How COVID-19 could impact future practice: Q and A with Tanios S. Bekaii-Saab, M.D., F.A.C.P.

May 09, 2020

How COVID-19 Could Impact Future Practice: Q and A with Tanios S. Bekaii-Saab, M.D., F.A.C.P.

This interview originally published on April 1, 2020, in OncLive by Jessica Hergert. It has been updated and is shared here with permission from OncLive.

As the number of confirmed cases of the novel coronavirus 2019 (COVID-19) continues to rise in the United States and around the world, hospitals, clinics and academic institutions have implemented protective measures to keep vulnerable patients safe during the pandemic, said Tanios S. Bekaii-Saab, M.D., professor at the Mayo Clinic College of Medicine and Science, leader of the Mayo Clinic Cancer Center Gastrointestinal Cancer Program and consultant at Mayo Clinic in Phoenix, Arizona.

Such measures include the use of telemedicine, postponing elective surgeries, rotating providers, maintaining social distancing and surge planning.

"COVID-19 has moved us into a new world. While the history of humanity has seen a lot of pandemics, we haven't seen anything like this in our lifetimes," said Bekaii-Saab. "However, I am an eternal optimist. This will be over at some point — hopefully sooner rather than later — and then we will get back to caring for our patients in the way we always did."

In an interview with OncLive, Bekaii-Saab, medical oncologist, discussed the increased need for telemedicine, the impact of protective strategies on the trajectory of COVID-19 and the potential aftereffects of the virus.

What safety measures have been put in place at Mayo Clinic to reduce the spread of COVID-19?

Since we first started seeing the data coming out of China, we've been most concerned for our vulnerable patients who are the most susceptible to getting sick and dying from the virus. Up to 20% of older patients who have comorbidities can die of COVID-19.

We took measures early on. We knew that we would move to telemedicine at some point, so at Mayo Clinic, we started implementing telemedicine and digital platform strategies even before COVID-19 [spread to the United States].

How have your patients responded to these protective strategies?

My patients have been incredibly understanding. We want to protect them; that is the primary goal. We want those patients who do not need to be physically present to [remain at home].

In many cases, patients may be best served by coming into the clinic, based on the stage and severity of their illness. We know that patients who are in the clinic may be at higher risk without proper measures in place. We want to protect the most vulnerable patients who require treatment regardless of this pandemic. Some precautions we've implemented are safety screenings before a patient arrives on campus and again upon arrival, universal masking for patients and staff, and enhanced cleaning above and beyond CDC guidelines.

Additionally, we want to protect our providers. Of course, as providers we understand that we take risks all the time when treating our patients. However, this is certainly a different level than we have seen. We want to protect ourselves because we are the ones who take care of the patients. If we lose our providers to illness — or potentially death — we can no longer take care of our patients.

What other measures have been taken to reduce the spread of the virus?

We want to preserve resources. Elective surgeries and other elective [procedures] have been temporarily postponed to preserve masks, protective gear, ventilators and other materials for patients who may need them. That is what we call surge planning. I pray it will not get to that point, but if it does, we are going to be ready so that we minimize morbidity and mortality. We consider most cancers to be medical urgencies that cannot wait eight weeks or more for treatment, so we've implemented appropriate precautions with COVID-19 testing for operative candidates prior to surgery, including preoperative COVID-19 testing for all patients and appropriate risk triage.

We have been working aggressively to rotate our providers. Those who are not actively seeing patients on a particular day are asked to work from home. It is strange for physicians to think about home as [a place to work] because we are used to being in the clinic and hospital all the time for our patients, but it is understandable. This principle keeps the standard of social distancing. The fewer of us who are in the hospital at a given point of time, the less we will be in contact with each other.

Those measures have certainly affected our day-to-day operations in many ways, but we are focusing on safety measures [regarding] COVID-19.

Do you anticipate there being disruptions or delays in care?

My biggest concern is that once this is over — and it will be over — a lot of patients who will delay their care, will present with more advanced disease. Some patients will not come to see a doctor even if they are symptomatic because they are scared to be at the clinic or hospital. I am hoping that the measures we have taken at Mayo Clinic will reassure our patients that their safety is paramount to us and we hope that their care will remain uninterrupted.

Also, we may have to sacrifice the intensity of treatment for some patients for their own protection or because that is their desire. That may affect long-term outcomes.

We are trying to balance things out as much as possible — while also doing what's right for the patient and their disease, and our patients are incredibly understanding.

How could this affect clinical practice in the long-term?

At Mayo Clinic, we have been quite focused on telemedicine as an option, along with traditional in-person visits. We understand the capacities [of telehealth] are large, and [it may aid] a lot of our patients who travel quite far to see our experts, when appropriate to be seen via video.

This pandemic has accelerated the desire to further implement telemedicine, and it is happening faster than planned. That is good news in the long term for our patients because many of them may not need to be physically in clinic for each and every visit.

As we move toward more oral drugs, fewer patients will need to be present in infusion centers. However, many centers are still bringing patients in on a routine basis. Frankly, at some point these patients will need to be physically seen every three months instead of the typical one month interval. For my patients with colon cancer, if I am scheduled to see them for a routine follow-up and their test, scans and cancer markers look great, I'll call or preferably video conference with them in six months. Then I'll go through their symptom checks and [assuming everything looks good], I tell them I will physically see them in one year.

Of course, if I see something concerning, I am going to bring them in. As I said, we are seeing so many improvements in how we care for our patients, but we know a virtual visit won't work in all situations. Due to the tremendous and meaningful advances in cancer care, the likelihood of getting patients to remission and curing them is going to significantly go up and, in turn, the need for patients to be physically present in the clinic frequently will go down.

Based on the COVID-19 pandemic, we are going to change a lot of what we do, but that was needed. This crisis led us to the understanding that we need to move more quickly toward [telemedicine] as an option. We don't always need to bring patients into the clinic to do the scan, do the blood test, and have them spend one or two days doing everything we require of them. Now, they can do the test, go home and we can talk to them [virtually]

What areas of practice will be impacted the most?

Globally, we've witnessed recent epidemics such as severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS). However, those were represented on a smaller scale, and while they did not go away completely, they [are largely gone].

We've learned from the COVID-19 pandemic that we can never become complacent; we have to be ready. We shouldn't be paranoid and constantly think that the world is going to come to an end; but when this happens again — not if, when — we will be more prepared.

During this pandemic, we have established a lot of things that will become part of our routine. Hopefully, [these measures] will make [the virus] less burdensome to the overall health care system.

Our level of care at Mayo Clinic will not be compromised regardless of this pandemic as we have been quick to adopt safety measures for patients and staff to allow uninterrupted care for all who need it. This crisis shall pass. I hope we learn from this and evolve. In the meantime, everyone needs to continue social distancing. As providers, we always appreciate the thoughts and prayers from everyone as we continue to [care for our patients].