Approach to Outpatient Clinics
The multidisciplinary HNS clinic includes 8 specialists and 5 APPs and
typically sees 1100 to 1200 new cancer cases every year. Beginning March
15th, a widespread clinic freeze was instituted by the
department. Clinicians were asked to review their schedules for the next
several weeks in order to identify patients on a case-by-case basis that
could not be postponed. Patients were contacted individually by phone to
reschedule although clinics were still open from an institutional
standpoint. Until March 27th, clinics were continued
on a limited basis and patients were limited to head and neck patients
with an urgent need; new confirmed cancer diagnoses, post-op care, or
patients with worsening symptoms due to their malignancy.
Beginning March 30th, all HNS clinics were
consolidated to initially one clinic, one day per week. Due to volume, a
second clinic day was added beginning April 6th. With
the removal of dedicated clinic and OR block time, clinicians were able
to remain flexible when covering the clinic days to allow for back up in
the event of clinician exposure. Our department was fortunate to not
have any confirmed cases of COVID-19 amongst the health care team,
however one attending was symptomatic and subsequentially
self-quarantined although ultimately tested negative. This clinician was
able to continue to participate in telemedicine from quarantine.
Additionally, our department instituted a proactive and aggressive plan
to pursue telemedicine for suitable patients to maintain continuity of
care. It was left to the discretion of providers to determine patient’s
that would require in-person visits. As mentioned earlier, patients with
a new cancer diagnosis, with recent surgery requiring wound checks or
drain removals, or patients symptomatic with malignancy related symptoms
were prioritized for in person clinic visits. When clinically
appropriate, imaging was substituted for a physical exam to limit
physical contact. While telemedicine certainly has its limitations, it
also has notable advantages that merit discussion. Immunocompromised and
medically infirm patients are able to stay at home and not risk
exposure. There is more time for discussions regarding diagnoses, goals
of care, etc. as well as a possibility of more frequent follow up. We
anticipate that our practice patterns in the future will be adjusted to
include more telemedicine as a result of this pandemic.
There continue to be limitations to this model. Telemedicine visits
require patient access to an internet network or a “smartphone”,
limiting its use in some more isolated patient populations. Limiting the
use of flexible scope exams in clinic and relying more heavily on
imaging will likely have unforeseen consequences with regards to cancer
surveillance, although this has yet to be seen and more data necessary
to draw conclusions.