Marc Eigg, MD, FACOG, director of urogynecology and pelvic reconstructive surgery for West Ridge Obstetrics & Gynecology, LLP, in Webster and Greece
COVID-19’s impact has relaxed somewhat in New York State, but it still has the power to create serious anxiety among western New York residents. The undercurrent of fear has kept people who have health issues unrelated to COVID from seeking the medical help they need.
Physicians’ practices of all types have worked hard to respond to this issue, ramping up their ability to provide health care even if the patients cannot visit their offices. Telehealth, a tool already in use for consultations between physicians, surgeons, and other medical professionals in disparate locations, has become one of the most important technologies to come into common use during the pandemic.
An analysis of Medicare fee-for-service data by the US Department of Health and Human Services (HHS) at the end of July , for example, noted that in February, just 0.1% of primary care visits across the country took place via telehealth—but by the end of April, 43.5% of appointments took place over video, or as many as 1.28 million visits per week. Even as doctors’ offices reopened to in-person visits in many areas of the country in May and June, telehealth visits continued and held steady, with 22.7% using video chat apps like Zoom as of June 3.
This has led to some discoveries about the effectiveness of
“Patients are even more cautious than usual, but that’s as it should be. With telemedicine, we don’t have to defer their care.”
seeing patients as they remain in their own homes versus venturing out, especially when they are having certain kinds of health issues. Women in particular have seen value in consulting their gynecologist on video about issues like interstitial cystitis/bladder pain syndrome, and overactive bladder. “When we had to stop doing routine care in the office, we started a telehealth capability within a few days,” said Marc Eigg, MD, FACOG, director of urogynecology and pelvic reconstructive surgery for West Ridge Obstetrics & Gynecology, LLP, in Webster and Greece. “We went from doing no telemedicine to it being about a third of our visits right away. We did urgent problems in the mornings at times, and all telemedicine in the afternoons.”
Patients with overactive bladder may have only one symptom: uncomfortable urgency not caused by other factors such as cystitis, Dr. Eigg said, while bladder pain syndrome’s main symptom is the pain. “Once we determine that they don’t have a bladder infection,” a process that requires a urine test, “treatment doesn’t really require a physical exam.” This condition really lends itself to treatment via video, he said. “A lot of times, they’re sitting at a kitchen table with their phone or laptop,” and “I’ll say, ‘You should be limiting your fluid intake to eight-ounce servings’—typically, for someone with overactive bladder, we strive for emptying the bladder every two hours. I’ve had patients walk over to the sink and show me the glass they’ve been using, and it’s actually a 12-ounce glass instead of an 8-ounce glass. Sometimes they change their excess intake and find dramatic relief.”
Many of the things that irritate an overactive bladder also cause a painful bladder, Dr. Eigg noted. “Coffee, tea, carbonated beverages can all be irritants,” he said. “Moderating these things can provide great relief. Counseling is better by telehealth, so they don’t risk exposing themselves to the virus.”
Treatment often involves specimen collection using a urinary hat—a device that can be purchased online and delivered directly to the patient’s home—and a voiding diary, said Dr. Eigg. “They write in the diary that they had 8 ounces of water at 2 p.m., and an hour later they used the bathroom, and they record the amount of urine,” he said. “What people tell us they drink is often not the same as their output. They don’t think about soup or smoothies as part of their input. If they’re putting in 48 ounces in a day, they should not be putting out much more than 30 ounces. So if they’re putting in too much, the overactive bladder says, ‘I’ve got to go.’”
Changing the behavior to mitigate the symptoms does not require an office visit, he said. “To be able to address these issues that improve their quality of life, that can be done through telemedicine. Addressing this while keeping the patient in a safe environment, that’s great patient care and service. Patients are even more cautious than usual, but that’s as it should be. With telemedicine, we don’t have to defer their care.”
Beyond the pandemic, telemedicine can be better for many patients than having to make an in-person office visit, he added. “They still have a highly skilled medical visit, but with no arranging for child care, having a family member bring them, or medical transport,” he said. “It’s something we all had to do acutely, but it should not end once the crisis is over. Everyone wants things to get back to normal, but we don’t know if or when a well-tested, effective vaccine or better treatments will be available. How do we do what we’re currently doing, but better? Some of the things we’ve put in place should not disappear.”
“They still have a highly skilled medical visit, but with no arranging for child care, having a family member bring them, or medical transport”
Cardiology gets a video makeover
For Mohan Madhusudanan, MD, FACC, a cardiologist with Trinity Medical WNY and Catholic Health whose practice includes nuclear cardiology, cardiovascular CT, echocardiography and vascular interpretation, the swing from in-person office visits to telemedicine came swiftly and suddenly. “We are all used to Mohan Madhusudanan, MD seeing patients in the office, examining them, doing EKGs, and then we had to switch to telemedicine suddenly,” he said. “We came together as a team and we restructured our clinic, and moved 90% of our practice to telemedicine.”
Patients turned out to be very receptive to the idea, he said. “The patients were always happy to hear your voice, and see you on televideo. It was a relief to them to have someone they could talk to. Most of our patients are known to us—we’ve seen them before, and we know what their issues are. We were able to address most of their issues by talking to them over the phone/video, and if we needed to address something urgently, we brought them into the office. It’s not the same, but it’s easier to do if you know the patient. You can get a sense just by looking at them on televideo to see if something was not right.”
Having conversations about symptoms with patients via video could also reveal when a patient’s symptoms are more acute than they realize. Symptoms can be more subtle in women, ranging from chest discomfort to nausea and vomiting, excessive sweating, and unusual fatigue. Women may be more likely to minimize their symptoms or to attribute them to something else—like stress, muscle soreness from exercise, menopausal hot flashes, or depression—rather than a heart attack.
“Our biggest worry was that patients would not seek immediate care for issues they would normally go to the ER for,” said Dr. Madhusudanan. “When they were finally coming to see us in the office, there were times that we were surprised that the patient had the symptoms for several weeks and was reluctant to address them sooner. We do see some of that even now—patients who sat on their symptoms and are just starting to see their cardiologists.”
Worse, some with active chest pain refused to go to the emergency room for fear that they would contract COVID-19 while they were there. “There’s no way to know if they’re having a heart attack without an EKG,” he said. “In
“Our biggest worry was that patients would not seek immediate care for issues they would normally go to the ER for”
one case, a patient had a bleeding issue with blood thinners, and I advised them to go to the ER, and they wouldn’t go. The next day, they called again, and I told them again they had to go to the ER. They ended up needing a blood transfusion. But as a patient, their concern was that they did not want to go where they might get more sick. These things are hard to manage over the phone or video.”
At the height of the pandemic in New York State, the practice limited in-person visits to urgent cases only, he said. Now that the office has reopened, the cardiologists have a long list of patients who need to be seen in person for routine care and testing. “We built up a backlog of cases that had to be addressed as we opened up,” Dr. Madhusudanan said. “When a patient has a history of heart disease, we like to do a routine stress test or an echo every few years. We had to postpone those; emergent cases took priority.”
Even now, however, some patients hesitate. “I often ask my patients if they are comfortable coming in,” he said. “Most are trusting of the situation now and are satisfied with the protocols in place in our offices.”
With much of the practice returning to normal, Dr. Madhusudanan does see a continued role for telemedicine now and in the future. “Many of us are wondering how this will be incorporated into our practice when the situation improves,” he said. “There will be room for telemedicine going forward. It is possible to take care of some patients that way—patients that you have known for quite some time, and have an issue but are not able to travel. This may be something that will likely be part of their care in the future.”
At Great Lakes Cardiovascular in Buffalo, noted Laura Ford-Mukkamala, DO, FACC, the practice incorporated telemedicine as a way to protect its most vulnerable patients.
Seeing patients via videoconferencing “allowed us to manage social distancing and preserve PPE in the offices when there were shortages,” she said. “It provided a way for us to manage some of our chronic disease states and to make sure that patients did not require a visit to the emergency room.”
A patient with chronic hypertension whose numbers were higher than normal could have a video visit to discuss the issue, she said. “With the use of some home monitoring, we were able to adjust medications and potentially prevent them from ending up in the emergency room,” she said.
Self-monitoring at home provided the information doctors needed to advise the patient and prescribe treatment without an in-person exam. “If they had congestive heart failure, patients would weigh themselves and take blood pressures,” Dr. Ford-Mukkamala said. “They would report to us how they were feeling, and we would look at their data to see if medication needed adjustment. The use of telemedicine at that time was critical in an effort to give peace of mind to the patients and prevent the emergency room from being inundated.”
The video visits could not fill every gap in patient care, Dr. Ford-Mukkamala and her colleagues discovered. The technology itself presented stumbling blocks that proved difficult to surmount. “The drawbacks of telemedicine are related to technology, such as service issues—certain carriers that did not seem to meld well with our EMR system,” she said. “Some of our patients had a difficult time managing the directions and using technology that they weren’t typically acclimated to. From a visit standpoint, we had to rely on history and whatever data they could provide us. We obviously could not listen to their heart and lungs. In our specialty, this is obviously an important piece of the evaluation.”
For patients that required angiograms or surgery, “medi
cal stabilization during that time was vital,” she said. “For patients who could not be stabilized medically, it was challenging to get them into the hospital with the confidence that many safety measures were being taken by the hospitals and staff.”
Still, having a way to communicate effectively with patients provided considerable benefits—and Dr. Ford-Mukkamala expressed her respect for the resilience of the area’s entire healthcare community’s willingness to embrace a new way of working.
“All in all, what impressed me most was the ability for multiple healthcare systems to flip the switch of using the technology that was readily available but was not being utilized,” she said. “It really helped transition a lot of patients and gave them a lot of comfort knowing that we were able to talk to them in some capacity. This truly took teamwork from our administrative team and IT support staff, to medical assistants who were prepping charts, calling patients and trying to talk them through the process, to nursing staff and all of our providers who were trained and acclimated quickly to the situation.”
As the office reopened to in-person visits, “there was a lot of catch-up with regards to inpatient evaluations,” she continued. “This I found challenging, because most patients who were seen via telemedicine wanted to come in sooner than they typically would, so they would have the benefit of the physical examination. This created a hectic schedule and still has, catching up with that time period.”
Outpatient procedures continue
Not every practice had to shut its doors or leave patients untreated during the pandemic’s peak. For J. Dana Dunleavy, MD, at Windsong Radiology, a practice focused on women’s health that offers interventional and vascular services and radiology services at five locations throughout the greater Buffalo area, it has been possible to continue to offer outpatient vascular services to patients with an acute need. “COVID has put the entire world on edge,” he said. “We find that patients are more stressed and in more pain than they normally would be. When people are struggling with anxiety and depression, the pain they normally cope with becomes more difficult to manage.”
Dr. Dunleavy, who worked at the internationally renowned Fibroid Clinic at Johns Hopkins hospital, specializes in uterine fibroid embolization (UFE), a minimally invasive elective procedure performed in Windsong’s innovative angiography suite, a safe site without COVID-19 patients or hospitalization. Uterine fibroids are not a life-threatening condition, but they can adversely affect quality of life for women who experience pelvic pain and heavy menstrual bleeding—enough to make them reluctant to leave the house for fear of bleeding through tampons, sanitary pads, and their clothing. This af- front to quality of life can be exacerbated by stress, making it even more difficult to live with during the pandemic. “With symptomatic uterine fibroids, which are invisible without medical imaging, women going untreated are ‘silent sufferers,’” he said. “It’s hard for people to go around in an open forum and say, ‘My vaginal bleeding is awful. How’s yours?’ It’s something women learn to cope with—they don’t want to have a hysterectomy with a three-day hospitalization and a seven-week recovery. Since it’s embarrassing to talk about, patients with fibroids don’t know that there is an option besides surgery.” Windsong offers this procedure in an office-based lab, a safe environment without any COVID patients, said Dr. Dunleavy. “This endovascular treatment of fibroids treats all of the fibroids but does not require hospitalization. Patients are discharged a few hours after the procedure to their home and have a one-week recovery. Furthermore, the goal of delaying elective surgeries during the pandemic was that surgeries utilize hospital staff, equipment, and resources that could otherwise be utilized for treatment of COIVD-19 patients. In addition, people undergoing hysterectomy need to be hospitalized and use a limited bed that could otherwise go to a COVID patient requiring hospital care.”
Because of its minimally invasive nature, UFE is performed with local anesthetic and intravenous conscious sedation, as well as intravenous Tylenol and intra-arterial lidocaine, making this procedure very well tolerated. “We also offer a nerve block targeted to the sensory nerves of the uterus,” he said. “This is called a superior hypogastric nerve block and takes a few minutes when performed at the beginning of the fibroid embolization (performed under fluoroscopic guidance in the angiography suite). The procedure can also be performed from the traditional femoral access (groin) or more modern radial access (wrist). Patients choosing radial access can ambulate immediately following the procedure, position themselves how
Dr. Dunleavy is the Medical Director at Windsong Interventional & Vascular Services in Buffalo.
ever they want, avoid the need for a bladder catheter during the procedure or during recovery, allowing patients to get home sooner.”
While some services offered at Windsong Interventional were voluntarily shut down during the height of the pandemic, treatment of uterine fibroids with menorrhagia was considered appropriate to continue (due to the negative impact of a delay in treatment). For instance, some patients that were being evaluated for UFE or hysterectomy ended up being hospitalized and receiving blood transfusions while waiting for treatment, negatively impacting patients, their families, and cost to the healthcare system. “On the other hand, for varicose vein procedures, mammograms, and other non-urgent exams, we didn’t feel it was the right thing for the region to continue during that time,” he said. Therefore, certain elective procedures were shut down during the height of the pandemic.
This delay, however, resulted in some issues going undiagnosed, which led to bigger problems for patients. “We have seen people come in with large blood clots that could have been diagnosed earlier,” he said. “We find that the severity of whatever they’re coming in for has progressed during the pandemic, because people have not come in for evaluation as soon as they usually would. But fortunately, Windsong’s officebased interventional suite has optimal technology for complex endovascular procedures, avoiding the need for hospitals and
“We have seen people come in with large blood clots that could have been diagnosed earlier”
unnecessary exposure to hospital patients being evaluated and treated for COVID-19. It’s a safe place to come for treatment, especially if you’re immunocompromised.”
Randi Minetor is the author of Medical Tests in Context: Innovations and Insights (Greenwood 2019), and is a freelance journalist based in upstate New York.