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July 2020 Volume 4 Issue 4

COVID CONCEPTS

Virtual Continuity Clinics: A Hybrid Approach to Longitudinal
Patient-Dermatologist Relationships in the Wake of COVID-19

Alexander J. Jafari, BA1,2, Andrea T. Murina, MD1

1Department of Dermatology, Tulane University School of Medicine, New Orleans, LA
2Tulane University School of Public Health and Tropical Medicine, New Orleans, LA

The current coronavirus pandemic (COVID-19)
caused by the novel SARS-CoV2 has
revolutionized medical practice in the United
States. Physicians have rapidly adopted
telehealth to communicate with their patients
and it may remain an important tool for
maintaining continuity of care in residency
programs. Continuity of care, or longitudinal
patient-physician interaction, is associated with
greater patient satisfaction, including more
appropriate follow-up care and fewer missed
appointments.1 More patient-physician contact
can lead to stronger patient-physician
relationships and higher rates of resident
satisfaction.1,2 Continuity has historically been
challenging to achieve in ambulatory graduate
medical education (GME) training settings.1
The implementation of virtual continuity clinics
in dermatology via telehealth during the
COVID-19 pandemic may highlight its merits in
GME training.

Resident scheduling and time constraints are
the main barriers to maintaining longitudinal

care in ambulatory medical specialties.
Methods to improve continuity in medicine and
pediatrics residency programs showed mixed
results when using same-day appointments,
scheduling to an individual resident or team,
and fixed day clinics.1

Appropriating a fixed time for virtual continuity
clinics allows residents to connect with patients
seen in clinic or following discharge from the
hospital. Virtual continuity visits can be
scheduled with the same faculty teams that
previously evaluated the patient in-person.
While it may be challenging to include all team
members from the patient’s initial visit, having
the same resident-physician at follow-up can
solidify patient-physician rapport. These check-
ins are opportunities to address patients’
concerns, monitor symptoms, emphasize
medication adherence, and assess medication
side effects. Residents can participate in
patient and family education and identify social
and environmental barriers to care. Tele-
dermatology could be used to connect with

ABSTRACT

The COVID-19 crisis has altered the delivery of healthcare due to the rapid utilization of
telemedicine. Dermatology residency programs may benefit from the use of teledermatology for
the purposes of establishing and maintaining continuity over a three-year training program. We
examine the current evidence on the effect of continuity on patient and resident satisfaction and
elaborate on how teledermatology can help to overcome some of the barriers to longitudinal care.
Integrating teledermatology into a continuity clinic allows resident physicians to check-in more
frequently with patients and provide medication monitoring. We offer suggestions on how programs
can integrate teledermatology into a virtual continuity clinic for residents.

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July 2020 Volume 4 Issue 4

every new patient seen by a resident in clinic,
or used to follow up biopsy results during the
resident’s scheduled continuity clinic.
Additionally, any patient starting on a new high-
risk medication could be assessed by
telehealth within 1-2 weeks of starting the
medication. This could decrease patient
dosing errors that we commonly see during the
use of weekly dosed medications, such as
methotrexate.

Virtual visits provide ease of access,
eliminating the need for patients and residents
to travel to specific clinics. This would
significantly decrease travel time for patients
who live in rural areas that lack dermatologic
care. Virtual or telephone encounters could
offer greater access to these underserved
patient populations who are at most risk of
being lost-to-follow-up due to lack of reliable
transportation and limited sick-days.3,4 Many of
the underserved also lack computers for
telemedicine, but in our experience most lower-
income patients do have a cellular phone and
can download a telehealth application.
Continuous care for these vulnerable groups
can provide increased access to medical
services. In the past, both patients and
residents have generally been satisfied with
teledermatology.5 While both groups preferred
in-person consultations over telemedicine
visits, satisfaction with teledermatology still
remained high and mainly differed based on the
format offered (e.g. store-and-forward versus
live-interactive sessions).5 During the current
COVID-19 pandemic, teledermatology may
emerge as a suitable alternative for
establishing longitudinal care for patients.

The virtual continuity model can be applied to
medical specialties that include inpatient and
ambulatory care to improve health care
transitions. After a patient’s initial visit at the
hospital or clinic, he or she can be monitored
over time ideally by the same team of
physicians who performed the initial in-person
evaluation through virtual visits. Dermatology
program directors can assess residents’ and

patients’ experiences with telehealth during the
COVID-19 pandemic to determine the
feasibility of this model downstream. In the
wake of COVID-19, this hybrid model
consisting of both telehealth and office visits
may reset the culture of care to support
longitudinal interactions between patients and
their physicians.

Conflict of Interest Disclosures: Dr. Murina has been a
speaker and/or consultant for Abbvie, Amgen, Eli Lilly and
Company, Janssen, Novartis, Ortho-Dermatologics.

Funding: None

Corresponding Author:
Andrea T. Murina, MD
Department of Dermatology
Tulane University School of Medicine
1430 Tulane Ave, #8036
New Orleans, LA 70112
Phone: 504-988-1700
Fax: 504-988-1721
Email: amurina@tulane.edu

References:

1. Walker J, Payne B, Clemans-Taylor BL, Snyder
ED. Continuity of Care in Resident Outpatient
Clinics: A Scoping Review of the Literature. J
Grad Med Educ. 2018;10(1):16-25.
doi:10.4300/JGME-D-17-00256.1

2. Dorrell DN, Feldman SR, Huang WW-T. The
most common causes of burnout among US
academic dermatologists based on a survey
study. J Am Acad Dermatol. 2019;81(1):269-270.
doi:10.1016/j.jaad.2019.01.021

3. Wang RF, Trinidad J, Lawrence J, Pootrakul L,
Forrest LA, Goist K, Levine E, Nair S, Rizer M,
Thomas A, Wexler R, Kaffenberger BH. Improved
Patient Access and Outcomes with the
Integration of an eConsult Program
(Teledermatology) within a Large Academic
Medical Center. J Am Acad Dermatol. 2019. doi:
https://doi.org/10.1016/ j.jaad.2019.10.053.

4. Buster KJ, Stevens EI, Elmets CA. Dermatologic
Health Disparities. Dermatol Clin. 2012;30(1):53-
59. doi:10.1016/j.det.2011.08.002

5. Marchell R, Locatis C, Burgess G, Maisiak R, Liu
WL, Ackerman M. Patient and Provider
Satisfaction with Teledermatology. Telemed J E
Health. 2017;23(8):684-690.
doi:10.1089/tmj.2016.0192