Ethical outpatient dermatology care during the coronavirus (COVID-19) pandemic

Dear Dr Dermatoethicist: I am a dermatologist at a busy practice concerned about continuing outpatient clinic during the COVID-19 pandemic. How do I handle acute medical concerns from patients as well as questions from staff during the pandemic?

—Dr Concerned About Coronavirus

Dear Dr Concerned About Coronavirus: As of March 17, a total of 179,111 confirmed COVID-19 cases have been reported to the World Health Organization, 3503 of which are within the United States.¹ The coronavirus has broad virulence and a 14-day latent period, making risk of viral transmission and subsequent illness high.² In the outpatient setting, dermatologists are challenged with upholding seemingly competing professional duties. For example, triaging a patient who requires urgent in-person evaluation but is at high-risk of COVID-19 transmission or illness illustrates the current moral dilemma facing dermatologists. Values also conflict when the very measures that protect staff and others from infection threaten employee salary and practice solvency.

Dermatologists at West China Hospital, located in a province hard-hit by 2019-nCoV, initially closed outpatient clinics and cancelled elective operations.³ As the pandemic progressed, they resumed outpatient office visits and operations on a case-by-case basis.³ The timeframe of return to outpatient services and triage decision-making strategies were not described. Similarly, some dermatologists in the United States have temporarily closed their practices to reduce transmission risk. From a public health standpoint, the decision to temporarily close a practice is reasonable. It reduces infection risk not only for patients, staff, and providers but also for others in contact with them. However, closing practices prevents providers from delivering needed care and has financial consequences for the practice and staff.

Teledermatology permits consultation without increased risk of infection, is cost-effective, and provides accurate diagnostic information.⁴ Providers can use teledermatology for routine follow-up appointments and to triage individual patients for emergency in-person care. Providers who have temporarily ceased in-person visits could transfer most visits to teledermatology. Regulatory and reimbursement requirements for telemedicine have eased substantially during the pandemic.⁵

Not all patients, however, have the desire, skills, or technology to engage in teledermatology and may have dermatologic problems that are not amenable to telemedicine. Elderly patients, for example, may be unable to participate in teledermatology but are at high-risk for COVID-19 infection and dermatologic emergencies that require in-person care. Despite these limitations, teledermatology is a useful tool for providing adequate outpatient care for many patients during the pandemic.

Significantly reducing office-based, in-person services while increasing teledermatology consultation has the potential to permit effective and reimbursable dermatologic care that also upholds public health. Keeping patients with dermatologic conditions out of overwhelmed emergency rooms and urgent cares, where the risk of contracting or spreading COVID-19 may be high, is critical.⁶ Ultimately, dermatologists will need to determine what warrants an urgent office visit during the pandemic. Dermatologists should weigh the potential harm of delaying an in-person visit against the potential harm of COVID-19 infection to the patient, practice, and community. We argue that only those cases in which the delay of in-person care exceeds the risk of COVID-19 infection should be considered for evaluation in the office during the pandemic.

—Dr Dermatoethicist