Introduction

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is a novel coronavirus of zoonotic origin, which was identified at the end of 2019 in Wuhan, China, and eventually spread all over the world [1,2]. Till now, there is no approved treatment available for COVID-19 and the management is empirical [3]. Many countries have taken strict measures, like social distancing, quarantine, and lockdown, to protect and prevent further spread of the virus [4]. For instance, curfew is a major step for the management of COVID-19 pandemic as it mitigates the spread of the disease among individuals [5].

According to the Ministry of Health (MOH) of Saudi Arabia, the first case of COVID-19 was detected on 2nd March 2020 in a citizen who had returned from abroad [6]. The lockdown in the Kingdom of Saudi Arabia was gradually implemented, starting as a partial curfew (i.e., individuals were allowed to go outside of their houses only from 6 am to 3 pm) that lasted for 3 weeks. Furthermore, full curfew (i.e., individuals were not allowed to go outside of their houses for 24 hours) was implemented, which lasted for 8 weeks. Then, partial curfew was applied again, following an ease of restrictions and opening of some public and commercial activities with precautions and preventive measures [7].

It was reported that the risk of severe COVID-19 illness was higher in immunocompromised patients, such as acute leukemia patients, who were receiving chemotherapy [8]. For instance, a recent study found that cancer patients had a higher risk of developing severe events, such as ICU admission, invasive ventilation, or death, compared with non-cancer patients [9]. Public health measures implemented to control the disease spread were aimed at decreasing preventable hospital admissions and elective procedures [10].

In Saudi Arabia, hospitals implemented several strategies to reduce potential infectious hazards, and patients were advised to limit hospital visits according to the instructions received from their medical team. Hence, physician-patient communication became affected due to current circumstances. Subsequently, some electronic applications, such as WhatsApp and Zoom, were used as an alternative to minimize the impact of this pandemic [11]. Furthermore, the physicians were encouraged to cooperate and benefit from the experiences of each other [12]. Therefore, this study aimed to evaluate how physicians mitigated hematological disorder patients during the COVID-19 pandemic in Saudi Arabia. In addition, the impact of the curfew on hematologists and their recommendations according to their current experience was also assessed.

Subjects and Methods

This cross-sectional survey was conducted among 62 hematology physicians in Saudi Arabia during the COVID-19 pandemic from 6th to 29th June 2020. Data were collected either by direct contact, via telephone, or ZOOM application. Data from 39 participants were collected via a web-based questionnaire using Google Forms which was distributed through WhatsApp, Twitter, and e-mail. Participants were from different hospitals, hematology subspecialties, and experiences. Clinical hematologists of both genders working in Saudi Arabia were included in the study; however, non-clinical hematologists or non-Saudi clinicians were excluded.

A predesigned questionnaire was used that included questions to assess the effect of the COVID-19 outbreak on physician-patient communication during the curfew. Phone calls were interactive, and physicians shared their recommendations and pieces of advice for any similar situation for the future. The questionnaire consisted of 21 questions, which was divided into four sections. Data were coded, tabulated, and analyzed using Statistical Product and Service Solutions version 20 (Armonk, NY: IBM Corp.). Qualitative data were expressed as numbers and percentages, and chi-squared (χ²) test was applied to test the relationship between variables. A p-value of < 0.05 was considered to be statistically significant.

Results

This study surveyed 62 clinical hematology physicians of both genders and different ages. Furthermore, the surveyed physicians were from almost every medical institution in Saudi Arabia and embodied all clinical hematology subspecialties (Table 1).

When physician-patient communications was assessed, it was found that the most common method of contact between physicians and their patients was using actual and virtual clinics and WhatsApp (22.6%). Most of the participants (54.8%) reported more than one method for patient management and 41.9% mentioned that patients had contacted them for general concerns (Table 2).

It was also found that 53.2% of the participants were satisfied with the experience of handling patients during curfew and 71% found it effective to be repeated in case of any similar situation (Table 3).

The physicians were also assessed for their advice and opinions in case of any similar situation in the future. The pieces of advice were classified into three categories: first, piece of advice to patients; second, piece of advice to other physicians; and third, piece of advice to the decision-makers (Table 4).

Furthermore, participants’ attitudes toward giving permissions to patients, using social media, and its impact on communication with patients were also assessed, as shown in Table 5.

When the relationship between participants’ characteristics and their satisfaction with their experience of handling patients during the curfew was analyzed, a non-significant relationship was found between the participants’ characteristics (i.e., gender, age, years of experience, and position) and their satisfaction with their experience (Table 6).

Table 1. Demographic information of the surveyed physicians (n = 62).

Table 2. Assessment of physician-patient communication according to methods of contact with patients, type of work, common cases contacted, methods of management, and type of patients (n = 62).

Table 3. Assessment of physician’s experience in terms of their satisfaction and appropriate method to contact patients during the curfew (n = 62).

Additionally, a non-significant relationship was also found between participants’ characteristics and participants’ opinions about the effectiveness of their experience (Table 7).

Moreover, a non-significant relationship was also found between participants’ characteristics and their opinion about the most appropriate method to contact patients during the curfew (Table 8).

Finally, the relationship between participants’ characteristics and their opinion about the impact of social media on communication with their patients was analyzed. Interestingly, male participants and those in the age group of 46-55 years significantly correlated with those who saw that social media has a positive impact on communication with their patients, with p-values of 0.03 and 0.002, respectively. However, there was no significant correlation with the other participants’ characteristics (Table 9).

Discussion

This study demonstrated that hematologists, who participated in the current study’s survey, were successful in mitigating the communication gap with hematological disorder patients during the COVID-19 pandemic in Saudi Arabia. The physicians involved in this study were chosen carefully to represent the impact of the COVID-19 pandemic on the practice of clinical hematology in Saudi Arabia. The satisfaction of physicians during the COVID-19 pandemic is one of the main indicators for the feasibility of rapid expansion of telemedicine [13]. More than half of the physicians were satisfied with the experience of handling patients during the curfew, which indicated a greater opportunity for expanding and improving the practitioner’s satisfaction and experience. This level of satisfaction was good due to the implementation of novel alternative communication methods, such as virtual clinics. A similar high satisfaction rate was documented among physicians treating head and neck cancer patients, as well as physicians in child neurology care [14,15]. Participants in the current study agreed with other studies on the requirement for further improvement of virtual clinics.

One of the main measures to reduce the impact of the COVID-19 pandemic on patients and healthcare providers was to identify the risk groups and to reduce the load on the healthcare system. A recent cross-sectional study was conducted in Latin America, which looked into the impact of the COVID-19 pandemic on pediatric cancer care [16]. Vasquez et al. [17] showed that healthcare systems were not substantially affected in Latin America, which was consistent with the current study’s observations. Despite these encouraging reports, it is likely that if the pandemic evolves, the burden on the healthcare system would increase and the impact might become serious or even severe if preventive measures are not taken.

There are at least three published letters (correspondence) in which it was discussed how this COVID-19 pandemic would affect patients with hematological disorders [17-19]. However, these letters were derived from the experts’ point of view without surveying the physicians who were at the frontline and faced different scenarios. Almost all physicians agreed that managing patients’ concerns were very challenging for two main reasons. Firstly, the load on the physicians was high; most of the patients were contacting the physicians for reassurance or for questions that could be answered by other healthcare providers, such as pharmacists (i.e., questions about how to use a medication). Secondly, physicians commented on their concerns regarding the patient’s compliance as many of the problems were not controlled by the patients, specifically the delay in medication delivery and the lack of blood donors. Fear of contracting COVID-19 infection played a major psychological role, for example, avoiding hospital visits even if the patients had concerning symptoms or skipping few doses of scheduled medication to avoid visiting the pharmacy for a medication refill. There are many studies which reported that the psychological impact of the COVID-19 pandemic is worsening with time, which might cause paralysis in the healthcare system [20-22].

Table 4. Summary of the main physicians’ suggestions in case of future curfews.

Table 5. Participants’ attitudes toward giving permissions to patients, using social media, and its impact on communication with patients (n = 62).

Table 6. Relationship between participants’ characteristics and their satisfaction with their experience of handling patients during the curfew (n = 62).

Table 7. Relationship between participants’ characteristics and their opinion about the effectiveness of their experience (n = 62).

Table 8. Relationship between participants’ characteristics and their opinion about the most appropriate method to contact patients during the curfew (n = 62).

^aA = Virtual Clinics, B = WhatsApp, C = Actual clinic if needed, D = Others.

Table 9. Relationship between participants’ characteristics and their opinion about the impact of social media on communication with their patients (n = 62).

*Statistically significant.

MOH and other health organizations in Saudi Arabia played a great role in providing a wide range of awareness and information about the pandemic. However, these efforts were limited to the protection from COVID-19 transmission, which was not only related to the required information for patients with hematological disorders. For instance, patients with hematological disorders require personalized information regarding many aspects, such as their medication, which might reduce the immune system and make them more prone to SARS-CoV-2 infection. To partially solve this issue, some of the interviewed physicians used social media (mainly Twitter) with an aim to provide helpful information for patients with hematological disorders and to answer their questions. Therefore, it was found that the positive impact on communication with patients through social media was significantly correlated with male physicians and those in the age group of 46-55 years. However, it was strongly believed that a more appropriate platform must be implemented to fill this gap and work proactively.

Curfew during the COVID-19 pandemic affected logistic supply as well as the delivery of many goods and medications to its target areas. Medication-related issues were the main concern of the interviewed physicians. For instance, there are multiple consequences due to the delay of medication delivery that might lead to the deterioration of the patient’s health and it might create a high probability of hospitalization. It was believed that a thorough plan must be drawn up and implemented to solve this problem. The plan should include a protocol for early identification of any potential delay and clearly defined alternatives. These alternatives might include shipping of the medication with another agency or collaborating with other pharmacies (government or private) to supply patients who are near to them whenever needed or offering a refund for the patients to buy the medication from their nearest pharmacy. Another issue that was found in the current survey was the severe deficiency in the units of blood for patients who required frequent transfusions. Thereby, this issue also needs to be addressed to the experts in the blood supply centers.

Telemedicine is one of the most useful solutions utilized during the COVID-19 pandemic. In the literature, there are many definitions for telemedicine; however, all were adopted by the World Health Organization [23]. In other studies, telemedicine is described as telehealth or virtual clinics [17,18]. In Saudi Arabia, many initiatives were aimed at implementing telemedicine services all over the kingdom since 2018. For instance, MOH released an application (called Seha) that provided visual medical consultations and allowed face-to-face communications with the physicians [24]. This important initiative was accompanied by the release of Telemedicine Regulations in the Kingdom of Saudi Arabia by the National Health Information Center in the Saudi Health Council [25]. Telehealth in Saudi Arabia was underutilized based on the observations of the current study and previous studies [26,27]. It was believed that COVID-19 pandemic will accelerate the utilization of telehealth. However, the potential value of telehealth during and after COVID-19 should not be underestimated, as it provided an opportunity to monitor the health of a significant proportion of patients, and the service could still be provided if physicians were self-isolated [28].

The healthcare system in Saudi Arabia was actively in transformation stage before the COVID-19 pandemic occurred. One of the main pillars of this transformation plan was to improve the efficiency and effectiveness of the system through the maximum implementation of information technology (IT) and digital transformation [29,30]. In the current study, it was observed that the healthcare system was not extremely affected as it was predicted and that is largely due to the previous investments in the IT and digital transformation. As mentioned earlier, Saudi Arabia released the telemedicine regulations 2 years ago and it turns out to be one of the most successful initiatives that were helpful during the COVID-19 pandemic. On the other hand, it is also shown in this study that more work needs to be carried out to improve the delivery of telemedicine in Saudi Arabia.

The major strength of this study was its geographical coverage and the coverage of almost all subspecialties of hematology, with responses from physicians representing all healthcare providers in Saudi Arabia. However, the main limitation was the imbalanced number of participants between healthcare providers, making it difficult to be compared across healthcare sectors.

Conclusion

More than half of the physicians were satisfied with the experience of handling patients during the curfew. It was also found that most of the hematology physicians agreed that managing patient’s concerns was exhausting during the pandemic, for several reasons, and the most important of them was due to the high load on the physicians. Besides, delaying the delivery of medications had created a problem. Furthermore, telemedicine is one of the most useful solutions utilized during the COVID-19 pandemic; however, it needs to be improved and should be used routinely as a part of the healthcare system in Saudi Arabia.

Acknowledgment

The authors appreciate and thank all the hematologists in Saudi Arabia who participated in this survey.

List of Abbreviations

Conflict of interest

The authors declare that there is no conflict of interest regarding the publication of this article.

Funding

None.

Consent to participate

Informed consent was obtained from all participants.

Ethical approval

Ethical approval was obtained for the study from the Research Ethics Committee of the College of Applied Medical Sciences at Taibah University via letter number SREC/AMS 2020/64/CLD dated: 09/06/2020.

Author details

Abdulraheem Alshareef ¹, Hawazen Balkhair², Arwa Abbas³, Maha Rizq⁴, Hani Alhashmi⁵

1. Medical Laboratories Technology Department, College of Applied Medical Sciences, Taibah University, Madinah, Saudi Arabia
2. Clinical Laboratory Sciences, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
3. MBBS Candidate, College of Medicine, Al-Rayan Colleges, Madinah, Saudi Arabia
4. MBBS Candidate, College of Medicine, Taibah University, Madinah, Saudi Arabia
5. Adult Hematology and Stem Cell Transplantation, King Fahad Specialist Hospital, Dammam, Saudi Arabia

References

1. Malard F, Genthon A, Brissot E, van de Wyngaert Z, Marjanovic Z, Ikhlef S, et al. COVID-19 outcomes in patients with hematologic disease. Bone Marrow Transpl. 2020;55(11):2180–4. https://doi.org/10.1038/s41409-020-0931-4
2. McIntosh K, Hirsch MS, Bloom A. Coronavirus disease 2019 (COVID-19): epidemiology, virology, and prevention; 2020. UpToDate [cited 2020 Aug 18]. Available from: https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19-epidemiology-virology-and-prevention
3. Phadke M, Saunik S. COVID-19 treatment by repurposing drugs until the vaccine is in sight. Drug Dev Res. 2020;2:2–4. https://doi.org/10.1002/ddr.21666
4. Hernández-orallo E, Manzoni P, Member S. Evaluating how smartphone contact tracing technology can reduce the spread of infectious diseases: the case of COVID-19. 2020;8:1–15. https://doi.org/10.1109/ACCESS.2020.2998042
5. COVID-19 monitoring committee lauds the public interaction with curfew [press release]. Riyadh, Saudi Arabia: Ministry of Health (MOH); 2020. Available from: https://www.moh.gov.sa/en/Ministry/MediaCenter/News/Pages/News-2020-03-24-001.aspx
6. MOH reports first case of coronavirus infection [press release]. Riyadh, Saudi Arabia: Ministry of Health (MOH); 2020. Available from: https://www.moh.gov.sa/en/Ministry/MediaCenter/News/Pages/News-2020-03-02-002.aspx
7. Ministry of Interior: allowed period during curfew defined for holy month of Ramadan [press release]. Riyadh, Saudi Arabia: Ministry of Interior (MOI). 2020; https://www.moi.gov.sa
8. Chen Z, Xiong H, Li JX, Li H, Tao F, Yang YT, et al. COVID-19 with post-chemotherapy agranulocytosis in childhood acute leukemia: a case report. Zhonghua xue ye xue za zhi = Zhonghua xueyexue zazhi. 2020;41(4):341–3.
9. Liang W, Guan W, Chen R, Wang W, Li J, Xu K, et al. Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. Lancet Oncol. 2020;21(3):335–7. https://doi.org/10.1016/S1470-2045(20)30096-6
10. Cao Y, Li Q, Chen J, Guo X, Miao C, Yang H, et al. Hospital emergency management plan during the COVID-19 epidemic. Acad Emerg Med. 2020;27(4):309–11. https://doi.org/10.1111/acem.13951
11. Hamza M, Khan HS, Sattar ZA, Hanif M. Doctor-patient communication in surgical practice during the coronavirus (COVID-19) pandemic. Br J Surg. 2020:2020. https://doi.org/10.1002/bjs.11661
12. Provan D, Stasi R, Newland AC, Blanchette VS, Bolton-Maggs P, Bussel JB, et al. International consensus report on the investigation and management of primary immune thrombocytopenia. Blood. 2010;115(2):168–86. https://doi.org/10.1182/blood-2009-06-225565
13. Smith AC, Thomas E, Snoswell CL, Haydon H, Mehrotra A, Clemensen J, et al. Telehealth for global emergencies: Implications for coronavirus disease 2019 (COVID-19). J Telemed Telecare. 2020;26(5):309–13. https://doi.org/10.1177/1357633X20916567
14. Lee AKF, Cho RHW, Lau EHL, Cheng HK, Wong EWY, Ku PKM, et al. Mitigation of head and neck cancer service disruption during COVID-19 in Hong Kong through telehealth and multi-institutional collaboration. Head Neck. 2020;42(7):1454–9. https://doi.org/10.1002/hed.26226
15. Rametta SC, Fridinger SE, Gonzalez AK, Xian J, Galer PD, Kaufman M, et al. Analyzing 2,589 child neurology telehealth encounters necessitated by the COVID-19 pandemic. Neurology. 2020;95(9):e1257–66. https://doi.org/10.1212/WNL.0000000000010010
16. Vasquez L, Sampor C, Villanueva G, Maradiegue E, Garcia-Lombardi M, Gomez-García W, et al. Early impact of the COVID-19 pandemic on paediatric cancer care in Latin America. Lancet Oncol. 2020;21(6):753–5. https://doi.org/10.1016/S1470-2045(20)30280-1
17. Willan J, King AJ, Hayes S, Collins GP, Peniket A. Care of haematology patients in a COVID-19 epidemic. Br J Haematol. 2020;189(2):241–3. https://doi.org/10.1111/bjh.16620
18. Taher AT, Bou-Fakhredin R, Kreidieh F, Motta I, De Franceschi L, Cappellini MD. Care of patients with hemoglobin disorders during the COVID-19 pandemic: an overview of recommendations. Am J Hematol. 2020;95(8):E208–10. https://doi.org/10.1002/ajh.25857
19. Mohamad M, Arnon N, Bipin S. Practicing clinical hematology during the COVID-19 outbreak: a challenge like no other. Clin Hematol Int. 2020;2(2):41–2.
20. Temsah M-H, Al-Sohime F, Alamro N, Al-Eyadhy A, Al-Hasan K, Jamal A, et al. The psychological impact of COVID-19 pandemic on health care workers in a MERS-CoV endemic country. J Infect Public Health. 2020;13(6):877–82. https://doi.org/10.1016/j.jiph.2020.05.021
21. Al Sulais E, Mosli M, Al-Ameel T. The psychological impact of COVID-19 pandemic on physicians in Saudi Arabia: a cross-sectional study. Saudi J Gastroenterol. 2020;26(5). https://doi.org/10.4103/sjg.SJG_174_20
22. Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet. 2020;395(10227):912–20. https://doi.org/10.1016/S0140-6736(20)30460-8
23. Telematics WHOGCoH. A health telematics policy in support of WHO’s Health-for-all strategy for global health development: report of the WHO Group Consultation on Health Telematics, 11-16 December, Geneva, 1997. Geneva, Switzerland: World Health Organization; 1998.
24. MoH: All the Kingdom will be covered by Telemedicine in two months [press release]. Riyadh, Saudi Arabia: Ministry of Health (MOH); 2018. Available from: https://www.moh.gov.sa/en/Ministry/MediaCenter/News/Pages/news-2018-03-06-006.aspx
25. Telemedicine Regulations in the Kingdom of Saudi Arabia. V1.3 ed. Riyadh, Saudi Arabia: National Health Information Center (NHIC); 2018.
26. Alshahrani A, Stewart D, MacLure K. A systematic review of the adoption and acceptance of eHealth in Saudi Arabia: Views of multiple stakeholders. Int J Med Inform. 2019;128:7–17. https://doi.org/10.1016/j.ijmedinf.2019.05.007
27. AlSadrah SA. Electronic medical records and health care promotion in Saudi Arabia. Saudi Med J. 2020;41(6):583–9. https://doi.org/10.15537/smj.2020.6.25115
28. Curtis JR, Kross EK, Stapleton RD. The importance of addressing advance care planning and decisions about do-not-resuscitate orders during novel coronavirus 2019 (COVID-19). JAMA. 2020;323(18):1771–2. https://doi.org/10.1001/jama.2020.4894
29. Adams JG, Walls RM. Supporting the health care workforce during the COVID-19 global epidemic. JAMA. 2020;323(15):1439–40. https://doi.org/10.1001/jama.2020.3972