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Surgical Perspectives

Letter to a Young Surgeon During Coronavirus Disease 2019

Alverdy, John C. MD, FACS

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doi: 10.1097/AS9.0000000000000003
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For generations of surgeons, the coronavirus disease 2019 (COVID-19) pandemic will be remembered as the single greatest change agent of our careers. It will also have reminded us that our preparedness for a complete shutdown of our day-to-day elective surgery practices had no contingency plan. In retrospect, our ignorance to anticipate this possibility is likely to have occurred as the infection control measures, antibiotics, and technical advances over decades shifted our practices toward nonemergent elective surgery. Daily schedules became more predictable, and our practices more specialized. Yet in the midst of the COVID crisis, we are now forced to reconsider what constitutes “indicated surgery” versus “unnecessary surgery,” at every level, medical, ethical, in the context of equitable use of resources and in terms of the risk to other patients and health care workers.1,2

The sudden disruption in “elective” surgery due to the COVID-19 crisis has forced many surgeons and surgical practices to rethink their referral strategy. Direct marketing to patients through media outlets by vein clinics, aesthetic surgery practices, spine centers, bariatric clinics, among others, may no longer yield the financial returns previously enjoyed. Hospitals whose financial health depends on a narrow profit margin driven primarily by elective surgery may have to reconsider their robotic surgery programs, their construction plans, and their executive overhead. Many of these hospitals are likely to close their doors.

Were the future of surgical care to undergo a massive shift in the workforce as hospitals close and individual surgeons’ elective practices become financially unsustainable, not only will regionalizing care be important but also regionalizing surgeons may be necessary.3 Structure, process, and governance will need to be developed to create statewide cooperatives in which individual surgeon skills and practices are deployed by need. As with the current COVID-19 crisis, a surgeon’s skill set and practice might be repurposed or relocated to meet the needs of a given population in a given location. How this will play out in a free market system will be challenging. Yet an open market for such services and their locations might itself evolve into a free market economy in which competition for the best posts emerges. How telemedicine, remote robotic surgery, alignment with referring medical centers/universities, and consolidation of service lines will play out, remains to be seen.4 Yet for current trainees to consider this an unwanted change, in my opinion, is wrong. Here I posit that our current trainees are among the best-educated and trained surgeons to meet these challenges and will make surgical practice and services safer, more available, and more equitable than has ever been imagined.

Our computer savvy, robotically facile surgery residents have accumulated an unprecedented amount of knowledge as medical doctors. The rigor and sheer volume of information in their undergraduate education, the competition to enter into medical school and the competition for a surgery residency, has resulted in the best, brightest, and most skilled trainees witnessed to date. Their quest for excellence to study health outcomes, health services sciences, and surgical biology by taking years off of their residency, coupled with more general surgery residents pursuing subspecialty training than ever before, has produced the most well educated and trained surgeons to date. To this professor of surgery of 30 years as a university surgeon, the future of surgery has never seemed brighter. The selfless resolve of our residents to provide the highest level care for patients who enter the emergency room in the time of COVID to their time in the intensive care unit to their discharge has been nothing short of remarkable. In their undaunted service, they are documenting and closing their electronic medical record encounters, taking call for their fellow residents who are sick, protecting their families from the contagion by living apart, and even producing scholarship incident to their clinical care. This is an unprecedented time, and we are witnessing unprecedented service.

It is because of this very crisis that a future vision of how surgical practice might emerge for the better can be imagined. Although telemedicine applications are already in place in most electronic medical record platforms, they are rapidly developing into web portals in which patients can be prompted to answer directed questions, upload radiographic images, and electrophysiologic (electrocardiogram, etc.) and biometric (temperature, weight/body mass index, respiratory rate, food logs, sleep patterns, etc.) information.5 Telemedicine can then be used to remotely communicate when adequate testing (blood work and imaging) has been achieved and recommendations can be made either for expectant observation or an in person consultation if indicated. A question to ask ourselves, that is, those of us training this group of surgeons, is who is most skilled, experienced, and nimble at driving this technology to achieve safer, more accurate, and more cost-effective care in anticipation of the next healthcare crisis?

Although regionalization of services has many challenges, many issues remain unresolved including coverage of travel costs, methods to monitor patients once they have been discharged and tracking those test results obtained outside of the reach of the primary surgeon. Another important consideration of regionalization, separation of patients from their families, has emerged from the COVID-19 crisis. Although previously addressed by others, the current pandemic demonstrates the importance of creating innovative ways to resolve this issue.6 For example, can payors develop a menu of online housing for families that is a covered benefit? Can telemedicine manage postoperative care, data entry, and patient tracking? Since our current trainees' vacation in a completely different manner than prior generations of surgeons, there is much to learn from them about lodging, use of communication services, etc. There is little doubt that as they take on leadership posts, this manner of travel, communication, lodging, online education, training simulation, and remote robotic surgery will dominate the surgical arena and care tomorrow will look much different than today. This will not be at the expense of the doctor–patient relationship or medical ethics as these disciplines have never been7 more formally organized and the output of scholarship more productive.7,8 Not only is this current generation of trainees faithful to their bond with the patient, but they are formally studying it and generating the much needed scholarship and guidelines to understand and maintain it.

As we are in the middle of the COVID-19 crisis, many major medical centers and universities have halted all recruitments and new hires indefinitely. Many trainees finishing their residencies and fellowships are concerned that their job prospects are becoming limited. Yet, here is the equation that cannot yet be formulated and whose product cannot yet be calculated. It includes the following variables: how many retirement age surgeons will suddenly retire given that their practices are no longer financially sustainable? When smaller hospitals close and services are consolidated to referral centers, will the demand for subspecialty services increase? Will displaced surgeon-generalists be able to be competitive or retrained for these positions? Will COVID-19 have increased the demand for subspecialists who can also function as generalists? Although no one can predict the future, for this surgeon who is comfortable with his own obsolescence, in a world that historically rewards specialization, lower costs, higher efficiency, and increased productivity, the training, education, and scholarship of our current trainees point to a future of surgery in the aftermath of COVID that shines bright.

REFERENCES

1. Prachand VN, Milner R, Angelos P, et al. Medically necessary, time-sensitive procedures: scoring system to ethically and efficiently manage resource scarcity and provider risk during the COVID-19 pandemic. J Am Coll Surg. 2020doi: 10.1016/j.jamcollsurg.2020.04.011. [Epub ahead of print]
2. Slidell MB, Kandel JJ, Prachand V, et al. Pediatric modification of the medically necessary, time-sensitive scoring system for operating room procedure prioritization during the COVID-19 pandemic. J Am Coll Surg. 2020doi: 10.1016/j.jamcollsurg.2020.05.015. [Epub ahead of print]
3. Nakayama J, El-Nashar SA, Waggoner S, et al. Adjusting to the new reality: evaluation of early practice pattern adaptations to the COVID-19 pandemic. Gynecol Oncol. 2020doi: 10.1016/j.ygyno.2020.05.028. [Epub ahead of print]
4. Grenda TR, Whang S, Evans NR 3rd. Transitioning a surgery practice to telehealth during COVID-19. Ann Surg. 2020doi: 10.1097/SLA.0000000000004008. [Epub ahead of print]
5. Contreras CM, Metzger GA, Beane JD, et al. Telemedicine: patient-provider clinical engagement during the COVID-19 pandemic and beyond. J Gastrointest Surg. 2020doi: 10.1007/s11605-020-04623-5. [Epub ahead of print]
6. Symer MM, Abelson JS, Yeo HL. Barriers to regionalized surgical care: public perspective survey and geospatial analysis. Ann Surg. 2019; 269:73–78
7. Angelos P. Surgeons, ethics, and COVID-19: early lessons learned. J Am Coll Surg. 2020; 230:1119–1120
8. Zakrison TL, Martin M, Seamon M, et al. COVID-19, ethics and equity-what is our role as surgeons? Ann Surg. 2020; 272:e14–e17
Keywords:

Coronavirus disease 2019; Regionalization; Telemedicine

Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc.