Pandemic, urology, and Waiting for Godot

As I sit contemplating what to highlight for this editorial in the middle of our collective pandemic lockdown (my last as Editor-in-Chief of CUAJ), I am struck by the generally thoughtful and balanced conversations within our healthcare teams, particularly within our urological community. Undoubtedly, all of us are closely watching the passionate and often animated discourse around the political impacts and economic sequalae of COVID-19, as well as our relatively early national responses to mitigate excessive pressures on our healthcare system. Nonetheless, at this juncture —writing this editorial in mid-April — the dialogue that I have been privy to within our regional institutions, as well as several provincial and national groups, has been a remarkable calm and pragmatic approach to preparing for an unprecedented future challenge. It is remarkable that only a few months ago, some of our most existential deliberations relative to our work lives focused on mounting gaps in care and the escalating pressures on our health systems heightened by the development of expensive solutions to many of the urological illnesses in our aging population. Not that today’s conversations are without controversy and complexity: it is amazing how many of us have suddenly completed our Masters of Epidemiology and/or infectious diseases sub-specialization. Exams are postponed; annual meetings cancelled; scheduled, elective operative lists are at a stand-still; worry around income stabilization is ubiquitous. Still, most healthcare workers appear to be preparing for the worst, hoping for the best, and looking forward to getting back to some semblance of routine clinical duties.

For most readers of CUAJ involved in delivering urological care to our population, one major contribution has been the conscientious, wholesale scaling-down of elective clinical care: exaggerated triaging of surgical cases and figuring out how to run (virtual) clinics; that, staying home, and wondering what our future clinical practice is going to look like. As I have slowly developed rising antibody titres to Netflix and finished re-painting all the baseboards in my house, I had the opportunity to re-discover some classic books collected from pre-medicine days and came across the play Waiting for Godot by Samuel Beckett. For those of you who are unfamiliar (or unwilling to reminisce back to your high school English literature classes), Waiting for Godot was written in the mid-1900s, on the heels of World War II, and an intriguing read in the middle of this pandemic. In the play, the two main characters, Vladimir and Estragon, wait for the arrival of someone named Godot who never arrives. While waiting, they engage in a variety of rambling conversations, clown around, contemplate suicide, and wait some more. Even if you dislike the absurdity of Beckett’s play, it certainly does resonate in times of political or social crisis. The play doesn’t really “mean” anything in particular, specifically not the identity of Godot, and instead seems to represent a blank slate for us to fill in during these critical moments — about enduring without immediate answers.

These are unsettling days, but our political and health systems leaders, capably advised by public health experts, seem to be assessing the evolving evidence daily that will inform the decisions to eventually get us back to work and play. As we wait, it is useful to consider any sage commentary about potential lessons learned from this ordeal when the dust settles. Although there is a lot to choose from, a recent editorial by Clarke and Abdool did a good job articulating some thoughts.¹ First, they suggest that healthcare research and development need to be a priority for the Canadian government, not to be left solely in private hands. Second, and similar to above, the crisis has emphasized our supply chain weaknesses, including prescription drug sources. Third, surge-capacity needs to be built into the system when the economy is booming, not as an afterthought during bad times. Finally, they suggest we need to re-consider our “healthcare-productivity nexus,” funding of routine services that keep us healthy and productive (read economically sound). For a heavily technical specialty with a lot of breadth in the type of care we undertake, that might represent an interesting conversation within the urological community.

In this regard, we have received a number of well-considered manuscripts focused on the delivery of urological care during the pandemic and especially how to prioritize as we emerge from the more severe constraints in elective work.^2–6 Maybe these considerations seem premature as of this writing, because COVID-19 is still unfolding and there is a lot of uncertainty. But, at some point, this coronavirus outbreak and our diligent reactions will moderate. Although no one can say for sure when (hopefully we are on our way by the time this is published in June), we do need to prepare for our near and intermediate future. These authors provide some practical solutions to start that conversation. CUAJ has fast-tracked these submissions related to COVID-19 and its impact on our urological care. We are also interested in how to best relate other examples of innovation and fortitude in these uncertain times. Write to us and tell us your stories.

As Beckett wrote, “ESTRAGON: I can’t go on like this. VLADIMIR: That’s what you think.”