Gynecology in the Time of Coronavirus
Jennifer O. Howell
3009 Old Clinic Building
Campus Box 7570
Chapel Hill, NC 27599
919-966-5280 (p)
johowell@med.unc.edu
Healthcare delivery has undergone a rapid transformation as we grapple
with reality in the time of the novel coronavirus. I daresay, regardless
of specialty, we are all adapting new models to care for our patients,
mitigate contagion, and preserve resources. Every day we structure a
measured response to the number of new cases, the amount of personal
protective equipment on hand, as well as the projections of lost
revenue. The response of modern medicine to this pandemic is astounding.
The sheer volume of e-mail memoranda, power point presentations,
web-based tools, and other electronic weapons amassed against this
disease cannot be underestimated. Indeed, we have a duty to treat. Can
we fulfill this duty as obstetrician/gynecologists in present times
without further endangering our patients, or depleting the healthcare
workforce?
To answer this question, it may be useful to reflect on the practice of
our vocation during past pandemics. In the 14thcentury, the Black Plague caused by the bacillus Yersinia Pestiskilled twenty million people in Europe. Those who cared for the sick had
only crude treatments such as bloodletting, burning incense, and bathing
brows in rosewater or vinegar. Doctors commonly refused the care of
patients, priests avoided burying the dead, and family members were
forced to abandon their loved ones in desperation. The cause was
unknown, but divine retribution was suspected. Thus, instead of
advocating wearing facemasks in public, displays of self-flagellation
were encouraged as protective.
During the influenza pandemic of 1918, fifty million people perished
worldwide. While we then understood the concepts of antisepsis and
microbiology, we had little but ourselves to offer. There were still no
diagnostic tests, no antibiotics, no effective vaccines, nor mechanical
ventilators. There was basic ‘PPE’ to don while administering aspirin,
epinephrine, and oxygen by face mask. Fortunately, the healthcare
ethical code during the 1918 pandemic was robust. Patient welfare came
first, even in the face of a serious risk to physician health. Public
health measures such as mass closures, quarantines, and masks were in
effect. There is documentation of doctors, hospitals, and morgues being
overwhelmed in certain ‘hot spots,’ but there are no stories of the
medical establishment closing shop. This was still the age when doctors
came to your house – and by all accounts, they continued to do this
work.
In our work as OBGYNs, we treat many hidden conditions which require
relatively invasive exams to properly assess and diagnose. Surely, there
must be something in our technologic armamentarium that will allow us to
persevere in the digital pandemic age. While I may not know what it was
like to be healer during the Black Plague, or a doctorduring the “Spanish” flu, I am learning quickly how to be ahealth care provider during COVID-19. I introduce to you a new
framework that will be adopted in the OBGYN department at our
institution. I welcome all to adapt as you see fit in your local
facilities. We simply must marry safety and duty. And while naturally
money is a secondary concern, we simply must keep our fiscal heads above
water. Our patients depend on us.
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VIRTUAL Gynecologic visits
Document for workflow in the Ambulatory Environment.
Approved by the Sub-committee of Ambulatory Operations, the Taskforce
for Increasing Virtual Visits, and the Gynecology Working Group.
As many of you have now heard the good news, reimbursements for
“virtual” visits will be at the same rate as “in-person”
appointments during COVID-19. Therefore, effective immediately please
adopt this new 9-step protocol.
- Patients may now obtain a speculum for home use with a provider’s
prescription. An updated e-tip sheet will be forthcoming on the
durable goods pharmacies that are providing this service including the
10 easy steps you must follow for getting this equipment mailed to our
patients.
- Must use only approved electronic platforms for these transactions
given the sensitive patient information to be transmitted. Providers
and nurses must watch an e-learning module entitled “Oh Yes We Can:
Handling Sensitive Information 2.0 - Privacy Concerns, Questions, and
the Law”Action item: It is expected you will watch the module in the
next 24 hours!
- Schedulers will call the patient and inform them of their “virtual
speculum tutorial.” This is a new visit type available on the last
update of our EMR – called SPEC TUT, 20-minute slot. Write in notes
section on the schedule tab – “patient agrees to home speculum
teaching.”
- Patient instructed to sign up for ‘MyChart’ app and message provider
directly when home equipment has arrived. We understand that many of
our patients speak other languages and this may be difficult. Thanks
for the incredible work you do. Kudos to our Personnel Support
Managers for putting together this helpful resource entitled “My
speculum has arrived” in 19 languages – click this hyperlinkmi espéculo casero ha llegado to access.
- Nurses will then call the patient from a private location and perform
a demonstration using the ‘MySpeculum’ app which can be downloaded in
5 easy steps. An e-tip sheet from your EEP (Embedded Electronic
Medical Record Professional) will be forthcoming. Nurse will then
write in Notes section: “patient successful” initials, date,
time
- On the day of the video pelvic exam visit, there will be a light-up
speculum icon on the schedule that will turn green when your patient
is “checked in” for the visit. Click the wrench icon on the schedule
bar to get this notification column to appear if you do not see it.
E-tip sheet coming – stay tuned.
- Providers – Be on time for your visit, introduce yourself, and make
sure you know your patient’s location. They must be in a state,
province, county, district, and territory where your medical license
is valid. This is changing rapidly so in order to protect you from
litigation we ask you to go to this website to check on licensing
reciprocity
www.incredibleamountsofbureaucracy.com.
In addition, you must ensure patient location is not a fast-food drive
through before connecting the camera.
- After the patient has placed the speculum and positioned the camera
correctly – be sure to use the verbiage: “I am all done
looking now.” The patient will then know they can take the speculum
out.
- As always, be sure to properly document and use this e-smart phrase
which has all the billing embedded: .COVIDDIDVIRTUALPAP
______________________________________________________________________________
By now the astute reader has guessed that this ‘modest
proposal1’ for virtual pelvic exams is not for
implementation. Instead this perspective is offered as a wry critique of
our increasingly technocratic response to the crisis. A response, which
I believe, has drastically changed the standard of care in our field. We
must recognize that we are delaying or divorcing needed care from the
laying on of hands unencumbered by evidence that this will result in
acceptable outcomes. When I think of something as ludicrous as a virtual
gynecologic assessment, I am haunted by yet one other epidemic not yet
mentioned.
Whether justified or not, the mythology of the medical establishment’s
early response to HIV is not flattering. Reports abound of medical
professionals dodging the ‘duty to treat’ ethos. Physicians and nurses
were assured transmission would be unlikely with a bloodborne pathogen.
Yet, anxious perceptions kindled debate over the long-embraced
professional code of self-sacrifice. Ultimately, our better selves
prevailed. Medical societies worldwide issued guidance in the 1990’s
reaffirming our obligation to care for contagious patients. And now we
find ourselves in an ever more bureaucratic and entrepreneurial
healthcare landscape. Just how will history view our retrenchment to
care via computer screen for a virus spread by droplets? Surely, the
spread between two masked individuals taking proper precautions during a
medical visit must be quite low. Shall we stand by our commitment to
care with a human (gloved) touch and a physical exam as the gold
standard? Indeed, I stand ready to wipe my patient’s brow with rosewater
and vinegar, however ineffectual.
If perhaps you smiled as you recognized your institution in this
satire’s looking glass, then I am satisfied. Presently, it may be that
humor is the best medicine we have. Perhaps laughter will lower the
viral transmission rate. I will wager it is at least as effective as
self-flagellation, and better than bloodletting. I will end this
reflection to return to my screen with a sense of urgency – there are
workflows and memos to attend to. Afterall, leadership expects this
protocol to be in place next week to achieve our triple aim: reduced
exposure, maximum reimbursement, and operational efficiency in these
unprecedented times. You are all heroes. Thank-you for all that you do.
Stay safe!