PracticalDermatology

Like it or not, this is the future of dermatology. Apparently all of the training that some of the smartest medical students dive into for five years can be simply replaced by a camera and an algorithm manual. Not new news, but another notch on the post of bad news.

We have made jokes about “Dr. Google,” who never graduated from school, how “minute clinic” stands for “one minute of training,” and about the endless pharmaceutical bounty that is now stocked in the grocery store in the condiment aisle (Yes, coconut oil and apple cider vinegar, I am talking to you!). But the perception that has become part of the mindset of the patient is not go see your doctor, but look it up online, make a few guesses on what to do, and go see an “expert” or clinician at the pharmacy…because once again, our patients seem to trust pharmacists and assume doctors are either on the take or just bad to the core.

Take, for example, the patient I saw just the other day—one of the worst acne pickers I have ever seen whose middle name should be “Noncompliance.” Granted, she came to me this time announcing that she was 11 weeks pregnant, so my hands became tied on what I could prescribe for her. But she informed me that she was now being treated by an “acne expert” and that her skin was already looking better. I’m glad she thought so, even though it really didn’t look better to me. My question for her was what the degree and office setup was for this expert. As expected, she said, “I don’t know, but she said she had a chemistry major.” So I paused and said, “OK, so you went from your dermatologist—who is not only trained but has lectured on the science of acne and written book chapters and articles on how to treat it—to someone with a chemistry major? Seriously?” She looked at me and said, “But I’m better, and all you wanted to do was prescribe me expensive drugs!” Game, set, and match, I guess.

There are now many online portals and web-based teledermatology services are marketed for not only treating acne, but supplanting the need to see a doctor. Typically, all it takes are a few photos uploaded or emailed in, and a treatment plan will be created and sent back to patients for a flat fee. Now in the spirit of getting in the game, Walgreens has partnered with a teledermatology group, comprised of board-certified dermatologists. The stores have kiosks for “patients” (Are they really patients at that point? Or consumers?) to send their own photos in for an assessment and treatment plan for any skin issue. Walgreens’ gain is the flow of prescriptions that will follow after the evaluations, so in some respect this plan even cannibalizes the minute clinic practitioner as potential patients are now cyberpatients.

In one respect, many organizations including the American Academy of Dermatology have position statements regarding safe practices, appropriate use of teledermatology, and patient safety. On the other hand, the basic principles of responsibility for follow-up, liability for bad outcomes, proper patient counseling, and so many other issues of daily practice just seem to be missing. And I’m sorry, but when did dermatology become a 2D specialty? What happened to putting your hands on patients and examining them to make a diagnosis and establish treatment? While advances in technology have their benefits, and teledermatology can serve a purpose in allowing patients in remote areas or with few physicians nearby access to care, face-face interaction between doctors and patients is still the gold standard. But the painful question is: Was my patient right? Was it wrong to try to prescribe her a therapeutic regimen based on the science of the pathogenesis of the disease, to try to slow down her progress of her acne and reduce her scarring potential? Or should I have just prescribed her fluff to keep her happy? Isn’t that the template for merit-based and value-based payment models, where the “customer” is always right?

So as we continue down this path of steadily being marginalized, and the poaching of acne patients from the dermatologist’s office continues, and patients realize that they can “try this at home” and don’t need us, what comes next? We have already seen the results of consolidation. And the movement to a single-payer system is gaining speed, so is it time to let go of “do-it-yourself diseases” like acne and let the patients swim on their own? Drinks in aisle 3, toilet tissue in aisle 6, and acne diagnoses in aisle 9. Welcome to the one-stop shop! n

—Neal Bhatia, Chief Medical Editor