It’s an understatement to say it’s been a whirlwind since Dr. Henry Kaufman accepted the position of interim chief medical officer at Our Lady of Lourdes Regional Medical Center in early April.
At that time there were far more questions about coronavirus than answers — about drug availability, PPE supplies, challenges of securing rapid on-site testing. Would local hospitals be overrun with COVID-19 patients? Could the preparations and plans Lourdes had already put in place handle the impending crisis?
“My new role made a remarkable amount of data available to me,” Kaufman tells me, noting the amount of time he spent reviewing and applying the data to develop new policies and practices for patient care. “We were receiving directives from multiple governmental agencies and regulatory bodies that changed on an almost daily basis,” he continues. “It felt, at times, like drinking from a fire hydrant.”
What Kaufman did immediately grasp were ER visits falling precipitously, as even those experiencing heart attack and stroke symptoms feared subjecting themselves to the virus more than caring for their life-threatening conditions. Surgery volumes at the hospital were cut in half, and Kaufman, a surgical oncologist, was seeing his own practice completely disrupted by the pandemic. Since mid-March, the state had mandated that all elective procedures, which account for a significant percentage of a hospital’s and just about any surgeon’s revenues, be postponed to preserve personal protective equipment and other resources, like staffing and bed capacity, and ventilators — which are used in some semi-elective surgeries.
Health care facilities were instructed to postpone “any and all medical and surgical procedures … until further notice,” unless they were emergent. Clinic visits and consultations went virtual.
The financial hit has been staggering for many hospitals and doctors’ clinics. On April 20, the Lourdes system announced that, while it remains in a good financial position, it had experienced a net revenue loss of $120 million in March and April. Last month the system slashed hours for some employees to match reduced volumes, cut executive salaries and postponed expenditures. It continues to evaluate contract terms in light of the COVID-19 response.
In what appeared to be an acknowledgement that the halt had worked to preserve resources, last week Gov. John Bel Edwards said the state would start loosening the vise, allowing “time sensitive” medical tests and procedures to resume this week. That meant previously postponed procedures that may cause pain or distress or further negative outcomes for the patient could hit this week’s schedules with certain requirements.
Nearly a month into his new role, Kaufman is presiding over a medical staff with about a dozen Covid patients in a hospital that hasn’t yet had to use its ICU surge plan. That’s the good news, he says. But, he maintains, COVID-19 is here to stay.
“We’re all getting used to the fact that this is the new reality,” Kaufman says in a phone interview, “just like we take care of flu patients every year and they peak and they go down, this is going to be one of the illnesses that is going to be a part of humanity going forward, and we’re all getting used to how we’re folding that into routine life.”
We asked Kaufman how he’s navigated the upheaval, what a phased-in return to a full practice might look like and when the medical community could realistically return to some semblance of normalcy.
What did the ban on electives mean for you and your patients?
While we were under the original hospital authority order, we were only doing urgent and emergent cases where the life and the health of the individual was subject to immediate insult or concern. For example, we’ve got pretty good data that a patient with early stage breast cancer cannot have any interventions for 12 weeks without any change in their outcome. Now that’s usually a shocking piece of information, because you can imagine if you’re a woman and you get diagnosed with cancer and your surgeon says, “Oh, we’ve got three months to even start taking care of this.” That’s certainly not how you’re gonna feel emotionally, but we have a lot of data that supports that because people who unfortunately don’t get screening mammograms still have heart attacks, strokes, car accidents. They come into the ER and get scanned and are found to have cancer. And then we put that off for other lifesaving measures, so that’s a captive patient population and that not only applies to breast cancer, but we have similar data on other disease states. So early breast cancers were put off, early colon cancers were put off, some other early low-grade cancers were deferred. More than a few cancers were started on other pathways of treatment, like you could put a breast cancer patient on hormonal therapy and stabilize [them], which is what we did — not knowing how long this was going to take and anticipating it could be longer than 30 days.
Can you give us some specific examples of what surgeries couldn’t be done before but might now fall into “time sensitive” guidelines?
People who might have had gallstones and been symptomatic but not in a threatened way, just having mild symptoms, those were put off. But if they’re having increasing symptoms, what we call crescendo symptoms, that put them at more risk, that falls under “time sensitive.” People who have spine degenerative disc disease and impingement upon their spine and pain, those people were being put off. But if their symptoms are progressive, we know that the longer they wait the worse the disease process becomes. Those people need to get their spine fixed. These are the people who fit into the new order.
What types of screening tests does the new order open up?
Anybody who’s had symptoms who needs a diagnostic procedure. So if somebody’s having trouble swallowing and they need to have an endoscopy, or if they’ve become anemic and need an endoscopy, that would be completely appropriate as well.
How will each medical specialist know with some degree of certainty who fits into the “time sensitive” order.
All of the professional societies have put together some guidelines to help guide individual physicians in who we think should and shouldn’t be treated. To give an example, we’re going to start high-risk breast cancer screenings first (determined through statistical tools and other criteria like an abnormal mammogram), anticipating that we should be able to start routine screening mammograms shortly thereafter. The right and smart thing to do is the high-risk patients first anyway.
What types of procedures are you still not doing in the initial rollout? At least for the first week, we won’t be doing routine screening mammograms, routine screening colonoscopies, routine pulmonary function testing. (Kaufman says medical professionals will need further guidance from the state before resuming those.)
So I can’t get a routine mammogram, but I can buy a new sofa?
Look at it from a medical community standpoint, how can we justify clearing people to go buy a couch or a piece of jewelry when a woman can’t go get a screening mammogram? We don’t need to fight it right now, because we’ve got enough people we can cue up who need high-risk screening anyway, as a soft opening toward routing screening and health maintenance.
If you had to guess, when do you think you’ll be back to business as usual?
We are never going to resume business as usual. The models of healthcare delivery are going to forever change as a result of this pandemic. I think we’re going to see a lot of telemedicine and maybe fewer doctor visits overall, and I think that could be a good thing. I’ve got a lot of patients who come in from hours away to see me. And a lot of those initial visits are just me sorting through their data and talking to them and getting a feel of how they want to move forward, figuring out which additional tests they need. I don’t necessarily have to have them drive in two or three hours to do that. But I always felt like I was compelled to because of the standard of care. I think we’ve all gotten a lot more comfortable with telemedicine visits, and it might prove to be a good thing for some patients.
Did you have patients whose anxiety was running high, lots of calls into the office?
We didn’t have a lot of repetitive calls. What we did is we spent a lot of time counseling and talking to each patient and explaining to them what our interval plan was going to be, what we felt the risk was to them and everything we were going to do to mitigate the risk. I know as a scientist that a breast cancer patient can wait 12 weeks; however, trying to get through the strong emotions that go around a diagnosis of breast cancer to get to a place where the patient will know she’s going to be OK takes some work. I think we got there with everybody.
There have been national and local media reports of people jeopardizing their health by not going to ERs.
There’s a lot of false perceptions about the safety of coming to the hospital. The hospital remains a very, very safe place to be, especially if you’re having a major medical issue. We would ask you to follow all the things you’ve heard in regards to stroke signs and symptoms and heart attack signs and symptoms and call 911 and come in right away. If there is any doubt or reticence, at a minimum call your doctor or call the hospital and talk to the triage nurse in the ER. For a lot of people, concern over the coronavirus is higher than their concern over their stroke or their heart attack or their major health event, and I don’t think that’s the right way to think about that right now. It should be just the opposite.
How has this affected your practice from a financial standpoint?
We took a big hit in the last four to six weeks as far as our accounts receivable. That is way down. Most of our payments come from CMS; generally we get paid about 90 days after we perform the procedure. In 30 to 60 days we’re going to see a significant drop in revenues. It’s going to be an issue. We’re going to have to work through that.
Any pay cuts, layoffs or furloughs at your private practice?
We have three surgeons and two nurse practitioners in my practice, and 11 other employees. When we went primarily to virtual visits and the stay-at-home order, the number of patients we were seeing in the office dropped significantly and as a result some of our staff didn’t need to be there, so we allowed them to go home and take paid time off and we kept track of that PTO. If we’re financially sound as we move through this, we’re going to give everybody their PTO back. We made sure everybody got their paycheck every month without any disruptions. Overtime and production bonuses went away, of course.
The new order from the state leaves virtually all discretion to medical professionals to resume only time-sensitive procedures. What’s your level of confidence that electives like face lifts will continue to be postponed?
If we continue to do what we think is in the best interest of the patient and the community, we’ll be doing the right thing. The physicians are going to police themselves in regards to the types of cases that they put on. The orthopedic surgeons as a group are going to make sure they follow their society’s guidelines, the gastroenterologists are going to the same, I’m following my society guidelines. We’ve all got a reasonable foundation from which to work. Now we’ve got a lot of colleagues, and I completely understand, who are just chomping at the bit to get back to work. They’ve taken a significant financial hit, they’ve got employees and families. Many of us are small business owners. It’s trying to balance doing the right thing for the community and the state and at the time, as a business, wanting to get back open. Physicians aren’t the only people feeling those conflicting pressures.
Are there any consequences for the rule breakers?
Absolutely, but there are mechanisms in place to prevent that. We’re going to hold ourselves and our colleagues accountable. If someone is scheduling cases inappropriately, I’m sure there will be a conversation. Could there be an isolated event? Yes, but everybody’s been remarkably understanding. Across the board there’s been a reawakening of the real reasons we went into medicine. We’re doctors first, and we’ve got a responsibility to the community and to our patients at large, and this is the right thing to do. So that’s what we’re going to do.