ESUO: The impact of the COVID-19 pandemic in urology

Prof. Ayhan Verit ESUO Member Fatih Sultan Mehmet Hospital Dept. of Urology Istanbul (TR)

veritayhan@yahoo. com

Despite the title of this article, there is no such thing as an ‘office urologist’ in Turkey, as there is in most European countries. The practice of ‘office urology’ is part of the general urological work performed by all urologists in variable degrees, just like, for example, in Spain (an EU country).

Office urology practice is the first line of urology and, as we know, demands close and frequent contact with the patient. This type of healthcare service had to change because of the demands of the COVID-19 (C19) situation. I would like to present some examples of modifications in office urology and the care provided by the urologist. Furthermore, I will discuss the legal rights of the urologist in pandemic Turkey, compared to other parts of the world.

Weakened medical care systems The extraordinary impact of this health event has weakened every aspect of the world’s medical care system and tested its long-term strength with regard to budgets. Naturally, the professional rights of the main ‘actors’ - the healthcare staff - at the battlegrounds of this war have gained importance and are worth being reinvestigated in the light of a pandemic situation, also seen in national context with their socio-cultural, economic differentiations [1]. As a striking example, the funeral costs for the healthcare workers who are victims of C19 is now an expense that is a concern, even reported in medical literature [2,3]. While funeral procedures are a free municipal service not only for healthcare workers but for all citizens in Turkey, it may be a significant expenditure for the relatives of South African healthcare employees. Thus, I think that cultural, legal, and economical factors should be rediscussed in each country separately, based on the needs of the community. Satisfactory solutions for health care professionals will in the end serve the public interest best. Even more so if healthcare staff will stay motivated and be prepared to fight in possible similar health battles in future. (see Figure 1)

Occupational disease Philosophically, while the universal definition of work accident is ‘an unexpected/unplanned event that causes harm or injury’, the term occupational disease is defined as ‘temporary or permanent illness, either physical or mental, due to the nature of the job or condition of the business’[4]. Depending on these explanations, the legal situation of healthcare staff who are exposed to C19 can easily be placed under the terms of both concepts: work ‘accident’ and ‘disease’. This dilemma may result in a different impact on the professional rights of healthcare workers in their legal environments1. So far, the ‘Turkish Labour Act’ views the situation of healthcare employees who become infected with C19 as an ‘occupational accident’. However, there is a heated ongoing discussion among social platforms about the present legal terminology. So far, it has not resulted in an answer that satisfies the expectations of the healthcare professional community, despite some current improvements [4,5].

Working area On the other hand, Prof. Olaf Michel claimed in his paper that, without a doubt, a C19 contamination can be categorised under the terminology of a pandemic. This means that all public levels present equal risks of viral exposure and, therefore, it cannot be seen as a work accident, based on investigation of the German law system. However, he emphasised that ophthalmologists and especially Ear-Nose-Throat physicians are exposed to a greater risk of C19, due to the fact that the colonisation site is close to their working area. Thus, for them an infection should be defined as occupational disease [6]. In addition, dentists should also be categorised under this definition. All things considered, it is no exaggeration to state that office urology should be considered the riskiest part of the urology field due to the need for close contact with the patient. It starts with patient admission and continues with the determination of an approach to the problem by drawing up detailed patient history and a physical urological examination. Furthermore, the urologist uses diagnostic instruments and asks for frequent patient office admissions.

COVID-19 adjustments Moreover, there have been special changes in office urology because of the pandemic. Below you will find some examples about the modifications in office urology practice in Turkey: - There have been restrictions for appointment intervals between patient visits in connection with the severity of local C19 peaks in public hospitals, which are entirely supported financially by the state insurance system covering 80% of the health workload [7]. Turkey is a populated country and there have been high office admissions per hospital. In addition, there are no strict hospital referral chains in the Turkish system. Patients can be admitted to any hospital and thus, this system increases the urological office workload of all hospitals. - Some of the postponed workload, caused by the restrictions during transient intense local pandemic periods at the clinical urology departments in public hospitals, has been taken over by office urologists working in private medicine and insurance systems. - Several medical treatments by office urologists, for example BPH and stone patients who need operations, continued during this period. - The regular control cystoscopy in patients with bladder cancer became irregular due to the lack of appointment opportunities with hospital office urologists or due to patient concerns. This may result in increasing communication between the physician and patient via telephone or other distant communication methods. There are no standard intervals for control cystoscopy for individual patients supported by scientific data and thus, longer intervals may lead to oncological risk. - In polyclinics, staff switched to initial cystoscopy under local anaesthesia as an office urological procedure more frequently, instead of a procedure in the operating room in clinical urology. - In my opinion, patients and office urologists hesitate to have prolonged contacts with each other in the form of e.g. counselling, physical examination and diagnostic instrumentation during office visits. This may present another factor that results in ineffective diagnostical procedures.

Generalisations All of the above irregularities may lead to medical and legal frustrations in the future. The Italian insurance system confirmed that corona virus infections of MDs, nurses and all other health employees are now considered occupational disease. They announced that the causal link between work and the infection would be automatically established for these groups in their advantage in case of conflict [8]. Actually, these kinds of general rules can simplify the formal procedures and prevent troublesome discussions in favour of healthcare staff. Nevertheless, in the related official definitions, possible lifelong health deformations have not even been considered yet. I think that C19 may become a chronic disease in healthcare staff with chronic detrimental effects on several human organ systems, such as central nervous, cardiovascular, renal and respiratory, via a long-term sequel of scarring/fibrosis in the vessels [9-11]. These totally unexpected effects can lead to a severe burden on the healthcare system, possibly lasting for many years after the current pandemic.

Critical health problems Although these possible chronic health effects have not yet been confirmed, it is logical to presume that they can lead to critical health problems, such as mental-motor sequels, chronic renal insufficiency that may extend to chronic haemodialysis, renal transplantation and chronic respiratory insufficiency. All these discouraging scenarios may pose a pessimistic view on the future of healthcare staff and their relatives by means of moral and financial concerns related to professional rights.

It is essential to reach consensus with regard to the legal position of healthcare staff, in order to formulate their legal rights in the struggle with C19. Independent of the quibble in the terminology of national law and economic systems, states should solve this paradox in favour of healthcare workers in view of the need for long-term general public health care provision, which also affects the economy, both nationally and globally. As a result, in my opinion, the main goal should be the protection of human resources as a qualified, irreplaceable ingredient in the struggle in unexpected public health disasters, such as the C19 pandemic.

Figure 1. A cartoon from late Ottoman times (5 Jan 1911, Comedy journal “Kalem-Pencil”) about the cholera pandemic. The woman with her stomach-ache has been applying atomizer for the suspicion of cholera clinics, however, she has just given birth to the second scene (not shown here). Reference: Kazım Cihan Can (“Birikim Dergisi” Journal of Backlog, 2020) Corona-Fear-Comedy-Cholera. https:// birikimdergisi.com/guncel/10061/korona-korku-komedi-kolera References

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Med (RJLM) (on publish). 2. George R, George A. COVID-19 as an occupational disease? S Afr Med J. 2020; 110(4): 12874. 3. George R, George A. COVID-19 in South Africa: An occupational disease. S Afr Med J. 2020;110(8):12985. 4. Mega E.COVID-19: Meslek hastalığı iş kazası ikilemi (article in Turkish) (COVID-19: Dilemma of occupational accident or disease). Sağlıkçıyız (We are healthcare professionals). 2020, April 02. Available in Turkish website: http://www.saglikciyiz. com.tr/2020/4/ covid-19-meslek-hastaligi-is-kazasi-ikilemi-m1182. html 5. LBF partners. http://www.lbfpartners.com/tr/yayin/ covid-19-occupational-disease-or-work-accident .html 6. Michel O. BK 3101: COVID-19-Infektion des HNO-

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