Dermatology residents and the care of patients with coronavirus disease 2019 (COVID-19)

Dear Dr Dermatoethicist: I am a dermatology resident. Recently, I was notified that I might be pulled from dermatology to work in the emergency department or on the hospital floors to help with patients with coronavirus disease 2019. Can I refuse, and even consider litigation? My contract with the hospital states that I will be practicing dermatology, with no mention of general medicine.

–Reluctant Resident

Dear Reluctant Resident: As if prescient, a 2016 dermatoethics publication in this journal discussed this very topic, except that the dermatologist was requested to consult on a rash in a patient with Ebola.¹ The good news is that COVID-19 is far less fatal, particularly for young, healthy residents² (Tables I and II ). Therefore, your fear of dying should be tempered with facts. Most importantly, as a physician who cited the Hippocratic oath at graduation, you have sworn to solemnly serve your patient as your first consideration before your own interests.³ You are therefore ethically (because of professionalism, beneficence, nonmaleficence, justice, and dignity) and morally bound to perform your duty when called upon, especially in a medical crisis, as we are presently living through. Additionally, there is an American Academy of Dermatology Code of Medical Ethics that states, “It is …unethical for a dermatologist …to refuse the management of a patient because of medical risk, real or imagined (page 18, section 1C).”⁴ Subsequently, in the current pandemic, it is a dermatologist's duty to treat patients in the clinic, in the hospital, in the emergency room, and in the intensive care unit if called upon.

Table I.

Estimated global COVID-19 case fatality rate distributed by age group^∗

Age, y (deaths/cases)	Case fatality rate, % (95% CI)
≤9 (0/416)	0
10-19 (1/549)	0.18 (0.03-1.02)
20-49 (63/19,790)	0.32 (0.25-0.41)
50-59 (130/10,008)	1.3 (1.1-1.5)
60-69 (309/8583)	3.6 (3.2-4.0)
70-79 (312/3918)	8.0 (7.2-8.9)
≥80 (208/1408)	14.8 (13.0-16.7)

CI, Confidence interval; COVID-19, coronavirus disease 2019.

^∗Case fatality rate estimates are subject to change as more data becomes available. Reprinted from Oke and Heneghan.²

Table II.

Estimated global COVID-19 case fatality rate in patients with comorbid conditions^∗

Condition	Case fatality rate, %
Cardiovascular disease	10.5
Diabetes	7.3
Chronic respiratory disease	6.3
Hypertension	6.0
Cancer	5.6
No comorbidities	0.9

COVID-19, Coronavirus disease 2019.

^∗Case fatality rate estimates are subject to change as more data becomes available. Reprinted from Oke and Heneghan.²

Your concern is understandable. In the current COVID-19 pandemic, reports of exponential increases of confirmed cases; the rising death toll; and limited resources for testing, treatment, and personal protective equipment can cause an overwhelming sense of anxiety, even for health care workers. Health care workers in Italy make up approximately 9% of confirmed COVID-19 cases in that country as of March 10, 2020.⁵ There is no question that physicians are at high risk of exposure and infection. However, as already noted, the cases of infection in adults younger than 65 years have been less severe, resulting in significantly fewer intensive care unit admissions and case fatality rates in the United States, ranging between 0.1 and 0.2 in patients 20 to 44 years old.⁶ Thus, you need to behave professionally and do whatever is required in our joint effort to mitigate this outbreak.

Historically, the physician's duty to treat has been an accepted obligation of the profession, akin to police officers or firefighters willing to place themselves in danger to help others. The current COVID-19 pandemic is a public health crisis that requires physicians, of all specialties, to step up and help. The bottom line is that to fulfill your obligation as a professional in the house of medicine, ensure medical care is delivered to those in need (distributive justice), help patients, and do no harm (beneficence and nonmaleficence,) and for your own dignity, do not call a lawyer! Instead, grab your stethoscope and do the right thing!

–Dr Dermatoethicist.