December 2019 saw the world’s first cases of the novel coronavirus outbreak caused by the virus now known as SARS-CoV-2, in Wuhan, China.1 January 2020 brought the United States’ first case of COVID-19 in Washington state.1 March 2020 saw the declaration of a global pandemic by the WHO, followed by the implementation of national and statewide recommendations to halt all non-essential medical services, including cosmetic and non-urgent procedures.2 Although teledermatology has been widely utilized throughout the pandemic and restrictions on elective medical services were recently lifted, the months-long shutdown produced economic ramifications that may affect medicine and the field of dermatology for years to come. Hospitals and practices may still be operating at lower capacity to ensure social distancing, resulting in a lower possible number of daily appointments and loss of revenue. For example, one of our own training institutions was still operating at 25 percent capacity at the time of authorship. As of April 2020, only 20 percent of surveyed dermatology practices in New York City were open, with some only offering urgent procedures.3 In Italy, dermatology consultations dropped by 80-90 percent during the pandemic.4
Third-year dermatology residents are graduating into this uncertain job market, with anecdotal evidence of delayed start dates, reduced compensation, lost signing bonuses and incentives, reduction from full time to part time offers, and floundering practices with some facing permanent closures. Many universities and hospital systems have implemented hiring freezes, and new hires have had start dates delayed by up to six months, including this author (TC). There is also anecdotal evidence that some residents have been forced to find temporary work to fulfill their financial obligations in the interim. Other residents report losing the signing bonuses that were their incentives for accepting offers or having entirely lost their promised base salaries in exchange for exclusively collections-based compensation. Our own Wayne State University dermatologists took a 30 percent cut in base pay in April, lost 403b matching, and will now receive Relative Value Unit (RVU)-based pay. Twenty-one percent of the more than 840 physician respondents (66 percent of whom were specialists, with an unknown proportion of dermatologists) from a recent survey from recruitment firm Merritt Hawkins and The Physicians Foundation indicated that they had either been furloughed or received pay cuts.5 Some private practices closed their doors during the pandemic for the last time.
Many of the lasting consequences of the novel coronavirus outbreak remain to be seen, but it is likely to change the landscape of dermatology practice for years to come. Recruitment, compensation, social distancing practices, and utilization of teledermatology may look different going forward.
It remains to be seen how long the expansion of telehealth coverage by the Centers for Medicare & Medicaid Insurance will persist.6 Will the perennial popularity of dermatology wane due to the uncertainty of the job market and slashed pay, as this year’s graduating residents are left jobless for months in the face of an average debt of around $200,000? Or will inpatient dermatology consults increase from their drop early in the pandemic as our specialty’s utility in recognizing the early cutaneous manifestations of COVID-19 (as described in the AAD COVID-19 Dermatology Registry) aids in diagnosis?4
Further study specific to the effects of the SARS-CoV-2 pandemic on the field of dermatology are warranted. We may suggest that graduates who find themselves affected by these changes to the job market serve in rural areas for the time being, where the need for dermatologists is still great.7
The authors received no funding for this article and have no conflicts of interest.
Legal Expert Addresses Employer Questions During COVID-19
Practical Dermatology® magazine spoke to Josh Alloy, JD, Counsel at Arnold and Porter in Washington, DC, about common questions from medical practices about employee management in the face of COVID-19. Visit PracDerm.com/covid19 to read the full story. Here, a look at employee behavior outside the office.
Can I ask employees to practice safety measures outside the office? Can I sanction those who do not?
“For the most part, employees are at-will, which means their employment can be terminated at any time for any reason—as long as it’s not an unlawful reason,” says Mr. Alloy. Employees who flout practice guidelines to host or attend a large dance party with hundreds of maskless attendees could be deemed to show poor judgment and present a risk to existing staff and patients. This is also true if that employee is a partner or lead physician whose actions could impact the reputation and business of the practice.
“There are exceptions,” Mr. Alloy notes. Some employees, including many physicians, may have an employment contract that has limitations on when their employment can be terminated. Some state laws make it illegal to discriminate or take employment actions against someone for engaging in lawful outside activities.
“At the end of the day, I think employers that find out that employees are engaging in high-risk and irresponsible behavior outside of work that has the potential to lead to either reputational risk for the practice or worse, or creates a health and safety risk for the practice, they can take action,” Mr. Alloy offers. “I don’t think that most employers want to be going out of their way to monitor or police outside personal activity for the most part, though.”
1. Holshue ML, DeBolt C, Lindquist S, et al. First case of 2019 novel coronavirus in the United States. N Engl J Med. 2020;382:929-36
2. CMS Releases Recommendations on Adult Elective Surgeries, Non-Essential Medical, Surgical, and Dental Procedures During COVID-19 Response [press release]. CMS.gov, March 18, 2020.
3. Muddasani S, Housholder A, Fleischer AB. An assessment of United States dermatology practices during the COVID-19 outbreak [published online ahead of print, 2020 Apr 15]. J Dermatolog Treat. 2020;1-3. doi:10.1080/09546634.2020.1750556
4. Gisondi P, Piaserico S, Conti A, Naldi L. Dermatologists and SARS-CoV-2: the impact of the pandemic on daily practice. Journal of the European Academy of Dermatology and Venereology. 2020;34(6):1196-1201.
5. Merritt Hawkins TPF. Physicians and COVID-19: A Survey Examining How Physicians are Being Affected by and are Responding to the Coronavirus Pandemic. Merritthawkins.com April 2020
6. Medicare telemedicine health care provider fact sheet. [fact sheet]. CMS.gov, March 17, 2020.
7. Feng H, Berk-Krauss J, Feng PW, Stein JA. Comparison of Dermatologist Density Between Urban and Rural Counties in the United States. JAMA Dermatol. 2018;154(11):1265-1271. doi:10.1001/jamadermatol.2018.3022
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