Emerging from COVID-19: Successful Office-Based and OR Strategies

Welcome, and thank you for attending. This event is brought to you by Cooper Surgical, a leading provider of medical devices for women’s health care. For thirty years, Cooper Surgical has worked with health care providers to provide highly effective clinic and practice based contraceptive surgical and obstetric solutions.

To complement our portfolio of trusted and reliable medical devices, we have also broadened our offerings, investing in the areas of reproductive genomics and in vitro fertilization.

We are fully committed to helping improve the delivery of health care to women and their families. Cooper Surgical manufactures over six hundred clinically relevant medical devices used by health care providers in offices, clinics, operating rooms, labor and delivery suites, and reproductive IVF clinics worldwide. Clinicians overwhelmingly say they trust our products for their reliability, innovation, and efficiency.

Here are some other interesting facts you may not know about Cooper Surgical.

Since our inception in nineteen ninety, our focus has always been women’s health care. With more than six hundred medical devices and over thirty two hundred product numbers across a broad range of market segments, physicians know and trust our products. We ship over fourteen hundred orders per day of which ninety nine point seven percent are shipped the same day. Our customer service department handles over two thousand inquiries per day. We employ seventeen hundred fifty people worldwide.

We are pleased to provide this educational opportunity on behalf of Cooper Surgical.

Good evening, everyone. Hello. My name is Kelly McKeon, and I am your meetings manager. I’ll be assisting in running the ritual presentation this evening. I’d like to welcome you all and thank you very much for your participation.

First, I’ll go over a few notes on how this presentation will run. We have our presentation tonight with questions and answers to follow. Please keep in mind that all participants will be on mute for the duration of the meeting. However, you’ll have the ability to submit any questions to the q and a feature during the entire presentation, which you’ll see at the bottom of your screen. Both doctor Abigaila and doctor Goldstein will participate in a q and a session upon conclusion of the presentation.

For any questions that we do not get to this evening, you’ll receive a response from Cooper Surgical or the speakers following the meeting. I’d now like to introduce our speakers for this evening. Doctor Arnold Abicula is a Levine family professor of women’s health and vice chair for the department of obstetrics and gynecology, as well as the chief of gynecology at the Sloan Hospital for Women at Columbia University Medical Center, New York Presbyterian Hospital.

Doctor Ethan Goldstein is an obstetrician and gynecologist at Detroit Medical Center Medical Group, Tennant Physician Resources.

He’s also the founder and president of ZPOG Surgical Service PLC and the director of GYN robotics and minimally invasive surgery at Huron Valley Sinai Hospital.

I’ll now turn the presentation over our speakers to begin. Doctors, you now have presenter privileges.

Good evening, everybody, and welcome to this webinar event sponsored by Cooper Surgical.

First of all, I’d like to start by thanking Cooper Surgical for hosting what, doctor Goldstein and I believe will be, very educational event as we address what seems to be a constant topic on all of our minds, and that is how to practice medicine, particularly office based strategies and operating room strategies in the era of COVID nineteen.

It’s interesting in that when we began to develop this presentation, we talked about it as strategies emerging from COVID nineteen.

But given the dynamics and the changes that we have been seeing across the country, it really has evolved into a discussion around what are the things that we do on a day to day basis to successfully run an office based practice or to successfully manage patients in the operating room. And so, hopefully, over the next forty five minutes to an hour, we’ll be able to address a variety of issues, and I’m really excited to be sharing this evening’s platform, with doctor Ethan Goldstein. Ethan?

Well, thank you very much, Arnie. And it’s my pleasure to be, in your presence. You’ve been a, sort of a a surgical hero of mine for a long time, and I have appreciated all the work you’ve done in promoting and advancing, us in the area of minimally invasive gynecology. So thank you for that, and it’s a pleasure to be here. And thank you very much, Cooper Surgical, for hosting such a timely event.

Well, let’s go on and, we’re gonna, use some slides this evening to kinda help serve as, as ticklers in terms of topics that we’d like to address, with you, the audience. And in terms of objectives, as I stated earlier, we’re really gonna focus on the impact that COVID nineteen has had on our clinical practices and and how we function in the operating room. We’re gonna spend a little bit of time on the role of telemedicine, the role of office based procedures, and mitigation strategies. You know, how are we managing, keeping ourselves and our patients safe in this era of COVID nineteen?

So as we get started, I thought it would be very, very timely and also appropriate to begin with what we do in the office. And with that, I’m gonna, talk to or turn things over, I guess, I should say to Ethan in terms of what are you doing, in the office. What are the considerations that you’ve been having as you practice in this ever changing clinical environment?

This is obviously on on the minds of all of us, who practice, medicine. And and specifically, as a general OB GYN, it’s pertinent every day into making sure that we are providing, safe and effective care, in this new era of medicine. So, as, Arnie mentioned, you know, this is a ever evolving situation, and I think we had maybe a a three week period of time where most of the country thought maybe we would be sort of, on the other end of this, but that’s clearly not the case as we are reading and seeing in the news on a daily basis. And I think in talking to my patients in the office, I hear quite frequently when I ask them how they’re doing, how is their family, how has this pandemic, you know, affected them, you know, the the the phrase, this is the new normal, and it is what it is, and we just need to get used to how things are.

And that’s really true. I think, like most things, change is very difficult, and this is no different. But the sooner that we adapt and, and move forward in understanding and accepting where we are, I think we can actually, you know, move forward, to to get through this together in a safe and effective way. So in terms of, you know, how this affects me and my practice as a generalist, I think number one is addressing patient concerns and fears.

You know, I’ll tell you, I’ve I’ve I’ve seen the gamut in terms of what patients, you know, feel about COVID and and how it arrived and and all the missteps that were taken perhaps and and all of the, the implications and the things that we read about and see in the news. And, you know, obviously, I try to take as neutral a stance to that as possible and alleviate their fears and try to guide them, down the right path of understanding what we do know, as opposed to what we don’t know and trying to separate fact from fiction because it’s very easy to get caught up in all of that. So addressing patient fears and anxieties, especially when it comes to, their care and hospital visits.

And I I think it’s really important as we’ve seen in the media and the news, that a lot of patients have, been misdiagnosed or underdiagnosed or have been seriously affected, by non COVID, medical emergencies or calamities because they were too fearful of going to the hospital. And I think while there was a a heightened concern early on about going to the hospital for such things, I think now, in most areas, even though, you know, different parts of the country are in different stages of dealing with resurgence, hospitals and staff, have better protocols in place and better procedures, to take care of those patients who are COVID, versus those patients who need, medical attention for other things.

So really addressing patient anxieties and fears is a is a priority for me. When it comes to the operating room, and talking preoperative, assessments, patients will ask me often, is it safe to go to the hospital? And I will always tell them, if there’s ever a place I’m most comfortable, it’s always in the operating room. I mean, with the the sterility and safety protocols and procedures that we had in place even before COVID and the and the and the and the stricter, more stringent policies and procedures we have in place now, of all the areas in the hospital, I think the operating room is one of the safest for our patients.

I think something that has been an issue for a lot of my colleagues both in this area and around the country, as we were initially, you know, not allowed to or we had to pause doing elective GYN cases, now being able to kinda ramp back up is trying to position some of our GYN surgeries and along with our our our fellow colleagues and other disciplines, general surgery, orthopedics, and etcetera, to try to get equal time in the operating room, which has been challenging. And I think this talk will will sort of, lead down a path of describing ways that we can, really focus on moving those those surgeries and those cases that we have to take to the operating room, and getting them proper recognition and proper proper placement, in our OR booking.

And then taking some of those, cases and maybe moving them back to the office if we haven’t done office based procedures, maybe thinking about doing that, maybe utilizing our local outpatient surgery centers for procedures that we don’t have to take to the operating room, alleviating some congestion so that everybody can get their patients that need to be operated on into the hospital in a timely fashion, which again sort of leads into this whole navigating the surgical backlog because all of us are feeling that. Some of us, when this happened in my practice, we basically just rescheduled patients a few months out and moved them.

Some of my colleagues actually just canceled cases altogether. Unfortunately, these are the these are the people that are having a hard time getting their patients rescheduled because those slots, were taken. And a lot of, ORs that utilize boarding time, that’s kinda gone away for the period, for this period of time while we’re trying to address, the needs, and concerns of all these, cases that were pushed off pushed off because of COVID. I think that it’s it’s also important to understand that even though we are a wealthy nation, and there is a surplus of a lot of things, we’ve realized that besides just toilet paper and hand sanitizer, we really need to be careful with our p p PPE.

Even now that we have, what’s described as as adequate supply in most places, I think it’s important to be cautious going forward about the supply as COVID is gonna be here with us for probably months, if not years to come. And we are gonna need to be able to rely on having a a steady supply of PPE. So using it responsibly, and effectively is gonna be important going forward.

Yeah. You know, Ethan, those are really great points. And, you know, some of the things that for me really stand out that I think is important for the audience to to keep in mind is that this really is a new normal. And, the way we come out of it is that, you know, you have to reimagine and move forward with a new way of doing things.

And and being entrenched in the way things were done in the past is gonna make it very hard to come out of it. And so, being able to reimagine and innovate is the key. And just to use an example, even today, that I noticed in my office as I was seeing patients, As the pandemic has evolved, the patient fears and anxieties have also evolved. So whereas you said in the beginning, people were afraid to kinda come to the hospital, now the the new perspective is we’re okay coming to the hospital.

We just wanna get in right away because we’re worried about a shutdown in the fall. That’s what I’m hearing in the New York City area. And so that’s the new fear and anxiety is, can I get surgery this summer because I’m worried that my doctor’s gonna not be able to operate in the fall when things get bad again? And I think that’s gonna happen around the country.

So, these are really important things. They’re they’re more principles than anything else, but, you know, I really think it’s something that truly frames what we’re gonna be talking about here, over the over the, over the next bit.

So, Ethan, you know, as you’ve changed your practice and and sort of what I say reimagine how you do things and innovate it, what are you doing in the office itself in terms of, you know, when your patient comes in and they call and they want an appointment with you, how are you managing that flow? Because, obviously, things have changed nowadays in your practice.

Absolutely. And, as we’re all doing, we’re following, you know, our locals and state guidelines, for practicing, you know, effective, efficient, and, obviously, safe, care in in lieu of of COVID. And so there’s been changes that we’ve had to implement, such as limiting the number of staff or number of patients rather in the, waiting room. And we’ve done this by physically actually taking chairs out of our waiting room so that patients can be, you know, have to be at least six feet apart. When we have more than three or four patients in the waiting room, we will then move to a car check-in system, where patients will check-in from the car, and they’ll be texted when it’s appropriate to come back up. In order to reduce the number of patients that are coming in and out of the office, and we have, there’s four providers in our practice.

In order to limit the the number of patients, we’ve actually limited the number of providers that are practicing in in each of our two offices on a daily basis down to one provider. So we have less traffic coming into the office to begin with. Sometimes we have ancillary service like, ultrasound.

When we have patient when we have days like that where there’s more patients coming in, we are gonna make sure that patients are are spread out sometimes in the hallway or, again, from their cars so that we are starting from the very front, when the patients arrive, limiting the number of patients that we have and making sure that we’re practicing our social distancing.

We are also we’ve also increased our appointment times by five to fifteen minutes depending on what type of, appointment it is, to allow a little more buffer for patients to get in and out of the office without too much interaction with other patients.

We utilize telemedicine whenever possible, and I’ll go into that more in detail in a few minutes, but that’s been very helpful to sort of, just to space our patients out and make sure those that are coming in have been triaged ahead of time.

And we are, right now, are currently only allowing patients in the office. And so I know this this varies by, health system, but ours, has been very supportive of just having patients only, unless, obviously, we’re caring for a minor, or somebody that needs a translator. And that’s actually helped in many ways, to speed up our patient visits and keep people safe from having, you know, other, possible exposures.

Yeah. No. I I I like that because, we’ve done the same thing. We we limit it to just the patients in the office.

And, you know, we’ve had some difficulties, I’ll admit, being in an urban setting with our office practices.

Right.

The majority of our practices are are not, easily done as a check-in from the car, but whenever possible, that’s what we do. And, otherwise, we use texting, so that when people come off the subway or they’re or they’re walking in from somewhere in the city, we sort of text them and let them know, okay. It’s time to come up, and we literally take them right through the waiting room directly into a into an exam room. So they’re they’re just we always make sure that we have a a significant number of exam rooms per provider.

And like like you, we’ve dramatically limited the number of providers at any time, in the in the clinic setting. You know, I had a quick question for you. You mentioned telehealth, which I know we’ll get into a little bit later. But do you tend to cluster patients that you see in person in a certain part of the day, or do you alternate your telehealth visits with, with the, in person visits?

I I’ve been sort of doing a mix of both where I’ll do a couple telehealth visits, see an in person, you know, visit, go back to a telehealth, and I kinda just sprinkle that throughout the day.

I I think that’s one that’s one way I know a lot of people are doing it. We sort of, moved to dedicated, telehealth days. I think initially, when we were in the in the middle of the the first wave, each practitioner, in our practice was only seeing patients live, in the office one day a week, and those are pretty much only either GYN emergent patients or OB patients.

And so the rest of the days, two or three days, were spent doing telehealth. So now each of us have, about two to three clinic days per week, and I have one dedicated telehealth day. And for me, and for my staff, that’s just how they they wanted to work it. It was just easier to have it clustered, but I have had some times where patients couldn’t make it or I’ve kind of gone through my schedule and seen patients that I feel will be better, suited for a telehealth visit and have them plugged in for that day. It just it sometimes can create a little bit of a, a jam in the in the system just because the MA that’s that’s working with me is different from the MA who’s dedicated for telehealth with, that provider. So it’s like one provider, one MA who is doing telehealth per day, and that’s just how we’ve had it, work for us. And and so far, it’s worked out okay.

Interesting.

Now, you know, when you see your patients, are you, like, we require mask for both the provider and the patient. Are you the same?

Absolutely. Any patient, facing a staff member has to be wearing, has to be wearing a mask and not a cloth mask.

And all of our patients when they come in have to be wearing masks as well. In addition, they’re screened before they come in, with questions about their health, and certain, obviously, poignant symptoms, relating to COVID, as well as travel history, exposure history. They all get, temperature check when they come in as do we, which is logged every day, and then and then we go from there.

Yeah. We do the same thing. We actually are are required to to do an app, in our in our hospital system where we have to do that every day and make sure that we have a the green go sign on the app that means that we’re we’re okay to come to work. So well, you know, let’s let’s jump into telehealth because Absolutely. You know, before we get into that, I’m just gonna ask you, first impressions. Are you a fan or not a fan?

I am a fan.

I was leery. I was definitely leery about it to begin with.

And I have to, you know, commend our our our medical group for really jumping on it. Within two weeks, we were, providing telehealth, and I was really kind of intrigued to see how that would fit into an OB GYN setting for obvious reasons. A lot of what we do has, surrounds intimate conversation and, obviously, physical exams that can’t be, can’t be done, online. So I was I was intrigued as to how it would work. And I’ll tell you, I think patients and, providers have been very happy, with it so far. How about you?

I I’m a big fan. I just love the ability to put telehealth anywhere in my schedule. Yeah. You know? I I don’t feel confined by the by the the the physicality of an office setting.

If I need to see somebody or do an add on, I can add that anywhere in my schedule, and that’s something that I’ve truly, truly enjoyed. I do telehealth visits in between OR cases. I mean, it’s it’s been, really something that I’ve embraced, and and I I really, you know, see I enjoy it, actually. I I know that sounds odd, but No.

I I think I think that’s the the majority of us feel the same way. And and asking patients how they feel about it, they’re I mean, the the convenience factor has been amazing.

They just like that they can be at home. They can be at work and step into a private area and do it.

And, you know, you know, for for simple things and, you know, I know you’re being in a in a specialty situation in a in a referral center like you is different than being a journalist like myself. But for patients who are, you know, birth, you know, birth control refills or, who have vaginitis symptoms, who may not need an exam, and it’s a perfect it’s a perfect, way to to do that. And for me, I’ll tell you, and I’m sure you, since you do so much surgery, and you could probably get into this even more, but my pre op and post op visits, I mean, this is a slam dunk.

Oh my god. It’s I I this has been transformative for my pre op and post op visits. I the only post op visits I really need to do in person now are, vaginal cuff checks after TLH. Otherwise, I mean, I’ve been able to decant all of those cases or patients really out of my office schedule and, really focus on the consults, the problem patients, and the patients really appreciate that.

Yeah. It’s really it’s really been a a big plus. It’s definitely a HIPAA compliant platform. I know that comes up a lot of times, and it’s definitely something that, you know, as Ethan said, you can really streamline your office schedule and really focus on the, you know, the big ticket items, like being able to do your pre and post op visits, by telehealth.

Absolutely. And and for those of us who are generalists, you know, usually, you know, doing the one to two week post op c section incision check, you know, if we’re still doing that, this is another great way. You know, new moms at home, obviously, tired and and don’t wanna take the added risk of coming to the office. This has definitely become a staple for them as well.

So I I can’t I I I’m very I’m very happy with it. I’m glad it’s I think it’s here to stay for all of us.

Yeah. I know. I agree. But why don’t we move on then? You know, one of the things that, I know you have a great expertise in and and, I I wish I was more facile with it or and even had the time to do it because my, it’s just I don’t think my clinical setup really lends itself well to that is is integrating office based procedures into your office practice. And to me, it’s something that I know I’m I’m definitely being pushed to do more, just by natural evolution because of the pandemic and the need to try to streamline how I’m working up patients and who needs to go to the operating room and kinda, again, you know, minimize my OR schedule to the things that really need to go to the operating room. How are you utilizing that in your practice?

We’ve been doing a lot of office procedures for years, in our practice. I think because, we’re a young group and we’ve been kind of, just kinda forward thinking in terms of trying to bring as much into our practice as possible, early on, we were doing, endometrial ablations and LEAP procedures we were already doing. And those things continue to be something that we, enjoy doing in the office. And we have dedicated office space.

We have a procedure room, that we do these dedicated, procedures in. We like to try to group them together. Patients appreciate it because, you know, when you do something like a leap or an ablation and you realize, how much goes into it in an OR setting, so much there’s, I think, a lot of unnecessary time, not just for the patient, but for the support person who brings that that patient to the, hospital, utilizing a day of their schedule, you know, all the, you know, pre op, anesthesia, labs, medications. It’s it’s really overkill for a lot of the things that we do.

And I understand that a lot of doctors are uncomfortable doing office based procedures, and that’s understandable. But I think with the right guidance and time and, and and and interest, it’s really a remarkable way to improve patient satisfaction because, again, patients really appreciate not having to go to the hospital, as well as, alleviate your OR schedule. As you know, Arnie, when you go to the OR and you’re going in for a TLH and you’re backed you’re backed up because the guy in front of you is running late, and you’ve got two more cases to follow, your day becomes kinda messed up.

And, you know, for those of us who are doing some more minor procedures, let’s say a DNC, for example, and we have to wait because there’s, you know, god forbid, a complication or something ahead of us, you know, that puts our day off as well. So then we’ve got, you know, other patients that, you know, got, you know, got reshuffled or rescheduled, and it just it’s not very convenient. Doing something like office based procedures really helps eliminate a lot of that.

Is is endo c something that you utilize, in in your office to not only, kind of die make diagnoses, but also to sort of prepare you for the operating room. I’ve heard you use this term OR readiness once, and I I liked I liked the that concept of of really truly being prepared for the operating room with what you do in the office.

So NDC is a perfect example of something that when it was introduced to me, I thought of it as a point of care or same day tool for endometrial evaluation. A way to take patients, for example, who are presenting with abnormal bleeding, and we all know that makes up at least thirty percent of our our benign GYN visits, for those of us in in general practice, as a way to take that and sort of, move our exam from outside in to really evaluate the endometrial cavity. So EndoC has been, you know, something I’ve utilized as a point of care device, and I’ll go into that more in in a minute, as well as something that I’ve had to bring patients back for depending on their, their insurance or their timeline. But it’s been a real patient satisfier, and I’ll explain more, about that in a minute. But, yeah, it’s a it’s a phenomenal tool, and the second generation, the Embassy Advance, has really taken it to a whole another level.

And I I’m I’m, you know, so glad that we we have the ability to use it.

You know, I know point of care is something that you certainly the concept is being able to do something on the fly, so to speak.

Yeah.

But when you see patients, do you try to time things, in terms of, like, their menstrual cycle to get a better better visualization, or or does that matter at all when you’re doing EndoC?

It does. I mean, obviously, if somebody’s actively bleeding or, you know, they’re getting close to, you know, the day of their period, if we’re doing something for abnormal bleeding and trying to identify and treatment pathology, that’s not an ideal time. So taking cycle timing into consideration, which is very important, point of care, availability is is is an option if we can use that patients appreciate. Now I know it kinda goes against the training even when that I had that, you know, we try to maximize, you know, the the the economy of visits in a sense that, you know, you bring the patient in, you do an e and m visit, you, evaluate them, you do your history and physical, you then outline the next step, you bring them back maybe for an imaging procedure, you may then bring them back again and do something like an endo c or an office hysteroscopy or take them to the OR.

And you’ve now taken, you know, a problem, and you’ve kind of made several steps out of it. And I understand how that mindset was back, you know, years ago, but I think now it’s a different time. And especially in lieu of what we’re dealing with in terms of, like you said, decanting the number of patients coming into the office, and and making sure that we are streamlining, their appointments from from time of presentation to treatment, that being able to employ and deploy point of care, techniques such as endo c is is really helpful. So you’re really reducing the the the length of time from presentation to treatment.

Patients are happier. They’re oftentimes getting results the same day.

So it’s a it’s a it’s a real big patient’s ass fire.

So, Ethan, from you know, having spoken with you before, it sounds like, the concepts we talked about earlier with how we manage just the the office setting and bringing patients in for an office visit really applies to, point of care and and dedicated procedure visits. You you have to think the same way in terms of how you’re how you’re managing your schedule and and the flow through, I guess. Right?

Absolutely.

You know, point of care, techniques such as NOC take time to implement, properly. You have to have full support of your staff. And, you know, understanding how it works, is is important. And and and for us, it was just seamless, after we started using it. But, yeah, absolutely. The the the same the same principles apply, to procedure visits, point of care, or dedicated otherwise dedicated procedures, as they would for a regular routine office visit.

You know, I know we’re gonna talk about things like COVID testing later, but, are you, since this is a procedure, are are you doing just, basic, you know, PPE in terms of mask for your patients, or are you using n ninety five mask? Are you doing preoperative COVID testing, you know, with these procedures?

For office for our office based procedures, we don’t do any, COVID testing ahead of time. And I know, like you said, we’ll get into that in a minute as it as it pertains to the OR setting. And our ORs are doing that, seventy two hours ahead of time. But for us, we are not. We do use full PPE, including the n ninety five respirators. If we’re doing procedures such as LEAP, procedures that does create, you know, smoke and potential aerosolization risk, we will, use full PPE and shields. Otherwise, we’re gonna use just regular, you know, mask and and face coverings.

So, Ethan, you know, in in the office when you do either point of care or or a a scheduled procedure like EndoC, are you utilizing it, to a certain degree for managing your biopsies or polyps?

Absolutely. I I think in no other area of medicine do we rely on blind biopsy, and gynecology should be no different. We know that, blind endometrial biopsy samples are very limited, maybe four to twelve percent of the, endometrial cavity, and often misses, the diagnosis in our patients, with abnormal uterine bleeding, for example. So I won’t do an endometrial biopsy without doing an embassy advance, a a a basically, a directed visualization, of the endometrial cavity without, you know, doing that first.

And this is a very well tolerated procedure that can be done in any room at any time.

You don’t need to do much in the way of, anesthesia or analgesia. I use a little bit of Motrin. I don’t do periscervical blocks, and patients do very well. And the nice thing is we kinda touched on earlier is, you know, we’re obviously helping the patient, you know, reach a diagnosis and then obviously a resolution sooner.

And like you said, it’s been very helpful in terms of OR preparedness or OR readiness. So when I take a patient back for, let’s say, a, resection or a morsellation hysteroscopic morsellation, I know exactly which tool I’m gonna need. It’s already set up and primed and ready, which is reducing operating time, reduces cost, and, again, reduces potential exposure for our patients, and staff. So it’s kind of a win win win for for everybody involved.

And now with the NOC Advanced having a, a five French, working channel, you can actually do simple procedures like polypectomies, like I said, directed biopsies, areas of concern, IUD removals.

I’ve been using it even to address things like retained products because we all know how unreliable ultrasound can be for that. So it’s really been, it’s really kind of just, been it’s been a perfect, what I call, the otoscope for the gynecologist. We we wouldn’t go see our primary care, for, a earache or a sore throat without getting an evaluation of our ears, nose, and throat. So why not have the opportunity to do the same thing for our our GYN patients?

No. I mean, I I think that’s fantastic. I mean, to be honest with you, you know, I I I wish I had the ability to do more of this in my in my office setting because you’re absolutely right. I mean, I’m definitely an advocate of not doing things blindly.

A lot of folks will do, you know, sort of blind polypectomy, sort of the blind DNC, and I I’m just not in favor of that. I mean, we should be doing this as a directed guided removal, similarly, directed guided biopsy. And I think the endoC is really, it’s a great tool, as you said, for transforming how to elevate the standard of care of practice. Absolutely. That is something, that we all need to be doing in the office setting. And it it that’s one way to get your patient’s fears and anxieties down is by giving them an accurate diagnosis and accurate surgical planning. And I think the EndoC Advance definitely is a is a key to that.

Absolutely. Couldn’t agree more.

Well, let’s jump to the operating room.

That’s where I spend a lot of my time, and certainly, it’s been it’s been a roller coaster ride, I have to say, and and living in New York City, we were on hiatus for quite a while. But some things that I definitely have learned over the last few months are the fact that COVID, nineteen definitely impacts how you practice surgery.

It requires really good coordination.

As you said before, telemedicine is key. It’s a key piece of how we prep our patients for surgery and manage them postoperatively.

I think things that I learned that I never even thought about when we started to go back into the operating room was, we were running into initially some difficulties with the authorization process because once they opened up the ORs, everybody was trying to get into the OR. Right. And everybody was trying to get their patients authorized. And our poor, authorization folks in my in my, office staff were sitting on the phone a lot, you know, waiting on hold to try to get through to people to make sure that our procedures were authorized. So I think that’s something people need to keep in mind as we wax and wane through this, era of COVID nineteen.

I think, again, like I like, we were both talking about your concept of OR readiness is, is awesome. I think we need to trademark that, Ethan, because, that’s something that, I think is really important in terms of just being prepared for what you’re gonna deal with in the operating room. And I know what I’ve been running into is most of my cases going back have been, pretty complicated. Because as would be expected, you’re gonna do this the sicker, more symptomatic patients first.

Absolutely. And, of course, you know, in the setting of COVID nineteen, I don’t know what what your feelings are about this, but, minimally invasive is still the preferred way. You know? I know there’s a lot of discussion in the beginning about, oh, is that gonna put you at risk?

Should we just be opening patients? And I think that’s the worst thing you can do is revert back to, poor surgical routes. And I think we really need to stick with what’s tried and true and and practice the mitigation strategies that you and I will talk about later.

Absolutely. When I when I saw some of the articles that were coming out, even suggesting perhaps, moving away from minimally invasive surgery. You know, it was it was it was very hard to see. So I’m glad that that’s, not the case and that we are still sticking to the principles of minimally invasive GYN surgery for our patients.

Yeah. You know, it’s really interesting. We’ve we’ve had so much information overload over the last several months. Like like you said, there’s just a lot of stuff coming out. And, you know, what we’ve done is we’ve really stuck close with following our state department guidelines, which have been very good actually, in New York.

We follow the CDC guidelines. Sure. And just like you said, local laws and regulations really govern a lot of what we do. And then we supplement that with society guidelines and recommendations.

Have you been doing a similar thing up in Michigan?

Absolutely. And, I I’d have to say, I think, I’ve been I’ve been equally, impressed with our, state and local, guidelines and the input that they’ve, given physicians in terms of, management. And I have to actually give hats off to AAGL as well. I thought AAGL jumped on this, really early on in terms of, their, really informative, multinational webinars from around the world, incorporating information from everywhere as it was moving towards us to just sort of have that awareness and be ready and prepared, and and understanding how this is gonna affect us. So I really give AGL a lot of credit, for what they’ve done in in with COVID.

Yeah. You know, it’s it’s, as long as you can filter through the important information, there def there’s definitely a wealth of knowledge out there to tap into.

You know, one of the things that certainly I think is important for surgeons out there in the community across the country to keep in mind is, you know, as you manage your surgical schedule, it’s really good to be able to organize things into different buckets. You know? For us, we’re sort of naturally, forced to do so just because we function in subspecialty groupings.

But, you know, we we definitely organize our surgeries into the major buckets like, oncology, you know, pelvic reconstruction, the benign GYN surgery, which I know you and I spend most of our time in the benign bucket. But that, I think, to me, helps when you’re, trying to figure out which patients need to go, which ones are in categories that might be high risk, which are ones that can’t be postponed. And it then it becomes much easier to think through it as opposed to looking at, like, a mishmash of cases. Because when you start looking at cancer, you can start to say, hey. Those cancer cases definitely, you know, they they need to go. We can’t we can’t postpone those cases. Absolutely.

What let let me ask you for a quick second. What is, what does your hospital require, in terms of any kind of, when you’re boarding these cases, do you have to have a checklist of, of importance or severity, so that, you know, they know, you know, which of these cases, like you mentioned, really, need to be handled in the time that you wish to do them in?

Yeah. And that’s a great question, and that’s really a great lead in to something I think is really important to talk about, and that is your state state or local guidelines. You know, for us, what’s interesting, which we didn’t really appreciate until we started looking into it, was the fact that what we do, what you and I do, Ethan, is considered essential services.

Being able to manage things like fibroids, endometriosis, cancer care, even, family planning services. All of those things are considered essential services and technically shouldn’t be postponed. And I think it’s something that, gynecologists around the country need to be aware of that their state may actually have guidelines like this that actually help you provide the information needed as you adjudicate cases to to show your hospital that, yes, you need to have block time, and you need to get these patients taken care of. And we also had, guidelines passed down to us that show us how we can get back into the operating room.

What are the metrics that we need to meet to be able to open up the operating room in terms of hospital capacity for beds for ICU care? Those are the things that we needed to follow to be able to open up to elective surgery. And, essentially, to go back to your question, what we’ve been, doing is we fill out a special form that goes to a governance committee that basically makes sure that we are doing cases that meet the the highest tier. So the urge obviously, emergency cases are gonna go.

Of course. But the urgent, semi urgent cases, what I what are called the tier three a, tier three b cases are the ones that we really have been prioritizing to do first. And then after that are the purely elective cases.

But, you know, most of most of the cases that we’ve had deferred are really falling into those categories, and it’s just really managing the backlog at this point. What about you at your hospital?

I practice at a small community hospital. It’s part of a a larger health care system, part of the Detroit Medical Center, but it’s a smaller community hospital. And so, you know, I think where you’re at, your volume is much higher, than where I am at. So for us, it was basically you know, the OR director just basically said to us, if this is something that needs to go, you just have to put, the the the reason why or what you feel is the reason why, and and they would pretty much approve almost anything. I think as a group, as a collective of of g y insurgents, we were very cautious to sort of sort of follow these guidelines even though we we didn’t know we were following them in terms of making sure that we are putting our sickest most, you know, most at at risk or in need patients first, to be cognizant of our other colleagues to make sure that everybody had equal opportunity to get those really important cases done first.

It’s true. And, you know, it for us, one of the things that I think was very helpful, for throughout this whole process was, also letting the hospital know what resources we were tapping into. So every time we schedule a case, we indicate whether or not we need, ICU care, whether or not we need even simple things like a cell saver. Sure. Things like that start to, like, sort of get get really highly requested and utilized when there are a lot of sick patients in the health system. And so it was a way for our health system to manage its resources and determine whether they had the capacity to to do a certain type of case.

So that’s definitely Go ahead. Yeah.

Speaking of PPE, does your hospital require everybody in the OR to wear n ninety fives? How do you guys manage that?

No. I mean, that you know, that’s kind of been one of those, I guess, I should say, maybe pet peeves of mine is the is is how we manage PPE because it’s pretty clear that, we’re seeing areas around the country that are, to this day, still lacking adequate numbers of PPE.

The resurgence across the country is certainly not helping our stockpiles.

And so we really need to be strategic about PPE. And and as you see, there are a lot of factors that affect resuming surgery. And if we don’t manage the PPE correctly, that’s definitely gonna limit our ability to get into the operating room when we really need to get in there. And, you know, besides the local guidelines, there are definitely, a lot of national society guidelines that emphasize, these factors, that you need to know when you resume elective surgery.

And with regards to PPE, a lot of our management is based on testing, which is something I think is really important, for us to go over, because when it comes to testing, if the patient is COVID negative, there’s technically no reason that everybody needs to be wearing n ninety fives. We really truly reserve that for the patients who are PUIs or a person under investigation or or truly positive. Somebody who’s not known but worrisome for having it or is truly positive. Those are the cases where, we’re u utilizing the n ninety five mask.

But in in every other circumstance, we’re doing basic universal precautions that we normally would in in any other pre pandemic time.

Absolutely.

And our institution, I think, right now is still the anesthesia department, the CRNAs, anesthesiologists. Those people intimately involved with intubation, extubation are still wearing the respirators, but the the the rest of the staff, are just, you know, using regular surgical masks.

Yeah. Well, before we get into, the PPE bit in a little bit more detail, you know, I just wanted to make sure that the folks on this, evening event, are aware that similar to state guidelines, there are also ranking systems and guidelines that have been put forth by a variety of different societies that help give you guidance in terms of the types of cases that you can take to the operating room. So I know, Ethan, you’ve been utilizing those guidelines as well to try to help steer, as you said earlier, steer which cases are gonna go to the operating room first. And I think to me, that’s those have been very helpful resources, as we’ve navigated through things.

And and one of the the recent publications that I think has been really, helpful for me in terms of how to think about prioritization is a recent study that that, was published on medically necessary time sensitive procedures and how to think through that. And in that particular study, what they did is they looked at factors related to the procedure itself, factors related to the disease, and then factors related to the actual patient. And every every variable has a has a point. And based on the scoring system, you would either develop too many points that you wouldn’t really be allowed or wouldn’t be advisable to do that surgery, or you’d have the the least amount of points, meaning that it was an optimal candidate for going to the operating room at a time of low resource, and those are the patients who would go first.

So I think those are the types of things that that we need to think about, in addition to the tier tiering cases. And and these things also apply to the office setting. So I don’t know if you’ve done the same thing in the office because I know you do a lot of office procedures, Ethan. Are you prioritizing which ones get done first in the office versus other ones?

We were initially. And now I think just that, you know, at least in Michigan, as it pertains to to to health care and medical care, we’ve we’ve we’ve had the the room and availability to sort of open it up to to do most things as they as we see fit as they come in.

That’s that’s great.

Well, you know, let’s jump back into PPE because, I I don’t wanna constantly sort of, you know, beat the PPE drum. But if there’s one thing that that I know is there are some places around the country and around the world that are just going full court press, they do everything. And, you know, one of my friends recently sent me this picture of what they’re doing in their operating room for all procedures. And I thought that was just, to me, insane how much PPE they were utilizing and but that’s what they were doing. And and so you could either make an argument for universally going full court press, or you can be strategic about it, as I said before. And for us, and you mentioned testing earlier, we do the COVID, swab. We it’s a it’s a PCR based, rapid test, and that’s what we utilize for our patients preoperatively.

We don’t do antibody testing because that’s not really accurate. You know, a lot of people ask, well, can I just get my blood drawn? Well, you know, we’re interested in knowing whether somebody is acutely ill because there are ramifications for having surgery when you’re acutely ill. Those patients don’t do well, when they’re exposed to general anesthesia.

So we wanna know who’s acutely ill, not only for the patient’s sake, but we also don’t wanna infect the entire operating room team. Right. And people don’t necessarily mount an antibody response right away even if they’ve had it. And so we wanna make sure that we’re getting the acute, infected infectious patients.

As well as those asymptomatic carriers.

Absolutely right. And you’d be surprised how many of those patients we see as we’ve been testing preoperatively and patients come back and say, I can’t believe I tested positive. And we’re like, I can’t believe you tested positive either. Right.

But but we typically do it within three to five days now, before the surgery. We’ve actually expanded the the time frame a little bit now to five days. Our hospital is allowing us to do five days in advance. And and once they get tested, we tell them to basically stay home and Right.

Don’t expose yourself. And, you know, if they know they’re having surgery in a couple weeks, we tell them start practicing good mitigation strategies with social distancing and, you know, not putting yourself in a vulnerable situation.

Yep. Absolutely.

But, you know, what’s interesting is I don’t know how you manage this, Ethan, but with some of the testing, what’s interesting is we’ve we’ve we’ve had patients now because this pandemic’s been going on for a few months who have tested positive a while ago and then recovered and now are coming for surgery, but they are again showing up positive.

We have had patients like that both in the obstetric realm as well as the GYN realm as what yeah. Addition in addition.

Yeah. So that yeah. And that’s an interesting thing to to make note of because if somebody has a known documented positive test few months ago and they’re coming in now and getting surgery, they can definitely still test positive on the PCR test, but if they’re not infectious. In other words, sometimes you can still pick up with these tests, the dead virus particles that trigger the the the swab to turn positive.

But as long as you have an accurate history and if you really need to get that surgery done, you can do that surgery. That patient is no longer going to be infected. Because if you look at the infection curves, beyond ten days after initial symptoms, it’s really hard to culture active infection. Right.

And so those patients are not going to be, infectious. And so as long as you know that history, you can go ahead and do that surgery. And if you want, you can certainly do the the n ninety five mask and and and, you know, higher level of PPE, but but, technically, they’re no longer infectious. And if they do come back truly positive for the first time, and that is a true active infection, we’ll typically postpone their surgery for about three weeks and then bring them back and safely do their surgery.

Have you, army, have you heard of patients, being reinfected, though, like, with, truly being reinfected, with active disease a subsequent time?

There’s a lot of talk about that, about the fact that just because you’ve had it once doesn’t mean you’re invincible and that you couldn’t get it again. Right. There are definitely cases that are being reported of people being reinfected.

I’ve not come across that yet myself, but I’m it’s certainly something that I’m I’m keeping my eyes and ears open to because I certainly don’t wanna put patients at risk nor myself and my team at risk.

Absolutely. And I think it’s also gonna be interesting to see how the antibody studies go going forward to see what the, you know, how how long, those antibodies persist and if they are, like you said, actually, going to help prevent reinfection.

Yeah. So, you know, let’s, let’s move into mitigation strategies. You know, that’s what we’re gonna sort of round out this conversation with tonight. You know?

And as as we talked before, there are a lot of things to keep in mind. You know? This is just one example of of things that we do to help keep us safe. One of the things we started practicing in the height of the pandemic in New York because we just still were figuring things out was we knew intubation and extubation was a high risk aerosolization procedure for something that is transmitted by by droplets.

And so we would just leave the OR during intubation and extubation, and we limited who was in the OR during those procedures of takeoff and landing.

This is an example of a of a shield that people were using to protect everybody as they were intubating. But it’s certainly something that is important to keep in mind. I know there are a lot of resources out there to help provide guidance because I know that there’s a lot of concern because we do laparoscopy about transmission of of COVID nineteen. And a lot of that is really born out of people’s concerns for blood borne pathogens. Right? Right. We worry about things like, hepatitis or anything like that that is a blood borne pathogen being aerosolized and somebody contracting it.

There’s not a lot of data on the viral particles related to COVID nineteen, since it’s a a respiratory droplet infection that’s passed on, but there are a lot of resources. And this is one from SAGES, that certainly you can reference when it comes to looking at what what’s available to help during our various procedures.

What kinds of things are you using in the operating room, to reduce your exposure?

Well, I mean, we when in a lot of our cases, we use the, system here that helps us, you you know, filter the smoke as we release it from our laparoscopic cases. Similarly to the reference that I that you saw earlier from SAGES, there’s a medical device repository that you can find as well that lists all the devices in an agnostic way that you can utilize. What about yourself?

Yeah. We use the same thing as well as, air seal technology when we can for the same reason, and and that’s been very effective.

Yeah. We do that too in our robotic surgery cases. You know? And and what’s been great is our hospital has been very supportive of us utilizing technologies that facilitate keeping everybody safe.

And, you know, it’s great that, you know, we get to collaborate, with companies like Cooper Surgical that really provide devices that help us mitigate against things like COVID nineteen. And, you you don’t even really think about it sometimes, but even uterine manipulators and having a best in class pneumo occluder balloon is extremely helpful. Because, again, if you’re managing your pneumoperitoneum, you’re managing smoke, the one thing that you don’t wanna do is have uncontrolled release of gas into the operating room when you’re doing your copotomy. And so, you know, for me, utilizing the the pneumo occluder balloon, appropriately in surgery really helps with that. And I I’m not sure what your experience has been in your OR with, you know, making sure that that you control gas flow, but this has been one of those things that we’ve been a big stickler about.

I’m a huge fan, of this technology and utilize it in in every TLH that we do.

Yeah. And, you know, another thing that we’ve done, which I utilized it a lot before, you know, Ethan, but I didn’t realize how much it would be so impactful. And in fact, it’s really been an easy way to for me to justify getting a few more of these in my in the two hospitals that I work at is, you know, one of our concepts around COVID has been minimize the number of members of the team in the operating room, you know, not utilizing too much PPE. We don’t need to have, like, five people scrubbed in and keeping it just to the essential personnel. And using the Ally Uterine positioning system for all of my cases, particularly my robotic cases, has been has been great. I mean, I’ve utilized it always before, but now I I truly think about every case and try to optimize where I can use it to eliminate a body in the operating room so that I don’t have to expose another member potentially to, COVID nineteen potentially. Right?

And Let me tell you. This system has been something, I’ve seen utilized, and I know you’re showing a a really helpful video to to demonstrate how easy it is to use, and I am gonna take your video tonight and show it to my, OR, department and to our executives to try and get this what has been a wish list, device for me for many years and hopefully get it into our operating rooms as well.

So, well, yeah, you know, Ethan, what you saw in that video was, just me demonstrating that the uterine positioning system mounts behind your stirrup because that’s often a question that comes up. So I just wanted to make sure that people know that that bracket goes behind. But if we jump to the following video, you really will see how truly easy it is to, set this up. And so there’s that bracket that goes behind your stirrup, and it literally takes less than a minute to set up.

And it is I call it the iron intern because now I’ve just kind of, you know, decanted all my excess house staff out of my operating room, and I’ve got, this device to hold my uterus when I’m doing procedures like myomectomies or even, laparoscopic hysterectomies. And particularly for robotic surgery, it’s great. This mounts directly behind your stirrup. It’s it’s balanced, so you hold it by the blue handles, plug it in, turn it on, and, you know, then you then you make sure that you prop it up once it’s it’s turned on, and then you can, prep and drape your patient.

There’s a drape that goes on the, the positioning system, and the drapes have adapters that are specific to one of the three, Cooper Surgical uterine manipulators. And and it’s been great because, if you position your patient correctly and you have this hooked up, it really is, is that extra hand that you need in the operating room without having an extra body in the operating room.

I’ll tell you, Arnie, I wish this was around in two thousand and seven and eight when I was, just starting out with robotics and having to sit between the legs when the old, standard system came center docked and you’re sitting there for hours, holding the manipulator. This would have been a great thing to have. So Right. It is it’s a it’s a it looks like a great device, something that I hope we can get as well.

Yeah. I know. Absolutely. I remember those days. Those were very painful days. Very painful.

But but yeah. I mean, it’s it’s, there are a lot of things that, you know, we forget that we can leverage technologically to make us more efficient in the operating room. And I know, you’re you you utilize this, I I believe, Ethan, right, in your in your practice.

Absolutely. We, you know, we use the InSorb Skin Stapler, on almost always now for all of our cesarean sections, prime and repeat. Peat. It really expedites, the the closing and gives a remarkable cosmetic appearance that that patients will appreciate. A lot of my colleagues who are still using, that technology have quickly, moved to InSorb for, obviously, convenience, for expediting their skin closure as well as not having to have their patients come back, to the office, for that added step. And now with telemedicine, we utilize, you know, silver impregnated, foam, dressings over these incisions that the patients keep on for a a week, and they can shower with them. And then take them off, during their telemedicine, you know, one week or two week post op visit to to evaluate their incisions, and they do just great.

That’s awesome. I mean, you know, again, this is this is the one thing I have to say. If there’s a silver lining to this era that we live in now, it’s that it’s really pushed all of us to be creative and innovative with how we practice medicine, how we practice in the office, how we integrate office based procedures, and how we manage our surgical caseload. And, you know, sort of just to summarize, you know, the way we’ve been thinking that that, you know, Ethan, you and I have talked a lot about these things.

You know, there are a lot of things that you can do in the operating room to keep your patients safe, to keep yourself safe, and to keep your staff safe. And and, certainly, as as you heard us say, it it it could be as simple as, a smoke filter, thinking about how you do your copotomy, how you release your gases at the end of the case, and then even things like skin closure, which, you know, sometimes you you can forget about something as commonplace and mundane as that. But if you leverage the right technology, you can really mitigate against infection and also make yourself super efficient. And I’m hoping that, you know, after listening to tonight’s discussion, I hope that there are a couple nuggets that people can come away with that can help them in their practice.

I think it’s really easy, during this time of change and adaptation for all of us as we move to, you know, provide efficient, safe care in the era of COVID nineteen, that we still enjoy what we do, and it’s important for our patients to see that too. So it’s important to have a little fun in the office. So so my way of doing that is to, don my, my my PPE with, quote new quotations every day, of inspiration just to add a positive spin and and mood in the office. And I I think that that’s been a fun, effective way to sort of, you know, keep things a little bit lighter when, going through all of this.

Well, I love your quote on your n ninety five mask. If you cannot do great things, I hope I’m reading this right, do small things in a great way. Is that what that is?

Or That is.

Yes.

Yeah. That’s fantastic. I mean, that that’s truly what I hope people walk away from from this is is, you know, every little thing that you can do, if you can do it to the best of your ability, it’s it’s gonna have a significant impact. Absolutely. And, and, again, you know, hopefully, be able to answer some questions here.

And, again, Ethan, it’s been a real pleasure, getting to the time with you this evening.

I I hope that we get to see each other in person and not through a webinar or Right.

Right. Right.

Meetings. And, you know, I hope that, that folks stay safe and, hopefully, they’ll walk away with a few nuggets tonight to help their patients.

Well, thank you, Arnie. You’re, as always, so informative, and you you have a a real mastery of taking a lot of information. And like you say, decant it down to the essentials and make it, consumable, for all of us. So thank you.

No. I appreciate it. And thanks again, Cooper Surgical, for sponsoring this educational event.

Thank you so much, doctor Abigail and doctor Goldstein. I’m going to now turn the q and a portion of our program over to Chris Khan and Doug Kaye from Cooper Surgical, who will present the questions to the to the luminaries.

Chris and Doug, the platform’s all yours.

Thank you. My name is Christopher Khan. I’m the senior product director at, Cooper Surgical. Thank you so much to our presenters tonight. Excellent talk, and thank you to everyone in our audience who logged in tonight and listened in on this presentation.

Let’s get to some of the questions, and what my colleague and I, Doug, will do is we’ll pass kind of back and forth to get through some of these questions that have been submitted.

The first one is, what are you doing to get your office prepared for the next COVID surge? Whether that happens in the fall or winter, you know, are you changing the way you’re using any medical or surgical products today, and are you considering any staff changes?

Let me start with that.

No no staff changes for us. We we we did furlough half the staff during the the peak of the pandemic, that volunteered, to to take some time off, and we closed one of our offices down, to sort of streamline our services. But, now that we’re on the other side or at least the first surge here in Michigan, we’re pretty much back to to normal functioning. I think we’ve learned a lot over the past several months, and I think that, has allowed us to be prepared, for what’s definitely, I’m sure to come for all of us again as this, you know, becomes part of our our sort of everyday existence going forward. You know, we we definitely are more conscious about, PPE utilization, and, again, just trying to do more cost effective, patient centered practices to keep patients out of the hospital, even now if possible, and maintain that going forward.

Yeah. Similarly for me, we we we we’re not really doing any major staff changes.

We feel like our staff have really, they’ve been drinking from the fire hose over the last few months, so they really kind of, in many ways, gotten comfortable. I don’t know if that’s the best term to use with with how to interact with patients coming in and out of the office setting as well as, you know, in our ORs.

But similar to Ethan, you know, we’re sort of, paying very close attention to our PPE stores and just making sure that our office staff in particular have everything that they need. You know, on the hospital side, they’re they’re usually pretty good about making sure we have what we need. But but just in the office setting, we’d we’re just seeing patients face to face and with procedures and making sure that everybody’s comfortable.

That’s been one of our big, big pushes just to make sure that that’s all buttoned up, particularly going into the fall.

Thank you. You both, discussed telemedicine at length. This question is, how do you balance the use of telemedicine prior to scheduling an appointment with the urgent need to work down your backlog of patient procedures and and bring the patients in right away? How do you find a balance between those two things?

Arnie, you wanna start that?

Yeah. I mean, it’s it’s been difficult. I’ll be honest with you. You know, one of the biggest concerns is, you know, we wanna, you know, we’re we wanna make sure we continue to to see patients because, you know, we obviously wanna make sure that practices remain viable, that that that we keep our ORs running. And, certainly, as we work through our backlogs, I think we we don’t want to deter any patients from coming in who are new consultations. So we’ve been seeing these new, new patients, as they come along. As an example, when we initially shut down in mid March, we deferred in our group about a hundred and thirty plus surgeries.

But then during the following six weeks of deferring those cases, we also then gained about seventy new cases because we’re just seeing telehealth visits. And so it’s I I’ll be honest. It’s not been easy trying to juggle the deferred with the new patients because sometimes you see new patients who have acuity levels that are, putting putting them in front of a deferred patient. So when we talked about the tiering process and having a sort of strategy about how you’re gonna prioritize patients, we find that’s very important because it really helps manage that sort of clinical conundrum is, you know, what do you do about the patient that you see that’s brand new, but, technically, really is a higher acuity than somebody that you deferred. And just by having that level of transparency, I think it’s great because it helps us explain things to patients, but also to the hospital staff about why we’re shuffling cases around and why this person all of a sudden leapfrogs the wait list.

But it’s not an easy process. I’ll be very honest with you. We’ve it’s been, you know, something that we’re constantly learning as we go along. And, Ethan, I don’t know what you’ve been doing or if you’ve been seeing the same situation.

Yeah. You know, our I mean, our practice is very somewhat, but I think the way we’re using telehealth is very similar. And, I think it is a work in progress, here to stay as we said we said.

You know, we put patients on a list, you know, the annuals and and the problem patients. And then my my colleagues and I sat down with a list much like your tiering system before I think we even saw that in publication to come up with our own sort of, list of patients that, you know, prioritize, need of office visit versus telehealth. And then we also go through and so when patients call in with problems, they the the staff know how to how to sort of, you know, shuffle them around. And then we’ll go through a week ahead of time.

Usually, like, Sunday night, I’ll look at my schedule for the next week and see which patients might be able to come off the in office list. Let’s say, birth control refills or, you know, vaginitis, let’s say, something simple or a post op like we talked about and put them on telehealth day. Thursdays happen to be my telehealth day. And very often, they’ll go you know, there’ll be maybe two or three patients, and then on Wednesday, all of a sudden, there’ll be a nice list of of people that get added on that way.

And it’s been a nice way to even have access, like you said, for some newer patients and gain some surgical consults. That way, they can then be streamlined to to further, evaluation.

Thank you. Let me turn it over to Doug.

Thanks, Chris. So, Doctor. Vincula, I think this is for you. There was a question around how high UPS. You you showed the system and, talked about how it benefits you in the OR. The question was, how do you actually use it during the procedure? Do you manipulate the uterus and then return to it, or how do you actually work it into the procedure?

Yeah. I mean, I I use it I mean, I do a a significant amount of of reproductive surgery in my practice. Probably sixty percent of it is reproductive surgery.

And as many of you know, when you do those cases, whether it’s a myomectomy or a a big adnexal case or endometriosis surgery, you need to park things in a one location and basically work. And so for me, I usually will, situate the uterus, in whatever location I need it to be to optimize access, and then I’ll operate. And these are typically robotic cases. And then if I need to make an adjustment, I’ll either rely on on on a bedside assistant or my scrub tech, or I’ll just walk up to the bedside with, and ask for a sterile blue towel, and I’ll grab this the, the draped handle and just readjust it myself and then go ahead and sit back down and continue to operate.

I I also do it with hysterectomies. Although with a very large uteri, I typically don’t hook it up to the ally because I do a lot of dynamic movement with the with the really big uterine, so I rely on a bedside assistant for that. But it really has, been extremely helpful. I’ve always used it before the pandemic, but I’ve just found that its biggest bonus during during this COVID nineteen era has been just minimizing the number of bodies in the operating room. We’re we’re really cognizant of that and not just for safety, but, again, for, like, preserving PPE and and not wasting gowns unnecessarily and gloves and mask and things like that.

That’s good. So so another question that’s come in. We’ve got several times is, and I think both of you touched on this a little bit during the presentation was, you know, obviously, different surgical specialties now are competing for OR time. Right? And and I’ll add that we’ve heard in particular, you know, a lot of times the ortho guys, in some cases, are moving to the front of the line. Right? So how, are you making sure that gynecology is properly represented?

Do you want me to take that, Ethan?

Or yeah. Go ahead, Arnie. You had you had a good, you had some information on that.

Yeah. Well, I mean Yeah. First of all, you’ve you’ve gotta you’ve gotta walk, you know, head high and go into the OR, and and nobody’s surgery is any more important than what you have to do. I mean, that’s my philosophy.

I mean, I work in a big health system where there are a lot of big fish, but, you know, we’re big fish too. I mean, we do some pretty important stuff, and it’s pretty complex surgeries that we do as gynecologic surgeons. And so what I’ve done is I’ve utilized a lot of the documentation that exists, like, in the state of New York for essential surgeries and pretty much everything that we do. Most of the people who are tuned into this webinar is considered essential surgery with the caveat being that, obviously, you have to have resources to do the surgeries and depending on what the the virus is doing, that affects your ability.

But, you know, we have a, a governance committee that exists. We fill out, surgical case submission sheets. They go to that group. We justify based on a tiered process, and, you know, majority of the things that we’re operating on clearly are high acuity, and, we’ve been able to compete.

We certainly have the volume to back it up, but, we’ve been able to get our fair shake of all our time. But I think it does require a lot of active management and having a good plan in place and organizing your surgical cases in a way that allows you to, very, you know, very in a very organized way, make the argument for why they need to need to be done. I’m not sure what you’re doing, Ethan, in your hospital, but that’s sort of been our approach.

Yeah. I mean, we it’s it’s it hasn’t been. I think our hospital just the the volume itself has been a little bit, you know, different. So it’s it’s been a little easier to get back on board.

And, you know, we we’ve we’ve everyone’s been pretty fair in terms of allowing equal time, for those patients that need to get in.

You talked a little bit about COVID testing. Can you reiterate what you said about the types of patients you do or do not COVID test? And even more specifically, if a patient tests positive, you know, can you remind us what the protocol should be for when we can do surgery?

Yeah. So, we basically you know, obviously, any aerosol lies generating, procedure needs to be COVID tested because, I mean, those are those are definitely high risk patients for spewing virus if they were positive. But we basically from an operative standpoint, we test all of our patients going to the operating room with a, PCR based, rapid test that we do as a swab.

We do that between two and five days in advance of the surgery, and that’s so that we can make sure we get the results because sometimes there have been delays.

So, typically, my my my, practice is we usually do it three days in advance to make sure we have the results in time.

If a patient does come back positive, we will cancel that surgery, unless it’s obviously an emergency. Emergencies go without saying you’re gonna do the ruptured at the top. You’re gonna do the ovarian torsion regardless of status. But, if it’s if it’s a procedure that can be deferred, we will defer that for three weeks.

And then after that three weeks, we will do the, do the surgery. But, you know, interestingly enough, we our hospital requires that we reswab them. And and that’s why I brought up that issue earlier, which is don’t be surprised if even after they’ve recovered in, you know, three weeks, a month, two months go by that, you know, the test could come back positive. They’re healthy.

They look great, but these PCR tests sometimes pick up the dead virus particles and trigger the the test to come back positive.

As long as you know the clinical history, there should be no reason why you you wouldn’t be able to do that surgery. And, obviously, if your team is concerned about the positivity, you could certainly do your full PPE with the n ninety fives. But, certainly, if they’re negative, we certainly go forward. If they’re positive and it’s a new positive, we definitely will delay that surgery just because we don’t wanna take the chance not only of of, you know, getting the rest of the team, infected, but, certainly, it it those patients don’t do as well if they’re having an elective surgery with the intubation with that active COVID infection.

Do you perform endo c same day or schedule out, Ethan, number one? And, the second half of that is what does it take to set up your office to do endo c advance?

We we do both same day and schedule out depending on, cycle timing, you know, patient availability, you know, off my office day, how it looks, if it’s if it’s crazy. I mean, my staff, we’ve been doing it long enough now that they look out ahead of time to see who’s coming in. They can kind of, pick out those patients that may be end of see patients at the front, the front staff, can can look at their insurances to see who might be, who might need prior authorization, for a same day procedure, to have that lined up or at least tell me that they can’t be.

And, you know, it really doesn’t take much to to do this. I mean, it takes a little a little practice, getting used to in office procedure on an awake patient. But, you know, if you’re motivated and and I think most of us wanna be motivated for our patient’s best interest and and and, you know, to to help now especially keep keep more of our patients out of the OR, then it’s it’s a really handy tool to have and doesn’t doesn’t take long to become efficient, with it.

Okay. Excellent.

Thank you so much. I really appreciate your time tonight, both both doctors. And again, thank you to our audience.