Managing dermatologic care in a COVID-19 hot zone

Dermatology World Weekly talked to Bobby Buka MD, JD, from The Dermatology Specialists in New York City, about his efforts to keep his practices afloat in a coronavirus “hot zone.” This interview reflects the situation as of April 20.

DW Weekly: Tell us about your practices.

Dr. Buka: I am the CEO and co-founder of one the largest dermatology practices in New York, located in the epicenter of the COVID-19 crisis. We have 17 dermatology offices with just over 200 employees. We have 30 physicians and non-physician providers and we typically see 850 patients a day, pre-COVID-19. We’re currently down to about 150 patients a day, including both teledermatology and in-person visits. 

DW Weekly: How has the pandemic affected your staffing situation?

Dr. Buka: It’s been mixed. We furloughed probably close to 80% of our patient-facing staff, like medical assistants and managers, because there’s much less patient-facing activity at present. For the folks who run our teledermatology platform or receptionists who answer phones off-site and schedule visits, we’ve kept nearly everyone. I have been touched by the way our staff and providers have banded together in the face of this pandemic. We’ve made difficult furlough calls individually to certain providers, and colleagues have shown they are willing to adapt wherever possible. Our staff needs to pay rent and put food on the table for their families, so we’re doing what we can to help them navigate various state and federal programs while also making sure they’ve got a home with us.

DW Weekly: What types of cases are you seeing in person and via telemedicine?

Dr. Buka: There are folks who need acne refills that we absolutely refer to the teledermatology side of our practice. Patients who carry a diagnosis of mild atopic dermatitis or controlled psoriasis are also referred to our teledermatology platform. However, dermatology has a broad spectrum of conditions. Our patients with uncontrolled bullous disorders or cutaneous T-cell lymphoma need to be seen in person. We have faced some criticism from colleagues who would prefer we close, but our practice has a responsibility to safely be part of the health care infrastructure of New York City. Melanoma progression does not stop in the face of COVID-19. Infectious conditions persist. And so out of the 17 practices, we keep six open to serve our various communities. Our patients, many of whom travel hours to see us because so many practices have been forced to shutter, are super grateful for this continuity of care, and we are humbled to show up for them. 

DW Weekly: Tell us how your practices got up to speed and running with telemedicine.

Dr. Buka: We did not have much of a telemedicine system before COVID-19. We now use a mix of our current EHR and password-protected Zoom. We’re all in cost-cutting mode, so the question was: How do we get up and running fastest in a secure HIPAA-compliant fashion to help the patients who need it tomorrow, and not in two weeks or a month? I applaud our operations team, because they had to integrate a platform very quickly and cost-effectively. Well done, Jamie and Carl! We were able to get teledermatology up and running over a weekend.

DW Weekly: How are you protecting your patients who do have to come in for a visit during the pandemic?

Dr. Buka: We have always taken standards for cleanliness, infection-control, and inter-patient sanitization very seriously. Most, if not all, of the sterile practices we now highlight have always been in place. Patients and OSHA expect you to wipe down the exam room in between patients, but now we perform this function more visibly for patient reassurance. Our waiting room – fit for 15 – now only serves one person at a time. If patients get backed up, we move folks back to an exam room. If we get really backed up, we ask the next patient to wait a few minutes outside and we’ll text them when the waiting room is clear. A lot of these recommendations came from our weekly town hall meetings. Each week we take suggestions from our entire staff during our team call – we collect feedback on the challenges our Practice is facing. Does everyone have enough PPE? What can we do to improve staff safety? For example, on a recent call, a nurse suggested that we ask patients to wear masks upon arrival for their visit (before Gov. Cuomo mandated it). Great recommendation. Next day, not only were our doctors wearing masks for visits, our patients were too.

DW Weekly: How are you protecting staff who have to come in?

Dr. Buka: So far, we have a sufficient supply of PPE and disinfectant supplies. Because 11 of our offices are temporarily shuttered, we have been able to redistribute supplies from those locations to offices that remain open. One of the things that we did early days with our health care supply distributor was, even though they were out of supplies at certain points during the month, we asked them to place us on their waitlist for when items were restocked. It was surprising to me how often that simple step resulted in material replenishment.

DW Weekly: What are you doing to strengthen morale among your staff?

Dr. Buka: Humanity is so important, not just for our own sanity, but for future staff retention. I want my staff to know that I don’t have all the answers, but I am willing to get together every week and discuss the answers that I do have. We all get on video conference (your staff needs to see you!), and we share both professional and personal insights. In the early days we had some staff members ask, ‘How do I pay rent? When can I come back to work?’ These are questions that even the governor is struggling with. I can at least say, ‘I don’t know, but this is what we know about unemployment benefits and the various federal assistance programs that may help.’ This transparent humility, I believe, wins us the continued respect and loyalty of our staff.

DW Weekly: What are you doing to attempt to stay afloat through the pandemic, in terms of rent and other expenses?

Dr. Buka: We reached out to our landlords early to discuss the pressures on our business and how we can work together to alleviate near-term fiscal pressure. We want to talk to them now when the situation is still in its early stages. Landlords are going to be facing this issue across the board, and I believe some of the acquiescence that we currently enjoy may gather additional resistance six months from now. We didn’t hear back from about half of our larger landlords, but we tried. Those landlords that did respond were very conciliatory and offered a three-month abatement to be paid off later this year.

DW Weekly: Have you taken advantage of any of the small business relief programs?

Dr. Buka: We applied on the very first morning on the very first day we were allowed to apply for a PPP loan from the CARES Act stimulus program. A couple applications bounced back, and a couple had follow-up questions. We received about one-third of the total CARES Act stimulus package available before they ran out of funds in April. Like many of my colleagues, we are looking for additional relief from the next round of stimulus approved.

DW Weekly: Overall, what are your thoughts about the COVID-19 situation, being in one of the nation’s hot spots?

Dr. Buka: What’s fascinating to me is how this disaster is affecting different parts of the country so differently. There are regions clamoring to reopen and other areas like ours that would not even consider it yet. At least for New York, I believe this will be our new normal through the spring/early summer, but the country as a whole will naturally adapt. For our practice, and many others in high-concentration, urban areas, the floodgates will not open; business will not return to normal overnight. This will be a slow ramp, and we’ll all need to protect our payroll, because patient volume will not immediately return to pre-COVID-19 levels. But it will get there. Until then, I am inspired by my dermatology colleagues who volunteer their time in emergency rooms and urgent care centers across New York state. We all continue to work at their side during this life-changing pandemic.

Bobby Buka, MD, JD, is a co-founder of The Dermatology Specialists, a full-service dermatology practice in New York City with locations across Manhattan, Brooklyn, Queens, and Long Island.

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Are you on the front lines managing COVID-19 patients? Share your story with DWW. Email dweditor@aad.org.