PracticalDermatology

It is by far the most challenging time that any of us has spent as clinicians and dermatologists. The COVID-19 pandemic has altered so many aspects of our lives. The concept and realization that things are just going to be “normal” again is something that is hard to comprehend. Yes, we will go out again, to restaurants and sporting events. We will even get on an airplane again, book a vacation, and attend medical meetings. But that seems like a lifetime away for many, and that is okay. We will make it through this. We will come back stronger and with more determination to make sure that we are all protected and safe, even when we socialize.

For many of us in dermatology, the reality of the past month and for the next several weeks is that we have seen our offices either close or be reduced to “essential and emergency cases” only. That places a pretty big burden on many of us. We are lucky that we do not have too many dermatological emergencies. So how have we been dealing with two of the more common dermatological diseases we see regularly in our clinics: acne and rosacea? How do we “see” our patients and how do we deal with the personal interactions that are the backbone of how we all practice medicine? What is the reality today and what might happen when this pandemic is over? What will become of our practices, and how are we going to maintain what we had? How are we going to get patients to want to come back to our offices so we can have that personal connection with them once again?

Those who know me know that I am one of the most optimistic people when it comes to dermatology and our incredible specialty. I truly think we are blessed. I tell young dermatologists regularly that they should kiss the ground every day in thanks that they are dermatologists. They should be grateful to their mentors who paved the way to be in this incredible specialty of medicine. Yes, there are several sides of dermatology, including medical and cosmetic, that this article will not deal with. The focus here is specifically acne and rosacea. Ahead, we will cover what we are doing now for our acne and rosacea patients. How we are keeping in communication with them, helping them with medicine and reassurance? Where might we be heading in the not too distant future when this is all over? (We will all face concerns about cosmetic dermatology post-COVID-19; many of us use energy-based devices (EBDs) regularly with our acne and rosacea patients, although that, for now, has virtually stopped all over the world.)

Acne and rosacea are two of the “bread and butter” dermatologic diseases that we see every day in our medical clinics. Since the COVID-19 outbreak, the number of these patients coming to our offices is zero in many instances; on occasion others treat an essential need, such as an enlarging cyst that may require an intralesional injection. How many patients have you not seen in the past month with acne or rosacea? Is it substantial? They are not getting your personal interaction; they are not getting a discussion of your treatment instructions; they are not getting to purchase skincare products if that is part of your treatment plan from your office; and they are not learning about other procedures that you do regularly, such as chemical peels or EBDs to help improve their conditions more quickly. All of this is a problem and one that will have an impact now and in the future.

Turning Toward Telehealth

In the COVID-19 era we have turned our attention to telemedicine or teledermatology. This technology is not brand new and has been used by some for quite some time prior to the COVID-19 pandemic outbreak. Since the outbreak started, we have been under Stay at Home or Safer at Home measures in order to prevent widespread dissemination of the virus. Many in the dermatology community have applied those rules to our clinics, in that we are only seeing essential or emergency dermatology visits. This is the correct approach, and for all the dermatologists out there who are following these guidelines, we applaud you; if you are open as usual, that to me is a problem and can be debated at a later time. So without our bread and butter patients coming in to our clinics, what are we doing? We are doing more and more teledermatology “visits” with these patients and doing our very best to care for them during this current situation. In fact, our teledermatology practice has seen an exponential growth in numbers since we began doing this, and so far, as best we can tell, the process is serving those who utilize it very well.

How do we do it in my office? There are many services out there that offer telemedicine for your clinics. Do your research and ask your colleagues what they are doing and which platform they are using. Once you chose the platform, work with your team and set up a work flow that is simple and makes sense for your practice and for your providers. In my clinic, we have four providers and we are all doing teledermatology each and every day at the present time.

It works like this: The patients call the office and the people who answer our phone screen the call for the type of concern the patient is having. If the patient needs a teledermatology “visit,” the patient is then sent to one of our medical assistants who are acting as triage nurses to determine the actual need and if a provider is going to need to speak with the patient. If the patient needs a medication refill, we are doing that at this point and the discussion with the patient can be finished with the prescription(s) being e-mailed to the appropriate pharmacy. If the patient needs a visual examination with the provider, they are sent to our team who verifies insurance and if needed, they will collect a co-pay and then place them in queue for one of the providers to “see” the patient. We will then do a live video chat with the patient and determine what the concerns are, what the best treatment approach should be, explain what prescriptions we are going to be sending in, and answer any concerns the patients might have. We end by discussing if a follow-up visit is required and proceed to end the call. Next, we enter all of the pertinent information into our electronic medical records and send off the prescriptions that we have discussed to the appropriate pharmacy. Following this, we do fill out a super bill and pass this on to our in-house billing team who then forward it on to our billing service.

That may sound like a lot of steps and people involved in our teledermatology process, and maybe it is. But in this COVID-19 period, many of us are trying our best to keep our employees on the payroll and not lay off or furlough workers, which is the decision we made early on. The staff and providers are socially distanced, and everyone is wearing a mask and gloves, while keeping the office clean and as disinfected as possible. For the time being it is working.

Is this the “best” way to practice medicine? I would say “no,” but in this COVID-19 era, this is the best we can do and something that we all should be doing. Taking this a step farther: each person in our office who is involved in the teledermatology part of what we are doing is able to do this remotely via VPN connections to our servers and our computer network, which is another variable that one must consider if you are not in the office, as at this time.

What Next?

Now, this bodes the next question. What is going to happen to teledermatology in the post-COVID-19 era? Many will hope that it will just go away and that we will get back to seeing each and every patient in the office. I hope so, but a more realistic approach will find that teledermatology is something that is here for good and that there will be many that find using this type of technology is “better” than coming into our offices for their care. Each of us will need to determine if this service is something that we will want to continue post-COVID-19. We will have to determine what that will look like for our practices and for our businesses. I believe that my practice will continue to offer teledermatology and incorporate it into our daily clinic lives. I will continue to improve upon it and be able to help those patients who for whatever reason cannot come in to my clinic or need something that I can easily handle via teledermatology.

Focus on Care

Our acne and rosacea patients are getting the “care” they need now from teledermatology. It might not be ideal, and it does take away the personal touch that many of us enjoy. It takes away from adding in-office treatments and procedures. But it has provided a service that has helped with those who have needed us during this time. It has kept our clinics open for these types of visits, which has been a good thing for our employees. I think it is a service that is here for good, and something that we will be adopting in some shape or form in the post-COVID-19 era.