The demands of the worldwide coronavirus pandemic are having major effects on health care delivery in the United States. Some of those effects are likely to create lasting changes, such as extending the use of telehealth for specialized care, according to health and management professionals participating in a recent webcast sponsored by Newswise. Speakers said they also hope the pandemic will lead to better U.S. preparedness, coordination, and communication at all levels of government and a rethinking of the supply chain for vital personal protective equipment (PPE) used by health professionals.
"Cancer is not elective. Cancer can't wait. It's incredibly scary to have a life-threatening diagnosis like cancer and also have the fear associated with the COVID pandemic on top of that," said Eunice Wang, MD, Chief of the Leukemia Service and Director of Infusion Services at Roswell Park Comprehensive Cancer Center.
"The cancer patients that I treat, which are perhaps the ones with the most aggressive medical cancer, acute leukemia, are individuals whose lifespan is measured in weeks or even a few months, so delaying therapy until the [coronavirus] outbreak improves is not an option for those individuals."
For many of these patients, she said, "delaying or putting off radiation, surgery, or chemotherapy is going to allow the cancer 100 percent to progress."
Change in Patient Care
Wang noted that Roswell Park has continued to prioritize delivery of cancer care "through the pandemic's ups and downs. We've remained fully operational throughout."
"I have continued to see patients and administer active chemotherapy with the knowledge that if I stopped my patients would not be able to see the end [of the pandemic.] We don't know how long this is going to last, this is not a 2- or a 4- or a 6-week delay...This could go on for months."
But Wang said she and her colleagues are very aware of their vulnerable cancer patients' fears and anxieties about the coronavirus, and "we have converted those patients that maybe didn't necessarily have urgent needs or weren't getting chemotherapy actively or were getting surveillance to virtual visits."
Roswell Park also has staff dedicated to screening patients for COVID-19 before they enter the hospital, at the time of their entry, and throughout their hospital stay depending on symptoms. "We are testing all patients prior to admissions and cancer surgeries," noted Wang.
These measures, necessitated by the coronavirus pandemic, have heightened health professionals' awareness of the role all play on the front lines in infectious disease control, said Wang. What is changing is "our awareness and our attention to infectious disease control and prevention, and I think that that realization that we play an important role in protecting and guaranteeing the safety of our patients and our staff...will go a long way and will be long-lasting after this [pandemic] has really been over."
What may also be long-lasting is a new understanding of science in certain subject areas, said Wang. Just as there was a surge in cancer research in the 1970s, so now "This pandemic might lead to advances in immunology and infectious control in genomics that might last for years to come," she said.
The pandemic has also spotlighted the need for focused attention on end-of-life care, she noted. "One thing the COVID pandemic has allowed us to do is to address the issue of end-of-life care and goals of care," said Wang. "Because we don't have good treatments and we are talking about putting people on and off ventilators, it has brought to the forefront that having discussions about DNR, do not intubate, do not resuscitate, really need to be done with patients at any stage whether they be young or old."
Boost in Telehealth
Wang said telehealth is here to stay, and has been boosted and strengthened by the pandemic.
"By doing virtual visits we've been able to extend outreach, particularly to those patients that live at quite a distance," she said. "If you look at the health care system in the U.S...the majority of people don't live within driving distance per se of a large city, so having the ability to connect with them virtually has allowed us to extend our care to those individuals who otherwise would not have access to the subspecialty care that we can provide."
As previously reported in Oncology Times, Congress recently passed a law to allow the Centers for Medicare & Medicaid Services to lift most telehealth restrictions after the pandemic emergency was declared, meaning that physicians can be reimbursed for telehealth visits.
Telehealth is especially useful for connecting on a regular basis with cancer survivors: "Cancer survivors require a lot of feedback and a lot of communication," Wang said. "So, for example, over the last few weeks I have done virtual visits with individuals from Canada and New York City, as well as South Carolina and Texas, through this new methodology which I wouldn't have been able to do otherwise."
But, like a number of physicians, including ASCO President Howard A. "Skip" Burris, MD, FACP, FASCO, Wang noted that not being able to see their patients in person is a big disadvantage to oncologists when using telehealth technology. "I did not go into clinical medicine and hematology, oncology specifically, to do virtual medicine 24/7," she said.
Wang said the desire that every medical student has "is to interact with patients and to feel that direct connection that you're helping individuals, you're improving their lives in some ways. Although I do appreciate the technology and the convenience of the virtual visit platform, what I miss is the personal interactions. I feel that it works best for those patients that I already have an established relationship with and I have seen over and over again, and I can easily re-establish that even through a poor telephone or video connection.
"For new patients, however, and for patients getting active chemotherapy and those who have symptoms, it is lacking. I can't shake the person's hand and I can't interact with them, they don't get to know me, we don't get to form that bond or that commonality if I'm meeting them for the first time over the Internet."
Even more important, Wang noted, is that when using telehealth for patients with acute symptoms such as chest pain or arm pain or difficulty breathing, "it's very inadequate because I can't make an assessment about whether they're having a seasonal allergy or whether they're having cardiac pain-not necessarily without an exam and without further evaluation."
Agreeing with Wang that some patients cannot wait for specialty care-pandemic or no pandemic-was Joseph A. Dearani, MD, President of the Society of Thoracic Surgeons and Chair of Cardiovascular Surgery at the Mayo Clinic in Rochester, N.Y. He noted that, in the field of surgery, there are "grades of urgency." In the world of cardiothoracic surgery, some patients can die if surgery is delayed, he stated. "And there are cancer patients where there is some ability to delay a bit, but not too long; otherwise you run the risk of the cancer perhaps spreading," he said. "So it is a specialty that has been difficult to delay for too many patients for too long."
Health Care System Changes
The global pandemic has made painfully clear the need for better U.S. health care infrastructure coordination and communication at all levels, said Robert Bonar, DrHA, the Gordon A. Friesen Professor of Healthcare Administration at George Washington University.
Drawing on his 40 years of health care administration experience, Bonar stated, "On a national basis, I think that this crisis has brought forward the importance of crystal clear communication and coordination, especially as it related to protecting our health care service providers and offering the best advice to patients. I think that's going to have to change and is in the process of changing."
Bonar said it is evident that better communication and coordination need to occur among health care providers and government agencies regionally, in the states and nationally. He also hopes that the pandemic will help the general public have a much better appreciation of health care professionals and the need for smooth health care service delivery. He said that ideally this increased appreciation could be translated into increased support for the U.S. public health infrastructure through taxes.
The pandemic has also brought to the fore issues with the inadequacy of supply chains for PPE and other medical equipment urgently needed in a time of crisis, said Gilberto Montibeller, DSc, Professor of Management Science at Loughborough University in the United Kingdom and Senior Fellow at CREATE (the Center for Risk and Economic Analysis of Terrorism Events) at the University of Southern California.
"There should be no doubt that we have underinvested in public health," he said. "If you need it right now, you might not have it. And I think this would call for a more strategic take on these supply chains of PPEs and other critical medical equipment."
Webcast speakers agreed that a benefit of the COVID-19 pandemic is that it has brought medical professionals together in important ways.
"All anesthesiologists get training in critical care medicine," said Mary Dale Peterson, MD, MSHCA, FACHE, FASA, President of the American Society of Anesthesiologists and Executive Vice President and CEO of the Driscoll Health System. She described how in her health system intubation teams were organized and some operating rooms were converted to deal with the pandemic. She also said a number of anesthesiologists left their homes in Florida and traveled to New York when the pandemic was at its peak there to serve patients at personal risk to themselves.
"It's inspiring what has happened, against a lot of difficulty in our fragmented health care system...whether in medical specialties or surgical specialties, it's very impressive how people have functioned," said Susan McDaniel, PhD, Professor of Families & Health in the Department of Psychiatry and Family Medicine at the University of Rochester.
Dearani agreed. "I think that the pandemic has really tested our physical and our emotional well-being and our communication skills because it adds pressure to the situation," he said. "I think that in the eyes of the world the medical profession has performed really quite well under very untoward circumstances; personally, I feel proud to be part of a profession that [has shown] the higher the pressure the better the performance."
"I feel that during this crisis, we have all risen to the challenge," said Wang. "I feel like patients and doctors and respiratory techs and psychiatrists and even down to the people who clean and sterilize and change the linen in my exam room, we feel in a way a common purpose that we are continuing to provide care." She added that there has been "a lot of recognition of health care providers and frontline workers-flyovers and donations and so forth-and some of us feel a little bit guilty, because we're just doing what we're trained to do."
Peggy Eastman is a contributing writer.