Navigating the new normal in ophthalmology

“Times of transition are strenuous, but I love them. They are an opportunity to purge, rethink priorities, and be intentional about new habits. We can make our new normal any way we want.”

- Kristin Armstrong

COVID-19 has turned out to be the metaphoric Black Swan of the twenty- first century – an unexpected event of large magnitude and consequence that has completely changed the way we live.[1] It has caught the world off-guard and thrust powerful nations into utter chaos.[2] It has claimed millions of victims directly and many more to its collateral damage. An event like this, of this magnitude, has never occurred in modern history.[2] Add to it the insecure uncertainty of what we do not know about the disease, which is far greater than what we do. Yet, the panic we can do without; it is neither the remedy nor the cure for this pandemic.[2] We must not lose hope and rely on our strong resilience, existential adaptability, and deep wisdom to come out of this crisis.[2]

New Normal is a term that refers to conditions following the financial crisis of 2007-2008, the aftermath of the 2008–2012 global recession, and now, the expected human behavioral changes post-COVID-19 pandemic.[3] It simply means that “a previously unfamiliar or atypical situation will come to be standard, usual, or expected”.[3] Having known the pandemic for the last five months, it is reasonable to assume that the unwelcome guest is here to stay in some form or the other for years to come. Vaccines are at least 12-18 months away if at all, and universal vaccination is an extremely difficult, expensive, and distant reality.[4] Although we aggressively Test, Trace and Contain, with a hope to flatten the curve, slow down the pandemic and mitigate the damage, our surrendered goal is to patiently await the onset of herd immunity. Assuming an R₀ estimate of 3 for SARS-CoV-2, the herd immunity threshold is approximately 67%, if the virus does not unduly mutate with time.[5] Hunkering down until it is completely safe may be a choice for a privileged few. For most of us, it is imperative that we make a cautious, calculated, and timely beginning to reopen and meet the new normal head-on or perish.[4] As we pussyfoot through the process of recalibration, reinforcement, and reopening, we have a unique opportunity to create and shape the new normal and adapt to it. This would encompass many facets of our professional life including ophthalmology practice, financial stability, training, and learning.

Reopening Ophthalmology Practice: Universal Precautions, Extended Work Hours, Day Care Surgeries and Reduced Throughput are the New Normal

The All India Ophthalmological Society (AIOS) and Indian Journal of Ophthalmology (IJO) have been providing timely guidelines to ophthalmologists to deal with COVID-19.[6,7,8,9,10] The essence of it all is the unfailingly meticulous practice of physical distancing, hygiene, and universal precautions to protect the workforce and the patients. The central government guidelines currently allow us (except in designated containment zones) to routinely see patients and perform even non-emergency surgeries including cataracts. Specific measures to be taken at the point-of-entry, waiting room, out-patient clinic, procedure room and operation theater constitute the new normal in our ophthalmology practice.[6,7,8,9,10] If you are a facility that admits patients for surgery, it is time to completely move over to daycare surgeries. The price that we pay to regain and maintain the patient volume would be in terms of an increased financial burden to enforce the safety norms, extended work hours and reduced throughput to maintain optimal physical distancing.

Always-On Access to Care: Tele-ophthalmology is the New Normal

Although the telemedicine technology has existed for over a decade, it has been sparsely used. We have come to very quickly rediscover the power of virtual care during the lockdown. This issue of IJO carries a lucid description of a gamified teleconsultation model.[11,12,13] As we understand that specialty triage of new patients can be performed remotely and several patients with chronic ophthalmic diseases need not physically visit us for periodic evaluation and prescription refill, we can build-in the now legalized routine practice of teleophthalmology seamlessly into our existing systems. Incorporation of simple, light, robust, scalable and fast cloud-based electronic medical records (EMR) and hospital management systems integrated with teleophthalmology would provide access to medical records at any point of consultation, minimize touch-points, and yet, have complete control on clinical documentation and help us provide an accurate prescription over teleconsultation. The visionary leadership of AIOS has seized the opportunity to constitute a well-represented teleophthalmology and EMR committee, which will very soon release its recommendations and roll-out several free-to-use platforms. Virtual care at scale would release chair time in clinical practice to be used for the patients who truly benefit from it, and thus help the cause of physical distancing.[14]

Staying Afloat in Troubled Times: A Lean (but not so Mean) Strategy is the New Normal

Financial prudence is the key to stay afloat in troubled times.[15] Today's new normal for healthcare businesses includes dealing with workforce management, sick workers, disrupted supply chains, cash flow crunches, uncertain compliance obligations, and the mechanics of incorporating new government programs.[16] The keys to success are preparation, agility, accurate data collection, and a willingness to harvest good ideas.[16] Cost containment without impacting the quality of care, recovery of financial dues, work-efficiency, remodeling, and multi-tasking of the workforce and deferring needless expenses are some of the sound strategies for financial prudence.[16] It may be, however, counter-productive to aggressively furlough or terminate essential employees and cut back much on their remuneration, unless that remains the only option for an organization to survive. The economic challenges are very real, and these actions may be unavoidable for some organizations.[16] However, cutting costs only to preserve profits may serve to sink us further into recession.[16] Pre-crisis profit targets have been overtaken by events that none of us could have reasonably anticipated, and, understandably, we will miss those targets.[16] It is commendable that several charitable non-governmental organizations have not resorted to pruning employee remuneration and are volitionally concentrating on retaining talented employees. This may be a wise managerial strategy in the long-term, for a grateful employee is often a loyal employee, and the troubled times logically yield a higher gratefulness quotient. Optimal financial prudence with a heart may be the new mantra to stay afloat and thrive again.

Ophthalmology Training: Online Teaching and Assessment is the New Normal

It is estimated that the training of about 80% of ophthalmology residents is adversely affected by the lockdown during the pandemic.[17,18] Even when we open-up, it may not be safe enough to conduct physical lectures and bedside teaching in larger groups. As we have already discovered, online teaching can be a gratifying experience and can considerably fill in for lost learning opportunities. As the opportunity-driven enthusiasm of the organizers of the me-too webinars' wanes, it is time to roll out robust, standardized, well-curated, curriculum-based, interactive, year-long online teaching modules by skillful teachers. The online avatar of the popular annual postgraduate education program iFocus is all set to debut in the next few weeks. The AIOS Ophthalmic Education, Training, and Evaluation Committee envisages the production of high-quality online teaching modules with the incorporation of standard assessment tools.

Ophthalmology Professional Leaning: Physical Conferences Morphing into an Immersive Online Experience is the New Normal

Physical ophthalmology professional conferences are neither safe nor feasible under the circumstances. Uncertainty prevails as to when it would be safe again for large groups to gather, learn, browse through ophthalmic products, and socially interact. Several prominent physical meetings have transformed into online versions – World Ophthalmology Congress is the first such that we will witness in June 2020. Technologically, it is feasible to create an immersive and engaging virtual conference environment with several simultaneous session halls and a walk-through trade exhibition with an option to buy online. This may be the way to go until it is safe to meet again. A hybrid version with an optimal combination of physical and virtual meetings may develop over time.

Reboot to Ophthalmology 2.0

VUCA is an acronym – first used in 1987, to describe Volatility, Uncertainty, Complexity, and Ambiguity of general situations[19] and it fits perfectly with the way the world is today, thoroughly overwhelmed by the current COVID-19 pandemic. The concept of VUCA naturally progresses to a smart leadership response - VUCA-2.0, incorporating Vision, Understanding, Courage, and Adaptability, which may show us a way out of this crisis, alive and kicking.[20] Let us wish each other a successful rebooting to Ophthalmology 2.0. See you on the other side.

“Humankind is now facing a global crisis. Perhaps the biggest crisis of our generation. The decisions people and governments take in the next few weeks will probably shape the world for years to come. They will shape not just our healthcare systems but also our economy, politics, and culture. We must act quickly and decisively. We should also take into account the long-term consequences of our actions. When choosing between alternatives, we should ask ourselves not only how to overcome the immediate threat, but also what kind of world we will inhabit once the storm passes. Yes, the storm will pass, humankind will survive, most of us will still be alive — but we will inhabit a different world.”

- Yuval Noah Harari