For doctors and patients, worries are rising about pandemic-delayed treatments for other conditions

drscope-300x200The public health restrictions put on much of the nation to battle the Covid-19 pandemic also have created complications for patients’ receiving other kinds of health care — a reality that the nation will need to deal with in the weeks ahead.

Doctors and hospitals will need to see whether their coronavirus case loads are such that they can begin to reconsider providing what were deemed nonessential medical services, including often performed procedures like shoulder, knee, and hip surgeries.

Most hospitals, responding to federal and state requests, put off elective procedures, notably because they did not want to put patients and heightened risk and because medical facilities nationwide have experienced desperate shortages of personal protective equipment and drugs. Some institutions have pressed ahead with operations they have deemed needed, despite questions from critics.

For cancer patients, the coronavirus-related shutdown of medical services has been scary and concerning, the independent, nonpartisan Kaiser Health News service reported:

“People with cancer are among those at high risk of complications if infected with the new coronavirus. It’s estimated 1.8 million people will be diagnosed with cancer in the U.S. this year. More than 600,000 people are receiving chemotherapy. That means millions of Americans may be navigating unforeseen challenges to getting care.”

The news article noted that major cancer organizations have been inundated with calls from worried patients and their loved ones. KHN interviewed Dr. Len Lichtenfeld, the American Cancer Society’s deputy chief medical officer and he others observed:

“This is uncharted territory for cancer care … Hospitals are making these ‘decisions on the fly’ in response to how the pandemic looks in a particular community. ‘There is no single national standard that can be applied. I am afraid this is going to become much more common in the coming weeks.’ The cancer society recommends that people postpone their routine cancer screenings — for now. The American College of Surgeons has published guidance on how to triage surgical care for cancer patients. But Lichtenfeld said every decision ultimately depends on the availability of resources at the hospital and the pressures of COVID-19. In Washington state, which has been hit hard, hospitals are shifting surgical space and beds away from other kinds of treatment.”

Treatment decisions for patients with advanced cancers can be especially difficult because they may be more vulnerable to infections after chemo and radiation therapies, an oncologist said in a New York Times Op-Ed:

“[M]y patients’ immune systems are so exquisitely fragile, because the cancer treatments they need to fight a disease that can be scarier than Covid-19 leave them so immunosuppressed, that it doesn’t take much even without a pandemic for them to catch an infection that could kill them. For some patients, I can schedule a virtual visit. But I can’t draw a patient’s labs to look for leukemia over Skype. Zoom doesn’t have the functionality to transfuse blood.”

Another cancer specialist, in a separate New York Times Op-Ed, expressed concern about treatment delays but tried to find some optimism still, writing:

“In many instances, there is already evidence that changing the order of treatments does not change cancer outcomes. ‘Patients who would ordinarily have their breast cancers removed surgically as their first treatment are now being treated initially with hormone therapy or chemotherapy,’ said Dr. Lawrence Shulman, a medical oncologist and deputy director for clinical services at the University of Pennsylvania’s Abramson Cancer Center. ‘This can delay surgery for three to six months without reducing the patient’s chance for cure.’ Doctors are trying to do what they believe is best for their patients, but so much crucial information is unknown.”

The specialist raises another medical concern — how the Covid-19 restrictions may be slashing at important research on cancer and other diseases, as clinical trials confront serious and growing disruptions. The doctor wrote:

“Beyond its effect on standard treatments, the pandemic has also affected trials of experimental therapies. Many clinical trials have stopped enrolling patients over concerns about infection. These suspensions may be devastating for some patients who may not live to see the trials reopen.”

For patients with heart conditions, the pandemic strictures may be yet another cause for health care worry, wrote Dr. Harlan Krumholz, a professor of medicine at Yale and director of the Yale New Haven Hospital Center for Outcomes Research and Evaluation. He reported in the New York Times from this institution:

“What is striking is that many of the emergencies have disappeared. Heart attack and stroke teams, always poised to rush in and save lives, are mostly idle. This is not just at my hospital. My fellow cardiologists have shared with me that their cardiology consultations have shrunk, except those related to Covid-19. In an informal Twitter poll by @angioplastyorg, an online community of cardiologists, almost half of the respondents reported that they are seeing a 40% to 60% reduction in admissions for heart attacks; about 20% reported more than a 60% reduction. And this is not a phenomenon specific to the United States. Investigators from Spain reported a 40% reduction in emergency procedures for heart attacks during the last week of March compared with the period just before the pandemic hit. And it may not just be heart attacks and strokes. Colleagues on Twitter report a decline in many other emergencies, including acute appendicitis and acute gall bladder disease.”

What’s going on? It’s not good, he contended:

“The most concerning possible explanation is that people stay home and suffer rather than risk coming to the hospital and getting infected with coronavirus. This theory suggests that Covid-19 has instilled fear of face-to-face medical care. As a result, many people with urgent health problems may be opting to remain at home rather than call for help. And when they do finally seek medical attention, it is often only after their condition has worsened. Doctors from Hong Kong reported an increase in patients coming to the hospital late in the course of their heart attack, when treatment is less likely to be lifesaving.”

A technological advance may be occurring due to the pandemic, with more patients and doctors taking up telemedicine, especially as federal authorities have encouraged this practice and changed reimbursement rules to foster it.

That said, much of medicine remains hands-on work, raising worry with those like dialysis patients who need sustained treatment. And pediatrician, fret not only about youngsters missing scheduled vaccinations and important preventive care but also whether their declines in patient visits may crash the finances of their practices, as KHN reported in a separate story:

“Across the U.S., thousands of pediatric practices that provide front-line care for the nation’s children are struggling to adjust to a dire new reality: crashing revenue, terrified parents and a shortage of protective equipment, from gloves and goggles to thermometer covers. And all while they are being asked to care for young patients who could well be infected with COVID-19 — and prime vectors for transmission — without showing symptoms. How well these practices adapt will be key as the nation looks to weather the pandemic: Pediatric offices provide a crucial release valve for the health care system by treating the broken bones, lacerations, colds, flus and chronic illnesses that might otherwise flood overburdened emergency departments.”

In my practice, I see not only the harms that patients suffer while seeking medical services, but also the benefits they can enjoy by staying healthy and out of the U.S. health care system. The coronavirus threatens to swamp our health resources, which, in their better times, already had notable problems with infections acquired in hospitalsnursing homes, and other medical care giving facilities, as well as major challenges with medical error and misdiagnoses. That said, at this difficult moment, we need to support doctors, hospitals, and public health officials as they marshal science, evidence, and facts to battle the global menace of Covid-19.

If you or your loved ones feel ill — and not only with coronavirus symptoms like fever, dry cough, and racking aches and pains — you should call your doctor or see if there are medical services available in offices, clinics, or other facilities besides emergency centers or hospital ERs. Your doctor can advise you by phone or telemedicine about appropriate care that safeguards you appropriately, too, against Covid-19 contact. If you have a chronic condition for which you have been under care, keep in touch with your doctors and don’t neglect her recommended regimens. Parents need to keep in touch with their youngsters’ pediatricians throughout the stay-at-home period, particularly if youngsters are hitting developmental or health milestones that require medical attention. By the way, if you can, consider donating blood as supplies are always needed, especially during these tough times.

In thick and thin times, of course, it is helpful to have researched and seen regularly a doctor you know and trust. If the lockdown leaves you time on your hands, this may be a useful project to pursue — finding good caregivers. By the way, if you’ve got them, they may need your support, too, in the days ahead with your resumed treatment with them.

Patrick Malone & Associates, P.C. listed in Best Lawyers Rated by Super Lawyers Patrick A. Malone
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