Matt Katz:

I'm Matt Katz. This is The Takeaway. As the number of COVID-19 cases rises in hospitals across the U.S., many states have started calling for all non-urgent and elective procedures to be delayed.

Dr. Alyssa Burgart:

For example, if you had scheduled to have a knee replacement or a hip replacement, that is an absolutely important procedure to have. It will hopefully really help improve someone's quality of life, maybe really decrease the amount of pain they have and increase their functionality. But it's something where right now it's just not the right time to have those procedures, given the other constraints on the healthcare system.

Matt Katz:

That's Dr. Alyssa Burgart. She's a bioethicist at the Stanford Center for Biomedical Ethics.

Dr. Alyssa Burgart:

The goal is to conserve the personal protective equipment, the ICU beds, the ventilators, all the things that we need to take care of critically-ill patients, not just with COVID-19, but also the patients who will continue to have severe illnesses that need treatment.

Matt Katz:

The Takeaway's Duarte Geraldino spoke with Dr. Burgart a couple of days ago. To start, he asked her how we're defining essential care in this moment.

Dr. Alyssa Burgart:

The terminology can be very frustrating and difficult for people because, of course, if you've planned your entire life around having a surgery, you've arranged to have time off work. Maybe it's a surgery for a child and you've arranged it over their vacation, of course it absolutely is essential to you. What the American College of Surgeons has done, however, is given a tiering system to really help guide surgeons, patients, anesthesiologists, other caregivers, to help determine what is a procedure that is essential today, or essential in the immediate time period around this pandemic versus what are procedures that can safely wait for weeks to months to be rescheduled.

Duarte Geraldino:

How much does the safety of patients themselves factor into postponing these procedures?

Dr. Alyssa Burgart:

I think that patients are our number one concern when we're making these decisions. I had a case on my schedule recently where there were specific reasons to that patient, that having that procedure was very important and made it much more urgent than it would have been for another patient. And so I think we really want to make sure that our patients are safe, that they're able to get urgent care as quickly as possible. Understanding that there are additional risks to coming to the hospital right now, that we would like to be able to avoid for as many patients as we can in a safe way.

Duarte Geraldino:

Who exactly is making the decision about what can be delayed or canceled? Are we talking about state government, hospital administrators, or surgeons themselves?

Dr. Alyssa Burgart:

I think this is a changing environment. I think on March 17th, when the American College of Surgeons made their recommendation, they were really thinking about surgeons with their patients making these decisions. That's absolutely where the first part of this conversation needs to happen, is between the patient and a physician who knows them well, who knows the context of their disease. Different hospitals are dealing with where to go from there differently. I think leaving it solely to surgeons to decide if and when to cancel their surgeries, that's not going to work for everyone. There are going to be surgeons who have different conflicts of interest. Surgeons care very deeply about their patients and may struggle to cancel certain cases, even if they are ones that could wait. There's also a lot of financial difficulties that hospitals and surgeons and anesthesiologists and everyone who is supported by the perioperative environment can experience.

Dr. Alyssa Burgart:

Many hospitals are using a little bit more of a collaborative approach, where that initial conversation is between the surgeon and their patient. But there's usually some sort of a process that can help to deal with disagreements, or if a surgeon feels really strongly like, "Listen, I know that this might sound like this is a non-essential procedure, but I feel really strongly because of X, Y, and Z." and if there's a significant disagreement there, having a system where that can go up to somebody else who can help resolve that issue.

Duarte Geraldino:

Some hospitals are still doing procedures that are considered non-essential or elective. What are some of the reasons that they're moving forward with these procedures?

Dr. Alyssa Burgart:

Certain reasons that a hospital might move forward with elective cases or non-essential surgery, is that there may actually be patient specific factors that make that an important procedure to do today, and only the patient and their physician will know that. There's other hospitals that truly are struggling with the fact that they have low incidents of COVID-19 in their community right now and they're dealing with really significant financial implications where they're worried they might not be able to keep the lights on. Hospitals work on a very narrow margin, even the best funded hospitals do not work with a significant amount of margin. And so for many hospitals, like rural hospitals, very small hospitals, sometimes greater than 60% of their funding comes through these outpatient surgeries, and so the financial concerns are huge and they are absolutely important. Obviously we've seen significant damage to our economy already due to the pandemic and hospitals are part of that.

Duarte Geraldino:

We're also seeing some states like Ohio and Texas classify procedures like abortion as non-essential. What do you make of this move? Are abortions being misclassified as non-essential healthcare?

Dr. Alyssa Burgart:

I would argue that abortions are being misclassified. I think it's an incredibly opportunistic move by people who have very strong feelings about abortion. Unfortunately, if you need to have an abortion, that's a very time-limited procedure and many states have significant time limitations on when an abortion is going to be possible. They're safer for women earlier in a pregnancy and so if you make someone wait four weeks, eight weeks before they can have their procedure, or even have access to medication which might be an easier time earlier in a pregnancy, then you're really disproportionately affecting the lives of women who are already going to be hit very hard economically, emotionally, and health-wise during this pandemic.

Duarte Geraldino:

Are there any other types of procedures which you believe are also being politicized in this moment?

Dr. Alyssa Burgart:

I think one of the things that I worry about is the care of people who have disabilities and the care of people who are in other marginalized groups such as transgender patients. I know that there's procedures, for example, that transgender patients will be life-changing and may really significantly improve their mental health, may decrease their chance of suicide. What's difficult is that in the middle of this pandemic, those cases are being delayed, and I think that it's very understandable, and I think right now it's the right thing to do. But oftentimes patients with transgender needs, or just gender care in general, have their care delayed over and over and over again. And so I do worry about how significantly those cases in particular might be delayed given the fact that they are politicized.

Matt Katz:

Dr Alyssa Burgart is a bioethicist at the Stanford Center for Biomedical Ethics.

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