as toxicity control when changing drug doses. Or in other areas, for example, the psychologist who works with us migrated to remote consultations; likewise, part of the education sessions of our nurse and the exercise sessions guided by our kinesiologists are also done remotely, but in many cases the face-to-face consultation of rheumatology will have to be maintained.

 

On a personal level, what were the challenges posed by the COVID 19 pandemic to a healthy work-life balance?

 

Dr. Miguel Albanese

Indeed, now those are the same spaces. Personally, I have a house with exterior and interior spaces that allow me to separate my times. At the beginning of the pandemic, I set up a working space in the back of my house where there is an open space and I also have a small office inside the house, then I can go from one space to the other. I have also interspersed my working and leisure hours, it was quite difficult to separate them since I am a person that, before the pandemic, used to work 12 hours outside. Today I am the whole day at home and sometimes I go to the hospital, thus finding time to spend with my family, either watching movies or series, cooking, or learning something new, was crucial. That is to say, I reinvented working and leisure spaces. I reinvented my whole world at home.

 

Dr. Deshiré Alpízar 

Personally, I transferred pretty much all my activities online. A great part of my professional work is on clinical investigation, which is also changing, with the increased use of electronic tools for research. As for my clinical practice, the follow-up of most of my patients has been online.

 

Dr. Carlos Toro

Personally, the challenge was knowing how to actually stay productive during my working hours, so leisure and family time was not affected. Work privacy is also important, then, it was crucial to designate “working areas” inside the house. Me and my family have successfully managed our times, so we have been able - as a group - to handle the situation. A great advantage of working remotely is that you can end your workday and being at home “right away”, which is a tremendous time saver. 

 

Dr. Vianna Khoury

The beginning of the pandemic was very hard for me, because I was working as a Rheumatology professor at the university and all of a sudden, we had to start with virtual classes and the development of tests within the virtual platform. Then it meant plunging into a whole new context both for teachers and students. As for external consultation, although it was suspended for several months, patients kept in touch by telephone, reporting their symptoms, doubts and fears.

On the other hand, as a member of the administrative council of the health center where I work, I had to face daily challenges and deal with eventualities related to the management of a disease about which little was known at the time. That is, looking out for the staff, since some of them did not want to work for fear of contagion, working hand in hand with nurses, doctors, and other health support staff, offering them all the protection measures; in addition, I had to make sure that there was no shortage of supplies, which as everyone know, were in short supply at the time. It was an odyssey.

And, in addition to all of the above, as a mother, wife, and new grandmother, I had to take care of all the household chores -although I could count on the help of the other members of my family- therefore the days were not long enough for everything I had to do. However, the satisfaction of being able to fulfill each of the tasks I took on outweighed the fatigue and the feeling of helplessness that sometimes arose when I could not do more to help the patients who came to the center in search of that most precious good: health.

 

Dr. Annelise Goecke

During this pandemic period, in addition to my practice as a rheumatologist, I supported the care of COVID patients on the ward and also performed shifts in intermediate care wards. I had not practiced intensive care medicine for many years. The stress of a practice for which I did not feel professionally prepared was great; I was worried about becoming a vector of contagion for my family, but on the other hand, as a physician, I knew that it was my duty to support patients in times of need, and also to support young colleagues who were overwhelmed. Therefore, it was unthinkable for me not to be there with them.

Finally, the emotional burden of seeing many seriously ill patients, many of them deceased, many with the whole family group ill, with no possibility of being visited by their loved ones, was a factor that added to the difficulties of those times.

However, not everything was negative; to return to internal medicine, to be again the “intern” of young colleagues, putting oneself at their disposal; to have periods of relaxed conversation during shifts that generated bonds of affection and camaraderie, which showed me once again how beautiful the work of the physician and the health team is. Also, seeing how groups were created to make it possible for patients to contact their families from a distance; seeing them connect again, trying to talk with them to ease their loneliness... In short, like everything in life, these were hard times, but with some sweet and sour parts.

 

How do you see your practice in one year and in five years?

 

Dr. Miguel Albanese

The change is to return to the normality we had before. But with this injection of technology that we had during the pandemic, I declare myself a great friend of digital communication tools; but I also maintain the validity of face-to-face, that is, we will move in a hybrid world of face-to-face and deferred consultations, as well as face-to-face and deferred classes, a 50/50 world.  

Regarding the next five years, obviously the pandemic was a milestone for humanity, a threat, but we are beginning to see a world that is increasingly globalized and truly connected. So no matter where we are in the world, there are points in common; we no longer think only in terms of one country, but – in our case – in the region and globally. A problem for one, is a problem for all, and a solution for one, is a solution for all. So we have to adapt to a global world, to a more integrated world, to know different cultures. We are moving towards a global village.

 

Dr. Deshiré Alpízar 

In the future, I envision my professional practice as a hybrid, that is, using online resources for follow-up and contact with patients, while continuing to see those who require it in person. I also envision using more tools such as e-health apps that could gradually be adapted to function as key supports for clinical research in which we measure patient reported outcomes.

 

Dr. Carlos Toro

In one year, I see the situation similar to how it is developing at present; that is, most patients will be seen by teleconsultation and some in person. In five years, I believe that the majority will be attended in person, but a significant percentage, close to 20%, could be examined by teleconsultation. I also believe that in a few years we will be better prepared in terms of infrastructure and digital literacy.

 

Dra. Vianna Khoury

I can tell you in advance that I am an optimistic person. I see my professional practice in one year as good and improving, I plan to continue with the usual tasks that occupy me for the moment and I know that they will get better, I am already living it. In five years, I visualize myself a little calmer, with less academic and administrative load, more focused on the professional part with the patient and with more time for my personal and family enjoyment.

 

Dra. Annelise Goecke

I believe that the pandemic is not going to disappear quickly; we will have to adapt to it, incorporating some care into routine practice, so we will continue to avoid crowds in the waiting room and this will mean longer intervals between patients, among other aspects.

In my case, face-to-face consultation will continue to be my forte; remote care is a help, but only for specific activities, low complexity controls, between face-to-face consultations or exam revision and educational work.

 

 

REMAINING CHALLENGES

 

COVID-19 has changed our world. The pandemic transformed the way we rheumatologists learn, teach, communicate, and care for our patients. A recent article on the future role of the rheumatologist asked these questions: who among us knew a couple of years ago what Zoom or telehealth meant? How do we perform or teach a rheumatologic examination or the art of injecting via telehealth? How will we reasonably integrate telehealth into a broader menu of care than we have so far? (4-6)

Interviewees agree, on one hand, that this situation generated changes in the doctor-patient relationship as we knew it, interruptions of medical care and treatments (due to shortages), problems adapting to technology, and patient isolation. 

On the other hand, while governments around the world were deciding on quarantines, given the numbers of infections and deaths, this pandemic brought with it a life change for everyone (doctors and patients) and the reorganization of fronts, such as education, work, and cohabitation. Regarding the practice of medicine, the COVID-19 pandemic fractured the tradition of face-to-face training of health professionals and the physical examination as the holy grail of the doctor-patient relationship. 

There may be a silver lining, though. Reinvention was a crucial word during this pandemic. In the healthcare field, it opened the opportunity to explore telemedicine as technology massively. Once tested, specialists and their patients started feeling more comfortable and recognized its usefulness and a new style of care that can go on with these dynamics.

In addition, this will lead to a progressive adaptation to technological advances and to discover the advantages of telemedicine, which will become more critical as time goes by, as well as the use of social networks for educating physicians and patients. 

Many believe that the immediate future will incorporate telemedicine and office visits. Telemedicine should remain a desirable option for those who have stable diseases or cannot travel to the office. Conferences and meetings will hopefully go back to being face-to-face with additional virtual assistance. The workday of the future might become drastically different from what we experience today. (6)

Telemedicine connects convenience, low cost, and easy accessibility of health-related information and communication through the Internet and associated technologies. During the coronavirus epidemic, telemedicine has been the first line of defense for healthcare providers to stop the spread of infections by providing services through telephone calls or videoconferencing for personalized care in mild cases while limiting healthcare resources for more urgent cases (7).

Last, but not least, the practice of medicine -whether virtual or face-to-face- should be framed for the benefit of all and under health systems that are equitable for all population groups. Concern for those vulnerable patients who have precarious access to the Internet or limited digital knowledge is relevant, as are the benefits to be gained for those who could potentially avoid long trips thanks to these technologies. Still, it is no secret that we live in a society with population sectors that still face digital barriers.

In this regard, a group of researchers pointed out the need to consider the challenges that teleconsultation could pose. To ensure that the current implementation of telemedicine does not exacerbate health disparities, the authors suggest four key actions for clinicians and health system leaders (7):

 

  • Proactively explore potential disparities in telemedicine access.
  • Develop solutions to mitigate barriers to digital literacy and the resources needed to participate in video consultations. 
  • Clear all obstacles created by the healthcare system to accessing video consultations. 
  • Advocate for policies and infrastructure that facilitate equitable access to telemedicine. 

 

In the short, medium, and long term, the evolution of rheumatology will undoubtedly be influenced by these new and changing paradigms. Rather than remaining passive in the face of these advances, there is a need to prepare for the ongoing challenges that the future will bring (8).

In this sense, PANLAR is preparing a soon-to-be launched online course titled “Telehealth as a tool for the diagnosis and follow-up of rheumatoid arthritis”, which aims to provide rheumatologists with comprehensive information on the strengths and weaknesses of telemedicine for the management of rheumatoid arthritis, including technological tools for diagnosis, evaluation and data recording, legal implications, and patient safety. The course will allow us to evaluate what the region has experienced in the context of the pandemic. 

2020 was a challenging year and, beyond figures, software, technologies, all those interviewed point out that the fundamental issue will lie in not losing the human nature of the doctor-patient relationship during in-person visits and teleconsultations. Undoubtedly, the COVID-19 pandemic, to which we were all radically exposed, raises questions for the future: How can we perfect telemedicine? How can we adapt to a “hybrid” future? What barriers exist? All these questions will be answered over time, the same time that allowed us to rethink healthcare under a deadly virus.

We are certain that even in difficult times, patients and their protection must be at the center of the profession’s approach and practice. This challenge goes beyond a virus that arrived without warning and changed all routines and practices.

 

REFERENCIAS

 

  1. Teleconsulta durante una pandemia - Hoja Informativa. OPS. 2021: 2. Disponible en: https://www3.paho.org/ish/images/docs/covid-19-teleconsultas-es.pdf 
  2. Sistema de Salud ha realizado 63,1 millones de atenciones virtuales y telefónicas. Ministerio de Salud y Protección Social. República de Colombia. Boletín de prensa 590; 2021. Disponible en: https://www.minsalud.gov.co/Paginas/Sistema-de-Salud-ha-realizado-63.1-millones-de-atenciones-virtuales-y-telefonicas.aspx 
  3. Gelman L. How Did the COVID-19 Pandemic Affect Medication Choices and Doctor Visits? What Data on 10,000+ Rheumatic and Musculoskeletal Disease Patients Shows. Creaky Joints. 2021. Disponible en: https://creakyjoints.org/living-with-arthritis/coronavirus/patient-perspectives/covid-19-pandemic-impact-rheumatic-disease-medication-doctor-visits/ 
  4. Lim, N., Wise, L. & Panush, R.S. Challenging Issues in Rheumatology: Thoughts and Perspectives. Clin Rheumatol 2021;40:1669–1672. https://doi.org/10.1007/s10067-021-05709-4
  5. New Way of Treating Patients (Podcast/Spanish) Global Rheumatology Disponible en https://globalrheumpanlar.org/podcast/la-nueva-forma-de-atender-pacientes-429?language=en&page=2&title= DOI : https://doi.org/10.46856/grp.232.e039
  6. Lim N, Wise L, Panush R. Challenging Issues in Rheumatology: Thoughts and Perspectives. Clinical Rheumatology 2021; 40:1669-1672. Disponible en: https://link.springer.com/article/10.1007%2Fs10067-021-05709-4 
  7. Jancin B. Telerheumatology will Thrive Post Pandemic.  Medscape. 2021. Disponible en: https://www.medscape.com/viewarticle/947628 
  8. Nouri S, Khoon E, Lyles C, Karliner L. Addressing Equity in Telemedicine for Chronic Disease Management during the COVID-19 Pandemic. NEJM Catalyst. 2020; 1-13. Disponible en: DOI: 10.1056/CAT.20.0123
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