SPECIAL EPISODE: Private Pain Practice Response to COVID-19 w. Dr. Timothy Deer

This week I’m joined again by Dr. Timothy Deer to discuss his practice’s response to the COVID-19 pandemic.  We discuss how they quickly migrated to telemedicine with the help of his staff, how the clinical approach has changed, and the different responses other practices across the country have taken to try to cope with the current situation.

Justin (00:00)
Hello and welcome to this special episode of anesthesia success. I’m pleased to be joined by dr Tim Deer. Uit is his second time here now, so that officially makes you a friend of the show, dr deer. Uhe is the president and CEO of the spine and nerve centers of the Virginias, obviously a key thought leader in the pain community. And I wanted to get his thoughts on how we see currently navigating these crazy times with coronavirus and understanding what is the role of a interventional pain practitioner with the interesting times in which we live. So, dr. Dear, thanks for joining.
Dr. Tim Deer (00:55)
Well, thanks for having me. It’s certainly a, an important time in history for us to talk to each other and continue to while we were socially apart that we continue to socially engaged. So thank you for having me.
Justin (01:06)
Yeah. So just tell me a little bit about kind of what’s on your mind right now. What are the things that have your attention as a physician and as a business owner?
Dr. Tim Deer (01:14)
Well, I think number one, you know, I think we have to be really aware of our local surroundings, where we are and think about our families and friends and make sure everyone’s staying at home as possible. And social distance scene. So number one, we’ve got to take care of our families. And number two is healthcare providers. We have to take care of ourselves because if we get ill, we may take that disease home to our loved ones. So that becomes more important than everything else. And to be engaged with patients in whatever fashion that may be. And as you know, many anesthesiologists, they’ll listen to you. And also our pain physicians as well. So there’s all these different hats people are wearing, but number one is to be a good shepherd of your, of your people in yourself and health. Cause if you’re unhealthy, nothing else will model.
Justin (01:57)
That’s right. And is there anything specific you’re doing right now to try to be extra attentive in these ways?
Dr. Tim Deer (02:02)
Well, absolutely. You know, we we’ll meet, do any type of urgent things here at the hospital or have interactions. We’re doing mostly tell the medicines. We’re not really interacting in person with very many people, which is a good thing for both the staff and the patients, right? But when there’s an urgent procedure, we’re doing no electric procedures at all. So that’s also reducing our use of PPE and our use of O ours. But we are doing some urgent things. For example, I understand someone a moment ago had a herniated disc and she really needs surgery probably, but they didn’t, they’re trying to avoid back surgery. And so we you know, the patient has to be consented, that it’s an urgent procedure and that they’re in severe pain and they can’t wait a month or two, which is what we be able to need to do.
Dr. Tim Deer (02:41)
Maybe three, we’ll see how long this goes. But when I, when I leave, I come to the facility in my street clothes, I take those off, put those away, put on a long sleeve productive gear and then, and scrubs and where my in 95 mask and the scrub mask over it to try to preserve it cause we don’t have very many of those. And then if I’m engaging with a patient, but then when I, before I leave, I’ll take off all those materials. But the minute dirty receptacle, they call them a Marsh really. And then I’ll take a shower at work and put on clean clothing. And when I get home I leave my shoes outside because certainly we can track in this virus into your, into your house or pets can get on their, on their feet. And so many ways as far as has been shown to spread around the world. So yeah, I’m really trying to engage in all those good, best practices and those are important.
Justin (03:28)
Yeah. And you mentioned telemedicine. I’m curious, this is probably something that for most practitioners out there was like an ancillary consideration mostly in rural areas and sort of like a something that was a very small minority of the way that you would provide care. And now it’s like such a major part of things. Talk to me a little bit about how you scaled that or did you have to initiate it or,
Dr. Tim Deer (03:48)
Yeah. Yeah, it’s pretty, pretty fascinating actually. You know, so we never had that before. You know, I’ve never had the capability. And then when we realized that we, that people need a social distance a few weeks ago I’m going to have to get credit to a couple of our team Ashley Comber or a nurse practitioner who’s amazing and Stacy wide who runs our clinic. They were here all weekend setting up doxy.me, which is a home telemedicine service. And by Monday we decided to do this on a Friday. By Monday it was fully up and running and I embraced it. You know, it’s like, it’s like, you know, 15 years ago when I embraced electronic health records, all of my colleagues thought it was too burdensome and I embraced it right away. And so I embraced tele health and our patients really like it. You know, we’re doing some exams, if you will, on the phone watching people walk around Ben new twist and talking with them and we’re seeing, you know, we’ll, we’ll schedule something eight weeks from now, 12 weeks from now for you. So I think that the transition to telemedicine has been really easy and you know, I think if you’re not using it in your practice, you’re really missing out on helping people. So our whole team has engaged with that. Now we’re trying to see no one in the office unless they have an urgent procedure. Yeah, no one at all.
Justin (04:58)
So it sounds like within the course of just a weekend, you were able to scale up to be able to provide sufficient capacity for anybody who needed telehealth services.
Dr. Tim Deer (05:09)
Yes, we had all four of our physicians or our four extenders or the whole team. I went to telemedicine and within three days. So if someone says it’s too hard to do, then they’re, they’re not, they don’t have the right people on their team to do it. Now I give myself no credit for that. It was my team that did it. But, you know, I really, I really realized very quickly that was the best thing to do for our patients, to keep them safe
Justin (05:29)
From a hardware standpoint. Is that as easy as like buying a stack of iPads and given one to everybody?
Dr. Tim Deer (05:35)
No. It’s easier than that. I can do it off my computer. I use every day and we have you know, there’s a HIPAA compliant, there’s different HIPAA compliant tools that the patient gets in a link, they click on it. If they have a phone that has a camera or a computer that has a camera and you can immediately see them and talk with them. And even in rural areas like West Virginia, we’ve had great success with that. Most people have some, some form of internet service with a camera. If not, then in the federal government and the state government has relaxed some of the rules about seeing people. We’d prefer to see you and talk to you and Abe or do some sort of exam via video. But if we can’t, then we’re allowed to talk with you instead and then that’s, that’s not as good, but we’ll take it, you know, it’s better than making someone come in, you know, 70 year old person come into our office is not good unless they have a real reason to be here.
Justin (06:23)
Right. Have you found that the regulatory environment has been able to adapt quickly enough to be able to give you the latitude that you as a physician need to get people care in a timely way?
Dr. Tim Deer (06:33)
I think so, yeah. I think the, I think both the state and federal government have done a really nice job of really surprisingly, you know, most things are bureaucratic as you know, and terrible. It takes 10 years to change something. But both the state of West Virginia and the federal government have done a very nice job, I think of helping us with regulatory limits on both HIPAA where you can actually do things like phone calls and things and things like billing for virtual phone calls and videos and, and you know, being able to prescribe about seeing someone versus, you know, send them a person. You know, now I’m working with a lab to start looking at some home lab. You’re in toxicology and biomarkers at home. I mean, those, everyone’s adapting. It’s, it’s been a while. It’s a tragic time and very petrifying for all of us. It’s at the same time it’s pretty encouraging the human spirit that we’re adapting so quickly and a lot of ways.
Justin (07:24)
Yeah, it’s funny. I think the, the American ethos in this instance is kind of a two edged sword. We look at somewhere like South Korea where they have very quickly had like, I think a pretty unified response. Plus they’ve been prepared with these types of events in the past where here in the States where like ruggedly individualistic has kind of hardwired into us. And so it’s, I think from a public health standpoint, it’s difficult to have a unified response in some ways, but it also provides opportunities for creativity, problem solving, people solving problems in new and exciting ways. And that’s, that’s kind of fun to see from a human standpoint. I think.
Dr. Tim Deer (07:57)
Yeah, I think it’s going to change what we do with longterm. I think there’ll be a lot of patients who live, you know, three or four hours from me that have to drive so far cause we’re kind of a tertiary center that we may do their, their, their future visits by telehealth as much as possible, you know, because it’s so much easier on them and so, so much more cost effective for them. And so I think it is going to change a lot of things. We do. And it’s funny what you said about the individualism of American, you know, as you know, many parts of the country have responded differently or seen. And I think it’s real important that we don’t criticize each other. You know, some people on Twitter for example, or for this thousand people for being true to a paranoid and other people could still do Rubin being not turning enough. And I think we just need to educate, not criticized. And that’s what I’ve been trying to try to tell my young colleagues, is this, this edgy. If you think someone’s doing something stupid, don’t criticize them. Educate them. Right? Because if you criticize them, they’re going to fight you back. But if you educate them, maybe they’ll learn, right? That’s what we’re hoping.
Justin (08:52)
And the truth may be somewhere in the middle. And I myself have been somebody who’s had to intentionally unplug from med Twitter periodically just to maintain my sanity.
Dr. Tim Deer (09:00)
You’re a smart man. You’re a smart man. I think the truth, probably, I’m a, I’m a locked down everybody type guy person. But you know, that’s, that’s just me. And that doesn’t mean I’m right. But that’s, that’s where I’ve been. I’ve been paranoid from day one. I’ve been told by my friends. But yeah, it is a, it is a good time to be turned away when there’s a pandemic. Right?
Justin (09:16)
Yeah. And I’ll tell you, I’m over here on the Eastern seaboard in Philly, we’re looking up to New York and we’re like, we’re just kind of waiting for the tsunami. And I, I certainly kind of feel similarly. Absolutely. So I’m curious, you know, as a, so obviously you’re a practitioner, you’re doing procedures for patients, but you’re also a business owner. You’re an employer, you’re somebody who sort of has people that you look after and care for from an employment standpoint. So this as a business owner, this is a a crazy time. I mean, there was this stimulus bill that was passed on Friday. Many of the implications of which we’re still figuring out what it all means. So for the practice owning physicians out there who are looking at their revenues, getting crushed because of elective case volume dropping and having to adapt. But I know you’re not making as much on telemedicine as you’re, as you’re doing, doing implants and how, how are you thinking about this? What’s on your mind and how are you kind of preparing and trying to equip and adapt to be able to give yourself as much runway as possible, to be able to do the best you can as far as compensating and employing and knowing that it’s a tug of war and that patient volume eventually will come back. But it’s kind of a war of attrition to some extent.
Dr. Tim Deer (10:23)
Well that was a long question that rightfully so. It’s very complicated. So I’ll talk, I’ll talk kind of in generalities a little bit cause I’m talking to a lot of people around the country, you know, and so I’m getting phone calls every day, you know, I would love to hear while we’re here. So you know, so there’s a variety of responses. So let’s go through those variety of responses and then I’ll give you kind of a generic answer of what could be done. We’re not doing, you know, I know there’s still people out there doing implants and things. I think it’s a mistake right now because if you get an infection, they have to go in the hospital, you’re going to have to deal with an inpatient in a COBIT hospital, taking up resources, but also putting everyone in danger, including yourself. So I’m doing no implants, no Virta flags, no aside fusions, no.
Dr. Tim Deer (11:04)
You know, any requires incision or anesthesia or an or blood transfusion. I think we should not be doing that would be my recommendation to everyone. Not that I’m the world expert, but I just, I’m watching what’s going on around the country. So, so no electric procedures of any type. And then you have emergencies where you have an infected pump, a pump that’s going to die with Baclofen where someone may go on just terrible, you know, withdraw from backwards. So those are cases you have to do is you have the those tunes in spectrum elective we shouldn’t be doing. And then you have the emergency you have to do then. And that requires an O or usually an and she told us even though you have to do it, you really need to do everything you can to avoid that one too. Anything that requires potential blood transfusion or anesthesiology being needed, I think we need to really be good citizens.
Dr. Tim Deer (11:48)
I’ll get back to your business question in that. This is framing, I’m framing this for you and the business side. You think about an elective, a small procedures. We do, you know we’re doing about 10% of those right now because patients that are, you know, when we talked to them about something, we’ll say, you know, is your pain severe enough that you can wait eight to 12 weeks to have whatever it is, you know we need to do done and the patient can wait eight to 12 weeks and then they should wait for sure. Right. There’s no doubt about it. But then some people will say, if I don’t get something done in the next two weeks or four weeks, I’m going to have to go to the emergency room. I’m miserable. And what we don’t want as people, you know, flooding the emergency rooms right now with chronic pain that kids acute flare up.
Dr. Tim Deer (12:26)
So, so the patient feels their pain is so severe that they can’t function or take care of themselves, take care of their daily needs and they live alone. They can’t Coker stand. And I think it’s reasonable to do a procedure in those people that would be an urgent procedure based on the CMS guidelines. But then they have to sign a consent that they realized that their pain is that severe and that they know that certainly coming into any facility, but it shouldn’t be an orange and only be in a procedure room. It shouldn’t require anesthesia and it shouldn’t require any type of resources that we might need for PPE. Now that’s where, that’s where asthma came down. I think they came down correctly there, you know, acute bone fracture to just, you know, chronic conditions with severe acute flare ups. I think all those things are very reasonable so that that means you’re doing 10% of your normal volume with the, with the staff of the same number of people.
Dr. Tim Deer (13:12)
So right now I’ll get to the business part of what people are doing. So it’s a very long answer, but I think it’s a complicated question and I’m giving kind of an overview and then I’ll, I’ll, I’ll give you about two minute answer on the next part and then we can go back into discussion. Option one, some people have closed their practicing down and they’ve laid people off permanently and they’ve panicked. You know, and I think that’s a bad mistake because I do think in 12 weeks or 16 weeks it is going to come back to where people need us. And if you’ve been in your home, not moving, you’re gonna get stiff and be in a lot more pain than normal. And so I think more people may need us an ever in three or four months. So I think to close your practice down, call it a day until you’re going to restart later as a bit of an overreaction that may hurt everyone in your community, including those who have acute urgent needs right now because you may be able to keep people out of the church grew up, remember back surgery or the ER admission, right?
Dr. Tim Deer (13:58)
So, so that’s one extreme. The other extreme is people doing everything is normal. That’s, that’s a good business model. Short term, a terrible, terrible person model, right? You don’t want to do that. That’s a terrible mistake. So in the middle, you know, people like us, we’re seeing people lay off some furlough, some their staffs. If you furlough someone, and some States, obviously it may vary from state to state, they can keep their benefits, but they can go on unemployment for three months or whatever that may be. And that’s one model we’re seeing for some employees model two is they keep every one that they cut everyone’s salary, you know, and try to keep as many people on the payroll as possible, but realizing no one’s going to make what they would normally make. And that really comes back to how long you have resources to survive.
Dr. Tim Deer (14:37)
And then the last thing that I think is important, and you mentioned this Justin, it’s important that is these federal small business association loans. And if you can get one of those, I think you might be able to keep people on a salary. They can at least pay their bills, even even your employees that you know, may not be utilized right now because of the restrictions. But you know, and that’s part of the forgivable loan program. If you can bring back the physical therapist you’re not using right now and, and, and pay them a salary that keeps them where they can pay whatever necessities they need. I think to me that’s going to be the way to go to keep our economy and our medical healthcare coins. So that’s what we’re trying to do. We’re, we’ve applied for several small business administration loans and our goal will be to bring every single employee in bender furlough a few folks right now, but we want to bring everyone in the next week or two hopefully in which that loans and intact and, and hopefully keep them whole. And then when this is over and we go back to normal policies and I think we’ll be able to number one, make sure our community’s intact, but all number two will be helping people’s families. And that’s really what I’m hoping.
Justin (15:38)
Yeah, that makes a lot of sense. There’s a lot more review into, but I know we’ve got a few other things to cover. I wanted to keep it moving. I’m curious from a, like a resources standpoint, can you talk a little bit about the role of the ASC versus the hospital as far as doing these urgent procedures? And is that something you thought about at all?
Dr. Tim Deer (15:54)
Well, so you know, the, the question is why are they a C is do only electric procedures. So a lot of those AFCs are gonna have to close because they don’t do urgent procedures. They do electric procedures, you know, and so I think that’s what they’re going to have to really figure out. Are they doing things that are truly urgent? So and, and I think if they are that’s fine. But they usually have the Cesia or an O or that can be used for other things and probably it’s not a good use of resources. Now if you’re in a hospital facility and there’s a, or you definitely don’t want to use that for anything at all, if you can help that either. Right. So I think, I think hospitals and AFCs both if they, or it could be used for, for other, other things in, in a high impact areas like New York city or new Orleans or Miami, unfortunately as it gets worse.
Dr. Tim Deer (16:38)
And you definitely should not be using those rooms. If you have a procedure in the hospital where you have a team that can talk to the patient detail, make sure it is urgent. That’s what we’re doing. And every single person that would do anything with at all. Now is it really urgent? And if it really is and that I think that’s very acceptable. Knowing the patient is concerned that they have a risk of coming outside of their house. Right. Cause they get they, they’re not social distancing. But I think AFCs are in general going to be mostly closing in American and high endemic areas because they’re going to need the resources that would be used there, the PPEs anesthesiologist. So I would be shocked if mini antsy stay open over the next two to three months. They will most probably mostly all close hospitals that have procedure rooms that are not, or rooms this were probably urgent procedures can be done or in someone’s office. But they have an office that requires minimal PPE and minimal resource use. I think that’s where that should be done if you’ve done it all.
Justin (17:31)
Okay. I haven’t conversations with a lot of fellows right now who are, you know, we’ve maybe been looking at contracts together for the last couple of months and now all of a sudden the way that we’re thinking about a prospective job offer is totally different because the response of a practice to the current situation, what you just gave us option one and three, either they panicking close or they furlough and try to make it work or business as usual. I think understanding how the practice is responding probably goes a long way towards describing the future potential employment experience of somebody looking at an opportunity for like August, September. I’m curious, what advice would you give to a fellow who’s trying to figure out what they’re going to do after fellowship?
Dr. Tim Deer (18:12)
So you know, Aspen has a webinar tonight and there are certain pain nurse answers. So I have found that we’ve talked about before. We have a webinar on this issue. We have a forum for fellowship directors, we have some fellows and recently graduated fellows. It’s petrifying if you’re a fellow right now, right? You know, are you going to be a call to the or because you’re an anesthesiologist or you call it the ICU cause you’re an anesthesiologist, you know, a physiatrist and may be a little bit different cause they don’t have the anesthesiology ability. But it is scary where we have a, a physician joining us and we’re gonna honor her contract. Totally. we have some, some help from our facility, our hospital to help us do that, which was very nice. Not everyone has that ability. So if you’ve, if you’ve entered a contract with a group and you know, times of emergency contracts, we’re pretty imbalanced because I don’t think any judge would hold that contract up in this situation.
Dr. Tim Deer (18:58)
Right? So I think what you probably need to do for a fellow right now, we need to contact the leader of the group you’re joining. She or he, you know, what’s my status? And there is some options. You know, universities have some research type jobs. They pay about 200,000 a year and they you work one day a week clinically and four days a week during research. And those, those are available at some major universities. So you can talk to, you, maybe can talk to your fellowship director about that. There’s some part time jobs out there where they need some, some help, you know, and they need some help with anesthesia, the anesthesiologist support to the ICU and you can go to you know, to Omaha, Nebraska and do some pretty awesome. That’s right now that’s getting kind of busy cause the anesthesiologists are pulled to the ass for use.
Dr. Tim Deer (19:39)
That’s a way to make a living obviously. And then thirdly, you know, you might be fine and you may have to be willing to take a lower salary. That’s a, you agreed to take, you know, X dollars. If the group says we’d still like to have you come but we’re going to be really in bad trouble for three months, you might go and stay on your fellowship salary for the first three months for that new group, you know, just to take you pay me what I was making in fellowship and, and, and help you to be part of the team, the solution then. So then they’re still glad to have you. They’re not resentful to you cause you were trying to get your full salary and and then at the end of the three months you can have an agreement that my new contract starts that day. That’s another way to do it, I think. And I’ve heard it a couple of groups that are offering fellows to honor their job, but they can’t pay them a salary they agreed to. And I’ve heard a couple of fellows who’s accepted that as a, an offer, but then they get a new contract that says, okay, November 1st rent started new original deal. And so all you’re doing there is you’re really continue your training. Right. If you go towards some experienced people, maybe they can help you get better at some of the procedures you missed. Yeah.
Justin (20:37)
Makes sense. I got one last question and then we’ll close with, I know we’re coming up on time here and I appreciate your giving us a few minutes generously running out of the Orr to jump on the phone here. So I anticipate, it sounds like you do as well. There’s going to be all this pent up demand in a few months from all these people that are going to have to defer care. And then in the fall whenever it happens, there’s going to probably be a surge. And not only is there going to be more patients but there may be less practices because of the current turmoil. So for physicians who are trying to be forward thinking and position themselves for growth and scalability and to build in capacity, what types of things are you thinking about or would you recommend for either an individual doctor or for a practice to be able to defer for awhile and then to address a big, a a much higher patient volume?
Dr. Tim Deer (21:23)
Well I think you know people are going to suffer cause it cam something done, right? So let’s say for example, you had two back surgeries, your leg is killing you, you had a simulation trial done. You know by me, I have two patients like that. We did a DRG trounced syndrome before this hit and there worked great for them and they had hope like, Oh I’m going to be getting relief. And now they can’t have their procedure done probably for a couple of months, maybe three. And so they’ve been calling Tim are miserable, but it doesn’t really meet the criteria for urgent because it’s, you know, I’ve had pain for a year, right. So it’s not an urgent thing. So it’s really difficult. So when that, when we get this, this situation improving, I think what were you doing? And I’m not saying we were the, were the smartest tools in the shed, but we were pretty good at this.
Dr. Tim Deer (22:02)
We’re using our, our apps are advanced practice providers and you know, our nurse practitioners I mentioned actually earlier in a couple of different practitioners with us who were using those folks when their skills and their talents to do a lot of our follow ups, our new patient visits in the short term as we go forward. Because we’re going to need to be doing more, more procedure time. So I think where we really think that we’re going to, we’re going to have such a pent up demand and people who’ve been miserable. Now we’re going to need to be probably available for procedures four days a week when this is over just to, just to catch up on where we would have been for patients who had been suffering. And then after we get, I think three or four months back into the normal realm, we’ll go back to normal practice.
Dr. Tim Deer (22:38)
But I think if you are blessed to have good and advanced practice people in your group, they can be very, very helpful to the situation. And I think so those you have that you’re in good shape if it’s physician only. And unfortunately I think you’re, you know, you’re going to see patients have to wait a long time to get care and that’s bad for the patients. Certainly the physician will be very busy when this is over, but I think the patient will have to wait a long time because you can only do so many procedures in a day safely. Right. So it’s one of those things, so it’s going to be complicated, but for us it’s going to be app based teamwork to get this done.
Justin (23:11)
Yeah. Awesome. Well. We’ll close with that. Dr D, I really appreciate your time. Thank you for joining us today and thanks for offering your, your perspective is always appreciated.
Dr. Tim Deer (23:19)
Great to talk to you again and anytime and God bless. Stay safe up there in Philadelphia. Thanks very much.