Primary care physicians’ narratives on COVID‐19 responses in Japan: Professional roles evoked under a pandemic

Abstract Background Within the vague system of primary care and COVID‐19 infection control in Japan, we explored how primary care (PC) physicians exhibited adaptive performance in their institutions and communities to cope with the COVID‐19 pandemic from January to May 2020. Methods Narrative analysis conducted by a team of medical professionals and anthropologists. We purposefully selected 10 PC physicians in community‐based hospitals and clinics and conducted a total of 17 individual and group interviews. The verbatim transcript data were analyzed using the conceptual framework of adaptive performance. Results We identified three “phases” of the time period (January–May 2020). In Phase 1, PC physicians initially perceived the disease as a problem unrelated to them. In Phase 2, the Diamond Princess outbreak triggered adaptive performance of the physicians, who began to deal with medical issues related to COVID‐19 by using social networking services and applying the collected information to their organization and/or communities. Following this, in Phase 3, the PC physicians’ adaptive performance in their own communities and institutions emerged in the face of the pandemic. Reflecting their sensitivity to local context, the PC physicians were seen to exhibit adaptive performance through dealing with context‐dependent problems and relationships. Conclusions PC physicians exhibited adaptive performance in the course of coping with the realities of COVID‐19 in shifting phases and in differing localities in the early stages of the pandemic. The trajectories of adaptive performance in later stages of the pandemic remain to be seen.


| INTRODUC TI ON
Across the globe, the COVID-19 (coronavirus disease 2019) pandemic has transformed the lives of medical professionals. While experts have debated various factors for Japan's "success" in holding back "the first wave" in March-May 2020 (Table 1) 1-4 despite its lenient restrictions, 5 data-based analysis is scarce.
Primary care (PC) physicians on the front line of community efforts to cope with infectious diseases should intervene quickly to the pandemic in principle. 6 PC physicians around the world are struggling to cope with COVID-19, 7-10 but how are PC physicians in Japan coping with the pandemic? We should begin by highlighting the structural context they are situated in. The boundaries between primary/secondary care and clinic/hospital care in Japan are more ambiguous than elsewhere, and the roles of PC physicians working under a universal health insurance and free access healthcare system are not clearly demarcated. 11 Primary care is practiced not only by PC physicians based in clinics but also by hospital physicians whose main role is in secondary care. 6 Moreover, Japan lacks a centralized command system of government and/or medical experts for COVID-19 responses. Japan does not appoint a Government Chief Scientific Adviser as in the U.K., nor does it house an equivalent to the CDC (Centers for Disease Control and Prevention) in the United States or the State Council in China, 7,12 which coordinate joint multi-sectoral responses to pandemics and provide resources for disease control. In February-March-the initial stages of the pandemic-the Japanese government asked public health centers (PHCs) to play a gate-keeping role for COVID-19, but the PHCs were overwhelmed by increasing demands. 13 Consequently, PC physicians were tasked with triaging patients with suspected COVID-19 and were forced to facilitate early detection in the community with limited medical evidence and a lack of resources.
To outline the experiences of PC physicians coping with the everchanging pandemic in these challenging circumstances, we shed light on their adaptive performance. Koopsman et al define adaptive performance as "adapting to changes in a work system or work roles," which can include "adjusting goals and plans according to situation, generating new innovative ideas, learning new tasks and technologies, understanding other groups or cultures, being flexible and openminded towards others, showing resilience, quick analysis, remaining calm, and acting appropriately." 14 Exploring the PC physicians' adaptive performance in response to COVID-19, in a structural context where their roles are ill-defined-both socially and institutionally and in terms of infection control-will enhance our understanding of PC physicians' roles in uncertainty. In the following, we illustrate the trajectories of their adaptive performance under the COVID-19 pandemic.

| Study design
Our study aims to explore PC physicians' adaptive performance in response to COVID-19. To capture ways in which the physicians struggled to adapt their practices in a timely manner, we adopted social constructionism, 15 which focuses on how human behaviors contribute to constructions of perceived social reality and ways in which knowledge and meanings are predicated on social context, as a paradigm for our research. Based on this paradigm, we used "narrative inquiry," employed in examinations of infectious disease pandemics, 15-17 as a methodological framework. 18 Narrative inquiry is a research method where commonalities observed in story-telling are interpreted and analyzed. 19 Typologies of narratives are inductively created, conceptually organized by thematic categories, and illustrated by exemplar narratives or vignettes. 18,20 The qualitative approach we have undertaken, supported by the anthropologists in our team, has allowed us to capture complex perceptions and emotions of the physicians that are at times ambivalent and hence difficult to grasp in quantitative studies and to refine our interpretations through multifaceted examination. This study has been conducted since March 2020, and here, we focus on the narratives on their experiences from January to May, during which there was a high degree of uncertainty and lack of knowledge about COVID-19 and its future course.

| Data collection
The researchers-all native Japanese speakers in our thirties and forties-used our personal networks to select 10 JPCA (Japanese Primary Care Association)-certified PC physicians through purposive sampling which assured regional diversity and balance in the number exhibit adaptive performance through dealing with context-dependent problems and relationships.
Conclusions: PC physicians exhibited adaptive performance in the course of coping with the realities of COVID-19 in shifting phases and in differing localities in the early stages of the pandemic. The trajectories of adaptive performance in later stages of the pandemic remain to be seen.

K E Y W O R D S
adaptive performance, contextual performance, COVID-19, infectious disease, Japan, primary care, qualitative research of physicians in hospitals and clinics. After the physicians gave their consent to participate in the study through e-mail, our research team conducted online interviews using Zoom, the videoconference application, from March (Tables 2 and 3; Figure 1). We asked interviewees to tell us about when they first learned about  and what they have experienced and felt in their everyday practices TA B L E 1 Timeline of the "first wave" in Japan and around the world 1 were created from recorded data and were analyzed together with the sub-interviewers' notes. The entire process of interviewing and analyses was conducted in Japanese, and the narrative data were translated into English for this publication.

| Analysis
In this study, we found patterns in the interviewees' narratives, while taking account of the variations in the number of infections by region, type of institution they work for, and time period. We then identified and streamlined the adaptive performances revealed in the narratives.
The texts were analyzed primarily by JH, who identified key themes that emerged consistently across a series of narratives. The research team members then reviewed the data including its appropriateness in sampling and critically examined these themes to maintain the robustness of the data and analyses. 18,19 Our discussions with the anthropologists on the team who emphasize the contexts in which our interviewees are situated has encouraged us to be reflexive throughout the research process.

| Ethical consideration
The JPCA Ethics Committee approved this research project. All study participants provided informed consent prior to participation.
To protect the anonymity of the interviewees, quotes in this paper are identified by randomly assigned alphabet codes rather than participants' names or initials.

| RE SULTS
A total of 17 interviews were conducted with 10 PC physicians in their thirties and forties (Tables 2 and 3).

| Findings
We divided the period between January and May 2020 into three phases to analyze the PC physicians' shifting adaptive performance,  an everyday reality in their communities. Due to regional variations in the timing of the pandemic outbreaks, each phase was experienced in different time periods depending on the region where the physicians worked. Readers can see Table 4 for more information on the narratives.

| Phase 1: Seeing the epidemic as an othered problem
In the initial stages of the global outbreak of COVID-19-January 2020-despite the geographical proximity of the outbreak in neighboring China, the PC physicians perceived COVID-19 as a problem that does not directly concern them. They also had a hopeful assumption that the outbreak would be contained. Dr. A confided that with a lack of information, he "felt like it was occurring in a completely distant country." Dr. B similarly said, "It seemed distant to me. I didn't realize how bad it was, and I thought it was mostly just a minor illness." At this point, except for Dr. J, who specializes in infectious diseases (see Table 4), the physicians did not recognize a need for adaptive performance associated with COVID-19, since it was considered as an othered problem, and their job performance seemed unchanged from their usual routine. health center and told them that we had two beds for accepting patients. This was probably in early to mid-February." Dr. H: "Our hospital started to prepare for COVID-19 when we heard that there was a massive outbreak on the Diamond Princess and that the designated infectious diseases hospitals didn't seem to be able to handle it alone. I remember it was around early to mid-February that a task force for the infection control of COVID-19 was set up to discuss how to handle the outbreak, who would examine the patients, and how to deal with the situation." Exhibiting adaptive performance through discerning credible information on COVID-19 and preparing for future outbreaks Dr. A: "There were so many different opinions swirling around on Twitter and other places. There were a lot of people blaming others without understanding the reason. There were a lot of hoaxes going around. After I realized that, I had a hard time looking at Twitter, so I stopped tweeting." Dr. B: "I don't usually read Facebook much, but with regard to COVID-19, I always turned to it. I'm grateful that a trusted infectious disease specialist, who I know in person, posted trustworthy information." Dr. D: "I referred to information sent out by doctors who curated the scattered information and who knew a lot about what was going on inside the Diamond Princess [cruise ship]. They posted important information on Facebook, and if I followed their posted links, I would be taken to important texts from the Ministry of Health, Labor and Welfare. So, I always followed the postings on Facebook by those who selected and shared valuable information." Dr. F: "The information came from a thread on Facebook on how medical professionals coping with COVID-19 dealt with the condition. We would look at it and ask questions from time to time, and share the information in our hospital. … I checked with each doctor to make sure that each piece of information was applicable in our hospital setting. We drafted the policies at our hospital based on this information." Dr. G: "Through Facebook, … I felt that something strange was going on when competent people … started arguing over each other's comment. I feel like it was something that was too soon to be considered a crisis. I am not sure, but I think social networking has had a big impact on me, and if I hadn't been on Facebook, I would have felt more like the problem was not my concern." (Continues) | 323 HARUTA eT Al. movements on a sheet of paper." "I think that the movement of people in March and April is dangerous for this infection, and there is a possibility that many people will be infected with COVID-19." (Note: In Japan, the school year as well as the fiscal year for many private corporations starts in April and ends in March. Therefore, this is a season when many people relocate, change jobs, and mingle with new acquaintances.) (In discussing the institutional strategies of personnel management in the hospital) "[We made sure that] COVID-19 patients are attended by different physicians. It's become a Russian roulette within the internal medicine team. This is a good way to engage everyone and to encourage everyone's involvement in COVID-19. On the other hand, it also exposes more people to the risk of being infected. … There are also differences in the awareness level between staff in the wards who see COVID-19 patients and those who don't." Dr. H: "We set up a booth in the emergency room for febrile patients and set up a waiting area near it. We struggled to figure out how to divide up the space so that there would be no intersection with other patients. … When I asked for a CT scan of a suspected COVID-19 patient, our staff answered 'can I do it in the evening because there would be no other patients then?' I was like, no, no, no, I'm telling you there's a patient here right now…" "We had to divide our staff into days of the week to see people with fever in a container -a prefabricated hut -outside the hospital, once a week. The respiratory specialist took on that role with, well, what I think is a sense of mission. It's a respiratory issue so they'd have to be involved. The PC physicians also took on that role with a sense of mission." (With a hint of fatigue on his face) "When a patient is admitted to the hospital, there is a lot of nervousness about whether the patient's condition has worsened and whether he or she needs to be transported to a university hospital. We have to wear personal protective equipment, manage multiple people on the ward, and perform PCR testing for negative confirmation before discharging the patient from the hospital. The number of not only young but also elderly patients is increasing, so there are more and more people who need help. We need to ask other departments' doctors to handle the outpatient services. I've asked the hospital to send someone to the team. Recently, my practice has been limited to only COVID-19 or suspected patients. I rarely conduct physical examinations or anything else to avoid contact with these patients." "When I asked one of the doctors on night duty to take the call from the health center and record the results of the PCR testing, he said, 'Is that my job?'"

Trajectories of adaptive performance Quotes
(2) Metropolitan areas: Exhibiting adaptive performance through adjusting their priorities while dealing with uncertain and unpredictable work situations, learning work tasks and procedures, and demonstrating interpersonal adaptability Dr. A: "I'm seriously thinking of starting a full-fledged version of telemedicine practice. We're talking about which company is better for online practice and when the system will actually be ready. We're discussing the issues of how to cope with patients who are known to be positive and are staying at home." "We're told that we need to reduce the amount of time we spend with patients, so I don't have the opportunity to talk to them for so long. Patients themselves don't want to see each other for long periods of time because many of them really just want to receive medications." Dr. B: "Towards the end of January, we talked about what to do when a patient is suspected of having COVID-19. The procedural manual was completed in the clinic by February 14th. … Since that time, we've tried to separate the places completely and properly, and if people had cold symptoms in the waiting room, we asked them to go upstairs. We kept the first floor for seeing regular patients. … It wasn't until March 10th that the entrance to the symptomatic patients was completely separated. [Around that time,] I started wearing goggles, a mask, gloves and an apron when seeing these patients. We started opening windows." TA B L E 4 (Continued) (Continues) exposed to different everyday realities in the following manner: those working in (1) hospitals serving COVID-19 patients, (2) metropolitan areas, and (3) regional cities and suburban areas.

Hospitals serving COVID-19 patients
The PC physicians working in hospitals serving COVID-19 patients were forced to not only urgently face the demands of coping with medical issues related to COVID-19, but also to immediately figure out how to deliver information on dealing with suspected COVID-19 patients and mapping institutional flows to cope with COVID-19. Dr. F mentioned creating a manual for dealing with infected or suspected cases and sharing it with his colleagues on March 16th, which did not work.
They then created "action cards," which "mapped out key procedures on a sheet of paper, so that each department could move quickly." In The PC physicians' work therefore involved not only serving their patients and preventing outbreaks within their institutions, but also reaching out to their communities and being sensitive to their needs as guardians of their local communities.
In response to the increasing number of infections and the state of emergency declaration (Table 1, April) in April, the examinations and treatments of outpatient fever cases were incorporated into regular clinical routines for the physicians in these regions. Some PC physicians started avoiding extended medical interviews and physical examinations to minimize their contact with their patients.

Trajectories of adaptive performance Quotes
(3) Regional cities and suburban areas: Exhibiting adaptive performance within and for their institutions and their communities through handling work stress and making the most of their interpersonal adaptability Dr. E: "We think of ourselves as physicians in the community, and I thought it was very important to send out information to residents we provide medical services to as it relates to this community. … So, from the end of February, we began to hold study meetings, step by step, to discuss things like social distancing and time separation. We talked about it at every study meeting. We delivered information to residents in the local community about how to prevent COVID-19.
We thought about what we should do in our daily lives, rather than just ordering people or telling them to do this or that." Dr. G: "During a morning meeting on March 9th, I told our staff in the clinic that the outbreak had also occurred in our prefecture. At that time, I told them that it would be a six-month to twoyear battle, as a nationwide epidemic would be unavoidable. … I think our staff were worried that the elderly and those with chronic illnesses in the clinic might get infected with COVID-19, especially since they would have to be hospitalized. I told the staff members that it's important to protect our patients and ourselves, and assume that it  will slowly see outbreaks in our community." Dr. J: "I think our staff members understand that they have to handle the situation properly.
So when I give them instructions and explain the rationale behind them, they follow the instructions without hesitation. No one wants to quit -they are all very cooperative. … Normally, people make appointments online or by phone, but we get calls from people in the community who are hesitant about coming to the clinic. The staff would then explain over the phone that we are dividing up the time slots for patients so they don't have to worry. During the evening review, we would hear that the patients were very happy when we explained to them in this way, or that they came to the clinic feeling safe and comfortable. Hearing these stories, we all praise each other for handling the situation properly."

TA B L E 4 (Continued)
Dr. A lamented having to focus on "laboratory tests, and not on the physical examination" and noted that he "didn't want to do this." He was asked to "reduce the amount of time The PC physicians in metropolitan areas therefore exhibited adaptive performance, through adjusting their priorities while dealing with uncertain and unpredictable work situations, learning work tasks and procedures, and demonstrating interpersonal adaptability.
Regional cities and suburban areas , and assume that COVID-19 outbreaks will slowly surface in our community." The PC physicians working in regional cities or suburban areas made efforts to relieve the staff's anxiety level in preparing for potential outbreaks in their local context and to summarize and share specialized knowledge on COVID-19 with the healthcare staff in their institutions and local communities. They therefore demonstrated adaptive performance within and for their institutions and communities through handling work stress and making the most of their interpersonal adaptability.

| DISCUSS ION
As we have seen, PC physicians exhibited adaptive performance in the course of coping with the realities of COVID-19 in various phases and localities. Initially, the physicians did not necessarily recognize a need for adaptive performance associated with COVID-19, but facing the pandemic, some physicians working in hospitals had to demonstrate their adaptive performance immediately. Others in metropolitan areas needed to adapt quickly to cope with local outbreaks, while those in regional cities gradually adapted to prepare for imminent outbreaks. The key factors of adaptive performance 14,21 were demonstrated in shifting phases and differing local contexts in coping with the realities of COVID-19. Partly due to this, Japanese PC physicians may find it difficult to respond immediately to a pandemic, as was observed in Phase 1.
We found, however, that enhanced communication with colleagues, patients, staff in PHCs, and citizens-a key in adaptive performanceand creating and maintaining a supportive environment have helped PC physicians cope with the high level of uncertainty under the pandemic. In an increasingly complex society, not only adaptive performance but also contextual performance has been seen as essential for effective job performance. 26,27,28 Contextual performance is reflected in activities that support the organizational, social, and psychological environment, such as motivation, cooperation with and helping others, communication, interpersonal relations, and organizational commitment. 29 It is evident that PC physicians were required to show contextual performance in order to achieve effective adaptive performance in response to the pandemic. The fact that they are trained to be sensitive to context may have positively impacted their adaptive performance. 30 While strict requirements for adherence to practice guidelines in training and service design in the U.K. may limit the development and the implementation of individualized and contextualized care from GPs, 31 the vagueness of PC physicians' roles in Japan may have contributed to the physicians' high contextual performance. These PC physicians' adaptive performance could be keys in coping with the pandemic, 32 and the trajectories of their adaptive performance in the early stages of the COVID-19 outbreak may potentially be applicable to those medical professionals responding to the subsequent waves of the pandemic and beyond, although further investigation of the adaptive performances of these PC physicians in later stages of the pandemic is needed to critically examine this applicability. This study offers insights into the constantly changing pictures of the pandemic based on the physicians' fresh memories, and the anthropologists' involvement in the study has helped enhance our contextual insights.
There are, however, several limitations. This is a small-scale study based on purposive sampling with a significant lack of variety in terms of age and gender, and a more macro-level study are needed for a comprehensive analysis of PC physicians' responses to COVID-19. Using the researchers' personal networks to seek interviewees may have not only led to this limitation but also affected our interactions and analyses. Not all Japanese PC physicians may interpret their roles as described above, and considering the increasingly severe pandemic situations in more recent months, our current observations on the effectiveness of their adaptive performance may be overly optimistic. A longitudinal investigation of the transitions of their adaptive performance is therefore needed.

| CON CLUS ION
Faced with a need to cope with the changing realities COVID-19, PC physicians in Japan exhibited effective adaptive performance in shifting phases and differing contexts in the early stages of the pandemic.
The trajectories of adaptive performance to be demonstrated by the PC physicians in later stages of the pandemic remain to be seen.

ACK N OWLED G EM ENT
We sincerely appreciate the support from the Specialist Committee, the Disaster Medical System Committee, and the Ethics Committee of JPCA (Japanese Primary Care Association).

CO N FLI C T O F I NTE R E S T
The authors have stated explicitly that there are no conflicts of interest in connection with this article.