Patients diagnosed with cancer have been hearing a common refrain these days: they must wait. They must wait to see their doctor and even wait to undergo life-saving treatments like surgery, radiation and/or chemotherapy, care that is currently on hold. At the start of the COVID-19 pandemic, nobody knew for how long. As the U.S. hits the peak of the pandemic, we are finally seeing some light.
As surgeons, we are planning how to get elective surgeries back on the schedule. Turning on the lights and bringing staff back to work is the easy part. The hard part is addressing the large number of patients who need surgery that currently exceeds the resources available to perform surgeries.
The Department Heads of Surgery at Mass General Brigham recently highlighted the necessity to prioritize patients with the greatest needs and allocate surgical care equitably. In normal times, elective surgery is by and large allocated on a first-come-first-serve basis, with each surgeon given a block of time to take care of their patients.
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U.S. hospitals have enough capacity to address patients without having to worry about the timing of care or how delays in surgery may lead to worse outcomes. In times of scarcity, patients need to be triaged by order of priority based on the perceived risk of delaying care, an approach advocated by major surgical societies.
However, what it means to prioritize high-risk patients first is less straightforward. Those tasked with juggling the triage question rely on clinical judgment and experience of their surgeons rather than data. After all, this crisis is unprecedented in the history of modern health care. When we are confronted with the question of “how much time is reasonable," we intuitively know there are more rapidly progressive cancers, “the tigers from the cats," but we lack the high-level studies to address the question. What is more, things get complicated when we cross interdisciplinary lines — how will we decide if a patient with prostate cancer is more urgent than our colleague’s case of breast cancer?
Surgeons will be an additional constraint in the reopening of operating suites. Typically, oncologic surgeons and patients have a close relationship and patients are keen to have a particular surgeon perform their operation and understandably so given the high stakes nature of oncologic surgery. However, this arrangement may not be the most optimal way to allocate surgical resources in times of scarcity.
A particular surgeon only has a finite amount of dedicated operating room time and thus patients who stick with a single surgeon may be subject to undue postponements in care. Consider the transplant surgery model of allocating surgical resources based on a team approach, where priorities are given to patients with the highest need, while minimizing delays in time of care by utilizing a team of surgeons to address the care of a patient, effectively “matching” surgeons and patients in the most optimal way.
Finally, as we begin to consider the reopening of the operating room, we must be explicit that there is potential to exacerbate racial and socioeconomic disparities, something the pandemic has already proven for many blacks and Latinos. Will we allow those with fewer means but high-priority health conditions to wait because privileged patients have priority access? Will exacerbations of systemic inequities lead to nonoptimal prioritizing of patients? For example, thus far we have seen an unprecedented loss in jobs and along with it employer-based health care. Lack of health care, financial insecurity, and competing priorities may lead to excessive delays in treatment or leave underserved populations ill-equipped to deal with recovery from major surgery.
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In the aftermath of the pandemic, a convenient explanation may be a biologic disposition, however, the real answer lies in systemically failing to address issues of these disparities proactively. Parallels exist between the current pandemic and after Hurricane Katrina when health care delivery was significantly disrupted, disproportionality affecting underserved populations.
As we look to the future, we have the opportunity to ensure that patients continue to receive the best care possible. This may mean a departure from traditional models of delivery of care towards those that optimize patients with the highest surgical needs, working in surgical teams to prioritize the oncologic care of patients and advocating for equitable care. Lives are on the line and it is our responsibility to find the answers and evolve our health care system to have the best outcomes for all.
Stephen W. Reese is a senior resident in Urology at Brigham and Women’s Hospital. Quoc-Dien Trinh is an associate professor of surgery at Harvard Medical School, co-director of the Dana-Farber/Brigham and Women's Prostate Cancer Program, and director of clinical operations at the Division of Urology at Brigham and Women’s Hospital. Follow him on Twitter: @qdtrinh. The opinions expressed in this article are solely our own and do not reflect the views and opinions of Brigham and Women’s Hospital.
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