When routine bites hard…

Many of us develop earworms – those pieces of music that get stuck in your head –and it appears that they seem to be especially intrusive at times of stress.¹ During the period of intense COVID-19 activity, mine was Joy Division's Love Will Tear Us Apart, from the first line of which comes the title of this foreword to the July 2020 edition of Clinical Medicine. It is a magnificent ‘break-up’ song, which somehow seemed to fit the sudden change of the routine of our working lives. But at this stage of the pandemic, with the peak of cases having abated, it appears that ceasing the routine and redeploying staff was the easy part compared with the challenges of re-opening services. Doing this in a way which protects patients and staff while ensuring the judicious use of personal protective equipment (PPE) is an especial challenge.

It is therefore a highlight to have a piece by Rees and Penman on the reintroduction of endoscopic services, summarising the guidelines from the British Society of Gastroenterology.² It is a piece relevant to all physicians since endoscopy is a multimodal intervention – encompassing diagnostic, therapeutic, technological and consultation modalities – and, as such, the piece is of great value to a wide range of readers wrestling with restoration of clinical provision. The piece makes the case for risk stratification and use of PPE resources based on immediate pre-procedure testing. The other COVID-19 pieces in this print edition also cover aspects related to the current stage of the pandemic. While the May edition of the journal dealt with the clinical manifestations and supportive treatments of the viral illness, the pieces here reflect on some of the challenges presented by interpretation of serological testing (in patients and the population generally) and on the opportunities for service design (specifically as related to the rehabilitation of patients who have recovered from the acute illness).³ There are several other high-quality COVID-19 manuscripts in the online journal, which we eagerly steer you to, one of which is signposted in our Research in brief section.⁴

Life beyond COVID-19? We are in the much anticipated ‘new world’ now and, in terms of practice, we can maybe look to the cliché that at times of uncertainty we should fall back on that which we can control. One such controllable theme is that of patient safety, and we are happy to publish a piece on the long-standing vexed topic of emergency management of the patient with adrenal insufficiency. Simpson and colleagues summarise the recent guidelines and highlight the introduction of a patient-held Steroid Emergency Treatment Card.⁵ The challenge of incorporating this into practice across the NHS is discussed in the accompanying editorial by John Dean.⁶ Strategic redesign is also a feature of a paper by Evison and colleagues in Manchester, demonstrating that joint working between radiology, physician and administrative teams to optimise access to, and reporting of, computed tomography in symptomatic individuals could result in more timely diagnosis.⁷ This award-winning work was achieved without the need for increased resources or compromising care of other patients. Modifying what the authors describe as the ‘front end’ of the pathway showcases the principles and practical aspects that can be replicated in other sites.

Beyond these highlights, there is a return – after an acute COVID-19 hiatus – of the CME series, covering issues of diagnosis and management of common chronic neurological diseases. It marks a novel approach to this section in having been jointly curated by a trainee colleague, Linford Fernandes along with an associate editor of the journal, Philip Smith. The involvement of trainee grade doctors is key to the future of the journal, and the final item to highlight in this foreword is the inaugural Foundation column reflecting frontline experiences of future physicians in their first years.⁸ So, it feels apt to finish with Joy Division too, ‘And we're changing our ways / Taking different roads’ but it would be good if those roads see us continuing to work together, as we did in that early phase of the pandemic.