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Getting Non-Coronavirus Care a Complicated Effort

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March 23, 2020 -- There’s never a good time to be sick, but with so much medical attention focused on COVID-19, this is a particularly stressful time to need medical attention for anything else.

Even as this new coronavirus terrifies people and monopolizes the health care system, women will continue to give birth, people with chronic illnesses will need care, and strokes, heart attacks, and accidents will continue to happen.

Recognizing that reality, doctors, clinics, and hospitals are taking more steps to protect their patients from COVID-19, while still providing necessary treatment.

Hospitals are canceling surgeries that aren’t emergencies, aiming to cut down on using masks and gowns that soon might be urgently needed to treat COVID-19 patients. Some hospitals are being designated to treat non-COVID patients only, while others will focus on caring for people who are infected and struggling to breathe. The new coronavirus has blanketed the globe over the last 3 months, leading to more than 350,000 cases and more than 15,000 deaths.

Dentists offices are closing or only treating emergencies. Routine checkups are being canceled outright or put off by several months. Patients are being asked to come to doctors’ offices alone or with just one companion. Pregnant women getting ultrasounds are being asked to share their joy and get moral support only via video chat.

And the age of telemedicine is finally coming in earnest, says Joe Kimura, MD, chief medical officer of Atrius Health, a nonprofit medical group that treats more than 745,000 patients in Massachusetts.

This has forced everyone to at least try it as an alternative,” he says of telemedicine. “I think it really is going to help people -- out of necessity now, but probably out of convenience later.” There are limits for both medical professionals and patients in medical care via video. But this experience will also prove that telemedicine is “absolutely able to handle a lot of things,” Kimura says. And he predicts this new role for telemedicine will outlast the present crisis.

At Keck Medicine of the University of Southern California in Los Angeles, all providers have been trained in telemedicine, and they had already moved to lessen physical contact with patients before Friday’s announcement of a lockdown across California.

“We are able to accomplish a lot by speaking to patients directly by phone (or video) and addressing their needs to the extent possible,” obstetrician and gynecologist Laila Al-Marayati, MD, says via email. “It also helps to reassure patients who are worried about rescheduling appointments for more than 8 weeks without some contact with their provider."

She says her practice is offering phone or video appointments to patients who were scheduled for annual visits “to establish care, review their concerns and medical history,” and they’re bringing people in only when absolutely necessary. Other offices, she says, are canceling routine annual well-woman visits outright and scheduling them 3 months or more from now.

Appointments for pregnant women are being spaced out to reduce the risk of passing on infections, and women must come alone to appointments and ultrasounds, says Marc Incerpi, MD, chief of the Division of Maternal-Fetal Medicine at Keck. “While we know that coming to appointments without a loved one or significant other for pregnant patients can be difficult, we are doing so only to protect our patients, staff and community,” he wrote in a Thursday email. “We assess the situation daily and will make changes as needed.”

At New York City’s Hospital for Special Surgery, a leading orthopedic hospital, nonessential care has been canceled, though the hospital will “continue to provide essential onsite care, and are rapidly broadening virtual care (telehealth services), and will be increasing the availability of injury care at all locations,” according to an emailed statement. The hospital will accept orthopedic patients displaced from other hospitals that are focusing on COVID-19 care, and has donated its extra gloves and masks to New York Presbyterian, the statement says.

Risks to Cancer Patients

The people who are perhaps at the highest risk in this outbreak are cancer patients. If they continue treatment like chemotherapy that weakens the immune system, it will be more likely for them to have a serious case of COVID-19, and they will expose themselves to other people in the doctor’s office. If they stay home and skip treatment, they may risk a recurrence or spread of their cancer.

David Quinn, MD, medical director of the University of Southern California Norris Comprehensive Cancer Center, has been helping his patients make such difficult decisions over the last few weeks. With each, he discusses their chance of getting a serious COVID-19 infection -- a risk that is known to increase with age and other medical conditions such as heart disease -- vs. the possible danger of stopping treatment early.

“If you’ve got an end point such as we want to get them into remission, or you think risk-benefit is worth it, you may try to keep them on schedule,” he says.

Different medications also warrant a different equation, Quinn says. Chemotherapy lowers immunity, which is a riskier decision right now, while targeted therapies -- like hormone-receptor drugs for prostate or breast cancer -- and immunotherapies don’t seem to have the same effect.

For now, he says, most of his patients are choosing to continue their treatment.

But Quinn says he’s very frustrated that he can’t give patients a better sense of their risks because of the lack of testing for the virus. He had one former patient, he says, who tested positive -- after 5 days of trying to get access to a test. In the meantime, the man infected his wife, who has multiple sclerosis and is now fighting for her life. “Would a [timely] test have made a difference? I kind of think it might have,” he says.

And the situation could get worse, he warns, if the COVID-19 outbreak in Los Angeles, where he’s based, gets so out of control that every medical facility needs to focus full-time on treating people sick with the virus.

Bottom line: Now is a good time to defer medical treatment or do it by phone or video, if possible, instead of in person.

People sick with the new coronavirus need to be the focus of medical attention, and you don’t want to increase your own risk of catching COVID-19, says Marc Lipsitch, PhD, an epidemiologist at the Harvard T.H. Chan School of Public Health.

“Obviously sick people come to hospitals,” he says. “The general notion of trying to avoid hospitals is an even better idea than avoiding shopping malls or bars.”

Correction: An earlier version of this story had the incorrect name for Joe Kimura, MD, chief medical officer of Atrius Health in Massachusetts. 

WebMD Health News Reviewed by Michael W. Smith, MD on March 23, 2020

Sources

The Boston Globe: “Carney Hospital in Dorchester establishing COVID-19 treatment center,” March 17, 2020.

ArcGIS Online: “Coronavirus COVID-19 Global Cases by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University.”

Jim Kimura, MD, chief medical officer, Atrius Health.

Laila Al-Marayati, MD, obstetrician and gynecologist, Keck Medicine of the University of Southern California.

Marc Incerpi, MD, chief, Division of Maternal-Fetal Medicine, Keck Medicine of the University of Southern California.

David Quinn, MD, medical director, University of Southern California Norris Comprehensive Cancer Center.

Marc Lipsitch, PhD, epidemiologist, Harvard T.H. Chan School of Public Health.

 

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