The pandemic’s toll on non-COVID care

With the state’s ban on elective outpatient procedures lifted in Monroe and 34 other counties, a backlog of untreated and undertreated conditions awaits a local medical community that has been strained to its limits.

To be sure, UR Medicine and Rochester Regional Health, which between them control most of the Rochester region’s health care delivery, have urged patients not to forgo needed care. So have area private practice providers, most of whom are associated with either or both of the systems through physician organizations. 

“UR Medicine is treating all patients who need care, not just patients with COVID-19,” read a message on the University of Rochester Medical Center website. RRH made similar assurances. But the calculation of who gets treated when for what has changed. COVID-19 has been an insatiable consumer of a very finite pool of medical resources. 

The resumption of elective surgeries is good news, says RRH Chief Medical Officer Robert Mayo M.D. It is possible because the Rochester region has flattened the COVID-19 curve, freeing hospital space the pandemic had claimed. 

Still, Mayo cautions, the five or six-week backlog of unperformed procedures will take weeks to whittle down and some triage will still be needed. The same is true for UR Medicine’s hospitals, says Michael Apostolakos M.D., chief medical officer. 

Robert Tripp M.D. is a member of RRH’s Genesee Surgical Associates group. Where surgeons only weeks earlier performed as many 100 operations a day at Rochester General Hospital, he says, the number during the ban was down to 20 or 30. 

As a general surgeon, “I do a little bit of everything,” Tripp says. 

Everything includes elective surgeries, a category that includes cosmetic surgeries but more often covers medically necessary but not urgent procedures like tonsillectomies, back surgeries, rotator cuff repairs or kidney stone removals. It also includes operations to remove malignancies and operations on endocrine system organs like the thyroid gland. 

Opening up again

As it stands now, the Rochester area has a more than month-long backlog of unperformed elective procedures, says Michael Mendoza M.D., Monroe County health commissioner. Any resumption of such surgeries will proceed very slowly and carefully, and could be reversed if we see a new COVID-19 surge, he adds.

How many procedures might be undertaken and which procedures might be done are questions being worked out in discussions among county and state officials, UR Medicine and RRH, says UR Medicine spokesman Chip Partner. 

And for privately practicing surgery groups, questions abound, says Christopher Bell, executive director of the Monroe County Medical Society. Would only hospitals be allowed to resume elective procedures or would permission also extend to private ambulatory surgery centers? Would a hand surgeon be able to relieve a trigger finger sufferer’s distress in a simple in-office procedure, or would that still be banned?  

“(So far), we have been lucky,” says surgeon Lori Medeiros M.D., a specialist in breast cancer who serves as executive director of RRH’s Breast Cancer Line. 

Medeiros quickly clarifies the statement. She means that we are lucky only by comparison. We are not overwhelmed by COVID cases to the point where our doctors must ignore the most seriously ill patients, which hospitals as distant as Italy and as near as New York City were forced to do only a few weeks ago. 

Even though Rochester so far has been spared from that fate, says Medeiros, the goal posts have moved. Many surgeries that only a few weeks ago would have been given immediate attention have had to wait. A new calculus put their treatment weeks in the future. 

Medeiros believes the statistical guidelines—known in medical jargon as population measures—that doctors are using to decide who can wait and who cannot are sound. Still, she concedes, statistics can be a less-than-perfect predictor of individual outcomes. 

So far, Medeiros says, the guidance provided by population measures have been good predictors. But we are only a month or less into a new normal whose ultimate duration is unclear. Where she stood in population measures would matter little to a woman whose cancer has advanced faster and further than her statistical chances led doctors to believe it would. 

A big drop-off

While the coronavirus curve has been flattening locally, the disease is still a long way from being fully contained. As the current best defense against the virus, social distancing, takes hold, COVID-19 still devours a big share of local, national and global medical resources.

Specialists like gastroenterologist Surinder Singh Devgun M.D. as well as Tripp and Medeiros report similar experiences: Their regular practices are cut to a 50 percent to 80 percent of pre-COVID-19 volumes. 

The experience of primary care doctors like internist John Genier M.D is similar. For specialists and primary care providers, much of the drop-off reflects the medical community’s agreement to postpone or cancel appointments and procedures deemed less vital than they might have been before the pandemic struck. 

But, notes Genier, some of the decrease traces to patients’ reluctance to seek treatment at a time when the medical system is seen as overwhelmed and hospital and clinics promise to be filled with COVID-19 sufferers who might transmit the disease. 

And here Medeiros points to a source of possible future worries: screenings like mammograms came to a virtual halt. Even in more normal times, she says, too many patients put off such procedures and tests either because they find them unpleasant or fear what tests might find. 

In normal times, doctors view as essential only preventive measures like cancer screenings but regular checkups such as annual physicals for healthy people and more frequent wellness visits for people with risk factors like diabetes or heart conditions. 

According to the American Cancer Society, “screening increases the chances of detecting certain cancers early, when they are most likely to be treated successfully.” ACS guidelines call for preventive testing for most cancers. 

Devgun’s specialty puts him on the front lines in the battle against colon cancer. With nearly 150,000 new cases diagnosed each year, colorectal malignancies are the second most diagnosed type of cancers and the third most lethal for U.S men and women.

Such cancers have been in decline in the United States, for several decades. A key reason, according to the American Cancer Society “is that colorectal polyps are now being found more often by screening and removed before they can develop into cancers or are being found earlier when the disease is easier to treat.” 

Colonoscopy, a procedure in which gastroenterologists like Devgun visually check patients’ colons and remove any pre-cancerous or malignant growths they find, is a chief colon-cancer screening tool. 

A partner in Rochester Gastroenterology Associates, Devgun and each of his two partners have typically performed several colonoscopies a day at the privately practicing group’s Linden Oaks facility.

“Until March 3, we were going full steam ahead,” Devgun recently told me, speaking on a weekday midafternoon from his basement home gym. 

“Right now we’re closed,” he said. “We decided it would be best for patients’ safety and for ours and we realized we would have to shut down the practice.” 

Ambulatory surgery centers like the one Devgun’s group runs can now open for business, but Mayo says they face the same backlog as hospital operating rooms. 

Virtual triage

While his group closed its office and indefinitely put off screening colonoscopies, he and his partners made themselves available for telephone and, using newly installed software, telemedicine consults. He and his partners had to decide on a case-by-case basis how to see or treat patients with troubling symptoms like rectal bleeding or blockages as well as those with previously diagnosed cancers.

Physicians in virtually every other specialty—heart doctors, cancer doctors and others—have had to do the same sort of triage. 

During the elective surgery shutdown, the new COVID normal involved having to tell cancer patients that their previously scheduled surgery will have to wait, a message many were not happy to hear.

“A lot of cancer patients have anxiety,” Tripp says. “They don’t want to wait.”

As backlogs are whittled down, some may still see cause for anxiety.

Bowing to social distancing, Genier and his partners have postponed routine physicals and other regular checkups. He estimates that his patient-care volume is half or less of what it was before the pandemic.

Some of the reduced volume results from patients shying away from care, Genier says. For reasons ranging from patients’ assuming that the medical system is too overwhelmed to attend to non-COVID care to unwillingness to risk going into a medical office, many are simply not seeking care or consultations they otherwise might not have hesitated to ask for, he believes.

Like Devgun and his partners and Tripp, Genier and his partners have rapidly transitioned much of their practice from office visits to telemedicine consultations. Some older, less technologically astute patients can do only telephone consultations.

“Telemedicine is working well, it’s useful,” Genier says. 

Still, for a physician for whom close observation of patients’ deportment is often an invaluable part of diagnosis, remote diagnosis can be less than ideal.

Says Genier: “It’s good to have face-to-face visits.” 

Telemedicine and telephone consults tend to be shorter than office visits. Patients often seem to want them over sooner, he notes.

Unlike most area private primary care physicians still in active practice. James Gaden D.O. has resisted installing an electronic medical record system in his one-doctor office and has not joined either UR Medicine’s or RRH’s physician organizations. 

Gaden’s office is in Orleans County, one of the region’s poorest and most rural. He routinely does not press for payment or accepts reduced amounts from uninsured patients, and is similarly tolerant of insured patients who have trouble meeting deductibles or coming up with co-pays. His primary reason for not installing EMR is that he cannot afford the tens of thousands of dollars systems cost to install or the thousands more in annual upkeep they require.

Although like the other doctors he is seeing fewer patients, Gaden still travels from his Hilton home in Monroe County to his office. He is doing more phone consults. Recently, he had to convince a woman with respiratory issues to come in for a checkup. It wasn’t COVID-19, but still could not be adequately diagnosed remotely, Gaden says. Some insurers have relaxed rules to allow more reimbursement for telemedicine are paying for telephone time but not always at full rates. 

Coping with pent-up demand

As they adapt to a landscape that virtually overnight has changed radically, the doctors I spoke to expressed confidence in their own and the local health care system’s ability to cope with COVID-19. 

Still, they agree that a reservoir of postponed exams, delayed treatments and symptoms too long ignored by patients is creating pent-up demand that at some point will need to be dealt with. Apostolakos and Mayo say their health systems have adequate capacity to deal with a new COVID-19 surge but also concede that a surge or an uptick of flu in the fall could again burden resources.

How big that reservoir is and how well local, state and national health care systems are ultimately positioned to deal with it will depend on when the coronavirus is fully tamed and what measures are taken until it is under control. Any prediction on how soon COVID-19 can be brought to heel seem highly speculative at best.

The consensus among medical experts is that the virus will not be fully under control without a vaccine to immunize individuals against its spread. Clinical trials of vaccines are underway. But scientists say it is unlikely that one will be available in less than a year; in the meantime, the best hope of mitigating COVID-19’s threat lies in developing treatments to blunt the virus’s effect.

In an April 13 interview with American Medical Association chief experience officer Todd Unger, Howard Bauchner M.D., scientific publications editor in chief of JAMA, the AMA’s peer-reviewed medical journal, said social distancing is working for now. In the search for a proven treatment or a vaccine, however, “there appears to be more questions than answers.”

While several possible treatments are under study including a clinical trial of the antiviral remdesivir at the URMC, effective treatments including the highly touted malaria drug chloroquine “remain unclear,” Bauchner said. Vaccines now in Phase I trials could enter Phase II clinical trials this autumn, but still might require months of further testing, he added. 

In the meantime, the ability to contain COVID-19’s tax on the region’s pool of medical resources promises to be touch and go. 

In regions where tight controls and testing are more widespread than is currently available in the United States, the virus has been contained enough to allow cautiously returning to normal, a recently published article in the British medical journal, the Lancet, reports. It found through modeling that in the Chinese provinces where the outbreak began and is now well controlled, “relaxing the interventions … when the epidemic size was still small would increase the cumulative case count exponentially as a function of relaxation duration, even if aggressive interventions could subsequently push disease prevalence back to the baseline level.”

In the U.S. today, as a White House anxious to restart the stalled economy looks for ways to ease up on social distancing and protesters in several states egged on by President Donald Trump clamor for an end to all restrictions on public gatherings, how safe Americans will remain appears to be an open question. 

Will Astor is Rochester Beacon senior writer. All Rochester Beacon coronavirus articles are collected here.