Journal of Dermatology for Physician Assistants

The official journal of the Society of Dermatology Physician Assistants

A YEAR LATER. Lessons Learned from Practicing Dermatology in a Pandemic

By Cynthia Faires Griffith, MPAS, PA-C

Where were you when you first heard the word coronavirus? I don’t know. It is interesting the things that are crystalized in your memory.

Jan 18, 2020 – The last proper trip I took was to New Orleans with a colleague. We stayed in a double room to save continuing medical education (CME) moneys, and we attended a Biologics conference put on by Tulane University. It was muggy, but we enjoyed a ride down the Mississippi on a paddleboat. (Photo 1)

Mid March 2020 – I was walking through the front office and I remember hearing that the dermatology department clinics and other ambulatory departments were noticeably decreasing their schedules and I needed to print out my schedule for the month, see all my patients on that Tuesday and the office staff would be calling all the patients from the next day onward to cancel their appointments.

I work at a large academic medical institution. I knew that clinic could not function as normal for very much longer. The day before our laundry courier said he was not coming back (the dry cleaners had closed), so the clinic’s linens and dry cleaning were no longer going to be laundered.

General skin examinations were canceled.* Urgent patients with cancer rashes, concerning lesions for skin cancer, drug rashes, and abscesses were going to be seen on a very limited basis Tuesday – Thursdays. Several of my colleagues who were immunosuppressed, have high risk conditions, or were over the age of 65 were unable to see patients. So, as many started the 10-week (though we didn’t know how long it would be at the time) break from clinic, I started to see more urgent care type dermatology patients.

March 27, 2020 – My husband (a critical care paramedic) had his first COVID-19 exposure and started the 14-day monitoring period, which included twice daily temperature checks. No testing was available at this time. From this point on, there were COVID-19 exposures reported during every shift.

Early April 2020 – University initiated mask and temperature screening for employees and patients.

June 1, 2020 – We started to see general dermatology patients again. This brought in more people into the clinic. More patient interactions meant more stress and additional risk of exposure to the staff. Patients berated nursing staff that would call them to ask screening questions like, “Have you come in contact with anyone with COVID 19?”

June 26, 2020 – I was notified that I had an in-clinic COVID exposure when a patient started feeling bad after he left the office and tested positive that same evening (two days previously). The internal medicine clinic that did the test realized the patient saw me on the same day as his test and contacted the dermatology clinic. My supervising physician told me to leave clinic and wait for a call from occupational health. I was COVID-19 tested and was negative. I quarantined at home for 10 days. I took another COVID-19 test, which was negative, and then I was permitted to come back to work.

Jan 2021 – I was notified via email at 8:30pm one evening that I could register for my vaccination time slot. Early the next morning, in a very efficient vaccine roll out at my university, I got my first dose of the Pfizer-BioNTech COVID-19 vaccine. Standing in line to get my shot, I had a lot of emotions; my heart was beating fast. I was excited, overwhelmed with gratitude, and I had goosebumps thinking about how I was living through history. I also felt a sort of survivor’s guilt thinking of my husband and other healthcare worker friends who were more high risk that deserved the vaccination more than me. I pushed this negative emotion aside. My thought was the important thing is that we all get the vaccine when we have our chance to get it so that more and more people will be offered the vaccine.

Mid Jan 2021 – My husband received the Moderna COVID-19 vaccine through his employer.

Early Feb 2021 – Bill,* one of my patients with a history of lung transplant, had a skin cancer and was being sent for Mohs surgery. As his skin cancer was on his face, he was sent for a a pre-Mohs COVID-19 test, new standard protocol since early in the pandemic. Bill’s wife, Lisa,* who is also my patient, sent a message via the online patient portal asking for a COVID-19 test for herself. She said she had “allergies” for two days but was feeling better. She saw her primary care physician (PCP) who offered her the test, but she wanted to have the testing done at our institution instead. So, I ordered my first (and only) COVID-19 test.

To my dismay, Lisa’s COVID-19 test came back positive. The transplant team caring for Bill wanted Lisa to be treated with a monoclonal antibody infusion to give her the best chance of her infection not progressing, as she was in a high-risk category due to her age (> 65 years), and to hopefully protect her husband. The transplant team asked me if I could order this antibody for her. Initially, my supervising physician and I were concerned that ordering this might put Lisa ahead of others that may be more acutely in need of the treatment. We learned that our institution’s procedure was that our order triggered review by a separate team that decided eligibility based on system-wide requests and availability. I had a telehealth visit with Lisa and consented her for the infusion with two nurses from my clinic witnessing the consent. I submitted the order/request and I heard back within the hour that my patient’s request was approved.

That same day, we scheduled the appointment and Lisa received the infusion. Her symptoms did not progress, and her husband never tested positive for COVID-19.

Being a Dermatology PA during a pandemic came with some feelings of helplessness, but advocating for my patient in this instance helped me remember that all of us PAs are providing needed care for our patients.

It was a window into the collective psyche to see patients every week in person from March 2020 to now. It was one of the only spaces that people were getting in-person interaction with someone who wasn’t in their household. There was a feeling of shock, the feeling from patients of panic having to leave their houses for the first time to enter a public building. There were tears and anger and hostility from patients that I attributed to solitary, loneliness, and grief. Looking back, I realize I did not have the bandwidth I normally do to provide empathy and compassion for my patients. I was also scared and frustrated. I felt that it was inevitable that my husband and I were going to contract the disease from our work exposures.

CONCLUDING THOUGHTS
I really appreciated an interview series published in the Fall 2020 issue of Journal of Dermatology for Physician Assistants (JDPA) titled, “Dermatology physician assistants strong, essential to COVID-19 response coast to coast.” Part 1 of the series spotlighted Jang Mi Johnson, PA-C, who went to Elmhurst Hospital in New York to work on the front lines. It was an interesting blend of clinical and family life experiences. After reading that interview, I was asked by my alma mater to write about being a healthcare worker during the pandemic. I confess that I found it difficult to start gathering my thoughts and writing on the topic. I felt that, as a Dermatology PA who stayed and worked at my “normal job,” I had nothing to add to the conversation. However, as I look back now, I do think the reflection is valuable for all of us. This was a year like no other in our lives. The loss of life will forever be with us, but we have gained knowledge and resilience.

LESSONS LEARNED
1. The benefit of breaks.
I did not have any days off from Jan to July 2020, and this was too long for me personally. When I took time off in July, I was burnt out. My empathy and compassion were waning. Since July 2020, I have prioritized taking a couple days off every quarter for my own sanity. I sit in the sun (with sunscreen on), run, garden. Some days, at least for a couple of hours at a time, I could forget about the pandemic. When I return to clinic, I find that I have more restored empathy and compassion levels.
2. A remedy for provider burn out can be volunteering.
Most of us are drawn to helping careers because we are helpers. Bringing milk to elderly neighbors or picking up donuts for the office gave me back the feeling that I was doing good. My husband and I volunteered two weekends at a community vaccination site. I felt like Santa Claus! Having not given an intramuscular injection in 10 years since PA school, when I went to give my first shot, I could not remove the plastic guard on the needle. It was a humbling experience, but everyone was so thankful for our time. (Photo 2)
3. Confidence in my clinical judgement.
I saw the need for physical distancing interventions before they were implemented, like universal masking in close contact situations. Working in an academic medical institution, I am frequently the least formally educated person in the room, but this past year and its experiences increased my confidence in my own clinical judgement.
4. Lowering expectations is a coping strategy.
As conferences, weddings, and holidays fell off the calendar, there was a sense of loss and grief, however, in return I got the opportunity to live in the moment and enjoy the simple things in life like daily walks outside, pulling weeds, and writing.

Editor’s Note: In this article, the author states her experience often without full explanation in some cases as she was not always aware of reasoning for procedures/protocols at the time. Additionally, patient names have been changed for the purposes of anonymity.

REFERENCES:
1. Hyde, M, Johnson, JM. Dermatology Physicians Assistants Strong Essential to COVID-19 Response Coast to Coast Part 1: East coast New York City-the “Insane Experience” of Working on the Frontlines at the Height of the COVID-19 Pandemic. Journal of Dermatology for Physician Assistants. Fall 2020; 34-38.

Cynthia Faires Griffith, MPAS, PA-C, is a Dermatology Physician Assistant at UT Southwestern Medical Center in Dallas, Texas, where she also earned her Masters of Physician Assistant Studies. Ms. Griffith is the co-founder of the UT Southwestern High-Risk Skin Cancer Transplant Clinic, a twice-monthly clinical initiative to serve patients who are immunosuppressed after solid organ or bone marrow transplant. She also practices general adult medical dermatology. She is Dermatology Grand Rounds Department Editor for the Journal of Dermatology for Physician Assistants (JDPA) and is a guest lecturer in the UT Southwestern PA program and a lecturer at local, regional, and national conferences. She is a member of the Texas Academy of Physician Assistants, the Society for Dermatology Physician Assistants, and the American Academy of Physician Assistants. She was awarded UT Southwestern’s PA of the Year in 2017. When not practicing, Ms. Griffith is an avid sailor, marathoner, and long-distance cyclist.

Disclosures: The author has disclosed no potential conflicts of interest, financial or otherwise, relating to the content of this article.

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