A lack of nurses is keeping Alexander Vaccaro, president of Rothman Orthopaedic Institute, awake at night. When the spine surgeon operates at local hospitals, he finds the nursing staff down about 25% from before the pandemic.
There’s also been a shift in how nurses are being employed. Some left the field completely, but others became traveling nurses during the pandemic layoff, often for salaries greater than what they had earned before.
“It’s causing consternation among the nurses who didn’t leave because they are seeing these visiting nurses getting paid more and it kills morale,” he said.
A lack of staff is just one of the many challenges health-care workers are now facing. Another great concern is the surge of patients trying to get caught up on the routine testing and elective procedures they skipped during the pandemic, and health-care workers are trying to keep up with the demand. According to a study published in the JAMA Network Open in April, there remained an estimated screening deficit of 9.4 million Americans for monthly breast, colorectal, and prostate cancer screenings in 2020.
Health-care providers learned valuable lessons during the pandemic, enacted new protocols, and developed practices that will likely endure once the pandemic ends.
“We are now more critical of the way we practice medicine, thinking harder about what we need to do rather than what we could do,” said Lawrence Shulman, deputy director for clinical services for the Abramson Cancer Center at the University of Pennsylvania.
Leveraging virtual visits
“Today 50% of the people I operate on I meet [in person] for the first time in the operating room,” said Rothman’s Vaccaro. Telemedicine now accounts for nearly 70% of his nonsurgical visits.
That may have been unthinkable pre-pandemic, but the practice has become routine, even for complex surgeries. And it’s worked out well, Vaccaro said, for both the patient and doctor. The appointment is quicker for the patient, who doesn’t need to drive into the city, find parking, and spend time in the waiting room risking exposure to COVID-19.
For the doctor, “a call is less formal and the patient often ... isn’t as nervous,” he said.
Virtual visits also make sense with diminished staff. Overall, Rothman’s office staffing is down about 15% to 20% since January, but slowly improving with widely available vaccinations, Vaccaro said.
“With these technologies, it’s just me and the patient online, so we don’t need to have a medical assistant bring them back for an interview or to be seen in the office,” he said. “Information gathering can all be done online.”
Catching up on preventative screenings
For the first three months of the pandemic, screenings for breast or colorectal cancer plummeted, said Penn’s Shulman. “And the number of patients who were on clinical trials for cancer went down significantly during the pandemic,” he said, citing uncertainty about how to keep patients and staff safe from infection.
As patients began to return for care this summer, Penn Medicine mandated that all on-site staff be vaccinated by Sept. 1. Much of the staff that had worked remotely is now back while still socially distanced.
New scheduling rules have also allowed for more appointments as staff’s schedules are now spread out each day to maximize the amount of time patients can be seen. Telemedicine continues to be used on a judicious basis. Typically taking less time than an in-person visit, this allows more patients to be seen.
The center has also adjusted the timeline for when certain tests can safely be administered. For example, patients with advanced lung cancer may not need to be scanned as often as was once thought.
“We found out that we could very safely and effectively monitor patients with fewer visits and fewer scans,” Shulman said. “We’re very cautious to not compromise patient well-being and prognosis, but we could, in fact, practice in different ways than before.”
Shulman believes the thoughtful evaluation of previous practices has led to positive new protocols going forward.
Expanding office options
During the pandemic shutdown, ophthalmology was greatly affected, said Julia Haller, ophthalmologist-in-chief at Wills Eye Hospital and a retina surgeon.
“Most eye diseases can be treated successfully and managed by a variety of great options, but patients need to see their ophthalmologist and stay on top of their vision,” she said. “During COVID, understandably, many folks stayed home and deferred those appointments. Studies show that quality of life is most impacted by vision — independence, driving, recognizing people, working, reading.”
Pandemic shutdowns prevented patients from caring for very serious conditions, including blinding complications of diabetes, retinal detachments that needed immediate attention, glaucoma, eye cancers, and many neurological conditions like strokes.
“One of the frustrating things is seeing people who have very advanced problems that we could have readily treated earlier, and now the conditions have advanced, are more complex, and often require multispecialty collaborations,” she said.
To accommodate more patients, the Philadelphia eye hospital is increasing capacity and offering additional locations by utilizing satellite offices in the region, specifically for less emergent eye conditions. They opened two new offices in Paoli and King of Prussia within the last year, which had been part of their long-term plan.
“You’re scaling up an office but hiring is challenging now,” she said. “We’re hoping the hiring scene improves relatively soon.”
Wills’ regional network of affiliated ophthalmologists, many of whom are alumni or part-time faculty, have also pitched in, specifically with less complex issues that can be addressed outside a care center. Those include eye exams, uncomplicated cataract surgery, diabetic retinal screenings, and regular glaucoma checks.
“The pandemic has put in stark relief the patients who really suffered and lost vision,” said Haller, who is doubling down on initiatives to educate people on the importance of eye care through social media and community outreach. “We need to get the word out that certain segments of the population need better care. The message that ‘I’m diabetic and I can’t see and I need to come in right now’ is missing.”
Realizing that many patients had skipped important chronic care management, earlier this year the Virtua Medical Group in South Jersey began focusing on outreach. For example, staff, including a community-based health manager, social worker, and lead medical assistant, are now contacting patients with diabetes to review their blood sugar monitoring devices to be sure their needs are being met.
“We are seeing patients overdue for bloodwork or medication refill for conditions like high blood pressure and elevated cholesterol that require monitoring,” said Steven Santangelo, primary care medical director with the Virtua Medical Group. “Some of these health concerns and medication side effects are asymptomatic, so lab results are our best resource for monitoring progress and determining how to proceed with medication adjustments or other interventions.”
Since early summer, the group has seen a surge in patients who require pre-op visits for elective procedures they put off during the pandemic. Others, seeking non-COVID-related emergency room treatment which leads to hospital admittance, then need follow-up office visits.
“We are trying to identify those with the greatest need,” Santangelo said. “For instance, we are reaching out to everyone who gets discharged from the hospital to be sure they understand their discharge instructions and then get them seen in a timely manner.”
He said COVID-19 has “widened the net of people we care for” and offered more opportunities to create proactive care relationships.
The group has streamlined communication with patients through the MyChart website, where patients can make appointments, ask a question, and refill medication. The site also makes patients aware of the office’s procedures for in-person visits, including masking, social distancing requirements, and how to reach the office when they arrive.
“Convenient communication is the key,” he said. “The easier it is to communicate with patients, whether it’s a change in procedures or hours, in an urgent manner is important.”
The Future of Work is produced with support from the William Penn Foundation and the Lenfest Institute for Journalism. Editorial content is created independently of the project’s donors.