After the shakeup caused by the emergence of the novel coronavirus worldwide, countries are in different stages of their attempts to bounce back and reopen schools and businesses. In the U.S., the White House had set baseline parameters needed for states to reopen, including a 14-day decline in the number of new cases and sufficient capacity for testing and tracing. Lack of testing has been an issue since the beginning, first due to the actual absence of authorized tests and later because of a shortage of supplies needed to conduct tests.
In a survey of laboratory directors across the country conducted by the College of American Pathologists (CAP), more than 60% of respondents indicated they were having problems with shortages of critical supplies needed for COVID-19 testing, such as test kits, nasopharyngeal swabs, and transport media. Furthermore, almost 80% of labs offering testing reported that they had capacity to do more testing than their current level. (The survey was conducted in the last week of April; CAP reached out to 3,784 laboratory directors and received 434 responses.)
Lockdown policies and the reduction of scheduled tests and procedures have taken a heavy toll on the field of lab medicine, with a median drop in revenues of 50% among responding labs, regardless of whether they were offering COVID-19 testing, CAP reported.
A different survey conducted in late April also charted the declining fortunes of clinical laboratories in the U.S. Of 191 clinical lab respondents, 59% reported a significant impact from the COVID-19 pandemic, according to the survey, which was conducted by Kalorama Information, a sister company of LabPulse.com. The results indicate declines in almost all testing categories, with histology and cancer experiencing the biggest hit.
Reaching for federal lifeline
For the health of the country, it's especially important for small groups with fewer than 15 pathologists to stay viable, commented Dr. Emily Volk, president-elect of CAP.
Dr. Emily Volk.
"I am hearing from a lot of small pathology groups that are struggling because of the loss of volume and struggling to keep their doors open," she commented in an interview.
U.S. federal aid for small practices was initially offered through the Coronavirus Aid, Relief, and Economic Security (CARES) Act, which included more than $350 billion in emergency funding for the Paycheck Protection Program. This program provides loans to cover payroll and other expenses for small businesses that are forgiven if practices keep their employees. When that package ran out of funds, Congress extended financing through the Paycheck Protection Program and Health Care Enhancement Act. CAP has been offering a variety of resources for practices, tapping into the Paycheck Protection Prgoram as well as other programs such as $10,000 grants offered through the U.S. Small Business Administration's Economic Injury Disaster Loans (EIDL).
CAP recently held a roundtable webinar on financial assistance programs available during the pandemic and has been fielding questions during special sessions on Twitter. A large number of programs are available to small pathology practices, and if applications are approved, money is delivered relatively quickly, Dr. Jonathan Myles, chair of the Council on Government and Professional Affairs at CAP, commented in an interview. Practices are best advised to review the programs available and evaluate what is best for their own particular situation.
"No one solution fits all practices," said Myles, who is also a staff pathologist in anatomic pathology at the Cleveland Clinic.
In addition to financial stress, personnel issues are at the forefront. The CAP survey indicated furloughs in some cases and a rise in stress and burnout. In the same vein, the Kalorama Information survey found that the greatest concern for labs during the pandemic was their people, with almost two-thirds concerned about hiring, reducing, and maintaining staff.
There has been a tremendous decrease in volumes -- most pathologists across the country have seen this, commented Dr. Patrick Godbey, president of CAP and CEO of Southeastern Pathology Associates, based in Brunswick, GA. Godbey said that his practice has not laid off any pathologists, but it has repurposed some staff and cut seven independent contractor positions hired through agencies. Regular staffers have seen some cuts in hours and more people are working remotely, he said.
"We have excellent pathologists. We have excellent laboratory scientists," Godbey told LabPulse.com. "So we are trying to protect them in any way we can."
Dr. Patrick Godbey.
There have not been any furloughs or salary reductions for pathologists at the Cleveland Clinic, commented Myles. However, due to the decrease in the number of specimens tested and the need to protect the workforce, scheduling in the department has been redone to allow several pathologists per day to work from home. The reduction in the number of pathologists onsite means less risk for infection and that there are backups who are available to come into the hospital as needed.
Furthermore, visitation to the hospital is limited and anybody who enters has a temperature check, he added. The Cleveland Clinic has also increased the number of virtual visits for outpatients through telephone and web-based platforms.
"Prior to the COVID-19 crisis, we initiated that program and had it in place, and it certainly has been expanded during the crisis," Myles said.
Prior to the pandemic, one of the clinical pathologists on staff had face-to-face visits with patients and this individual has been trained to work on the virtual platform, including education on reimbursement codes to use for televisits, Myles added.
Expansion of digital pathology
Digital pathology is also coming into greater use among the 100 pathologists at the Cleveland Clinic, compared with during the prepandemic days. Previously, clinicians used the technology primarily during international consultations. Now, it has been expanded to include use for in-house subspecialty consultations. Whereas pathologists used to congregate around a multiheaded microscope to collaborate on difficult cases, cases are now displayed virtually on a computer screen to staff working individually in their offices.
Dr. Jonathan Myles.
"That has been a real boon to us," Myles said.
Godbey reported that home working is more common at his practice and that some shifts have been staggered to have fewer people in the building at any given time. Temperatures are taken for everyone coming in, everyone wears masks, and cleaning procedures have been stepped up. Office workstation arrangements have been changed to allow for more social distancing and all large gatherings have been canceled. If meals are brought in for catered occasions, food is given in boxed individual portions. As for visitors -- they aren't allowed into the building.
The pandemic has also necessitated some changes to medical education, commented Volk, who is senior vice president of clinical services at the University Health System in San Antonio. None of the pathologists at her institution have been furloughed; rather, they are still involved with educating residents and preparing them for board exams. Residents are participating in virtual lectures, such as CAP's free daily lecture series, giving them access to leading experts across pathology.
Are pathologists concerned about the lack of job opportunities? Volk believes there will be challenges across the board in medicine.
"I think there are few fields that won't be impacted by this," she said.
With reopening underway, there are still many uncertainties. Laboratory directors responding to CAP's survey at the end of April said that they expected their COVID-19 testing volume to increase by about 40% over the next two weeks. There is also the promise of a return for tests related to "elective" procedures, as well as acute services that patients may have been avoiding for conditions such as chest pain.
Volk said that her health system in San Antonio is beginning to open up to some elective cases. Patients may still be afraid to come to the doctor, and they are getting mixed messages stating that things are opening up but that they should stay home if they can, so it's not as if the gates have been fully released, she said.
"We are welcoming the opportunity to serve more patients. However, I don't believe that the return to normal will happen quickly," Volk said.
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