Richard Smith, MD, has gone from seeing patients in his regular otolaryngology practice to assisting his institution with COVID-19 patients in newly created ICU spaces in the hospital.
© Richard Smith, MD
Q: How do you think otolaryngologists are coping physically and mentally? Do you have any advice for them in terms of what to expect and how to deal with this extraordinary situation?
Explore This Issue
May 2020A: Everyone understands our role in taking care of people and really wants to help. I’ve heard that from all of our faculty, all of our residents, all of our advanced practice providers, and all of the office staff. I’m sure that all of our colleagues across the country are just like ours, ready and wanting to help in whatever way they can. I believe that having that basic motivation to care for patients and each other gives us all the ability to move past the initial discomfort when you’re in a new area of practice and then rising to the occasion to do our best. We all have the skill set and training necessary to do the things we’re being asked to do; it just isn’t what we do on a regular basis. The kind of behaviors that make you an excellent otolaryngologist will also make you an excellent physician across the board.
Q: How have you been accommodating patients who require cancer surgery?
A: In New York, we’re in a more acute situation than some other programs around the country in that we’ve had a much more rapid increase in the number of critically ill COVID-19 patients. Like many other programs, we’ve had to eliminate elective surgery within our institution for about 10 days at this point. We feel that there could be additional risk to surgical patients right now from being in the hospital unnecessarily, given the nature of COVID-19.
We’re addressing this issue in our cancer patients by consulting with our multidisciplinary team again, knowing that we cannot perform cancer surgery right now. If we were planning to do surgery, we’re looking at effective nonsurgical treatments that patients are getting instead. There are some patients for whom surgery is really their only option, so we’ve looked at methods of temporary palliative radiation, such as the “quad shot,” to control the tumor locally and avoid significant growth in the short term. Our hope is that we can then get these people back on the surgical schedule as soon as the pandemic issues decrease. Postoperatively, the types of procedures that would be most concerning would usually be the ones that require a potential ICU stay, tracheotomy care, or prolonged hospitalization. The smaller ambulatory surgeries are less of a worry, but they aren’t being done either, as again we don’t want to put people at risk, and we need those resources for taking care of the acutely ill across our system. We’ve also treated some patients with preoperative chemotherapy where there’s a reasonable chance of a positive result, and we have tried to avoid toxic therapies that might put the patients at risk of neutropenia.
Q: Are there other treatments you’re postponing? How are you keeping in touch with your regular patients?
A: We’re trying, to the best of our ability, to not have any ambulatory in-person visits in the office right now, just to minimize the risk to the patients. Although we feel it’s quite safe in the office space, we don’t want to have people coming here on the subway, or other public transportation, if they don’t need to be, and we’re doing our best to follow the mandates for sheltering in place. We’ve implemented telehealth measures, both on the phone and via video, and I will say that patients have been incredibly thankful for it—they really appreciate that we’re still there for them. If, while on a telehealth visit, we find that a patient really has an acute problem, we’ll absolutely bring that patient into the office to help manage it, because at that point we feel that the benefits of the in-person visit outweigh the potential risks.
Q: How do you think the COVID-19 pandemic will change what you do at your facility? Will it have a lasting effect?
A: I can’t see how it won’t have a lasting effect. I think this is going to be one of those seminal events in people’s personal histories that will also be evident in medicine. As an example, otolaryngology as a specialty has tended to have not been particularly concerned about wearing masks when routinely performing fiber optic laryngoscopy or even doing mirror examinations in the office—we’re good about gloves, but masks haven’t been part of what we thought was routinely necessary. The COVID-19 pandemic will change that because we understand the importance of the nasal cavities, nasopharynx, and pharynx as a reservoir of virus and potential vector for transmission. I think we’ll approach the way we examine patients differently and be more consistent about using universal precautions.
I also think one of the potentially significant benefits to patients will be the ability to tailor the type of visit to the needs of the patient through a greater implementation of telehealth. There are many patients who now come back for a follow-up visit who could be appropriately managed via a telehealth visit without making them take time off from work. I think we’ll have to define who those patients are, but I believe this will serve as a catalyst for some practice models that will be more beneficial. Our specialty has also developed regional and national educational efforts in response to this pandemic and has implemented remote learning on the local level as well. I do believe we’ll use this experience to drive change in our education techniques, all for the better.
Q: Is there any advice that you would want to pass on to otolaryngologists?
A: One of the things we’ve seen in the news media, and heard from our colleagues, is the exceptional reports about people who get better and then get acutely worse. For me, the challenge has been knowing that I’m going to be okay, understanding that I have colleagues who have been much sicker than I. Every once in a while, I see something on the news that gives me a little bit of irrational fear and makes me question that, but that’s human nature. That makes it important, when we have crises like this, to be able to evaluate the evolving information and make sure that our decisions are as scientifically grounded as possible, and not simply based on emotion.
One of the great things to come out of COVID-19 is that we’ve had a really significant improvement in collaboration among everyone in our field through online educational conferences and lots of email chains across different programs and leadership levels. It isn’t unique to otolaryngology, I’m certain, but it’s really done a lot to demonstrate how we can get out information quickly and how important it is to be connected.