The evolution of telehealth in plastic surgery
The COVID-19 pandemic accelerated the adoption of telehealth in plastic surgery, with technological and social trends that once held little-to-no clinical relevance to the practicing surgeon now deeply woven into the field. With the mandatory moratorium in place on elective procedures in 2020 and the implementation of distancing guidelines, plastic surgeons had to rapidly and dynamically adapt their practices amid economic challenges and unprecedented changes in regulatory requirements, safety and quality standards, patient preferences and consumer trends.
The trends propelled by the pandemic continue to exert a lasting impact on the specialty. A majority of respondents to a recent survey of ASPS members revealed that telemedicine has been integrated into breast, cosmetic and reconstructive practices for initial preoperative consultations and routine postoperative visits, with plans to continue using virtual platforms. Social media also emerged as a unique tool for patient engagement, education and advocacy.
Taken together, these elements add a new, virtual dimension to the patient-physician relationship that residents and Fellows should consider as they develop their professional presence and transition to practice. As new stages of the pandemic unfold, plastic surgeons in academic, employed and private-practice settings continue to reimagine their practices and care-delivery models.
Still, while plastic surgeons agree that telehealth options have and should continue to provide benefits for patients and surgeons, there are differing opinions as to the most effective timing of these virtual interventions.
Aesthetic surgery
Virtual telehealth visits with patients, combined with proactive social media outreach, provided an avenue for plastic surgery practices to provide uninterrupted access to clients throughout the pandemic – despite office closures and elective procedure cancellations. Through live Q&A sessions, direct messaging and the interactive sharing of audiovisual content and progress updates, the physician-patient relationship has extended into an ongoing exchange over public platforms. Social media can facilitate a new range of interactions, but telemedicine encounters performed via non-public-facing platforms ensure privacy and quality requirements.
For patients seeking an expert opinion remotely, virtual encounters optimize time, travel and cost commitments – and avoid undue exposure to COVID-19. In addition to the convenience of discussing treatment options from the comfort of home, some patients might feel more comfortable with a virtual discussion of the nuances of their appearance than in an in-person visit. Some might enjoy more privacy when seeking consultation or receiving routine, postop follow-up without being seen at the physician's office or waiting room. It remains unclear how patients' perceptions of their providers and surgical options are affected by the nature of an initial, virtual encounter and whether this significantly affects the likelihood that a patient would eventually proceed with aesthetic surgery.
"One of the main advantages of telehealth is really for the patient," says Kristen Broderick, MD, director of the Johns Hopkins Resident Cosmetic Clinic. "Many patients who need to travel long distances, obtain childcare or take off work in order to attend a doctor's visit find that it's a big burden on them. Telehealth allows them to really be able to access care in a way that they can avoid that additional cost to their lives.
"It's more likely to be here to stay for our surgeons, in the initial stages," she adds. "But surgeons need to figure out: What are the best ways to utilize it for what we do? A lot of what we do as surgeons is to literally place our hands on the patient's tissues, manipulate, test and maneuver them. It's a very different interaction as compared to speaking with someone concerning their mental health or blood pressure, as is done in the primary-care setting."
Arya Akhavan, MD, a resident in the University of North Carolina's plastic surgery division, says figuring out when to use telehealth in plastic surgery remains a tricky proposition.
"Careful use can really save time and resources," he notes. "An initial surgical consultation isn't the best use, as patients appreciate meeting their physician face-to-face. But for brief preoperative appointments or answering patients' last-minute questions, a virtual visit can save travel time and clinical resources."
Dr. Broderick says telehealth provides a good screening tool for preop patients.
"We can help identify appropriate candidates – and perhaps more importantly, identify those who aren't yet ready without them having to come into the clinic," she says. "For postop patients, unless there's an additional hands-on procedure that needs to be performed – such as pulling a drain or removing sutures – it can be very useful for assessing progress and educating the patients."
Patrick Assi, MD, a Vanderbilt University Medical Center resident, agrees that the sweet spot for plastic surgeons seems to be in postop follow-up stages.
"Telemedicine theoretically can be applied to every stage of patient care," he tells PSR. "But it's not meant to replace human interaction, physical examination and personal patient-physician rapport, which are the fundamentals of our surgical practice."
For providers, the recouped time can be repurposed into maximizing the patient experience by more thoroughly discussing goals, setting expectations and reviewing preop preparation and postop considerations. Still, virtual consultations don't replace subsequent, in-person physical examinations. This is particularly true in the setting of complex re-operative scenarios or when addressing urgent postop concerns, where a virtual visit can only be useful as a preliminary triage tool.
Even in follow-up scenarios, Dr. Akhavan notes critical downsides.
"Getting a good view through Zoom can be difficult and therefore may necessitate an in-person exam, and patients in rural areas may not have adequate internet access," he says.
Reconstructive surgery
Data from academic medical centers reveals diverse applications of telehealth in reconstructive procedures such as breast cancer reconstruction, free-flap monitoring, hand surgery, burn, trauma and craniofacial care. At the height of the pandemic, experienced centers recorded improvement in the ratio of completed to scheduled visits, compared to in-person clinic visits the year prior. The expansion of telehealth also allowed providers to see more new patients, with up to a 22-fold increase in the percentage of new patients seen in February to April 2020.
In Connecticut's Veterans Health Administration (VA) system, 83 percent of surveyed patients referred for non-urgent plastic surgery consultation expressed high satisfaction and preference for utilization of telehealth in future visits. Data from France confirms the benefits of telemedicine in wound-care procedures, such as pressure ulcers and diabetic foot ulcers, with 75 percent of treated wounds improving or healing; a 72 percent reduction in hospitalizations; and a 56 percent reduction in ambulance transfers to specialized wound centers.
Although barriers to the implementation of telehealth exist in rural areas, virtual encounters are well-received by patients and are successful when deployed appropriately. Funderburk, et al., developed a telehealth workflow for postop patient visits using the Lean Six Sigma framework – a quality-improvement methodology proven to be highly effective in the business sector. Seventy-two patients undergoing non-cosmetic plastic surgery procedures and living in rural areas of New Hampshire or Vermont with an average travel time of 30-60 minutes to the medical center participated in the study. On initial preoperative survey, 73 percent of patients expressed preference for traditional in-person clinic visits.
After their postop telehealth encounter, nearly 100 percent expressed satisfaction with the telehealth experience and reported that they would use telehealth again in the future. These reports are particularly relevant for institutions serving a broad catchment area. Long-distance travel can be taxing for patients, with time off of work, arranging for the care of dependents and out-of-pocket travel expenses adding to the logistics of attending a clinic visit. Plastic surgery patients are reinforcing this preference.
"We have patients who live many hours away, and telemedicine has allowed us to bridge the distances by facilitating outpatient visits without the necessity of travel," says Francesco Egro, MBChB, chief resident at the University of Pittsburgh Medical Center. "Patients are very grateful for this option."
Global surgery
Reviewing data in Australia on pediatric plastic surgery patients demonstrates that telehealth programs can improve access to care. When appropriate, screening or managing patients within their home environments can reduce the associated financial and psychosocial burdens, and potentially prevent unnecessary transfer to tertiary centers.
Integrating emerging technologies into surgical education and clinical care can also maximize the scope and impact of outreach interventions. In a 2020 prospective study, Vyas, et al., demonstrated that remote, virtual interactions using an augmented reality platform over 13 months can effectively transfer cleft-surgery knowledge and skills to overseas colleagues. The collaboration between cleft lip-repair surgeons based in the United States and those located in an underserved area of Peru resulted in significant improvement in all facets of this subspecialty. Remote sessions promoted improved understanding of cleft anatomy as well as operative design and efficiency. At a 30-month follow-up, no children with cleft lip repair required transfer to tertiary care centers.
With travel bans and limited availability of personnel and resources, communities with limited, local surgical capacity suffer. Suspension of surgical outreach programs in such settings results in significantly delaying patients' surgeries and crucial aspects of their comprehensive care. For nongovernmental organizations providing international cleft care, video calls with patients and their caregivers during the pandemic has ensured the continuation of longitudinal care – including peri-surgical and speech therapy, education and support.
Social media can also improve the reach and dissemination of timely educational messages on safety precautions and preventative measures, while providing a forum for answering questions and addressing misconceptions with evidence-based recommendations during uncertain times. Such approaches reinforce partnership, trust and the respect between remote and local professionals and the communities they serve together, while promoting a more sustainable model of care that empowers local providers.
Pertinent telemedicine CPT codes and related information can be found at cms.gov, by typing "Telehealth Services" into the search field.
Resident training
The integration of telehealth into plastic surgery is already transforming surgical education. For residents and Fellows joining the workforce in the post-COVID-19 era, the ensuing paradigm shift has important practical implications, as trainees and faculty now experience a sizable proportion of outpatient surgical planning and follow-up in virtual format. This is even more pronounced in complex clinical scenarios that require multidisciplinary collaboration. Meanwhile, the traditional residency-training framework continues to adapt to an evolving emphasis on surgical simulation, virtual conferences and web-based professional interviews. With these elements at play, trainees have to develop a new skill set that will prove to be valuable throughout their education and eventual clinical practice.
Practical aspects, further considerations
Regulatory requirements for telemedicine services vary regionally within the United States and abroad. These are evolving rapidly – and include considerations relating to interstate licensing, liability and malpractice, reimbursement schemes and privacy concerns. Although restrictions on the appropriate use of telemedicine and the use of non-compliant Health Insurance Portability and Accounting Act technology for videoconferencing were lifted during the pandemic, changes are expected as the dust settles. The Accreditation Council for Graduate Medical Education and Centers for Medicare and Medicaid Services provide guidance on resident participation in the use of telemedicine under appropriate faculty supervision to mimic in-person care.
The proven benefits of convenience, time and cost savings – as well as patient and physician satisfaction – must be constantly weighed against the limitations inherent in being unable to perform a full physical examination and the attendant risk of potentially missing subtle clinical and interpersonal nuances that would otherwise be accessible in a face-to-face encounter. Additionally, a thoughtful implementation of telemedicine should aim to deliver optimal, quality care with sensitivity to socioeconomic disparity, disability and literacy barriers.
Despite the challenges that still surround the telehealth medium, this evolving paradigm offers plastic surgeons unprecedented opportunities for quality care through innovative pathways.
Dr. Ramly is a chief resident in general surgery at Oregon Health & Science University and plastic surgery Fellow at the Mass General Brigham Plastic and Reconstructive Surgery Program at Harvard Medical School.