What your doctor is reading on Medscape.com:
APRIL 15, 2020 -- Monday
8:00 AM. Standing in the Stop & Shop parking lot, the sheer number of things wrong with this picture hits me like a gut punch. Monday morning and I'm not at work seeing patients. Instead, I'm gearing up with my wife to shop for weekly supplies. We don gloves and face masks like we're about to perform surgery.
My cell phone buzzes: texts from my partners. Nonstop emails and status updates from the hospital. Facebook and Instagram posts with morbid coronavirus memes. Minute by minute, alerts scream more bad news from New York City, the new global epicenter of this exploding plague.
I glance at the screen and then put the phone back in my pocket. Time to scavenge for eggs, bread, and maybe—one can always hope—toilet paper.
10:00 AM. Home again. The kids are on their laptops doing "distance learning." Assignments done on Google Classroom, virtual attendance checks, and even plans for online 45-minute Advanced Placement exams later this spring. My older son is a senior, so he'll need to make his final decision about college soon. No last campus visits to help him decide, as all of his prospective schools are closed for the remainder of the academic year. All of the celebrations and social events of senior year—prom, graduation ceremony, parties—probably won't happen. He seems to be taking this in stride. First-world problems, I know. But I can't help but feel that he and his friends have been cheated.
I dress for work, forgoing the shirt-and-tie combo for scrubs which can be tossed into the washing machine when I get home. My patient schedule is decimated, but that's the way it should be right now. If you want Botox in the midst of a global pandemic, you need to get a clue. That milium can wait another 3 months to be extracted. Skin tags? Not. An. Emergency.
One of my guilty pleasures lately is checking Instagram for the latest saysmyderm post. This week, she (I'm assuming the gender here) has been shame-posting screen shots of supermodels who think it's cool to pose in bikinis made from N95 masks, and fake dermatologists who advertise drive-by Botox house calls.
11:00 AM. I clench my teeth and grip the steering wheel. Time to brace for a conference call with my partners. We're doctors but also small business owners, and we're facing some daunting decisions. All nonessential businesses have been ordered closed, but this is a soft mandate. I mean, who knew that liquor stores fall under the "essential services" category?
As healthcare providers, we're exempt from this order, but does that mean we should keep our doors open to anyone who wants a dermatology appointment? Where do we draw the line? Obviously no cosmetic or elective procedures. But how about routine skin checks or follow-up visits for nonacute issues such as acne, mild psoriasis, and atopic dermatitis?
We consider the question. Through long bouts of silence, we mentally balance the financial cost (optimistically a 50% revenue hit), including the obligation we feel to our staff versus the ethical mandate to keep our patients safe. I'm relieved to find that we're all in agreement. Protecting lives trumps business. Always. We'll postpone all nonessential visits for a month and then reassess.
This is in keeping with recommendations from the American Academy of Dermatology (AAD). The Centers for Medicare & Medicaid Services and then, begrudgingly, private insurers, have said that these telemedicine visits will be reimbursed like regular office visits. However, the checks aren't in the mail yet. Some of my colleagues have reported rumblings from big third-party players that they already may be looking for a way out of their vague "commitment" to pay. Who doubts that, in a month, there will be strings of denials? Missed modifiers. Contractual exclusions.
Now that we've outlined how we plan to operate over the near term, the real agonizing begins. How do we adjust to the financial fallout of these decisions? Will recent legislation, The Coronavirus Aid, Relief, and Economic Security Act (CARES), designed to help small businesses, help us? As our office manager reviews his recommendations, my chest tightens enough to make me wonder whether I have been exposed to coronavirus already. (There was that consult last month with the patient visiting from California. He had been admitted for "the flu." Or was it pneumonia?)
Focus! My mind snaps back to the painful choices at hand. Furloughs for nonessential staff. Pay cuts for everyone else, with partners drawing no salary for weeks, if not months. Tough conversations with our salaried employees.
This will be painful. The nurses, medical assistants, and receptionists are like family. In some cases, we've worked together for decades. They have their own families to take care of and bills to pay. Our message will be the same one we share with each other: We're all in this together. We'll come out on the other end stronger.
We end on that note, but no one is naive enough to think that we have solved anything. Like everyone—governors, restaurant owners, school districts, the CDC, WHO, nations around the world—our approach to this pandemic must change day by day, and sometimes hour by hour.
The Action Plan
In keeping with guidance from AAD and based on our combined decades of experience, we develop plans for specific patient scenarios.
We'll divert what we can—routine acne, rosacea, well-controlled eczema, and psoriasis patients, etc.—to telemedicine consults.
Only patients with true dermatologic emergencies will be seen. Don't roll your eyes. Remember erythroderma? Cellulitis? What about Stevens-Johnson syndrome and flares of pemphigus vulgaris? Patients still get these things. If we are not in the office to see them, they'll be heading to the emergency room or urgent care. Not places they need to be going right now.
In accordance with recommendations from the American College of Surgeons to delay nonemergent surgical procedures, we will postpone surgery 3 months for patients with skin cancers that aren't imminently life-threatening. For patients with melanoma skin cancers, we will refer to guidelines disseminated by the National Comprehensive Cancer Network to guide care during this pandemic.
For isotretinoin patients, the iPLEDGE registry just announced that it will accept telemedicine visits with documentation of a negative home urine pregnancy test.
For patients on biologics and immunomodulatory therapies, we review the AAD interim recommendations. Patients already on these therapies who have not tested positive for or do not exhibit signs or symptoms of COVID-19 will be continued. Therapy will be discontinued in anyone who does test positive. And we'll avoid starting anyone new on these drugs.
Last December, near the dawn of 2020, SARS-CoV-2 emerged in China and rapidly adapted to attack us. We need to do the same. What might this look like in a day or a week? Will we be called on, like specialists in Europe and the hardest-hit regions of the US, to brush up on our general medical skills so that we can back up our overwhelmed colleagues on the front lines? One large hospital system in New York has already told its medical staff to expect to be redeployed to areas with the greatest need—or be furloughed without pay.
We're not there yet where I live, but who knows what tomorrow will bring?
Graeme M. Lipper, MD, is a clinical assistant professor at the University of Vermont Medical College in Burlington, Vermont, and a partner at Advanced DermCare in Danbury, Connecticut.