Work in the Time of Corona

February 2020 started like any other month. Our small surgical practice located outside of Charleston, South Carolina was gearing up for its 12th February since opening in the spring of 2008. Our management team often joked about the poor timing in opening a new practice 12 years prior during the worst economic downturn in recent history. That timing was a challenge economically, but certainly strengthened our resolve for managing CMS reimbursement cuts, increased administrative burdens and social media platforms that not only allowed, but encouraged, patients to easily post anonymous online reviews without validation or verification. Although January 2020 was already promising new challenges, vague media stories about a new, or ‘novel’ virus in China was strange enough to be interesting, but subtle enough to suggest this small southern community had nothing to fear.

March 7, 2020: Local Charleston SC news outlet Live5News reports “First possible S.C. novel coronavirus cases detected in Charleston, Kershaw Counties”. Huh? This thing has actually entered the Charleston area? Is it real? Is it a media fabrication? As administrators, we are charged with protecting our practice – our doctors, our patients, and our staff. Although admirable is our quest to protect the humans around us, everyone in healthcare secretly knows the real #1 priority for administrators is protecting the money. Without money we cannot employ staff, maintain facilities, and continue taking great care of patients so it is ultimately through the money that everything else remains possible. The one thing I know for certain is that I would survive in the wild. When stress kicks into high gear my innate survival instincts take over and the checklist begins: Do we have payroll covered? Check. Full clinic and OR schedules? Check. Staff healthy and happy? Check. Solid compliance plans? Yep. So then we don’t have anything real to worry about, right? The world has viruses and surely this thing is nothing more than a new type of flu. Regardless, it surely won’t affect my practice. Right?

March 16th: What a weird week! Patients have been rescheduling like crazy and ASCs across the state have cancelled all elective surgeries, including ours. Other than a couple of emergent procedures, this ‘home or work’ directive halts 99% of our surgical revenue stream. We are a surgical practice. Our entire overhead formula only works if we have surgical revenue coming into the bank. In the best of calendar quarters, decreased reimbursement rates for clinical encounters already barely covers the overhead. Decreasing those volumes 70-80% from COVID cancellations and then removing surgical revenue altogether....and we have problems. Real problems. With survival instincts still activated, things are feeling a little more uncomfortable. Survival instincts are great, but they only work if there is still revenue. And generating revenue requires patients. It is time to call a staff meeting.

April 6th: This has been one of the toughest weeks in the 13 years I have worked for my practice. There is something counterintuitive to building up a practice and then in one day having to terminate half of your staff in order to survive. With CARES Act approval in late March there is at least hope that practice bankruptcy will be delayed, but we still have got to see patients for our practice to survive. Thankfully, our practice owners are financially conservative and CARES Act funding looks promising. Maybe we can figure out this telemedicine thing after all. Time to pull in the reigns and see which bills to pay, and which ones can wait.

May 25: Somehow celebrating Memorial Day seems pointless and confusing. Why would the practice close for a holiday when we have barely been open for the past two months? Our skeleton staff is amazing, literally moving between different roles and tackling any task asked of them. The HHS grant and CARES Act funding has literally saved our practice and those of us left are working reduced hours and staying isolated at home as much as possible. If I think about any of this too long I feel overwhelmed and sad. But then I think about it anyway and realize I am incredibly thankful. As we pause to honor others this Memorial Day holiday, I am reminded that sometimes the greatest acts of heroism are happening all around us, right where we are.

June is confusing. Surgery schedules are full and insurance payments are once again hitting the practice bank account. We are back to 100% of our original staffing numbers and are cautiously seeing clinical patients under heightened safety precautions. Although I have heard rumors of patients suffering with COVID-19, the virus has seemed to miss our little pocket of the world and I am cautiously optimistic it will soon be over. Will children really return to school as suggested? Will my family actually be able to travel by airplane again sometime soon? Will my parents be able to eat dinner in a restaurant without fear of hospitalization? Although it is difficult to ignore skyrocketing anxiety levels, or the fact that patients are more argumentative than ever before, there is a small glimmer of hope that “normal” might return after all. Sure, we had a couple of employees quarantined with symptoms, but they ultimately tested negative for the virus and we seem to have skirted our biggest fears. Yes, the news continues to report on hundreds of positive tests per day, but wasn’t it thousands of cases per day just a few short weeks ago? Is this thing finally coming to an end?

With an increased - yet unfounded - sense of confidence, July brought to our practice the long-missing VACATION. Perhaps we just needed to feel normal, if only for one week the entire year. Perhaps the need to travel overshadowed the fear of travelling. Or, perhaps, families just needed to remember what a family vacation felt like again. For whatever the reasons, July in our practice brought several vacations amongst doctors and staff. Although most vacation plans were altered for safety reasons, several of us enjoyed time away to recharge and connect with loved ones, even if that time was masked, sanitized, and closer to home than originally planned. Could this new found freedom be a sign that things were moving toward normal again? Team members returned from vacation healthy and refreshed. Clinic schedules remained full and we still had zero cases of COVID-19 in the house. Perhaps our crazy mask-wearing, desk-wiping, hand-cleaning, six-foot distancing protocol was enough after all and we were going to make it. Thank you, thank you, thank you. 

And then came August. August 17th started like any other Monday. As our busiest day of the week, Mondays are always extra hectic with full clinics and emergent cases trickling in from the weekend. On the best of days we are fully staffed and everyone is ready to tackle the day. This particular Monday, however, was already stressed with two employees cautiously staying home, one with a slight fever and one with a sore throat and headache. The practice’s strict COVID policy requires all illness to be treated at home and any COVID-19 symptoms to be met with immediate COVID testing, self-quarantine and a negative test result before returning to work. In what now seems like both a blur, and a moment frozen in time, my registration lead signals me from outside of my glass office door. Since I now keep my office closed to protect my personal space, I asked her to call me and tell me what she needs. She explains, “My lower back was hurting and I thought I had a kidney infection so I made an appointment at lunch with my primary care doctor. They are now requiring COVID testing for anyone with new symptoms and my results just came back. I am positive.” Wait, what? This employee does everything right. She doesn’t party on the weekends or ride in cars unmasked. She doesn’t eat in the lunch room and is constantly wiping down her space, keyboards, phones. How is this even possible? What does this mean? Barely able to comprehend the full meaning of what she just said, I send her home and think. The survival instincts start waking back up and I initiate Plan B. Okay, we got this. We have plenty of coverage and we are super careful. Surely the others that already called out sick that morning are just coincidence. Surely this is some weird anomaly and everything will be fine tomorrow. We are safe and careful. Surely this thing is over . . . right?

Tuesday morning is met with another call out from an employee who awoke with body aches, headache, and slight fever. While mentally tracing the contact of my one COVID positive employee with the now three employees awaiting results at home, I am still confident we were dealing with one isolated case. Confident . . . or hopeful? None of these four individuals hang out together. Their positions are separated and they are not social friends. Everyone in our practice has spouses, kids at home, and unmonitored social lives. Even though we interact with hundreds of people on a daily basis, I am convinced this is a glimpse into bizarro-world, and everything will be fine. Until the texts begin. Employee #1 from Monday texts me a picture of her positive COVID-19 test results with a note that she will be in quarantine for the next 10 days. We are now two down and it is only Tuesday. As most administrators have done every minute since March, I constantly review our COVID-19 safety protocol. Staff is drilled on cleaning procedures, mandatory masks are worn at all times, temperatures are taken at every entrance to the building, and any guests in the building are by appointment only. What am I missing? Is it time to halt clinics altogether until we figure this out? Before I can meet with the practice physician team to start formulating a plan, another text comes through. Employee #3 with positive test results. Is this really happening?

Something unique happens during times of crisis. The fight or flight instinct is triggered and unspoken concerns become palpable. As rumors start spreading throughout our small practice, we begin to see the true character of what lies beneath the surface of our daily routines. Employees are worried, but they step up. Patient appointments are scheduled weeks – if not months – in advance in our specialty practice, so unexpectedly having three front desk employees out all at once creates major distress. Somehow we make it through the day without upsetting too many patients and we realize the next 10 days might be tough, but we will be okay. We sadly realized years ago that if you want to play in healthcare, you gotta’ be tough. This year Ophthalmology was the lucky recipient of some of the largest reimbursement cuts in the history of Medicare so we are unfortunately thick-skinned and ready for battle most of the time already. But this is different. This silent enemy has turned on our own team. Will everyone be okay? Could anyone else be sick?

Day #3 of what I now refer to as the “COVID Run” in our practice proved to be a day of defeat. By Wednesday afternoon we had four confirmed employee cases of COVID-19, three more awaiting test results at home and two providers now symptomatic. By Thursday morning our positive COVID cases exploded to seven employees and two providers and we have no clue if it is still lurking within our practice. Over the past six months there were a handful of times we waited to learn if an employee was COVID-19 positive. In an ironic turn of events, I now realize that nearly half of our staff has now tested positive for this virus and instead of waiting for a random positive test result, I am now awaiting results to see which of my employees might actually still be negative.

By the end of August we are finally returning to normal. Our first six positive employees have returned from quarantine and the rest will return by the end of the week. I am thankful for our safety protocol that kept sick employees home and patients safe. I am also thankful that everyone has recovered, and the virus’ flu-like symptoms and bouts of exhaustion were the worst of it for our crew. Although we are still analyzing the “how” and “where” the virus unleashed itself on our team, there are a few things we know for certain. First and foremost, we know that our protocol is good and patients were kept safe at all times. Our strict screening, distancing, and masking protocol has allowed our team to continue patient care without a single confirmed exposure for a full six months. The unfortunate culprit, it seems, is that we let our guard down in our lunchroom. Although our lunchroom protocol required seating in “every other” chair, no more lunch buffets or shared meals, and staggered lunch breaks, the reality is that our team became lax and unguarded during this brief period of their hectic day. That’s right - for a few minutes over lunch our awesome team chose to have an unguarded moment to connect with their friends and co-workers while taking a much-deserved break from their demanding jobs. A moment to feel normal, to see the smile on another’s maskless face, and to decompress with their friends. We now know that sometimes the perfect storm starts with a single raindrop and something as simple as one person having one family dinner at one restaurant on one night one week prior led to an exposure which was then carried unknowingly into our practice and shared with one more person, who shared it with one other person, and then another, until it was done. Could we have done something better? Sure. We could have closed the lunchroom and forced employees to eat alone in their cars indefinitely until this thing is gone. Did we learn any lessons? Yes. But I think lesson is the wrong word. The lesson I learned the most is about the human spirit, and how the roots of adversity are nourished by kindness. How the team will rally when their team members need them. And how an office full of ordinary human beings can do extraordinary things. I wish our story was unique and we were the only ones in all of healthcare recovering from our own private pandemic. Unfortunately, it is not. Unfortunately, this is what it means to Work in the Time of Corona.
- Ashlie LB Malone