Interview with Dr Deborah Keller by Zoe Garoufalia.
Dr Keller is currently an Assistant Professor in the Division of Colon and Rectal Surgery and member of the Cancer Population Sciences Group in the Herbert Irving Comprehensive Cancer Center at Columbia University Medical Center in New York, NY. She has accepted a new post and will be joining the Colon and Rectal Surgery team at the Medical University of South Carolina in Charleston, SC this summer to help develop Rectal Cancer and Pelvic Floor Centers of Excellence.
ZG: Dr Keller, thank you for agreeing to speak with us on the subject of the second wave of COVID-19. These are challenging times for all of us with multiple issues and a lot of grey areas demanding clarification. It is clear that it has become imperative to rethink and reshape the way we live and practice our everyday activities, regarding work and leisure, in respect to our mental and physical health.
The post-COVID era finds us feeling insecure. Everybody is wondering about the new ‘normal’ in clinical practice, the PPEs, the best timing for a procedure, educational issues and so on. What are your thoughts on the readiness and stability of the US health system for the after COVID-era? What changes in the framework of operations do you foresee or propose?
DK: I agree that these thought are on everyone’s minds, but it’s difficult to talk about the new normal while we are still in the midst of the problem. The US healthcare systems were definitely not prepared for the impact of a pandemic, overwhelming resources and halting elective procedures, the main revenue stream for most centres. The effect on patients, providers, and supporting staff will be long-lasting as we try to resume trust and routine operations under this cautious new framework. However, there is such wide variation in the way different regions were impacted and the way that different centres normally operate compared to the UK and other primarily single payor nations, it is difficult to talk about the stability of the system in general. Some absolutes for certain - hospitals will need to more efficient in scheduling, staffing, providing the appropriate amount of PPE and instruments for procedures, and the timing for turnover between procedures. This will require multidisciplinary teamwork from nursing, anesthesia, surgery, and the support staff, as well as the administration to set the standards.
ZG: Now, that in many countries all over the world, the COVID crisis has peaked, what are your thoughts on the resumption of elective surgeries - do you have any concerns?
DK: I do, as while the virus may have peaked, it is still a reality we are living with. It is not eradicated. There are still 100s of deaths daily. We do not have solid data on reinfection, immunity, or the status of an effective vaccine. From the images in the media and what I see outside myself outside, as a society we do not have the common sense to maintain social distancing and face covering to push the transmission rates towards zero. Thus, I have concern of subsequent peaks from resurgence overwhelming PPE and staff capabilities once restarting elective cases. From exposing patients that come into the hospital from the lack of proper universal testing, or conversely having asymptomatic patients expose providers and other patients. This adds a whole extra layer to discussions on risk and informed consent for surgery. Regardless, elective surgery needs to be restarted in a calculated fashion.
ZG: Given these variations in the COVID crisis in the US, what are your thoughts about resuming colorectal surgery specifically in New York? Can all recommendations apply evenly across the USA? And if not, what would be closer to a one-fit all approach? (Federal versus State approach)
DK: Again, elective cases need to be restarted for the benefit of patients, providers, and the healthcare systems. But in a calculated fashion. All recommendations definitely cannot be applied evenly across the USA. They can't even be evenly applied across New York City. At this point, healthcare is so disjointed that the decision has to be made at the institutional level. Factors all should consider include the availability of beds (ICU and non-ICU), PPE, appropriate staff, ventilators, medications, anesthetics and all medical surgical supplies, available operating rooms, the COVID census, and the patient’s willingness to resume in-person services. As we restart, the institution’s capacity with the above in mind should be considered. Case and specialty priorities must also be considered. Then, designing a phased opening of operating rooms strategy, to ensure the actual capabilities are aligned with estimates before. Strategising a scheduling for resuming high volume, low resource consumption ambulatory cases amidst longer, resource consuming inpatient surgeries in balance with the institution’s capabilities. In lines with efficiency, looks at ways to increase OR and procedural time when the institution can support it, such as extended hours and weekends. Past that, the reviewing list of previously cancelled and postponed cases for priority and patient satisfaction. Above all, a testing strategy and safety plan should be in place and clearly communicated to patients and staff.
ZG: The lack of PPEs was a core issue during this pandemic placing the safety of health workers in jeopardy. Moving closely to the resumption of elective surgeries, what are your thoughts about personal protective equipment issues supply?
DK: It’s terrifying. Previously, it would be wrong to wear the same mask into a case with separate patients. Now, reusing is expected and necessary to maintain what is regarded as 'adequate PPE'. I think part of the plan for resuming elective cases is considering the PPE needs for cases and postoperative care against the current supply and pipeline to replenish supplies. All with the contingency plans for subsequent surges that could occur.
ZG: The COVID-19 pandemic changed the standard of medical, as well as the surgical practice. A lot of surgical diseases were treated medically (e.g. appendicitis). What changes do you foresee in permanent standards of care?
DK: Regardless of COVID, cases where surgery is the standard of care should have surgery for the best outcomes. What we are seeing is patients afraid to come into the hospital or perhaps trying to treat cases where surgery is necessary non-operatively, and coming in with more advanced pathology. Evidence like the Comparison of Outcomes of antibiotic Drugs and Appendectomy (CODA) trial should determine if medical management of appendicitis is non-inferior, not COVID.
ZG: Regarding endoscopic procedures (EMR, other endoluminal procedures, routine colonoscopy) as well as minimally invasive surgery, almost all were halted during this period because of the aerosolization properties of the virus. What is the current situation in the US and what are your thoughts on this?
DK: This is something that changes with updated data, and is more appropriately covered by surgical societies like SAGES and ACS. That’s where I go for my data, and would encourage others to do the same.
ZG: Do you think that the patient (and maybe even the patient’s family) has a bigger place to play in decision making regarding the type of treatment? And how have patient expectations changed?
DK: I think the patient always had a key role to play in decision making - that is the point of informed consent. We have the duty to continue to provide the standard of care, but need to appropriately introduce the new risks present. As always, honest two-way communication is key. One thing we have seen change is the use and acceptance of telehealth and mobile apps, which despite some quirks and limitations, can be a huge benefit for patients, especially after surgery. I’m sure patients will expect these to stay in place, and I also hope they do.
ZG: This pandemic has taken its toll (emotionally and physically) to healthcare workers. How do you think we can address this second victim syndrome? And now a more personal question; how did you cope under the COVID crisis? And is this experience going to change you or your future practice?
DK: This is a great question, and extremely relevant, even though (in true surgeon form) it is discussed less than other aspects of the pandemic. And it is something that I’m honestly struggling through. Above all, we need to acknowledge that second victim syndrome exists and is actively affecting us. Any provider during this time that says they aren’t impacted is not being truthful with themselves. We need to recognise that everyone is going through hell right now, it just means something different for everyone. The self-actualisation and acceptance of the situation, being flexible to make changes to yourself and the circumstances to get through each day, as well as taking advantage of any support or mental health resources for personal strength are critical.
I can only speak for myself, but seeing colleagues, friends, and patients personally affected, and being sick myself had a profound effect that will endure. Being separated from my family (and dog) for months putting safety first was heart wrenching but deemed necessary. Seeing the differences in institutional responses to the pandemic and their employees has also been an impactful learning experience. I have felt the toll and sadness of social isolation from social distancing on myself. I recognise I have been more emotional and had a shorter fuse with others around me. I’ve been less productive and needed to search for motivation that’s usually inherent in my DNA. I may be more vulnerable from this experience.
Honestly, coping is a work in progress. But things I have done to cope will be incorporated into daily life even after COVID. I try to continue some normal routine, like the daily run, which has been amazingly therapeutic. I have to say that anything I feel or those around me feel is valid. I am trying to give myself a break to not need to operate at the unsustainable pace I normally live at. Seeing how life as we know it can change almost instantly has made me reprioritize the importance of the work-life balance and focusing on loved ones and life outside of work everyday. I recognised that it is physical distancing, but cope by being even more connected socially. I reach out to friends and family more. I use FaceTime more so that I can at least see loved ones even if I cannot be with them. I make sure to keep mentorship meetings, and we allot time to talk about how we are really doing and what we can do better. This human touch that is normally glossed over with 'fine' by all parties is especially appreciated now.
ZG: Εducational activities have been reduced during this pandemic, not only for medical students but also for surgical trainees and fellows. Weighing the risks of spreading the virus, what are your thoughts and suggestions to overcome this obstacle?
DK: I would suggest using social media channels, including online sources, interactive webinars, apps, video reviews, and journal clubs, as well as and digital health platforms more heavily. Tools such as Proximie that allow the real-time OR experience and post-operative audit without physically being in the OR are an amazing asset for trainees during this time and beyond. To some degree, ESCP has done this and been the model to follow. But there is still room to expand and make these convenient, easily accessible forms the standard for surgical education when outside of the hospital.
ZG: To date more than 14,000 articles, referring in some aspect to the pandemic, have been published, commonly with contradictory approaches. In this respect how do you advise young surgeons to source information, regarding their practice?
DK: I would caution readers to digest the publications to date with caution, and not be pushed to accept everything in print as fact amidst the hysteria from the pandemic. The vast majority of papers published, even from highly reputable peer-review journals, are unsupported research, uncontrolled trials, small sample sizes, and opinion pieces. I understand that journals need to pull readers in and remain relevant, but when we look back at research during this period, I think we will be embarrassed at what made it through into print. I would instead advise young surgeons to use vetted society guidelines, like SAGES, and practical frameworks and information repositories, like the COVID portal from the AIS channel.
ZG: Are there any messages you would like to convey to the young ESCP members?
DK: Stay involved with this organisation. Take advantage of all the opportunities provided. They are unique and valuable. This society has met the challenge presented from COVID by transitioning the education to SoME channels so all can stay active and up to date in a unique fashion. Young members should recognise this and use the myriad of tools provided.
ZG: Thank you for your time and insight Dr Keller; it has been a real pleasure and privilege working with you on this project.