The line between ‘elective’ and ‘essential’ is often hazy – Bryan-College Station Eagle

Posted: June 22, 2020 at 3:56 am

Late February was the last time I saw Mr. Fields, a man in his sixties with debilitating nausea, bloating and regurgitation. (To protect his privacy, I have changed his name and other identifying details.) His symptoms made it difficult for him to eat, and he was losing weight visibly from one clinic visit to the next. His last upper endoscopy - a procedure to inspect the top of his gastrointestinal tract - was aborted because there was a pile of food sitting in his stomach, despite his having fasted since midnight the day before. We had discussed repeating the endoscopy after a prolonged liquid diet to determine what was holding up his digestion (a tumor, an ulcer, or a general sluggishness of the muscle) and to use this information to guide his treatment.

Then the pandemic hit, and priorities changed. On a Friday afternoon in mid-March, I was asked to cancel the bulk of the procedures I had scheduled for the following Monday. From higher up, we received instructions to review every patient's chart, to separate the emergent from the urgent from routine. Mr. Fields certainly wasn't the only one perched on a borderline - it's the nature of my gastroenterology practice, as it is for most diagnostic proceduralists, not to know what I'll find until I go looking. My colleagues and I turned to each other for guidance. How worried would you be about an 80-year-old with iron-deficiency anemia? How about a 40-year-old with rectal bleeding? A 20-year-old unable to swallow? There was no question that they merited procedures, but when? Could they stand to wait four weeks? Eight? Twelve?

What does "elective" mean, really? It's intuitive to think about illness as varying along a spectrum of urgency: On one end, a hangnail; on the other, a heart attack. The term also implies that treatment can also vary along a spectrum of need, from cosmetic surgery to cardiopulmonary resuscitation. Most of medicine sits in the middle, asking us to balance potential health benefits against potential costs, such as missed diagnoses, procedural complications or, more recently, a covid-19 infection after visiting a medical building.

While the country debates whether to prioritize reopening the economy or minimizing preventable deaths, we face our own complicated trade-offs within the practice of medicine. The pandemic logic of triage - a process, borrowed from wartime, of prioritizing sick individuals according to the severity of their prognosis - exerts novel pressure on a system not used to such resource scarcity. Individual clinicians are grappling with what is truly necessary and urgent.

During my first week back to work in the endoscopy suite last month, I had trouble convincing any of my originally scheduled patients to come in for their procedures.Their episodic abdominal pain, refractory heartburn, and unrelenting diarrhea had seemed pressing just a few months before, but now the threat of infection loomed larger. Alongside clinicians, patients make their own judgments about what constitutes essential health care - about how to value the reassurance of resolving old symptoms against the risk of getting sick with something new and even more uncertain.

The calculus quickly gets complicated. We have to weigh not only the patient's health but that of the physicians, nurses, technicians and custodians who keep a procedural space operational. Concerns about infection also ripple from patients and providers to all their family members who might be affected. The masks and gowns protecting one cohort of health care workers could always be set aside for a needier cohort later. And staff relieved of their nonessential duties in a procedural suite could theoretically be reassigned to other settings where they might be of greater service.

On the other side of the equation, there are certainly diseases that become more dangerous when left unattended. A few of my colleagues in other cities worry vocally about how many gastrointestinal malignancies they'll find once routine practice picks up again. Less vocally, they worry about the legal implications of not having made the diagnosis earlier, wondering if they'll be liable for not having pushed more procedures into hospital settings even as federal or professional society guidance and state executive orders limited elective procedures. The potential hazards of clinical lag time also hold true for other specialty areas - blurry vision can herald impending strokes, and unattended orthopedic injuries can settle into contractures. In the background is the unsettling awareness that interventions deemed essential in one state may be elective in the next, particularly for politically sensitive services like abortion.

The line dividing essential from elective care is always a subjective one, because risk-benefit calculations tend to shift over time. The past few months have occasioned especially dramatic fluidity, but larger-scale changes have also unfolded over the past several decades. In the 1960s, specialties began lobbying for new interventional environments like the ambulatory surgical center, while emergency rooms arose as distinct hospital spaces for managing acute concerns. Meanwhile, chronic disease prevalence and pharmaceutical incentives inspired increasing professional interest in the idea of risk states (like high cholesterol as a precondition for heart disease, or age and gender as preconditions for breast cancer), which in turn entrenched preventive maneuvers (from annual physicals to mammograms to a daily aspirin) as vital elements of routine care. The insurance industry overlaid these developments with thorny questions about medical necessity.

In a sense, it's been remarkable how successfully patients have avoided clinical settings in these first few months of the pandemic. Early anecdotal reporting noted surprising drops in hospital admissions for common medical emergencies like cardiovascular events, appendicitis and strangulated hernias, and international data have begun to confirm these trends. In the United States, emergency catheterization procedures for life-threatening heart attacks were down 38 percent in the early phase of covid-19, despite predictions that those events would be, if anything, more prevalent during a viral pandemic. Fewer cirrhosis patients are being admitted to Veterans Health Administration hospitals, according to a study recently published by my colleagues at the University of Pennsylvania, and those who are admitted have been, on average, measurably sicker than baseline.

Contemporary biomedicine certainly prioritizes procedures financially, but also emotionally and culturally. Objective observations gathered by diagnostic maneuvers like CT scans, tissue biopsies and cardiac catheterizations have become a linchpin of clinical certainty. They are vital to a confident diagnosis and treatment plan and, when edged with the promise of life extension, serve as a kind of salve for the threat of mortality. These assumptions are so foundational to modern medicine that it can be shocking to question their validity.

Well before covid-19, the writer Barbara Ehrenreich detailed her decision to turn away from screening tests like colonoscopies, contending that they delude us into approaching death as a problem to be solved while at the same time invading the body to the point of violation: "if mammography seems like a refined sort of sadism," she notes, "colonoscopies mimic an actual sexual assault." It's a provocative argument, easier to accept in the abstract than when I recall patients with cancers I've found on years-overdue colonoscopies. Our infrastructure of high-tech diagnostic intervention can seem particularly bloated in the context of a pandemic, but patients and clinicians alike are often deeply and justifiably invested in it.

Ultimately, clean distinctions between essential vs. elective care are rhetorically convenient but clinically reductive. Sacrifices are entailed on both sides, and the messy work of negotiating the pros and cons will persist as the pandemic recedes. The same might be said for all-or-nothing debates pitting human life against a solvent economy - a compelling thought exercise, but less relevant in practical terms. Accumulating job losses are leaving more and more people uninsured, for example, forcing them to continue deferring elective medical care once it picks up again. Progressive dreams of radical reform notwithstanding, the medical and financial priorities of our healthcare system are deeply enmeshed, and for now, grappling with either means grappling with both.

Every day provides new data, and with it another opportunity to reweigh our priorities. In Philadelphia, where I work, our projected peak was at the end of April, and the first surge of covid-19 cases appears to have crested. Stocks of personal protective equipment are no longer dangerously depleted, and opportunities exist for systematic testing. These developments will afford us more space to evaluate those uninfected patients with separate, slow-burning complaints.

I recently re-connected with Mr. Fields; I hope he doesn't hold this interruption of his care against me. I'm ready to pick up where we left off, but covid-19 has made it harder to pretend that medicine operates in a vacuum. I marvel at the confidence of our pre-pandemic therapeutic encounters, which so often left implicit all the indelicate questions of financial incentives, workers' well-being, and the capacity of medicine to harm as well as to heal. Once the crisis lifts, it's hard to imagine returning to such thoughtless certainty.

Ahuja is an assistant professor of clinical medicine in the division of gastroenterology and hepatology at the University of Pennsylvania.

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The line between 'elective' and 'essential' is often hazy - Bryan-College Station Eagle

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