Technology’s impact on dermatology [PODCAST]

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“During COVID, the medical training system had to adapt because people couldn’t meet in person and even those that could didn’t have access to patients or facilities in the same capacity. However, the explosion of remote training tools that became available make this hybrid training method as good in many ways, and perhaps even preferable to one that consists mainly of in-person lectures. In fact, some medical schools have suggested that all preclinical classes should be available exclusively online by 2025. As a result, schools and other stakeholder organizations should examine alternative methods of medical training and can use this opportunity to embrace new technologies in order to effectively and efficiently educate trainees. It may be time to abandon the old ways and fully embrace the advantages virtual training environments, including video games, have to offer.”

Peter Lio is a dermatologist.

He shares his story and discusses his KevinMD article, “The evolution of medical training in dermatology and the impact of technology.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Peter Lio. He is a dermatologist, and he wrote the KevinMD article “The evolution of medical training in dermatology and the impact of technology.” Peter, welcome to the show.

Peter Lio: Thank you so much for having me. I’m excited to be here.

Kevin Pho: We’ll get into the article in a little bit, but first off, can you share your story and journey to where you are today?

Peter Lio: Yes. I’m originally from Chicago, from the northern suburbs, and I went out east to medical school at Harvard and fell in love with dermatology because I had some incredible teachers and mentors. I stayed on at Harvard for my residency, got to be the chief resident in my last year, and then actually stayed on as faculty for a few years before coming back home to Chicago and joining up with Northwestern.

Since then, it’s been a little bit of some mini journeys, as I’ve now forged my own practice, and I started the Chicago Integrative Eczema Center. That’s been really exciting. I really focus a lot on atopic dermatitis, but I also trained in medical acupuncture, so I focus on some integrative approaches in dermatology as well. It’s been an exciting journey.

Kevin Pho: As a private practice dermatologist, what are some of the challenges that you face?

Peter Lio: There are a lot of challenges. One of the biggest things is that there is a huge demand for our services, which is wonderful, and you feel very needed, but it’s also really hard to meet the need of the community. There’s a waiting list sometimes, and some of our patients are suffering and miserable and itchy and infected, and we’re trying to get those patients in.

We also have a duty to do screening. We do a lot of skin cancer screening, and I still am a general dermatologist, so I see everything, even though I focus a lot on atopic dermatitis. We’re also trying to balance clinical research, educational stuff, I like to have medical students and residents come through, all of these things. I think most doctors share this kind of stress of trying to balance everything, but in our line of work, it’s really trying to make people happy and meet their needs while not running yourself too ragged and burning out.

Kevin Pho: I’m interested in hearing about the intersection between technology and dermatology, which you write about in your article. It’s titled “The evolution of medical training in dermatology and the impact of technology.” Now, for those who get a chance to read your article, can you just walk my audience through it and share the story of why you decided to write it?

Peter Lio: Yes. I just think it’s so fascinating. Part of what really captivated me about dermatology when I was a medical student is that not only is it visual, and everyone sort of says, “It’s so visual,” and it is, and that is striking and a big part of it, but there are a lot of interesting thoughts and tons of therapeutics, and there’s a lot of chronic disease management. We have all these different things. We have all these different approaches for therapies, too.

Part of what really blew me away with dermatology is that we use oral medicines and injectable medicines, but we also use topical medicines, all these different vehicles. Then we use things like physical modalities: cryotherapy to freeze stuff, thermal therapy where we can heat things up. We use different types of lasers. We use toxins injected into the skin. We inject fillers. I mean, we do surgery. It’s incredible.

There are so many different things that we have to learn, such varied skill sets, and each one of those really does require a different approach. So I think, by default, we have to learn from other specialties. From the surgeons, we can see: How do they teach procedures? How do they get people comfortable? From other areas of medicine, we say, “OK, what do we do to get good diagnostics? How do we teach people to do that?”

Now we’ve of course been pushed, sometimes kicking and screaming, into the world of telemedicine. So we’ve had to look at radiology and say, “OK, what are they doing?” because they have to look at screens and make these diagnoses and give feedback. How can we learn from them?

I think that’s part of what drew me to it and continues to keep me excited and passionate about dermatology: We have all these different worlds we pull from, and the medical education has to reflect that if we want to keep making great dermatologists, which we most definitely do. And we want to keep being great dermatologists, right? Because we’re constantly learning. So I’m very interested in seeing our educational approaches also modernize and keep up with the technology.

Kevin Pho: Now, can you describe what current dermatology training is like and what specific technological approaches you would like to see to train the next generation of dermatologists?

Peter Lio: I think right now we’re still, in a way, and I do love it, beautifully old-fashioned. It’s very much an apprentice model. When you are a resident, you spend time in different clinics, you learn from different attendings, and you get that repetition over and over and over. One of the things about dermatology is that we’re a very high-volume specialty. Some people can see 30, 40, or 50 patients in half a day. I don’t see that many personally, but there were clinics where we’ve seen this kind of tremendously fast throughput.

So you have to be quick on your feet, you have to be a good communicator, and you have very little time to establish rapport with the patient and to get that educational message out. You find that you have to be very refined. Over those three years of derm training, I think we get people there, but I would love to see us be able to use more technology.

Part of what has changed as well is that we often now carry dermatoscopes. Dermatoscopy, or dermoscopy, as some people say, is a little magnifying glass with lights around it that actually uses polarized light and a polarized filter, so we can see a little bit deeper into the skin. We can also look at, particularly, pigmented lesions, which is really where we use it most, so if we’re worried that something could be precancerous or melanoma. But I use it for everything. There’s even literature looking at it for different types of hair loss and for looking at other types of non-malignant lesions. We’re even doing a study right now where we’re using this little dermatoscope to look at atopic dermatitis up close and see if we can get some new ideas about how we can give a diagnosis and get a sense of the severity of the disease.

All of these things come with challenges of education, and we really need some novel ways to do it. Instead of pulling the person over to the microscope or to the dermatoscope to let them see it, I’d love to leverage things like video game-type approaches, where we can actually have people do this in a simulated way over and over and over in the comfort of their own home.

Kevin Pho: With the evolution of smartphone technology, I have patients come to my primary care clinic with some type of app, right? They take a picture of a skin lesion or a mole, and the app says, “This is potential cancer,” or it purports to give a diagnosis. So what are your thoughts in terms of that intersection between smartphone technology and dermatology?

Peter Lio: Yes, it has been thrust upon us, for sure. I kid you not, sometimes, you can imagine, patients come in with their iPad, and they have an entire album of skin stuff that they want to show me. We’re going, “And on November 7th, here’s my left leg,” and they’re going through, and I’m like, “Wait, I got it. I’m with you.” So people really do want to share.

There’s no doubt that sometimes it can really make or break it, because some of the things in dermatology are kind of evanescent. They’re not there the day I see them, and the patient’s frustrated. But with a good-quality photograph, which comes from their iPhone camera or their smartphone camera, they can actually show me exactly what it looked like when they were having trouble. There’s no doubt that we can make diagnoses and can counsel that way, so that’s been exciting.

But again, we’re kind of unprepared for it. It sort of came out of nowhere, so I think that has to become part of our training, too. That’s why I’m grateful to have some more teledermatology that’s formally brought into many residency programs now.

Kevin Pho: Now, in other fields, you mentioned radiology, sometimes there are some algorithmic approaches to dermatologists that sometimes take away from radiologists’ jobs. Now, with the advent of, like I said, apps that, they say, can automatically diagnose lesions based on various patterns, do you feel that technology can take away some of the job opportunities of future dermatologists?

Peter Lio: That’s a really interesting one, and that’s a hot-button topic. I will tell you that among my colleagues, there is a lot of discussion about it and a lot of concern. My honest opinion is yes. I do think at some point the machine learning will get so good that it will be able to replace a lot of what we do. I mean, to some degree, it’s kind of coming for all of us, right? No matter how insulated we think our job is, no matter how difficult we think it is, well, people like Elon Musk are building robots to take us over.

That being said, I often stress that 99 percent of my job is actually not diagnosis, at least for me. Now, again, everyone’s a little bit different in their practice. Derm is such a heterogeneous specialty. But for me, most of my patients come in, and I know what’s going on. So the bulk of that visit is really me explaining to the patient what this is, what to expect, and what we’re going to do, and joining them on that therapeutic journey to get them better and work on this.

So I guess for me personally, if a machine could tell them what it is, if anything, it saves me one minute, because I can usually tell. Most of the stuff we do is Augenblick. I walk in, and it’s like, “OK, I think that’s a basal cell.” A machine could tell you, sure. You come to see me, and we’re going to take care of the bases. I’ll talk about how to treat it, talk about the sun protection that needs to go into it, and talk about, maybe, are there other things we can be doing to help minimize the risk of future skin cancers, and so on. I don’t think computers are going to be able to do all of that anytime soon. But yes, in the big picture, I think the singularity approaches eventually, and probably we’ll all be replaced, largely. But I still think there’s a role for that human touch.

Kevin Pho: Give us a look into your crystal ball. In the next, say, three to five years, what are some of the top trends you see dermatology taking?

Peter Lio: I think one of the hardest parts for our specialty is that we are so, so heterogeneous. There are so many different areas, and we do feel that pull. Many great dermatologists get pulled toward the cosmetic world or the surgical world, which are super important and give tremendous quality-of-life enhancements to those patients. But there’s no doubt that we medical dermatologists really want to pull people and attract them and keep them in medical dermatology, because I feel like that is really an unmet need in general, and this, unfortunately, is getting worse.

Overall, even people that seem like they’re going to be amazing medical derms hear the siren song of doing a little bit more cosmetic or more procedural, which, the way our current system is set up, is more lucrative. So they get pulled. That’s one thing: How do we get people interested, and stay interested, in it?

I think dermatology education also is under fire, like a lot of medical education. I think we’re seeing funding to programs disappear. I think it’s getting tighter and tighter. I think a lot of people are worried that the old days of having some more luxurious time to hang out and do things, and having funding to do different events, are drying up. So I am worried about it, and I think we need to take some evasive actions to make sure that we really keep thinking about the next generation of trainees and take good care of them, because I want these fields to continue to thrive. Our patients certainly need us.

Kevin Pho: We’re talking to Peter Lio. He is a dermatologist, and he wrote the KevinMD article “The evolution of medical training in dermatology and the impact of technology.” Peter, one of the things you mentioned earlier was really a shortage of dermatologists. In my practice, it sometimes takes three, six, nine months to see a dermatologist. There has been an influx of advanced practice practitioners going into dermatology, and sometimes that can alleviate some of that shortage. But can you comment on what the role of the advanced practice practitioner is, specifically in the field of dermatology?

Peter Lio: Yes, this is another hot-button issue, and I think you’ll see some polarized opinions on this. I honestly do think that we can’t do it alone, that we need advanced practitioners to help us in many ways. I am someone who really feels like, especially if they’re going to be taking care of patients, I want to give them all the tools that I can in terms of education and support, so they do a good job, right? It’s one of those things. I’m much more interested in helping the patient than saving my job or being right. Maybe I’m an idiot. Some of my colleagues would say, “Boy, you’re a dummy. You’re going to lose your job, because you’re training the people to replace you.” I suppose. But to me, it’s a moral discussion that is very clear.

That being said, I do think that many advanced practitioners are best suited as part of that team. If I were the tsar of the universe, I would just say maybe the best way to use my time would be to have a number of people that can kind of work under me. They can do a lot of the heavy lifting: get to know the patient, get the history, kind of go through that, talk to me, and bounce it off me. Then I can say, “You know, what if we try X, Y, and Z?” And then they can do the next heavy lifting, which is to explain to the patient, get the drugs covered, and all that.

Because no doubt I’m very old-fashioned, and it’s probably stupid. I spend an awful lot of time on the phone with the pharmacist clarifying something, or sometimes patients even feel comfortable enough to send me the school note, and, “OK, I’ll just do it.” That’s probably not the best use of our time. So can we utilize some of these associates, who are wonderful in their own right, to help spread that out, so you don’t have to wait six to nine months to see a dermatologist?

Kevin Pho: For my primary care audience that is listening to this podcast, what would you say is the number one dermatological tip that you could share with them?

Peter Lio: The number one tip is, I think, don’t be afraid to refer. There’s no dumb referral. But if you can find a way to maybe even do a teletriage, that can help a lot, if you can find a dermatologist that’ll work with you that way. I have a few PMDs and pediatricians that work with me that way. They’ll send me a picture, they’ll call me real quick, and I’ll say, “You know, this sounds fine. I’ll help get them in, but it’s not urgent.”

Some of that teletriage can really make or break it, and forging that relationship with someone you trust, I think, can make a huge difference, not only in your life but in the life of your patients. Because I really think that’s going to be the important piece to get the people who need us in to us at the appropriate time.

Kevin Pho: My final question: What’s your take-home message that you want to leave with the KevinMD audience?

Peter Lio: Give your dermatologist some love. A lot of people give us grief. They’re like, “Oh, you guys are hanging out and all glamorous.” But there’s no doubt that we do try really hard, and we work hard to take good care of our patients. We have this bizarre range of people, with gigantic non-healing ulcers that are infected in one room, and then sometimes the next room is somebody who wants to talk about their wrinkles on their forehead. So you’re constantly shifting gears. Even though it seems glamorous, many times it is not.

So give us some support, and we will definitely try our best to take good care of our patients and take good care of our referring folks, because if people don’t refer to us, then obviously we won’t be so busy. So we really appreciate that, and our job is to help in many ways, in every way we can.

Kevin Pho: Peter, thank you so much for sharing your time and insight, and thanks again for being on the show.

Peter Lio: Thank you for having me.

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