Medical Colleagues Research Articles

Differences in Clinician Electronic Health Record Use Across Adult and Pediatric Primary Care Specialties

Clinicians spend a large proportion of their days using the electronic health record (EHR). There are known negative associations between measures of EHR use and clinician experience.1 Primary care clinicians spend significantly more total and after-hours time in the EHR than medical specialty and surgical colleagues.2 However, little is known regarding variation in EHR use across primary care specialties, such as between adult and pediatric care. In this cross-sectional study, we compared EHR use across general pediatrics, general internal medicine, and family medicine clinicians.

Partnering With Families of Medically Complex Children Transitioning From the Hospital to Home.

Partnering With Families of Medically Complex Children Transitioning From the Hospital to Home.

In Memoriam: professor Antonio Salvetti (1936-2021).

In Memoriam: professor Antonio Salvetti (1936-2021).

Health-Related Quality of Life of Twenty-Seven Patients with Gaucher Disease Type I in China

Gaucher disease (GD) is a lysosomal storage disorder characterized by the deficiency of beta-glucocerebrosidase which results in the accumulation of the glucocerebroside in macrophages throughout the body. Gaucher disease Type 1 (GD1) is the most common form. Enzyme replacement therapy (ERT) with Imiglucerase is effective for the disease. So far there is no study on the Health-Related Quality of Life (HRQoL) for patients with GD1 in China. Objects: To investigate the quality of life (QOL) of GD1 patients followed-up in Peking Union Medical Colleague Hospital(PUMCH) and analyze the possible influence factors. Method: Twenty-seven patients with GD1 diagnosed from Jan.1994 to Jul.2017 in PUMCH who were more than 18-year-old at the time of survey and willing to join the study were included. Clinical and social data form the patients were collected and Short form-36 (SF-36) score was calculated for each patient. Factors which may affect the score were further evaluated using statistical method. Results: Of the twenty-seven patients, twenty-two patients (81.5%)had received and continued to receive adequate dosage of ERT (kindly provided by Sanofi investment Co. Ltd) while the other five patients did not receive any GD related therapy. Sex, age of survey, age of disease onset, education background and economy income of the patients were shown in table 1. Next we compared the eight dimensions of SF-36 between the GD1 patients and the aged matched controls in China (from the literature). Most SF-36 scores were lower in GD1 patients, but the general health perceptions, vitality and mental health in ERT patients of 18-44 year-old were similar to those of the health controls (table 2). Further analysis of twenty-two patients treated with ERT showed age of survey had negative effect on the eight dimensions of SF-36 score while age of disease onset negatively influenced the role-physical, body pain and vitality. Time from disease onset to treatment had negative relationship with physical functioning, general health perceptions and social functioning (table 3). Conclusions: Patients in our center mainly live in undeveloped area with lower education background and lower income. Patients had lower QOL compared with normal controls but younger patients who receiving ERT may benefit in some of the dimensions of SF-36. Age of survey, age of disease onset and time from disease onset to treatment may influence the QOL in patients with ERT. DisclosuresNo relevant conflicts of interest to declare.

Bridging the gap: improving liaison psychiatry documentation quality to meet the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) treat as one recommendations at newcastle hospitals

AimsThis project aimed to assess and improve the quality and frequency of documentation from Psychiatric Liaison Team (PLT) to ward-based medical colleagues against the Treat as One recommendations. From experience, we hypothesised that written documentation of information crucial to patient care is not consistently meeting standards. This communication breakdown directly affects patient safety, potentially introducing additional risks to our already vulnerable patient group.Effective communication between PLT and our medical colleagues bridges the gap in providing continuity of care and ensures patients’ mental and physical health needs are met in acute trusts. The NCEPOD found that there remains many barriers to high quality mental healthcare provided to patients in general hospitals and recommended 7 elements that PLT documentations should encompass.MethodWe audited initial PLT assessments and the resulting documentation to determine if these met the 7 standards set by NCEPOD. Baseline audit undertaken from 21-27/09/2020 encompassing 130 patient referrals to PLT.A period of time was allotted to implement robust changes to improve the service. This included a streamlined e-template that automatically populates in the acute hospital eRecord system which prompts clinicians to document according to the NCEPOD standards, structured clinician training and education, and the nomination of “Treat as One Guardians” in the team to ensure that acute trust documentations are present during daily multidisciplinary meetings.The cycle was then completed on 22-28/02/2021 with a re-audit capturing 55 referrals.ResultImplementation of our recommended changes saw an increase from 58% of documentations with ≥50% NCEPOD elements to 98% in the re-audit.We also saw an increase in number of the NCEPOD 7 elements included following intervention: formulation (0% to 8%), legal status and capacity (47% to 79%), risk assessment (2% to 28%), risk management (18% to 53%), and discharge plan (2% to 29%).Completion rate of acute trust documentation increased from 74% to 96%.Our interventions also led to more contemporaneous communication, significantly reducing mean time from assessment to documentation in both acute trust and mental health records from 6.02 to 3.53 hours, (p = 0.04) and 6.12 to 3.50 hours, (p = 0.05) respectively.ConclusionFollowing our interventions, the results showed improving trends in the frequency and quality of our documentation with secondary outcomes showing increased documenting efficiency. Our current practice is not yet optimal and retains potential to adversely affect our patients. We propose further investigating barriers to change using the quality improvement PDSA (Plan, Do, Study, Act) methodology to continue innovating.

Recruiting medical students from underrepresented backgrounds to a project to identify support challenges amongst their peers whilst encouraging early career engagement in psychiatry

AimsTo engage lived experience individuals to run a project identifying the mental health challenges unique to medical students who self identify as belonging to marginalised groups;To use the project findings to inform mental health support and education during medical training and beyond;To encourage the individuals to engaged mental health policy and education whilst also using the process to inform their future medical careers, including in the field of psychiatry.MethodLived experience individuals were recruited to the project following open applications from medical students. The role was to design a project to create an evidence base for tailored support methods needed to reduce marginalised medical students’ increased risk of poor mental health. This formed the basis of guidance on how medical schools and healthcare systems can improve wellbeing support for their students and staff. With support from a trained staff and student member, the recruited officers were encouraged to follow their preferred method for fulfilling the project aims, using their own and peers’ experiences to inform what was most useful.ResultRepresentatives were selected from BAME, LGBT+, international, disabled and widening participation backgrounds. The students decided to conduct a survey open to all medical student colleagues across the United Kingdom. The survey questions were split into four sections based on the challenges faced by their own lived experience: General Information; University and Community Experiences; Medical School Experiences and Teaching and Clinical Experiences. There were 58 questions in total including 26 multiple choice; 24 open answers; and 8 Likert scale.Following data collection, the information taken from the survey and focus groups, supported by background reading, was thematically analysed to identify the key challenges. This will then be used to create a report to share with the medical school containing areas for improvement in mental health support, education and engagement. The officers themselves would also reflect on their experiences throughout the process, including their ability to engage in mental health policy, education and further career options such as psychiatry.ConclusionFrom creating an appropriate and supportive structure, it can be possible to encourage students with lived experience to share their challenges whilst becoming engaged in mental health policy and support. Furthermore, from creating a culture of reflection in the area of mental health, they are helping raise awareness of the subject early on in medical careers and promote engagement into specialties such as psychiatry.

Ensuring equity in the management of patients, over 70 years of age, on immunotherapy during the COVID-19 pandemic.

e21526 Background: Immunotherapy (IO) has transformed the landscape for melanoma. Checkpoint inhibitors (CPI) are now routinely given to older patients. The impact of performance status (PS) and age on the immune response remains unclear. During the COVID-19 pandemic, most older patients elected to continue their cancer therapy. Meta-analysis from trial data thus far has not demonstrated any association with cancer immunotherapy survival. This abstract reports on real –world experience of older patients with melanoma treated during the global pandemic. Methods: Real world data of all patients over 70 years of age receiving IO for melanoma, was collated at a tertiary cancer centre from Oct 2019 – Dec 2020. The objective was to see how these older patients tolerated CPI, in both the adjuvant and palliative settings, during a global pandemic. Information on demographics including age at diagnosis, intention, sites of metastases, PS, co-morbidities, toxicity, impact of COVID-19 and the patient outcomes were collected. During the pandemic the majority of patients on CPI treatment were assessed and followed up by telephone call rather than face to face. Results: Fifty-six patients over 70 years,were identified to have received CPI during the time period. There were 36 male and 22 female patients. Median age was 74 (range 70-88 years). Sixteen patients (29%) were treated with adjuvant intent; the remaining 40 patients (71%) were treated with palliative intent. Most patients with metastatic disease had 1-3 sites. All patients were PS0-1, except for one patient who was PS2. There were 19 patients (34%) who developed significant grade ¾ toxicities. No patients were treated on a clinical trial during the pandemic. Three patients (5%) elected to stop treatment during the pandemic. Calls to triage were taken as normal and the majority of patients had toxicity managed as an outpatient. No patients received the vaccine by the end of the study period. Conclusions: Real-world data explored the use of CPI in older patients and the impact of the COVID-19 pandemic on their management. Older patients were able to continue on CPI during the pandemic and it was given safely in adjuvant and palliative settings. Comprehensive geriatric assessments are planned to be integrated however the current demands on medical colleagues has delayed the introduction. However clinicians working in partnership with patients ensured the safe delivery and no patients died from toxicity of therapy or COVID-19 during this time. These findings suggest that shared decision-making during a pandemic with older patients is essential to support patients and optimise outcomes. We suggest cancer therapies should not be restricted to patients based on age and IO can be given safely if precautions are taken during a global pandemic. Patients have now received first COVID-19 vaccinations and ongoing assessement of the impact of the vaccination is in progress.

Raymond R Phillips FBIPP Hon FRPS AIMI Hon FIMI RMIP 1931–2021.

Photograph courtesy of Mrs. Pamela Phillips, gratefully acknowledged.In March this year, I lost a friend and illustrious erstwhile medical photographer colleague of nearly sixty years. Ray and I me...

EVIDENCE-BASED MEDICINE IN THE TIMES OF COVID-19: A CROSS-SECTIONAL SURVEY TO UNDERSTAND THE INDIAN PERSPECTIVE

Introduction: During the COVID-19 pandemic, there is a tremendous amount of literature published regularly. In a country like India, historically, where there is a paternalistic approach to practicing medicine, there is a lot of hindrance to evidence-based medicine (EBM). Doctors have always weighed one's clinical experience superior over any other form of decision-making. This system of practice has made decision-making difficult for the physicians during this pandemic as COVID-19 is a reasonably new disease entity and the physicians lack enough 'prior experience' dealing with such a situation. Our survey tries to address the common barriers to evidence-based medical practices especially during the COVID-19 pandemic in India. We also try to explore the various source of information used by the doctors.
 Methods: It is a descriptive cross-sectional survey. The questions were provided in multiple-choice question format. An online survey comprising of 10 questions entitled “Hurdles faced by physicians to assimilate evidence-based guidelines on COVID-19” was made using Google Forms (Google Inc, California, US) and circulated through email to medical practitioners in the Ghatkopar (Mumbai, India) Medical Association's register from 17th June 2020 to 1st September 2020.
 Results: Our survey collected 213 responses, out of which 80.3% (n=171) of doctors were involved in care, counseling, or management of COVID-19 patients. The most opted primary sources for evidence-based information during this pandemic were teachings of/discussions with medical colleagues (71.4%, n=152), followed by online webinars (59.6%, n= 127) and social media (41.8%, n=89).
 When questioned about the main obstacles faced by them to obtain evidence-based information, the responses were as follows: Overload of medical literature (53.5%, n=114), limited access to quality resources (40.8%, n=87), unfamiliarity with the bio-statistics analysis (39%, n= 83), difficulty in locating relevant medical literature (38%, n=81), unfamiliarity with the research methodology (37.1%, n=79), lack of time (30%, n=64). 
 Our respondents' perspective concerning EBM attributes: 57.3% (n=122) think evidence-based practice takes their clinical experience into account. 93.4% (n=199) of them have shown an interest in broadening their skills. There was no significant difference between doctors' attitudes with less than 10 years and more than 10 years of experience (chi-square value = 0.857, p = 0.65).
 Conclusion: Our survey results highlight the balance maintained between evidence-based medicine and experience-based medicine by Indian physicians. They identify the importance of EBM while acknowledging its shortcomings. They realize the significance of developing their repertoire to understand, appraise, and practice EBM.
 Keywords: EBM, COVID-19

The Many Benefits of the Futures Program

I must admit, my attendance of the Futures Program in 2013 felt like pure dumb luck. I received the AMDA Foundation Futures Educational Grant through the Gerontological Advanced Practice Nurses Association. I was not completely sure what the program entailed, but I knew I wanted to learn more about the environment I loved working in — nursing homes. When introductions were made during the Wednesday evening reception, I recall being one of two nurse practitioners among my cohort. Initially, I was a little intimidated, but then as the evening and subsequent days went on I felt completely accepted. During that Wednesday reception, all the Futures participants played a game where we picked a shape and then broke into cohorts based on that shape. I do not recall the shape anymore, but I do recall that I was only one of three individuals out of the whole cohort to choose that shape. I really enjoyed meeting those colleagues and learning their stories about why they chose to go into geriatric medicine. One of the many benefits of the Futures program is networking. Four geriatric fellows and I continued to have regular conversations outside our Futures education sessions, and I keep in touch with two of those individuals to this day. They are both now certified medical directors and working in the post-acute and long-term care setting. Another benefit of this program is the guidance and leadership set forth by those providers who support the Futures program. For example, Cari Levy, MD, CMD, was the Futures Program co-chair when I participated in the program, and I now have the privilege of collaborating with her on the NP/PA Advisory Council for nurse practitioners and physician assistants. She has provided valuable education in defining the long-term care continuum and the role of the medical director. I was not familiar with all the responsibilities of the medical director before this program, and this education has helped me not only to better understand my medical director colleagues but also to appreciate the role they serve. I have found great collaborators and educators among medical directors because I better understand their purpose and function within the nursing home. Additionally, this program provided me with my first leadership training. Daniel Swagerty, MD, MPH, talked about the importance of effective leadership, and I continue to agree with his point regarding communication with team members to “establish trust with candor, transparency and credit.” The content from that lecture provided tangible examples of how to be a leader and support our colleagues working in PALTC. Leadership is an abstract concept and learned skill, so I found value in starting this conversation early in my career. Lastly, the curriculum covered crucial concepts to know about PALTC. Although my nurse practitioner program provided a great foundation, the Futures program went deeper into Medicare benefits, understanding risk management, surveys and F-tags, quality indicators, and the roles of providers working in PALTC. I am so thankful that I participated in this program and would strongly encourage experienced PALTC providers to support the program and encourage novice PALTC providers to go through it. Dr. Nalls is the Director of Education for Capital Caring Health (CCH), where she collaborates with all service lines to meet their educational needs as well as provides wound care consults to CCH patients in their home environment.

Assessing anaesthesiology and intensive care specialty physicians: An Italian language multisource feedback system.

BackgroundPhysician professionalism, including anaesthesiologists and intensive care doctors, should be continuously assessed during training and subsequent clinical practice. Multi-source feedback (MSF) is an assessment system in which healthcare professionals are assessed on several constructs (e.g., communication, professionalism, etc.) by multiple people (medical colleagues, coworkers, patients, self) in their sphere of influence. MSF has gained widespread acceptance for both formative and summative assessment of professionalism for reflecting on how to improve clinical practice.MethodsInstrument development and psychometric analysis (feasibility, reliability, construct validity via exploratory factor analysis) for MSF questionnaires in a postgraduate specialty training in Anaesthesiology and intensive care in Italy. Sixty-four residents at the Università del Piemonte Orientale (Italy) Anesthesiology Residency Program. Main outcomes assessed were: development and psychometric testing of 4 questionnaires: self, medical colleague, coworker and patient assessment.ResultsOverall 605 medical colleague questionnaires (mean of 9.3 ±1.9) and 543 coworker surveys (mean 8.4 ±1.4) were collected providing high mean ratings for all items (> 4.0 /5.0). The self-assessment item mean score ranged from 3.1 to 4.3. Patient questionnaires (n = 308) were returned from 31 residents (40%; mean 9.9 ± 6.2). Three items had high percentages of “unable to assess” (> 15%) in coworker questionnaires. Factor analyses resulted in a two-factor solution: clinical management with leadership and accountability accounting for at least 75% of the total variance for the medical colleague and coworker’s survey with high internal consistency reliability (Cronbach’s α > 0.9). Patient’s questionnaires had a low return rate, a limited exploratory analysis was performed.ConclusionsWe provide a feasible and reliable Italian language MSF instrument with evidence of construct validity for the self, coworkers and medical colleague. Patient feedback was difficult to collect in our setting.

Coping Strategies for medical students during the pandemic: A Nigerian Perspective

The COVID-19 pandemic was an unexpected experience for medical students all over Nigeria. Many medical schools were forced to halt academic activities while a few private institutions continued using online sessions.   Medical school in Nigeria gives less time for medical students to pursue other extra-curricular activities and although COVID-19 has brought a lot of unprecedented times, medical students have utilized the opportunity positively by engaging in different activities while accessing a variety of opportunities. Prior to the pandemic, medical students are also known to spend lesser time for social interactions, personal and professional development. Since the lockdown led to the halt of academic activities including lectures and exams in most medical schools in Nigeria, students have more time to explore other activities. Through constantly interacting with my medical colleagues all over Nigeria during the lockdowns, this experience provides a summary of the activities medical students have been engaging in during the lockdown to cope with the shocking changes.

Local primary care 'dental clusters': Improving collaboration and the delivery of specialised services in dentistry?

There have been numerous challenges faced by the dental profession during the COVID-19 pandemic. Throughout this difficult period, a spirit of collaboration and peer support have been crucial in helping to maintain urgent care access for patients and in assisting practices with their return to full operational activity. Dental clusters can provide a different model of working, and can provide improved access to dental care for patients as well as reducing inequalities. They can also improve collaboration and communication between primary care dental services. Furthermore, clusters can help to provide a support network for clinicians and facilitate better integration with medical colleagues. Dental clusters may also provide a better platform for innovation to meet the demands of local populations. Importantly, we feel that clustering can bring educational benefits to colleagues, as it can encourage a multi-disciplinary teamwork approach to patient care and to the needs of the local population, through regular cluster meetings. This can benefit colleagues through peer review, case-based discussions, mentoring and upskilling within clusters. We aim to outline our experiences of a basic cluster model.

Editorial

Editorial

“It’s Like Drowning and You Can’t Get Out”; the Influence of Intimate Partner Violence on Women With Chronic Low Back Pain

As intimate partner violence (IPV) can have a long-term impact upon physical pain and psychological distress, the lived experiences of six women with chronic low back pain (CLBP) who survived IPV were studied in order to deepen the understanding of how they have experienced CLBP and IPV. Two superordinate themes were identified from the findings; “psychological interface of IPV and pain” referring to the psychological impact and “pain as a symptom of IPV” reflecting the physical trauma responses that the women identified. This article identifies clinical implications for counselling psychologists to consider when providing therapy for people with CLBP. This study suggests that if issues associated with the trauma are not identified, treated or supported, pain experiences may be impacted, which could compromise therapeutic treatment. Questions need to be asked about trauma history when assessing for CLBP, and management treatments need to incorporate strategies for understanding and coping with the impact of IPV. Counselling psychologists need to be at the forefront of delivering training to medical colleagues who may not consider the significance of trauma upon CLBP experiences and responses.

Attitude of Nursing Students Towards Work in the Clinical Learning Environment

Introduction: Exposure to the clinical learning environment is indispensable for the nursing students as it provides experiences which are basic and significant to the development of professional skills as well as bridge the theory-practice gap. Despite the importance of clinical learning, nursing students’ attitudes in the clinical environment has been a concern.Purpose: This paper reviewed the attitude of nursing students towards work in the clinical learning environment.Method: Electronic searches using scholarly databases were employed and only significant articles that met the review objective were utilized.Findings: This review revealed that there is a high rate of unauthorized student nurses’ absenteeism as majority are absent from clinical work without permission. There is also an appalling display of lateness behavior as students arrive at work after the scheduled time. Interestingly, most students are willing to carry out procedures while some are nonchalant due to the stressful and anxiety provoking tasks. Student nurses felt that there is an unspoken comparison, discrimination and disrespect displayed by their seniors and medical colleagues towards them.Conclusion: There is overwhelming evidence from literature supporting the negative attitudes of nursing students in the clinical environment. It was therefore recommended that students should be psychologically prepared in their schools before exposure to the clinical environment. There should be an effort to build students’ self-esteem and professional self-concept by the relevant authorities. Finally, to bridge the rift between inter-professionals, there is need for more social interaction opportunities where everyone will value what each member contributes to the team.

Revitalizing Alfred Adler: An Echo for Equality.

The work of Alfred Adler’s Individual Psychology arguably applies to contemporary social work practice and education. The tenets of Individual Psychology are reviewed in the context of a historical sketch of Adler's work as a medical doctor, psychoanalyst, and colleague of Freud. His eventual divergence from psychoanalysis to begin his own psychological and education movement which focused on social reform is emphasized. Individual Psychology is examined in detail including original case examples demonstrating his influence on and compatibility with contemporary social work theories. Empirical evidence is provided supporting present-day application of his theory. Adler serves as a much-needed example of a professional who successfully and simultaneously advanced both the micro and macro world of mental health. Adler's contribution deserves to be explicitly included in social work curricula.

Regional differences in general practitioners\u2019 behaviours regarding influenza vaccination: a cross-sectional study

BackgroundThe World Health Organization recommends vaccination rates of 75% against seasonal influenza for patients over 65 years old. In the 2013/2014 season, the German vaccination rates ranged between 14 and 65%. This study aimed to compare the attitudes, personal characteristics and vaccination behaviours of general practitioners (GPs) in regions with high and low vaccination rates in Germany.MethodsIn May 2016, a questionnaire was sent to 1594 GPs practising in 16 districts with the highest and the lowest vaccination rates in Western and Eastern Germany as described by the Central Research Institute of Ambulatory Health Care in Germany for the 2013/2014 season. Descriptive statistics and multiple regression analyses were computed to identify potential factors associated with high vaccination rates.ResultsA total response rate of 32% (515/1594 participants) was observed in the study. GPs reported their attitudes towards vaccination in general and vaccination against influenza as mostly ‘very positive’ (80%, n = 352 and 65%, n = 288, respectively). GPs practising in regions with low vaccination rates reported their attitudes towards vaccinations in general (p = 0.004) and towards influenza vaccination (p = 0.001) more negatively than their colleagues from regions with high vaccination rates. Multiple logistic regression identified an increasing influence of year-dependent changing efficiency on GPs’ influenza rates as the strongest factor for predicting GPs from highly vaccinating regions (OR = 4.31 [1.12–16.60]), followed by the patient’s vaccination refusal despite GP advice due to already receiving a vaccination from another physician (OR = 3.20 [1.89–5.43]) and vaccination information gathering through medical colleagues (OR = 2.26 [1.19–4.29]).ConclusionsThe results of this study suggest a correlation between GPs’ attitudes and regional vaccination rates. Beneath GPs’ individual attitudes, the regional attitude patterns of patients, colleagues and medical assistants surrounding those GPs seem decisive and should be integrated into future campaigns to increase vaccination rates at a regional level.

Health and medical care for refugees: design and evaluation of a multidisciplinary clinical elective for medical students.

Objective: Caring for refugee patients places special demands on health professionals. To date, medical students in Germany have rarely been systematically prepared for these challenges. This article reports on the development, conceptualisation, implementation, evaluation, and relevance of a multidisciplinary elective for medical students in the clinical study phase.Methodology: The course content was developed based on a needs-assessment among medical students and in cooperation with medical colleagues working in the field of refugee care. The course consisted of a seminar with medical, legal, administrative and socio-cultural learning content as well as a field placement in the medical outpatient clinic of the local reception centre for asylum seekers, which was accompanied by a systematic reflection process. The evaluation concept contained qualitative and quantitative elements. Results: 123 students completed the elective over six semesters (summer 2016 through to winter 2018). It was continuously evaluated and further developed. The students reported learning progress mainly in the following areas: Legal foundations of the asylum procedure and health care entitlements for asylum seekers; multi-perspectivity through multidisciplinarity as well as professional, ethical, interpersonal, and political insights gained through the practical experience.Summary: To prepare students for the complex challenges to be faced in medical care for refugees, a structured, multidisciplinary teaching programme, which combines theory, practice and reflection helps to foster insights into the many facets of this field of activity. The questions students brought to the seminar, the course contents and evaluation results are intended to inspire the design and implementation of similar courses at other universities.

When Physicians Engage in Practices That Threaten the Nation’s Health

This Viewpoint proposes response options for specialty societies, medical licensing boards, academic leadership, and faculty and colleagues when physician public health leaders spread misinformation detrimental to patients' or the public's health, as happened in the first year of the COVID-19 pandemic