Lisa Cassileth, M.D. recently had, perhaps, the most Beverly Hills-sounding pandemic experiences a doctor could have.
“We literally bought certified N95 masks out of the back of someone’s Maserati a week ago,” said Cassileth, M.D., a plastic surgeon who works in an independent practice in the Los Angeles enclave.
“We were like: ‘How did we know these are good?'" said Cassileth, founder of Skincare Center and Bedford Breast Center and Cassileth Plastic Surgery. "It’s so crazy around here. We go from like a totally intact society to the Wild West. How fast did we get here?"
Cassileth is among the thousands of physicians working to get their practices up and running again after weeks of shelter-in-place orders due to the COVID-19 pandemic deemed much of their business nonessential.
Physicians have reported challenges obtaining adequate personal protective equipment, establishing procedures that give them confidence that cases of COVID-19 won't spread on their watch and convincing patients to come back into the office once they have.
But with state-by-state guidance, physician groups say they are feeling their way through new territory as they seek to keep their businesses running.
Many of the moves physicians make will be largely tied to their particular specialty and local conditions.
"When COVID hit, California basically shut down and said ‘All the businesses are closed.’ On top of that, Beverly Hills took even more initiative a few days earlier and said ‘There is no more elective surgery.’ That kind of left a gray area at that time for exactly what elective is," said Cassileth, who performs cosmetic surgery as well as breast cancer reconstruction surgery. "The way we interpreted it was: 'If it’s cancer-based—if it’s not safe to put it off, let’s say, a month—you should do it.'"
The reconstructive cancer surgery wasn't a huge part of her practice; less than half of the work she does. "But the silver lining on that is that it kept us from completely losing our income because a lot of plastic surgeons in Beverly Hills are 100% cosmetic," she said.
Cassileth said reopening has also been less than clear, at least for cosmetic surgeons, as Beverly Hills and the state of California began to loosen restrictions.
"[Gov.] Gavin Newsom two weeks ago came out and said: 'We can do elective surgery. I’m not talking about cosmetic cases, but we can do elective surgery.' So everyone was holding their breath in the Beverly Hills community. When is he going to say it’s OK to do cosmetic cases?" Cassileth said. "The answer, we realized, was never. Can you just imagine the PR? People are dying of coronavirus and Gavin Newsom stands up and says ‘Now you can get a facelift.” That’s never going to happen."
So surgeons in that region began scheduling surgeries on May 15 that were more cosmetic in nature while taking precautions to ensure patients aren't contracting or spreading the virus in their practices, she said.
Houston-based endocrinologist Medhavi Jogi, M.D., was also able to begin reopening his practice for procedures in early May after a frustrating two months of indefinitely delaying certain procedures such as biopsies.
"We were saying: ‘Yes, we know you have thyroid cancer, yes I know you have a nodule. Yes it could be cancer. I’m sorry I can do nothing for you other than tell you to see me sometime in six weeks, eight weeks, a month. We don’t know.'”
But Jogi said his practice decided to move slowly to bring patients back into the office despite grappling with the financial ramifications of fewer in-person visits.
"What we decided was, instead, to not change anything because then we'd have to call every patient on the schedule which is a lot of man-hours," he said.
The paradigm shift to telehealth
Before COVID-19, about 30% of business at Jogi's office was delivered via telehealth. In about a day's time back in March, 100% of the practice's business shifted online.
It wasn't a terribly difficult shift to make, since protocols were already in place and the group had experience delivering care via telehealth, he said.
However, for a practice that treats diabetes and thyroid conditions, some elements remained tricky, Jogi said. For instance, some patients just couldn't get their glucose monitors to connect back to the practice. And then, of course, there were the delays for the biopsies. Despite the practice making the shift to mostly delivering care online, the number of patients seeking care dropped precipitously.
One trick that worked to pump up volumes: When Jogi opened up his schedule for times as early as 5 a.m. or as late as 9 p.m., he found those hours were popular.
“It made sense. These are people that have kids at home, they don’t have time because they’re already doing 20 things at once," Jogi said. He expects that even as the physical office opens up, the extended telehealth hours will continue.
For Cassileth, one of the best investments her practice made was near the beginning of pandemic-related closures into a new feature provided by the electronic health record (EHR) platform she uses.
That feature is a digital intake questionnaire that takes a patient's entire health and surgical history and automatically pulls that information into the patient record. While 90% of work shifted to telehealth, that feature is crucial to providing more efficient care online and getting paid for that time, she said.
"I’ve noticed a lot of doctors online will be like: ‘I’m just going to do it because I want the patient. I don’t want to charge.' I’m like: ‘No, you charge. Now is a really good time when we’re finally able to bill.' So make sure you take the total history," Cassileth said. "That’s been much more efficient and my billing has actually been better during this period because of the telehealth elements and the EHR acquisition."
Creating a safe space
The first step to reopening the physical office is obtaining adequate personal protective equipment (PPE)—and therein lies one of the greatest challenges.
Practices and others around the country discovered the supply chain for masks still hasn't been able to catch up even after months of companies ramping production.
"Can my staff and doctors wear something to protect themselves? And we didn't have any," Jogi said. Statewide medical organizations sent out an email offering up to 200 N95 masks to doctors who needed them but emailed back just minutes later saying they'd run out. "I'm sure every physician in Texas was flipping out saying 'We're open, but we have no way of seeing anyone because we don't have masks.'"
Jogi said he paid $600 for about 20 N95 masks in late April. They each got brown bags labeled Monday through Friday and drop their masks in the bags to save for reuse week after week. Members of the practice also got alcohol spray bottles they can carry around to sanitize throughout the day. The spray bottles are also set at the front of the office as patients enter to be able to carry and sanitize their hands during their visit as well.
Cassileth's office donated much of their own supply masks to Cedars-Sinai Medical Center at the beginning of the pandemic.
"Nurses didn’t have PPE over there, and we have very close ties to Cedars," Cassileth said. "So we gave them half of our masks and then we totally regretted it."
With a dearth of testing, Cassileth said her practice was doing only the most emergent cases. Amid reports that the viral load—or the amount of virus a person was exposed to over time—might lead to a greater chance of serious illness, her practice was concerned infected patients might pass the screening protocols and end up spreading the virus during surgery. There was a special concern for anesthesiologists doing intubations.
So, upon the guidance of Cedars-Sinai, the practice began clearing the room after a patient was intubated for a period of time due to concerns the virus aerosolized. With the availability of adequate testing, Cassileth said they no longer delay procedures in that way.
Masks are starting to become easier to come by, Cassileth said. "We’ve got a system now where we’ve got enough that we’re still trying to look for the backs of Maseratis occasionally, but we’re OK. We finally have enough."
Jogi said after about a month and a half, his practice was able to obtain a very limited number of N95 masks. Patients are told they are required to wear a mask when they come to the office or do a telehealth visit. They are also screened for fever when they arrive.
Jogi said technology has helped reopen his physical practice.
First, the office removes any reason to talk to someone at the front desk by collecting information online ahead of time. The practice uses a telehealth service which has a texting system for patients to interact with when they arrive at the office. Once the rooms are full, patients are given a period of time when they can leave and will get a text when it's time to come back for their in-person visit.
"We said: 'What do we do when the waiting room is full?' And we said: 'What do the restaurants do?'" Jogi said. Many restaurants say, we don't have a table yet but we'll text you when we're ready, Jogi said. When the room is ready, patients receive a text saying: "'Well, go straight to room number one or room number two.' You don't wait in a waiting room," he said.
Physicians can alternate throughout the day between physically seeing patients in their office and seeing patients via telehealth visits. "This hybrid approach is something we kind of were playing with prior to COVID and now we feel it's the only way to do it," Jogi said. "Some have said, 'I want to do an office visit.' And then they chicken out ... they just let us know and we shift it to a telehealth visit without having to make massive shifts in the schedule."
Jogi recommends keeping information to patients as simple and straightforward as possible and simply focusing on using practice's real estate in a more intelligent way once patients arrive.
"The more rules you have to follow as a group or a practice, and the more you have to tell a patient, and the longer those messages get that you're sending out through whatever communication method, the less they will be read. And the less they will be followed," Jogi said. "So essentially, if you're trying to space people out and that's the major change COVID has created, then space them out without disrupting the clinic as much as possible."
At Cassileth's office, every single staff member gets temperature tested regularly and gets COVID-19-tested weekly. Everyone must wear masks in the office despite knowing they are COVID-19-negative. "It's a pain, but imagine if one person had COVID, they brought it in, they got a preop patient sick or brought it into the OR," Cassileth said. "You’ve got to close your office down because you can end up spreading it to everybody."
Every single patient gets a COVID-19 test a few days before surgery. The group went with a saliva test from Microgen which reports it is 100% specific and sensitive. But because it has a 24-hour turnaround, it requires the clinic to test the patient a few days before a procedure in order to have the results in time.
This process opens up a small window of possibility the patient could be infected between the time they take the test and when they show up for surgery—but it is one of the best options available for now, Cassileth said.
When patients arrive for an appointment at Cassileth's office, they call or text and are met by a staff member in an outside courtyard for a temperature check and to ensure they are wearing a mask. They are then escorted directly back to an exam room. When those patients leave, they are escorted out through a different exit. The room is then turned over as staff wipe down the entire room just in case.
"There are a million little things that the doctors feel like protects the patients but also gives the appearance that we’re trying to do everything we can," Cassileth said. "It’s probably overkill but also I think patients are really nervous coming back. They’re thinking, ‘Oh my gosh. I don’t want to go to a doctor’s office. They’re going to make me sick.'"
That is another major hurdle facing physicians' offices and hospitals alike in the wake of COVID-19: convincing patients it is safe to come in for treatment.
Cedars-Sinai, also in Los Angeles, launched a communications campaign with other health systems in the region to get the word out that patients could continue to utilize emergency departments after volumes for emergency care plummeted in recent months. Other health systems around the country have similarly focused on communications to patients about not being afraid to seek the care they need.
Cassileth said she thinks physicians should also try another tactic: Tell patients they aren't allowed to come in unless they pass certain screening protocols.
"You’re going to screen them to make sure they don’t have a temperature. You’re going to not allow them to bring their family members to their appointments," Cassileth said. "And when patients see you’re being protective against them—don’t come in and give me COVID—they also feel way more confident that your practice is safe as well."