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04/02/2020

How is Your Practice Responding to the COVID-19 Pandemic?

Connect with other MSHO members to share resources and best practices related to the clinical management of patients as we face this challenging time.

The first day in the office after the announcement of the national emergency, I felt uneasy. Patients and family members are calling to ask whether they should come in or bring their family member in for their treatment. Many of the questions had to do with the general benign heme follow-up which can comprise a large portion of our days. It raised questions in my own mind as to what was needed for these patients. Many are elderly and infirm from other comorbidities. Some are simply well but with a lab abnormality that has not yet achieved clinical significance.

As I thought more and grappled with the issue of self-quarantine, reducing the spread of Coronavirus, balancing the needs of patients and staff, I realized that what I am hearing requires a place for us to vent, share experiences, give and receive advice. Several nurses commented on their concerns about how to answer patient/family questions. There were concerns about where health system leadership is in this crisis. I received (albeit some is secondhand) conflicting opinions from colleagues about how to structure our office visits, the process of triage, etc, all while receiving a blitz of helpful advice from many organizations in the interest of educating their customers. I am feeling my way through this as well, without any sense of experienced leaders taking charge. I realized that as part of the way I need to process this, I must take charge of my own piece of the situation – how and with whom I interact, in keeping with recommendations for social distancing. But, how does a practicing heme/onc doc comply conscientiously and compassionately, where hands-on is a must for many of our patients. Do port flushes need to be deferred? How about those ESA and GCSF’s? What about transfusions? How will our bottom lines be affected? And if that is a source of concern, what does that say about us?

Feel free to comment -  maybe we can be the MSHO community that we desire and need at a time like this. Please stay away from political grandstanding. Postings will be monitored and rejected if they cross the line.

Jerome Seid, M.D., FACP
Greats Lakes Cancer Management Specialists

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7 Comments

Kristian Koller, DO on Tuesday 03/17/2020 at 12:03AM wrote:

In my practice, physicians have been given discretion as to how each will manage their own schedules and cancellations. I have made the decision to drastically limit the number of patients that I see in person. I hope that my Hematology Oncology colleagues across the state will do the same.

We care for an at-risk population, and as such, I feel it is our duty to both minimize the total amount of patient contact that we have as well as to limit our patients' exposure to health care facilities.

Given this reasoning, I have made the following changes:

1) I have delayed most of my "cured" visits by 2-3 months. Examples would include breast cancer patients on adjuvant endocrine therapy, or solid tumor patients who have completed adjuvant treatment and are scheduled to discuss stable CT results. I feel these patients are at quite low risk for harm by not having an in-person visit.

2) Stable MGUS patients and stable CLL patients. These patients can be managed short term by lab draws and phone calls without risk of exposing them to others

3) Benign heme patients - this covers a lot of ground, but unless the issue is acute many of the common conditions including myeloproliferative disease, bleeding disorders, thromboembolic disease, and stable cytopenias can safely be managed in the short term without a face-to-face visit.

In addition, I am planning to utilize telemedicine for my outreach site for the next 1-2 weeks and perhaps longer. Our hospital system is exploring whether or not we have the capability to offer this service more broadly to other patients in the region.

I hope that others find these suggestions useful, and I welcome feedback as to what my peers think and how they are changing their practices.

Kristian Koller, DO
Grand Traverse Oncology Hematology

Ulka Vaishampayan on Tuesday 03/17/2020 at 08:57AM wrote:

agree, confusion abounds and this is driven by lack of data.
Gathering evidence will take time which we don't have unfortunately!
I think any visits that can wait, please cancel. I am trying to communicate results by phone as much as possible.
Is 14 day quarantine still required or if you have no symptoms can you wear a mask and keep working?

Jerome Seid, M.D., FACP on Tuesday 03/17/2020 at 10:16AM wrote:

Kristian - Thanks for starting the thread. I appreciate the ideas and description of your own current approach - it does make a difference. I think this is a time when we should demonstrate to our patients not only our concern for their well-being by reducing their exposure and the associated anxiety but the concern for unnecessary exposures for our staff. It is clear to me that much of what we do with respect to surveillance-type visits for "well" patients is done without any true evidence. And yet we deal with a population of already frightened patients. This should be a time for practice and individual self-evaluation as to our motivations and priorities. I believe the phone calls and face-time visits will go a long way to alleviate the isolation and fear.

Jerome Seid, M.D., FACP on Tuesday 03/17/2020 at 10:24AM wrote:

Ulka - I have no idea! I think it is prudent to wear a mask and keep working if you can reliably and truthfully know you are not exposed, or meet the current criteria for testing. That said, I have concerns that I may be inappropriately using a resource that is currently considered potentially in short supply. Is it sensible to periodically take your temp and once testing is more available, get tested as well? Just questions - no answers.

Jay Winegarden on Tuesday 03/17/2020 at 10:32PM wrote:

Ulka-
The 14 day quarantine per our department is for those who are exposed to a COVID19+ patient unknowingly (thus without PPE on). Discussion within the GME department here has led to a lot concern as the resident work force can be "taken out" pretty easily which can cause strain on the system. My understanding is that in Seattle what they are doing is sending those exposed home for 7 days then bringing them back and testing them on days 7 and 9 allowing them to work with an N95 respirator and other appropriate PPE during that time. The idea being that now we can test and thus should be able to identify if you have been infected.

Kristian- we are doing the same in our practice with phone encounters and pushing those out wherever possible. In addition we have completely closed the cancer center to all visitors (along with through traffic to the adjacent hospital).

I have just spent the last 8 days as the inpatient rounder and have witnessed a lot of confusion regarding guidelines. The lack of PPE in our hospital is staggering and I have adopted my consult strategy for those in droplet precautions/rule out COVID19 by not going into the room. If I think a phone call to the service is really all that is needed I do that. If not, then I will do a chart review and talk to the patient by their bedside hospital phone. My reasoning is that burning through PPE while we wait for test results (taking too long btw) does no one any good and why risk exposure which will dwindle the work force.

What has been keeping me up at night is the very real possibility that the health system could become overrun soon as many suggest. The reality for us as oncologists is that if that comes to pass we will be seeing many of our patients die as they will not be deemed appropriate for ventilatory support given their underlying diagnoses. Are you aware of any discussions going on about this at your institutions?

-Jay

Jerome Seid, M.D., FACP on Wednesday 03/18/2020 at 08:09PM wrote:

Jay - I have not heard of any discussion of possible need to allocate resources to those deemed in need but also most likely to recover if severely affected. I have to say I have never thought I would be in the position of having to decide that for any of my patients. Yet I have had those ideas for several days now. The concept has the potential to create a true dilemma in trying to determine what we consider necessary treatment vs that which is hopeful (even with evidence of benefit). A patient who is NED may still be a high risk to not survive.
As another example of concern, does the process of bringing an elderly patient with stage IV lung cancer receiving palliative chemo to the office for treatment in fact place that patient at a higher risk of death than the cancer itself merely by increasing viral transmission risks? ASCO's COVID-19 FAQ's are informative but leave things too open-ended to make me feel less conflicted.
Has anyone's practice resorted to a process like some restaurants do with a beeper, or their smart phone etc and have patients wait in their car rather than a waiting room and have them escorted in from the door by staff, to control congregation and movement? I have heard of one solo ENT practice doing this.

Jerome Seid, M.D., FACP on Tuesday 03/24/2020 at 02:52PM wrote:

So, here goes - I am sitting here at home, sort of self-quarantined, on the basis of a discussion with my partners - to try and reduce my exposure out of deference to my "advanced age" (a strapping 61), and the idea that we can rotate docs out to keep us healthy and able to step in if a doc truly "goes down" due to exposure or symptoms. Not easy for me because I am so used to being in the thick of things. Yet I must admit I am scared of this virus even though I am otherwise healthy. I have had to tell my wife and kids that I am prepared for the fact that I may end up on a ventilator and might not survive.
My wife has me home quarantined as well so I don't inadvertently breath on her!- my basement couch is quite comfy and truth be told I don't mind the quiet.
Yet, I am also uncomfortable at home and feel sort of guilty as if I am not doing my share, and putting others in harm's way by not being in the office or seeing patients in the hospital. Yet my own judgement is that until PPE distribution is available to protect us adequately, I am not comfortable being where my services are not emergent and possibly risky to others and myself. Is anyone else feeling the same degree of conflict or is it just me? And how are you managing it? Drugs? Meditation? Psych? Spiritual guidance?

Disclaimer: The opinions expressed in the comments shown above are those of the individual comment authors and do not reflect the opinions of this organization.