How Will This Uncertain Time Define You?

Early last month, I decided to get on a flight to Miami for a seminar that I had been looking forward to for a year. The organizers of that meeting decided not to cancel even though other meetings later in the month were already being rescheduled or cancelled until further notice. 

None of us really had much information at that time other than COVID-19 was potentially lethal to the elderly and for those with preexisting conditions. I took precautions to wipe down my airplane seats. The planes were fairly empty so I did not worry as much about large crowds. We practiced social distancing at the meeting. I felt safe and not overly concerned.

I returned on March 16 and went to my office directly from the airport. My staff was working. There were no urgent calls or inquiries from them during the time I was away to ask if they had to come in. They were just there. We had a brief meeting and discussed how we would handle the scheduled patients for the week. We implemented the plan I formulated while I was flying back. We called all patients for the next two weeks and asked them to call us when they arrived in the parking lot. We advised them that the front lobby would be empty. We would take their temperature in the lobby, ask some questions about current symptoms and ask about any travel for themselves or family in the past two weeks. 

If everything worked out, we take them to the treatment room immediately. We did this with new patients as well. Everyone registered in the treatment room. We followed social distancing protocols and staff washed their hands before and after seeing patients (a normal procedure). We also kept a safe distance and staff wiped down all surfaces between patient visits (again a standard process), including staff areas in the office. We also offered FaceTime and Skype appointments as per the relaxed HIPAA rules from the Centers for Medicare and Medicaid Services (CMS). We did great and only had a few cancellations. We ended up seeing 70 to 80 percent of our normal patient load. When we explained our process, most patients expressed little concern and kept their appointments. However, I decided to push back all palliative care patients for two weeks. 

I took the opportunity to use the available time in the schedule to perform activities with my staff we had on our “someday” to-do list. I initially envisioned maybe two weeks of lower patient volume due to the pandemic. I planned to use this time wisely and keep my staff employed during this challenging time. We accomplished so much in one week as my staff was so engaged in the entire process. Some of the items we worked on included …

• complete inventory of all of our supplies;
• online training for staff on electronic medical records (EMR) in order to work on sections of weakness;
• thorough office cleaning, including windows; and
• setting up Skype and FaceTime access on our tablets so we could continue to perform follow-up visits for lab results and the like, and for patient visits that could occur via telemedicine.

We started to see more cancellations the second week with visits shifting down to 50 percent of our normal patient load. I decided to see patients at limited times each day, which allowed us to consolidate time to accomplish more on the administrative side of things.   

• We reviewed our fee schedule.
• We updated and added fees and codes to our charge ticket and EMR system.
• I ran financial and management reports from the EMR to assess current status and to start planning for when things returned to normal.
• We worked on changing or modifying office protocols.
• I working with my staff on patient interaction scripts. They had them in their manuals but had not learned them thoroughly. Accordingly, we took time to role play and practice these scripts out loud. One staff member said to me later in the week that she felt more confident in answering questions and how to present herself to our patients. It made me better appreciate my staff’s interest in doing better and presenting the practice more professionally, but there may have been a lack of confidence or knowledge to so. As the leader of the practice, I should invest in more training.

I also paid my bills and replaced needed supplies so we can hit the ground running when we return to full speed. I texted a few of my referring physicians to ask if they needed regular masks as we found six extra boxes that we did not need immediately. They are likely seeing people with fevers and coughs. A colleague at one of the larger groups we have a relationship with texted me, saying how much he appreciated our thoughtfulness. 

I also sent a fax blast to 20 of my referring doctors to advise them that my office is open and included my cell number to call me 24/7 if they have a patient with lower extremity wounds that they feel may need hospital admission. Explaining that we can do X-rays and vascular studies in the office, and that I am a board-certified wound care specialist, I conveyed I would do my best to keep these patients out of the busy emergency room. We might prevent an admission that would put a strain on the already possibly overwhelmed hospital and prevent potential amputations. I explained that debridement, even down to bone, can take place in my office.

More recently, the federal government extended social distancing guidelines until April 30. This week, I am planning for the remainder of the “stay at home” policy duration. These are things I want to accomplish personally and professionally. 

• I have a list of books I have wanted to read. I will order them now.
• I will check on my colleagues, especially those in New York, to see if I can be of any help to them.
• I received an email from my hospital CEO recently. He had a list of requests for all of his physician partners, including the sourcing of scrubs and surgical gowns. I immediately contacted my industry representatives to see if their companies have these items, since they are not holding any of their surgical training programs.  
• I also sent a list of 10 ideas to the hospital CEO. One idea was looking into how we can decontaminate masks and surgical gowns. It has been suggested that ultraviolet light might be a way to do this if this personal protective equipment were not really soiled but just worn to enter a patient room.¹ The reason for the shortage is not that we have so many COVID patients on ventilators, it is all of the regular patients and non-ventilated COVID patients who require provider use of these resources as well. There was talk that the hospital is looking for resources to sew cloth gowns and masks. 
• I will continue to work on my practice by updating my business plan and preparing to apply for the small business loan that will be made available to most of us.

On a side note, my husband and I worked outdoors almost the entire weekend, planting fruit trees we purchased three to four weeks ago. We fertilized the fruit trees we already planted and improved our vegetable garden. Until last year, I could not grow anything to save my life. Now I grow lettuce all year. Every tree and vegetable I planted in the past 12 months is still alive and thriving. I am a big city girl from Los Angeles. Now I feel like an urban farmer in Tucson, Arizona.

What will you do during the next four weeks? While I watched one of President Trump’s daily briefings, there was a commercial from Go Daddy that represented what I have always believed and have tried to live by, especially during these trying times: “Make the world you want.” This message spoke to me. I accept the current challenge to stay positive, proactive and apply this mantra from another industry to “make the practice I want.” What kind of practice do you want for the future?

Dr. Aung is Chief of the Podiatry Section of the Tenet Health System/St. Joseph’s Hospital and a panel physician at Tenet Health System/St. Mary’s Hospital Outpatient Wound and Hyperbaric Center in Tucson, Ariz. She is a member of the APMA Coding Committee, the APMA MACRA/MIPS Task Force and is on the Exam Committee of the American Board of Wound Management.   She is also an Editorial Board Member of Wound Management and Prevention.  Her website is www.healthy-feet.com.

Reference

1. Card KJ, Crozier D, Dhawan A, et al. UV sterilization of personal protective equipment with idle laboratory biosafety cabinets during the COVID-19 pandemic. MedRxiv. https://doi.org/10.1101/2020.03.25.20043489 Available at: https://www.medrxiv.org/content/10.1101/2020.03.25.20043489v1 . Published March 27, 2020. Accessed April 7, 2020.