SINGAPORE — Although the authorities recently relaxed the circuit breaker rules to allow some allied health professionals to see their patients face to face, some practitioners are lamenting that the cap of six patients a week is overly restrictive.

They told TODAY that the limit forces them to prioritise some patients over others who may have equally urgent needs that could result in their health deteriorating if left untreated.

On April 28, the Ministry of Health (MOH) announced that allied health services — which include physiotherapy, podiatry and speech therapy — had been recategorised as essential services.

This means that members of the public are now able to receive these services in person, though their practitioners’ clinics have to follow several requirements listed by MOH.

They include:

• No more than six patients within eight hours of operation from 9am to 5pm on one day a week.

• Clinics can provide service on Monday or Wednesday, depending on whether their unique entity number — an identification number for entities to interact with government agencies — ends with an odd or even number.

• Each session should not last longer than an hour.

MOH, however, also said that practitioners should use teleconsultations to address clinical needs “as far as possible”.

‘UNENVIABLE TASK’ OF PRIORITISING PATIENTS

One physiotherapist said that while his patients welcome the change, especially those with time-critical conditions who were deprived of such services under the earlier circuit breaker restrictions imposed on April 7, he said it has led to more questions than answers.

Mr Wesley Chee, director and chief physiotherapist at the Physio and Sole Clinic group, said physiotherapists are now given the “unenviable task” of prioritising six patients to be seen each week.

“What happens to the seventh or eighth patient in line if they have conditions requiring urgent treatment?” asked Mr Chee, 36, who is also director of HeartlandHealth medical clinics.

He said these could be patients who have recently undergone ankle or shoulder surgeries.

“The initial phases after the surgery requires a lot more attention, particularly if it involves the joint,” said Mr Chee. “If you do not have any hands-on (attention to help) move the joint through a range of movement, they may develop complications, which counteract the (positive) effects of surgery.”

Mr Chee also said stipulating that clinics may operate only one day a week within restricted hours also defeats the purpose of having safe distancing measures.

He explained that clinics with multiple practitioners will now have to arrange all treatment sessions on the same day.

He said that this was “as opposed to allowing clinics to operate normally to spread out the appointments, this measure naturally goes against the safe distancing intentions”.

On the topic of teleconsultations, Singapore Physiotherapy Association president Lee Sin Yi noted that aside from requiring certain logistics, such as a good internet connection and having caregivers on standby for elderly patients, there are limitations to their effectiveness.

Ms Lee, 35, said the lack of face-to-face interaction makes it difficult to “progress any kind of intervention”, especially when the physiotherapists are unable to conduct hands-on assessment of their patient.

“That is why physios will be a bit more cautious with (progressing treatment), because there is only that much we can teach through a screen, and it may not be that reliable compared with a hands-on (session).”

One physiotherapist who has had to modify her approach while treating patients remotely is Ms Shern Lim.

The founder of the Work Lift Balance fitness studio said she is typically “aggressive” in suggesting therapy exercise when she is with her patients in person.

“I would normally give the patient an exercise that is very hard for them to do, as it actually strengthens them,” said Ms Lim, 29. “But in the case of rehab telehealth consultations, I have to be very conservative.”

She added that she now films instructional videos for her clients to follow, as she does not want to put them at risk of injuring themselves by carrying out the exercises incorrectly.

Speech therapist Eugenia Tan said the effectiveness of teleconsultations is highly dependent on the caseload as well. She said that older patients among the children treated by her peers, such as teenagers, tend to fare well with teleconsultations.

But for the founder of Communikidz Therapy, only 5 to 10 per cent of her patients are suitable for teleconsultations.

Ms Tan, 34, said she regularly deals with autistic children aged about four, and it is much harder to get them to focus remotely than it is during a face-to-face session.

Meanwhile, the principal podiatrist at East Coast Podiatry warned that the lack of timely or regular treatment could have severe consequences for some patients

Dr Michael Lai said podiatrists regularly see diabetic patients, and these patients who might have foot ulcers would require wound care at least once a week, for example. Left untreated, he said the wounds could become infected.

“They are not going to heal in one week,” he said. “So that means for a whole month, I am just treating six people.”

Before the pandemic, Dr Lai, 48, said his clinic had been treating “more than that” in a single day.

He said the cap on patient numbers does not make sense, and there is no way these patients can be treated via teleconsultations.

“It does not make sense. It is a hard limit,” he said. “It is asking us to arbitrarily ration out patient care to only a few people who need it urgently.”

Dr Lai questioned what would happen to the rest of the patients, who also need treatment urgently.

“The war on diabetes does not suddenly disappear because of Covid-19.”

In response to TODAY’s queries, an MOH spokesperson said the ministry is adopting a “cautious and incremental approach” for allied health professionals.

The spokesperson said the restrictions are in place to “minimise overall movement and interactions” during the circuit breaker, as many allied health professionals have prolonged and close physical contact with patients during their treatment.

Where teleconsultation is not suitable, the spokesperson said practitioners will have to “prioritise face-to-face consultations” for patients whose condition may significantly or rapidly deteriorate, and potentially threaten their health and well-being.

“For patients with conditions that require urgent medical attention, we urge them to seek medical care promptly at the hospitals or polyclinics if need be,” said the spokesperson.

Nevertheless, MOH said it will review the measures and take into account the needs of the patients and feedback from practitioners, and “adjust further as necessary”.

In response, Mr Chee, the physiotherapist, said he did not think this was ideal, as these healthcare resources could be used for the “Covid war”, rather than taking care of patients that the allied health practitioners were capable of treating on their own.

NOT ALL BAD

Despite the challenges, some allied health professionals said they will just have to work with the restrictions.

Dr Jaclyn Reutens, founder of Aptima Nutrition & Sports Consultants, said her clinic has been trying to make do with teleconsultations, even if this means no longer being able to give customised advice to her clients.

“We do understand that in the spirit of Covid-19, we should try to limit contact as much as possible,” said the 39-year-old clinical and sports dietitian.

Ms Lee of the Singapore Physiotherapy Association said that teleconsultations are not without their benefits.

Citing Australia and Canada as examples, she said teleconsultations have provided patients living in remote areas with another option of consulting a physiotherapist.

“In Singapore, I guess it is because we are very small and localised that the pick-up rate is not fantastic,” said Ms Lee, adding that Singaporeans and their healthcare providers will need some time to get used to teleconsultations.

In the meantime, Ms Lee said that the association has released a set of telehealth guidelines for physiotherapists, and will soon be introducing a triaging framework.

Physiotherapy patients TODAY spoke to had mixed views about MOH’s requirements.

Mr Daniel Yeo, a 28-year-old project engineer who suffered a sports-related anterior cruciate ligament (ACL) injury in February, said he went for only one physiotherapy session in late March before the circuit breaker restrictions kicked in and the physiotherapist closed his clinic.

He said he was concerned about the recovery of his knee and found it inconvenient that he now needs to wait for treatment, as his work is physical in nature.

Mr Yeo said his physiotherapist did not offer any teleconsultation services for him, and instead gave verbal advice over the phone, which he did not find helpful.

When Mr Yeo last checked on April 30, he said the clinic was still closed, but he has no plans to seek the services of another physiotherapist as it would not be paid for by his company’s insurance.

Another physiotherapy patient, Ms Regina Tan, found her teleconsultation sessions useful.

The 32-year-old freelance film crew member similarly injured her ACL while playing football some years ago, and had been going for rehabilitative treatment about twice or thrice a week before April 7.

While she was initially worried she would lose her motivation to exercise her knees, she found that she became more disciplined instead.

She explained that previously, her physiotherapist would help her through the exercises.

But now that there is no one to physically help her, she is more conscientious about performing her exercises properly, while her physiotherapist keeps an eye on her form remotely.

“I am a bit abnormal that way,” said Ms Regina Tan. “I know for most patients, they would find stopping their physiotherapy sessions to be quite disruptive.”