COVID-19 and the response to COVID-19 has resulted in the near complete cancellation of elective surgical cases across the United States. The volume of surgery has sunk to its nadir in a society in which the financial viability of our health-care systems and the quality of our citizens’ lives are directly proportional to that very surgical volume.
Elective surgeries are just now starting to be performed again, and debate surrounds their integration. The necessary delay, rationing, and cancellation of surgeries is now a true public health challenge. The bottleneck of multiple specialties will be desperately trying to get cases done with an already limited asset: operating rooms.
Guidelines about when to perform surgery during the COVID-19 crisis by the American College of Surgeons attempted to balance public health and the infinite variables of doctor–patient interactions. They were and are necessarily limiting. We absolutely do not and cannot label the guidelines as unwise in any way. Rather, we want to point out that these guidelines, already put into motion, have lasting effects individually, communally, and ideologically.
Shutting down surgery, just like shutting down the economy, hurts people too. It’s just harder to find the direct link. But the surgery shutdown is impacting a wide variety of patients. Each decision regarding the cancellation of a surgery was a form of a risk-benefit decision.
Leg pain, for instance, under these circumstances, was not considered a sufficient reason for scheduling surgery. In fact, the necessary preoperative imaging and testing were no longer ubiquitously available unless the surgeon could show risk to life or limb. But during the inevitable flood of need after restrictions are lifted, patients may go months without relief. A difficult-to-measure but real and slowly eroding mobility, especially in elderly patients, becomes impossible to restore at some point.
So where do we look for a solution? We look back to the doctor–patient relationship.
One of the fundamental precepts of our health-care system allows individuals with informed consent, including the risk of hospital-acquired infection, to decide for themselves how to proceed.
Frank, open, and honest conversations need to occur between the surgeon and the patient. The best local data needs to be integrated, and the patients’ clinical courses need to be weighed against their risk for surgery in general and their specific risk of coronavirus exposure. The threshold of which surgeries can realistically be performed is going to be different in New York City than in Montana. It needs to be. And that threshold also needs to be different in a 30-year-old marathon runner compared to a 79-year-old smoker.
Both authors have each individually cancelled surgeries under the guidelines. This was necessary to do But, we also remain concerned and vocal regarding the risk of not performing surgery on certain patients. These patient–surgeon conversations are as difficult as they are blunt: “Mr. Smith, if you get coronavirus, you are at a staggeringly high risk to die. I do not feel comfortable proceeding with surgery,” or “Mrs. Johnson, if you don’t have this surgery, you will be paralyzed in a matter of days.” Traditionally patients have had a right to different risk tolerances and as rational adults exercised those rights. We as physicians are comfortable with the reality that most people make the best decision for their own medical needs when given all necessary information and education. Our experience has been that the doctor–patient relationship has been more effective in reaching desired outcomes than any form of rigid administrative protocols.
One of the fundamental precepts of our health-care system allows individuals with informed consent, including the risk of hospital-acquired infection, to decide for themselves how to proceed. This American health-care structure, like capitalism, focuses on individual interactions with a resultant societal benefit. The principles of Adam Smith, when applied to health care, are not meant to give us some proposed ideal population-based outcome, but rather a coalescence of the chosen outcomes of each individual. Some choose pain over surgery, some death over intubation, some life at all costs — but all choose in one way or another.
A blanket of socialized medicine, not in the political sense, but as it’s being applied today to this crisis, leads us down a road that could ignore consent and ignore choice for a proposed greater public good. Whether this proposition is temporary or becomes part of our medical fabric over time is not yet known. But “electivity” in medicine is not something to be removed lightly. It cannot be permanently discarded in a crisis. It is fundamental.
Richard Menger, MD, MPA, is an Assistant Professor of Neurosurgery and Assistant Professor of Political Science at The University of South Alabama. He is a lead editor of the textbook The Business, Policy, and Economics of Neurosurgery.
Chris Karas, MD, is a board-certified neurosurgeon in Columbus, Ohio.