As a surgical oncologist, I have developed principles that helped me build a successful practice; provide excellent care to my patients; work and lead multidisciplinary teams; mentor medical students, residents, and fellows; expedite patient visits, and perform research and clinical trials.
However, the COVID-19 pandemic has turned my world upside down. Every instinct I follow and every decision I make has been uprooted and skewed. Pre-COVID, I would see patients face to face in clinic and had no hesitations about expediting in referrals and adding patients to my already packed clinic schedule. Now that has all changed. My team is reviewing our clinics on a weekly basis to determine which patients must be seen face-to-face, but more importantly which patients can be contacted virtually, via telephone or videoconferencing. For some patients, we even consider whether their visit can be delayed for a few months. This can become quite confusing for our staff, schedulers, and patients, because many patients who are being rescheduled also see other physicians the same day and have additional tests, procedures, therapies, or labs that need to be rescheduled and coordinated. Â Lastly, a lot of our patients travel from some distance adding to the complexity of the situation.
In my surgical outpatient clinic, I naturally greet patients and their families with smiles, handshakes, fist bumps, and, frequently I’m greeted with hugs, kisses, and gifts. Unfortunately, at times this also includes discussing bad news; if their cancer has returned, if we cannot operate on their tumor, if their cancer is not responding to therapy or even having end of life or hospice discussions. Along with compassion these discussions usually include a warm embrace with physical contact, holding hands, and sharing tears. Sadly, all of this has been halted, and it is very difficult for many of us as medical providers. I cannot even imagine how my patients feel alone in the clinic without their families on the other side of these discussions, or worse having these conversations remotely. We have lost many of our nonverbal cues, our smiles, and body language, which are now concealed by a mask, gown, and gloves. It turns out that patient and social distancing is very hard for all of us to manage. We have moved quickly to institute telephone and video visits, but there is no replacement for a face-to-face smile or hug in times of joy or sadness.
If we can treat a patient with oral chemotherapy or use radiation, rather than having them come into the center so the drug can be infused, we will consider this as an option. However, both these options still affect a patient’s immune system and require visits to the institution which could put them at increased risk of COVID-19. We have also had to determine not only how to treat our patients safely and effectively, but have had to consider how to best utilize the resources we have, such as personal protective equipment and ventilators.
An even more difficult predicament is dealing with surgical operations. Nationally government entities and the American College of Surgeons have outlined criteria and guidelines to help limit all elective operations. However, is cancer an elective operation? Can you imagine your cancer surgeon reviewing your case and then telling you that your surgery needs to be delayed? It goes against every instinct that was drilled into all of us during our training. Multidisciplinary teams at my institution and other cancer centers around the country have worked together to develop cancer specific treatment guidelines for the COVID-19 era. We initially drafted these reports and are continually meeting to analyze, adapt, and adjust these guidelines, as the situation is continually fluctuating. We come together weekly to review all cases and determine who cannot wait for surgery. Currently, we can still operate, but if COVID-19 cases increase in our region, the operating room may not be an option if we need additional space or ventilators, which is a scary and unsettling fact to consider.  However, our newer discussions are centered around the safest way that we can gradually reinstitute OR cases that will be safest for our patients, OR staff, nursing, and surgeons.
The impact of COVID-19 is not only felt when I am on duty. When I get home, I strip down in my garage, which is a little weird because my garage door has glass panels. Right after that, I jump in the shower, distancing myself from my wife, children, and bulldog without any hugs or kisses until I’ve gone through my decontamination routine. I have not worn my engagement ring or watch to work and generally just wear scrubs into work to avoid contaminating any of my clothes. I have avoided bringing my laptop and pens to work.  Before the pandemic, I felt like I washed my hands hundreds of times a day (wash in and wash out). Now, I feel like it’s more than a thousand times.  We are wearing masks constantly at work, avoiding contact with staff, social distance in our cramped clinic space, and undergo daily screening on entry into the facility. I never hesitated or had a problem staying at work to complete all catch-up tasks at the end of a day including make phone calls or signing my notes. Now I leave the facility as soon as possible, complete these tasks at home, and have virtual meetings from my home office or deck almost every evening.
The American College of Surgeons Surgeon Well-Being Index has a site for surgeons where you can answer questions. These include if in the past month they have felt burned out from their work, worried that their work is hardening them emotionally, or have felt down, depressed, or hopeless. Unfortunately, many physicians can relate to these feelings. Thankfully these feelings generally wax and wane for most of us. It’s only human. In times like this, I think we are all hyper-vigilant about our well-being, our staffs’ well-being, our patients’ well-being our trainees’ well-being, and most importantly our families’ well-being.  These times are not easy for any of us. That being said there are many glimmers of light I see daily with staff coming together to support one other and our patients in ways I never could have imagined. My family and I go on walks together every day, exploring and discovering in our neighborhood. The time has allowed us to take a step back and hopefully improve and re-think how we deliver health care, perform research, and collaborate with colleagues.
Jeffrey Farma MD, FACS
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