This Memorial Day, I spoke to Dr. Mitchell Spinnell from The Gastroenterology Group of Northern New Jersey. Bergen County where Dr. Spinnell and his partners practice is a red zone. After prolonged closure, they are opening up their office and surgery center this week.
In this incredibly insightful interview, Dr. Spinnell shares his experience while working at a COVID unit to Cologuard to consolidation in New Jersey.
◘ Closing down the surgery center and opening it now (“Number of cases skyrocketed”)
◘ Exact steps they took to open up from staff training to PPEs (“cases every 45min to an hour”)
◘ What if someone tests positive AFTER you start? Do you open or close?
◘ We furloughed our entire ASC staff (The financial piece is a struggle)
The Transcribed Interview:
Praveen Suthrum: Dr. Spinnell, welcome and it’s really nice to see you. I would want to start by asking you about your practice. If you could tell us a little bit about your practice.
Dr. Mitchell Spinnell: Great. Well, I appreciate the invitation Praveen. This was a really welcomed way to start my Memorial Day celebrations. So, I am a gastroenterologist practicing in Englewood, New Jersey. Englewood is in Bergen County in Northern New Jersey right across the bridge from New York City. And we were you know, sort of in the hotbed of the COVID pandemic.
We’re a 11 physician GI specialty group with some roots in internal medicine. We have one nurse practitioner. We work out of an ASC that is partly hospital-owned. Middle of March, things had really exploded at an exponential level and Bergen county has remained a red zone after that.
Praveen Suthrum: And you worked at the COVID unit in the Englewood Hospital. How was that experience?
Dr. Mitchell Spinnell: Yeah. It was incredible. The hospital was sponsoring weekly or bi-weekly meetings and was sort of updating what was happening at the institution. And as the number of cases was mounting, there really was an effort to convert the hospital, increase its ICU capacity, and turn the majority of the units into COVID units.
There still was an incredible shortage of manpower. So, there was an outreach to some of the specialty physicians to assist. I devoted a little over two weeks to the COVID unit specifically. I wanted to carve out a block of time and you know; over that period, I was involved in the care of over 40 COVID patients.
Praveen Suthrum: How long has your practice or your surgery center been closed?
Dr. Mitchell Spinnell: Our last day of full operation was on March 16th and it was the weekend before that Monday that we really began to see the number of cases in New Jersey skyrocket. And I believe on the 13th, the Governor declared a state of emergency. I was doing endoscopy on that Monday, the 16th, and there was great concern because the unit didn’t have appropriate PPE.
Many of our cases either dropped off because of patient concerns and we had to cancel quite a few because we were concerned about upper endoscopy and not having proper protective gear for the staff, the physicians, and the anesthesiologists. The unit officially closed on the 16th of March. I’m happy to report though that we are scheduled to open up this coming week on Thursday, May 28th.
Praveen Suthrum: And how are you transitioning, you know from this phase to the phase of opening up back again? Do you have enough PPEs? What kind of staff training and physician training did you have to undergo in preparation of this opening?
Dr. Mitchell Spinnell: Yeah. So, that question really encapsulates my last two weeks because it has really been a challenge. You know, we have three rooms in our facility and what we’ve opted, at least to start is that we’re going to have one provider toggling between two rooms. We are going to schedule cases every 45 minutes to an hour. And for the first weeks, we plan on scheduling no more than 12 cases on a given day. Part of that is because of our lack of PPE. Part of that is to gain comfort for the staff and the physicians, many of the physicians have not been on the hospital environment during the pandemic and they are not familiar with protocol and we have done extensive training.
We have been able to secure some PPE. The biggest variable are the N-95 masks. As a result, we have actually purchased some respirators, a number of them for the entire staff. And those are hopefully going to arrive this week. We do have enough N-95 masks to maybe last for 10 working days. So, those are the limiting factors. We’re going to really start at a snail’s pace. We spent three days training the staff last week. And we have really put in a protocol that I think is going to be quite effective.
The detail on that is because we’re in a red zone. As per our hospital protocol, which we will be following and now it’s mandated throughout the state of New Jersey, all patients receiving elective procedures and we wouldn’t consider our initial patients to be elective, they’re more semi-urgent cases, all patients will require a COVID nasopharyngeal swab 72 to 48 hours prior to their procedure. We’ll have documented a negative swab upon the patient and the patients are then asked to self-isolate from the time of their swab till the time of the procedure. They’ll arrive at our unit where they will be questioned by a nurse. They’ll get a temperature check and we will also be evaluating them with the pulse oximetry and then, assuming that their COVID is negative, and they haven’t answered affirmative to any of the questions, they will be admitted and the procedure will take place.
We’ve also asked our staff if they were interested in getting swabbed and antibody tested prior to restarting and all of the staff were interested. I’m happy to report that everyone was negative. But this is the protocol that we set up and I think it is the best way we can maintain safety for our staff and our patients.
Praveen Suthrum: Yeah. I’m glad to hear that everybody tested negative. When you were going through this training with staff, what kind of concerns did they have? What were they fearful about?
Dr. Mitchell Spinnell: You know, I think it’s the fear of the unknown. There is not a single employee in our unit that has not been affected by this pandemic. Everyone knows someone who has had the virus, knows someone who was hospitalized, and we have had several family members who have lost relatives.
So, there still is great concern about exposure. I think that we’ve really tried to reassure the staff that with proper PPE, they can remain safe. You know, when I was working on the unit, I was very concerned about my exposure, I have a young family I was away from my family during my time of work and I was concerned that when I did reunite with them, that I would be bringing the virus back. And I think this is a big concern that the family had that you know, after a workday when they return home, what will they be bringing with them?
I was able to reassure them that, after my stint in the COVID unit where I was seeing 10 or 12 COVID patients a day, at the end of my term, I nasal tested negative and my antibody was negative. So, the PPE clearly works, if it’s used properly and you’re absolutely fastidious about the details of donning and doffing, I think you can remain safe.
Praveen Suthrum: So, if after you start, someone tests positive. As in you end up discovering that the patient was infected maybe after you do the procedure or after you’ve seen the patient. Then, do you remain open or do you close? What is part of your protocol? How have you thought about that?
Dr. Mitchell Spinnell: Yeah. I mean that’s a great question. You know, the big concern is that we don’t want our unit to be associated with any infection. Because clearly as things open up, everyone is going to be hyper-vigilant about new clusters of cases that emerge.
Our plan is that obviously we are not going to admit anyone into our unit that either test positive or answers affirmative to any of the approving questions and their cases can be deferred. But after their procedure, typically we would do a follow-up call on their first post-procedure day. Our plan is to extend that. So, we will follow-up the day after the procedure, a week after the procedure, and 14 days later.
And this is our way of contact tracing, making sure that nothing has happened to the patient after an exposure. And this will all be tied-in with the local health department. If we do find a positive, obviously we’re going to need to restore. We’ve also offered to our staff, you know, they will be tested daily on arrival at the unit with temperature checks. We’re going to be logging all of that data and if they do want to get periodic swabs or periodic antibody testing, that is available. Our hospital network has really ramped up its capacity to provide necessary testing, particularly for healthcare workers.
Praveen Suthrum: I want to ask you about what must be confusing for you right now, both as a clinician and as a physician partner or business owner?
Dr. Mitchell Spinnell: The financial pieces is clearly a struggle. We furloughed our entire ASC staff and more than 50% of our office staff during the height of the pandemic. We’re bringing back 50% of our staff in the ASC and about 75% in the office as we ramp up and start to see patients.
We were lucky that we were very aggressive in applying for the PPP (Paycheck Protection Program) loans that were available and we did receive all aspects of the loan. And that has carried us through. We are now obligated to try to utilize that money during a certain time period. So, having our staff back and paying our staff is very satisfying. Most people want to come back.
Clearly there were some people affected by the pandemic in a variety of ways. Some are still at home mourning others have childcare responsibilities given the fact that schools are still out. Summers programs will probably not be available. So, these will all be challenges moving forward.
You know, the financial piece of it will remain a challenge. I don’t think we can expect things to get back to normal for quite some time. I think it’s going to be a matter of just surviving and working our way through this. The financial piece will hopefully come maybe towards the end of the year but that’s all contingent on whether or not we see a second wave. But at this point it’s just a matter of staying positive and trying to forge forward. You know, I don’t have a better response to that. It’s scary.
Praveen Suthrum: Do you foresee patient behavior change during this period? Do you think, that patients would think, ‘If I can avoid screening colonoscopy, maybe I should. Why get into a healthcare facility if at all it can be avoided’?
Dr. Mitchell Spinnell: I think that many patients are going to feel that way. And I think that the internists that we work with are quite sophisticated and are aware of all the screening tools. You know, we have seen a significant uptick in Exact Sciences’ Cologuard use. Over the last year, year and a half. I mean, it’s there. We utilize it ourselves for patients that are higher risk or endoscopic procedures that do require a screening test. I think to bury your head in the sand, and think it’s not going to have a major impact, I think is false.
It’s here to stay and it will continue to grow. I think we’ll have to be creative in terms of how we structure our practice moving forward. There are many services that we provide, and we continue to expand the services and patient offerings. And I think we need to be innovators. I think Cologuard is a force and I would rather be a part of that force than to fight against it.
Praveen Suthrum: Talking about consolidation in your region. So, you’ve had small practices talk to you? Smaller practices call you, share their concerns? What is the vibe about consolidation in your area?
Dr. Mitchell Spinnell: So, you know consolidation has been in and out of New Jersey for the last four years now. There have been multiple attempts at trying to form a large super-group and private equity has had its hand in New Jersey for quite some time. I know that there were quite a few deals that were being explored. Our group has certainly considered the possibility of syndication either with a private equity group or with a large hospital network. We have been in talks and we’re trying to decide on which direction we want to go.
I’m amazed that some of the groups that have been exploring, investing in gastroenterology groups in New Jersey have fallen off and have not been expressing the same kind of interest as they were months ago. But there still are some very dominant, large private equity groups that are still showing interests. So, the talks are ongoing. There has not been a major transaction in New Jersey, but I anticipate that in the months to come something may finally come to market.
Praveen Suthrum: If the valuations change, would the interest from doctors also change?
Dr. Mitchell Spinnell: I think so. I think a lot of it is going to depend on whether or not it makes financial sense. But more importantly, depending on what your horizon is I think we know that consolidation is really the only way forward. In order to mount some strength against the payors, groups of two or three physicians won’t be able to survive. Larger groups have a better chance.
But I think the weight of a private equity partner or a hospital partner is really what’s needed in order to see some light. Clearly as a result of the pandemic, our expenses are going to increase significantly. And the only way we can whether those added costs is if we are part of a larger entity and have the ability to negotiate. So, I think consolidation remains the way in the future.
Praveen Suthrum: What kind of advice do you have for GI practices or endoscopy units that are outside of the red zone and looking to you. You know, you’re in the thick of things and you’re opening up now.
Dr. Mitchell Spinnell: You know, I don’t think you can underestimate the variety of ways that this virus presents. We have all been blown away by the variety of clinical manifestations and presentations. I remember a patient of mine who was in the emergency room with what sounded like peptic ulcer symptoms. They did a chest X-ray on him and they saw bilateral ground glass infiltrates. He had absolutely no respiratory symptoms at all and was diagnosed with COVID. So, my point is that we have to take this virus incredibly seriously. I think that PPE is critical. We have to be sensitive to our staff and make sure that they feel protected. And I think appropriate questioning and screening of our patients remains essential.
I mean, even in people that are outside of red zones, I think we need to change our approach to donning and doffing the PPE and I think we need to remain absolutely fastidious about the details of putting on the equipment and taking off the equipment, using shields, things that we very often took for granted in that past really need to be adopted and we need to be absolutely strict and we need to call each other out. When people are not doing things properly, whether it’s a physician or a nurse or a technician, we really need to be on top of each other because that’s the only way we’re going to be protected.
Praveen Suthrum: Dr. Spinnell, thank you very much for sharing all these insights. Incredibly useful. I wish you all the best in opening up this week. I wish you well, I wish your staff well. Take care. Thank you!
Dr. Mitchell Spinnell: Okay Praveen. Thank you very much, I really enjoyed it. We’ll talk soon.
By Praveen Suthrum, President & Co-Founder, NextServices.