Joshua Jennings, M.D., Cowen’s Medical Supplies & Devices analyst speaks with
- Antonia Chen, M.D., MBA,Brigham and Women’s Hospital, Orthopedic Surgery, Director of Research, Arthroplasty Services; Associate Professor of Orthopedic Surgery, Harvard Medical School
- Charles Kanaly, M.D., FAANS, Saint Anne’s Hospital, Chair of Neurosurgery; Medical Director, The Spine Center at Saint Anne’s Hospital
- Brian Whisenant M.D., F.A.C.C., F.S.C.A.I., Medical Director for Structural Heart Disease at Intermountain Heart Institute; Adjunct Associate Professor of Medicine, University of Utah School Of Medicine
Discussion centers on how hospitals are planning for the potential increase of COVID-19 patients and how their administrations are prioritizing elective procedures in each vertical.
Press play below to hear the full discussion.
Speaker 1: Welcome to, Cowen Insights, a special look at the Coronavirus and its effects on sectors across the economy, as well as the policy arena. You will hear the latest insights from leading experts about where things stand and what’s around the corner.
Josh Jennings: [00:00:30] The first panel of the day, going to help us dig into a major concern throughout the medical device industry, which is, what is going to happen to elective procedure volumes in the United States? So let me introduce our expert physician panelists. We have Dr. Antonia Chen, orthopedic surgeon from Brigham and Women’s Hospital, director of research in arthroplasty services, associate professor of orthopedic surgery at Harvard Medical School. We have Dr. Charles Kanaly, a neurosurgeon specializing [00:01:00] in spine at St. Anne’s Hospital. He’s the chair of neurosurgery, medical director of the Spine Center at St Anne’s Hospital. And Dr. Brian Whisenant, interventional cardiologist, he’s medical director of structural heart disease at Intermountain Heart Institute, and adjunct associate professor of medicine, University of Utah School of Medicine. Thank you three for joining us. We’re very excited to have you here and to help us navigate through some challenging topics.
Maybe we could start with you, Dr. Whisenant, just about [00:01:30] your hospital’s current policy on elective procedure postponement or cancellation. It’s our understanding that the partner system in Boston, where Dr. Chen works has put out a formal policy, but just wanted to get updates on the status at Intermountain.
Dr. Brian Whise…: We also have system-wide cancellation of elective procedures, and our hospital’s quite quiet, and we’re really not doing a lot. That went into effect on Monday. We’ve also scaled back our clinics dramatically, where patients [00:02:00] are being contacted and encouraged not to come unless they feel like it’s essential.
Josh Jennings: Thanks. Dr. Kanaly?
Dr. Charles Kan…: Yeah, good morning. It’s been a definite process that’s in flux. It’s actually changed last week. I’m in Massachusetts, but I’m more community-based, I’m not in the big Boston area, and so last week, it was still a routine, normal schedule. I know a lot of the bigger university hospitals had already canceled elective cases, but we [00:02:30] had not. Most of my healthcare system had not steward health care, but then over the weekend, so it was just a couple of days ago, the governor actually tried to clamp down on this, and told all the hospitals they have to stop elective surgeries. It wasn’t very clearly defined what that meant, and it was supposed to go into effect as of last night. So Monday and Tuesday was still pretty routine schedule at the hospital, but now it’s really dropped off dramatically. It’s changed. It’s still being worked out what exactly qualifies as [00:03:00] a necessary surgery or not.
So first the healthcare system had put out a memo saying, “Well, we can’t make that decision. It’s a decision between the doctor and the patient,” but then people were still trying to book very routine, small, lipoma excisions and all these things, and insisting that this was critical. So now it’s actually become more of a top-down thing where they’re reviewing every case that they try to book. Actually, the head of anesthesia and the chief medical officer are going through and reviewing. You have to basically get their approval to do the surgery. [00:03:30] So it’s really dropped off to much more critical things only.
Josh Jennings: Thanks for sharing that. And then, Dr. Chen, if we could hear about what’s happening at Brigham and Women’s Hospital?
Dr. Antonia Che…: Interestingly enough, we actually had elective cases at full steam ahead as of last Friday, and the Surgeon General came up and said that we should not have elective cases of
. The Surgeon General is actually an anesthesiologist, which is ironic. And based on that, we were toying with [00:04:00] the idea, starting Wednesday, but the leadership didn’t actually come down to it until Friday, around 4:00 to 5:00 PM, where they wanted to make a complete, system-wide shutdown of elective cases.
So in orthopedics, what that means is, patients who have fractures or bone breaks, infections, tumors, or certain emergency spine cases can go in our hospital. That is not Partners-wide, that is what we elected to choose in our department for orthopedics. So barring [00:04:30] all of those, all elective cases had to be canceled, starting Monday of this week. So we’ve had no elective cases this entire week. Again, there’s emergent cases could go on. And this is actually spreading to our clinics as well, too, in that we are removing all non-emergent clinic patients as well, so that certain personnel, almost all personnel, are not in the hospital for cases.
And this is true for our main hospital, which is Brigham and Women’s Hospital, which does have COVID-19 cases, as well as Brigham with Faulkner Hospital, [00:05:00] which does not have COVID-19 cases, but has made it a blanket policy across the institutions.
Josh Jennings: Thanks for that. And just to be clear, it sounds like in each of your hospitals, and anyone can chime in if this statement is not correct, but it sounds like your procedure volumes were at historic capacity, or volumes, until this week, pretty much.
Dr. Antonia Che…: Correct.
Josh Jennings: Gotcha.
Dr. Charles Kan…: Well, I would say I’ve actually noticed the [00:05:30] change, so yeah, I guess I’ll say first, so mine have been going down, my numbers, week by week case numbers have been stable, but my backlog over the past three, four weeks has definitely dropped. So it’s honestly easier for me to cancel things now than it was, because I used to have a lot of people waiting, and not so much anymore. I’ve had quite a few people even in clinic three weeks ago saying, “Well, I’ll wait on my therapy, I’ll wait to this future testing. Maybe I’ll do my surgery in a [00:06:00] couple of months. I’ll let you know.” So the backlog has also really dropped off. So we were still doing our volume until early this week, I guess, but certainly I don’t have all the people waiting, banging on the door, saying they need surgery, that we used to.
Josh Jennings: Well that’s
Dr. Brian Whise…: I agree with that. We’re very similar in Salt Lake. We generally do about, for example, eight TAVRS a week. Last week we did five, and this week we only had two that we had to cancel. [00:06:30] So things were scaling down last week. And, but I agree that the overall cadence of pre-procedure activity has definitely slowed in the last two weeks.
Josh Jennings: Thank you. It’s a nice lead-in, just in terms of, I think one of the challenges for our team, and I think investors looking at the medical device space around this topic, is just trying to parse out what is elective, what is non-elective, or [00:07:00] in different subspecialties on their number of classification systems out there that we’ve seen. I think there’s elective surgery acuity scale out of St. Louis University, then there’s just, I think, the historic general buckets we’ve thought about, elective, expedited, urgent, and then immediate being at the top of the list. But maybe it’d be helpful to just hear what type of surgeries and procedures each of you believe you’ll still be performing in this era of elective procedure postponement.
Dr. Chen, if we can start with you, because you gave us a nice list there of [00:07:30] what continue to be performed, and what would be postponed or canceled. We can review that one more time and maybe dig in a little bit deeper.
Dr. Antonia Che…: For sure. So in our cases, we said the ones that were non-elective were fracture cases, infection cases, tumor cases, and then select spine cases, and that’s obviously a little more nebulous.
So the thought process behind that, I do hip and knee replacements and at baseline, so if you can live without [00:08:00] a hip or knee replacement, you can live with osteoarthritis. So those came off the list pretty quickly, and that includes compendium on partial knees, patellofemoral, knee cap replacement, the whole nine yards. So my area became much more reduced. And the real question I think that we asked ourselves is, “If we waited two months for this patient to undergo surgery, would that change their outcome?” And for example, in a spine case, if you have a herniated disc that has not responded to, let’s say, steroids or medications, and things like that, and you [00:08:30] are losing what we call bowel and bladder habits, basically it’s compressing the spinal cord, where you can lose use of your legs, eventually, down below, then that is considered emergent. That cannot wait two months.
So I think we use the time metric, knowing that we don’t know when elective cases will be allowed back on again, but knowing that if a patient has to wait that timeframe, is it okay? And this actually applies to fractures, in some ways, too, there’s some fractures that have to be fixed, because there’s no way they can be healed non-operatively [00:09:00] or non-surgically. But there are certain fractures we call distal radius, which is in the wrist, or ankle fractures, some of them can be treated in a cast, or a boot, or some sort of immobilizing device. In those cases, you may not need surgery and why risk a patient’s exposure to COVID-19 if you don’t have to? So what we’ve done is use the metric of, “Can we wait two months?” And if so, and it won’t hurt the patient outcome, and it’s okay to proceed that way.
Josh Jennings: Great. And maybe just being a joint surgeon, [00:09:30] can you just talk about maybe back the envelope estimate of what percentage of your knees, and then what percentage of your hip replacement surgeries will be, I guess, considered elective, and be postponed?
Dr. Antonia Che…: To be perfectly honest, it’s probably going to be a hundred percent of both. In all cases, you could probably get away with doing some sort of conservative treatment, either an injection or some nerve ablation treatment, freezing, [00:10:00] blocking. So at this point, all of them are considered a hundred percent elective.
Josh Jennings: Gotcha. And then just a hip fracture to be even more specific. I guess, a traumatic hip fracture. There’ll be some of those cases that will go through, or are those manageable or deferrable?
Dr. Antonia Che…: So those will probably a hundred percent go through.
Josh Jennings: Okay. Okay. And what percentage [crosstalk 00:10:24] your hips? What percentage of your hip cases are those traumatic hip [00:10:30] fractures?
Dr. Antonia Che…: From the ones that I see in clinic, I’ve only had two out of my last three years. So it’s a very uncommon thing. Most patients will come to the emergency room first. So in that case, they’ll come in emergent. And we do have a backup call for emergency. So I’m doing emergency cases, which will include hip fractures, which I can do a total [inaudible 00:10:49], but they would have to be through the emergency room.
Josh Jennings: And maybe any, I know these numbers are hard to pull up without any spreadsheets in front of you, but maybe just to help [00:11:00] us think about, of the total hip cases, maybe, at Brigham Women’s and Faulkner, what percentage of those are hip fractures that got done emergently, or come through the emergency room?
Dr. Antonia Che…: That’s a good question. I’d say no more than 5%.
Josh Jennings: 5%. Okay. Appreciate that.
Maybe we can move over to Dr. Kanaly and the same question, just in terms of, what procedures do you see as elective versus non-elective, and maybe you can provide [00:11:30] us with some buckets to think about?
Dr. Antonia Che…: Sure. Well, certainly some of the ones that were just mentioned with orthopedics, if there was an unstable fracture causing spinal cord impingement, or cauda equina, or something like she’s talking about, where you’re losing bowel and bladder, those are still certainly getting the green light to go ahead. But there are a lot of fractures that can be managed non-operatively, so most of those will tend towards not having surgery. Cancers, there’s still [00:12:00] no delay on those. That’s still normal practice. If those had needed surgery or if they’re compressing the cord or something, that’s still going like normal.
But the vast majority of what I do is degenerative spine conditions, and so most of that will be shut down. A lot of it is chronic pain patients that, sure, they have pinched nerves, neurologic impingements causing bad pain or difficulty walking, but it shouldn’t really affect their outcome if you wait another month or two. I guess it [00:12:30] is a gray area with some of those people, because if you had a foot drop or something like that, where you have significant weakness, there are studies that the longer that goes on, for the less optimal outcomes. So it depends, I suppose. If you’ve already had the footdrop for six months then it doesn’t really matter, but if you just got that, that would be a consideration still, I guess. It would be a discussion. There isn’t really a clear hard and fast protocol for some of the gray area. That’s why [00:13:00] there’s now a panel at my hospital that you basically have to talk to these people about [inaudible 00:13:05]. And I think that’s going to be constantly in flux.
Right now, my hospital has no COVID-19 patients. I think if they start getting in a lot of them, there’s going to be greater concern on the anesthesiology part, of intubations causing spread of disease and, and things like that. So right now the threshold is probably a little bit looser than it would be two weeks from now, if things get worse, which they probably [00:13:30] will.
I guess part of the problem, too, that we’re running into, is we just don’t have any timeframe, because certainly certain things can be stopped a month or two, but the president’s saying this might go till August. If this keeps going for four or five months, sometimes it becomes less and less safe. And if the world is getting worse over those four months, it might be safer to get some of those people through the system now, than getting them through the system a month from now. So that’s still [00:14:00] a very gray area with some of that.
I guess, just to give you some estimates, since you were asking the last speaker, normally I’d probably do eight or nine cases a week. I would assume we’re probably going to be down to about one a week, so it’s a pretty dramatic drop-off, but still not completely zero. So just to give you an idea.
Josh Jennings: No, I appreciate that. Maybe we can move over to Dr. Whisenant, and hear about, I guess, how [00:14:30] you expect your cases and the different buckets in terms of, if you could start with what types of cardiology procedures you are performing? And then we can take it through that lineup, and think about what’s truly elective versus non-elective that will continue to be performed.
Dr. Brian Whise…: Sure. So the majority of procedures that are being done in our cath lab right now are coronary cases, and these are hospitalized [00:15:00] patients with acute coronary syndromes. My guess is that our coronary volumes in the cath lab are down 75%, but we’re still doing some cases every day of hospitalized patients. The guys in the EP labs are still doing some pacemakers, and even a few ablations for unstable, usually ventricular, arrhythmias. We have stopped our structural program pretty much cold right now, [00:15:30] but I think everyone recognizes that this is very fluid, and is open to starting some procedures pretty quickly. For example, there are some TAVRs scheduled at another Intermountain facility next week that are hanging out in limbo with the question about whether or not we would do them, because everyone recognizes that severely symptomatic AS patients can’t be put off too long. So I think that that could pick up again pretty quickly, but right now everything’s just [00:16:00] on hold.
MitraClips is largely held, except for patients who are hospitalized, has been our discussion, with heart failure or highly symptomatic, in which case we will have a committee to approve them. Watchmans are a hundred percent on hold, with the idea that these are really elective. That’s where we are.
Josh Jennings: No, thank you for that. And just in terms of, I think, the coronary [00:16:30] reduction, have there’ve been any, I guess, algorithm changes in terms of the treatment algorithm for acute coronary syndromes or even STEMIs, in terms of intervening with device-based, or using a thrombolytic, or why are coronary cases down that far?
Dr. Brian Whise…: Yeah, I think it shows that our threshold for cardiac catheterization is still largely low for patients with abnormal stress tests [00:17:00] and newer symptoms, and now we’re probably more aggressive in managing these medically. There’s been a lot of discussion about changing algorithms, for example, using thrombolytics. We have not instituted that in our hospital, and I don’t think that many people will do that. What we’ve agreed upon is that we will be more diligent in our precast assessments, and make sure that whatever we do is truly indicated and necessary [00:17:30] before we move as quickly as we have in the past.
So usually, historically, anyone can activate the STEMI team, for example, and it’s pretty simple for a hospitalist to refer a patient for cath, often without a significant cardiology evaluation, for example, maybe just a phone call. Now we’ve agreed that the cardiologist will eyes-on evaluate the patient, and make a decision [00:18:00] before we move quickly to the cath lab.
Josh Jennings: Understood. And so, in terms of the 25% of coronary procedures are still being performed, are those mostly STEMIs, are those coronary syndromes that are unstable, or more unstable angina versus really stable angina? Any other way you can parse that?
Dr. Brian Whise…: Well, this is only two days [crosstalk 00:18:24] here, we’ve done a couple of STEMIs in the last 48 hours, [00:18:30] and we’ve done, majority have been hospitalized patients with positive enzymes, non-STL ration and the like.
Josh Jennings: Got it. And maybe just moving over to structural heart and thinking about TAVR first, I guess, how do these two patients get on the schedule next week? Are there other specific criteria now in place, or are they older patients, just more symptomatic or other comorbidities, or? [00:19:00] I guess, maybe help us think through the tiering here with most of the structural heart procedures being shut down?
Dr. Brian Whise…: Well, these are actually three cases at an outside hospital that’s also an Intermountain Hospital, that had been scheduled for a long time because they were complicated, and I had given them this date as a day when I could go down and help them. And I think just because such a lot of logistics have gone into scheduling these patients, they’ve been waiting for a long time, that everyone’s reluctant to cancel [00:19:30] them. And I think people also recognize that a lot of our structural interventions are done without ICUs, can be done without intubation. So I had both a MitraClip and a TAVR on for Monday, and I called them both on Sunday to talk about canceling, and both patients were highly reluctant, so we went ahead and did them both on Monday and sent them up both home the [00:20:00] same day, without ICU admissions.
So I think there’s growing recognition that we can do most of these procedures in a minimally-invasive manner with very short hospitalizations. There’s also recognition that there’s no guarantee, and every once in a while we have complications that can lead to the ICU. So this is a fluid discussion about where we should be with these procedures, and I think the immediate response was to shut everything down, and I anticipate this will loosen up a little bit in the [00:20:30] upcoming weeks.
Josh Jennings: Gotcha. Maybe we can just talk about, I guess, maybe adjudication of these decisions on elective-ness of the procedure. It sounds like you guys, each hospital already has maybe a committee in place, so maybe we could just go through and maybe just to follow up with you, Dr. Whisenant. As department chair of interventional cardiology, and all of the team getting together [00:21:00] and putting these criteria together, is there still going to be a case by case evaluation? We heard some, I think from Dr. Chen about… Or, sorry, maybe we can just go through it with you, Dr. Whisenant, about how these decisions are being made and finalized, versus a procedure getting done, and maybe in a gray area, versus being shelved or deferred?
Dr. Brian Whise…: So there are a couple of different levels of decisions here. We have the medical directors of cardiology floating around the system, [00:21:30] we have a daily conference called, One O’clock, where they try and coordinate the decisions across the Intermountain system. As we do have about 20 hospitals across the Intermountain system, we’re trying to set up similar policies in each hospital. So that’s that’s happening there, and then on the local level, we’ve agreed that we would bring together a multidisciplinary team to discuss [00:22:00] and make appropriate patient-centered decisions, and that we would generally clear this with the chief of cardiology locally, and keep him informed of our decisions.
Josh Jennings: Great. Dr. Chen?
Dr. Antonia Che…: Ours is pretty straightforward in that we have a chief, who does adult reconstruction, and a chair. So the chief isn’t doing anything really, because from an adult reconstruction or orthoplastic standpoint, we’re not doing any elective cases, [00:22:30] but from an infection, and certain dislocation, that’s just one area I didn’t add in there, as a complication of a hip replacement, for example. If they’re dislocated, we can’t leave them dislocated. So I would run that by my chair.
Josh Jennings: Gotcha. And just to follow up on knees and just, I guess, revisions associated with infection that they seem to be immediate-type procedures. What percentage of your knees and hips are [00:23:00] infection cases, or revision cases catalyzed by infections?
Dr. Antonia Che…: When you talk about infections within our own populations, so for example, a patient that I’ve operated on and then subsequently gets an infection, we’re at 0.5% at our hospital, which is good, but as a tertiary hospital, we get patients who are referred from outside. So the infection cases that we get are probably two to 5%.
Josh Jennings: Okay. Thank you. [00:23:30] Dr. Kanaly, maybe just talk about the, I guess, decision-making process around whether a procedure’s elective, or non-elective your hospital, at St. Anne’s.
Dr. Charles Kan…: Yeah. Well, I touched on it briefly before, but so certainly there’s some more clear indications, like cancer and unstable fractures and things that, spinal cord compression, I guess, with acute neurologic changes, that would just sail right through. If I wanted to book it, it could happen, no problem. But [00:24:00] some of the ones that are a little bit more questionable, the middle, is pretty much right now, a discussion. There isn’t really like a formal policy on it. There was, as everything was happening, the impetus for things even cutting back at our hospital was basically the governor giving a speech, saying, “We need to stop elective surgeries.” And then finally, I think, a day or two later, the Massachusetts Department of Public Health put out a list of what they thought that [00:24:30] definition of elective was.
Unfortunately, nowhere on that list, the list I’ve seen, anyways, didn’t ever mentioned anything about spine. So it doesn’t really say, “Elective spine, non-elective spine.” It doesn’t really parse that out at all in the list. It’s certainly says, “Hips and knees are elective,” and things like that, but it doesn’t say much about it. So that’s why I’m in this gray area where right now, if, to book something, I would basically send it over to and have a discussion with our chief medical officer, and our anesthesiologist, and the [00:25:00] head of anesthesia. And we talk about it and they want to look at it and see, and certainly if it looks reasonable, they would go ahead with it. So it’s pretty informal, I guess, but for the most part, the tendency is to not do these surgeries.
Josh Jennings: No, thanks. Maybe we can follow up with you, Dr. Kanaly, to start on this next question. Just, if you think about your schedule and your backlog, what happens to that? Is there a time period that your hospital is thinking about? Are you rescheduling some of these [00:25:30] patients that have had their procedures postponed, or are all these procedures being canceled, and you have to rebuild your book, assuming that we get into a recovery period down the line?
Dr. Charles Kan…: Yeah. It’s basically, they’re just being canceled as of now, and so I wish we had some kind of timeframe, but that’s the problem, is I don’t know whether this is going to be a month or four months or what. And I don’t know if it’s going to get worse with bookings before getting better, and so it’s kind of hard. So right now, we’re just telling people [00:26:00] that you’re on hold, and honestly, a lot of people are fine with that. It’s the people that aren’t fine with it that we’re considering, like “Well, what’s going on here? Is there some,” and so if they did have some sort of more serious issue, we’re trying to get those people through quickly, I guess, to get them off the schedule before things get worse. But for the most part, most people are just on a permanent hold, and we’ll call you back once things clear. So we don’t really have any advanced [00:26:30] schedule at all right now.
Josh Jennings: Is that similar at Brigham Women’s and Faulkner, Dr. Chen?
Dr. Antonia Che…: There’s a fluid target, very similar, in our settings. So, originally, we were told, “Cancel two weeks’ worth of surgery.” So last Friday we kept for the next two weeks, which takes us to the end of next week. And then this Friday, actually, we’re going to reassess, because there’s whispers, rumors, that people are saying that elective surgeries may not return until June 1st. [00:27:00] And there’s actually a recent one, people are saying we may not return till July 1st. And I think really because we’re mirroring the Italy situation, more than anything else, and we’re actually looking at what China did, and Italy did as well. So very similarly, we’re not rescheduling patients, or we’re calling patients to cancel and say, we’re putting them on a list, and we’re going to go on a case-by-case basis as to when they can get back on the list. But I anticipate every two weeks, we’re going to cancel, every two weeks, we’re going to cancel. And then eventually we’re going to say, “Okay, we don’t cancel, maybe, every one week,” and [00:27:30] then either do those cases.
So when we get back on the horse again, essentially, we’re going to basically try to do everything over time. So regularly, and I do my cases from 7:30 in the morning to 5:00 in the afternoon, well, there’s a good chance, when we go back, and we’ll go from maybe 7:30 to 10 o’clock at night, and do this multiple times a week, increase our nursing staff, increasing the rest of our staff. So we can get more of our patients back off the backlog that we’re creating right now. Same will go for the clinic as well, too.
Josh Jennings: [00:28:00] No, that’s helpful, and we’ll dig a little bit more into that topic in terms of the potential recovery period in a minute. Then, Dr. Whisenant, can you help share, just in terms of your scheduling and these procedure cancellations, is it a little bit more fluid, just because some of those patients are more critical or potentially critical?
Dr. Brian Whise…: Yeah. We’ve just notified all of our patients that if they become more short of breath, to call us and we will get them and evaluate them immediately. That’s been a consistent [00:28:30] message to them, but at this point we haven’t scheduled anything, either outpatient or inpatient. So we’re just trying to keep ourselves available.
Josh Jennings: Understood. And a question [crosstalk 00:28:44]-
Dr. Brian Whise…: [crosstalk 00:28:45] I’m going to have to go on about five minutes. I actually just got called for a STEMI that’s on its way, and I’m sorry about that.
Josh Jennings: Oh, no. No problem. Maybe we’ll just follow up with you real quickly, then, Dr. Whisenant, on a couple of topics down the list, here on our question list. I guess, [00:29:00] in terms of the recovery, Dr. Chen alluded to it in her last answer, but has there been any planning, is there any time restrictions put in place by your hospital in terms of, I guess, an optimistic period where you could see a recovery, and then what do you think that recovery period looks like for structural heart and for coronary cases?
Dr. Brian Whise…: We don’t have any projections on this yet. It’s interesting that, in Utah, we have [00:29:30] 52 cases of diagnosed COVID-19, and as far as I know, none of them are hospitalized yet. So I’m not aware that we’ve had a single sick COVID-19 patient hospitalized in Utah, and so it’s so hard to have projections when we’re simply waiting for a possible storm that might be coming, and that hasn’t hit us yet.
Josh Jennings: Understood. And then just lastly, for you, Dr. Whisenant, and again, we really [00:30:00] appreciate you joining us today. I know you’re busy and you even had an earthquake out there in Salt Lake City that you had to deal with, so much thanks. But just in terms of any purchasing priorities that your department is thinking about, anything from devices down through supplies?
Dr. Brian Whise…: Well, everyone is, obviously, extraordinarily alarmed about the personal protective gear and [00:30:30] talking about how we need to conserve that, and how we don’t have enough. There’s been discussion that some of the masks may have walked off the shelves, and that we have unusual shortages, even though our volumes are low and we don’t have sick patients. So that’s been another story about why we need to limit the number of cases that we’re doing, and we’re doing our best to purchase more, but what we’re hearing from the hospital, [00:31:00] but that they’re not available.
Josh Jennings: Great. Well, thanks again, and good luck out there in Utah.
Dr. Brian Whise…: I’m going to excuse myself. Thanks, Josh. Sorry.
Josh Jennings: Thanks a lot. Maybe we can circle back with Dr. Kanaly, had a question come in online, and it’s another topic that we’d like to address, but just in general, as we think about these inpatient procedures, maybe we can talk, starting with you, Dr. Kanaly, any outpatient procedures that could be [00:31:30] restricted, or do you see outpatient procedures moving forward? And what procedures could be restricted, what procedures may not be restricted?
Dr. Charles Kan…: Well, in terms of spine and things. Certainly, I’ve noticed that there’s a strong trend towards getting people out of the hospital as quickly as possible. So it’s one thing I’ve noticed in the last week or two, is patients are leaving tremendously, way faster, after surgery than they normally do. [00:32:00] So classically, ACDF neck fusions usually stay one night just for safety to watch. They all want to go home the same day, now. I was planning to do an open laminectomy, just an open lumbar decompression on someone yesterday, and they really wanted to go the same day, so I ended up doing it through a tube [inaudible 00:32:22], and he went home that day.
So there’s a very strong trend towards getting people out of the hospital as soon as possible. It’s not even really [00:32:30] from the administrators, it’s even from the patients. Some of that, too, is just some of the rules in a hospital. There’s a lot of fear going on with that, for one thing, but there’s also been a real clamp down on visitors. So it’s honestly sad, but even if you do operate on someone at my hospital, the family basically doesn’t see that patient until they’re discharged. They can talk to him on the phone, they can do these FaceTime and Skype things on the phone with them, but they’re really, really strongly discouraged [00:33:00] from even coming into the hospital to see them. So I end up calling them on the phone to tell them how they’re doing. So that’s, just a family separation from these things has actually really encouraged people to leave, too. So that’s definitely gone down.
Then, in terms of outpatient versus inpatient, I guess, well, a lot of the outpatient ones were more electives anyways, so that certainly has gone down. So I guess, yeah, more of the percentage of residual remaining cases is probably going to be inpatients, I [00:33:30] suppose, just because they’re going to be on-call things, and things like that, that happened, more urgent cases, and they’re already been admitted to the hospital.
Josh Jennings: Great, thanks. I just, could some patients that may be looking for revision or, I guess, de novo surgery for degenerative disease, could some of those patients move and get a spinal cord stem device? I don’t know if you are involved in any of those procedures or lead placements at your hospital, but is that something that your department [00:34:00] is thinking about, or were spinal cord stem implants to also be postponed?
Dr. Charles Kan…: Well, yeah. It’s a nice idea, I suppose. Usually people, that’s going to be a longer-term change. Referring doctors and even the treating physicians don’t usually change their treatment paradigms quite that quickly, I guess. Yeah, I agree, you could put a stimulator in, in a much less [00:34:30] invasive environment, and get them out. But usually, so far, anyways, I haven’t seen doctors referring to me or, because I do implant some stimulators. So I haven’t seen that referral pattern change, and I haven’t really flipped my treatment paradigm. I guess we’re still holding out.
So I don’t think it’s going to all of a sudden, because we look at stimulators, we look at fusions and surgeries and things, as long-term treatments. So I guess [00:35:00] we haven’t changed our plan on the long-term treatment yet, based on the short-term issue. That certainly could change as this goes on until July or August, but as of now, that hasn’t happened.
Josh Jennings: Great. And maybe, Dr. Chen, can you talk about any, I guess, maybe clinic procedures to start with, that may pick up in this era? Or are you, it sounds like you’re reducing number of clinic visits as well, so maybe then we shouldn’t be thinking about anything along those lines?
Dr. Antonia Che…: [00:35:30] Yeah. We’re actually struggling with this right now, because this is obviously unprecedented for all of us. I will actually go back to the OR and the clinic setting. So for the OR setting, actually very similarly, we’re now toying with the idea of outpatient surgery. We’ve done outpatient procedures for hips and knee replacements, and partial knee replacements as well. But to date we’ve just canceled all elective cases across the board, just to centralize our personnel. So it’s for personnel reasons, not for patient reasons, [00:36:00] per se, because we don’t have COVID-19 in our outpatient settings, and we don’t have it in our community setting as well. We are trying to develop an outpatient, we have outpatient capabilities and once we’re given the green light to go ahead, we want to implement those. So we do have facilities available to do so, and this is not just hip and knee replacements, but we aren’t traditionally always outpatient settings, for very specific patients. So we can coordinate that effort since the rest of us aren’t operating at this moment, with regards [00:36:30] to elective cases.
With regards to clinic cases, right now we are obviously shutting it down to patients who basically need suture removal. If they need like casts, or some sort of fracture care, that needs to be addressed at that time. And then the other thing that we are looking for is, potentially, let’s say you have really bad hip or knee arthritis and you can’t walk. And obviously mobility is important, so those type of patients may be able to get injections, but injections are still viewed as an elective. So we’re being also very selective with our patients.
What we [00:37:00] are trying to do, though, in our patient population is say, “All right, normally I would send you to the emergency room, potentially. But right now, sending you to the emergency room will burden the healthcare providers in the emergency room unnecessarily if it’s a musculoskeletal problem.” So we’re trying to see those patients in clinics first, treat them in clinic first, before the emergency room. So our acuity of patients in clinic now has actually increased, as opposed to our normal clinic patients.
Josh Jennings: Thanks for that. And then just back to, [00:37:30] I guess, these outpatient centers, would these be standalone centers, like ambulatory surgical centers that may take on procedure volumes at some point here within your system?
Dr. Antonia Che…: Both, actually. So we have one facility where most of us are sports and foot and ankle surgeons, who really just do outpatient surgical procedures, and they have not done joint procedures there, but we would like to put joint procedures there. If that’s the safest facility for our patients, versus our community [00:38:00] hospital, where we’ve been doing outpatient procedures, but it’s not an outpatient standalone center, and it’s actually a hospital setting with an emergency room, but we don’t want to burden the care there.
Josh Jennings: And when do you think that outpatient, I guess, center setting for joints could kick in? Is that a fluid situation, or is there a set time, or is that just on the back burner, in terms of planning potential avenues of getting patients done electively?
Dr. Antonia Che…: Unfortunately, it’s a back burner, fluid scenario, because [00:38:30] they even shut it down for sports medicine, which traditionally does operate there.
Josh Jennings: Gotcha. They’ve shut it down for sports medicine currently, and then they’ll have to see how things progress?
Dr. Antonia Che…: Correct.
Josh Jennings: Okay. Thanks for that. And then, Dr. Kanaly, just back to the spinal cord STEMI, and are those being considered elective procedures now, and being canceled, or could they be done at ambulatory surgical centers? I know it’s very, very early days at your center, but how do you see that evolving? [00:39:00] Sorry to go back to spinal cord STEMI.
Dr. Charles Kan…: Yeah, it’s fine. But yeah, I just want to add one thing about the ASC issue. So my hospital system actually has two ASCs nearby, two ambulatory surgery centers, and they traditionally did a lot of outpatient procedures, and they have been the first ones on the chopping block. They were dramatically scaling those back. I do understand the rationale of, “Oh, if this is a healthy patient, we’re not worried about COVID-19, maybe we should be doing that at a separate, [00:39:30] small place, where they can go home same day,” and it makes perfect sense. But our hospital, anyways, has had the exact opposite reaction. They’re trying to minimize what we do, and pull it all to the main hospital and basically close down these outpatient centers. So that might change in a month or two, because it does make sense. But as of right now, there’s been no discussion to maybe do smaller things out there, and keep them away from the main hospital. It’s been actually more circling the wagons and falling back just to the main hospital.
Then, in terms of the [00:40:00] way, with spinal cord stimulators, I guess, what I’d say with that is, so the way we’ve been doing it is there’s actually some pain management clinics, they’re the ones that do the epidural steroid injections. They typically do the spinal cord stimulator trials, and then the more permanent implants have traditionally been done by me or similar surgeons. We usually do those at the hospital, even though people go home same day, that’s just been the local practice. [00:40:30] My understanding is, the pain clinics, the outpatient centers, where they’re doing the injections and the trials, have really cut back on what they’re doing. Even the other day, just earlier this week, they actually closed down clinic for a time because there was, I don’t know what the number, more than 20 people in the waiting room, and they didn’t want people congregating like that. So they actually literally shut the clinic down for the rest of the day. So even the injections and the stimulator trials and everything has really dropped off, for right now.
Josh Jennings: Okay. [00:41:00] No, thanks for circling back on that topic. Appreciate it. Maybe we can talk, Dr. Chen, you started to talk about, I guess, ramping back up in a period where we see a recovery, maybe we can dig into that. You talked about a, maybe, June timeframe. Again, I know none of this is fully on the table, but can you talk more about just the expectation for when elective procedures could come back? Or let me just, I do [00:41:30] know this is all preliminary forecasting that your planning team is probably doing, but if you view that quickly. Then we can then start to think about, you talked about extending hours for surgery and I’d love to dig into that topic as well. But maybe just start with the assumptions that your team is making, or the orthopedic department, around the duration of COVID-19 impacting elective procedures.
Dr. Antonia Che…: Yeah. So the hard part is, the patients that we’re calling to cancel right now are all asking us, “When can I get [00:42:00] on, then?” And understandably, they want to plan their lives, and they’ve already planned everything around this, until everything changed. So, and some of the patients, I actually have two surgeries scheduled, I’m doing one of their hips, and then I’m going to do the other hip at another point in time. So they don’t want to ruin their timeframe of recovery between them.
So long story short is, we know it’s a fluid target, we are not actually putting a date down, but we’re telling patients it could be as late as June or July, so that patients are anticipating that [00:42:30] it could be later. Then, when it comes to ramping up again, just as I said before, is that I would definitely anticipate that, obviously, operating room space will be at a premium, where everyone’s going to want to get back on. And if I could do it the way I wanted to do, I would basically just cancel clinics for a week, or two weeks, and just clean up the whole backlog of surgeries if possible. But, obviously, everyone’s thinking the exact same thing.
So really it’s going to come to coordinated care, at that point in time, working with my colleagues. [00:43:00] And I think at one point in time, we’re going to have to sit down and say, “These are the patients that should go, and for what reason?” So I anticipate that we’ll probably form a committee. Right now, we have a committee to say, who can go, from an emergency standpoint, but the next step, obviously, is who gets OR space, based on people’s either acuity, or different life circumstances, or ways that we would justify a patient undergoing an elective surgery earlier than potentially someone else.
At this point, we’re just going to do it by chronological order. So [00:43:30] I’m basically going to just do it saying, “All right, you were the schedule on March 17th or 16th, when we first canceled it. So because of that, we’re going to put you first in line,” but at the same time, then, we’re going to displace people who are already scheduled at that time. The nice thing about elective hips and knees is we already had patients scheduled in May, June and July, right? Because patients are like, “Well, I want to wait for the summer, when the weather’s nice,” or, “That’s after my daughter or son’s wedding,” or something like that. So there’s life events that have people scheduled at that time, [00:44:00] and I don’t want to punish them for this as well, right. So there’s a good chance that maybe what we want to do at the end of the day is double up, so instead of doing five cases, we’re trying to do eight, nine cases a day.
Josh Jennings: Gotcha. Is that sustainable just for surgeons, just in terms of fatigue, burnout, or it doesn’t sound like that would be a big issue for you, but I’m sure it’s an issue. But anyway, any thoughts there?
Dr. Antonia Che…: It’s a great question. [00:44:30] So I have to admit, our hospital right now normally does three to four cases a day in one room. So if I have two rooms, at the practice I came from, we were doing 12 cases a day in a room, and finishing by five or six. So we can do it. It really is going to depend on the staff and availability of that. And that’s really where our abilities, let’s say, to do elective surgery at this point in time are truly curtailed. It’s not just the exposure to patients, which is obviously a very big concern, exposure to healthcare workers, which is also a big concern, but actually just personnel.
So right now, our medical [00:45:00] assistants, our physician assistants, are starting to be pulled to other specialties, emergency medicine, internal medicine, etc., because of COVID-19. And that goes to, the operating room staff probably doesn’t get affected as much, but the next step will be actually physicians. So there are other facilities, especially in other countries like Italy, where the orthopedic surgeons have been pulled to the front lines, to help screen patients and see patients and do that, as opposed to just being within our own surgical subspecialty.
Josh Jennings: [00:45:30] Gotcha. And then just what would the hurdles be in terms of, do you see going from six to 10 to 12 procedures a day in a recovery period as plausible, or I guess, what would be the hurdles? Would they be any administrative hurdles, or I guess there’s competition for OR time from all the other sub specialties? Anything you can help us think through there?
Dr. Antonia Che…: So a few things I think would be problematic. One is, changing culture is also really hard to do. [00:46:00] So in order for me to do that right now, to double it, it would take two rooms, and the infrastructure only allows so many rooms to be running simultaneously, right?
Two, will be trained staff. So there’s only a select number of people who are trained in, for example, orthopedics, but obviously this is true for every subspecialty. So, to train or to bring in more people who can do that, or have them stay overtime, is also maybe potentially problematic. To be fair, it’s also more expensive to keep people over time. And as [00:46:30] you can imagine right now, all of our hospitals are losing a lot of money, because we’re not doing these elective cases.
And the one area that we haven’t really touched on is actually supply chain. So I worry about that, because some of the implants that we’re using, or equipment, or drapes, and things like that, could be manufactured in countries that have been highly affected by COVID-19, where they’ve shut down manufacturing. So we actually might be limited by the volume of cases we do based on what’s available.
On top of it too, just like was stated earlier, I use a mask when I operate, right. [00:47:00] And to find a mask, now, obviously they’re all being sent towards COVID-19 frontline people, which is great, but in order for us to operate, we do need masks. We do need some protective equipment. And if we don’t have access to that, that could curtail our ability to operate as well.
Josh Jennings: Appreciate it. Appreciate that, and, Dr. Kanaly, any thoughts just in terms of, I know it’s super early, but in terms of a rebound or recovery path at St. Anne’s, on the spine surgery side of the equation?
Dr. Charles Kan…: Well, I’d [00:47:30] like to say that once things clear and the dust settles, we’re going to be able to make up all this volume, but I just don’t see it happening. Especially with the people that are getting pushed off. They’re elective spine cases. They are people with pain, for the most part, right. And a lot of those people have been living with pain for years. So I’ve, just in my practice in the past, I’ve seen that those people, you have a window with some of them, too, they end up just deciding to live out in pain and sit [00:48:00] on their couch and not get it fixed, and not have surgery. So I do think that the people that we’re not operating on now, a fair amount of those people will probably never have surgery, or be able to come back in a year to see me. They’re not going to be banging down the door saying, “Please do this surgery,” in three months. Some of those people, we will lose.
Also, I’m at a smaller hospital. We do some trauma cases, but we don’t have [00:48:30] a full complement of ORs running overnight, or anything like that. So, like a typical hospital, we have an on-call team, but we won’t be able to have every room running until 10 at night. I wish I could just get my backlog and catch up one day over the summer. I’d be willing to work it if they let me, but the best I can see is, the OR staff is unionized. They have limited resources. So we were already mostly [00:49:00] operating at fairly full capacity in our ORs, and that’s what we’d go back to. I just don’t, maybe I could squeeze on an extra case a week, but they’re not going to let me double up my cases to catch back up or anything. It’s just, they just don’t have the staff to do it, or they don’t even have the rooms to do it, really.
So everyone’s trying to get their cases back on. It would be nice to say we could catch back up, after the dust settles, and then three months later, we’ll be back to having made up to volume, but I just don’t see it happening. I think it’s going to take [00:49:30] a long time for us to catch back up to the backlog, months, at least, at the minimum. And even that, I don’t think the numbers at the end of the year are going to be what they were if this never happened. I just don’t see it going back up to that level.
Josh Jennings: Gotcha. Thanks for that. And just in terms of new patient appointments, Dr. Kanaly, how are you handling that? Are you still evaluating patients that are prospects for spine surgery, or have they been [00:50:00] permanently shut down right now?
Dr. Charles Kan…: No. Well, we are. So they’re getting screened on the phone. In the United States, it’s still kind of, I think it’s very different than South Korea or something, so it’s hard to get people tested. So right now, we’re asking, do they have foreign travel? Or do they have fever and cough? And if they basically, I think if they have two of the three, we’re telling them to go away for a while. And, but if they’re meeting the basic COVID questions on the phone, they are still getting booked for appointments, [00:50:30] if they want to come in. We’re trying to minimize the purely elective ones, but sometimes it’s hard to tell, based on the referrals being sent over. I mean, “Are you able to move your leg? Can you actually walk?” It’s not always clear, from primary care doctors, how bad their neurologic problem is.
So those people are still getting booked. Most of those people, I’m not promising anything in terms of surgical times, we’re much more skeptical about booking someone for surgery, [00:51:00] but they are still getting evaluated, I guess. But certainly we’re minimizing the appointments whenever possible.
Josh Jennings: Great. And Dr. Chen, is that safe to say on your side, can you help us understand if you’re evaluating new patients that are prospects for hip or knee replacements?
Dr. Antonia Che…: Yeah. So we’ve actually made a really big push towards virtual visits, and it’s been nice in that we had the infrastructure in place first. We hadn’t really taken advantage of it. [00:51:30] So we are now doing virtual visits by phone and by video as well, too. So a video one has to be scheduled like a regular visit. So we spend the same amount of time that we normally would, and we actually bill these visits as well, too. Medicare just released that they will cover virtual visits. So most of our patient population is of Medicare, Medicare age, even for younger patients, so a lot of the other insurances are covering virtual visits, just to reduce the amount of face-to-face time that we need.
So we’ve been doing those, even for new [00:52:00] patients, and we just tell them, most of the times I manage most new patients non-operatively to begin with. And if non-operative management has failed, they’ve tried everything, I just tell them that we can’t book them for surgery now, if they are a surgical candidate, and we will wait until afterwards to do so, because it’s not emergent. And they tend to understand that. So it’s been a different way of interfacing or interacting with our patients, but also good.
Josh Jennings: Excellent. And then just, I know we’ve talked at our healthcare conference a [00:52:30] couple of weeks ago, about robotic systems, and have there been any changes in terms of capital purchasing within your department. I don’t know if you guys had any plans, but had there been any messaging from administration about any capital purchasing plans being shelved or postponed, or any details you can provide there would be helpful. Understanding that there may not be, if it’s still early days, there may not be an official plan in place.
Dr. Antonia Che…: The good news is, from an orthopedic standpoint, we really didn’t have any capital purchases [00:53:00] ready to go, but from a robotics standpoint, I know that they were looking to get newer robots, the robotic system as an OB GYN and general surgery. I think for right now, they’re just putting all resources towards just COVID-19, knowing that we will lose money during this timeframe. So from my understanding, I think capital purchases are being held off for now.
Josh Jennings: And, Dr. Kanaly?
Dr. Charles Kan…: Yeah. Yeah, we have a robotic spine system [00:53:30] that we use. So, we weren’t even really looking to purchase a new one or anything. It wasn’t a huge capital purchase like that. There were additional capabilities to our robotic system, there’s an inner body navigation system that’s coming out. My understanding is, even the release of these is being delayed, and for good reason. I don’t think anyone’s going to buy it right now, but obviously, I couldn’t even really have a conversation with anyone in my hospital about even looking at a purchase right now. All [00:54:00] anyone wants to talk about, or read about, or anything is COVID-19, so pretty much all that is shelved. Even over the summer, I just don’t see it happening, because they’re going to lose so much money from all these elective surgeries, that there’s just no finances available for that. So it’s a dramatic drop in anything like that happening anytime soon, I think.
Josh Jennings: Great. And just in terms of the clinical trials that you guys may be a part of, where there’ve been any directive from your department or [00:54:30] administration about halting clinical trial enrollment? We’ve heard from other physicians that that is the case, but just wanted to hear specifically as it relates to both of your departments.
Dr. Antonia Che…: Yeah. The answer is, we’re definitely halting clinical trial enrollment, just because the enrollment comes from clinic, and our clinics are being halted. What’s a little bit frustrating, from our perspective, is two things. One, enrollment is being stopped, and that’s okay. That’s something we anticipate.
Two, the hard thing is we [00:55:00] have some clinical trials where a patient needs to start the medication one month prior to surgery. Well, some of the patients had already started that medication, because they thought they were going to go surgery at this point in time. And now the question is, do we start the medication now, but we actually don’t know when their surgical start date will be, right? Because we are being pushed back, potentially, to June or July. Or, we could operate on them in May.
So we don’t actually have an answer to that. So we reached out to our IRB, and our IRB is basically saying, “Go ahead and start like they’re going to have surgery, [00:55:30] but then go ahead and put a protocol deviation.” So it’s really frustrating, from our perspective, from an administrative perspective, that everything is going to have to be a deviation to it, because of the uncertainty of when to start, and when not to do things.
Josh Jennings: Great. And maybe I can just ask you, Dr. Chan, a follow-up. What vendor does Brigham Women’s use for virtual visits?
Dr. Antonia Che…: We actually developed our own.
Josh Jennings: Developed your own. Great, thank you.
Dr. Antonia Che…: Yeah, we [00:56:00] did.
Dr. Charles Kan…: [crosstalk 00:56:02] From my side of things, I suppose with it, I would say we have some observational studies. We’re mostly community-based, and so we don’t have any prospective clinical trials really going on. The only real effect would be some of the follow-up visits. So, mostly because we were using this newer robotic technology for spine, we’ve been entering a lot of those patients just consecutively as they come in. So certainly the numbers on that enrollment will go down, but it’s not really changing [00:56:30] that so much. It’s the followup visits that are actually getting harder. So this is still pretty new, but I imagine at some point you might end up having to start calling people to see how they’re doing, because a lot of those routine follow-ups aren’t happening, and getting rescheduled, and things like that.
Josh Jennings: Great. Well, we appreciate your time. Maybe we can end up with one last question, and this may be a tough one to answer, but just thinking about some of the projections in hospitals being overrun with COVID-19 patients, how do we think about, I guess, a spine [00:57:00] surgeon and a orthopedic surgeon’s role evolving? Is the expectation going to be that orthopedic surgeons and spine surgeons are going to be on the front lines, helping take care of these critically ill patients, if more and more patients need critical care? And how, I guess, if there’s been any discussions around that at your hospitals, or how are you guys thinking about it individually? Maybe, Dr. Chen, we can start with you.
Dr. Antonia Che…: Sure. So looking at Italy, there’s a very good chance [00:57:30] that we could get pulled in to be in the front lines. So we’ve had discussions with our group right now, and essentially this becomes a willingness issue. Right now, we have orthopedic trauma surgeons in place, and they’re not rotating at the same time. So it’d be like two days on, two days off, so that they don’t come in contact with each other. If one or both go down, we have a three-tiered system by which we all take over call from them. It is still within orthopedic subspecialty, and we’ve divided that into the upper extremity, lower extremity of pelvis, [00:58:00] when it comes to trauma call. So I’m in that call pool as well. If that goes down, too, and we are being brought to the frontline, it’s happening in Italy now, too, there’s actually talk that physicians, who are two years retired, are actually being called back in to help on the front line. So we anticipate it. We’re ready for it, if we need to, and it is going to come by on an answer-the-call basis.
Josh Jennings: Understood.
Dr. Charles Kan…: I would say from-
Josh Jennings: [crosstalk 00:58:28]… yep. Thanks, Dr. Kanaly.
Dr. Charles Kan…: Oh yeah. I was going to [00:58:30] say, I would say from my standpoint, honestly, at the smaller hospitals in the community, I think the bigger concern is resources. Our ICU isn’t gigantic. We don’t have a ton of ventilators. There are enough doctors to go around. So unless it’s becomes an absolute horrible situation, where we have field hospitals, I don’t see me being involved on the front lines. It’s certainly not in our hospital, there’s enough other medical doctors that can help with that. [00:59:00] There has been some discussion about the PAs and the mid-levels, actually, covering, which Dr. Chen had mentioned earlier. So that actually might happen, where they might help with some of the other services, because certainly even our inpatient services and our outpatient services are way down. So that is an extra resource, and they’re a little bit better cross-trained than we are, anyways. So there might be some the mid-levels extension happening, but the specialists, otherwise, as of right now, that’s not foreseen in my area.
Josh Jennings: Fantastic. [00:59:30] Well, we’re at the top of the hour here. We truly, truly appreciate you taking time out of your busy schedules to help us understand what’s happening in your respective centers. And we just want to thank you for helping to take care of society, and being there in the middle of this crisis.
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