How a Small Oncology Practice Has Adapted to COVID-19

David H. Henry, MD; Matthew Lonergan, MD

Disclosures

May 28, 2020

This interview was originally published as part of MDedge's Blood & Cancer Podcast series. In this episode, podcast host David H. Henry, MD, of Pennsylvania Hospital, Philadelphia, spoke with Matthew Lonergan, MD, chief medical officer at Willamette Valley Cancer Institute and Research Center in Eugene, Oregon, about the myriad ways in which COVID-19 is reshaping inpatient care, clinical trials, and physician education. This transcript has been edited for length and clarity.

David H. Henry, MD: How has this pandemic changed your approach to inpatient visits?

Matthew Lonergan, MD: We used to have a system where we would round in the morning, come to clinic, go to one office, maybe go to another office. That's all stopped in order to minimize potential exposure. Basically, we now have one person who rounds for the entire week, one person who rounds on the weekend. You are allowed to go to only one clinic site. Then you either telemedicine from offsite or support another site. The biggest change has been the compartmentalization of your day, which is normally built on two or three different sites of practice, to only a single one. Another change is learning how to communicate with those other sites through your partners.

Henry: I've personally been asked to be offsite two out of five business days. Has there been a similar dialing down of showing up at the office in your group?

Lonergan: Yes. We've asked every physician to be out one week out of every three. Knowing the natural history of COVID and the incubation period, we feel like that's the safest way to do it.

Henry: What are you using to communicate with patients?

Lonergan: We were a little slow to adopt a video platform, even though the guidelines were basically that you can do whatever you want, without having to worry about the Health Insurance Portability and Accountability Act. We've since started using a product called VSee, which we had some experience with before. Before that, we were doing a lot of phone call visits; they don't pay enough to even warrant billing for, so we have opted to do telemedicine. Of course, we have patients who need to be seen in person, who require treatment for adjuvant or metastatic disease, who need to be in clinic, who need labs. I think our total volume of patient visits is probably down 40%-50% in the past month or so.

Henry: Are you doing anything differently with new patients? For example, if you have a new metastatic lung cancer that is referred to you, do you see that patient online or in-person for the first visit?

Lonergan: Originally, we didn't conceive the possibility of seeing new patients by video. But once we started doing it, we realized that there were certain clinical circumstances where this was possible, like for an adjuvant breast cancer patient who already had surgery and pathology and just needs to be sent for molecular testing to risk-stratify them for therapy. Those conversations don't really require a physical exam.

We started using the video platform for our established patients. I've been surprised with the number of people who don't have internet access to allow for that in any functional way. We live in an area that's a little more rural, although I'm sure that cities have the same problem. Some patients literally end up calling me from their front porch where they can get cell service, because that's the best we can do.

Probably 10%-15% of the time, internet access becomes absolutely impossible, and then probably 10%-15% of the time there are additional equipment failures; for example, somebody doesn't know how to install the appropriate software. I think it's easier for the people who live in the city of Eugene, Oregon, but as we move farther out, the technology gets more challenging for people.

Henry: This has been surprising to me as well, although I guess it shouldn't be. We've been told for some time about the inequitable distribution of internet availability and computers.

A patient I have who works in an electronics store here in Philadelphia told me they're doing unbelievable business selling equipment, laptops, and desktops for people who need to gear up in this new era.

Lonergan: We quickly discovered the same problems even with our own employees, whom we sent home relatively early to minimize risk. Many didn't have a laptop with the necessary software to securely and capably work from home. I even tried to buy a couple of laptops, and the stores were sold out.

It's also been interesting, as a small practice, to deal with the supply and logistics required to keep our practice open and running. I spend most of my time trying to figure out how I can get another 200 masks here or there, or how I can get water. We have an appropriate mandate to monitor every staff member's temperature, here and at their home, and every patient who arrives. All of a sudden, I need 250 thermometers. You're trying to find them and you can't.

I find it interesting that the things that you don't initially anticipate, but which make your daily operations compliant and efficient, you can't find. You spend a disproportionate amount of time dealing with that.

Learning Remotely Has Surprising Advantages

Henry: Staying up-to-date is increasingly difficult in hematology/oncology, given how quickly things move from bench to bedside. How are you managing a teaching function or things like tumor boards?

Lonergan: Several people in our group do a fair bit of research. They have always served as sort of the de facto experts who teach us by simply our asking things like, "I have this new male patient who is 67 years old with a bad myeloma. What would you do?" That function has stayed pretty much the same. The difference is that we would call them while driving home, as opposed to now they may be in the office next door.

As far as tumor boards, our hospitals have made the switch to a Skype platform for those, and surprisingly, I actually kind of like it better. I know there is value with the in-person tumor board. But I find it easier to see the images, to deal with distractions, and to meet the onsite presence rules that are always a problem for billing. It's hard to both go to a tumor board and be here at 7:00. So it's been easier, especially with less staff, to meet all of those legal requirements. I actually really enjoy the online tumor board as much as the in-person.

Henry: I agree with you completely. I was on our breast cancer tumor board 2 days ago. Both the images and the pathology come up; you can see your colleagues or the system will identify them when it's only their voice. We get a lot done.

Speaking of research, at my institution they've made a system-wide requirement that no new studies will open and no open studies will accrue. The problem is resource allocation, given that all our research staff are offsite now. How has the research function changed at your institution?

Lonergan: Before this moment, this had already changed because the research staff are in a separate building. I hardly ever see them, except for passing them in the parking lot. They will come into the clinic only when absolutely required, such as with pharmacokinetic studies.

We're not actively enrolling in a lot of the registry-type trials. But the critically important research trials that are required for things like hematologic malignancies are still going on, but at a reduced rate.

There is no formal rule, but our research director has asked us to be thoughtful stewards of the research staff and our patients when it comes to the risk for infection. We've obliged in a general sense. Our enrollments are certainly down substantially. But for patients who need those unique treatments, they're still available. We just have to be very thoughtful about whether it's appropriate.

Is Virtual Education an Adequate Substitute?

Henry: Then there's the issue of ongoing education. We used to hold a weekly journal club here for our providers—doctors, nurse practitioners, and physician assistants. Everybody would come for that, usually over lunch. Of course, that's stopped.

So I found a replacement option which we just used with some success. Like everyone, we get emails from various continuing medical education organizations offering updates on the latest in certain indications, with presentations from leaders in the field. We've used those as a way of keeping up our journal clubs. Now, instead of me droning on about the most recent article in Blood, we can have a nice online lecture from a key opinion leader. Have you done anything like that yet?

Lonergan: We have not. With the exception of those doing a lot of research or with disease-specific practices, I believe that most of the literature we've read in the past month has been focused on COVID-19. In many ways, all of that other education has momentarily stopped.

Then all of the educational meetings we normally would attend, both locally or regionally, have also stopped. I've attended a couple of them virtually and found it actually very efficient. I think as the platforms for offsite meetings like this become more sophisticated, that may be my preferred way of doing things. It's a little antisocial compared with how I used to be, but I find it very efficient, especially if I can choose to listen to it at my own time and place.

Henry: It really is true. I would go to the American Society of Hematology and the American Society of Clinical Oncology annual meetings, and also to the update meetings afterwards, where you can speak with your colleagues and specialists over lunch. That social benefit disappears, but otherwise, at your leisure you can get a really nice lecture from whomever.

Lonergan: I miss the questions. I often find that's the one thing that's different about the videoconferencing, especially when you're on a delay. There's always somebody in the audience, even in a small group, who asks a useful question about what to do in certain circumstances. With these distance platforms, there is a lack of interesting questions, and I've found in many cases in the past that I've learned the most from those.

The Precedence for What Feels Unprecedented

Henry: The New England Journal of Medicine featured a beautifully written perspective on what's happening now, titled "Escaping Pandora's Box – Another Novel Coronavirus." It notes that in 1918, what was called the Spanish flu (but didn't actually originate in Spain; they were just the first to report it) killed 50 million people, equivalent to 200 million people now. It's 100 years later, and although we unquestionably have better supportive care, we don't have anything to prevent these epidemics from happening, as they have for millennia.

Lonergan: I was trained in medical school during the HIV epidemic. That didn't have the same widespread level of communal fear that COVID-19 has had, but people were worried about it.

Once every quarter or so we would have pizza with some senior physicians. There was one conversation when I was a first-year medical student where we were asking, "What's going to happen when I'm on phlebotomy duty at the VA, drawing blood, and I stick myself?" There were no antiretrovirals then. It was irrationally fearful. In reality, the risk was minimal, but it didn't make it any less fearful.

One of the senior physicians we were discussing this with actually trained during the Spanish flu. He said that you come to understand the difference in severity when there is fear in both the medical community and the general society. He noted that with polio, most of the providers weren't afraid but society was terrified. However, with the Spanish flu, both the providers and the general society were scared.

This moment feels more like how he described the Spanish flu. It's different from anything I've ever experienced. The memory of that conversation sort of came back to haunt me the past few weeks of going through this whole process. But it also served as a reminder that we have been through this before.

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