The shutdowns across the globe in response to COVID-19 have created tremendous hardships for the public. In addition to the economic costs, many people have been unable to receive care for their orthopedic conditions as hospitals have sought to conserve resources and slow the spread of disease. The mitigation strategies were important to protect the vulnerable and maintain health care capacity, but many local and state governments are now pushing for the return to a “new normal.” As hospitals permit the scheduling of elective cases, it is important to understand that the presence of the pandemic did not eliminate the musculoskeletal pathology requiring care. Advocacy on behalf of patients with orthopedic conditions is essential as society progresses through this and future crises.
One lesson from this pandemic is that the term “elective” is too broad. Although patients with hip arthritis do not need urgent treatment, those with significant pain and limited mobility would hardly consider a hip replacement elective. In fact, the cost-effectiveness of and improvement in patient quality of life after primary hip arthroplasty are well documented. This is just one example of how orthopedic surgery positively contributes to public well-being. The ability of patients to walk, exercise, and live a pain-free life is the goal of any physician providing care. Orthopedic surgeons can directly treat, and at times immediately ameliorate, symptoms that prevent a fulfilling life. Although conserving resources and limiting exposures are essential during a pandemic, rather than canceling elective surgery, procedures that can be safely delayed should instead be postponed.
Safely delayed surgery is a more accurate term than elective surgery when describing operative care in orthopedics. The terminology used by politicians, the media, and administrators has consequences in shaping public perception. For example, it may never be appropriate to perform elective surgery during a time of scarce resources. However, should this pandemic or future crises extend for months, must patients with debilitating conditions be forced to suffer for this period? Although the answer is not clear cut, there is a moral obligation to begin planning the care of patients waiting for surgery. Therefore, procedures designed to address these conditions should be considered safely delayed rather than elective, as these patients will ultimately require treatment. Safely delayed cases could be appropriately subcategorized to take each individual patient's condition into consideration. Patients who were safely delayed for surgery but had persistent pain or inability to work would be prioritized over patients who were safely delayed with minimal consequences. Use of the correct vernacular is only part of the solution.
The current pandemic emphasizes the need for more orthopedic surgeons to be in positions of administration and policy-making. Decisions regarding the care of patients with orthopedic conditions are often made by leaders with limited experience in musculoskeletal pathology. Additionally, the impact of elected officials, usually with no medical background, on the lives of patients and the sustainability of practices must be considered. The time line for returning to a normal surgical schedule is certainly up for discussion; however, to have any role in that decision, orthopedic surgeons must have a seat at the table. Orthopedic surgeons enjoy a fulfilling career in clinical practice, and orthopedics is among the top five specialties for experiencing happiness outside of work. However, orthopedic surgeons can no longer afford to defer important policy decisions to others.
The COVID-19 pandemic will lead to lasting changes across the health care system and society. The lessons from the early stages of the pandemic should motivate orthopedic surgeons to be more active in advocating for patients to receive access to appropriate care. Changes in the way orthopedic conditions are described to the public and the level at which orthopedic surgeons participate in forming health policy will be necessary to achieve this. Although delaying surgery is an important part of maintaining health care system capacity during crises, patients with musculoskeletal pathology should not be left to wait indefinitely for treatment.