Across history, there are those touchstone moments that unite a generation. These are the events when all individuals – regardless of race, ethnicity, gender, religion or other defining features – can easily say, “I can tell you exactly what I was doing when …” Such disruptions include the bombing of Pearl Harbor, assassination of President John F. Kennedy and the resignation of President Richard Nixon. For many, the COVID-19 pandemic will become that touchstone event. During these last six months, each of us has lost something. At the extreme, many of us lost loved ones, often unable to see or be with them in their final days. Many have relinquished graduations, proms, long-planned vacations, visits with aging parents and newborn grandchildren, and more. For those of us in medicine, more has been given up, including many educational programs (national and specialty meetings), traditional processes of caring for patients and interacting with families, as well as freedom to move around the hospital without layers of personal protective equipment (PPE). Certainly for neurosurgeons, this is the first time we have been forced to draw down our surgeries and then accelerate them again during uncertain times. What did this process reveal and what are the future implications?
Ramping Down on Demand
As the crisis in New York accelerated and limited predictive data was shared, much of U.S. health care responded rapidly and dramatically. There were concerns about ICU beds, staff and equipment. Scarcities of PPE were a reality. All resources were threatened, no one could predict the next week or month but all signs pointed to disaster on a major scale. One of the first decisions made was to shut down all “elective” surgery and to dramatically reduce the use of PPE by limiting the number of residents and others in training in the operating room (OR). This all sounds simple and appropriate and from what I witnessed generally, there was outstanding cooperation. There were some very good things I experienced, including:
- A rare opportunity for a surgeon to call and speak with a patient/family about the cancellation and all the surrounding issues. This provided the opportunity for us to connect during difficult times, which felt intensely rewarding and created a bond that helped carry the day.
- Tremendous cooperation across the system in determining how to best make these changes while still maintaining quality patient care and education.
However, there were less optimal issues that proved challenging and frustrating:
- The burden was not equally shared – I witnessed less efficiency outside the surgeon’s team (OR staff and anesthesia) in limiting personnel, shift changes and similar to protect PPE.
- No one could really define what was essential and not elective and sometimes individuals took on the job of “playing god” rather than allowing appropriate mechanisms to be developed.
- There was talk that some institutions tried to “use the opportunity to get ahead” by implementing very lax restrictions.
- The financial impact to all health care systems was enormous.
Everyone found they had extra time on their hands. Some used with great purpose, helping their systems devise emergency plans, ramping up education on all levels, establishing innovative practices, using time off to be with family or volunteer. But, I also witnessed many sinking into that malaise that comes with inactivity. Human resources were often squandered – it was disheartening to watch numerous staff playing online video games, watching movies, doing their banking, etc. Some physicians used it as an opportunity to bend the rules and to communicate with their staff and patients less. I saw some things that did not make me proud.
We also discovered that many systems were not prepared for cancellations and rescheduling:
- Time-consuming, expensive electronic medical records (EMR) were not good at tracking the surgeries.
- Insurance company processes were grossly insufficient and inefficient.
Finally, there was that ultimately sticky question: what was “essential,” “elective” or something else? There are some obvious choices like a brain hemorrhage after a car accident (essential) and face lifts (elective), but in neurosurgery many things fall in a much grayer zone. Some of my patients were incensed that we refused to do their surgery because of pain (from herniated discs), while others with progressive spinal cord injury (cervical myelopathy) declined surgery feeling the risk was too high. Many questions were raised in my practice and no doubt others as well.
Ramping Back Up
The first critical decision was when to do and how. Most of the decisions were local and driven by state regulations in terms of resumption, but all other decisions were based on incredibly limited science. For example, most institutions opted to restart with outpatient surgeries and those deemed “urgent” if not “essential.” Did we really know that the risk to all was so much lower for ambulatory cases? How much higher was the risk if a surgery required hospitalization for one night? Two nights or more?
Many other questions and issues arose:
- Should we still consider PPE precious and protect it?
- How did we account to the remarkable lack of efficiency in everything we now did?
- Would insurers play fair with approvals or use this opportunity to be difficult?
- How could a huge backlog of cases be accommodated along with all the new demands?
- How quickly could systems that had been shut down ramp back up?
Overall, I found my patients to be gracious and thankful. None have complained about the inconvenience of rescheduling or the extra testing required. Most have willingly complied with wearing face masks and using telemedicine. A new rapport between doctors and patients seems to be growing, replacing the decade slide of confrontation and distrust. More often, my work felt like a true collaboration between the patients, their families and my team. That was incredibly rewarding.
On the flip side, during the COVID pandemic, it seems there are those who take on considerable extra burdens (stay-at-home parents, grocery store workers and many physician leaders) and those who chose to snooze. There are those inevitable individuals who too rapidly get accustomed to the “easy life” with little work or responsibility, leaving early most days or “working” from home (please understand, I don’t include those many who work effectively from home). These people are resentful when a return to full capacity is expected and often create a difficult work environment. This included the whole spectrum of staff from professional to support. As the saying goes, these bad apples could spoil the whole bunch!
2021 and Beyond
Hopefully, we have all learned important lessons from the last six months – I certainly have. Life is short, and you can weather many storms by keeping to what is really important and meaningful in life. Having a meaningful interaction with your patients brings immeasurable rewards beyond the medical care they seek. Challenges and roadblocks breed opportunity for innovation, and those that think outside the box will help propel others forward, beyond the impediments and to a better place. Let us hope that these are all gifts we can receive from the challenging days we have endured.
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