Is your office still open?

[4ophtho]

Is your office still open?
How are you handling payroll and taking care of your staff?
If you’re still open, how are you protecting yourself and your staff?
Do you wear a mask while seeing patients?

I don’t understand why you would shut down your clinic for 2 weeks, this virus isn’t going anywhere and it will still be there after 2 weeks. Seems like to really get through the outbreak you’d need to shut down for 4 weeks, but then your staff isn’t getting paid and your practice bills still have to be paid and you’re losing many tens of thousands of dollars

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[mjohnsonets]

Don't own a practice but can report that I have client practices still operating as usual and a few that have switched to emergency only patients and surgery. Some are switching to emergency only at the end of the week. Right now, every doc and admin I've talked to is inundated with COVID-19 planning.

 

[CECFellow2018]

I own a practice ( 3 months in...yey) . I converted to emergencies only this week. All surgeries cancelled.
The consensus seems to have strongly transitioned to ED only; there is certainly ethical debate about "running as usual".

 

[OphthoApplicant04]

Academic medical center: only seeing sight threatening emergencies.

 

[mjohnsonets]

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Thought I would add this. As I've spoken with more throughout the day it seems I'm seeing many of the practices I work with implementing the same measures. Some of the things listed here are beyond what I've heard and sound like good ideas.

 

[increscence]

It was only today that the AAO officially recommended closing clinics to all but emergency-only cases. We closed at the beginning of the week, as did many of my friends' offices. All of our ASCs also closed to non-urgent cases earlier this week. When we decided to close, it was really just an educated guess that it was the right move, because we lacked official guidance from the AAO.

A few ophthalmologist friends' employers were holding out until today. One of my friends ultimately walked off the job because his boss refused to close.

I am honestly disappointed in the AAO for waiting until today to officially advise clinics to close. They should have given an official directive much earlier, both to reduce confusion, and to avoid giving the naysayers an excuse to keep their doors open.

 

[4ophtho]

The AAO guidance is great for employed ophthalmologists who can still expect a salary or some type of protection from their employer or university. But for those of us who run a practice and have staff to support and bills to pay and/or practice in areas that are not yet affected it’s useless bleeding heart dribble without some concrete directions on how to navigate these very scary and uncertain times.

 

[increscence]

But keeping practices open will lead to loss of revenue in the medium- and long-term, because it'll worsen the spread of the virus and prolong the duration of mandated closures. Being proactive in this situation will likely mean softening the overall economic blow. Terrible to characterize official guidelines in this situation as 'useless bleeding heart dribble' (I'm guessing you meant 'drivel'?) in light of the very real threat that we, our patients, and our society face right now, as we speak.

 

[elementals]

The AAO guidance is great for employed ophthalmologists who can still expect a salary or some type of protection from their employer or university. But for those of us who run a practice and have staff to support and bills to pay and/or practice in areas that are not yet affected it’s useless bleeding heart dribble without some concrete directions on how to navigate these very scary and uncertain times.

I realize this is going to sound harsh, but how much do you think you'll make when you, your staff, or your patients start dying? This situation is real and escalating fast. Look at what happened to Italy in a matter of days, because they too were cavalier when this started. Now look at what's happening in Singapore, where they jumped all over this at the first sign of trouble. If you're waiting for positive tests to show up, you're already way behind the eight ball.

We've got a choice here. I know you have real and concrete concerns, but your first priority is to your patients. You serve no one and nothing by helping covid spread. Also, at least you have the option of closing up shop and staying safely at home. As a resident, I'm fully expecting to be called to the front lines in the next few weeks. I'm terrified at the thought. When I'm facing potential infection, illness, or even death, forgive me if I'm not too sympathetic toward your apparent intention to keep your office open, which at this point amounts to aiding and abetting a pandemic.

 

[dantt]

The AAO guidance is great for employed ophthalmologists who can still expect a salary or some type of protection from their employer or university. But for those of us who run a practice and have staff to support and bills to pay and/or practice in areas that are not yet affected it’s useless bleeding heart dribble without some concrete directions on how to navigate these very scary and uncertain times.

Employed ophthalmologists are not totally immune as many are per diem or payed on production. Of course not a good time to be a highly payed employee but not earning your keep either.

Interesting optometry has not made the same recommendation.

 

[LightBox]

It wont matter unless there is a federal mandated quarantine/shutdown. When I run to the grocery score, no one seems overly concerned.

 

[increscence]

It wont matter unless there is a federal mandated quarantine/shutdown. When I run to the grocery score, no one seems overly concerned.

Two wrongs don't make a right.

But also, if one business stays open while the other one closes, that still does reduce the risk of spread. Something is better than nothing.

 

[Iladelphia]

It's painful to realize how "expendable" ophthalmology has become in light of current events. I would have never thought this when entering the field some ten years ago. From an economic standpoint I can't imagine any other field of medicine taking as much of a hit. Sobering

I'm going to go brush up now on my Harrison's Internal Medicine, you know, just in case **** really hits the fan and we are called upon to help.

<insert sad face emoji>

 

[Slide]

Academic medical center - only seeing necessary injection patients, post-ops, and true emergencies. Good or bad, in retina there are some patients that I have to absolutely see that cannot wait.

To all of those who are trivializing this issue, keep perspective of all of this. Many of the patients we see are at the highest risk of actually dying from this. This is not fake news, this is not just the flu. If you look at the data from China and Italy, it is as scary as the epidemiologists say it is. Italy's healthcare has been destroyed by this and the ICUs staff are literally deciding who dies and who lives due to ventilator and staff shortages. If our patients catch it and die from coming to a routine visit just to keep the capital flowing, then morally as physicians we are bankrupt. The excuse that optometry community is not doing it does not mean we should lower our ethical standards to theirs.

If anything, you should be doing this to protect yourself because we are at higher risk:

Europe’s Doctors Repeat Errors Made in Wuhan, China Medics Say

As Europe’s daily new cases of the coronavirus now eclipse China’s at the peak of its epidemic, doctors in Wuhan -- the city in central China where the pathogen first emerged -- are seeing worrying signs of similar mistakes unfolding.

www.bloomberg.com

From a medicolegal standpoint, after the AAO/ACS announcements, if a patient comes in for a routine/yearly visit and catches COVID-19 without a signed waiver, you may be liable. One of my co-residents' dad is a med mal attorney and gave my colleagues and I this advice. Lawyers are already fielding calls about employees suing employers in health care due to lack of proper PPE in clinic visits. This all sucks, but these are also not normal times. Everyone is suffering, but this too shall pass.

 

[airplanes]

It's painful to realize how "expendable" ophthalmology has become in light of current events. I would have never thought this when entering the field some ten years ago. From an economic standpoint I can't imagine any other field of medicine taking as much of a hit. Sobering

I'm going to go brush up now on my Harrison's Internal Medicine, you know, just in case **** really hits the fan and we are called upon to help.

<insert sad face emoji>

How many patients and procedures do you think dermatology is generating right now? GI? ENT? Ortho is hurting too. It’s not just us.

 

[DoctwoB]

Literally everyone who is not a core inpatient specialty (ED, IM, CCM, etc) is going to fare poorly. Even neurosurgery is a good chunk elective. However if you’re an employed doc you can be redirected to other things like running low acuity inpatient floors and paychecks will keep coming in, even if RVUs take a haircut. If you’re running you’re own private practice it’s going to be tough sledding.

 

[dantt]

How many patients and procedures do you think dermatology is generating right now? GI? ENT? Ortho is hurting too. It’s not just us.

Dentists are taking a massive hit.

 

[Tered99]

Academic medical center - only seeing necessary injection patients, post-ops, and true emergencies. Good or bad, in retina there are some patients that I have to absolutely see that cannot wait.

To all of those who are trivializing this issue, keep perspective of all of this. Many of the patients we see are at the highest risk of actually dying from this. This is not fake news, this is not just the flu. If you look at the data from China and Italy, it is as scary as the epidemiologists say it is. Italy's healthcare has been destroyed by this and the ICUs staff are literally deciding who dies and who lives due to ventilator and staff shortages. If our patients catch it and die from coming to a routine visit just to keep the capital flowing, then morally as physicians we are bankrupt. The excuse that optometry community is not doing it does not mean we should lower our ethical standards to theirs.

If anything, you should be doing this to protect yourself because we are at higher risk:

Europe’s Doctors Repeat Errors Made in Wuhan, China Medics Say

As Europe’s daily new cases of the coronavirus now eclipse China’s at the peak of its epidemic, doctors in Wuhan -- the city in central China where the pathogen first emerged -- are seeing worrying signs of similar mistakes unfolding.

www.bloomberg.com

From a medicolegal standpoint, after the AAO/ACS announcements, if a patient comes in for a routine/yearly visit and catches COVID-19 without a signed waiver, you may be liable. One of my co-residents' dad is a med mal attorney and gave my colleagues and I this advice. Lawyers are already fielding calls about employees suing employers in health care due to lack of proper PPE in clinic visits. This all sucks, but these are also not normal times. Everyone is suffering, but this too shall pass.

What protections do employed ophthalmologists have if the practice owner regards the recommendations simply as recommendations? My employer said I would be switched to part time if I turned down routine eye exams. I'm forced to choose between doing what's believed to be best for the public health and keeping my healthcare job. Are there other people in the same boat?

 

[4ophtho]

We have to learn to work with this virus and not shut down completely. In a few weeks these government mandated lockdowns will be untenable. The economic impact will be too great to bare.

 

[LightBox]

What protections do employed ophthalmologists have if the practice owner regards the recommendations simply as recommendations? My employer said I would be switched to part time if I turned down routine eye exams. I'm forced to choose between doing what's believed to be best for the public health and keeping my healthcare job. Are there other people in the same boat?

Your boss is facing the choice of bankruptcy vs. giving you part-time work. Feel lucky that you haven't been furloughed. (sorry to be blunt)

 

[Biketrail]

The AAO recommendations lack teeth. Only when practices stop getting paid for routine visits or are clearly forbidden from doing them will practices stop providing routine care.

Hospitals in FL continued their elective surgeries for several days after ACS recommended their postponement. They started cancelling only after the governor's executive order yesterday.

 

[4ophtho]

Any suggestions from those in practice on how to keep afloat?
We are having a rotating skeleton crew come in for daily so at least our staff can receive some income. Wiping down between patients, keeping waiting room chairs spaced, etc. However, we will be operating at a negative cash flow if we see only true emergencies, which we cannot sustain.

 

[MstaKing10]

Retina only practice. Regular hours for now, seeing only injections and true ER's. Likely next week will have to work reduced hours, close a few offices and only keep a few of our "hub" offices open. May have to furlough staff. Hope we don't have to fire staff but this is possible. Tough times.

 

[deleted941485]

My RO practice is pumping along. No tiering no delaying treatment just powering through and the MBAs Love it

 

[LightBox]

Yay, you have COVID now. Good work.

 

[Dusn]

Still need to do a fair number of injections for patients who would lose vision otherwise. Re-using an N95 mask and wearing eye protection because I'm not too far from the patient's face when I do injections.

If the patient is wearing a mask, I unfortunately feel I need to make them take it off because I worry that it will re-direct their breath toward their eye and the needle and increase their chance of getting endophthalmitis. I have noticed that I feel their breath on my hand and they fog up my handheld lens when they have a surgical mask on.

 

[dantt]

My RO practice is pumping along. No tiering no delaying treatment just powering through and the MBAs Love it

Short sighted. If your old macular degeneration patients or sick diabetic patients get COVID, there won't be anyone left to do OCTs/FAs/injections on.

 

[Equality]

If the patient is wearing a mask, I unfortunately feel I need to make them take it off because I worry that it will re-direct their breath toward their eye and the needle and increase their chance of getting endophthalmitis. I have noticed that I feel their breath on my hand and they fog up my handheld lens when they have a surgical mask on.

Interesting. I used to put mask ON patients before injections so they would stop talking. Some patients think they're at a hair salon chatting with their stylist during the injection prep.

 

[MstaKing10]

Still need to do a fair number of injections for patients who would lose vision otherwise. Re-using an N95 mask and wearing eye protection because I'm not too far from the patient's face when I do injections.

If the patient is wearing a mask, I unfortunately feel I need to make them take it off because I worry that it will re-direct their breath toward their eye and the needle and increase their chance of getting endophthalmitis. I have noticed that I feel their breath on my hand and they fog up my handheld lens when they have a surgical mask on.

Totally agree. I have them take mask off for the injection, rinse then back on. I also feel air redirected towards eye. Have heard some people tape the mask on the patient before injection, so that’s an option. I’m using a surgical mask. Not sure n95 any better if we are reusing. Key is no sick patients in the office. Had a patient with a chronic cough sneak in and I almost lost it on my staff. What % of your usual volume are you seeing? I’m definitely at 50% but am surprised how many patients still want to come in.

 

[airplanes]

Short sighted. If your old macular degeneration patients or sick diabetic patients get COVID, there won't be anyone left to do OCTs/FAs/injections on.

And not just risk to your elderly patients. At least 4 retina docs in NYC are COVID+. It's hard sometimes for younger practitioners to realize we aren't invincible. The physician whistle blower in China was an Ophthalmologist in his 30s who died from COVID. There is literature showing ENT and Ophthalmologists had the highest risk of infection as well. Be careful out there.

 

[MstaKing10]

Not trying to disregard any comments or the real risks posed by this very serious pandemic we are facing, but I find it interesting that most of the "data" we are seeing comes from self reported meta-analysis, correlation studies and case studies. In our evidence based era I'm surprised by how much decision making and in some cases fear and hysteria is being driven by the weakest of evidence. Just something to keep in mind as we analyze the literature.

 

[speyeder]

Totally agree. I have them take mask off for the injection, rinse then back on. I also feel air redirected towards eye. Have heard some people tape the mask on the patient before injection, so that’s an option. I’m using a surgical mask. Not sure n95 any better if we are reusing. Key is no sick patients in the office. Had a patient with a chronic cough sneak in and I almost lost it on my staff. What % of your usual volume are you seeing? I’m definitely at 50% but am surprised how many patients still want to come in.

I'm in a retina only practice and I'm at 50% of normal volume.

 

[The Doctor]

Work in private practice as employed doctor but currently not receiving contracted salary, legally or not. Even employees getting hit hard during this time.

 

[DOCnAbox]

I work in private practice in medium-size city in the south. We have closes ASCs and not doing procedures unless emergent. We are still seeing routine patients but giving them the option of doing Telemed via Zoom/FaceTime. I recommended seeing only urgent/emergent to my employer and office manager but they want to keep practice open to avoid mass layoffs. Fortunately, patients are not coming in for the most part so we are only seeing roughly 6-10 per day. About 2 per day are urgent and needed to be seen. I am only one seeing patients right now and my boss has furloughed himself. Our staff is working part-time for now. I agreed to a roughly 50% decrease in salary to help cover staff salary and keep lights on. I have patients wait in their car if more than two in our large waiting room. Check temp on everyone. We screen all patients before they see anyone over phone the day before and at window when checking in. I have a large face shield over slit lamp that I made from plastic sheets. I have N95 mask that I wear for all patients but I don't clean it. I put hepa filter in our waiting area. I wear gloves and clean everything religiously. I try to keep visits short as possible. It makes me upset to see that we are still open as I want to be part of the solution rather than the problem but I understand the position my boss is in and that he doesn't wanna lose the practice. I am pushing telemed hard but patients are resistant to it given their age. I have been to a few grocery stores and hardware stores and many are not socially distancing themselves like they should so I have a feeling that people are gonna get it one way or another.....

 

[dantt]

surprised older patients are resistant to telemed at this time given their significant risk of mortality if they were to get infected with COVID

 

[increscence]

It's been hard to get our patients to try telemedicine as well. A lot of our patients want to, but a lot of them are also not very tech-savvy. Many don't even have smartphones or computers. Some have smartphones, but they don't know how to use the videochat software.

 

[hello lady!]

Work in private practice as employed doctor but currently not receiving contracted salary, legally or not. Even employees getting hit hard during this time.

Yikes. Sorry to hear that.

Unless you don't have a 60/90 day notification of termination clause in your contract I'd imagine this is massively illegal. Especially since there is a 2-3 week lag time behind services performed and payment from Medicare/other insurances. Your practice is still getting paid money for things you've performed recently.

 

[dantt]

Yikes. Sorry to hear that.

Unless you don't have a 60/90 day notification of termination clause in your contract I'd imagine this is massively illegal. Especially since there is a 2-3 week lag time behind services performed and payment from Medicare/other insurances. Your practice is still getting paid money for things you've performed recently.

Not illegal when the option is presented as agree to this reduction in salary or you get paid out your 60/90 days and no longer have a job after that. Many contracts even have a non compete to go with that!

 

[DOCnAbox]

surprised older patients are resistant to telemed at this time given their significant risk of mortality if they were to get infected with COVID

Yeah, it seems the elderly patients would rather take their chances with a virus than to download an app on their phone. The good news is that most of them are not coming in anyways. I went from seeing 25-30 per day and my boss seeing 40-50 per day to me covering whole practice and seeing 5-10 per day.

 

[hello lady!]

Not illegal when the option is presented as agree to this reduction in salary or you get paid out your 60/90 days and no longer have a job after that. Many contracts even have a non compete to go with that!

Well I guess it depends what the relationship is with admin/the practice and how it was presented. It sounded like the deviation from the contract wasn't discussed but rather just changed.

I didn't think non-competes when the practice lets you go were very common. If the employee gets bored and wanted to walk away I can understand it, but not if the employer fires them.

 

[hello lady!]

surprised older patients are resistant to telemed at this time given their significant risk of mortality if they were to get infected with COVID

It's been hard to get our patients to try telemedicine as well. A lot of our patients want to, but a lot of them are also not very tech-savvy. Many don't even have smartphones or computers. Some have smartphones, but they don't know how to use the videochat software.

Yeah, it seems the elderly patients would rather take their chances with a virus than to download an app on their phone. The good news is that most of them are not coming in anyways. I went from seeing 25-30 per day and my boss seeing 40-50 per day to me covering whole practice and seeing 5-10 per day.

Do ophthalmologists really provide value to patients through telemedicine? Other than triaging complaints - I don't see how we're very useful over the phone.

 

[increscence]

Do ophthalmologists really provide value to patients through telemedicine? Other than triaging complaints - I don't see how we're very useful over the phone.

You can determine some things by phone, particularly for established patients whom you know well. But it's certainly pales in comparison to an in-person visit.

Side note, I wish CMS would change the reimbursement schedule to accommodate phone "visits" better. The difference between a G2012 and an E/M 991X3 can be almost $100, but audio alone can be sufficient in certain circumstances. Requiring video to justify an E/M code in a field like ophthalmology - especially when we're all trying to make this transition abruptly and without an adequate setup - basically means doing the same amount of work for peanuts right now.

 

[dantt]

I didn't think non-competes when the practice lets you go were very common. If the employee gets bored and wanted to walk away I can understand it, but not if the employer fires them.

It goes something like this, "Doctor covenants and agrees that during Doctor's employment and Employer and for a period of x years following the date of termination of Doctor's employment with Employer, whether voluntary or involuntary, and whether with or without cause, and regardless of who initiates the termination, Doctor will note engage in the practice of medicine within . . . "

Very very bad idea for anybody to agree to something like this no matter how much you like the practice or people. And unfortunately things like this slip by contract lawyers/reviewers all the time. Probably represents legal malpractice in my opinion.

 

[OphthoApplicant04]

Do ophthalmologists really provide value to patients through telemedicine? Other than triaging complaints - I don't see how we're very useful over the phone.

Oculoplastics can do a fair amount. But it's mostly checking in with existing patients.

 

[Bgladney]

It goes something like this, "Doctor covenants and agrees that during Doctor's employment and Employer and for a period of x years following the date of termination of Doctor's employment with Employer, whether voluntary or involuntary, and whether with or without cause, and regardless of who initiates the termination, Doctor will note engage in the practice of medicine within . . . "

Very very bad idea for anybody to agree to something like this no matter how much you like the practice or people. And unfortunately things like this slip by contract lawyers/reviewers all the time. Probably represents legal malpractice in my opinion.

This language is still fairly common out there. However, more and more, I am seeing the clause change, removing the RC if terminated without cause. The flip side is that any practice can find a reason to let someone go.