dermatology in the age of covid19

[asmallchild]

how is everyone handling clinic?

as a mohs surgeon, there are some cases i don’t feel comfortable leaving for a few weeks to months from now

on the other hand, i’m also deeply uncomfortable with grouping a bunch of 60+ year old patients in the waiting room for hours

have people started canceling or closing clinic to see how everything shakes out?

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[dermie1985]

how is everyone handling clinic?

as a mohs surgeon, there are some cases i don’t feel comfortable leaving for a few weeks to months from now

on the other hand, i’m also deeply uncomfortable with grouping a bunch of 60+ year old patients in the waiting room for hours

have people started canceling or closing clinic to see how everything shakes out?

Yes, cancelling/postponing visits such as routine skin checks, switching to phone visits whenever possible if things can be discussed over the phone. We’re continuing in person visits for some patients who we feel would still need in person evaluation - but this could certainly change in the next few weeks.

 

[doctalaughs]

Cancelling essentially everything unless it’s an invasive melanoma or rapidly growing poor diff SCC. Rashs etc evaluate over phone (and hopefully with a picture) just to make sure it’s not life-threatening.

Our practice this week will probably go from seeing 300-400 patients a day down to 4-5 essential ones.

Going to see a huge decline in revenue but it’s the right thing to do. Anyone continuing to see routine stuff is doing a big disservice to their patients and will not be looked at kindly when this is done. We are one of the most successful practices in my area and I estimate we can withstand 2-3 months of essentially shuttered-doors before having to cut payroll.... (this is with of course a big reduction in partner profit projected)

 

[asmallchild]

Cancelling essentially everything unless it’s an invasive melanoma or rapidly growing poor diff SCC. Rashs etc evaluate over phone (and hopefully with a picture) just to make sure it’s not life-threatening.

Our practice this week will probably go from seeing 300-400 patients a day down to 4-5 essential ones.

Going to see a huge decline in revenue but it’s the right thing to do. Anyone continuing to see routine stuff is doing a big disservice to their patients and will not be looked at kindly when this is done. We are one of the most successful practices in my area and I estimate we can withstand 2-3 months of essentially shuttered-doors before having to cut payroll.... (this is with of course a big reduction in partner profit projected)

Thank you to everyone for posting their experiences and this i particular

I think I am going to start doing this against the wishes of my employer. We will see if I still have a job when this blows over but I agree with you, it is the correct thing to do.

 

[TMP-SMX]

Academic practice general derm here. We are open for urgent infections, inflamed cysts, rashes/melanoma excisions. We start telederm next week.

 

[PhillyMed777]

Telederm is the way to go — and there are some growing pains for sure

 

[dermie1985]

Academic practice general derm here. We are open for urgent infections, inflamed cysts, rashes/melanoma excisions. We start telederm next week.

We're doing telephone visits and urgent in-person visits. Switching to mostly store-and-forward and video telederm next week. Still doing in-person visits for urgent visits, excisions, etc.

 

[PhillyMed777]

Telederm should be compensated by insurance companies. I’m sure everyone knew that already.

 

[asmallchild]

We're doing telephone visits and urgent in-person visits. Switching to mostly store-and-forward and video telederm next week. Still doing in-person visits for urgent visits, excisions, etc.

are you filtering what excisions come into the office?

 

[Skindoc83]

I have a lot of questions/concerns. If you shut down your practice now, what are the criteria by which you reopen? This is going to last months, not two weeks. If I shut down for three months, I can’t afford to pay my staff. Now if in four months I want to reopen, I will need to hire all new staff, grossly hampering my ability to quickly ramp back up. As a mohs surgeon I treat a lot of non-emergent lesions, but without knowing how long I might be shutting down for, I’m not comfortable saying a certain lesion can be left for that period of time. Can a BCC on the ala wait two weeks? Absolutely. can it wait four months? Maybe.... Not to mention there are a lot of things that we treat in derm that are not urgent. But that doesn’t mean patients won’t think it’s not urgent. So if I am unavailable to treat someone’s acne or cyst that person is likely to show up at the ED. How do I know this? Because patients call my answering service at 3am for acne med refills or because her face itches. I have a lot of employees who rely on me for paychecks and I believe that I serve an important Function keeping garbage out of the ED. So my plan is to stay open for as long as economically feasible and then I will switch to telederm.

 

[asmallchild]

I have a lot of questions/concerns. If you shut down your practice now, what are the criteria by which you reopen? This is going to last months, not two weeks. If I shut down for three months, I can’t afford to pay my staff. Now if in four months I want to reopen, I will need to hire all new staff, grossly hampering my ability to quickly ramp back up. As a mohs surgeon I treat a lot of non-emergent lesions, but without knowing how long I might be shutting down for, I’m not comfortable saying a certain lesion can be left for that period of time. Can a BCC on the ala wait two weeks? Absolutely. can it wait four months? Maybe.... Not to mention there are a lot of things that we treat in derm that are not urgent. But that doesn’t mean patients won’t think it’s not urgent. So if I am unavailable to treat someone’s acne or cyst that person is likely to show up at the ED. How do I know this? Because patients call my answering service at 3am for acne med refills or because her face itches. I have a lot of employees who rely on me for paychecks and I believe that I serve an important Function keeping garbage out of the ED. So my plan is to stay open for as long as economically feasible and then I will switch to telederm.

Some very good questions/concerns

We aren't shutting down our practice

We will remain open for urgent issues: skin cancers (melanomas, infiltrative SCCs, BCC on ala, etc), inflamed cysts, new onset rashes, etc

We do have a telederm service that we hope will cut down on the amount of traffic into our office.

I agree shutting down completely probably isn't the right response but business as usual probably isn't the correct one either. Hoping to straddle the middle and see how we fare (it was business as usual for us this week, we have begun implementing changes starting Monday given the recommendations by the AAD and the ACMS)

 

[werd]

we ramped way down early in the week, and yesterday made the decision to shut down nearly completely... one physician in the office per day to see urgent things like severe rashes, big inflamed cysts, do the couple melanoma excisions etc. that are in the queue. starting telederm and hoping to ramp it up as quickly as possible.

 

[TMP-SMX]

Many states have now outlawed elective surgeries as a "misdemeanor". More ammo to get patients into telederm first to save them a trip.

 

[asmallchild]

Thanks again for all the replies, hope everyone stays safe

I think we made the choice to begin shutting down too since now the AAD and the ACMS have released definitive statements that we really should be deferring as many in-office visits as possible

 

[doctalaughs]

Thanks again for all the replies, hope everyone stays safe

I think we made the choice to begin shutting down too since now the AAD and the ACMS have released definitive statements that we really should be deferring as many in-office visits as possible

Agree. New NCCN guidelines and ACMS say even most invasive melanomas should be deferred (and definitely mmis). If you are still doing Infiltrative BCC next week it certainly could be grounds for loss of your medical license....

We are shut down and trying to do telederm. Have reserves to pay staff for 3 months.

 

[reno911]

Agree. New NCCN guidelines and ACMS say even most invasive melanomas should be deferred (and definitely mmis). If you are still doing Infiltrative BCC next week it certainly could be grounds for loss of your medical license....

We are shut down and trying to do telederm. Have reserves to pay staff for 3 months.

The language is not that strong at least not in the ACMS guidance. It doesn't say "should be", it says to consider delaying. That's a huge difference and I think will make any attempts to take your license over this ineffective. They also have carve outs for "highly symptomatic BCCs" and BCCs with "potential for signficant rapid growth" (not even sure what that means, to be honest).

 

[reno911]

Many states have now outlawed elective surgeries as a "misdemeanor". More ammo to get patients into telederm first to save them a trip.

You have a link on "many states" doing this. I did a quick google search and I couldn't find it. I suppose I could have tried harder, but I figured it would be easier to ask you.

 

[username456789]

Agree. New NCCN guidelines and ACMS say even most invasive melanomas should be deferred (and definitely mmis). If you are still doing Infiltrative BCC next week it certainly could be grounds for loss of your medical license....

We are shut down and trying to do telederm. Have reserves to pay staff for 3 months.

I cannot imagine any of this would involve losing one’s medical license.

 

[dermie1985]

are you filtering what excisions come into the office?

Only excisions or MMS for malignant lesions. No benign lesions. We're deferring cyst excisions, but can be seen for ILK, I&D, oral abx, etc. for an inflamed cyst. Exact guidelines in flux. I only do 2 excisions per week, so hasn't really affected me much yet.

 

[reno911]

Only excisions or MMS for malignant lesions. No benign lesions. We're deferring cyst excisions, but can be seen for ILK, I&D, oral abx, etc. for an inflamed cyst. Exact guidelines in flux. I only do 2 excisions per week, so hasn't really affected me much yet.

Apparently NCCN has recommended deferral of excision of T0 and T1A melanomas for upto 3 months (or more in some cases), so arguably you can close of to all melanomas that you would excise. Most everything beyond that will have an indication for SNLB and you wouldn't be excising it in the office anyway (in most cases).

I think I'm on board for the MMIS, but if I were a young person with an thin melanoma I wouldn't want to wait 3 months even if NCCN is fine with that.

 

[doctalaughs]

Apparently NCCN has recommended deferral of excision of T0 and T1A melanomas for upto 3 months (or more in some cases), so arguably you can close of to all melanomas that you would excise. Most everything beyond that will have an indication for SNLB and you wouldn't be excising it in the office anyway (in most cases).

I think I'm on board for the MMIS, but if I were a young person with an thin melanoma I wouldn't want to wait 3 months even if NCCN is fine with that.

I think doing an invasive T1a melanoma is certainly reasonable for many patients.

I think doing essentially any BCC at this point you are on very thin ice. Especially if the patient is > 65 or with comorbidities - perhaps no one would take your license but it’s probably highly unethical. If I got wind that a Mohs guy was still doing that - definitely would never see another referral of one of my patients - ever.

 

[TMP-SMX]

You have a link on "many states" doing this. I did a quick google search and I couldn't find it. I suppose I could have tried harder, but I figured it would be easier to ask you.

WA, MI, OH, FL, CO, MA, CA, NYC. I'm sure there's more.

I just notified a younger patient regarding her MMIS on the leg. She's an anxious person. I'll have to think about if I'm rescheduling this if MMIS isn't life threatening over the next few weeks... I may have to call her back to move her to mid April.

 

[reno911]

I think doing an invasive T1a melanoma is certainly reasonable for many patients.

I think doing essentially any BCC at this point you are on very thin ice. Especially if the patient is > 65 or with comorbidities - perhaps no one would take your license but it’s probably highly unethical. If I got wind that a Mohs guy was still doing that - definitely would never see another referral of one of my patients - ever.

Yeah, gotta disagree with that. It is completely dependent on the situation.

If you are thinking of cutting off a Mohs surgeon for that reason, I'd advise you to at least talk to them first and find out what the exact situation was. There are certainly reasons why one would do this.

Here's a recent example I came upon:

~70 year old woman has poorly diff SCC on ear, accompanied by ~70 year old husband who has a BCC on his forehead. He was going to be with her at the appointment whether he had a tumor or not. She doesn't drive and needs help getting around. No reason not to treat both.

The point here is that if you heard of a Mohs surgeon treating a BCC, your default assumption ought to be that they probably had a good reason or they wouldn't have done it. I would think that anyone you trust enough to refer to regularly can be trusted to make good decisions in general.

 

[reno911]

WA, MI, OH, FL, CO, MA, CA, NYC. I'm sure there's more.

I just notified a younger patient regarding her MMIS on the leg. She's an anxious person. I'll have to think about if I'm rescheduling this if MMIS isn't life threatening over the next few weeks... I may have to call her back to move her to mid April.

It's not that I don't believe you, but can you post a link to source. I'm interested in reading about exactly how the laws are written.

 

[TMP-SMX]

It's not that I don't believe you, but can you post a link to source. I'm interested in reading about exactly how the laws are written.

If there's one source it would significantly simplify the search but it's not one source posting the above. I'll post the source for the Michigan executive order as an example.

 

[doctalaughs]

Yeah, gotta disagree with that. It is completely dependent on the situation.

If you are thinking of cutting off a Mohs surgeon for that reason, I'd advise you to at least talk to them first and find out what the exact situation was. There are certainly reasons why one would do this.

Here's a recent example I came upon:

~70 year old woman has poorly diff SCC on ear, accompanied by ~70 year old husband who has a BCC on his forehead. He was going to be with her at the appointment whether he had a tumor or not. She doesn't drive and needs help getting around. No reason not to treat both.

The point here is that if you heard of a Mohs surgeon treating a BCC, your default assumption ought to be that they probably had a good reason or they wouldn't have done it. I would think that anyone you trust enough to refer to regularly can be trusted to make good decisions in general.

I’m sure there are rare extenuating circumstances —and I’m certainly not going to assume things based on 1 tumor I heard of. I wouldn’t judge too much about the situation you describe although it’s far from clear-cut (many would go to great lengths to tell the husband to find alternative transport for a very low risk procedure for wife, give him mortality stats on covid19 at his age, tell him that some states are banning elective procedures like his etc).

However, most general dermatologists will review their patients Mohs notes and see a large “N” from each referral source (usually they only have 1 or two sources — so that’s a lot of tumors). I wouldn’t be too happy if I found that “the rare exception” was suddenly “a good proportion” of low risk tumors.

I’m well aware of the financial hit running a practice (it’s a HUGE hit) but it’s a slippery slope to try to justify more and more “exceptions.” There’s really not much in dermatology that will kill you in a month or so (I would estimate far less than 1%). I would say on average most practices *should* be cutting their surgical volume about 95-99%. Ask yourself truly what percent of your practice is poor diff SCC and invasive melanoma?

 

[reno911]

Ask yourself truly what percent of your practice is poor diff SCC and invasive melanoma?

It's highly variable. When I was in academia, it was nearly daily. I'm now at a tertiary referral center (but no residency prog), so it's less, but not that much less. I know some who see more than I do.

 

[Skindoc83]

Who said this is only going to last a month? A lot of states are now saying they expect schools to be closed for the rest of the year. So how long can these tumors wait if we are talking two, three, four months?

 

[reno911]

Who said this is only going to last a month? A lot of states are now saying they expect schools to be closed for the rest of the year. So how long can these tumors wait if we are talking two, three, four months?

I agree that postponing to mid to late April is kind of a pipe dream. I seriously doubt things will be better that soon (hope I'm wrong).

That's not to say I'm not doing it. When doing this, I've directed staff to explain to patients that they may get pushed back even farther depending on how things are then. These are mostly low risk BCC patients I'm thinking about.

 

[doctalaughs]

I agree that postponing to mid to late April is kind of a pipe dream. I seriously doubt things will be better that soon (hope I'm wrong).

That's not to say I'm not doing it. When doing this, I've directed staff to explain to patients that they may get pushed back even farther depending on how things are then. These are mostly low risk BCC patients I'm thinking about.

This is true but just postponing these 1-2 months may prevent our hospital colleagues from dealing with a few more admissions at a time they don’t have capacity.

I would argue 99% of BCCs can be deferred even 6 months, easily. 95% of SCC can be deferred 3 months.

Most BCC that I have to send to my Mohs colleagues have likely been there for several years anyway.

 

[reno911]

This is true but just postponing these 1-2 months may prevent our hospital colleagues from dealing with a few more admissions at a time they don’t have capacity.

I would argue 99% of BCCs can be deferred even 6 months, easily. 95% of SCC can be deferred 3 months.

Most BCC that I have to send to my Mohs colleagues have likely been there for several years anyway.

The problem on the SCCs is that beforehand, it's not always crystal clear which are the 5% that can't be delayed. And if you inadvertently delay one that you shouldn't have, you're going to turn a straightforward problem into one that is anything but straightforward.

 

[avidrapper]

At the end of the day, it’s up to your clinical discretion what can wait and what can’t.

No shame to those who close their clinics. Also no shame to ones that keep them open but provide a safe, sterile environment to reduce risk of spread (which might be a discussion on its own).

The only thing that we shouldn’t do is keep practices open simply for financial reasons. Get a SBA loan if needed to stay around. Responsibilities to employees can be worked out creatively.

 

[doctalaughs]

The problem on the SCCs is that beforehand, it's not always crystal clear which are the 5% that can't be delayed. And if you inadvertently delay one that you shouldn't have, you're going to turn a straightforward problem into one that is anything but straightforward.

From a genderm perspective if you don’t have telederm, that could mean bringing in every lesion because “it could be an aggressive SCC.”

If you do telederm (as we are now) I think it’s reasonable to bring in SCCs in high-risk locations, certain sizes and immunosuppressed if it looks invasive. I don’t think it’s reasonable to bring in everything that looks like SCC given a lot of my patients are 80 and have 2-3 small low risk ones every 3-month check, as these patients likely have a 20% mortality if they get COVID19.

if you are Mohs then, well - you have the path already and hopefully it’s fairly representative - make the best judgement you can given available info.

 

[doctalaughs]

At the end of the day, it’s up to your clinical discretion what can wait and what can’t.

No shame to those who close their clinics. Also no shame to ones that keep them open but provide a safe, sterile environment to reduce risk of spread (which might be a discussion on its own).

The only thing that we shouldn’t do is keep practices open simply for financial reasons. Get a SBA loan if needed to stay around. Responsibilities to employees can be worked out creatively.

No shame if you stay open and triage reasonably while heeding the AAD, ACMS and NCCN guidelines within your professional judgement for each patient situation.

Shame on you for sure if you are still taking all-comers in a “safe sterile environment.” (Or god forbid using patient-stated urgency as the only screen)

 

[Laradd]

My aunt is a dermatologist and she do visited her clinic thrice a week for severe skin cases only.