On July 1, 2020, Bill Prentice, ASCA chief executive officer, sat down with Dr. Tom Deas, a leading gastroenterologist who is board certified in both internal medicine and gastroenterology, to discuss some of the risks associated with delaying even common procedures such as colonoscopies.
Tom Deas practiced medicine for 20 years in the US Air Force before retiring as colonel. Over the course of his private sector career that followed, Tom has been the medical director of several specialty care facilities, held several distinguished academic positions and was active in several national medical specialty organizations, including a term as president of the American Society for Gastrointestinal Endoscopy (ASGE).
Welcome to the Advancing Surgical Care Podcast brought to you by ASCA, the Ambulatory Surgery Center Association. ASCA represents the interests of outpatient surgery centers of every specialty and provides advocacy and resources to assist them in delivering safe, high-quality, cost-effective patient care. As with all of ASCA's communications, please check to make sure you are listening to or viewing our most up-to-date podcasts and announcements.
Bill Prentice: 0:37
Hello and welcome to the Advancing Surgical Care Podcast. My name is Bill Prentice; I'm the ASCA CEO and host of this episode. This recording is taking place on Wednesday, July 1, 2020. On this episode, I'm very pleased to welcome Dr. Tom Deas. Tom is board certified in both internal medicine and gastroenterology. He began his medical practice in Fort Worth, Texas, after serving 20 years in the US Air Force retiring as colonel, and I thank Tom for his service. Over the course of his career, he was the medical director of several specialty care facilities, held several distinguished academic positions and was active in national medical associations, including a term as president of the American Society for Gastrointestinal Endoscopy (ASGE). In addition, Tom was a member of the ASCA Board of Directors for the past six years, completing his term this past spring, and I thank him for that service as well. I invited Tom on today to talk about the recent suspension and then resumption of elective surgeries and procedures due to the coronavirus and what that's meant to our healthcare system and patients who have had their treatments delayed. With surgeries and procedures such as colonoscopies resuming and with new safety protocols in place, it seems like an appropriate time for us to take stock of the impact the shutdown has had on both patients and outpatient medical facilities, and how that can inform future policies during this pandemic and beyond. Given Tom's expertise in the practice of gastroenterology and the fact that colonoscopies are one of the most common outpatient procedures in the country, I knew he would bring a lot of valuable experience and insight to this issue. Tom, welcome to the podcast.
Tom Deas: 2:19
Thank you, Bill. It's a pleasure to join you.
Bill Prentice: 2:21
Tom, there's been a lot of talk and a lot of government guidance in the past few months regarding elective surgeries and, most notably, when both hospitals and surgery centers were directed to postpone procedures for the fear that the pandemic would overwhelm our healthcare system, and allow it to focus resources on treating COVID-19 patients. Early on, for instance, there was a very legitimate concern that frontline healthcare workers might run out of personal protective equipment, or PPE, and that we needed to conserve as much of that as we could. A shortcoming of the guides to postpone surgery and procedures, however, was a lack of direction on what constitutes essential and nonessential elective procedures. Can you break that down and explain why some procedures may be elective, yet still essential?
Tom Deas: 3:08
Well, clearly some of those concerns were valid concerns. In the beginning, there were a lot of unknowns and a lot of fear associated with it. I tend to use a different terminology in describing procedures other than the term elective because I think most interventions, whether procedures or surgery, really can be graded based on their urgency. So, you have urgent procedures that may be lifesaving or critical that they occur in a very short window of time. And then on the other extreme, you have procedures or interventions that can be delayed or perhaps done at a later time. They're still important, and we use the term elective to describe those procedures that have a lower priority. And therefore, in the case of a limitation of resources and equipment and supplies and those kinds of things, those "elective" procedures or less urgent procedures might be sidelined briefly so that you have greater resources for the more urgent or the more critical interventions that need to occur.
Bill Prentice: 4:19
So would it be correct in saying that you're making a distinction between urgent and emergent, which are the things that you would think normally would go to a hospital emergency room and are critical in terms of their timing?
Tom Deas: 4:33
Right, right. And even the things that we consider elective, they're important procedures, but whether you do them this week, or next month, or perhaps the next month isn't as critical as when they may be more urgent or emergent.
Bill Prentice: 4:49
Got it. Well, let's turn to your field of expertise, gastroenterology, and one of the most common outpatient procedures, colonoscopies, which are broadly labeled as elective procedures. How many colonoscopies are performed in the United States each year roughly, and what's the difference between a colonoscopy that would be conducted for screening purposes versus one performed for ongoing surveillance or treatment?
Tom Deas: 5:13
I believe the estimates in 2019 were somewhere close to 18 or 19 million colonoscopies performed during that year. That's been a steadily increasing number because of increasing adherence to recommendations for colorectal cancer screening and, of course, other reasons for the endoscopic intervention. And I think one of the things that they use the term elective for screening colonoscopy, the timing isn't as critical. It doesn't mean it's not important and that it is a very effective tool for cancer prevention, but if you were to have to delay that a month or two, we wouldn't consider that critical. The problem is that what we're running into now is that the delays may be considerably longer than that, and with that you have a consequence of any delay in a procedure that's important. And that is the possibility that someone might develop a cancer in that interval or develop a more advanced stage of an underlying problem.
Bill Prentice: 6:19
That makes sense. So, how concerned are you that an across-the-board suspension of all colonoscopies for several months might have serious consequences for patients whose procedures are delayed for that period or longer?
Tom Deas: 6:33
Yeah, I think it's a serious concern because at some point you'll have to start looking at not the consequences of the COVID infections and perhaps COVID deaths and morbidity, but the consequences of delaying procedures and delayed diagnosis of cancer or even a missed diagnosis of cancer, not only in colon cancer but in other cancers like breast cancer where screening is done. And originally, I wasn't as concerned because it looked like we would be looking at a month or two delay, which, again, is not an alarming delay. But now we see that with the resumption of endoscopy, the productivity and the turnover rate is going to be slower because of all the precautions that are being taken to protect patients and healthcare workers from the COVID infection. So initially, the efficiency of an endoscopy unit doing colonoscopy may be about 50 percent, which means that we're actually going to be delaying even further, many months down the road, some of the procedures. My other concern is that patients who have had their procedures canceled or delayed just may be reticent to return to have their screening colonoscopy, which is a problem in and of itself.
Bill Prentice: 7:52
And I've heard about that myself; anecdotally, a lot of trepidation out there that I think we're going to need to work to educate and overcome. You kind of touched on this, but part of the rationale for suspending the surgeries was one, preservation of PPE but also to prevent the spread of the virus to staff or other patients within medical facilities. And again, I think we would all agree that that's a very legitimate concern. Today, however, and particularly with surgeries having resumed in most markets, we know that healthcare facilities, including ambulatory surgery centers, have adopted protocols and procedures to prevent a patient or staff member from either bringing the virus into a facility or spreading it. Can you comment on those new procedures and whether or not you think it's safe to continue performing outpatient surgeries and procedures in the current environment?
Tom Deas: 8:46
Sure. Well, I think two things have happened, Bill. Number one is the United States as a whole and the industry has responded dramatically to the perceived and real shortages of protective equipment and supplies that I think we're in a much, much better position today than we were just a few months ago. In addition, I've recently gone through the protocols that have been developed by the American Society for Gastrointestinal Endoscopy and the American College of Gastroenterology. They've put together expert work groups that have spent a great deal of time working on a very detailed and extensive process by which patients will be brought into the unit for their procedure and then discharged. And I would argue, Bill, that perhaps these endoscopy units may be some of the safest places on earth to avoid COVID infection, far safer than perhaps going to the post office or your barber shop or to a restaurant. They've done a really good job of that; I would be perfectly comfortable today going in to have an endoscopy with these protocols being followed.
Bill Prentice: 9:57
I'm really gratified to hear that and hopefully we'll get that word out. Tom, I think in some of the discussion we've had, you've been relying on some guidance from some professional organizations. Can you tell us a little more about that?
Tom Deas: 10:11
Sure. I'll tell you two of the greatest sources that I found would be at the American Society for Gastrointestinal Endoscopy website, asge.org, and then the American College of Gastroenterology, which is gi.org. And they both have invested tremendous resources in not only paper documents with outlines but also webinars and other educational materials around the resumption of care in the endoscopy unit.
Bill Prentice: 10:42
That's great. I think, I hope our listeners will go to those websites to find that information and, indeed, we'll look to try and see if we can provide links to them on ASCA's COVID-19 Resource Center page so people can look there as well. We have time for one more question and I'd like to get your thoughts on any unintended consequences related to the suspension of surgeries and other procedures this past spring, including the financial impact on both medical professionals and medical facilities, and basically shutting down a large portion of our healthcare system. Can you speak to that?
Tom Deas: 11:18
Absolutely. Well, it certainly is not without a consequence or several of those. I think the biggest one is the delay or cancellation of procedures. Most patients aren't terribly excited about having a colonoscopy in the first place, and I think with these delays and the distractions going on related to COVID and other things, patients are just going to be reticent to return and reschedule and get that procedure done. And there have been some serious estimates of potential increases in cancer rates in a number of areas. The other, I think, real serious concern is the lack of resources to perform the needed colonoscopies because some facilities have closed, practices have not survived this, there's bankruptcies, hospitals are having difficulties. So, I think the access to care may well be threatened in some areas, due to purely the economic impact of the shutdown for a period. I think we, even in considering a future shutdown, need to proceed with great caution about that because of the unintended consequences that would result.
Bill Prentice: 12:37
I think those are very powerful words and really important for us in terms of both the ASC community and the physician community to really make our policymakers aware of those concerns and those ramifications because they obviously could be catastrophic for a lot of Americans. Tom, I want to thank you for spending a few minutes with us on this podcast. As always, you have been very informative and really I think laid out some clear understanding of where we need to go when it comes to restoring these procedures during the pandemic.
Tom Deas: 13:14
Well, thank you, Bill. These are difficult times and I think it's going to take a lot of wisdom moving forward to make the right choices and consider all the possibilities and outcomes.
Bill Prentice: 13:24
Absolutely agree. Well, this concludes our discussion today. I'd like to thank Dr. Deas for coming on to the Advancing Surgical Care Podcast and sharing his knowledge and experiences with us. As always, if anyone listening has thoughts or suggestions for future topics or how we might improve these presentations, please send them to us. We want to hear from you. Thanks for listening and please stay safe and healthy.