Elan Newman, MD, FAAD, is a board-certified dermatologist in San Diego who practices both in person and via telemedicine. For the past several years, he has been seeing cases as a physician on the Spruce teledermatology platform, and we recently caught up with him to ask him what he has learned along the way. Read on for pearls and insight straight from an experienced expert in the field!
“Expert Interviews” is a recurring feature on the Spruce blog where we put you directly in touch with expert opinion and leadership on important topics in telehealth, value-based care, and medical practice at large.
Spruce: What was your earliest experience with teledermatology? How has the field changed over time?
Dr. Newman: Before there was anything like Spruce around, many doctors would send photos to me of their patients’ rashes and acne for management recommendations. The transition from in-person medicine to telemedicine was quite smooth for me. I think this is because we spend a lot of our training reviewing and studying static photos of skin conditions.
Spruce: Do you use synchronous (live video) telemedicine for teledermatology?
The advantage of asynchronous consults is that we can get the higher resolution that we need to make a proper diagnosis.
Dr. Newman: I have never used synchronous teledermatology. I don’t think there is any benefit over asynchronous (“store and forward”) because of the inherent lower resolution of moving pictures compared to stills.
Since our physical exam is based on looking at a static rash or lesion, we don’t need to assess movement, range of motion, or strength. The advantage of asynchronous consults is that we can get the higher resolution that we need to make a proper diagnosis.
Spruce: What conditions do you feel have been best for you to diagnose and manage via teledermatology?
Dr. Newman: I think acne is far and away the best and easiest condition to treat via teledermatology. This is where Spruce has really been a pioneer and leader in the field of teledermatology. In most cases, with only a few photos and questions, we can diagnose and prescribe a treatment plan that we believe will be effective. I also think that it is a better way to educate my patients about their skin and how to take care of their acne. In my clinics, I feel that patients are swamped with medical explanations and information, much of which is hard to retain. On Spruce, we deliver everything in an electronic message so the patients have resources to read and understand at their leisure. I’ve been really pleased to see how knowledgeable some of my Spruce patients have become about their skin.
Spruce: What limitations did you expect before getting into teledermatology?
Dr. Newman: I did not expect us to be able to diagnose and treat rashes via telemedicine. When looking at a rash on a live patient, I look at the general distribution of the lesions as well as what each one looks like. I also ask many questions about the history of the rash. Boy have I been impressed by what we have been able to do!!!
I did not expect us to be able to diagnose and treat rashes via telemedicine. […] Boy have I been impressed by what we have been able to do!!!
I think the success of our expansion into treating other skin conditions, like rashes, has been the amazing interplay between our doctors and the engineers at Spruce [Ed note: Spruce engineers build the technology to deliver the complaint-specific question sets that dermatologists on Spruce have designed]. We have really been able to pull key information from our patients and make a diagnosis using only a few photos and questions.
I also did not think that we would be able to use medications like birth control pills and spironolactone to treat acne. My colleagues and I had a lot of concerns about the risks of prescribing these medications remotely. But at Spruce, we have been able to connect patients with local labs to get the appropriate tests done.
Spruce: What would most improve your ability to practice effective teledermatology?
Dr. Newman: I think having better access to our telemedicine software would allow for a more rapid response to our patients. Having something like a phone app for the physicians would be very welcome.
In the future, I think dermatoscopes that are simple for patients to use would possibly allow us to look into evaluating skin lesions remotely. I don’t think we are too far away from having this technology as phones are being equipped with newer cameras and processors.
Spruce: Are there any patient populations you feel would benefit from teledermatology that you haven’t been able to reach yet?
I would like to see teledermatology services be used in large managed care organizations. There is tremendous demand to see a dermatologist in these groups. With large numbers of patients in these systems, this can translate into a prolonged delay in seeing a dermatologist. In some systems, the solution to the backlog has been to bounce patients between various dermatologists depending on availability. Both of these scenarios have led to dissatisfaction among patients. I think that we have shown that many common dermatological conditions can be treated via a remote platform, and we are also able to ensure continuity of care for our patients. Teledermatology services could make a great first-line level of management for many common conditions in these organizations.
Spruce: Do you have any favorite teledermatology success stories?
Everyone in our group is really focused on simply helping people who might otherwise be lost in our healthcare system. This is particularly true for skin conditions that are difficult for primary physicians to manage or diagnose.
Dr. Newman: We had a patient who was seen by a local dermatologist and told that she had pemphigus vulgaris. She used our service because she felt that her topical steroids were not controlling her condition and she was very itchy and distressed. She did not know where to turn; she had limited insurance, money, and could not travel very far. Normally, this is not a condition that we would treat at Spruce. But given her situation and the risks associated with untreated pemphigus vulgaris, we decided to do more. Working through our group of physicians on Spruce and through our non-Spruce colleagues, we were able to connect her with an expert in bullous diseases at a local tertiary care center within a week.
I really feel that this case illustrates our motivation to help our teledermatology patients on Spruce, beyond our goals of providing excellent care and growing as a practice group. Everyone in our group is really focused on simply helping people who might otherwise be lost in our healthcare system. This is particularly true for skin conditions that are difficult for primary physicians to manage or diagnose. It is even more true for patients who don’t have access to primary care. I’m really proud of what we accomplished.
There was another case of a patient who had recurring severe acne on her face. I ended up calling the patient and determining that she had acne fulminans. This is a rare and horribly scarring form of acne that appears suddenly. Ideally, we would treat this as quickly as possible. To make matters worse, the patient had an insurance plan that many doctors are reluctant to accept. But by using our network of doctors we were able to get her an appointment with a local dermatologist within a few days’ time.
Spruce: Have you seen any adverse outcomes or times where teledermatology may have let you and the patient down?
Dr. Newman: There have been a couple of occasions where some patients have experienced mild irritation reactions to common acne treatments. I think it would have been easier to convey my reassurance in person rather than via electronic messages. I think we can convey a lot more in our tone and expression when it comes to reassuring our patients. Perhaps emoticons would help?
Spruce: Do you have any tips or tricks you’ve picked up for successful teledermatology?
I think one of the most powerful aspects about teledermatology is how closely you can monitor your patient’s progress.
Dr. Newman: I think one of the most powerful aspects about teledermatology is how closely you can monitor your patient’s progress.
In my personal clinic, I may see a patient every few months for acne, or in two to six weeks for a rash. There are times when I would like to maintain closer follow-up. This is very challenging to do in my practice, and sometimes it just isn’t possible to have patients return so soon. But over teledermatology, the patient can send me a quick message or a set of photos to review within that interval. It really works well!
Spruce: Have you noticed any pitfalls to avoid in teledermatology?
Dr. Newman: Do not treat anything that you are not comfortable treating. Whenever I’m not perfectly sure of a diagnosis, I always tell the patient up front. I may offer one trial of treatment up front with the understanding that I may need to refer them out if we don’t see any improvement.
Spruce: What academic research is most needed in teledermatology?
Dr. Newman: Excellent question!!
We have the ability to collect large volumes of survey data from our patients and to evaluate photos as well. We can investigate head-to-head studies between different classes of medications or different treatment regimens. This would be great for acne.
It would be pretty cool to run clinical studies using only telemedicine, and the cost savings could be enormous. I think it might also reflect the real-world experience more closely than structured site-based clinical studies where we know a placebo effect can be significant. I would be curious to see how the teledermatology model for health care delivery compares in terms of overall cost to the traditional in-person model.