PracticalDermatology

Estimates suggest that about 55 percent of skin diseases in the US will be diagnosed by a non-dermatologist. It probably comes as no surprise that more than half of all skin diseases will be diagnosed by general practitioners and pediatricians, given that the patient population in the US continues to balloon. Consider also that a dermatology workforce shortage has long been predicted, and many dermatologists are also dedicating time to cosmetic services and procedures.

Against this backdrop, health information technology (HIT) has emerged as a possible way to increase efficiency and help dermatologists see more patients for diagnosis and management of medical skin conditions.

Art Papier, MD has been at the forefront of diagnostic clinical decision support, which he emphasizes is not synonymous with electronic health records (EHR). He is co-founder of VisualDX (along with Dr. Lowell Goldsmith; You can read more about the platform in the sidebar), which is used by thousands of dermatologists, emergency physicians, hospitalists, and general practitioners worldwide for assistance with therapeutic selection, differential diagnosis, and patient education. Ahead, he discusses the potential role for HIT in patient care and explains how technology can actually help dermatology get back to its roots.

Do you believe there is such a thing as “Forgotten Dermatology”? If so, why?

Art Papier, MD: Medical practice has become very high pressure for many dermatologists who are seeing 50 to 100 patients a day. They’re overwhelmed, for example, by the number of skin biopsies they must do as the population ages and skin cancer rates rise. Most of the day is spent treating pre-cancers, treating cancer, treating common inflammatory diseases. As such, clinicians have less exposure to rare diseases.

When we think about the art of dermatology, we could think back 100 years ago when the profession was the specialty of “Dermatology and Syphilology.” Everybody who is a dermatologist knows that we can see on the skin and in the mucosa, the hair, the nails signs of internal disease that internal medical physicians don’t recognize. The beauty of dermatology is the art of diagnosis through visual information and being able to, often without yet taking a history, make a diagnosis.

I think a little of the art of dermatology has been lost as we have moved into this much higher pressure world of higher volumes of patients. As clinicians continue to see patients with similar complaints, they have less opportunity to see and treat patients with rare disease. Many younger dermatologists and maybe some of the nurse practitioners and physician assistants, therefore, simply do not get a lot of exposure to the richness of dermatology.

When you think about dermatology and the number of diagnoses a dermatologist could see in her/his career, it’s over 1,000. Some people argue it’s closer to 3,000 diagnoses that can present on the skin. Look now at how global the world has become with both immigration and travel; you have patients coming from other countries, or traveling and coming back from other countries. If your patient travels to Peru or they travel to Thailand, or they travel to Haiti, there is a different set of infectious diseases in each of those countries to consider. There’s no way that a dermatologist or any physician can memorize every infectious disease by every country in the world.

“Forgotten Dermatology” is losing sight of the glory days of the expert diagnostician. I would submit that we’ve unfortunately demoted our profession through so much emphasis on cosmetics and the associated media and press coverage that overlooks the full gamut of services that dermatologists provide. The public really doesn’t appreciate how good dermatologists can be at diagnosis.

Why do you believe HIT can help? Where does it fit in?

Dr. Papier: Most people equate health information technology with the electronic record. However, for the most part, the electronic record is just a recording tool. It’s not really bolstering the differential diagnosis.

Forgotten dermatology, in my mind, is the lost emphasis on diagnosis. We know that quality care begins with an accurate diagnosis. If you don’t have the right diagnosis, you’re probably not giving the right treatment. Consider scabies, as an example. A patient comes in with an itchy rash, and you’re rushing, and you don’t look for the burrows of scabies and you just see some excoriated scratched scaly plaques, you might rush to judgment and think it’s dermatitis. The treatment for dermatitis is not the treatment you would use for someone with scabies. So you’ve got to start with the right diagnosis.

Part of the focus of my research and work is in the field of cognitive mistakes and decision making. I and others have been exploring how we, as clinicians, recognize and diagnose diseases and what pitfalls exist.

If a dermatologist is seeing 60, 70 patients in a day, which some do—some see even more—she or he is, let’s face it, they’re really in a rush. There’s a body of research around the problem of diagnostic error and cognitive mistakes. The research looks at known traps that doctors fall into. One of the ones that’s most discussed is something called premature closure. Premature closure can be likened to the concept of falling in love with the first puppy you see. Instead of thinking about all the possibilities then making a decision, the clinician settles on the first thing that comes to mind.

We are supposed to approach diagnosis with a differential diagnosis of possibilities in mind. If you’re in a rush and you just think of one thing and that becomes your diagnosis, you are setting yourself up for diagnostic failure. Because dermatologists are so good at visual recognition, pattern recognition, we latch onto that first puppy very quickly. Sometimes we don’t fully examine patient or listen to the relevant history.

There’s another notion in cognitive mistakes called satisfying, where you get one answer, but you didn’t push harder to get the full answer. Suppose you didn’t ask about potential causes for a given presentation. Then you just have a diagnosis without the cause.

There’s another cognitive mistake called representative bias. Representative bias means that you’re looking for the classic presentation of a disease but you are unaware of the variant presentations of the disease.

Dermatologists are generally good at knowing variants, but a lot of knowledge comes from experience. As such, some younger dermatologists don’t have exposure to the variants. With information technology, you can represent that variation and create resources that help novice dermatologists start to recognize things they have never seen.

This leads to one of the challenges in medicine generally, which is, “How do you diagnose what you don’t know?” It’s very hard to diagnose what you don’t know. So we tend to ask questions about what we know, not what we don’t know. Another goal of information technology is to help extend the reach of the human brain so that, just like a pilot flying a 747, we have instruments to help us fly better.

What skills or tactics should dermatologists focus on to help preserve the art of dermatology?

Dr. Papier: Number one would be thorough physical exams starting from the scalp and hair to the mucosa to the entire skin surface and the nails.

Two would be listening to your patient.

Three would be spending time on patient education, including showing them pictures. Dermatologists used to do that by going down the hallway and grabbing a book. But now it’s just much easier with digital tools.

Fourth would be having a logical differential diagnosis.

Five would be considering tried-and-true therapies, such as ultraviolet light therapy and compounded treatments, before expensive therapies. More and more patients have high-deductible health plans, and they resent us prescribing the most expensive therapies first.

I would really emphasize the importance of thoroughness and the art of diagnosis and the art of having a good differential diagnosis. This is being pushed aside as some dermatologists see too many patients.

There’s a principle called the ETTO Principle or Efficiency/Thoroughness Trade Off Principle. You can either be super-efficient, which in the dermatologic world might mean fast. Or, on the other side of the spectrum, you could be super thorough. But you cannot be both at the same time. You cannot be super-fast and super-thorough at the same time.

The art of dermatology is to be on the sweet spot of both thorough and efficient, and it behooves dermatologists to move back toward a little bit more thoroughness and keeping their patients happy. Because I’ve met way too many patients complaining about their dermatologic experiences.

I was on a plane recently. A 22-year-old sitting next to me saw a PowerPoint presentation I was working on, and he realized I’m a dermatologist. He started telling me a story about how he saw a dermatologist in his town that was in the room for about 20 seconds. Then he explains to me the treatment the dermatologist gave for his acne, and it was totally correct. And the patient himself felt that his acne was better. But the patient was totally dissatisfied with the visit because of how little time the doctor spent.

“Forgotten dermatology” also includes spending a little bit more time with patients.

What are some ways that information technology can improve dermatology practice and patient care? Is it possible that HIT could contribute to some of the challenges that exist in providing enhanced care to patients?

Dr. Papier: As I noted, unfortunately patients, doctors and the media conflate the electronic record with information technology. The electronic record often is cited as one of the number one reasons for physician burnout. But if you talk to doctors about medicine going back all the way to Hippocrates, you discover that doctors—and I’d say dermatologists especially—embrace useful technology.

When you consider Hippocrates and other references either on the desktop or the phone, like VisualDX or UpToDate, doctors are not saying they hate these tools. So it’s very different when you’re using these apps to find and present information to help support care, versus the drudgery and the pain of the electronic record and charting that makes you stay two hours late after the clinic day.

One form of HIT is quick and efficient; that’s the information resources. Then the drudgery of charting is what’s burning out physicians. They are both health information technology. But beneficial health information technology includes knowledge, resources, and decision tools.

Compared to EHR, HIT-based decision tools improve diagnosis, improve patient understanding and patient care, and give you quick alternatives to therapy. This is helpful, as you might not otherwise remember all the different treatment options.

As I said, the electronic record slows doctors down. We need to start showing physicians how health information technology speeds up their day. In fact, we did a survey of dermatologists and dermatology NPs and PAs where we showed a time savings of between 14 and 26 minutes a day for those who were using VisualDX.

We also have to think about patient-facing technology. Every dermatologist can identify with the problem of patients coming in with handouts from WebMD or Google. The patient has the wrong idea and is anchored on the wrong idea. Now the dermatologist has to move them to the proper diagnosis and educate them and move them off what they’re anchored on from the internet.

Consider the patient that comes in and says, “Doctor, I went on the internet and went to Google and I went to WebMD and I think I have eczema.” The dermatologist knows the patient has poison ivy. But the patient, unfortunately, may not be satisfied to rely on the dermatologist’s expertise. Technology allows the dermatologist to quickly search poison ivy, show the picture to the patient, and print a handout for the patient in 15 seconds. By making it easy to show the patient that picture and provide the handout, technology can be used to reassure the patient, and the patient stops arguing with the doctor.

Sharing pictures with the patient is a key part of building confidence. Consider the impact of doing the search right with the patient to say, look, I have a professional tool and I can show you pictures. The patients love that. It saves the doctor so much time.