Surgery and COVID-19: Three lessons that have improved patient care

Mr James Kirkby-Bott, an endocrine, hernia and general surgeon, shares his valuable insight into the lessons that have been learned from the COVID-19 pandemic and explains how surgery has been adapted for the better.

The learning experience

There has been a lot of conversation in the medical world about what the coronavirus COVID-19 has taught us. This doesn’t relate just to the use of ventilators and how critically ill people are helped; it also relates to how we manage our services and what we can offer.

As a general surgeon, I come to this from my own specialty viewpoint: How do I improve the services I offer patients despite the current restrictions? COVID-19 is a nasty disease and for every one of the 40,000+ lives it has taken in the UK, there have been scores more cruelly affected by it. When the media talks about the ‘new normal’, it is not yet clear what that is.

I’d like to share three lessons that I have learnt from the experience and how they can improve the services I offer my patients.

Lesson 1: Change doesn’t need to be slow

Pre-COVID-19, most surgeons had a way of doing things that worked well for us and that we thought gave patients a good and effective experience. As a vocal supporter of continuous improvement and routinely collecting data regarding surgical outcomes, I was already open to change for continually evolving our practice based on results and feedback.

The first lesson learnt was how an impending crisis can change a practice quickly. In the first four months of the COVID crisis, we saw many innovations that were achieved in one to two weeks but that had previously taken years to get working, for example:

• Making remote consultations possible
• Being able to write a prescription from home that arrives at the patient’s door within the next one to two days.

The old attitude to change in healthcare (why do I need to change?) disappeared in two weeks in March, as we planned how to manage the crisis.

So, the old attitude of doing what we have always done, just because it works for us, changed to one that fitted in with the concept of continuous improvement. Traditional wisdom was effectively challenged. The response and change made the next two lessons possible.

Lesson 2: Telephone and video consultations taught me that traditional wisdom can be wrong

We used to consult patients on a face to face basis - people came to see me in person from varying distances away, with the inconvenience of taking time off work and away from their daily commitments. We did this due to the traditional wisdom that face to face was the only effective form of communication.

Due to COVID-19, we very quickly switched to telephone and video consultations. I have used both and have decided they can really work effectively for doctor and patient - especially telephone consultations. The physical examination had been becoming unnecessary for some time, probably in 75% plus of my consultations. Even a groin hernia can be diagnosed in a phone call with a treatment plan made during that phone call.

Convenience for patients was another positive result. I also found that remote consultations increased the availability of potential consultation appointments. Patients and I no longer need to make a journey to have a consultation and it could happen at times more suitable for both parties.

There is one more lesson that I learnt from telephone and video consultations: It alters the doctor-patient interaction in a really positive way. The consultations became more relaxed and so answers to questions became more open and honest. To start with, it was odd but the situation forced me to learn how to make this way of consulting effective and I have found the resulting communication of a patient’s problem has become more effective.These changes have made the patient experience and effectiveness of the time spent in consultation even better than before COVID-19 for a vast majority.

Lesson 3: Hernia repair can be done better without general anaesthetic with improved outcomes

The third lesson is a much more specific one to my practice. The traditional belief had always been that hernia repair could only be reliably performed under general anaesthetic. Before COVID-19, some other surgeons and I had been advocates for performing hernia surgery under local anaesthetic. It worked when needed and opened up a simple surgical procedure to a greater range of patients for whom a general anaesthetic was dangerous, but it could be stressful and difficult.

During COVID-19, giving a general anaesthetic became more dangerous to the staff in operating theatres and significantly increased the risk to the patient receiving it. To avoid the dangerous part (general anaesthetic), we moved immediately to offering a local anaesthetic for all hernia repairs. To make the process better for patients who in normal circumstances could have a general anaesthetic, we added sedation to the local anaesthetic - this means that:

• Patients don’t need the more dangerous part (a general anaesthetic), but often still slept.
• Once completed, the patient is comfortable with no pain for the rest of the day.
• There is no ‘hangover’ effect from any anaesthetic.
• All patients could pass water (a real risk of general anaesthetic hernia repair).
• All patients were ready and able to get up and walk out of the hospital within one to two hours.

In the first four months post lockdown, I performed hernia repair two days a week. In that time I didn’t perform a single hernia repair under general anaesthetic, with happy, comfortable, well-treated patients. Again showing the received wisdom could be improved upon.

My three top lessons learnt from COVID-19:

1. Implementing change and trying innovative ideas showed that continuous improvement was possible and easier to do than imagined previously.
2. Telephone and video consultations can make communication more vocalised, extremely convenient and clearer than face to face consultation.
3. Hernia surgery is a better experience for patients when performed with local anaesthetic and sedation with fewer complications, faster recovery and available to everyone.

These are my three lessons and I am sure all other surgeons have their own too - that equates to a lot of improvement! Perhaps the real lesson will be whether continuous improvement can become the new normal?

You can receive Mr Kirkby-Bott’s first-class services for the management of endocrine diseases, hernias and gallbladder problems – visit his profile to book your video or face-to-face consultation.