Endocrinologists Navigate Deferments, Telehealth Amid COVID-19

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MAY 07, 2020 -- James V. Hennessey, MD, has been working from home, like so many others, since the lockdowns went into effect. The director of clinical endocrinology at Beth Israel Deaconess Medical Center in Boston, Massachusetts, has felt surprisingly heartened by his experience.

"So far, these [video-based] discussions have been reassuring," he told Medscape Medical News. "The images generating the referral have been available for review, and we've been able to reassure the patients that there are no danger signs in their histories." 

Hennessey noted that for patients who agree to thyroid nodule consultations via video consult, the arrangement has allowed for the assessment of difficulty swallowing and other obvious difficulties.

While Hennessey has not yet encountered anything serious during his virtual consults, such as a rapidly growing anaplastic thyroid cancer, "it will only take some time before we hear of one, I'm sure," he observed.

Surprisingly Productive

During the COVID-19 pandemic, many physicians have been forced to innovate and turn aspects of their practices virtual. Use of telehealth services has increased by 50% in the United States since the start of the pandemic, according to research by Frost and Sullivan consultants. Three endocrinologists report that telehealth, although not always ideal, may provide more information than expected.

Recent recommendations say physicians should defer biopsies of asymptomatic thyroid nodules until the risk for COVID-19 has passed. As a result, some patients may experience increased anxiety because of such delays.

But cases determined to require more urgent care should not be delayed, says the guidance.

Trevor Angell, MD, concurred that it's possible to safely defer thyroid nodule assessment.

"I would agree that with appropriate risk stratification by symptom assessment, ultrasound, and lab testing, thyroid nodules can be safely triaged for delayed evaluation," said Angell, an assistant professor of clinical medicine and associate medical director of the Thyroid Center at the Keck School of Medicine of the University of Southern California, in Los Angeles.

"I have found that patients with thyroid nodules that are not highly suspicious are reasonably reassured that the delay in obtaining FNA [fine needle aspiration] is very unlikely to have an impact on the ultimate outcome," he told Medscape Medical News.


But he does have concerns that many of the investigations needed to make a decision about whether treatment can be deferred are also on hold.

"In many settings, including my own institution, nonurgent radiology studies are not being performed," he noted. And "patients are reluctant to go to an ultrasound evaluation or a laboratory to perform testing" because of worries about COVID-19.  

"For possible thyroid nodules that have not yet been evaluated, this presents difficulty in getting the accurate ultrasound risk stratification and/or calcitonin testing that would help determine the need for immediate FNA biopsy or surgical consideration." 

And for patients in whom surgery has already been recommended, because of "indeterminate FNA cytology or suspicious molecular test result," there is likely to be even more anxiety, Angell said.

"Most Patients Happy" With Video Visits

American Thyroid Association President-Elect Victor J. Bernet, MD, noted that while his practice already had planned to start doing some video visits in April, the process was by necessity jump-started in March.

"Currently, about 90% to 95% of our appointments are video visit or phone-call based," he told Medscape Medical News.

"Most patients seem to actually be happy with the video visit experience," he said. "Some patients were very happy that they were given the opportunity to not have to come into the clinic in person at this point in time."

Bernet agreed that video consults can be productive in identifying some important clinical information.

"I have had at least a few patients with obvious goiter or nodule," said Bernet, an associate professor and chair of the Division of Endocrinology at the Mayo Clinic Florida, in Jacksonville.

"I also had a patient with hyperthyroidism from Graves' disease and we were able to assess her for tremor over video."

In the latter case, "we had the patient place a sheet of paper on the top of her hand while her arm was extended, which is the technique that can be used in person as well, and helps amplify the ability to detect if a fine tremor is present."


"It was obvious that this patient had a tremor by video," Bernet said.

In addition to tremor, video visits can be helpful in "looking for the presence of thyroid eye disease, enlarged thyroid, and possibly even skin changes." Video may also be useful in evaluating respiratory effort and some cognitive behaviors, Bernet noted.

Starting to Think About Elective Procedures Again

As centers in the United States begin to reopen and permit elective procedures again, patients being considered for FNAs will likely be reintroduced according to the level of need, Hennessey noted.

"Those with clear indications for FNA will be the first (to be scheduled)," while those who had very low risk findings, such as small nodules and cysts, "have already been deferred to 6- or 12-month follow-up ultrasounds, and decisions regarding FNAs will be made based on clinical course."

Angell agrees that efforts to address the most urgent cases once centers reopen will be of the utmost importance.

"To the greatest extent possible, providers should work together to coordinate the rescheduling of patients for FNA or surgery to avoid any further delay for those at most risk," he said.

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