Eleven spine surgeons outline how the pandemic has changed their plans for the future.
Charles Branch Jr., MD. Executive Director of the Spine Service Line at Wake Forest Baptist Health System (Winston-Salem, N.C.): I have experienced over a 50 percent reduction in my surgical caseload during the last month. In some ways we are fortunate because many of our spine cases involved patients who are developing neurologic deficit or disabling pain and this allowed us to move forward with time sensitive surgeries in these patients. In general these were one- and two-level decompression or fusion cage cases but did not the multilevel deformity projects.
We also continued with our trauma and tumor spine cases so overall we did not experience the devastating reduction in volume that some other specialties in our institution did. While extended future plans seem to be stable, the near term planning is disrupted by the uncertainties with testing, patient confidence in a healthcare system that is safe and in some cases a reconsideration of the disabling nature or extent of their pain. Unfortunately economics have put an almost complete hold on capital purchases so our anticipated robotic and imaging platforms will be put off for the time being.
Richard Wohns, MD. Founder and President of NeoSpine and Microsurgical Spine Center (Puyallup, Wash.): The pandemic has affected Neospine similarly to most spine practices in the country. We transitioned to telehealth, canceled elective surgeries and adjusted our work schedules and daily FTE requirements. Patients were very helpful in their compliance with our new requirements for safety and the necessary limitation in services. We were able to accomplish these changes essentially overnight, due to excellent organization and leadership, plus cooperation amongst providers, staff and patients.
Andrew Hecht, MD. Chief of Spine Surgery at Mount Sinai Hospital and Mount Sinai Health System (New York City): The pandemic greatly curtailed spine surgery to just emergent and urgent cases. Surgical volume was down in our spine program more than 95 percent over this time. We just started more chronic and semi urgent cases at the beginning of May (i.e. intractable pain, mild neurological deficits, stable myelopathy).
In addition, the outpatient volume of patients fell by over 70 percent. Most visits are done by telemedicine. We are just starting to open in-person office hours with a greatly curtailed schedule to emphasize the need for continued social distancing. We have encouraged our spine team to try to see patients who 'need' to be seen and where a physical exam may change what the physician/surgeon will do treatment wise.
It will be a slow return to any semblance of normal. We want our patients and staff to always be safe and will continue to monitor the government's recommendations regarding this evolving situation.
We have a tremendous backlog of cases that will be slowly unwound over time.
Choll Kim, MD, PhD. Spine Institute of San Diego: During the pandemic, my office stopped seeing elective patients in the office. My immediate staff of eight started working remotely, and we continued to care for patients via telemedicine. We discovered that working remotely had many advantages. Personally, I love the freedom of working in a comfortable environment, in my PJs at home. My staff felt the same. But most importantly, we found that patients, while reticent at first, also embraced telemedicine.
As an illustration, I often run late in clinic, often well past one hour. When patients can wait in the comfort of their homes, instead of a crowded waiting room, they do not seem to get upset when I run late. Everyone is less tense and I am less impatient during the encounter. I plan to continue telemedicine and work-from-home programs well after the restrictions of the pandemic are eased.
Scott Boden, MD. Chair of the Department of Orthopaedics at Emory University School of Medicine and Vice President for Business Innovation at Emory Healthcare (Atlanta): The COVID-19 pandemic has reduced our practice for six weeks to caring for only emergent, urgent, and time-sensitive orthopedic problems. We are only starting to resume 'essential' surgeries as of May 4. The biggest short term impact is that we were able to start up telemedicine from scratch in 72 hours creating new work flows, technical help teams, and scheduling templates thanks to our creative and flexible physicians and staff at the Emory Orthopaedics & Spine Center.
This is something we had been thinking about for years and were able to make it happen in days. We plan to keep our office traffic (patients and staff) at 25 percent normal density by utilizing telemedicine to enable social distancing and lessen the chances of spread among asymptomatic or pre-symptomatic employees and patients. We are also continuing with our 'two-team' approach with four day 'in office' and 10-day 'work from home' rotation cycles.
Kern Singh, MD. Co-Director of the Minimally Invasive Spine Institute at Rush (Chicago): The pandemic has led to a complete shutdown of my practice. We felt it was our social responsibility to adhere to the governor's stay-at-home orders. This dramatic shutdown led to an immediate shift towards telemedicine visits. We are now just beginning to emerge and the patient volumes have been exceedingly low, in large part due to the stay-at-home orders still being in effect.
Mick Perez-Cruet, MD. Beaumont Hospital (Royal Oak, Mich.): Our practice (Michigan Head & Spine Institute) is very active conducting telemedicine clinics. I find that patients are very comfortable and enjoy doing telemedicine clinic visits from home. We have developed a neurological examination that can be done via the telemedicine portal and a manuscript on the topic was just accepted for publication in International Journal of Spine Surgery. We hope other surgeons will find this manuscript helpful. I plan to continue these clinics well into the future especially for my older patients, those that live far away and out of state, and patients at higher risk for COVID-19 infection morbidity and mortality.
Dwight Tyndall, MD. Dr. Spine (Munster, Ind.): The pandemic has affected patients' desire to move forward with surgeries. This reluctance might be due to concerns about going to the hospital where COVID patients are being treated. As such, we have moved most cases to our outpatient center. In the office we have moved to telemedicine to decrease the physical patient load in the office.
Charley Gordon, MD. Precision Spine Care (Tyler, Texas): This pandemic has substantially affected our practice, which is focused primarily on elective care for patients. Our state had a mandatory lockdown of anything other than urgent procedures, which substantially curtailed our volumes. This has had a dramatic and unintended negative consequence of making it more difficult for us to combat the opioid crisis.
We are presently open and all staff and patients are using personal protective equipment while in clinic.
Nick Shamie, MD. Chief of Orthopedic Spine Surgery and Vice Chairman of International Affairs at the David Geffen School of Medicine at UCLA (Los Angeles): The pandemic has significantly impacted our volume in our clinic and the OR. The impact was obviously due to the mandate that the hospitals and healthcare facilities need to stand prepared for an exponential growth in COVID-19 patients needing supportive care. We have flattened the curve in Los Angeles and fortunately did not see the same surge that occurred in New York, but we are not yet through it completely and still need to monitor this fluid situation for the next year or two.
As we open our doors to in-person visits versus telemedicine and begin performing elective surgeries, we may continue to have lower volumes due to patients' fear of hospitals as a place with higher concentration of COVID 19 patients. Furthermore, with high level of unemployment and decrease in number of individuals with employer sponsored health insurance, we will see a decrease number of high cost elective surgeries unaffordable by individual patients. This will perhaps promote less invasive and lower costs surgeries that can be performed in surgicenters or as an outpatient in hospitals.
We will have to continue isolating our COVID 19 patients and staff caring for them in designated locations within our facilities to minimize the risk of nosocomial infections. We need to gain the trust of our communities by showing them that hospitals and surgical facilities remain safe havens for healthy patients' elective surgical needs.
Paul Slosar, MD. President of SpineCare Medical Group (Daly City, Calif.): We laid off almost 50 percent of our employees and cut spending as deeply and rapidly as possible. As a spine practice, we have had to maintain some clinic accessibility for patients as many are experiencing neurological symptoms that require an urgent evaluation. Our remaining staff have been amazing, making the waiting room and exam rooms re-designed for spacing and easy cleaning turnover. My partners and I have done some emergency cases each week to address those patients with symptoms that fit the emergent/urgent criteria and have worked closely with our hospitals on coordinating these efficiently.
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