Dermatology residents and the care of patients with coronavirus disease 2019 (COVID-19)
Authors: Victoria J. Stoj, Jane M. Grant-Kels
Journal: Journal of the American Academy of Dermatology (2020)

Dear Dr Dermatoethicist: I am a dermatology resident. Recently, I was notified that I might be pulled from dermatology to work in the emergency department or on the hospital floors to help with patients with coronavirus disease 2019. Can I refuse, and even consider litigation? My contract with the hospital states that I will be practicing dermatology, with no mention of general medicine.–Reluctant Resident Dear Dr Dermatoethicist: I am a dermatology resident. Recently, I was notified that I might be pulled from dermatology to work in the emergency department or on the hospital floors to help with patients with coronavirus disease 2019. Can I refuse, and even consider litigation? My contract with the hospital states that I will be practicing dermatology, with no mention of general medicine. –Reluctant Resident Dear Reluctant Resident: As if prescient, a 2016 dermatoethics publication in this journal discussed this very topic, except that the dermatologist was requested to consult on a rash in a patient with Ebola.1Shaw D.J. Maciage M. Bercovitch L. "I didn't sign on to die": the dermatologist's ethical obligations during a deadly epidemic.J Am Acad Dermatol. 2016; 74: 183-185Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar The good news is that COVID-19 is far less fatal, particularly for young, healthy residents2Oke J. Heneghan C. Global covid-19 case fatality rates.https://www.cebm.net/global-covid-19-case-fatality-rates/Date: 2020Date accessed: March 24, 2020Google Scholar (Tables I and II). Therefore, your fear of dying should be tempered with facts. Most importantly, as a physician who cited the Hippocratic oath at graduation, you have sworn to solemnly serve your patient as your first consideration before your own interests.3Parsa-Parsi R.W. The revised declaration of Geneva: a modern-day physician's pledge.JAMA. 2017; 318: 1971-1972Crossref PubMed Scopus (133) Google Scholar You are therefore ethically (because of professionalism, beneficence, nonmaleficence, justice, and dignity) and morally bound to perform your duty when called upon, especially in a medical crisis, as we are presently living through. Additionally, there is an American Academy of Dermatology Code of Medical Ethics that states, "It is …unethical for a dermatologist …to refuse the management of a patient because of medical risk, real or imagined (page 18, section 1C)."4American Academy of Dermatology. Code of medical ethics for dermatologists, article 1B, page 18, section 1C Available at: https://www.yumpu.com/en/document/view/34536599/professional-and-ethical-standards-for-dermatologists-american. Accessed April 12, 2020.Google Scholar Subsequently, in the current pandemic, it is a dermatologist's duty to treat patients in the clinic, in the hospital, in the emergency room, and in the intensive care unit if called upon.Table IEstimated global COVID-19 case fatality rate distributed by age group∗Case fatality rate estimates are subject to change as more data becomes available. Reprinted from Oke and Heneghan.2Age, y (deaths/cases)Case fatality rate, % (95% CI)≤9 (0/416)010-19 (1/549)0.18 (0.03-1.02)20-49 (63/19,790)0.32 (0.25-0.41)50-59 (130/10,008)1.3 (1.1-1.5)60-69 (309/8583)3.6 (3.2-4.0)70-79 (312/3918)8.0 (7.2-8.9)≥80 (208/1408)14.8 (13.0-16.7)CI, Confidence interval; COVID-19, coronavirus disease 2019.∗ Case fatality rate estimates are subject to change as more data becomes available. Reprinted from Oke and Heneghan.2Oke J. Heneghan C. Global covid-19 case fatality rates.https://www.cebm.net/global-covid-19-case-fatality-rates/Date: 2020Date accessed: March 24, 2020Google Scholar Open table in a new tab Table IIEstimated global COVID-19 case fatality rate in patients with comorbid conditions∗Case fatality rate estimates are subject to change as more data becomes available. Reprinted from Oke and Heneghan.2ConditionCase fatality rate, %Cardiovascular disease10.5Diabetes7.3Chronic respiratory disease6.3Hypertension6.0Cancer5.6No comorbidities0.9COVID-19, Coronavirus disease 2019.∗ Case fatality rate estimates are subject to change as more data becomes available. Reprinted from Oke and Heneghan.2Oke J. Heneghan C. Global covid-19 case fatality rates.https://www.cebm.net/global-covid-19-case-fatality-rates/Date: 2020Date accessed: March 24, 2020Google Scholar Open table in a new tab CI, Confidence interval; COVID-19, coronavirus disease 2019. COVID-19, Coronavirus disease 2019. Your concern is understandable. In the current COVID-19 pandemic, reports of exponential increases of confirmed cases; the rising death toll; and limited resources for testing, treatment, and personal protective equipment can cause an overwhelming sense of anxiety, even for health care workers. Health care workers in Italy make up approximately 9% of confirmed COVID-19 cases in that country as of March 10, 2020.5Livingston E. Bucher K. Coronavirus disease 2019 (COVID-19) in Italy.JAMA. 2020; 323: 1335Crossref PubMed Scopus (770) Google Scholar There is no question that physicians are at high risk of exposure and infection. However, as already noted, the cases of infection in adults younger than 65 years have been less severe, resulting in significantly fewer intensive care unit admissions and case fatality rates in the United States, ranging between 0.1 and 0.2 in patients 20 to 44 years old.6CDC COVID-19 Response TeamSevere outcomes among patients with coronavirus disease 2019 (COVID-19)—United States, February 12-March 16, 2020.MMWR Morb Mortal Wkly Rep. 2020; 69: 343-346https://doi.org/10.15585/mmwr.mm6912e2Crossref PubMed Scopus (1566) Google Scholar Thus, you need to behave professionally and do whatever is required in our joint effort to mitigate this outbreak. Historically, the physician's duty to treat has been an accepted obligation of the profession, akin to police officers or firefighters willing to place themselves in danger to help others. The current COVID-19 pandemic is a public health crisis that requires physicians, of all specialties, to step up and help. The bottom line is that to fulfill your obligation as a professional in the house of medicine, ensure medical care is delivered to those in need (distributive justice), help patients, and do no harm (beneficence and nonmaleficence,) and for your own dignity, do not call a lawyer! Instead, grab your stethoscope and do the right thing! –Dr Dermatoethicist. Comment on "Dermatology residents and the care of COVID-19 patients"Journal of the American Academy of DermatologyVol. 83Issue 1PreviewTo the Editor: As a dermatology resident who is currently redeployed to manage patients with COVID-19, I read this paper1 with great interest. There are several contextual factors that should be included in this discussion. Full-Text PDF What matters most: Why the COVID-19 pandemic should prompt us to revisit the dermatology resident selection processJournal of the American Academy of DermatologyVol. 83Issue 1PreviewTo the Editor: We read with great interest the analysis by Stoj and Grant-Kels1 regarding the ethical obligation of dermatology trainees to provide essential patient care. Expanding on this concept, we propose that the COVID-19 pandemic should serve as a call to action for our specialty to revisit the dermatology resident selection process, with the goal of emphasizing ideals highlighted as being fundamentally important in this time of global crisis. The upcoming shift of the United States Medical Licensing Examination Step 1 score reporting to pass/fail will leave a vacuum that may be filled by relevant selection criteria to meet the current and future needs of our specialty and medicine. Full-Text PDF