Karen Nash

Karen Nash is a medical reporter and media consultant based in Monroeville, PA.

Urology Times reached out to 3 urologists (selected randomly) and asked them each the following question: Besides the expansion of telemedicine, how has the coronavirus disease 2019 (COVID-19) pandemic affected your practice?


“For a while, the hospital was not allowing elective surgeries, so we had to cancel procedures considered elective. A lot of patients wanted to stay home, and they canceled their appointments. There were some days we didn’t see a full day of patients, and a couple [of] days when we just closed the office because people wanted to stay home.

I respected that decision, …and worked on other projects so I could make good use of the time. That was probably March and April. By May, we basically had a full load of patients and it’s been very busy in the past few months.

I didn’t have any patients who suffered adverse consequences because of the delays. The urgencies we took care of just as we normally would. Some of the elective follow-up visits we postponed, then they came back a few months later and we’re getting caught up.

We’re taking it in stride. We don’t overbook to the point where we’re overwhelmed, and we’re not exhausting ourselves. We’re catching up.

As I said, none of my patients suffered because of the delays. The people who had true emergencies we took care of, and people who had things that could be electively postponed, we postponed, and now we’re getting back to normal.”

“I’m a transplant surgeon as well as a urologist. We took a big step back when we first had [COVID-19]–positive patients [as] we were concerned about 2 things: Seattle had some of the first documented cases in the US, so we put a moratorium on living-donor transplants which were elective procedures. Then we cut way back on deceased-donor transplants because we [had additional concerns]. First, we worried about immunosuppressing patients who might then be exposed to COVID-19. Second, a lot of our patients come from outside the Seattle area—Montana, Alaska, Idaho. We didn’t want to bring people from low-frequency COVID-19 places into Seattle. That had a pretty significant impact on the transplant side of our practice.

Any time a patient doesn’t get an organ, you can say there’s a detrimental effect, but if you need a kidney, you can live on dialysis. Nobody we’re aware of died because he couldn’t get a transplant.

We’ve restarted both programs. Now that we know more about COVID-19, we realize most transmission is not hospital-acquired; people are getting it in the community. So we feel safe having people come in and stay 3 to 5 days.

We’ve been fortunate; just 1 transplant patient died of COVID-19. She was 6 months out from transplant; she and her mom both contracted it in the community. They came into the hospital and succumbed to the disease. Most of our transplant patients have comorbidities—diabetes, hypertension, [or] they’re elderly––we’ve had no new transplant patients develop it.

We still did cancer surgery. There wasn’t a day I didn’t do something in the operating room, but my clinical practice was down by 50% to 60% for a couple months. We’ve gone back to close to our normal practice now. Volumes are just down about 20%.”

“The most obvious impact is that we all had a shutdown. I practice at the Minneapolis VA hospital. We’re continuing at reduced capacity. So that’s a major thing.

We have a more finite capacity and fixed resources at the VA. The government doesn’t just allow people to work overtime. Work stops at a certain time of day. We’re more restricted than the private sector, so there’s a backlog of cases. Surgery dates we can offer are somewhat in the distant future, making the backlog longer than is already usual at the VA.

I don’t think any patients were actually harmed. I think it’s more psychological. I’m talking mainly about prostate cancer. Once you’re diagnosed with any cancer and have chosen a certain path, it’s hard to understand that you have to wait another couple months to have it taken care of. Patients who were really urgent, however, [were taken care of]. It’s just the additional burden to waiting. We care for many older patients with comorbidities and they’re certainly worried about getting COVID-19.

We’ve had a few patients who had to cancel surgery because they developed COVID-19. Patients of mine developed [it] through community spread, not within the hospital, and they’ve all done OK.

We are catching up. Nobody I’m aware of is overwhelmed; we always have lots of work and stress, but it’s what we’re here for, isn’t it? It’s part of our social contract as physicians.”

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"We’re taking it in stride. We don’t overbook to the point where we’re overwhelmed, and we’re not exhausting ourselves," says one urologist.

Besides the expansion of telemedicine, how has COVID-19 affected your practice?

Urology Times reached out to 4 urologists (selected randomly) and asked them each the following question: Is carrying cyber insurance needed in a medical practice?

“We have insurance for our EMR and computer system in case we break down, but we’ve also carried cyber insurance for at least 7 years. It covers us for ransom, as well as potential penalties if personal data is compromised.

Attacks are increasing across the world. Health care providers are prime targets due to personal data with which we’re entrusted. We have an in-house IT department working 24/7 to make our electronic medical records and our internet exposure as safe as possible from cybercrime, but cybercrime is ongoing, so cyber insurance will be normal for practices as time goes on.

In any medical practice, the first step in protecting themselves is to be as strong as possible—from password protection to firewalls and ongoing surveillance for scams.

Both financial and medical information security is important. From the HIPAA standpoint, it could be devastating if medical records were victimized to a cyber attack. Then there’s ransom that’s been seen in multiple businesses that has a huge financial impact.

Depending on the size of the practice, the amount of cash flow you’re out on a daily basis could be minimal, but HIPAA violation fines could be massive.

Government agencies can judge whether enough was done to protect against attacks. Our practice tries to maintain as tight security as possible, but that bar is constantly changing.”

“I have a Mac. They have pretty good internet security. They keep changing things based on what’s happening, so I’m not worried somebody could take us hostage and try to close down my 

I don’t see a need to insure against a cyber attack. My office has its own firewall system. I’m confident hackers can’t get through it.”

“When I think about security for medical records and electronic medical records, we’re a private practice group and it just hasn’t come up in our group.

We have IT people that we pay a lot of money to and they take care of all our security needs. If something does break so that we can’t log on, we call them and they’re here. They also work on our personal computers, so we’ve never had an issue. We feel we’re well protected by our IT professionals that maintain all that equipment in the office.

We haven’t discussed hackers. We have a huge practice, but there are only 3 of us, which is unusual in today’s landscape. Maybe that protects us also.

We’re extremely busy—we do every procedure in urology and see a ton of patients weekly, but cyber security hasn’t really been an issue because our IT guys protect us.

The strongest protection is a good IT system to keep security strong. We pay a decent amount of money, so we take this seriously. We have two guys who are here periodically to make sure we have no issues.”

“We were held for ransom. It’s a crazy story. We were transitioning from a local IT group we’d had for 10 years, to a new group, when one morning we got an email that said, ‘Get ready to have a bad day.’

We had a Russian-based attack. All of our data was encrypted. They said they’d give us back our data for $24,000 in bitcoins. We said, ‘Before we do that, we want to make sure you can do what you say you can do.’ The funny thing was, they said, ‘Oh, we’re sorry, the guy who unencrypts these files is on vacation.’ We said, ‘What the heck is this?’

We ended up paying a US-based encryption company more than $70,000 to fix it. Our new IT company took full responsibility, even though it was probably not their fault. We think a virus was sitting in our computers for weeks before being activated.

We lost probably 2 to 3 weeks of revenue because we were down to paper. We had 2 insurance policies—1 via our medical malpractice and another from insurance on our building that enabled us to reclaim some losses.

Actually, we recently paid a company to attack us. Before the electronic medical records (EMR) company would return our data, we needed to make sure we were secure.

When the penetration results came, we were stable, but the EMR company had 3 issues needing repair.

I would absolutely advise practices to carry actual cyber insurance—100%! We do carry specific cyber insurance now.

It’s interesting the hackers were not interested in patient medical or financial data …just in holding us hostage/demanding ransom.”

"We had a Russian-based attack. All of our data was encrypted. They said they’d give us back our data for $24,000 in bitcoins," says one urologist.

Is carrying cyber insurance needed in a medical practice?

Urology Times reached out to three urologists (selected randomly) and asked them each the following question: How do you decide between partial and radical nephrectomy?

"Indications for partial versus radical depend on tumor size or location, and on a desire for 

nephron sparing. The goal is always to remove the tumor but save any viable kidney tissue. The first priority is cancer control, and the second is nephron sparing.

The possibility of perioperative complications, risk of recurrence, and procedure difficulty are considerations. With robotic technology and experience, we try to do a partial if we can. Cancer control is an issue, but if surgeons are experienced, the positive margin rate should be low.

I don’t think there’s much controversy now between performing radical versus partial procedures. The state-of-the-art surgery, the gold standard, is nephron-sparing surgery, preserving renal function.

If someone has a relatively small kidney cancer and the entire kidney is removed, there’s a chance of developing cancer on the other side, or renal insufficiency for other reasons. Then they’d only have 1 kidney because the other one was removed when it wasn’t necessary.

If a person has a car accident after a kidney is removed and they lose their other kidney, they’re on the transplant list and need dialysis, which is pretty horrible. If you can do partial nephrectomy and spare the noncancerous part of the kidney, you should try to do that.

The controversy has been thoroughly debated and I believe the gold standard is partial nephrectomy.”

“Our goal is to do partial nephrectomies robotically. With urological guidelines, a partial is 

indicated for tumors that are 4 cm or smaller. For amenable tumors—good location, good anatomy—we may attempt a partial if we can get nice margins. Anything larger, or more technically complicated, like involvement of the renal hilum, we would probably lean toward a radical nephrectomy.

The only caveat would be someone with a solitary kidney, so you try to spare as much function as possible. We would lean toward a partial, even with soft indications.

In older patients, 75 to 80 years old, with a second normal kidney, I lean toward a radical for expediency of surgery, because blood loss may be riskier than potential recurrence or loss of another kidney. Even with an amenable tumor, at 80, I probably just remove the kidney, because the remaining kidney will probably last the rest of their life just fine.

Most problems occur when there is massive involvement of the collecting system or extensive dissection off the renal hilum. I wouldn’t consider a partial for anything with venous involvement. But with well-chosen candidates, complication rates with partials are relatively low.

We don’t do hundreds of nephrectomies, so I haven’t seen a higher risk of end-stage disease or shorter survival rates with partials. When a tumor is more technically challenging, I lean toward the radical, because risks increase.

With patients in whom a partial nephrectomy is possible but could be difficult, I refer them to the university, because I wouldn’t want to do them a disservice. Given my patient volume and technical skills, I would be more comfortable with the radical, and that might not be right for that particular patient.”

“It’s case dependent. For appropriately selected patients, partial nephrectomy is preferred. 

Patients tend to do equally well with either procedure. More than anything, it’s tumor characteristics that really define which we elect to do: mostly size, tumor location, and whether the tumor is primarily endophytic or exophytic.

Although we don’t have a strict size criteria, if the tumor is large enough, it’s likely to be higher-stage disease. Then I would perhaps opt for radical nephrectomy rather than a partial nephrectomy.

The potential for complications or recurrence is always in the discussion when we’re offering options to patients. It’s in the discussion, but whether I’m actually concerned about it? In our experience, recurrence rates have been low so if patients are appropriately selected, we expect recurrence rates are acceptable, if not negligible.

There’s always the potential for bleeding, and when a patient is borderline for a partial and they might be an appropriate radical nephrectomy patient, I’ve found that consideration of risks may guide the patient’s decision-making to some extent.

It’s basically a shared decision-making model for most cases. Often, when we discuss the partial nephrectomy option, we talk about other options, including cryoablation, for example, which we would have to refer out. Cryoablation may be an option for some people when otherwise they would be a candidate for partial nephrectomy.

We discuss multiple treatment modalities and all their attendant risks and benefits. To a large extent, discussing risks and benefits is just what practicing 21st-century medicine really means.”

“It’s case dependent. For appropriately selected patients, partial nephrectomy is preferred," says one urologist.

How do you decide between partial and radical nephrectomy?

Urology Times® reached to three urologists (selected randomly) and asked them each: What has been your experience with telemedicine?

“Before COVID-19, we called patients back, but we never did video or phone consults. Now we do both. Telemedicine will have an important place now in urologic care of patients.

Initially, it was intimidating. How would timing come off? How would the back-and-forth work conveying information? But we quickly felt comfortable, especially with video. With face-to-face interaction, especially in pediatric urology, you can have them point to the affected area. I’ve even done it on postop. ‘Point the camera at the area. Oh, it looks great.’

It saves people traveling for quick follow-ups. It helps [with] managing patient flow and educational aspects of care.

With pediatrics, often it’s not just one kid families have to wrap up when they need to see us. They’ve got several children to bring. If we can handle things over the phone, they’re elated.

Sometimes you can look at lab results and prescribe preliminary medication. Then you can see how it works before patients come in. That can streamline the management of disease.

You can provide educational links to patients before we talk about a particular procedure. That can save time.

Facial recognition and communication are important when you’re going to do a procedure. You need the video-conferencing.

Most of our patients, even the elderly, seem to access their charts online. On the site, there’s an easy link to connect to a video consult. ‘My Chart’ has a prompt that allows them an easy video consult link.”

“We didn’t do telemedicine before the pandemic. My experience now is fairly positive. It’s for reviewing labs, discussing people’s prognoses and potential outcomes, as well as the direction of therapy.

In urology, if patients need certain examinations, the initial consult can be telemedicine. Eventually, they’ll need an in-person visit because nothing replaces that physical examination.

Cognitive appointments, especially if you know the people, work well because these people don’t necessarily need a physical exam if their symptoms are stable.

It’s also good because older patients are at higher risk for coronavirus and many are anxious about possible exposure coming in. If physical exams are not critical for decision making, for example, if you’re following a patient’s PSA, you can check laboratory data by telemedicine. Eventually, they’ll probably need a physical examination but maybe that can be delayed until the environment is safer.

Telemedicine works best on video. With audio only, you miss face-to-face communication. Body language is important, otherwise you don’t know whether they’re grasping concepts. It’s also more personal. Without that connection, they’re probably less likely to follow those things they should.

I expect we’ll continue telemedicine when coronavirus is no longer an issue, but probably not to the same extent. I have patients who travel who may request video appointments, which I would do sometimes. Other patients are less mobile and can’t always get here. It’s better to do a video conference than just keep rescheduling them and eventually have them drop out.”

“We didn’t do telemedicine before the coronavirus. We considered it a couple years ago, but technology wasn’t great, and, frankly, the payer system didn’t facilitate it. Not that we didn’t want the work, but you have to be fairly compensated.

With coronavirus, the government basically said, ‘We’ll waive onerous requirements. If you visit patients through telecommunication devices, we’ll cover them as in-person visits.’

Telemedicine is a mixed bag. I definitely see where it’s useful, particularly for elderly patients, or patients with difficulty getting into the office without help. Some of our patients are octogenarians. As long as it doesn’t require a physical exam, it’s a great way to go.

I have seen it take time when there’s a lot of data to go through, and you have to go to a different terminal to look at x-rays , but there’s definitely a role for it.

I’m concerned the government may revert to rules from before COVID…making it difficult to code for visits the way they require.

Certain things still require face-to-face visits, such as feeling a mass. But I have patients living 60 to 70 miles away. Having to come back for a quick post-op check costs time and gas money. Telemedicine works well in those cases. So I definitely think there’s a place for this after the virus, especially in less populated areas, like the Dakotas, Idaho, Arizona. Patients need care, but there’s a big onus on them to travel in areas where it’s hard to get doctors to locate.”

3 urologists discuss their experience with telemedicine during the COVID-19 pandemic.

Author | Karen Nash

Articles

Besides the expansion of telemedicine, how has COVID-19 affected your practice?

Is carrying cyber insurance needed in a medical practice?

How do you decide between partial and radical nephrectomy?

What has been the telemedicine experience in urology during the COVID-19 pandemic?