29 May Jonathan Cartu Report: Michigan doctors and dentists sidelined by coronavirus
When a dental bridge fell out of his mouth in mid-March, Bob Swicker was left without five front teeth and no way to get it immediately fixed.
Swicker was switching to another dentist after his long-time dentist had retired. But the process stalled with the statewide shutdown of dental offices forced by the coronavirus crisis.
So Swicker, a 75-year-old Bloomingdale resident, has been living without front teeth for the past two months. He’s not in pain, he says, but it is hard to eat properly.
Relief is now in sight for Swicker and thousands of Michigan residents who haven’t been able to obtain timely health care because of the pandemic: As of today, May 29, Michigan hospitals as well as doctor, dental and veterinary offices once again can provide the full range of services, with the lifting of restrictions put in place March 21 by Gov. Gretchen Whitmer.
“We’re ready,” said Dr. Steve Meraw, a metro Detroit periodontist who also is president of the Michigan Dental Association.
But, he and others say, it will not be business as usual. The pandemic means a new normal for health-care providers, impacting everything from scheduling, to check-in procedures, to required use of masks by providers and patients.
“For patients, it’s going to have a different feel and a different look,” Meraw said.
Patients should expect, for instance, to be asked screening questions in advance about whether they have specific symptoms of COVID-19 or been exposed to the virus. When they arrive for an appointment at a medical or dental office, the waiting room likely will be off-limits. To maintain social distancing, patients typically will be asked to call the office when they arrive and wait in their vehicle until they can be escorted directly into an exam room.
Doctors, dentists and other staff will be wearing personal protective equipment such as masks. Dentists as well as some doctors also may be donning plastic face shields to protect themselves from the virus. Hand hygiene will be stressed. When the appointment is over, the checkout may be done in the exam room or perhaps after the person has returned to their vehicle.
Behind the scenes, there will be a huge emphasis on regular deep-cleanings and other infection controls, such as daily temperature checks of employees, to protect staff and patients.
Dr. Sheila Armstrong, a Southfield dentist and president of the American Dental Association, said exam rooms in her office will be cleaned between each patient and those cleanings won’t even begin until 15 minutes after the patient leaves to ensure that virus isn’t hanging in the air. She’s also looking into air purifiers, and said she anticipates that some dentists and doctors who own their offices will be looking to upgrade their ventilation system.
“First and foremost in our minds is doing everything to make sure that people are safe,” Armstrong said.
And many patients are anxious. As much as Swicker would like to have his bridge replaced, he’s not angling for an immediate appointment.
“What I’m worried about is that the dentist is working right in your mouth. You can’t do effective social distancing,” he said, adding he has multiple health issues that put him at particular risk if he catches COVID-19.
“I’ve had bypass surgery,” he said. “I’ve had a stroke. I have hypertension that is controlled by medication. I’m 75 years old.
“I want it to be done,” Swicker said about the dental work. “But I want it to be safe.”
Whitmer’s executive orders
Whitmer announced May 21 that non-essential health-care services could resume as of today, May 29. That announcement came after several weeks of pressure from the state’s health-care organizations.
They supported Whitmer’s decision to shut down non-essential health-care in March, but say the shutdown has gone on long enough.
Whitmer’s March 21 executive order banned hospitals, outpatient medical facilities and doctor and dental offices from performing surgeries and procedures that were not time-sensitive.
The order, which followed a recommendation from the federal Centers for Disease Control, specifically exempted cancer testing and treatment; procedures for advanced cardiovascular conditions; organ transplants; dialysis, and other medical care deemed immediately essential.
The order had several objectives. One was to conserve resources for COVID-19 patients, including emergency-department personnel and ICU unit beds and personnel, as well as surgical masks and gowns that became in critically short supply. Another was to protect non-COVID patients from possible infection by the virus.
The executive order “made sense,” said Dr. Bobby Mukkamala a Flint ear, nose and throat specialist as well president of the Michigan State Medical Society. “We had no idea where this was going to end up, and we were on the exponential growth side of the curve. So the thought was, let’s just put a lid on anything that doesn’t have to get done.”
In fact, Meraw said, the Michigan Dental Association was pushing for the executive order because dentists were hesitant to operate as COVID-19 cases were surging, and the executive order made the dental offices and their staff eligible for unemployment and other financial benefits available through the federal stimulus packages.
But by the end of April, it was apparent that coronavirus had peaked in Michigan and the shortage of personal protective equipment had eased as well as the strain on hospitals.
Moreover, the weeks of canceled surgeries and appointments created a substantial backlog in the health-care system, and also created substantial financial problems for Michigan hospitals and practitioners. Terminating lucrative non-emergency services while prioritizing the treatment of COVID-19 patients left hospitals strained for cash while they are most needed, resulting in layoffs and furloughs across the state.
At a May 1 press conference, Whitmer and Dr. Joneigh Khaldun, the state’s chief medical officer, urged health-care providers to begin the shift back to normal operations, and encouraged patients to reach out to their doctors to reschedule postponed medical procedures.
But even as Whitmer and Khaldun stressed that doctors had discretion to move forward, Mukkamala said that some hospitals and doctors were hesitant, noting that executive order was still in place.
“We saw a lot of people interpreting things differently,” Mukkamala said. “I’m on staff at three area hospitals here in the Genesee County area. One said it’s OK to start doing non-emergency ear, nose and throat work. Another hospital didn’t feel comfortable doing anything other than the strictest interpretation of the original executive order. So it was just left a lot of decision-making in the hands of individual facilities, which added to the confusion.”
Moreover, Whitmer — whose husband is a dentist — made it clear that dentists were still limited to performing emergency procedures only, noting dentists are a particular risk of coronavirus because they are working in patients’ mouths, the source of person-to-person transmission for coronavirus.
Meraw said that Whitmer pulled together a task force to develop best-practices for the Michigan’s dentist offices.
“We were holding on with bated breath, hoping it would be implemented right away,” he said. “But I also know she has a lot going on, and we’re just very happy and thankful the order finally came out” lifting the restrictions.
Dealing with the backlog
It’s been more than two months since Dr. Joseph Kirkwood has filled cavities or performed checkups in his Grand Rapids dental office.
He held a workshop Thursday for his staff to review new policies and procedures, and is spending today and Monday getting the office ready for patients. The official reopening is Tuesday, June 2.
“We’re going to be starting a little slower, having more time between patients at first — just to be able to know that we’re putting all our gear on properly, taking them off with clean hands and just trying to get everybody on the same page,” Kirkwood said.
As relieved as they are to get back to work, Kirkwood and others say health-care providers are facing several challenges as they reopen their offices.
One is dealing with a two-month backlog of canceled appointments. While some doctors, such as pediatricians and gynecologists, have been able to keep many of their patient appointments via telehealth services, many others largely shut down their practices, and most dentists closed their offices.
But catching up on cases is complicated by the need for deep-cleaning and other infection-prevention controls. That means doctors and dentists need to schedule more time for each appointment or procedure.
Mukkamala said he has a backlog of 120 surgeries, most of them tonsillectomies.
“The efficiency of the operating room is much less now because they need to sterilize the rooms in a much more thorough way,” Mukkamala said. “So whereas I used to schedule 20 procedures on a Thursday, they’re now limiting me to 10. And there are also new patients coming in, so it will roughly take me the rest of the year to catch up.”
Kirkwood, Mukkamala, Armstrong and Meraw all said they’re likely to expand office hours and/or days to help address the backlog. But they also said they’re looking at “soft” reopenings to help acclimate themselves and their employees to new protocols and procedures.
“We plan on seeing just a few patients this Friday, and really just doing what we call a soft trigger, slowly opening,” Meraw said about his dental practice. “Just to make sure everyone’s comfortable — that we’re comfortable with all the new guidelines, that patients are comfortable with the safety protocols.”