In my state of Arizona, Gov. Doug Ducey issued an executive order six weeks ago banning elective surgeries and procedures in order to conserve beds and equipment for an expected onslaught of COVID-19 patients. These orders have been in force across the country, and yet here and in many other areas, the onslaught never materialized. Instead, hospitals are half full or less, and are furloughing or laying off nurses and other staff. Likewise in other parts of the country. Hospitals and private medical practices in small towns and rural areas are struggling to keep their doors open.
What many people don’t know is that “elective” does not mean “non‐essential.” It means the procedures can be planned instead of being rushed as an emergency.
When elective procedures are restricted or discouraged, patients can suffer. Some are in pain from abdominal conditions. Others wait weeks for possibly malignant tumors to be evaluated. Cancer patients see chemotherapy and other treatments interrupted. People remain immobilized awaiting hip replacement surgery or are deterred by blinding cataracts. Non‐emergency cardiac catherizations have to wait, as patients hope they won’t get a heart attack in the meantime. Cancer screening colonoscopies don’t get done.
Not all elective procedures are equal
A few of the governors are relaxing the bans, at least partially. My state ban was provisionally and gradually lifted May 1, but in some cases the damage may be too far along to repair.
Even when it comes to elective procedures, one size does not fit all. As a general surgeon, I see patients with hernias that are only mildly symptomatic and have a minimal risk of strangulating. They can be scheduled weeks to months down the road. But I also see patients with uncomfortable gallbladder problems that prevent them from eating without pain or run a high risk of having gallstones obstruct the liver. They need surgery more promptly. Some patients present with masses in their abdomen, soft tissue or lymph nodes that might be malignant. For them, a procedure needs to be scheduled in a matter of days, not weeks or months.
Patients needing elective procedures and treatments are not the only people impacted by this centralized approach to managing the COVID-19 attack. Patients have been urged to avoid visits to the doctor’s office or emergency room. The Medical University of South Carolina recommended delaying non‐critical or routine appointments. Orthopedists are even encouraging some patients with broken bones to stay home. Consequently, patients forgo important preventive maintenance of chronic health conditions or fail to seek help for acute ones. The resultant delay in crucial care is another unintended, and possibly fatal, consequence of top down policy.
In my more than 35 years in practice as a general surgeon, I’ve never witnessed a statewide ban imposed on elective procedures. Prior to the COVID-19 pandemic, it was not unusual for the Centers for Disease Control and Prevention to give advance notice to local public health officials and hospitals of an expected severe flu season that might overwhelm the health care system. The hospital administrators would then inform the medical staff and ask us to be very judicious when we schedule elective procedures. We willingly complied. But judicious meant we were trusted to use our judgment regarding things that could wait and things that really shouldn’t be postponed. And as the strain on the hospitals would abate, the administrators would signal us to resume more liberal scheduling.
Sweeping bans aren’t the answer
With a one‐size‐fits‐all ban imposed statewide by a centralized bureaucracy, it is impossible to adjust policy to fit the specific circumstances of each patient. Explaining to my hospital administrator why my patient’s hernia operation can’t wait four more weeks won’t do any good. After an official request to my hospital administration, I must sign an attestation that the procedure is an emergency, which my hospital needs in order to ensure that Ducey and Arizona’s Department of Health Services don’t punish the hospital for violating the ban on elective surgery. This kind of problem should be resolved more easily at the site, by discussions between hospital administrators and medical staff.
In previous viral outbreaks, hospital administrators provided daily updates about their patient census and capacity, informing us of their ability to handle elective procedures. As hospitals in different regions of a state saw the surge in flu patients abate at different rates, each would inform their medical staff about liberalizing elective procedures accordingly.
Statewide bans are less flexible. Maneuvering them can be like turning a battleship around. Decisions about lifting the bans are influenced by political as well as public health factors. Fear of public criticism fuels a tendency for politicians to be overly cautious. Bans are lifted across the board as opposed to being individualized and locally calibrated.
Before governors began imposing anything resembling lockdowns on their state populations, the private sector had already taken major steps toward social distancing. Festivals and other events were canceled, professional sports leagues postponed or canceled their seasons and businesses were ordering their employees to work from home. This was all voluntary. Given good information and proper guidance by public health officials, the private sector and civil society can respond quickly and nimbly to a public health challenge like the one we face today.
As past experience shows, the health care sector is no exception. Governors should leave the matter of elective procedures to the judgment of those on the front lines.