Docs Must Take the Lead in Prioritizing Surgery

The post-COVID world will deliver a new patient experience to which spine specialists will have to adapt.

The surgery backlog will be a beast with which spine physicians will have to contend in the coming months as the pandemic begins to die down. Algorithms and ethical guidelines will help prioritize rescheduled surgeries, and SpineUniverse Editorial Board member Michael G. Fehlings, MD, PhD, a professor of neurosurgery and vice chair of research in the University of Toronto’s department of surgery.

“This unprecedented pandemic will have many unintended consequences in medicine,” says Dr. Fehlings. “A couple of these will be particularly important to spine surgical practices, and these have formed the subject of our new research initiative.”

Two Phases of Research

The project, which as of mid-May 2020 has no name, is a cooperation among University of Toronto hospitals, along with a hospital system in northern Ontario, a hospital system in Manchester, UK, and Dr. Fehlings’s own clinic. There are about 14 million residents of Ontario, with 7 million of them residing in the greater Toronto area.

“We’re going to be looking at real-time data in terms of previous surgery lists and cancellations to get a sense of what was going forward during the COVID lockdown and what was cancelled,” says Dr. Fehlings. “We’re going to set up some working groups to prioritize cases and establish working protocols.”

The second phase will involve machine learning algorithms to “predict the trajectory of cancellations and develop other algorithms to assist healthcare administrators, medical leaders, governments and funders to help prioritize rescheduling going forward.”

Of Canaries and Coalmines

Telemedicine is going to be the way forward even after shelter-in-place orders are lifted, and spine specialists will have to adapt to virtually seeing patients. Dr. Fehlings has tested virtual visits with patients who have spinal cord injuries.

Over a telemedicine platform, Dr. Fehlings and colleagues have been able to “assess stance, walking, coordination, muscle strength, range of motion, spine alignment and flexibility,” he says. “Although none have been validated, I think these kinds of algorithms are going to be required.”

Dr. Fehlings says he’s using his own clinic as a “test balloon” in assessing which sorts of canceled surgeries should be prioritized when stay-at-home orders are relaxed. “My clinic has done virtual assessments and been able to triage patients. We’ve also determined who might need surgery. There are two that are particularly urgent and we’re going to need to operate soon. We’ve made that decision already.”

Collaboration and Extrapolation

Dr. Fehlings’ group is collaborating with a rural hospital system in Ontario, as well as a hospital system in Manchester, United Kingdom. “We partnered with the Manchester system partly because we have trainees who have worked in the UK, and also because the UK also has a publicly funded healthcare system,” says Dr. Fehlings. “We thought there might be some analogies and learning points.”

Although the United States healthcare system is different—a public-private mix, and a far greater population to serve, for example—Dr. Fehlings believes the questions he’s trying to answer are universally applicable, and he’s looking for US-based partners.

“Our systems are more similar than different, and our societies are similar as well,” explains Dr. Fehlings. “I think the techniques we develop will be universally applicable. Access to care issues are a universal concern.”

Look to the Future

Dr. Fehlings sees the COVID-19 pandemic as much an opportunity for spine specilists as it is a hindrance to delivering care, but only if physicians take an active role in reshaping healthcare systems.

“It’s going to ve very important for doctors to take the lead around helping healthcare systems decide how to ramp up their surgical practices, what cases will need to move forward and how to prioritize,” he says. “There are opportunities to enhance efficiency, but unless doctors get involved and show leadership, decisions will come down from on high and be very blunt and not as effective.”  

Another message Dr. Fehlings wants to stress, he says, “is that virtual clinics represent a unique opportunity to enhance care deliver. They’re not just the second-best solution; they can revolutionize the patient experience.”

If you are interested in partnering with Dr. Fehlings on his research, you can email Michael.Fehlings@uhn.ca.