Panning for Pandemic Gold: Personal Lessons and Observation

A recent article published in one of Canada’s national newspapers asked, “Will life soon return to normal?”¹ It was one of the more optimistic pieces I have read this year. The authors – all of them infectious disease physicians – opined on the eventual return to our normal activities, made possible by the roll-out of COVID-19 vaccines. This past year brought such rapid change to our lives and to those of our patients and communities. I started to reflect on some of the changes that might persist beyond this “return to normal” and what follows is a recounting of my own experiences and those of my dermatology colleagues I have communicated with — via text, phone, and zoom — over the past few months.

Personal decisions and personal space. 

In previous winters, I typically caught a cold or two. In residency, it was more often. But this year, with more attention to handwashing and hand hygiene for patients and physicians, physical distancing, and masking, I have fared better. At the onset of the pandemic, tables were separated, stickers were affixed to floors everywhere, and even the big, illuminated signs on the overpass above my commuter route reminded us to “Stay apart to stay safe”. Since then, a general awareness of where our bodies are in physical relation to other people seems to have taken root remarkably quickly. In clinic, most of my patients know to reschedule appointments when they are feeling unwell, and if they need to cough or sneeze in clinic, they do so masked and into their elbow. We have all become more aware of our own droplets, and where they land.  “I hope the culture shifts so that, when doctors or patients are sick, they don’t come in”, states Dr. Jori Hardin of Calgary. I could not agree more. The chain of COVID-19 infection can be broken with the single decision to just stay home. This year, our clinic  started booking “open days”– one each month – so that, if patients need to be rebooked because a clinician or a family member is sick, the patients can be rebooked to the open day.

Another observation that I have made during this pandemic is that I have also found patients to be more understanding when it comes to rescheduling clinic. And I hope this continues long after we have all been vaccinated. 

Teledermatology – and a recognition of its best uses.

When public health orders triggered the shut-down of many dermatology clinics in 2020, most of us adapted by offering virtual care. The various technology platforms and software to deliver telehealth appointments has existed for years, but now, with no other means to see patients – and a fee schedule that supported it – many dermatologists were able to justify its use. Our clinic had the usual issues with photo quality and video feeds but managed to see a reasonable number of patients for follow up appointments, and we were even able to undertake some new consults.

Certain conditions were easily managed virtually, but the inability to biopsy or excise patients proved to be terribly frustrating. As clinicians, we had no idea when we would be able to open again, and in what capacity. A recent study by Canadian dermatologists Leis, Fleming and Lynde² evaluated dermatologists’ experiences during the summer of 2020 and found that 58% of dermatologists surveyed were dissatisfied with teledermatology, and 74% reported decreased job satisfaction. The broad takeaway from this study is that many of us went into medicine, and specifically dermatology, to see patients and help people. As we move forward and reimagine telehealth in a post-pandemic world, the technology can be reliably used to enhance care in many situations, such as to reach patients in remote communities, or to follow up with patients who are stable on long-term medications. But, unless we can engage with our patients in real life, how will we experience the satisfaction of extracting a massive, dilated pore of Winer?

Waiting rooms. 

Before the pandemic, our waiting rooms were full of uncomfortable patients seated cheek-to-jowl. Now, our waiting rooms are empty. Instead, patients are outdoors in their cars listening to a podcast or taking a work call, going for a walk around the neighbourhood, or having a socially-distanced coffee outside with a companion. They receive a text when it is time for them to be brought into an exam room, at which time they enter the clinic and are greeted by a team member. This process seems so much more civilized, and I think, so much more respectful of our patients’ time.

Another waiting room evolution shared with me by dermatologist Dr. Kim Tran has been  the implementation of software that simplifies and accelerates the patient’s intake form. In our clinic, we always asked patients to fill out a questionnaire in the waiting room prior to their visit, which was then scanned into the chart and reviewed by the team. Some of the newer software simplifies this process by emailing a secure link to the patient a few days prior to their appointment through which they provide their history, update their contact information, and add prior treatments and other details that they consider germane to their upcoming visit. The patient’s responses are uploaded to the EMR and automatically linked to their chart. Dr. Tran has found that she is better prepared to see each patient, offers more efficient and thorough care, and that patients are very happy with the process

Dress code. 

After having children, I started to wear scrubs to work. My cosmetic practice in Calgary, however, had a tonier dress code. So, when I started working there, I had to revert back to the world of business casual clothing during the workday. That all changed with COVID-19 as scrubs were mandated in our workplace. Many other clinics turned to wash-and-wear for infection control, and many of these dermatologists will continue to wear scrubs on an ongoing basis. Dr. Angela Law of Vancouver tells me that she has no plans to switch back from scrubs. She lists the many benefits including the fact that scrubs are affordable, machine-washable, and are easily worn with clogs or another work-appropriate footwear. Much has been published over the years about health care worker apparel, including studies that demonstrate home- versus hospital-laundered scrubs harbor similar numbers of bacterial pathogens^7,8, but patients have shown in the past that they prefer doctors to wear professional attire. It remains to be seen whether this perception will change post-pandemic.

Lab Monitoring. 

In recent years, much has been written about lab monitoring for commonly used dermatologic medications, specifically spironolactone³  and isotretinoin. The onset of the pandemic and the rapid closure and then limited re-opening of community labs, has caused many dermatologists to re-evaluate which patients need to be tested and when. Barbieri and colleagues concluded that “there are opportunities to improve the quality of care among patients being treated with isotretinoin by reducing the frequency of lipid and liver function monitoring and by eliminating complete blood count monitoring”.⁴ While the landscape continues to change in regard to the availability of community labs, clinicians can rely on follow up calls and screening questions with their patients to determine the safety of continuing medications and renewing prescriptions. The key learning is that the changes necessitated by the COVID-19 pandemic have forced us to consider what tests we order and why.

Empathy. 

I am fortunate to work alongside six wonderful family physicians, who have shared with me that patients have increasingly been reporting mental health-related issues over the past year. The scientific literature has shown an increased incidence of anxiety, depressive symptoms, anger and fear over the past twelve months.^5,6 This has affected patients of all ages, particularly children and adolescents, and the elderly. Many folks in our community are struggling with job losses, home schooling, and social isolation. On an ongoing basis, it is important to remind ourselves that patients are struggling with more than their skin disease, something that we may not have always considered before the COVID-19 pandemic.

Rebalancing. 

The pandemic has affected us all in many ways. I returned to the clinic in a reduced capacity to enable more time for proper infection control of the clinic rooms and found that I have enjoyed this relaxed pace very much. I am doing more thorough histories and exams, finishing my clinic day on time, and feel less harried during the workday. Several dermatologist colleagues have told me similar stories – that they are adding a telehealth day once a week so they can work from home, that the lockdown and home schooling helped them re-engage with their children, or that a reduced number of patients in their clinic has improved their outlook. Dr. Angela Law tells me that she will continue to see patients in 15-minute appointment times, as it has improved her relationships with patients and helped with staff morale.
Dr. Jori Hardin has found that the reduced number of extracurricular activities for her children, and the commensurate increase in “family time” has contributed to her well-being. She hopes to continue this post-pandemic. These small anecdotes demonstrate that selectively choosing certain aspects of our ‘new’ professional world, may lead to the betterment of our own mental health. We have all been touched in some way by the COVID-19 pandemic. This article is not to marginalize or diminish the pain and suffering that so many have experienced over the past 12 months, but rather to find an opportunity to use small lessons that can improve our practices and, by extension, the care we deliver to our patients. I wish you all good health this year, and a safe and happy practice.