Physicians navigate the new ‘normal’

In Community Health, Feature by admin

As Kansas slowly starts to loosen its business and commerce restrictions under Gov. Laura Kelly’s latest reopening plan, physician offices and hospitals in Sedgwick County are carefully adjusting to a new phase in delivering care.

Hospital systems such as Ascension Via Christi and Wesley Healthcare are now allowing some non-emergent surgical procedures while many physician practices that had gone dark during lockdown – or had greatly reduced their operations – are now looking at ways to slowly get their businesses functioning again.

Gone for the foreseeable future are busy waiting rooms where patients sit in adjacent chairs and flip through magazines while waiting to see their physician. In fact, check-ins today often involve prescreening over the phone and curbside forms delivery. In many practices, patients are asked to wait in their vehicles until the office calls them in, politely requesting they wear a face mask.

Dr. Breot

“I keep asking myself, “When will things get back to normal?” But I kind of know in my heart that we may never return to what we consider “normal,” said OB/GYN Sharon Breit, MD, whose specialty requires her to regularly visit hospitals as well as maintain office hours.

Her practice discarded its magazines, put away the children’s toys, instituted regular deep cleanings and established a “sick room” – a separate entrance for patients who present with any type of questionable symptom. And that’s if they need to come in at all. Breit’s office won’t hesitate to use telemedicine if a patient needs a follow-up consultation that doesn’t require an in-person exam.

“Nobody sits in the lobby,” Breit said. “We physically bring out the paperwork to them and they fill it out in the car, and when we’re ready for them, my medical assistants meet them at the door and take them directly to the exam room.”

West Wichita Family Physicians shut down its entire after-hours minor emergency clinic and converted it to a COVID-19 clinic where patients suspected of having the virus could be screened and tested outside of the practice facility. The practice also closed its outpatient surgery center.

Dr. Davison

But the number of people coming to be tested has declined, while the number of people who actually tested positive for the virus remains low, family physician Joe Davison, MD, said. Today, practice partners are talking about how to phase down from a full-time COVID screening clinic to perhaps a half-day clinic, or maybe a drive-by clinic, and reopening the outpatient surgical center.

“We’re eager to get going,” Davison said, adding that no one is 100 percent certain exactly what the next steps should be or how quickly to take them. “We’re not getting much guidance,” he said. “We’re trying to be the middle ground, to be safe, to take all the appropriate precautions. You want to be smart – and I think we have been – but I think we can start opening up in stages.”

The American Academy of Family Physicians said conflicting information about how and when to reopen physician practices has caused hesitancy among physicians trying to balance safety with the need to see and treat patients. In issuing guidance for physicians on reopening, AAFP officials suggest that a decision to resume in-person office visits should take into consideration, among other factors, a combination of local COVID trends, reliable testing and the availability of PPE.

“If your practice chooses to resume in-person care, you should continually monitor (your) local area’s incidence of COVID-19 to take appropriate actions if the risk increases,” AAFP officials said. “Until a vaccine is widely available, there will be a risk of COVID-19.”

Effective May 18, Gov. Kelly approved a cautious, slow opening of some local services. Her latest plan to reopen Kansas acknowledges that COVID-related deaths are on the decline but that the rate of spread among residents is not, thereby slowing plans to greenlight a full-fledged reopening of Kansas businesses and gatherings by a certain date as originally thought. Phase 1.5 highlights include:

  • Continued prohibition of gatherings of more than 10 people;
  • Allowing nail salons, hair salons and similar personal services to reopen, but only for pre-scheduled appointments or online check-ins;
  • Allowing fitness centers and health clubs to open, but with no group classes and no open locker rooms.

“Unfortunately, the daily rate of disease spread has not shown the downward trajectory necessary to move fully into Phase 2,” Kelly said on May 14. “I said from the beginning that public safety must remain the top priority, which means that our reopening efforts must be driven by data, not dates. Phase 1.5 will continue our transition, but with necessary caution.”

In line with this thinking, the decision by hospitals to reopen their ORs for some classes of non-emergent surgical services has many Wichita surgeons breathing a sigh of relief. Stories of patients putting off needed surgeries or waiting out of fear to see their doctors after experiencing potentially dangerous symptoms have resulted in escalated and more complicated health issues and, in some cases, death.

Dr. Brown

Surgeon Nick Brown, MD, estimates that before the pandemic hit, Wichita Surgical Specialists performed upwards of 25 to 40 cases a week. Once the local stay-at-home order went into effect and surgeries were limited to urgent and emergent cases only, surgeons were operating on fewer than 10 cases a week.

Now that hospitals are slowly opening back up for “elective” surgeries – a word doctors dislike because very few surgeries are truly “elective”; most are necessary and important – surgeons are finding their patients a little worse for the wear.

“The pathology has gotten a little worse and a lot of things we take for granted – something as simple as, for example, a gall bladder, has been made more complicated by waiting,” Brown said.

Brown, also a bariatric surgery expert, noted statistics released by the Centers for Disease Control & Prevention that listed hypertension, diabetes and obesity as the three most common comorbidities of people who passed away from COVID-19. Those also are the chronic conditions most associated with bariatric patients waiting for life-saving weight-loss surgery – but the surgery is considered a “Tier 2” procedure, and, until recently, was put on hold.

“The initial stance that (some) categories of procedures were the same as cosmetic procedures couldn’t be further from the truth,” Brown said. “We do those surgeries to prevent a lot of chronic medical conditions.”

Hospitals, for their part, are slowly and methodically introducing categories of surgeries of various acuities while keeping a close eye on safety for all involved.

If there’s any doubt as to whether a physician, the hospital staff or a patient is at risk for contracting or spreading COVID-19, the surgery will be delayed – and physicians aren’t giving pushback on that, said Brian Swallow, director of surgical services for Wesley Healthcare, which is testing patients for COVID-19 prior to surgery.

“Safety is trumping everything at this point,” Swallow said. “A lot of doctors are seeing patients who are sicker than normal because they’ve waited too long or delayed surgery. What we don’t want to do is get careless. The most important thing is to make sure everybody’s safe, including the patient, the staff and the doctors.”