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.