Commentary

I think it’s fair to say, none of us have seen anything like this before. Yet here we are, and we must lead. We are many weeks into the COVID-19 crisis. We moved our offices home and tried not to miss a beat. Our patients need us more than ever – and in different ways.

Lest we become like the shoemaker’s daughter who has no shoes, let’s make sure we take care of ourselves. The shock waves from this pandemic are going to be massive and long lasting. I am already witnessing massive psychological growth on the part of my patients, and I hope, myself and my family. We must be strong as individuals and as a group of professionals.

Now more than ever, we need to set boundaries. So many are suffering. We must take stock of our own lives. Many of us are extremely fortunate. We have homes, families, and plenty of food. We are doctors performing essential services, and we can do so without risking our lives.

The priority is to make sure you are safe, and keeping your family and loved ones safe. As physicians, we have learned to distance ourselves from illness, but the coronavirus has affected us in disproportionate numbers. As a group, we must be risk averse as we will be called upon to heal a very traumatized nation.

To be physically and mentally strong, we must get enough sleep. This is exhausting for some and energizing for others. It is definitely a marathon not a sprint, so pace yourself. Eat well. This is no time for empty calories, and that goes for alcohol as well.

Create new routines. Exercise at the same time each day or perhaps twice a day. Try to be productive during certain hours, and relax at other times. Eat at similar times each day. We must strive to quickly create a “new normal” as we spend our days at home.

Find safe alternatives to your usual workout routine. Use YouTube and Instagram to help you find ways to stay fit in your own home. Ask friends for tips and consider sharing workout time with them via Zoom or FaceTime. New options are coming on line daily.

Make sure you are getting enough information to stay safe, and follow the advice of experts. Then turn off the news. I offer the same advice for financial worries. Try not to stress too much about finances right now. Most of us are feeling the pain of lost income and lost savings. Many of us have spouses or partners who suddenly found themselves out of work. Most likely, we will have ample ability to recover financially as we move forward and find ourselves with more work than ever.

Meditate. This may be advice you have been telling your patients for years but never found the time to try yourself. You can begin very simply with an app called Headspace or Calm. Google “5-minute meditation” on YouTube or find a meditation of any length you desire. If not now, when?

Reach out to one another. We can all use a caring word, or some humor or advice about how to move our practices online.

You may find your concentration is decreased, so be realistic in your expectations of yourself. I am finding shorter sessions more often are providing more comfort to some patients. Other patients are digging deeper than ever emotionally, and the work is becoming more rewarding.

Make sure you take a break to engage in positive activities. Read a book. Listen to soft music. Dim the lights. Watch the sunset, or be in nature if you can do so safely. Watch a TedTalk. Brush up on a foreign language. Take a deep breath. Journal. Puzzles, games, cooking, magazines, and humor all provide much needed respite from the stress. If you are lucky enough to be with family, try to take advantage of this unique time.

Try to avoid or minimize conflict with others. We need one another now more than ever. If you lose your cool, forgive yourself and make amends.

Even in these most challenging times, we must focus on what we are grateful for. Express gratitude to those around you as it will lift their mood as well. I know I am extremely grateful to be able to continue meaningful work when so many are unable to do so.

The next waves of this virus will be hitting our specialty directly so be strong and be prepared. It is an honor to serve, and we must rise to the occasion.
 

Dr. Ritvo, a psychiatrist with more than 25 years’ experience, practices in Miami Beach, Fla. She is the author of “Bekindr – The Transformative Power of Kindness” (Hellertown, Pa.: Momosa Publishing, 2018), and is the founder of the Bekindr Global Initiative, a movement aimed at cultivating kindness in the world. Dr. Ritvo also is the cofounder of the Bold Beauty Project, a nonprofit group that pairs women with disabilities with photographers who create art exhibitions to raise awareness.

I think it’s fair to say, none of us have seen anything like this before. Yet here we are, and we must lead. We are many weeks into the COVID-19 crisis. We moved our offices home and tried not to miss a beat. Our patients need us more than ever – and in different ways.

Lest we become like the shoemaker’s daughter who has no shoes, let’s make sure we take care of ourselves. The shock waves from this pandemic are going to be massive and long lasting. I am already witnessing massive psychological growth on the part of my patients, and I hope, myself and my family. We must be strong as individuals and as a group of professionals.

Now more than ever, we need to set boundaries. So many are suffering. We must take stock of our own lives. Many of us are extremely fortunate. We have homes, families, and plenty of food. We are doctors performing essential services, and we can do so without risking our lives.

The priority is to make sure you are safe, and keeping your family and loved ones safe. As physicians, we have learned to distance ourselves from illness, but the coronavirus has affected us in disproportionate numbers. As a group, we must be risk averse as we will be called upon to heal a very traumatized nation.

To be physically and mentally strong, we must get enough sleep. This is exhausting for some and energizing for others. It is definitely a marathon not a sprint, so pace yourself. Eat well. This is no time for empty calories, and that goes for alcohol as well.

Create new routines. Exercise at the same time each day or perhaps twice a day. Try to be productive during certain hours, and relax at other times. Eat at similar times each day. We must strive to quickly create a “new normal” as we spend our days at home.

Find safe alternatives to your usual workout routine. Use YouTube and Instagram to help you find ways to stay fit in your own home. Ask friends for tips and consider sharing workout time with them via Zoom or FaceTime. New options are coming on line daily.

Make sure you are getting enough information to stay safe, and follow the advice of experts. Then turn off the news. I offer the same advice for financial worries. Try not to stress too much about finances right now. Most of us are feeling the pain of lost income and lost savings. Many of us have spouses or partners who suddenly found themselves out of work. Most likely, we will have ample ability to recover financially as we move forward and find ourselves with more work than ever.

Meditate. This may be advice you have been telling your patients for years but never found the time to try yourself. You can begin very simply with an app called Headspace or Calm. Google “5-minute meditation” on YouTube or find a meditation of any length you desire. If not now, when?

Reach out to one another. We can all use a caring word, or some humor or advice about how to move our practices online.

You may find your concentration is decreased, so be realistic in your expectations of yourself. I am finding shorter sessions more often are providing more comfort to some patients. Other patients are digging deeper than ever emotionally, and the work is becoming more rewarding.

Make sure you take a break to engage in positive activities. Read a book. Listen to soft music. Dim the lights. Watch the sunset, or be in nature if you can do so safely. Watch a TedTalk. Brush up on a foreign language. Take a deep breath. Journal. Puzzles, games, cooking, magazines, and humor all provide much needed respite from the stress. If you are lucky enough to be with family, try to take advantage of this unique time.

Try to avoid or minimize conflict with others. We need one another now more than ever. If you lose your cool, forgive yourself and make amends.

Even in these most challenging times, we must focus on what we are grateful for. Express gratitude to those around you as it will lift their mood as well. I know I am extremely grateful to be able to continue meaningful work when so many are unable to do so.

The next waves of this virus will be hitting our specialty directly so be strong and be prepared. It is an honor to serve, and we must rise to the occasion.
 

Dr. Ritvo, a psychiatrist with more than 25 years’ experience, practices in Miami Beach, Fla. She is the author of “Bekindr – The Transformative Power of Kindness” (Hellertown, Pa.: Momosa Publishing, 2018), and is the founder of the Bekindr Global Initiative, a movement aimed at cultivating kindness in the world. Dr. Ritvo also is the cofounder of the Bold Beauty Project, a nonprofit group that pairs women with disabilities with photographers who create art exhibitions to raise awareness.

I think it’s fair to say, none of us have seen anything like this before. Yet here we are, and we must lead. We are many weeks into the COVID-19 crisis. We moved our offices home and tried not to miss a beat. Our patients need us more than ever – and in different ways.

Lest we become like the shoemaker’s daughter who has no shoes, let’s make sure we take care of ourselves. The shock waves from this pandemic are going to be massive and long lasting. I am already witnessing massive psychological growth on the part of my patients, and I hope, myself and my family. We must be strong as individuals and as a group of professionals.

Now more than ever, we need to set boundaries. So many are suffering. We must take stock of our own lives. Many of us are extremely fortunate. We have homes, families, and plenty of food. We are doctors performing essential services, and we can do so without risking our lives.

The priority is to make sure you are safe, and keeping your family and loved ones safe. As physicians, we have learned to distance ourselves from illness, but the coronavirus has affected us in disproportionate numbers. As a group, we must be risk averse as we will be called upon to heal a very traumatized nation.

To be physically and mentally strong, we must get enough sleep. This is exhausting for some and energizing for others. It is definitely a marathon not a sprint, so pace yourself. Eat well. This is no time for empty calories, and that goes for alcohol as well.

Create new routines. Exercise at the same time each day or perhaps twice a day. Try to be productive during certain hours, and relax at other times. Eat at similar times each day. We must strive to quickly create a “new normal” as we spend our days at home.

Find safe alternatives to your usual workout routine. Use YouTube and Instagram to help you find ways to stay fit in your own home. Ask friends for tips and consider sharing workout time with them via Zoom or FaceTime. New options are coming on line daily.

Make sure you are getting enough information to stay safe, and follow the advice of experts. Then turn off the news. I offer the same advice for financial worries. Try not to stress too much about finances right now. Most of us are feeling the pain of lost income and lost savings. Many of us have spouses or partners who suddenly found themselves out of work. Most likely, we will have ample ability to recover financially as we move forward and find ourselves with more work than ever.

Meditate. This may be advice you have been telling your patients for years but never found the time to try yourself. You can begin very simply with an app called Headspace or Calm. Google “5-minute meditation” on YouTube or find a meditation of any length you desire. If not now, when?

Reach out to one another. We can all use a caring word, or some humor or advice about how to move our practices online.

You may find your concentration is decreased, so be realistic in your expectations of yourself. I am finding shorter sessions more often are providing more comfort to some patients. Other patients are digging deeper than ever emotionally, and the work is becoming more rewarding.

Make sure you take a break to engage in positive activities. Read a book. Listen to soft music. Dim the lights. Watch the sunset, or be in nature if you can do so safely. Watch a TedTalk. Brush up on a foreign language. Take a deep breath. Journal. Puzzles, games, cooking, magazines, and humor all provide much needed respite from the stress. If you are lucky enough to be with family, try to take advantage of this unique time.

Try to avoid or minimize conflict with others. We need one another now more than ever. If you lose your cool, forgive yourself and make amends.

Even in these most challenging times, we must focus on what we are grateful for. Express gratitude to those around you as it will lift their mood as well. I know I am extremely grateful to be able to continue meaningful work when so many are unable to do so.

The next waves of this virus will be hitting our specialty directly so be strong and be prepared. It is an honor to serve, and we must rise to the occasion.
 

Dr. Ritvo, a psychiatrist with more than 25 years’ experience, practices in Miami Beach, Fla. She is the author of “Bekindr – The Transformative Power of Kindness” (Hellertown, Pa.: Momosa Publishing, 2018), and is the founder of the Bekindr Global Initiative, a movement aimed at cultivating kindness in the world. Dr. Ritvo also is the cofounder of the Bold Beauty Project, a nonprofit group that pairs women with disabilities with photographers who create art exhibitions to raise awareness.

The histopathologic diagnosis of vitiligo is classically understood as the absence of melanocytes and melanin in the skin biopsy.¹ It is difficult for a pathologist to establish the absolute absence of melanocytes and melanin in a skin biopsy. Therefore, we need to take into consideration many variables when we face the possibility to biopsy a vitiligo lesion.

The basis of the clinical diagnosis of vitiligo is the appearance of achromic lesions in periorificial and acral areas; however, sometimes it is difficult to differentiate between an achromic or hypochromic lesion. Although Wood light is of great help in these circumstances, it still can be difficult to make the diagnosis with certainty.

In other cases, the lesions do not present a classic distribution of vitiligo, and other differential diagnoses are considered. For example, if we see a single hypochromic or achromic lesion in a young child, then the main differential diagnosis would be achromic nevus. If there are multiple lesions, then we may consider progressive macular hypomelanosis, postinflammatory hypopigmentation, and hypopigmented mycosis fungoides. In genital lesions, the differential diagnosis between initial lichen sclerosus and vitiligo also can be considered. Finally, we must always bear in mind that both sarcoidosis and Hansen disease can appear as achromic or hypochromic lesions.

The histologic diagnosis of vitiligo in a completely constituted lesion implies the total loss of melanocytes and melanin in the epidermis. Additional histologic findings are described at the edge of the advanced border, such as the presence of melanocytes that have increased in size with large dendrites and lymphoid infiltrate. In perilesional skin, vacuolated keratinocytes and Langerhans cells have increased in number and repositioned in the basal layer, with visible degeneration of nerves and sweat glands. Lymphocytes also can be found in contact with the melanocytes.² It is important to note that in addition to these histologic findings, it is common to find spongiosis, mononuclear superficial perivascular inflammatory infiltrate, and melanophages in biopsies of vitiligo.³

Given that ensuring the absence of melanocytes is central to diagnosis and melanocytes can be difficult to identify or differentiate from repositioned Langerhans cells in the basal layer with hematoxylin and eosin stain, immunohistochemical techniques must be performed every time we are dealing with vitiligo biopsies. Although there are no studies comparing the diagnostic value of the different immunohistochemical techniques in vitiligo, dihydroxyphenylalanine (DOPA) seems to be a good option, as it will only mark active melanocytes. Human melanoma black 45 (HMB-45), anti-TYRP1 (Mel-5), and antimelanoma gp 100 antibody (NKI/beteb) also have been used. Some authors recommend the use of pan melanoma because it includes 3 markers—HMB-45, tyrosinase, and Mart-1. Currently, SRY-related HMG-box10 (SOX10) seems to be a good option, as it is a nuclear marker that makes it easier to differentiate melanocytes from pigmented keratinocytes.⁴

Establishing a complete absence of melanocytes in the lesions or finding there are melanocytes but they are inactivated is key to evaluating the pathogenesis of vitiligo and directly affects the histologic diagnosis and eventually even the treatment. Le Poole et al⁵ used a panel of 17 monoclonal antibodies and a polyclonal antibody in lesions of 12 patients with vitiligo without identifying the presence of melanocytes. They concluded that there are no melanocytes in lesions of vitiligo.⁵

In a subsequent study with a larger number of patients, Kim et al² found melanocytes that marked with NKI/beteb and Mart-1 in 12 of 100 patients with vitiligo. They also showed melanocytes by electron microscopy in lesional skin of 1 of 3 patients with vitiligo.² Tobin et al⁶ managed to grow melanocytes from skin with vitiligo and confirmed the presence of melanin in basal keratinocytes of lesions of stable vitiligo. From this evidence we can conclude that the absence of melanocytes and melanin in the epidermis confirms the diagnosis of vitiligo; however, the opposite is not true—that is, the presence of melanocytes or melanin in a skin biopsy does not rule out the diagnosis of vitiligo.

Taking this information into consideration, we can understand that if our differential diagnosis is a dermatosis that requires the evaluation of the number of melanocytes as a fundamental diagnostic clue (eg, postinflammatory hypopigmentation), the biopsy will probably not be useful. On the other hand, when our differential diagnosis has characteristic diagnostic findings independent of the number of melanocytes or the presence of melanin, the biopsy will be useful (eg, hypopigmented mycosis fungoides).

Thus, we can understand why the histologic differentiation between vitiligo, pityriasis alba, postinflammatory hypopigmentation, and progressive macular hypopigmentation is difficult. The histology images of these 4 diseases may show different degrees of melanocyte and melanin decrease, spongiosis, and in the superficial dermis melanophages and mononuclear inflammatory infiltrate.⁷

Nevus depigmentosus also may generate diagnostic confusion with vitiligo. Although it is unilateral and usually congenital, it can appear as late as 3 years of age, leading to an initial clinical differential diagnosis of vitiligo. The histologic findings in this nevus also overlap with vitiligo. The characteristic findings are presence of melanocytes and decreased pigment in the keratinocytes compared with perilesional skin. Therefore, a biopsy is not a solution to this diagnostic dilemma.⁸

In all the differentials named, the solution to the diagnostic doubt is not based on the histologic findings but on the clinical evolution of the patients. In cases of vitiligo, the lesions will become more evident in the evolution. They will eventually disappear in pityriasis alba, postinflammatory hypopigmentation, and progressive macular hypopigmentation and will remain unchanged in nevus depigmentosus. It is important, especially when we are dealing with concerned parents/guardians, to convey the importance of assessing the evolution of the disease as the main diagnostic procedure. Even though a biopsy is minimally invasive, it is usually stressful on children, it may leave sequelae, and above all it will not contribute to the diagnosis in this clinical context.

There are other clinical circumstances in the scenario of hypochromic or achromic lesions in which the biopsy will be useful: If we consider an initial genital lichen sclerosus vs vitiligo. In lichen sclerosus the biopsy will show dermal hyalinosis and interphase changes; absence of both will support vitiligo. If we need to differentiate hypopigmented mycosis fungoides from vitiligo, we will find an infiltrate of pleomorphic lymphocytes in the epidermis and dermis in the former and an absence of these findings in vitiligo. Finally, if we find granulomas in a biopsy of an achromic or hypopigmented lesion, we may be dealing with hypopigmented sarcoidosis or Hansen disease.

It also is important to choose the best site to perform the biopsy to have the best chance at diagnosing vitiligo histologically. As already described, in the edges and in the perilesional skin we can find remnant melanocytes, Langerhans cells, and interphase changes that do not allow us to clearly evaluate the main change that is the loss of melanocytes and melanin. In fact, a biopsy of the edge of a vitiligo macula can lead to confusion. For example, if the differential diagnosis is lichen sclerosus and the image we see in the biopsy of the edge of a vitiligo lesion is an interface reaction, we can interpret it as a finding that favors lichen sclerosus. In this way, it is better to biopsy the center of a well-constituted vitiligo lesion where we have the best chance to assess the absence of melanin and melanocytes.

The vitiligo differential diagnosis can be divided into 2 groups: entities that are difficult to differentiate from vitiligo histologically (ie, pityriasis alba, postinflammatory hypopigmentation, progressive macular hypopigmentation, nevus depigmentosus) and entities that are easily distinguishable from vitiligo histologically (ie, lichen sclerosus, mycosis fungoides, sarcoidosis, leprosy). If our differential diagnosis was found in the first group, the final diagnosis should be based on the evolution of the patient. If it was in the second group, a biopsy of the center of the lesion will be useful and may allow us to reach a definitive diagnosis.

The histopathologic diagnosis of vitiligo is classically understood as the absence of melanocytes and melanin in the skin biopsy.¹ It is difficult for a pathologist to establish the absolute absence of melanocytes and melanin in a skin biopsy. Therefore, we need to take into consideration many variables when we face the possibility to biopsy a vitiligo lesion.

The basis of the clinical diagnosis of vitiligo is the appearance of achromic lesions in periorificial and acral areas; however, sometimes it is difficult to differentiate between an achromic or hypochromic lesion. Although Wood light is of great help in these circumstances, it still can be difficult to make the diagnosis with certainty.

In other cases, the lesions do not present a classic distribution of vitiligo, and other differential diagnoses are considered. For example, if we see a single hypochromic or achromic lesion in a young child, then the main differential diagnosis would be achromic nevus. If there are multiple lesions, then we may consider progressive macular hypomelanosis, postinflammatory hypopigmentation, and hypopigmented mycosis fungoides. In genital lesions, the differential diagnosis between initial lichen sclerosus and vitiligo also can be considered. Finally, we must always bear in mind that both sarcoidosis and Hansen disease can appear as achromic or hypochromic lesions.

The histologic diagnosis of vitiligo in a completely constituted lesion implies the total loss of melanocytes and melanin in the epidermis. Additional histologic findings are described at the edge of the advanced border, such as the presence of melanocytes that have increased in size with large dendrites and lymphoid infiltrate. In perilesional skin, vacuolated keratinocytes and Langerhans cells have increased in number and repositioned in the basal layer, with visible degeneration of nerves and sweat glands. Lymphocytes also can be found in contact with the melanocytes.² It is important to note that in addition to these histologic findings, it is common to find spongiosis, mononuclear superficial perivascular inflammatory infiltrate, and melanophages in biopsies of vitiligo.³

Given that ensuring the absence of melanocytes is central to diagnosis and melanocytes can be difficult to identify or differentiate from repositioned Langerhans cells in the basal layer with hematoxylin and eosin stain, immunohistochemical techniques must be performed every time we are dealing with vitiligo biopsies. Although there are no studies comparing the diagnostic value of the different immunohistochemical techniques in vitiligo, dihydroxyphenylalanine (DOPA) seems to be a good option, as it will only mark active melanocytes. Human melanoma black 45 (HMB-45), anti-TYRP1 (Mel-5), and antimelanoma gp 100 antibody (NKI/beteb) also have been used. Some authors recommend the use of pan melanoma because it includes 3 markers—HMB-45, tyrosinase, and Mart-1. Currently, SRY-related HMG-box10 (SOX10) seems to be a good option, as it is a nuclear marker that makes it easier to differentiate melanocytes from pigmented keratinocytes.⁴

Establishing a complete absence of melanocytes in the lesions or finding there are melanocytes but they are inactivated is key to evaluating the pathogenesis of vitiligo and directly affects the histologic diagnosis and eventually even the treatment. Le Poole et al⁵ used a panel of 17 monoclonal antibodies and a polyclonal antibody in lesions of 12 patients with vitiligo without identifying the presence of melanocytes. They concluded that there are no melanocytes in lesions of vitiligo.⁵

In a subsequent study with a larger number of patients, Kim et al² found melanocytes that marked with NKI/beteb and Mart-1 in 12 of 100 patients with vitiligo. They also showed melanocytes by electron microscopy in lesional skin of 1 of 3 patients with vitiligo.² Tobin et al⁶ managed to grow melanocytes from skin with vitiligo and confirmed the presence of melanin in basal keratinocytes of lesions of stable vitiligo. From this evidence we can conclude that the absence of melanocytes and melanin in the epidermis confirms the diagnosis of vitiligo; however, the opposite is not true—that is, the presence of melanocytes or melanin in a skin biopsy does not rule out the diagnosis of vitiligo.

Taking this information into consideration, we can understand that if our differential diagnosis is a dermatosis that requires the evaluation of the number of melanocytes as a fundamental diagnostic clue (eg, postinflammatory hypopigmentation), the biopsy will probably not be useful. On the other hand, when our differential diagnosis has characteristic diagnostic findings independent of the number of melanocytes or the presence of melanin, the biopsy will be useful (eg, hypopigmented mycosis fungoides).

Thus, we can understand why the histologic differentiation between vitiligo, pityriasis alba, postinflammatory hypopigmentation, and progressive macular hypopigmentation is difficult. The histology images of these 4 diseases may show different degrees of melanocyte and melanin decrease, spongiosis, and in the superficial dermis melanophages and mononuclear inflammatory infiltrate.⁷

Nevus depigmentosus also may generate diagnostic confusion with vitiligo. Although it is unilateral and usually congenital, it can appear as late as 3 years of age, leading to an initial clinical differential diagnosis of vitiligo. The histologic findings in this nevus also overlap with vitiligo. The characteristic findings are presence of melanocytes and decreased pigment in the keratinocytes compared with perilesional skin. Therefore, a biopsy is not a solution to this diagnostic dilemma.⁸

In all the differentials named, the solution to the diagnostic doubt is not based on the histologic findings but on the clinical evolution of the patients. In cases of vitiligo, the lesions will become more evident in the evolution. They will eventually disappear in pityriasis alba, postinflammatory hypopigmentation, and progressive macular hypopigmentation and will remain unchanged in nevus depigmentosus. It is important, especially when we are dealing with concerned parents/guardians, to convey the importance of assessing the evolution of the disease as the main diagnostic procedure. Even though a biopsy is minimally invasive, it is usually stressful on children, it may leave sequelae, and above all it will not contribute to the diagnosis in this clinical context.

There are other clinical circumstances in the scenario of hypochromic or achromic lesions in which the biopsy will be useful: If we consider an initial genital lichen sclerosus vs vitiligo. In lichen sclerosus the biopsy will show dermal hyalinosis and interphase changes; absence of both will support vitiligo. If we need to differentiate hypopigmented mycosis fungoides from vitiligo, we will find an infiltrate of pleomorphic lymphocytes in the epidermis and dermis in the former and an absence of these findings in vitiligo. Finally, if we find granulomas in a biopsy of an achromic or hypopigmented lesion, we may be dealing with hypopigmented sarcoidosis or Hansen disease.

It also is important to choose the best site to perform the biopsy to have the best chance at diagnosing vitiligo histologically. As already described, in the edges and in the perilesional skin we can find remnant melanocytes, Langerhans cells, and interphase changes that do not allow us to clearly evaluate the main change that is the loss of melanocytes and melanin. In fact, a biopsy of the edge of a vitiligo macula can lead to confusion. For example, if the differential diagnosis is lichen sclerosus and the image we see in the biopsy of the edge of a vitiligo lesion is an interface reaction, we can interpret it as a finding that favors lichen sclerosus. In this way, it is better to biopsy the center of a well-constituted vitiligo lesion where we have the best chance to assess the absence of melanin and melanocytes.

The vitiligo differential diagnosis can be divided into 2 groups: entities that are difficult to differentiate from vitiligo histologically (ie, pityriasis alba, postinflammatory hypopigmentation, progressive macular hypopigmentation, nevus depigmentosus) and entities that are easily distinguishable from vitiligo histologically (ie, lichen sclerosus, mycosis fungoides, sarcoidosis, leprosy). If our differential diagnosis was found in the first group, the final diagnosis should be based on the evolution of the patient. If it was in the second group, a biopsy of the center of the lesion will be useful and may allow us to reach a definitive diagnosis.

The histopathologic diagnosis of vitiligo is classically understood as the absence of melanocytes and melanin in the skin biopsy.¹ It is difficult for a pathologist to establish the absolute absence of melanocytes and melanin in a skin biopsy. Therefore, we need to take into consideration many variables when we face the possibility to biopsy a vitiligo lesion.

The basis of the clinical diagnosis of vitiligo is the appearance of achromic lesions in periorificial and acral areas; however, sometimes it is difficult to differentiate between an achromic or hypochromic lesion. Although Wood light is of great help in these circumstances, it still can be difficult to make the diagnosis with certainty.

In other cases, the lesions do not present a classic distribution of vitiligo, and other differential diagnoses are considered. For example, if we see a single hypochromic or achromic lesion in a young child, then the main differential diagnosis would be achromic nevus. If there are multiple lesions, then we may consider progressive macular hypomelanosis, postinflammatory hypopigmentation, and hypopigmented mycosis fungoides. In genital lesions, the differential diagnosis between initial lichen sclerosus and vitiligo also can be considered. Finally, we must always bear in mind that both sarcoidosis and Hansen disease can appear as achromic or hypochromic lesions.

The histologic diagnosis of vitiligo in a completely constituted lesion implies the total loss of melanocytes and melanin in the epidermis. Additional histologic findings are described at the edge of the advanced border, such as the presence of melanocytes that have increased in size with large dendrites and lymphoid infiltrate. In perilesional skin, vacuolated keratinocytes and Langerhans cells have increased in number and repositioned in the basal layer, with visible degeneration of nerves and sweat glands. Lymphocytes also can be found in contact with the melanocytes.² It is important to note that in addition to these histologic findings, it is common to find spongiosis, mononuclear superficial perivascular inflammatory infiltrate, and melanophages in biopsies of vitiligo.³

Given that ensuring the absence of melanocytes is central to diagnosis and melanocytes can be difficult to identify or differentiate from repositioned Langerhans cells in the basal layer with hematoxylin and eosin stain, immunohistochemical techniques must be performed every time we are dealing with vitiligo biopsies. Although there are no studies comparing the diagnostic value of the different immunohistochemical techniques in vitiligo, dihydroxyphenylalanine (DOPA) seems to be a good option, as it will only mark active melanocytes. Human melanoma black 45 (HMB-45), anti-TYRP1 (Mel-5), and antimelanoma gp 100 antibody (NKI/beteb) also have been used. Some authors recommend the use of pan melanoma because it includes 3 markers—HMB-45, tyrosinase, and Mart-1. Currently, SRY-related HMG-box10 (SOX10) seems to be a good option, as it is a nuclear marker that makes it easier to differentiate melanocytes from pigmented keratinocytes.⁴

Establishing a complete absence of melanocytes in the lesions or finding there are melanocytes but they are inactivated is key to evaluating the pathogenesis of vitiligo and directly affects the histologic diagnosis and eventually even the treatment. Le Poole et al⁵ used a panel of 17 monoclonal antibodies and a polyclonal antibody in lesions of 12 patients with vitiligo without identifying the presence of melanocytes. They concluded that there are no melanocytes in lesions of vitiligo.⁵

In a subsequent study with a larger number of patients, Kim et al² found melanocytes that marked with NKI/beteb and Mart-1 in 12 of 100 patients with vitiligo. They also showed melanocytes by electron microscopy in lesional skin of 1 of 3 patients with vitiligo.² Tobin et al⁶ managed to grow melanocytes from skin with vitiligo and confirmed the presence of melanin in basal keratinocytes of lesions of stable vitiligo. From this evidence we can conclude that the absence of melanocytes and melanin in the epidermis confirms the diagnosis of vitiligo; however, the opposite is not true—that is, the presence of melanocytes or melanin in a skin biopsy does not rule out the diagnosis of vitiligo.

Taking this information into consideration, we can understand that if our differential diagnosis is a dermatosis that requires the evaluation of the number of melanocytes as a fundamental diagnostic clue (eg, postinflammatory hypopigmentation), the biopsy will probably not be useful. On the other hand, when our differential diagnosis has characteristic diagnostic findings independent of the number of melanocytes or the presence of melanin, the biopsy will be useful (eg, hypopigmented mycosis fungoides).

Thus, we can understand why the histologic differentiation between vitiligo, pityriasis alba, postinflammatory hypopigmentation, and progressive macular hypopigmentation is difficult. The histology images of these 4 diseases may show different degrees of melanocyte and melanin decrease, spongiosis, and in the superficial dermis melanophages and mononuclear inflammatory infiltrate.⁷

Nevus depigmentosus also may generate diagnostic confusion with vitiligo. Although it is unilateral and usually congenital, it can appear as late as 3 years of age, leading to an initial clinical differential diagnosis of vitiligo. The histologic findings in this nevus also overlap with vitiligo. The characteristic findings are presence of melanocytes and decreased pigment in the keratinocytes compared with perilesional skin. Therefore, a biopsy is not a solution to this diagnostic dilemma.⁸

In all the differentials named, the solution to the diagnostic doubt is not based on the histologic findings but on the clinical evolution of the patients. In cases of vitiligo, the lesions will become more evident in the evolution. They will eventually disappear in pityriasis alba, postinflammatory hypopigmentation, and progressive macular hypopigmentation and will remain unchanged in nevus depigmentosus. It is important, especially when we are dealing with concerned parents/guardians, to convey the importance of assessing the evolution of the disease as the main diagnostic procedure. Even though a biopsy is minimally invasive, it is usually stressful on children, it may leave sequelae, and above all it will not contribute to the diagnosis in this clinical context.

There are other clinical circumstances in the scenario of hypochromic or achromic lesions in which the biopsy will be useful: If we consider an initial genital lichen sclerosus vs vitiligo. In lichen sclerosus the biopsy will show dermal hyalinosis and interphase changes; absence of both will support vitiligo. If we need to differentiate hypopigmented mycosis fungoides from vitiligo, we will find an infiltrate of pleomorphic lymphocytes in the epidermis and dermis in the former and an absence of these findings in vitiligo. Finally, if we find granulomas in a biopsy of an achromic or hypopigmented lesion, we may be dealing with hypopigmented sarcoidosis or Hansen disease.

It also is important to choose the best site to perform the biopsy to have the best chance at diagnosing vitiligo histologically. As already described, in the edges and in the perilesional skin we can find remnant melanocytes, Langerhans cells, and interphase changes that do not allow us to clearly evaluate the main change that is the loss of melanocytes and melanin. In fact, a biopsy of the edge of a vitiligo macula can lead to confusion. For example, if the differential diagnosis is lichen sclerosus and the image we see in the biopsy of the edge of a vitiligo lesion is an interface reaction, we can interpret it as a finding that favors lichen sclerosus. In this way, it is better to biopsy the center of a well-constituted vitiligo lesion where we have the best chance to assess the absence of melanin and melanocytes.

The vitiligo differential diagnosis can be divided into 2 groups: entities that are difficult to differentiate from vitiligo histologically (ie, pityriasis alba, postinflammatory hypopigmentation, progressive macular hypopigmentation, nevus depigmentosus) and entities that are easily distinguishable from vitiligo histologically (ie, lichen sclerosus, mycosis fungoides, sarcoidosis, leprosy). If our differential diagnosis was found in the first group, the final diagnosis should be based on the evolution of the patient. If it was in the second group, a biopsy of the center of the lesion will be useful and may allow us to reach a definitive diagnosis.

The expanding range of tick-borne diseases is a growing problem worldwide. Climate change plays a preeminent role in the expansion of tick species, especially for southern ticks in the United States such as Amblyomma species, which have introduced new pathogens to northern states.^1-5 In addition to well-known tick-borne diseases, Amblyomma ticks have been implicated in the spread of emerging severe and potentially fatal viral illnesses, including Bourbon virus and Heartland virus.⁶ The increasing range of Amblyomma ticks also exposes new populations to tick-induced meat allergy (alpha-gal) syndrome, whereby development of specific IgE antibodies to the oligosaccharide galactose-alpha-1,3-galactose (alpha-gal) following tick bites results in severe allergic responses to consumption of beef, pork, and lamb.⁷

Amblyomma ticks have now been identified close to the Canadian border in Michigan and New York, and predictions of continued climate change raise the possibility of northward range expansion into all provinces of Canada from Alberta to Newfoundland and Labrador during the coming decades.^8,9 Additional factors that contribute to the expanding range of many tick species include international travel, migratory patterns of birds, competition, and natural predators such as fire ants that feed on tick eggs and influence the feeding behavior of adults.¹⁰

Traditional methods of tick identification rely on gross morphology, including the presence of festoons, shape of the coxae where the legs attach, and markings on the hard overlying scutum. More recently, molecular identification has improved tick identification, leading to more accurate assessment of tick prevalence. These modern identification studies include analysis of 16S ribosomal DNA (rDNA), 12S rDNA, and ITS1 rDNA, and ITS2 rDNA genes.¹¹

The spread of tick vectors has huge public health implications, and better methods to control tick populations are needed.¹² New acaricides and growth regulators are being developed,¹³ and early spring applications of acaricides such as bifenthrin can suppress nymphs prior to the initiation of host-seeking activity.¹⁴ Controlled burns within tick habitats have proved helpful in reducing the risk for vector-borne disease.^15,16 Personal protection is best accomplished with the use of a repellent together with clothing impregnated with an acaricide such as permethrin.¹⁷ Efforts to slow climate change and continued surveillance for the spread of tick vectors is urgently needed.

The expanding range of tick-borne diseases is a growing problem worldwide. Climate change plays a preeminent role in the expansion of tick species, especially for southern ticks in the United States such as Amblyomma species, which have introduced new pathogens to northern states.^1-5 In addition to well-known tick-borne diseases, Amblyomma ticks have been implicated in the spread of emerging severe and potentially fatal viral illnesses, including Bourbon virus and Heartland virus.⁶ The increasing range of Amblyomma ticks also exposes new populations to tick-induced meat allergy (alpha-gal) syndrome, whereby development of specific IgE antibodies to the oligosaccharide galactose-alpha-1,3-galactose (alpha-gal) following tick bites results in severe allergic responses to consumption of beef, pork, and lamb.⁷

Amblyomma ticks have now been identified close to the Canadian border in Michigan and New York, and predictions of continued climate change raise the possibility of northward range expansion into all provinces of Canada from Alberta to Newfoundland and Labrador during the coming decades.^8,9 Additional factors that contribute to the expanding range of many tick species include international travel, migratory patterns of birds, competition, and natural predators such as fire ants that feed on tick eggs and influence the feeding behavior of adults.¹⁰

Traditional methods of tick identification rely on gross morphology, including the presence of festoons, shape of the coxae where the legs attach, and markings on the hard overlying scutum. More recently, molecular identification has improved tick identification, leading to more accurate assessment of tick prevalence. These modern identification studies include analysis of 16S ribosomal DNA (rDNA), 12S rDNA, and ITS1 rDNA, and ITS2 rDNA genes.¹¹

The spread of tick vectors has huge public health implications, and better methods to control tick populations are needed.¹² New acaricides and growth regulators are being developed,¹³ and early spring applications of acaricides such as bifenthrin can suppress nymphs prior to the initiation of host-seeking activity.¹⁴ Controlled burns within tick habitats have proved helpful in reducing the risk for vector-borne disease.^15,16 Personal protection is best accomplished with the use of a repellent together with clothing impregnated with an acaricide such as permethrin.¹⁷ Efforts to slow climate change and continued surveillance for the spread of tick vectors is urgently needed.

The expanding range of tick-borne diseases is a growing problem worldwide. Climate change plays a preeminent role in the expansion of tick species, especially for southern ticks in the United States such as Amblyomma species, which have introduced new pathogens to northern states.^1-5 In addition to well-known tick-borne diseases, Amblyomma ticks have been implicated in the spread of emerging severe and potentially fatal viral illnesses, including Bourbon virus and Heartland virus.⁶ The increasing range of Amblyomma ticks also exposes new populations to tick-induced meat allergy (alpha-gal) syndrome, whereby development of specific IgE antibodies to the oligosaccharide galactose-alpha-1,3-galactose (alpha-gal) following tick bites results in severe allergic responses to consumption of beef, pork, and lamb.⁷

Amblyomma ticks have now been identified close to the Canadian border in Michigan and New York, and predictions of continued climate change raise the possibility of northward range expansion into all provinces of Canada from Alberta to Newfoundland and Labrador during the coming decades.^8,9 Additional factors that contribute to the expanding range of many tick species include international travel, migratory patterns of birds, competition, and natural predators such as fire ants that feed on tick eggs and influence the feeding behavior of adults.¹⁰

Traditional methods of tick identification rely on gross morphology, including the presence of festoons, shape of the coxae where the legs attach, and markings on the hard overlying scutum. More recently, molecular identification has improved tick identification, leading to more accurate assessment of tick prevalence. These modern identification studies include analysis of 16S ribosomal DNA (rDNA), 12S rDNA, and ITS1 rDNA, and ITS2 rDNA genes.¹¹

The spread of tick vectors has huge public health implications, and better methods to control tick populations are needed.¹² New acaricides and growth regulators are being developed,¹³ and early spring applications of acaricides such as bifenthrin can suppress nymphs prior to the initiation of host-seeking activity.¹⁴ Controlled burns within tick habitats have proved helpful in reducing the risk for vector-borne disease.^15,16 Personal protection is best accomplished with the use of a repellent together with clothing impregnated with an acaricide such as permethrin.¹⁷ Efforts to slow climate change and continued surveillance for the spread of tick vectors is urgently needed.

I know that the world has gone upside down. It’s a nightmare, and people are filled with fear, and death is everywhere. In my little bubble of a world, however, I’ve been doing well.

I can’t lose my job, because I am my job. I’m a solo practitioner and have been for more than a decade. The restrictions to stay at home have not affected me, because I have a home office. Besides, I’m an introvert and see myself as a bit of a recluse, so the social distancing hasn’t been stressful. Conducting appointments by phone rather than face to face hasn’t undermined my work, since I can do everything that I do in my office over the phone. But I do it now in sweats and at my desk in my bedroom more often than not. I am prepared for a decrease in income as people lose their jobs, but that hasn’t happened yet. There are still people out there who are very motivated to come off their medications holistically. No rest for the wicked, as the saying goes.

On an emotional level, I feel calm because I’m not attached to material things, though I like them when they’re here. My children and friends have remained healthy, so I am grateful for that. On a spiritual level, I’m prepared to live or die. I feel grounded in my belief that life goes on one way or another, and I trust in God to direct me wherever I need to go. Socially, I’ve been forced to be less lazy and cook more at home. As a result: less salt, MSG, and greasy food. I’ve spent a lot less on restaurants this past month and am eating less since I have to eat whatever I cook.

Can a person be more pandemic proof? I was joking with a friend about how pandemic-friendly my lifestyle is: spiritually, mentally, emotionally, physically, and socially. Oh, did I forget to mention the year supply of supplements in my office closet? They were for my patients, but those whole food green and red powders may come in handy, just in case.

So, that is how things are going for me. Please don’t hate me for not freaking out. When I read the news, I feel very sad for people who are suffering. I get angry at the politicians who can’t get their egos out of the way. But, I look at the sunshine outside my window, and I feel grateful that, at least in my case, I am not adding to the burden of suffering in the world. Not yet, anyway. I will keep trying to do the little bit that I do to help others for as long as I can.
 

Dr. Lee specializes in integrative and holistic psychiatry and has a private practice in Gaithersburg, Md. She has no disclosures.

I know that the world has gone upside down. It’s a nightmare, and people are filled with fear, and death is everywhere. In my little bubble of a world, however, I’ve been doing well.

I can’t lose my job, because I am my job. I’m a solo practitioner and have been for more than a decade. The restrictions to stay at home have not affected me, because I have a home office. Besides, I’m an introvert and see myself as a bit of a recluse, so the social distancing hasn’t been stressful. Conducting appointments by phone rather than face to face hasn’t undermined my work, since I can do everything that I do in my office over the phone. But I do it now in sweats and at my desk in my bedroom more often than not. I am prepared for a decrease in income as people lose their jobs, but that hasn’t happened yet. There are still people out there who are very motivated to come off their medications holistically. No rest for the wicked, as the saying goes.

On an emotional level, I feel calm because I’m not attached to material things, though I like them when they’re here. My children and friends have remained healthy, so I am grateful for that. On a spiritual level, I’m prepared to live or die. I feel grounded in my belief that life goes on one way or another, and I trust in God to direct me wherever I need to go. Socially, I’ve been forced to be less lazy and cook more at home. As a result: less salt, MSG, and greasy food. I’ve spent a lot less on restaurants this past month and am eating less since I have to eat whatever I cook.

Can a person be more pandemic proof? I was joking with a friend about how pandemic-friendly my lifestyle is: spiritually, mentally, emotionally, physically, and socially. Oh, did I forget to mention the year supply of supplements in my office closet? They were for my patients, but those whole food green and red powders may come in handy, just in case.

So, that is how things are going for me. Please don’t hate me for not freaking out. When I read the news, I feel very sad for people who are suffering. I get angry at the politicians who can’t get their egos out of the way. But, I look at the sunshine outside my window, and I feel grateful that, at least in my case, I am not adding to the burden of suffering in the world. Not yet, anyway. I will keep trying to do the little bit that I do to help others for as long as I can.
 

Dr. Lee specializes in integrative and holistic psychiatry and has a private practice in Gaithersburg, Md. She has no disclosures.

I know that the world has gone upside down. It’s a nightmare, and people are filled with fear, and death is everywhere. In my little bubble of a world, however, I’ve been doing well.

I can’t lose my job, because I am my job. I’m a solo practitioner and have been for more than a decade. The restrictions to stay at home have not affected me, because I have a home office. Besides, I’m an introvert and see myself as a bit of a recluse, so the social distancing hasn’t been stressful. Conducting appointments by phone rather than face to face hasn’t undermined my work, since I can do everything that I do in my office over the phone. But I do it now in sweats and at my desk in my bedroom more often than not. I am prepared for a decrease in income as people lose their jobs, but that hasn’t happened yet. There are still people out there who are very motivated to come off their medications holistically. No rest for the wicked, as the saying goes.

On an emotional level, I feel calm because I’m not attached to material things, though I like them when they’re here. My children and friends have remained healthy, so I am grateful for that. On a spiritual level, I’m prepared to live or die. I feel grounded in my belief that life goes on one way or another, and I trust in God to direct me wherever I need to go. Socially, I’ve been forced to be less lazy and cook more at home. As a result: less salt, MSG, and greasy food. I’ve spent a lot less on restaurants this past month and am eating less since I have to eat whatever I cook.

Can a person be more pandemic proof? I was joking with a friend about how pandemic-friendly my lifestyle is: spiritually, mentally, emotionally, physically, and socially. Oh, did I forget to mention the year supply of supplements in my office closet? They were for my patients, but those whole food green and red powders may come in handy, just in case.

So, that is how things are going for me. Please don’t hate me for not freaking out. When I read the news, I feel very sad for people who are suffering. I get angry at the politicians who can’t get their egos out of the way. But, I look at the sunshine outside my window, and I feel grateful that, at least in my case, I am not adding to the burden of suffering in the world. Not yet, anyway. I will keep trying to do the little bit that I do to help others for as long as I can.
 

Dr. Lee specializes in integrative and holistic psychiatry and has a private practice in Gaithersburg, Md. She has no disclosures.

Eventually this strange Twilight Zone world of coronavirus will end and life will return to normal.

But obviously it won’t be the same, and like everyone else I wonder what will be different.

Telemedicine is one obvious change in my world, though I don’t know how much yet (granted, no one else does, either). I’m seeing a handful of people that way, limited to established patients, where we’re discussing chronic issues or reviewing recent test results.

If I have to see a new patient or an established one with an urgent issue, I’m still willing to meet them at my office (wearing masks and washing hands frequently). In neurology, a lot still depends on a decent exam. It’s pretty hard to check reflexes, sensory modalities, and muscle tone over the phone. If you think a malpractice attorney is going to give you a pass because you missed something by not examining a patient because of coronavirus ... think again.

I’m not sure how the whole telemedicine thing will play out after the dust settles, at least not at my little practice. I’m currently seeing patients by FaceTime and Skype, neither of which is considered HIPAA compliant. The requirement has been waived during the crisis to make sure people can still see doctors, but I don’t see it lasting beyond that. Privacy will always be a central concern in medicine.

When they declare the pandemic over and say I can’t use FaceTime or Skype anymore, that will likely end my use of such. While there are HIPAA-compliant telemedicine services out there, in a small practice I don’t have the time or money to invest in them.

I also wonder how outcomes will change. I suspect the research-minded will be analyzing 2019 vs. 2020 data for years to come, trying to see if a sudden increase in telemedicine led to better or worse clinical outcomes. I’ll be curious to see what they find and how it breaks down by disease and specialty.

How will work change? Right now my staff of three (including me) are all working separately from home, handling phone calls as if it were another office day. In today’s era that’s easy to set up, and we’re used to the drill from when I’m out of town.

Maybe in the future, on lighter days, I’ll do this more often, and have my staff work from home (on typically busy days I’ll still need them to check patients in and out, fax things, file charts, and do all the other things they do to keep the practice running). The marked decrease in air pollution is certainly noticeable and good for all. When the year is over I’d like to see how non-coronavirus respiratory issues changed between 2019 and 2020.

Other businesses will be looking at that, too, with an increase in telecommuting. Why pay for a large office space when a lot can be done over the Internet? It saves rent, gas, and driving time. How it will affect us, as a socially-dependent species, I have no idea.

It’s the same with grocery delivery. While most of us will likely continue to shop at stores, many will stay with the ease of delivery services after this. It may cost more, but it certainly saves time.

There will be social changes, although how long they’ll last is anyone’s guess. Grocery baggers, stockers, and delivery staff, often seen as lower-level occupations, are now considered part of critical infrastructure in keeping people supplied with food and other necessities, as well as preventing fights from breaking out in the toilet paper and hand-sanitizer aisles.

I’d like to think that, in a country divided, the need to work together will help bring people of different opinions together again, but from the way things look I don’t see that happening, which is sad because viruses don’t discriminate, so we shouldn’t either in fighting them.

Like with other challenges that we face, big and little, I can only hope that we’ll learn something from this and have a better world after it’s over. Only time will tell.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz. He has no relevant disclosures.

Eventually this strange Twilight Zone world of coronavirus will end and life will return to normal.

But obviously it won’t be the same, and like everyone else I wonder what will be different.

Telemedicine is one obvious change in my world, though I don’t know how much yet (granted, no one else does, either). I’m seeing a handful of people that way, limited to established patients, where we’re discussing chronic issues or reviewing recent test results.

If I have to see a new patient or an established one with an urgent issue, I’m still willing to meet them at my office (wearing masks and washing hands frequently). In neurology, a lot still depends on a decent exam. It’s pretty hard to check reflexes, sensory modalities, and muscle tone over the phone. If you think a malpractice attorney is going to give you a pass because you missed something by not examining a patient because of coronavirus ... think again.

I’m not sure how the whole telemedicine thing will play out after the dust settles, at least not at my little practice. I’m currently seeing patients by FaceTime and Skype, neither of which is considered HIPAA compliant. The requirement has been waived during the crisis to make sure people can still see doctors, but I don’t see it lasting beyond that. Privacy will always be a central concern in medicine.

When they declare the pandemic over and say I can’t use FaceTime or Skype anymore, that will likely end my use of such. While there are HIPAA-compliant telemedicine services out there, in a small practice I don’t have the time or money to invest in them.

I also wonder how outcomes will change. I suspect the research-minded will be analyzing 2019 vs. 2020 data for years to come, trying to see if a sudden increase in telemedicine led to better or worse clinical outcomes. I’ll be curious to see what they find and how it breaks down by disease and specialty.

How will work change? Right now my staff of three (including me) are all working separately from home, handling phone calls as if it were another office day. In today’s era that’s easy to set up, and we’re used to the drill from when I’m out of town.

Maybe in the future, on lighter days, I’ll do this more often, and have my staff work from home (on typically busy days I’ll still need them to check patients in and out, fax things, file charts, and do all the other things they do to keep the practice running). The marked decrease in air pollution is certainly noticeable and good for all. When the year is over I’d like to see how non-coronavirus respiratory issues changed between 2019 and 2020.

Other businesses will be looking at that, too, with an increase in telecommuting. Why pay for a large office space when a lot can be done over the Internet? It saves rent, gas, and driving time. How it will affect us, as a socially-dependent species, I have no idea.

It’s the same with grocery delivery. While most of us will likely continue to shop at stores, many will stay with the ease of delivery services after this. It may cost more, but it certainly saves time.

There will be social changes, although how long they’ll last is anyone’s guess. Grocery baggers, stockers, and delivery staff, often seen as lower-level occupations, are now considered part of critical infrastructure in keeping people supplied with food and other necessities, as well as preventing fights from breaking out in the toilet paper and hand-sanitizer aisles.

I’d like to think that, in a country divided, the need to work together will help bring people of different opinions together again, but from the way things look I don’t see that happening, which is sad because viruses don’t discriminate, so we shouldn’t either in fighting them.

Like with other challenges that we face, big and little, I can only hope that we’ll learn something from this and have a better world after it’s over. Only time will tell.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz. He has no relevant disclosures.

Eventually this strange Twilight Zone world of coronavirus will end and life will return to normal.

But obviously it won’t be the same, and like everyone else I wonder what will be different.

Telemedicine is one obvious change in my world, though I don’t know how much yet (granted, no one else does, either). I’m seeing a handful of people that way, limited to established patients, where we’re discussing chronic issues or reviewing recent test results.

If I have to see a new patient or an established one with an urgent issue, I’m still willing to meet them at my office (wearing masks and washing hands frequently). In neurology, a lot still depends on a decent exam. It’s pretty hard to check reflexes, sensory modalities, and muscle tone over the phone. If you think a malpractice attorney is going to give you a pass because you missed something by not examining a patient because of coronavirus ... think again.

I’m not sure how the whole telemedicine thing will play out after the dust settles, at least not at my little practice. I’m currently seeing patients by FaceTime and Skype, neither of which is considered HIPAA compliant. The requirement has been waived during the crisis to make sure people can still see doctors, but I don’t see it lasting beyond that. Privacy will always be a central concern in medicine.

When they declare the pandemic over and say I can’t use FaceTime or Skype anymore, that will likely end my use of such. While there are HIPAA-compliant telemedicine services out there, in a small practice I don’t have the time or money to invest in them.

I also wonder how outcomes will change. I suspect the research-minded will be analyzing 2019 vs. 2020 data for years to come, trying to see if a sudden increase in telemedicine led to better or worse clinical outcomes. I’ll be curious to see what they find and how it breaks down by disease and specialty.

How will work change? Right now my staff of three (including me) are all working separately from home, handling phone calls as if it were another office day. In today’s era that’s easy to set up, and we’re used to the drill from when I’m out of town.

Maybe in the future, on lighter days, I’ll do this more often, and have my staff work from home (on typically busy days I’ll still need them to check patients in and out, fax things, file charts, and do all the other things they do to keep the practice running). The marked decrease in air pollution is certainly noticeable and good for all. When the year is over I’d like to see how non-coronavirus respiratory issues changed between 2019 and 2020.

Other businesses will be looking at that, too, with an increase in telecommuting. Why pay for a large office space when a lot can be done over the Internet? It saves rent, gas, and driving time. How it will affect us, as a socially-dependent species, I have no idea.

It’s the same with grocery delivery. While most of us will likely continue to shop at stores, many will stay with the ease of delivery services after this. It may cost more, but it certainly saves time.

There will be social changes, although how long they’ll last is anyone’s guess. Grocery baggers, stockers, and delivery staff, often seen as lower-level occupations, are now considered part of critical infrastructure in keeping people supplied with food and other necessities, as well as preventing fights from breaking out in the toilet paper and hand-sanitizer aisles.

I’d like to think that, in a country divided, the need to work together will help bring people of different opinions together again, but from the way things look I don’t see that happening, which is sad because viruses don’t discriminate, so we shouldn’t either in fighting them.

Like with other challenges that we face, big and little, I can only hope that we’ll learn something from this and have a better world after it’s over. Only time will tell.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz. He has no relevant disclosures.

“I do not shrink from this responsibility, I welcome it.” —John F. Kennedy, inaugural address

COVID-19 has changed our world. Social distancing is now the norm and flattening the curve is our motto. Family physicians’ place on the front line of medicine is more important now than it has ever been.

In the Pennsylvania community in which we work, the first person to don protective gear and sample patients for viral testing in a rapidly organized COVID-19 testing site was John Russell, MD, a family physician. When I asked him about his experience, Dr. Russell said, “No one became a fireman to get cats out of trees ... it was to fight fires. As doctors, this is the same idea ... this is a chance to help fight the fires in our community.”

And, of course, it is primary care providers—family physicians, internists, pediatricians, nurse practitioners, physician assistants, and nurses—who day in and day out are putting aside their own fears, while dealing with those of their family, to come to work with a sense of purpose and courage.

We, as family physicians, have the training to lead with courage and empathy.

The military uses the term “operational tempo” to describe the speed and intensity of actions relative to the speed and intensity of unfolding events in the operational environment. Family physicians are being asked to work at an increased speed in unfamiliar terrain as our environments change by the hour. The challenge is to answer the call—and take care of ourselves—in unprecedented ways. We often use anticipatory guidance with our patients to help prepare them for the challenges they will face. So, too, must we anticipate the things we will need to be attentive to in the coming months in order to sustain the effort that will be required of us.

With this in mind, we would be wise to consider developing plans in 3 domains: physical, mental, and social.

Physical. With gyms closed and restaurants limiting their offerings to take-out, this is an opportune time to create an exercise regimen at home and experiment with healthy meal options. YouTube videos abound for workouts of every length. And of course, you can simply take a daily walk, go for a run, or take a bike ride. Similarly, good choices can be made with take-out and the foods we prepare at home.

Continue to: Mentally...

Mentally we need the discipline to take breaks, delegate when necessary, and use downtime to clear our minds. Need another option? Consider meditation. Google “best meditation apps” and take your pick.

Social distancing doesn’t have to mean emotional isolation; technology allows us to connect with others through messaging and face-to-face video. We need to remember to regularly check in with those we care about; few things in life are as affirming as the connections with those who are close to us: ­family, co-workers, and patients.

Out of crisis comes opportunity. Should we be quarantined, we can remind ourselves that Sir Isaac Newton, while in quarantine during the bubonic plague, laid the foundation for classical physics, composed theories on light and optics, and penned his first draft of the law of gravity.¹

Life carries on, amidst the ­pandemic. Even though the current focus is on the ­COVID-19 crisis, our many needs, joys, and challenges as human beings remain. Today, someone will find out she is pregnant; someone else will be diagnosed with cancer, or plan a wedding, or attend the funeral of a loved one. We, as family physicians, have the training to lead with courage and empathy. We have the expertise gained through years of helping patients though diverse physical and emotional challenges.

We will continue to listen to our patients’ stories, diagnose and treat their diseases, and take steps to bring a sense of calm to the chaos around us. We need to be mindful of our own mindset, because we have a choice. As the psychologist Victor Frankl said in 1946, after being liberated from the concentration camps, “Everything can be taken from a man but one thing: the last of the human freedoms—to choose one’s attitude in any given set of circumstances, to choose one’s own way.”²

“I do not shrink from this responsibility, I welcome it.” —John F. Kennedy, inaugural address

COVID-19 has changed our world. Social distancing is now the norm and flattening the curve is our motto. Family physicians’ place on the front line of medicine is more important now than it has ever been.

In the Pennsylvania community in which we work, the first person to don protective gear and sample patients for viral testing in a rapidly organized COVID-19 testing site was John Russell, MD, a family physician. When I asked him about his experience, Dr. Russell said, “No one became a fireman to get cats out of trees ... it was to fight fires. As doctors, this is the same idea ... this is a chance to help fight the fires in our community.”

And, of course, it is primary care providers—family physicians, internists, pediatricians, nurse practitioners, physician assistants, and nurses—who day in and day out are putting aside their own fears, while dealing with those of their family, to come to work with a sense of purpose and courage.

We, as family physicians, have the training to lead with courage and empathy.

The military uses the term “operational tempo” to describe the speed and intensity of actions relative to the speed and intensity of unfolding events in the operational environment. Family physicians are being asked to work at an increased speed in unfamiliar terrain as our environments change by the hour. The challenge is to answer the call—and take care of ourselves—in unprecedented ways. We often use anticipatory guidance with our patients to help prepare them for the challenges they will face. So, too, must we anticipate the things we will need to be attentive to in the coming months in order to sustain the effort that will be required of us.

With this in mind, we would be wise to consider developing plans in 3 domains: physical, mental, and social.

Physical. With gyms closed and restaurants limiting their offerings to take-out, this is an opportune time to create an exercise regimen at home and experiment with healthy meal options. YouTube videos abound for workouts of every length. And of course, you can simply take a daily walk, go for a run, or take a bike ride. Similarly, good choices can be made with take-out and the foods we prepare at home.

Continue to: Mentally...

Mentally we need the discipline to take breaks, delegate when necessary, and use downtime to clear our minds. Need another option? Consider meditation. Google “best meditation apps” and take your pick.

Social distancing doesn’t have to mean emotional isolation; technology allows us to connect with others through messaging and face-to-face video. We need to remember to regularly check in with those we care about; few things in life are as affirming as the connections with those who are close to us: ­family, co-workers, and patients.

Out of crisis comes opportunity. Should we be quarantined, we can remind ourselves that Sir Isaac Newton, while in quarantine during the bubonic plague, laid the foundation for classical physics, composed theories on light and optics, and penned his first draft of the law of gravity.¹

Life carries on, amidst the ­pandemic. Even though the current focus is on the ­COVID-19 crisis, our many needs, joys, and challenges as human beings remain. Today, someone will find out she is pregnant; someone else will be diagnosed with cancer, or plan a wedding, or attend the funeral of a loved one. We, as family physicians, have the training to lead with courage and empathy. We have the expertise gained through years of helping patients though diverse physical and emotional challenges.

We will continue to listen to our patients’ stories, diagnose and treat their diseases, and take steps to bring a sense of calm to the chaos around us. We need to be mindful of our own mindset, because we have a choice. As the psychologist Victor Frankl said in 1946, after being liberated from the concentration camps, “Everything can be taken from a man but one thing: the last of the human freedoms—to choose one’s attitude in any given set of circumstances, to choose one’s own way.”²

“I do not shrink from this responsibility, I welcome it.” —John F. Kennedy, inaugural address

COVID-19 has changed our world. Social distancing is now the norm and flattening the curve is our motto. Family physicians’ place on the front line of medicine is more important now than it has ever been.

In the Pennsylvania community in which we work, the first person to don protective gear and sample patients for viral testing in a rapidly organized COVID-19 testing site was John Russell, MD, a family physician. When I asked him about his experience, Dr. Russell said, “No one became a fireman to get cats out of trees ... it was to fight fires. As doctors, this is the same idea ... this is a chance to help fight the fires in our community.”

And, of course, it is primary care providers—family physicians, internists, pediatricians, nurse practitioners, physician assistants, and nurses—who day in and day out are putting aside their own fears, while dealing with those of their family, to come to work with a sense of purpose and courage.

We, as family physicians, have the training to lead with courage and empathy.

The military uses the term “operational tempo” to describe the speed and intensity of actions relative to the speed and intensity of unfolding events in the operational environment. Family physicians are being asked to work at an increased speed in unfamiliar terrain as our environments change by the hour. The challenge is to answer the call—and take care of ourselves—in unprecedented ways. We often use anticipatory guidance with our patients to help prepare them for the challenges they will face. So, too, must we anticipate the things we will need to be attentive to in the coming months in order to sustain the effort that will be required of us.

With this in mind, we would be wise to consider developing plans in 3 domains: physical, mental, and social.

Physical. With gyms closed and restaurants limiting their offerings to take-out, this is an opportune time to create an exercise regimen at home and experiment with healthy meal options. YouTube videos abound for workouts of every length. And of course, you can simply take a daily walk, go for a run, or take a bike ride. Similarly, good choices can be made with take-out and the foods we prepare at home.

Continue to: Mentally...

Mentally we need the discipline to take breaks, delegate when necessary, and use downtime to clear our minds. Need another option? Consider meditation. Google “best meditation apps” and take your pick.

Social distancing doesn’t have to mean emotional isolation; technology allows us to connect with others through messaging and face-to-face video. We need to remember to regularly check in with those we care about; few things in life are as affirming as the connections with those who are close to us: ­family, co-workers, and patients.

Out of crisis comes opportunity. Should we be quarantined, we can remind ourselves that Sir Isaac Newton, while in quarantine during the bubonic plague, laid the foundation for classical physics, composed theories on light and optics, and penned his first draft of the law of gravity.¹

Life carries on, amidst the ­pandemic. Even though the current focus is on the ­COVID-19 crisis, our many needs, joys, and challenges as human beings remain. Today, someone will find out she is pregnant; someone else will be diagnosed with cancer, or plan a wedding, or attend the funeral of a loved one. We, as family physicians, have the training to lead with courage and empathy. We have the expertise gained through years of helping patients though diverse physical and emotional challenges.

We will continue to listen to our patients’ stories, diagnose and treat their diseases, and take steps to bring a sense of calm to the chaos around us. We need to be mindful of our own mindset, because we have a choice. As the psychologist Victor Frankl said in 1946, after being liberated from the concentration camps, “Everything can be taken from a man but one thing: the last of the human freedoms—to choose one’s attitude in any given set of circumstances, to choose one’s own way.”²

The growing threat of novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), now commonly known as coronavirus disease 2019 (COVID-19), has forced Americans to stay home due to quarantine, especially older individuals and those who are immunocompromised or have an underlying health problem such as pulmonary or cardiac disease. The federal government’s estimated $2 trillion CARES Act (Coronavirus Aid, Relief, and Economic Security Act)¹ will provide a much-needed boost to health care and the economy; prior recent legislation approved an $8.6 billion emergency relief bill,² HR 6074 (Coronavirus Preparedness and Response Supplemental Appropriations Act of 2020), which expands Medicare coverage of telehealth to patients in their home rather than having them travel to a designated site, covers both established and new patients, allows physicians to waive or reduce co-payments and cost-sharing requirements, and reimburses the same as an in-person visit.

Federal emergency legislation temporarily relaxed the Health Insurance Portability and Accountability Act (HIPAA),^3,4 allowing physicians to use Facetime and Skype for Medicare patients. In addition, Medicare will reimburse telehealth services for out-of-state-providers; however, cross-state licensure is governed by the patient’s home state.⁵ As of March 25, 2020, emergency legislation to temporarily allow out-of-state physicians to provide care, whether or not it relates to COVID-19, was enacted in 13 states: California, Colorado, Connecticut, Delaware, Hawaii, Idaho, Indiana, Iowa, Maryland, Minnesota, New York, North Carolina, and North Dakota.⁶ Ongoing legislation is rapidly changing; for daily updates on licensing laws, refer to the Federation of State Medical Boards website. Check your own institutional policies and malpractice provider prior to offering telehealth, as local laws and regulations may vary. Herein, we offer suggestions for using teledermatology.

Reimbursement

Prior to the COVID-19 pandemic, 16 states—Arkansas, Colorado, Delaware, Hawaii, Kentucky, Maine, Minnesota, Mississippi, Missouri, Montana, Nevada, New Jersey, New Mexico, Tennessee, Utah, and Virginia—had true payment parity laws,⁷ which reimbursed telehealth as a regular office visit using modifier -95. Several states have enacted emergency telehealth expansion laws to discourage COVID-19 spread⁸; some states such as New Jersey now prohibit co-payments or out-of-pocket deductibles from all in-network insurance plans (commercial Medicare and Medicaid).^9,10 Updated legislation about COVID-19 and telemedicine can be found on the Center for Connected Health Policy website. An interactive map of laws and reimbursement policies also is available on the websites of the American Telehealth Association and the American Academy of Dermatology. The ability to charge a patient directly for telehealth services depends on the insurance provider agreement. If telehealth is a covered service, you cannot charge these patients out-of-pocket.

Teledermatology Options

For many conditions, the effectiveness and quality of teledermatology is comparable to a conventional face-to-face visit.¹¹ There are 3 types of telehealth visits:

• Store and forward: The clinician reviews images or videos and responds asynchronously,¹² similar to an email chain.
• Live interactive: The clinician uses 2-way video synchronously.¹² In states with parity laws, this method is reimbursed equally to an in-person visit.
• Remote patient monitoring: Health-related data are collected and transmitted to a remote clinician, similar to remote intensive care unit management.¹² Dermatologists are unlikely to utilize this modality.

The Virtual Visit

Follow these guidelines for practicing teledermatology: (1) ensure that the image or video is clear and that there is proper lighting, a monochromatic background, and a clear view of the anatomy necessary to evaluate; (2) dress in appropriate attire as if you were in clinic, such as scrubs, a white coat, or other professional attire; (3) begin the telehealth encounter by obtaining informed consent,¹³ according to state¹⁴ or Medicare guidelines; (4) document the location of the patient and provider; (5) for live virtual visits, document similarly to an in-person visit⁵; (6) for all other virtual care, document minutes spent on each task; and (7) select only 1 billing code per visit.

In some states, regulations for commercial and/or Medicaid plans require that other modifiers be added to billing codes, which vary plan-by-plan:

• Modifier GQ: For asynchronous care (store and forward).
• Modifier GT: For synchronous live telehealth visits.
• Modifier -95: In states where there are equal parity laws or if you are billing a commercial insurance payer (may vary by plan).

Medicare does not require any additional modifiers.¹⁵ If the plan reimburses telemedicine equally to a face-to-face visit, use regular office visit codes. The eTable¹⁶ lists billing codes and Medicare reimbursement rates.

Secure Software

Several electronic medical record systems already include secure patient communication. Other HIPAA-compliant communication options with a variety of features are available to clinicians:

• Klara allows for HIPAA-secure texting, group messaging, photograph uploads, and telephone calls.
• Doximity offers free calling and faxes.
• G Suite for health care offers HIPAA-compliant texting, emailing, and video calls through Google Voice and Google Hangouts Meet.
• Secure video chat is available on Zoom for Healthcare, VSee, Doxy.me, and other platforms.
• Multiservice platforms such as DermEngine include billing, payments, teledermatology, and teledermoscopy and allow for interprofessional consultation.

The Bottom Line

Telehealth readiness is playing a key role in containing the spread of COVID-19. In-person dermatology visits are now being limited to urgent conditions only, as per institutional guidelines.⁴



Acknowledgment
We thank Garfunkel Wild, P.C. (Great Neck, New York), for their expertise and assistance.

The growing threat of novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), now commonly known as coronavirus disease 2019 (COVID-19), has forced Americans to stay home due to quarantine, especially older individuals and those who are immunocompromised or have an underlying health problem such as pulmonary or cardiac disease. The federal government’s estimated $2 trillion CARES Act (Coronavirus Aid, Relief, and Economic Security Act)¹ will provide a much-needed boost to health care and the economy; prior recent legislation approved an $8.6 billion emergency relief bill,² HR 6074 (Coronavirus Preparedness and Response Supplemental Appropriations Act of 2020), which expands Medicare coverage of telehealth to patients in their home rather than having them travel to a designated site, covers both established and new patients, allows physicians to waive or reduce co-payments and cost-sharing requirements, and reimburses the same as an in-person visit.

Federal emergency legislation temporarily relaxed the Health Insurance Portability and Accountability Act (HIPAA),^3,4 allowing physicians to use Facetime and Skype for Medicare patients. In addition, Medicare will reimburse telehealth services for out-of-state-providers; however, cross-state licensure is governed by the patient’s home state.⁵ As of March 25, 2020, emergency legislation to temporarily allow out-of-state physicians to provide care, whether or not it relates to COVID-19, was enacted in 13 states: California, Colorado, Connecticut, Delaware, Hawaii, Idaho, Indiana, Iowa, Maryland, Minnesota, New York, North Carolina, and North Dakota.⁶ Ongoing legislation is rapidly changing; for daily updates on licensing laws, refer to the Federation of State Medical Boards website. Check your own institutional policies and malpractice provider prior to offering telehealth, as local laws and regulations may vary. Herein, we offer suggestions for using teledermatology.

Reimbursement

Prior to the COVID-19 pandemic, 16 states—Arkansas, Colorado, Delaware, Hawaii, Kentucky, Maine, Minnesota, Mississippi, Missouri, Montana, Nevada, New Jersey, New Mexico, Tennessee, Utah, and Virginia—had true payment parity laws,⁷ which reimbursed telehealth as a regular office visit using modifier -95. Several states have enacted emergency telehealth expansion laws to discourage COVID-19 spread⁸; some states such as New Jersey now prohibit co-payments or out-of-pocket deductibles from all in-network insurance plans (commercial Medicare and Medicaid).^9,10 Updated legislation about COVID-19 and telemedicine can be found on the Center for Connected Health Policy website. An interactive map of laws and reimbursement policies also is available on the websites of the American Telehealth Association and the American Academy of Dermatology. The ability to charge a patient directly for telehealth services depends on the insurance provider agreement. If telehealth is a covered service, you cannot charge these patients out-of-pocket.

Teledermatology Options

For many conditions, the effectiveness and quality of teledermatology is comparable to a conventional face-to-face visit.¹¹ There are 3 types of telehealth visits:

• Store and forward: The clinician reviews images or videos and responds asynchronously,¹² similar to an email chain.
• Live interactive: The clinician uses 2-way video synchronously.¹² In states with parity laws, this method is reimbursed equally to an in-person visit.
• Remote patient monitoring: Health-related data are collected and transmitted to a remote clinician, similar to remote intensive care unit management.¹² Dermatologists are unlikely to utilize this modality.

The Virtual Visit

Follow these guidelines for practicing teledermatology: (1) ensure that the image or video is clear and that there is proper lighting, a monochromatic background, and a clear view of the anatomy necessary to evaluate; (2) dress in appropriate attire as if you were in clinic, such as scrubs, a white coat, or other professional attire; (3) begin the telehealth encounter by obtaining informed consent,¹³ according to state¹⁴ or Medicare guidelines; (4) document the location of the patient and provider; (5) for live virtual visits, document similarly to an in-person visit⁵; (6) for all other virtual care, document minutes spent on each task; and (7) select only 1 billing code per visit.

In some states, regulations for commercial and/or Medicaid plans require that other modifiers be added to billing codes, which vary plan-by-plan:

• Modifier GQ: For asynchronous care (store and forward).
• Modifier GT: For synchronous live telehealth visits.
• Modifier -95: In states where there are equal parity laws or if you are billing a commercial insurance payer (may vary by plan).

Medicare does not require any additional modifiers.¹⁵ If the plan reimburses telemedicine equally to a face-to-face visit, use regular office visit codes. The eTable¹⁶ lists billing codes and Medicare reimbursement rates.

Secure Software

Several electronic medical record systems already include secure patient communication. Other HIPAA-compliant communication options with a variety of features are available to clinicians:

• Klara allows for HIPAA-secure texting, group messaging, photograph uploads, and telephone calls.
• Doximity offers free calling and faxes.
• G Suite for health care offers HIPAA-compliant texting, emailing, and video calls through Google Voice and Google Hangouts Meet.
• Secure video chat is available on Zoom for Healthcare, VSee, Doxy.me, and other platforms.
• Multiservice platforms such as DermEngine include billing, payments, teledermatology, and teledermoscopy and allow for interprofessional consultation.

The Bottom Line

Telehealth readiness is playing a key role in containing the spread of COVID-19. In-person dermatology visits are now being limited to urgent conditions only, as per institutional guidelines.⁴



Acknowledgment
We thank Garfunkel Wild, P.C. (Great Neck, New York), for their expertise and assistance.

The growing threat of novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), now commonly known as coronavirus disease 2019 (COVID-19), has forced Americans to stay home due to quarantine, especially older individuals and those who are immunocompromised or have an underlying health problem such as pulmonary or cardiac disease. The federal government’s estimated $2 trillion CARES Act (Coronavirus Aid, Relief, and Economic Security Act)¹ will provide a much-needed boost to health care and the economy; prior recent legislation approved an $8.6 billion emergency relief bill,² HR 6074 (Coronavirus Preparedness and Response Supplemental Appropriations Act of 2020), which expands Medicare coverage of telehealth to patients in their home rather than having them travel to a designated site, covers both established and new patients, allows physicians to waive or reduce co-payments and cost-sharing requirements, and reimburses the same as an in-person visit.

Federal emergency legislation temporarily relaxed the Health Insurance Portability and Accountability Act (HIPAA),^3,4 allowing physicians to use Facetime and Skype for Medicare patients. In addition, Medicare will reimburse telehealth services for out-of-state-providers; however, cross-state licensure is governed by the patient’s home state.⁵ As of March 25, 2020, emergency legislation to temporarily allow out-of-state physicians to provide care, whether or not it relates to COVID-19, was enacted in 13 states: California, Colorado, Connecticut, Delaware, Hawaii, Idaho, Indiana, Iowa, Maryland, Minnesota, New York, North Carolina, and North Dakota.⁶ Ongoing legislation is rapidly changing; for daily updates on licensing laws, refer to the Federation of State Medical Boards website. Check your own institutional policies and malpractice provider prior to offering telehealth, as local laws and regulations may vary. Herein, we offer suggestions for using teledermatology.

Reimbursement

Prior to the COVID-19 pandemic, 16 states—Arkansas, Colorado, Delaware, Hawaii, Kentucky, Maine, Minnesota, Mississippi, Missouri, Montana, Nevada, New Jersey, New Mexico, Tennessee, Utah, and Virginia—had true payment parity laws,⁷ which reimbursed telehealth as a regular office visit using modifier -95. Several states have enacted emergency telehealth expansion laws to discourage COVID-19 spread⁸; some states such as New Jersey now prohibit co-payments or out-of-pocket deductibles from all in-network insurance plans (commercial Medicare and Medicaid).^9,10 Updated legislation about COVID-19 and telemedicine can be found on the Center for Connected Health Policy website. An interactive map of laws and reimbursement policies also is available on the websites of the American Telehealth Association and the American Academy of Dermatology. The ability to charge a patient directly for telehealth services depends on the insurance provider agreement. If telehealth is a covered service, you cannot charge these patients out-of-pocket.

Teledermatology Options

For many conditions, the effectiveness and quality of teledermatology is comparable to a conventional face-to-face visit.¹¹ There are 3 types of telehealth visits:

• Store and forward: The clinician reviews images or videos and responds asynchronously,¹² similar to an email chain.
• Live interactive: The clinician uses 2-way video synchronously.¹² In states with parity laws, this method is reimbursed equally to an in-person visit.
• Remote patient monitoring: Health-related data are collected and transmitted to a remote clinician, similar to remote intensive care unit management.¹² Dermatologists are unlikely to utilize this modality.

The Virtual Visit

Follow these guidelines for practicing teledermatology: (1) ensure that the image or video is clear and that there is proper lighting, a monochromatic background, and a clear view of the anatomy necessary to evaluate; (2) dress in appropriate attire as if you were in clinic, such as scrubs, a white coat, or other professional attire; (3) begin the telehealth encounter by obtaining informed consent,¹³ according to state¹⁴ or Medicare guidelines; (4) document the location of the patient and provider; (5) for live virtual visits, document similarly to an in-person visit⁵; (6) for all other virtual care, document minutes spent on each task; and (7) select only 1 billing code per visit.

In some states, regulations for commercial and/or Medicaid plans require that other modifiers be added to billing codes, which vary plan-by-plan:

• Modifier GQ: For asynchronous care (store and forward).
• Modifier GT: For synchronous live telehealth visits.
• Modifier -95: In states where there are equal parity laws or if you are billing a commercial insurance payer (may vary by plan).

Medicare does not require any additional modifiers.¹⁵ If the plan reimburses telemedicine equally to a face-to-face visit, use regular office visit codes. The eTable¹⁶ lists billing codes and Medicare reimbursement rates.

Secure Software

Several electronic medical record systems already include secure patient communication. Other HIPAA-compliant communication options with a variety of features are available to clinicians:

• Klara allows for HIPAA-secure texting, group messaging, photograph uploads, and telephone calls.
• Doximity offers free calling and faxes.
• G Suite for health care offers HIPAA-compliant texting, emailing, and video calls through Google Voice and Google Hangouts Meet.
• Secure video chat is available on Zoom for Healthcare, VSee, Doxy.me, and other platforms.
• Multiservice platforms such as DermEngine include billing, payments, teledermatology, and teledermoscopy and allow for interprofessional consultation.

The Bottom Line

Telehealth readiness is playing a key role in containing the spread of COVID-19. In-person dermatology visits are now being limited to urgent conditions only, as per institutional guidelines.⁴



Acknowledgment
We thank Garfunkel Wild, P.C. (Great Neck, New York), for their expertise and assistance.

Previously I urged you to take a look at a clinical report from the American Academy of Pediatrics that makes an excellent case for the importance of physical activity in the physical and mental health of children. I suggested we should view with some skepticism the authors’ recommendation that we include a quantifiable assessment of physical activity as a vital sign in our EHRs because I found it an unrealistic goal for most busy clinicians.

I also promised to write again and address the authors’ recommendation that we learn how to write an exercise prescription. The authors representing the AAP’s Council on Sports Medicine and Fitness and Section on Obesity observed that many pediatricians feel they lack “the experience or training to guide their patients toward meeting physical activity recommendations.” This is in some part because few if any medical schools or training programs include how to write an exercise prescription in their curricula. Certainly I don’t recall anyone sitting me down and telling me how to prescribe exercise. But, I submit that writing a workable exercise prescription for most patients doesn’t require any special training. However, it does require some common sense and touch of creativity.

Writing any kind of prescription means that you first must know the patient for whom you are writing it. What are his or her capabilities? If the patient has some physical disabilities, you may need to involve a physical therapist or the patient’s specialists in developing the options. But in most cases, common sense will provide you with a place to start.

More important than knowing the patient’s capability is discovering what kind of things the patient and his or her family already find attractive. Convincing people, young or old, they should exercise because it is good for them is more than likely destined to fail. Most of us who enjoy being active have found that it makes us feel better. It is very likely that we developed that affinity by first doing something active that we found enjoyable. Finding that fun gateway into an active lifestyle is where it helps to be creative and to have the patience to suggest multiple options as interest levels fade. For the patient or family who seems to enjoy numerical goals, pedometers and smartwatch fitness trackers can be a hook, but in my experience these gadgets seldom result in a sustainable activity habit.

Does your community have the resources from which the family can choose an activity to fill your prescription? You should know enough about your community’s recreational opportunities and the family’s financial and temporal limitations so that the activity you have prescribed is achievable.

The bottom line is that you must be prepared for failure because most of your thoughtfully crafted prescriptions won’t be taken or even filled. The inertia that we have built into our societies is often too great for families to overcome. But don’t give up. Ask at every visit about activity. Make follow-up visits to discuss the progress or lack of progress to demonstrate that you still consider exercise a valuable and potent piece of the wellness package. And continue to discourage excess screen time.

If you are feeling frustrated by your lack of success writing exercise prescriptions, you may discover that you can be more effective by speaking out at school board and recreation department meetings. Armed with the research included in the AAP’s recent clinical report, you may find powerful allies in the community who share your passion for helping children become more active.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

Previously I urged you to take a look at a clinical report from the American Academy of Pediatrics that makes an excellent case for the importance of physical activity in the physical and mental health of children. I suggested we should view with some skepticism the authors’ recommendation that we include a quantifiable assessment of physical activity as a vital sign in our EHRs because I found it an unrealistic goal for most busy clinicians.

I also promised to write again and address the authors’ recommendation that we learn how to write an exercise prescription. The authors representing the AAP’s Council on Sports Medicine and Fitness and Section on Obesity observed that many pediatricians feel they lack “the experience or training to guide their patients toward meeting physical activity recommendations.” This is in some part because few if any medical schools or training programs include how to write an exercise prescription in their curricula. Certainly I don’t recall anyone sitting me down and telling me how to prescribe exercise. But, I submit that writing a workable exercise prescription for most patients doesn’t require any special training. However, it does require some common sense and touch of creativity.

Writing any kind of prescription means that you first must know the patient for whom you are writing it. What are his or her capabilities? If the patient has some physical disabilities, you may need to involve a physical therapist or the patient’s specialists in developing the options. But in most cases, common sense will provide you with a place to start.

More important than knowing the patient’s capability is discovering what kind of things the patient and his or her family already find attractive. Convincing people, young or old, they should exercise because it is good for them is more than likely destined to fail. Most of us who enjoy being active have found that it makes us feel better. It is very likely that we developed that affinity by first doing something active that we found enjoyable. Finding that fun gateway into an active lifestyle is where it helps to be creative and to have the patience to suggest multiple options as interest levels fade. For the patient or family who seems to enjoy numerical goals, pedometers and smartwatch fitness trackers can be a hook, but in my experience these gadgets seldom result in a sustainable activity habit.

Does your community have the resources from which the family can choose an activity to fill your prescription? You should know enough about your community’s recreational opportunities and the family’s financial and temporal limitations so that the activity you have prescribed is achievable.

The bottom line is that you must be prepared for failure because most of your thoughtfully crafted prescriptions won’t be taken or even filled. The inertia that we have built into our societies is often too great for families to overcome. But don’t give up. Ask at every visit about activity. Make follow-up visits to discuss the progress or lack of progress to demonstrate that you still consider exercise a valuable and potent piece of the wellness package. And continue to discourage excess screen time.

If you are feeling frustrated by your lack of success writing exercise prescriptions, you may discover that you can be more effective by speaking out at school board and recreation department meetings. Armed with the research included in the AAP’s recent clinical report, you may find powerful allies in the community who share your passion for helping children become more active.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

Previously I urged you to take a look at a clinical report from the American Academy of Pediatrics that makes an excellent case for the importance of physical activity in the physical and mental health of children. I suggested we should view with some skepticism the authors’ recommendation that we include a quantifiable assessment of physical activity as a vital sign in our EHRs because I found it an unrealistic goal for most busy clinicians.

I also promised to write again and address the authors’ recommendation that we learn how to write an exercise prescription. The authors representing the AAP’s Council on Sports Medicine and Fitness and Section on Obesity observed that many pediatricians feel they lack “the experience or training to guide their patients toward meeting physical activity recommendations.” This is in some part because few if any medical schools or training programs include how to write an exercise prescription in their curricula. Certainly I don’t recall anyone sitting me down and telling me how to prescribe exercise. But, I submit that writing a workable exercise prescription for most patients doesn’t require any special training. However, it does require some common sense and touch of creativity.

Writing any kind of prescription means that you first must know the patient for whom you are writing it. What are his or her capabilities? If the patient has some physical disabilities, you may need to involve a physical therapist or the patient’s specialists in developing the options. But in most cases, common sense will provide you with a place to start.

More important than knowing the patient’s capability is discovering what kind of things the patient and his or her family already find attractive. Convincing people, young or old, they should exercise because it is good for them is more than likely destined to fail. Most of us who enjoy being active have found that it makes us feel better. It is very likely that we developed that affinity by first doing something active that we found enjoyable. Finding that fun gateway into an active lifestyle is where it helps to be creative and to have the patience to suggest multiple options as interest levels fade. For the patient or family who seems to enjoy numerical goals, pedometers and smartwatch fitness trackers can be a hook, but in my experience these gadgets seldom result in a sustainable activity habit.

Does your community have the resources from which the family can choose an activity to fill your prescription? You should know enough about your community’s recreational opportunities and the family’s financial and temporal limitations so that the activity you have prescribed is achievable.

The bottom line is that you must be prepared for failure because most of your thoughtfully crafted prescriptions won’t be taken or even filled. The inertia that we have built into our societies is often too great for families to overcome. But don’t give up. Ask at every visit about activity. Make follow-up visits to discuss the progress or lack of progress to demonstrate that you still consider exercise a valuable and potent piece of the wellness package. And continue to discourage excess screen time.

If you are feeling frustrated by your lack of success writing exercise prescriptions, you may discover that you can be more effective by speaking out at school board and recreation department meetings. Armed with the research included in the AAP’s recent clinical report, you may find powerful allies in the community who share your passion for helping children become more active.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

On the evening of March 24, I got the email. When the bolded letters “We ask for your help” flashed across my screen, I knew exactly what was being asked of me: to graduate early and join the fight against COVID-19.

It would be a lie to say that my immediate reaction was to volunteer.

For the 120 fourth-year medical students in my class at NYU Grossman School of Medicine, the arrival of that email was always more a question of when than if. Similar moves had already been made in Italy as well as the United Kingdom, where the surge in patients with COVID-19 has devastated hospitals and left healthcare workers dead or drained. The New York hospitals where I’ve trained, places I have grown to love over the past 4 years, are now experiencing similar horrors. Residents and attending doctors – mentors and teachers – are burned out and exhausted. They need help.

Like most medical students, I chose to pursue medicine out of a desire to help. On both my medical school and residency applications, I spoke about my resolve to bear witness to and provide support to those suffering. Yet, being recruited to the front lines of a global pandemic felt deeply unsettling. Is this how I want to finally enter the world of medicine? The scope of what is actually being asked of me was immense.

Given the onslaught of bad news coming in on every device I had cozied up to during my social distancing, how could I want to do this? I’ve seen the death toll climb in Italy, with dozens of doctors dead. I’ve seen the photos of faces marred by masks worn for 12-16 hours at a time. I’ve been repeatedly reminded that we are just behind Italy. Things are certainly going to get worse.

It sounds selfish and petty, but I feel like COVID-19 has already robbed me of so much. Yet that was my first thought when I received the email. The end of fourth year in medical school is supposed to be a joyous, celebratory time. We have worked years for this moment. So many of us have fought burnout to reach this time, a brief moment of rest between being a medical student and becoming a full-fledged physician.

I matched into residency just 4 days before being asked to join the front lines of the pandemic. I found out my match results without the usual fanfare, sitting on a bench in Madison Square Park, FaceTiming my dad and safely social-distanced from my mom. They both cried tears of joy. Like so many people around the world right now, I couldn’t even embrace my parents. Would they want me to volunteer?

I reached out to my classmates. I thought that some of them would certainly share my worries. I thought they also had to be carrying this uncomfortable kind of grief, a heavy and acidic feeling of dreams collapsing into a moral duty. I received a unanimous reply: “We are needed. It’s our time to step up.” No matter how many “what ifs” I voiced, they wouldn’t crack or waver. Still, even if they never admitted it to me, I wondered whether they privately shared some of my concerns and fears.

Everyone knows information is shared instantly in our Twitter-centric world, but I was still shocked and unprepared for how quickly I was at the center of a major news story. Within an hour of that email, I was contacted by an old acquaintance from elementary school, now a journalist. He had found me through Facebook and asked, “Will you be one of the NYU students graduating early? Would love to get a comment.” Another friend texted me a photo of the leaked email, quipping, “Are you going to save us from the pandemic, Dr. Gabe?!” “It’s not a small decision!” I snapped back.

I went through something like the seven stages of grief in rapid succession. I found that with each excuse I made why I shouldn’t volunteer, I somehow became increasingly more anxious. To my surprise, when I decided I would join 50 of my peers at NYU, graduate early, and volunteer, my mind settled. The more I thought about it, the more I was overtaken by the selfless beauty of the profession I’m entering. This is what it means to be a doctor. I recalled a key part of the Hippocratic Oath: “I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.”

I am going to fulfill my special obligations.

The fear is still there. I’m scared of COVID. I’m scared to infect others. I’m scared of winding up paralyzed and intubated. But I have also realized that all we have is each other. Healthcare workers supporting healthcare workers. New Yorkers supporting New Yorkers. Citizens of the world supporting citizens of the world. This is my time to be there for others, unwaveringly.

Logistical details continue to roll in, although they feel trivial in relation to the decision I have already made. The paperwork tells me that I will be onboarded to NYU’s internal medicine residency program. I will be compensated and protected under a similar contract to what current NYU residents sign. I have been promised that I will remain insured until I start my official residency program in July. My student loans won’t begin accruing interest until my normally planned graduation date. I am told that I will have personal protective equipment in line with the Centers for Disease Control and Prevention recommendations.

Questions still linger. Is it safe for me and my newly minted physician peers to continue living with our spouses, children, and friends? How long will I need to quarantine after my contract ends? Will there be a virtual graduation ceremony for my parents and loved ones to enjoy? In these challenging times, each day gives me a little more clarity about what exactly I am signing up for, but there are still so many uncertainties.

Am I naive to say that I do feel prepared? Or at least as prepared as anyone can be. With respect to my training, I have completed the requirements to graduate, which is why I am being permitted to graduate early in the first place. Our faculty points to our professionalism as the most promising indicator of our preparedness. They are heartened that we have embraced this truest test: our duty to others.

There is an eerie calm to New York City that contradicts what is shown on the news. With stores closed and streets quiet, it almost feels like Christmas morning here. Yet, inside the hospital, a fire rages. All the metaphors being used right now speak about violence, devastation, and immeasurable human suffering. “A war is being fought.” Or so I have heard. I guess I am about to find out.

Gabriel Redel-Traub is a fourth-year medical student at NYU Grossman School of Medicine. He will be starting residency in internal medicine at Columbia Presbyterian this summer. He is the former editor-in-chief of Dartmouth College’s Mouth Magazine, an editor of NYU’s LitMed Database, and has published most recently in the Hasting’s Center Magazine. Gabriel Redel-Traub has disclosed no relevant financial relationships.

This article first appeared on Medscape.com.

On the evening of March 24, I got the email. When the bolded letters “We ask for your help” flashed across my screen, I knew exactly what was being asked of me: to graduate early and join the fight against COVID-19.

It would be a lie to say that my immediate reaction was to volunteer.

For the 120 fourth-year medical students in my class at NYU Grossman School of Medicine, the arrival of that email was always more a question of when than if. Similar moves had already been made in Italy as well as the United Kingdom, where the surge in patients with COVID-19 has devastated hospitals and left healthcare workers dead or drained. The New York hospitals where I’ve trained, places I have grown to love over the past 4 years, are now experiencing similar horrors. Residents and attending doctors – mentors and teachers – are burned out and exhausted. They need help.

Like most medical students, I chose to pursue medicine out of a desire to help. On both my medical school and residency applications, I spoke about my resolve to bear witness to and provide support to those suffering. Yet, being recruited to the front lines of a global pandemic felt deeply unsettling. Is this how I want to finally enter the world of medicine? The scope of what is actually being asked of me was immense.

Given the onslaught of bad news coming in on every device I had cozied up to during my social distancing, how could I want to do this? I’ve seen the death toll climb in Italy, with dozens of doctors dead. I’ve seen the photos of faces marred by masks worn for 12-16 hours at a time. I’ve been repeatedly reminded that we are just behind Italy. Things are certainly going to get worse.

It sounds selfish and petty, but I feel like COVID-19 has already robbed me of so much. Yet that was my first thought when I received the email. The end of fourth year in medical school is supposed to be a joyous, celebratory time. We have worked years for this moment. So many of us have fought burnout to reach this time, a brief moment of rest between being a medical student and becoming a full-fledged physician.

I matched into residency just 4 days before being asked to join the front lines of the pandemic. I found out my match results without the usual fanfare, sitting on a bench in Madison Square Park, FaceTiming my dad and safely social-distanced from my mom. They both cried tears of joy. Like so many people around the world right now, I couldn’t even embrace my parents. Would they want me to volunteer?

I reached out to my classmates. I thought that some of them would certainly share my worries. I thought they also had to be carrying this uncomfortable kind of grief, a heavy and acidic feeling of dreams collapsing into a moral duty. I received a unanimous reply: “We are needed. It’s our time to step up.” No matter how many “what ifs” I voiced, they wouldn’t crack or waver. Still, even if they never admitted it to me, I wondered whether they privately shared some of my concerns and fears.

Everyone knows information is shared instantly in our Twitter-centric world, but I was still shocked and unprepared for how quickly I was at the center of a major news story. Within an hour of that email, I was contacted by an old acquaintance from elementary school, now a journalist. He had found me through Facebook and asked, “Will you be one of the NYU students graduating early? Would love to get a comment.” Another friend texted me a photo of the leaked email, quipping, “Are you going to save us from the pandemic, Dr. Gabe?!” “It’s not a small decision!” I snapped back.

I went through something like the seven stages of grief in rapid succession. I found that with each excuse I made why I shouldn’t volunteer, I somehow became increasingly more anxious. To my surprise, when I decided I would join 50 of my peers at NYU, graduate early, and volunteer, my mind settled. The more I thought about it, the more I was overtaken by the selfless beauty of the profession I’m entering. This is what it means to be a doctor. I recalled a key part of the Hippocratic Oath: “I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.”

I am going to fulfill my special obligations.

The fear is still there. I’m scared of COVID. I’m scared to infect others. I’m scared of winding up paralyzed and intubated. But I have also realized that all we have is each other. Healthcare workers supporting healthcare workers. New Yorkers supporting New Yorkers. Citizens of the world supporting citizens of the world. This is my time to be there for others, unwaveringly.

Logistical details continue to roll in, although they feel trivial in relation to the decision I have already made. The paperwork tells me that I will be onboarded to NYU’s internal medicine residency program. I will be compensated and protected under a similar contract to what current NYU residents sign. I have been promised that I will remain insured until I start my official residency program in July. My student loans won’t begin accruing interest until my normally planned graduation date. I am told that I will have personal protective equipment in line with the Centers for Disease Control and Prevention recommendations.

Questions still linger. Is it safe for me and my newly minted physician peers to continue living with our spouses, children, and friends? How long will I need to quarantine after my contract ends? Will there be a virtual graduation ceremony for my parents and loved ones to enjoy? In these challenging times, each day gives me a little more clarity about what exactly I am signing up for, but there are still so many uncertainties.

Am I naive to say that I do feel prepared? Or at least as prepared as anyone can be. With respect to my training, I have completed the requirements to graduate, which is why I am being permitted to graduate early in the first place. Our faculty points to our professionalism as the most promising indicator of our preparedness. They are heartened that we have embraced this truest test: our duty to others.

There is an eerie calm to New York City that contradicts what is shown on the news. With stores closed and streets quiet, it almost feels like Christmas morning here. Yet, inside the hospital, a fire rages. All the metaphors being used right now speak about violence, devastation, and immeasurable human suffering. “A war is being fought.” Or so I have heard. I guess I am about to find out.

Gabriel Redel-Traub is a fourth-year medical student at NYU Grossman School of Medicine. He will be starting residency in internal medicine at Columbia Presbyterian this summer. He is the former editor-in-chief of Dartmouth College’s Mouth Magazine, an editor of NYU’s LitMed Database, and has published most recently in the Hasting’s Center Magazine. Gabriel Redel-Traub has disclosed no relevant financial relationships.

This article first appeared on Medscape.com.

On the evening of March 24, I got the email. When the bolded letters “We ask for your help” flashed across my screen, I knew exactly what was being asked of me: to graduate early and join the fight against COVID-19.

It would be a lie to say that my immediate reaction was to volunteer.

For the 120 fourth-year medical students in my class at NYU Grossman School of Medicine, the arrival of that email was always more a question of when than if. Similar moves had already been made in Italy as well as the United Kingdom, where the surge in patients with COVID-19 has devastated hospitals and left healthcare workers dead or drained. The New York hospitals where I’ve trained, places I have grown to love over the past 4 years, are now experiencing similar horrors. Residents and attending doctors – mentors and teachers – are burned out and exhausted. They need help.

Like most medical students, I chose to pursue medicine out of a desire to help. On both my medical school and residency applications, I spoke about my resolve to bear witness to and provide support to those suffering. Yet, being recruited to the front lines of a global pandemic felt deeply unsettling. Is this how I want to finally enter the world of medicine? The scope of what is actually being asked of me was immense.

Given the onslaught of bad news coming in on every device I had cozied up to during my social distancing, how could I want to do this? I’ve seen the death toll climb in Italy, with dozens of doctors dead. I’ve seen the photos of faces marred by masks worn for 12-16 hours at a time. I’ve been repeatedly reminded that we are just behind Italy. Things are certainly going to get worse.

It sounds selfish and petty, but I feel like COVID-19 has already robbed me of so much. Yet that was my first thought when I received the email. The end of fourth year in medical school is supposed to be a joyous, celebratory time. We have worked years for this moment. So many of us have fought burnout to reach this time, a brief moment of rest between being a medical student and becoming a full-fledged physician.

I matched into residency just 4 days before being asked to join the front lines of the pandemic. I found out my match results without the usual fanfare, sitting on a bench in Madison Square Park, FaceTiming my dad and safely social-distanced from my mom. They both cried tears of joy. Like so many people around the world right now, I couldn’t even embrace my parents. Would they want me to volunteer?

I reached out to my classmates. I thought that some of them would certainly share my worries. I thought they also had to be carrying this uncomfortable kind of grief, a heavy and acidic feeling of dreams collapsing into a moral duty. I received a unanimous reply: “We are needed. It’s our time to step up.” No matter how many “what ifs” I voiced, they wouldn’t crack or waver. Still, even if they never admitted it to me, I wondered whether they privately shared some of my concerns and fears.

Everyone knows information is shared instantly in our Twitter-centric world, but I was still shocked and unprepared for how quickly I was at the center of a major news story. Within an hour of that email, I was contacted by an old acquaintance from elementary school, now a journalist. He had found me through Facebook and asked, “Will you be one of the NYU students graduating early? Would love to get a comment.” Another friend texted me a photo of the leaked email, quipping, “Are you going to save us from the pandemic, Dr. Gabe?!” “It’s not a small decision!” I snapped back.

I went through something like the seven stages of grief in rapid succession. I found that with each excuse I made why I shouldn’t volunteer, I somehow became increasingly more anxious. To my surprise, when I decided I would join 50 of my peers at NYU, graduate early, and volunteer, my mind settled. The more I thought about it, the more I was overtaken by the selfless beauty of the profession I’m entering. This is what it means to be a doctor. I recalled a key part of the Hippocratic Oath: “I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.”

I am going to fulfill my special obligations.

The fear is still there. I’m scared of COVID. I’m scared to infect others. I’m scared of winding up paralyzed and intubated. But I have also realized that all we have is each other. Healthcare workers supporting healthcare workers. New Yorkers supporting New Yorkers. Citizens of the world supporting citizens of the world. This is my time to be there for others, unwaveringly.

Logistical details continue to roll in, although they feel trivial in relation to the decision I have already made. The paperwork tells me that I will be onboarded to NYU’s internal medicine residency program. I will be compensated and protected under a similar contract to what current NYU residents sign. I have been promised that I will remain insured until I start my official residency program in July. My student loans won’t begin accruing interest until my normally planned graduation date. I am told that I will have personal protective equipment in line with the Centers for Disease Control and Prevention recommendations.

Questions still linger. Is it safe for me and my newly minted physician peers to continue living with our spouses, children, and friends? How long will I need to quarantine after my contract ends? Will there be a virtual graduation ceremony for my parents and loved ones to enjoy? In these challenging times, each day gives me a little more clarity about what exactly I am signing up for, but there are still so many uncertainties.

Am I naive to say that I do feel prepared? Or at least as prepared as anyone can be. With respect to my training, I have completed the requirements to graduate, which is why I am being permitted to graduate early in the first place. Our faculty points to our professionalism as the most promising indicator of our preparedness. They are heartened that we have embraced this truest test: our duty to others.

There is an eerie calm to New York City that contradicts what is shown on the news. With stores closed and streets quiet, it almost feels like Christmas morning here. Yet, inside the hospital, a fire rages. All the metaphors being used right now speak about violence, devastation, and immeasurable human suffering. “A war is being fought.” Or so I have heard. I guess I am about to find out.

Gabriel Redel-Traub is a fourth-year medical student at NYU Grossman School of Medicine. He will be starting residency in internal medicine at Columbia Presbyterian this summer. He is the former editor-in-chief of Dartmouth College’s Mouth Magazine, an editor of NYU’s LitMed Database, and has published most recently in the Hasting’s Center Magazine. Gabriel Redel-Traub has disclosed no relevant financial relationships.

This article first appeared on Medscape.com.