Mrs. M is staring directly at me. I try to smile and look into the laptop camera to have some semblance of normalcy despite the telehealth video platform. She says, “Doctor, I am uncomfortable and I want to have a baby. How can you continue to delay my surgery? I may not have cancer, but I deserve treatment. You know I am not young anymore. I am running out of time.”
Mrs. M has massive fibroids and desires future childbearing. While she is speaking, my mind is racing. Does she have risk factors for COVID-19? What is the COVID-19 testing protocol and will she be able to complete it? Is she having any symptoms that are emergent? My department only has a certain amount of operating room time to allocate, my other patients have had their surgeries postponed since March in accordance with support from multiple obstetrician–gynecologist groups consistent with the American College of Surgeons’ and the U.S. surgeon general’s national guidelines regarding elective surgery. How can I rationalize her need for surgery amidst others with medical problems such as shoulder pain, cataracts, or even a hysterectomy?
I attempt to explain these complexities to Mrs. M. She continues to stare and says, “Do what you can, doctor.” I then speak to my surgery scheduler. Other providers are now submitting urgent surgeries for review and approval to anesthesia directly, which appears to be a mechanism to move things forward. I think to myself, “How could I not have thought of this before?” Awaiting assignments, transparency, following protocols, and expecting fair distribution of scheduling was what I had in mind, but now I have a way to advocate for my patients. I send an email request. I attach the SRS guidelines from ASRM that documents reproductive surgery as urgent. I organize (and agonize over) the order in which to put my patients week by week to have an equitable process in place. Is this a process that will be in place for months (or years) to come?
While COVID-19 has brought with it illness and policies for handling medical care, the surgical sector has struggled to accommodate care, especially for women’s health. Is reproductive surgery in someone who then needs to become pregnant a priority or is a hysterectomy in a 40-year-old with severe symptoms scheduled first? Should all services and surgeons have equal access to operating room time or should there be consideration for what has to occur after the operating room? Patients have unique needs and ovarian function decreases with age. Although we do not fully understand in what time frame this will occur and other treatments can be offered for decreased ovarian reserve such as donor egg or donor embryo, these treatments can be costly and are associated with socioeconomic disparity in the ability to administer them and the ethical principles that couples face in discussion of such treatment. My requests that put these patients at the forefront make me feel like the bad guy as instructions are given on how planning needs to be equitable among all members of the department. My feelings of doubt for doing what would typically be the right thing for patients creep into my psyche.
Meanwhile, a nurse practitioner stops by to query me on how she feels uncomfortable refilling birth control pills without blood pressure measurements for virtual visits that are being planned. Are annual exams (that include contraceptive counseling) a part of care that should continue right now? Contraception, pregnancy termination, vaginal burning or pruritus—how and who says which are too important or too insignificant to merit an evaluation?
And why am I coming up with so many questions and not the answers? Am I not being reasonable in terms of considering personal protective equipment, the need to continue preparation for a second wave of infection, appropriate use of resources, or ICUs and SICUs? But then Mrs. M returns to mind. The patients are the ones to advocate for and they trust us to have their best interests at the forefront; this is the reason for my entry into the medical field.
I pull out a list of all my surgery patients who have been cancelled. I re-evaluate the order in which I have placed them. I hit send on an email requesting they be considered for surgery with the rationale for doing so, especially in the setting of desiring future fertility. I am anxiously awaiting a response. Will my priorities be deemed correct during a time in which neither of us have control? For the sake of my patients, I hope so.
Stephanie J. Estes, M.D. is a professor in the Division of Reproductive Endocrinology and Infertility, Director of Robotic Surgical Services, Director of Outpatient Women's Health Services, and Director of Andrology Services at Penn State Heath in Hershey, PA.
Disclaimer: The thoughts and opinions in the Frontline Voices initiative reflect experiences of individual ACOG members and do not represent official organizational opinions of ACOG.