Practicing during a pandemic

By Emily Margosian, assistant editor, May 1, 2021

While the ongoing national vaccine rollout has offered a glimmer of light at the end of the tunnel, COVID-19 isn’t over yet. More than a year has passed since the first COVID-related shutdowns began affecting daily life in the United States, and many dermatology practices are still operating through profound changes caused by the pandemic. Dermatologists have had to face difficult financial decisions, adopt telemedicine nearly overnight, and navigate evolving public health guidelines to keep patients and staff safe. 

This month, DermWorld speaks with dermatologists across the country from different practice settings about how COVID has impacted their daily operations, the challenges they’ve faced, and their predictions on what changes will persist after COVID-19. 

Infection control and patient safety measures 

While businesses across the country shuttered in the spring of 2020, medical practices had to quickly adapt in order to safely provide care to patients. Many visits now begin at the appointment pre-screen. “Like most clinics, all of our patients are screened prior to their visit and during check-in. They all get a phone reminder asking if they have symptoms. The same thing happens when they come into the office, and we are doing temperature checks for everyone who comes in,” said Sara Perkins, MD, assistant professor at Yale University School of Medicine. 

Robert Buka, MD, JD, founder of The Dermatology Specialists in New York City, has also implemented a standard patient questionnaire about recent out-of-state or foreign travel and the presence of COVID-related symptoms. “These are all things that have become second nature for the practice,” he said. “Even simple steps, like a temperature check upon arrival — which doesn’t rule-in or rule-out infection — helps patients feel better and reassures providers as well. We’re learning; there’s some trial and error as we roll out steps for the first time.” 

Many offices have also implemented new patient flow strategies during check-in or longer procedures to reduce time spent in a waiting room. “For example, during photodynamic therapy, we used to have patients wait in the office during their incubation time between application of the aminolevulinic acid hydrochloride and when they would sit underneath the light. Now we allow them to go home or sit in their car, and obviously we review critical sun protection with them during that time,” said Dr. Perkins. “It avoids taking up a room and prevents another person from sitting in the waiting room. In our Mohs unit, we also used to have a communal waiting room with pastries and coffee. Our Mohs director jokes that he’s no longer in the catering business, and now we have patients wait in the exam room between stages to avoid anyone congregating in a communal space.” 

Changes to the physical office space 

Many dermatology practices have undergone a transformation of their physical layout in order to meet the safety demands of the COVID era. “There were a lot of things we had to do to make the office safe for both staff and patients,” said Alexander Gross, MD, a dermatologist in solo practice in Cumming, Georgia. “We took the majority of the chairs out of our waiting room and made sure those that remained were six feet apart so people could stay socially distanced. The International Sheet Metal Workers Union also donated some plexiglass windows for our front office so the staff who do intake and check-out were separated from patients. We started taking everybody’s temperatures — both patients and staff.”

Dr. Buka’s practice has also had to re-engineer its use of waiting rooms due to the physical constraints posed by some of their locations. “In one of our smaller offices, where the waiting room just can’t hold more than 10 people, we spaced out appointments a bit further,” he said. “In our offices with larger waiting rooms, we distance patients every fourth seat, and bring folks back to exam rooms much faster.” 

Dr. Buka’s practice has also implemented a touchless sign-in process with plexiglass front-desk partitions and sign-in kiosks that are sanitized after each patient use. “These are newer interventions in terms of how we practice,” he said. “Once you’ve got patient and provider back in an exam room, you now only need two people to be either COVID-negative or vaccinated. The waiting room, on the other hand, is a high-touch area where our best initiatives are focused.”  

Patient volume

Due to the initial adjustment period at the pandemic’s onset, followed by an ongoing ebb and flow of shutdowns since, many practices have experienced fluctuations in their patient volume over the past year and a half. Prior to COVID-19, Dr. Gross’s practice saw approximately 100 patients per week. By early COVID, they were seeing no more than 10. “We were limiting patients at that time to urgent and emergent care. Mainly people with infections or wounds. The overwhelming majority of patients we normally see had to be postponed,” he said. “That went on for five weeks. Although Georgia was one of the first states to re-open, it probably took us three months to get close to our original patient volume. Our cancellation and no-show rates are still very high. There are some days where as many as 20% of patients who are scheduled will either cancel or not show up. We anticipate that will fade as more people become vaccinated and feel safer about in-person visits. I honestly can’t blame people for wanting to protect themselves or still being concerned about going out in public.” 

In 2020, many residents fled the downtown districts of major U.S. cities, opting to quarantine with more square footage. Dr. Buka has observed some correlation between the COVID population shift and patient volume at some of his practice’s locations. “In June, we fully opened back up again, and patients felt increasingly comfortable leaving their apartments. We were at about 120% of our pre-COVID volume, because folks had missed their appointments in April and May and wanted to catch up, so we observed a big bump,” he said. “There’s been an interesting bifurcation, however: an influx of patients from the boroughs, like Brooklyn and Queens, while things remain slightly slower in Manhattan. A lot of New Yorkers have moved out of the City and have yet to come back.” 

Not all practices scaled back in 2020, however. “I think we’re back to about 80% of what our pre-COVID volume was,” said Vinh Chung, MD, a dermatologist in group practice in Colorado Springs. While many practices have experienced closures due to dips in patient volume, Dr. Chung’s office has expanded during COVID. “We actually opened up a sixth office in the midst of all of this, and are looking at adding two more next year,” he said. “These are decisions that were put in place before COVID happened, and we decided to move forward because we are thinking long-term. When shutdowns happen, it’s easy to be scared, but we are offering a valuable service as a medical office. Everyone needs dermatology care. We take care of skin cancers, which will not slow down. Regardless of the constraints we have gone through, we will re-emerge eventually and continue to take care of our community.” 

Scheduling changes 

COVID has also imposed new changes on many practices’ scheduling policies. Some have placed caps on the number of patients seen to avoid a high volume of people physically present in the office. Others have implemented longer workdays to stagger more time between patient visits to avoid back-ups and allow for full sanitization of exam rooms.

“We now have evening hours, which we added during COVID,” said Dr. Chung. “We’ve also made some adjustments due to childcare issues with our providers because of school being in flux.” 

Within the Yale system, COVID has also produced more flexibility to schedule visits for shorter durations. “Initially we were staggering appointment times to minimize the number of people sitting in the waiting room. Now we’re mostly back to our pre-COVID schedules,” said Dr. Perkins. “The biggest change is that we used to double-book. If we needed to add a patient, the default was, ‘Ok, just put them also at 9:45.’ Now we’ve changed templates to do 10-minute visits rather than 15 or add in a few five-minute visits for things you know are relatively quick. We’ve moved away from the standard of giving everybody a 15-minute slot and just doubling up when needed, to having a more flexible template where everyone has a slot, and the slots vary in time. It’s helped flow-wise and keeps us more uniformly on time throughout the day.” 

Personnel changes

Staff are the backbone of any practice, and COVID has put significant pressure on both staff and their employers from an economic and safety standpoint. 

Some practices have explored remote work as a way to reduce staff physically present in the office and cut down on potential viral exposures. This solution has its limits, however, depending on the staff member’s role within the practice. “We had medical assistants — whose entire role is patient-facing — ask to work from home, and that was hard, because I don’t have much for medical assistants to do in a telederm environment,” said Dr. Buka. “It really was role-specific. Even our office managers really couldn’t work remotely within their job description. Where we could, we tweaked job descriptions, and moved staff to an area where they could work remotely. In instances that were more intuitive, like our billing or coding personnel, absolutely: stay home, log in, and do all your work that way.” 

Dr. Chung’s practice also allowed non-clinical staff to work from home. “We utilize remote staffing to the extent that we can. Basically, if you aren’t patient-facing, then you’re working from home, which is something we’re continuing to do even today,” he said. “It’s only a temporary substitute, because there is so much value in physically being in the same space with your teammates.” 

Practices may also experience unexpected absences or fluctuations in staff due to COVID infection or self-quarantine following possible exposure. If a staff member does become infected, practices should consult CDC guidelines on when infected staff may return to work, as well as with their attorney, office manager, or representative responsible for HR concerns, for guidance on leave and benefits available to eligible employees. 

While the culture in medicine regarding coming to work sick has historically been lax (see responses for DermWorld’s January 2019 Water Cooler column, “How ill do you need to be to take a sick day?”, COVID has radically reset those norms in many workplaces. “I feel we have a much greater and healthier respect for contagious diseases, from simple colds to COVID,” said Dr. Chung. 

Unfortunately, there have also been widespread cuts in staff due to the financial impact of COVID. According to a May 2020 Commonwealth Fund report, dermatology is reportedly among one of the hardest-hit specialties, among other “surgical and procedural specialties and pediatrics.”

The financial impact of the immediate shutdown was a challenge Dr. Buka’s practice had to navigate. “I think we were more broadly hit because of our size, which at the time included 20 offices and 225 employees. We had a lot of administrative mouths to feed and corporate expenses that we did not have when we were a much smaller practice,” he said. “At the pandemic’s height, we had five offices open out of 20, so we offered as many working hours as we could, despite low patient census. Because of the excellent morale we built prior to COVID, most of our team stuck it out and understood we were all going through it together. When we came back fully after four or five months, just a few support staff members had understandably moved on.” 

Due to a 90% reduction in patient volume during the early days of the pandemic, Dr. Gross also had to impose temporary reductions on staff. “I ended up having to furlough 13 of my 19 employees. I’ve been in private practice now for 31 years, and I have employees who have been with me for 10 years. These people are my family, and I let them know at the very beginning that we were going to take care of them, and make sure that neither they nor their families suffered,” he said. “We got our stimulus checks from the government and that was very helpful. Then we got a Paycheck Protection Program (PPP) loan. We continued to pay for their medical insurance even while they were furloughed and made sure that all of their benefits remained in place. We got them unemployment through the state. When we were able to reopen, we brought all of our staff back.” 

Changes in health care delivery: The rise of telemedicine

According to results from the Academy’s Dermatologist Experience Under COVID-19 Survey, teledermatology use veritably skyrocketed during the pandemic, leaping from 9% adoption pre-pandemic to 90% by May of 2020. 

This yielded a steep learning curve for dermatology practices, many of whom did not have a platform in place to see patients virtually. “We hadn’t really used that modality much before as a department, but we learned a lot and optimized our process,” said Dr. Perkins. “In some ways, telemedicine has stuck with us throughout the past year.” 

“Telederm is fascinating,” agreed Dr. Buka. “We had telederm in place before it became widely popular, but COVID did force us to improve upon it significantly from what we had before. We were able to streamline the tech and make it a lot more user-friendly.” 

As COVID case rates have fluctuated, so has patient demand for telemedicine. “When COVID has been really active in the community, more patients request telemedicine visits or have requested to change their visit from in-person to telemedicine,” said Dr. Perkins. “For example, this past fall and winter, when the numbers were higher here and everywhere in the country, we saw more patients requesting telemedicine visits. Whereas in the summer and early fall, when Connecticut was doing pretty well in terms of our numbers, patients were more comfortable coming into the office.” 

Dr. Gross’s practice has utilized telederm for patients with active COVID infections in need of safe access to dermatologic care. “We’ve had a couple of patients actively infected with COVID-19, who we obviously did not want to come into the office. If someone has an active infection, and an issue that can be addressed with telemedicine, then it’s a great tool,” he said. “I think it’s not ideal for trying to diagnose pigmented lesions or sussing out the subtleties of certain types of rashes. My preference, if I’m trying to make a new diagnosis or examine skin lesions, is to see patients in person.” 

“I’ve been in private practice now for 31 years, and I have employees who have been with me for 10 years. These people are my family, and I let them know at the very beginning that we were going to take care of them, and make sure that neither they nor their families suffered.”

While some practices have scaled back teledermatology as the situation has evolved, others have adapted it for use as a triage tool going forward. “When a patient calls or sends a question through our patient-facing portal, we can turn that into a tele-triage visit where the doctor decides if the patient really needs to come in, or if they can do some initial management over telemedicine and then decide the need for follow-up from there,” said Dr. Perkins. 

How do dermatologists anticipate their telederm use in the future? It depends. “I think the answer is going to vary depending on who you talk to. I personally really do think that this care modality is going to stick around long after the pandemic, partly because patients love it,” said Dr. Perkins. “For example, my isotretinoin patients normally have to come into the office every month for the duration of treatment, which can vary from six to 10 months. That can be a burden depending on where they live and where they’re traveling from. Whereas it’s much easier to pop into the video visit for a quick check-in, and it really serves all the purposes of counseling that we need. I suspect that demand for that is going to persist even after we’re out of the pandemic stage.”

Dr. Buka’s practice, however, has seen telederm visits drop off a bit in favor of in-person visits. “We’re still using telederm, but its utilization has really slowed since folks are more comfortable coming back to the office. It was wonderful when we needed it, but at the end of the day, a lot of what dermatologists do is procedure-oriented, and that’s obviously off the table for telederm. Virtual visits are adequate for acne or eczema refills, but screens-only really does hamstring the full spectrum of care that we’re trained to deliver.” 

As patient and physician interest in teledermatology has accelerated during COVID, so has outside interest in the space. This is something dermatologists should be aware of, advised Dr. Perkins. “Interest in telemedicine was building before COVID, and it’s absolutely accelerated over time. There are a lot of people entering into the dermatology telemedicine space that aren’t necessarily dermatologists — private companies, for-profit companies — and so I think we have a responsibility in some ways to our patients to fulfill that demand as those best qualified to provide that care.” 

COVID silver linings

While COVID has left immeasurable loss in its wake for many, crisis has historically played a role as a catalyst for change. For Dr. Perkins, health care’s rapid adoption of telemedicine proved the profession to be nimbler than perhaps suspected, while paving the way for more accessible modes of health care delivery. “Being pushed to embrace or at least get familiarized with telemedicine is the biggest silver lining, I think. We made really tremendous strides in adoption that would not have happened if our hands weren’t otherwise forced,” she said. “There are certainly a lot of areas of frustration with telemedicine, but there are also a lot of opportunities to enhance or optimize the process. A lot of practicing dermatologists weren’t very involved with telemedicine before, and now many of us are. I think that’s actually a very good thing for patients.” 

According to Dr. Buka, the crisis has in some ways reinvigorated the physician-patient relationship. “One enhancement to arise from the pandemic is improved contact with our patients. Historically, we might only reach out once a year with a skin cancer screening reminder. Now, we’re in contact more often. I think it was important to let patients know that, throughout the pandemic, our practice The Dermatology Specialists is a stable medical presence, and we will find a way for you to get your skin care. COVID helped us fine-tune that patient connection,” he said. 

What will carry on after COVID?

While the ongoing rollout of new vaccines offers a glimpse at life after COVID, certain behaviors are likely to persist as “the new normal” after the pandemic is under control. “I could certainly see masks sticking around, especially during cold, flu, and what may become COVID season,” said Dr. Perkins. “Personally, in my own practice, I was the person who didn’t wear gloves for the entirety of a total body skin exam. I felt like I needed to feel the texture of AKs. Now I obviously wear gloves for the entire duration of the visit, start to finish, and I do think that’s something I’ll continue to do even after the pandemic.” 

Dr. Chung agrees that masking in particular is likely to stick around after COVID. “Going forward, during flu season for example, I would not be surprised if there will be new policy for staff and patients to wear a mask if they are going to come in,” he said. 

Certainly, we all are much less likely to go to work sick in the future — especially if that workplace is a medical practice. “Moving forward, if we have a staff member who’s not feeling well, it doesn’t matter what’s bothering them, we’re going to make them stay home,” said Dr. Gross. “If you’ve got a cold or the flu, we don’t want you in the office spreading it around. I think we will be much more cognizant of our own health and our employees’ health going forward.”

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