Prior to the novel coronavirus pandemic, Melissa Pynnonen, MD, would see about 20 patients during a typical day at the Michigan Medicine Otolaryngology Clinic in Ann Arbor. When Michigan Gov. Gretchen Whitmer issued a stay-at-home order in March, the clinic cancelled all nonurgent face-to-face appointments and transitioned to virtual care. Many patients were reluctant to use telemedicine, however, and on some days Dr. Pynnonen, who is also professor of otolaryngology at the University of Michigan, would see just two to six patients.
Explore This IssueAugust 2020
But since the May 29 announcement by Gov. Whitmer that nonessential medical services could resume, patients have been eager to return for in-person visits, and clinic schedules are full again. “Patients are reassured about the precautions that we’re taking to keep them safe,” she said.
Dr. Pynnonen’s experience seems like good news in light of findings from a recent report by the independent health research group Commonwealth Fund. According to the report, outpatient visits to primary care and medical specialty practices dropped by almost 60% between March 1 and March 29. Visits ticked up but were still down about 30% by May 10 (Commonwealth Fund, May 19, 2020.). The report looked at 17 specialties and found that otolaryngology was one of the most impacted by the COVID-19 pandemic—for the week of April 5, otolaryngology visits were down 75% from the baseline week of March 1. For the week of May 10, they were still down 38% from the same baseline week. Only ophthalmology experienced a larger reduction in volume.
Otolaryngologists interviewed by ENTtoday said patient volume has been increasing since March. Some said they’re fully ramped up or expect to be soon. Others acknowledged they’re seeing fewer patients, but mostly because new safety measures make it difficult to see the same number of patients as before the pandemic. All were in agreement about one thing: Patients need to be assured that it’s safe to come back.
Informing Patients about Precautions
Gavin Setzen, MD, is a partner at Albany ENT & Allergy Services in Albany, N.Y. The group, which includes 10 otolaryngologists and nine physician assistants, experienced a 90% reduction in visits in mid-March when they saw only patients with urgent cases, he said. As of June, they were seeing 80% of their pre-pandemic patient volume and expected to be at full pre-pandemic capacity by July.
Dr. Setzen definitely sees pent-up demand. “We were closed for approximately two months,” he explained. “Patients can go without care during those times, but they don’t want to delay potential new diagnoses or let existing conditions linger.”
The practice has informed patients of its many new precautions in place that are based on guidelines from the CDC and return-to-practice guidelines from the American Academy of Otolaryngology–Head and Neck Surgery that Dr. Setzen helped author (Future of Otolaryngology Task Force, Guidance for Return to Practice for Otolaryngology-Head and Neck Surgery, May 2020;). For example, staff call patients prior to their appointments to screen them for COVID-19 symptoms. Patients rarely use the waiting room; they stay in their cars until they get a text stating that an exam room is ready. Rooms are disinfected between patients, and clinicians wear varying levels of PPE, depending on the type of visit and whether or not they’ll be performing a procedure.
Dr. Setzen credited part of the increase in volume to a communication strategy the practice developed to inform patients, referring physicians, and staff that they are open and adhering to new safety standards. He said the practice’s marketing team has been sending patients text and email updates about these changes and posting about them on the practice’s website and social media accounts. Staff members have also reached out to patients to reschedule appointments that were cancelled during shelter-in-place orders.
Keith Sale, MD, vice president and chief physician executive of ambulatory services at the University of Kansas Health System in Kansas City, Kan., says his office is using Instagram, Twitter, and Facebook, as well as emails sent through their electronic health record system to reach patients. A description of new safety measures is posted on the health system’s website, kansashealthsystem.com. “Convincing patients to come back means convincing them it’s safe to be back,” he said.
If you want to regain your patient population, you need to make sure you’re providing patients with a sense of security. Part of it is putting in place these security protocols of temperature checks, masking, and social distancing. And don’t just talk the talk—walk the walk. —Robert A. Glazer
The clinic includes 25 otolaryngologists who, pre-pandemic, had full workdays. Dr. Sale said they cut back to essential visits only when the pandemic hit Kansas City in March and are now seeing a gradual increase in volume. As of June, the clinic was at about 80% of pre-pandemic levels. To promote physical distancing, shifts are staggered to reduce patient and provider overlap, and staff often see fewer total patients over the course of a longer workday. Otolaryngologists also conduct follow ups via telehealth rather than in person. “Our in-person safety approach has been to treat all patient encounters as potentially [SARS-Cov-2] positive,” he said.
As an academic provider who also works in a practice one day a week, Richard Orlandi, MD, shared perspectives gleaned from two settings. The problem in both locations isn’t that patients are afraid to come in, he said, but limited capacity because exam rooms need to be aired out between visits.
At the University of Utah Health in Salt Lake City where Dr. Orlandi serves as chief medical officer of ambulatory health, rooms that aren’t equipped with HEPA filters remain vacant for 45 minutes between appointments; with a HEPA filter, that time is reduced to 20 minutes. As of June, outpatient volume was down about a quarter from pre-pandemic levels, but rising, he said. At the practice where he works one day a week with similar room-turnover protocols, he was seeing about three quarters of his usual patient caseload.
“I haven’t had anyone outright refuse to come in,” he said. “We have had people hesitate and ask, ‘It is safe to come in?’ I’ve had patients hesitate around surgery, asking, ‘Is it safe for me to have surgery right now? I can put this off for a few months, if necessary.’ And I’ve had patients ask me, ‘Are you OK if I come in?’ In other words, they’re concerned about my safety, which is very nice of them.”
Similarly, Randall Ow, MD, of Sacramento ENT in Roseville, Calif., said appointments at his three-person practice are all booked. They’re operating at about 75% of their typical volume, however, because of the need to avoid having too many patients in the office at the same time.
Addressing Patient Fear
Robert A. Glazer, CEO of ENT and Allergy Associates, says new safety precautions may hurt the bottom line, but are the only way to reopen and gain patient confidence. His practice, which includes 44 offices in the New York City region staffed by 170 otolaryngologists, 50 allergists, and 130 audiologists, is following CDC guidelines. Volume in the practice’s Manhattan locations has dropped dramatically, he said, but offices outside of Manhattan were seeing about 65% of their typical volume as of June.
“If you want to regain your patient population, you need to make sure you’re providing patients with a sense of security,” he said. “Part of it is putting in place these security protocols of temperature checks, masking, and social distancing. And don’t just talk the talk—walk the walk. When I go to work in the morning, the first thing I do is get my temperature checked.”
Glazer said that during the first six weeks after the practice reopened, physicians could sense fear among patients. “They had to spend time at the beginning of each exam calming them down and counseling them about what methods we’ve put in place for their safety,” he said.
We were closed for approximately two months. Patients can go without care during those times, but they don’t want to delay potential new diagnoses or let existing conditions linger. —Gavin Setzen, MD
Months later, his physicians report less patient anxiety, but some fear is still there. “They still get comments such as, ‘Gee, I didn’t expect to be in the waiting room as long as I was.’ One of the things I don’t think I’ll ever go back to is allowing [clinicians] to schedule five patients an hour. We’ll keep it at four and limit the number of patients in our waiting room. You have to be cognizant of the fear that’s out there and change the way you do things to match the anxiety levels.”
Visiting a doctor is likely safer than other activities people are engaging in, Dr. Pynnonen said. “In healthcare settings, currently everybody who enters the building is asked about symptoms,” she said. “Everyone is given a mask or wearing one from home. In addition, we’ve taken care to try to create and preserve social distancing as much as possible. Given that everybody has been screened for symptoms and everyone is wearing masks, the risk is minimal. It isn’t zero—you can never eliminate all risk—but I think it’s minimal.”
As for the risk to clinicians and staff, “I think with the right level of PPE they’re only at slightly increased risk,” Dr. Ow said. “But doctors like me, in the offices keeping everyone out who has symptoms, our risk is probably less than someone who works at an In-N-Out Burger, honestly.”
Telemedicine as an Alternative
Another way to bring patients back is by continuing to offer telemedicine, otolaryngologists said. Dr. Sale said his practice communications have been emphasizing that a patient’s healthcare needs don’t stop because of a pandemic. Telehealth visits are available for patients who are truly afraid to come in, which he says works well for first-time patients, to figure out what their needs are, and for follow-ups.
“The elderly, nursing home patients, and immune-compromised patients are justifiably fearful of coming in, so we will provide tele-otolaryngology,” Dr. Setzen added. He explained that he uses telemedicine as a triaging tool.
Dr. Pynnonen said the increase in her telemedicine appointments is a silver lining of the pandemic. Return telemedicine appointments last 15 minutes, while appointments with new patients last 30 minutes. “I love providing virtual visits to patients, to see them in their home. It seems like a more personal connection,” she said. “It’s their space instead of my space, creating a different opportunity to connect with them personally. It also focuses that visit on me listening to them and gives me more space, time, and emphasis to provide some education. I think that’s been really valuable.”
Stephanie Cajigal is a freelance writer based in Los Angeles.