Comment on “Dermatology residents and the care of COVID-19 patients”

To the Editor: As a dermatology resident who is currently redeployed to manage patients with COVID-19, I read this paper¹ with great interest. There are several contextual factors that should be included in this discussion.

Firstly, Table I indicates a 0.32% case fatality rate for ages 20 to 49 years. While the true case fatality rate is likely lower, I must admit the cited 1-in-300 chance of dying if I become infected is not as reassuring as suggested in the paper. Also, additional risks of aerosolizing procedures, such as cardiopulmonary resuscitation, remain uncertain. These risks, known and unknown, carry greater weight when being experienced firsthand.

The subsequent assertions based on ethical principles, the American Academy of Dermatology code of ethics, and the Hippocratic Oath are meaningful but incomplete. If these are the true reasons a resident must accept redeployment to the floors, then the aforementioned fatality rate would not be relevant. If, in fact, “it is… unethical for a dermatologist… to refuse the management of a patient because of medical risk, real or imagined,” this statement would be true even if the case fatality rate were, say, 99%. The paper concerning caring for a patient with Ebola brings up this same point, in fact, and notes that physicians need not be martyrs.²

However, critical questions remain unanswered—difficult questions that I do not have answers for, either, and that warrant more extensive discussion:

• •What level of risk is acceptable? and
• •Who should determine that level?

These are key concerns, especially in the setting of nationwide personal protective equipment shortages and rationing. Hospitals may officially note that staff must not see patients without “adequate” personal protective equipment, but the definition of “adequate” varies from hospital to hospital. (Is it possible this definition varies based on the hospital's personal protective equipment inventory?)

The risk to the resident's family or friends who may be living with them should also be addressed. This risk was particularly meaningful to me as a resident living alone who volunteered to be prioritized for redeployment to try to prevent exposure to my coresidents' significant others and family members.

The power dynamics involved for residents are relevant to this discussion as well. Trainees have very little leverage in these situations. The answer to Reluctant Resident's question, “Can I refuse?” will often be no, regardless of the moral or ethical principles at play, simply because to answer otherwise may jeopardize the renewal of their contract, and it would be highly unlikely that the trainee would be able to complete their training elsewhere to continue their career. Owing to this vulnerable status, they can be redeployed at the expense of their own safety and education with no additional compensation.

I am proud to be helping my community survive this deadly pandemic and eternally grateful to be at an institution that is responsibly navigating this crisis. The aforementioned ethical principles, code of ethics, and Hippocratic Oath are critical to our profession and to this complex discussion. However, trainee redeployment must be considered in full context; residents (in all specialties) have earned that much, at least.