By Louise P. King, MD, JD and Sigal Klipstein, MD
In recent days, we have seen our efforts at physical distancing flatten curves to mesas and begun to discuss re-opening for “elective” –- more commonly referred to as non-urgent -– medical care.
At some fundamental level, almost all care is essential to the individual seeking it, just as all lives have intrinsic value. The question then is not what is “essential,” because in trying to create such a list we will invariably wish to include so many conditions that we will list much of the breadth of medicine.
Instead, the question must be: can we accommodate non-emergent/non-urgent care safely or not, and if yes, which care do we address first as we re-open? While we cannot address all the issues raised by these questions in this short piece, we will highlight some considerations below.
“Elective,” or non-urgent medical care includes a wide array of services, ranging from office visits to office-based procedures including IVF and ambulatory surgeries.
When we proceed with non-urgent procedures, we run a small risk of needing to admit patients and draw on potentially scarce hospital resources should a complication occur. Also of concern is the fact that office procedures may require the use of supplies such as PPE and anesthetic medications, as well as specialized staff such as anesthesiologists and nursing, all of which might utilize resources that are at risk of being scarce.
It was concern about these shortages that led to the decision by various professional medical organizations to recommend withholding “non-urgent” care including IVF and reproductive surgery. This decision was met with sharp criticism. One critique focused on the characterization of reproductive care as “elective” noting the apparent implication that women’s reproduction is not essential or core to health. “Elective” is a term of art used in surgery and other procedural specialties to indicate merely that a procedure is non-emergent or urgent. Unfortunately, the plain meaning of the word “elective” cannot be understated and it is completely reasonable that patients were offended by the use of this term.
New York’s governor notably responded to this critique and to threats to abortion care access by declaring reproductive health care “essential” and included within the list IVF as well as gynecologic and breast cancer treatments. Read alone, this statement removed all reproductive care from the call to temporarily postpone non-urgent “elective” procedures.
We strongly support the statement that reproductive health care is essential (in the most basic meaning of the term) and thus were happy to see such a definitive declaration. Yet, we would not prioritize women’s cancer care over that of men with cancer –- as is seemingly one unintentional effect of this declaration. Nor is it clear why women’s reproductive health care would be more deserving of prioritization during a time of rationing than other essential care, for example, surgery to restore sight and surgery to restore mobility, both of which have been delayed during this crisis.
The American College of Surgeons (ACS) has summarized guidance that is clear and concise, despite leaving a number of issues open. First and foremost, they ask, is a community ready to re-open? ACS defines the correct timing as after a “decrease in measures of COVID-19 incidence for at least 14 days.” This determination will be made by state and local health departments informed by epidemiologists modeling available data. Without widespread testing, ultimately, they are simply guessing whether we can safely proceed. Thus, facilities and health care professionals should be ready not only to re-open but also to potentially close again if COVID-19 rates resurge -– actions that each require advanced and complex planning.
Even assuming there has been a decision to allow resumption of non-urgent care, not every center or hospital will be able to do so. Much of this will depend on the severity of the COVID-19 pandemic at the local level, and the extent to which surplus resources are available for the care of non-COVID-19 and non-urgent patient needs.
ACS guidance goes on to encourage careful planning related to PPE, other necessary supplies, including anesthetics, which are scarce nationally, clinic flow, rooming, to ensure physical distancing as possible for patients and staff, and, ideally, masks for all. Similar but more specific guidance is available from national societies. If clinics and centers are unable to re-open because of a lack of supplies, they should report this to public health agencies charged with coordination of their state efforts to re-stock. In an ideal world, a federal response and coordination of production and distribution of needed supplies would allow for better and faster transitions to opening all health care services. Such a response has not occurred to date.
Testing represents another missing piece of this puzzle. Ahead of procedures, each patient should be tested for COVID+ status for a number of reasons. Reports indicate that post-surgical outcomes for COVID+ patients are worse than for those who test negative. Patients must be made aware of this, as they may opt to delay treatment.
PPE remains scarce and any procedure that requires anesthesia will require N95 or powered air purifying respirators for some members of staff. Laparoscopy may require N95 respirators for surgeons as well. Screening for COVID+ status will help determine when such supplies are not necessary, thereby preserving the stock.
If testing is not available, given that asymptomatic rates are relatively high, clinics would be well-advised to treat each patient as a person under investigation (PUI) -– further straining scarce resources. Community wide testing could identify areas of the country where the disease is less prevalent and who may be able to resume non-urgent medical procedures sooner than others. Yet, again, without a coordinated federal response to increase availability of such testing, our ability to move forward quickly and definitively is hampered.
Most hospitals and outpatient facilities are currently planning to reschedule up to 6 weeks of delayed procedures. The backlog of surgical and other interventional cases per hospital can number in the hundreds or thousands. Many are considering opening operating rooms and procedural units for regular cases on Saturdays. Triaging these cases will be difficult. We will likely turn to prior guidance dividing cases into urgent and less urgent.
When is surgery emergent or urgent? The ACS has fairly clear guidance here and divides procedures into those which can be safely delayed by 2 weeks, one month or multiple months. Even so, it can be difficult to make these decisions within a specialty, if not among multiple specialties. Is surgery for pelvic pain more urgent or less urgent than surgery to remove kidney stones at risk of causing bouts of pain? Is a colonoscopy for a person at risk of colon cancer more urgent than the removal of a suspicious ovarian cyst? These are not easy questions to answer.
It is unfortunately not uncommon for women’s health to take a back seat to other care. COVID-19 has brought many disparities into stark relief, and women’s health care is no exception. As we start to plan how best to re-open clinics and provide surgeries/procedures now is the time to address disparities in reproductive health and strongly advocate for change. Now is the time for providers to rally in support of women’s health and for a place at the table when making triage decisions related to prioritizing care.
We must also take time now and in the future to advocate for women who do not have access to care. We have deep sympathy for women who had no choice but to defer their fertility treatments at the start of the COVID-19 pandemic. Yet, as ASRM pointed out in their opinion on disparities in access, even before this crisis only 24% of Americans needing fertility care were able to access it. Many persons who should have the right to create families are denied that right each day — many more than have been affected during these past two months or will be affected during our fight against COVID-19. We must advocate for all persons in need, now more than ever.
Louise P. King, MD, JD is an affiliate faculty member at the Petrie-Flom Center, assistant professor at Harvard Medical School and director of reproductive bioethics at the Harvard Center for Bioethics
Sigal Klipstein, MD is a reproductive endocrinology and infertility physician at InVia Fertility Specialists in Chicago, and a Clinical Assistant Professor at the University of Chicago. She is the Chair Elect of the American Society for Reproductive Medicine Ethics Committee.