Set expectations: We must set expectations before a teledermatology encounter begins. We need the families to know how to prepare and what space they should be in. Patients need to understand the workflow of the various telehealth modalities: live-interactive video (synchronous), store-and-forward encounters (asynchronous) and a hybrid approach combining both of these. For instance, we require photos to be submitted prior to a video visit to be able to assess the skin conditions with still photos which is better than video quality, whereas in a store-and-forward encounter, we rely on photos alone and there is no live-interactive video component.
One of the consequences of the pandemic is the dramatic growth of Telehealth and Telemedicine. But how can doctors and providers best care for their patients when they are not physically in front of them? What do doctors wish patients knew in order to make sure they are getting the best results even though they are not actually in the office? How can Telehealth approximate and even improve upon the healthcare that traditional doctors’ visits can provide?
In this interview series, called “Telehealth Best Practices; How To Best Care For Your Patients When They Are Not Physically In Front Of You” we are talking to successful Doctors, Dentists, Psychotherapists, Counselors, and other medical and wellness professionals who share lessons and stories from their experience about the best practices in Telehealth. As a part of this series, I had the pleasure of interviewing Dr. Patrick McMahon.
Patrick McMahon, MD, is a pediatric dermatologist and passionate proponent of innovation in the field of telehealth as the Director of Teledermatology at a Children’s Hospital of Philadelphia (CHOP). Dr. McMahon always dreamed of being a pediatric physician and now enjoys having an impact on healthcare advancement as an Associate Professor of Pediatrics and Dermatology at CHOP and a member of the Society for Pediatric Dermatology; the nation’s only organization specifically dedicated to children’s skin, hair, and nail disease. Dr. McMahon is dedicated to using technology to lessen healthcare disparities and bridge the digital divide to bring high-quality, personalized, and compassionate care to families in need. As a pediatric dermatologist, Dr. McMahon has worked to expand patient offerings and overcome barriers to accessibility to make a large impact in the field of pediatric dermatology and teledermatology for all.
Thank you so much for joining us in this interview series! Before we dive in, our readers would love to “get to know you” a bit better. Can you tell us a bit about your ‘backstory’ and how you got started?
I started my medical career in a pediatric residency because I always knew I wanted to be a doctor for kids. During that first residency, I fell in love with dermatology and went on to complete an additional dermatology residency in San Francisco immediately after. To combine my passions, I further specialized in pediatric dermatology with a one-year fellowship. More recently, during my time as an academic pediatric dermatologist, I became more and more interested in innovation and pediatric teledermatology.
Can you share the most interesting story that happened to you since you began your career?
In 2015, after listening to my patients and becoming aware of their frustrations, I became inspired to develop a teledermatology solution dedicated to pediatric dermatology. The wait time for dermatology, specifically pediatric dermatology, is typically several months long. The demand to see providers in our clinic was incredibly high, and at a staff meeting where we were attempting to find solutions to manage the high volume, I realized in that moment that there must be a better way to connect with families and help them when they needed help. I set out to create something at our institution that would allow families faster access to our expertise, and it just so happened that the month that I thought of this and became incredibly passionate to do something about it was the same month that our hospital created the Office of Entrepreneurship and Innovation. Our hospital hired someone to start up the center and I scheduled a meeting with him to share my vision and my goals. I subsequently applied to the internal healthcare innovation accelerator and was selected to participate. Doors started opening and we put together a great team that was excited to get things started and after two years of hard work we launched a direct-to-patient pediatric teledermatology app that has since helped connect thousands of patients to doctors within two days instead of several months.
Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?
My favorite life lesson quote comes from Ralph Waldo Emerson: “Write it on your heart that everyday is the best day in the year. He is rich who owns the day, and no one owns the day who allows it to be invaded with fret and anxiety. Finish every day and be done with it. You have done what you could. Some blunders and absurdities, no doubt crept in. Forget them as soon as you can, tomorrow is a new day; begin it well and serenely, with too high a spirit to be cumbered with your old nonsense. This new day is too dear, with its hopes and invitations, to waste a moment on the yesterdays.” This speaks to how I aim to live each day. As a dreamer, I have excitement and vision for the future. I also know how important it is to learn from the past. However, if we are too stuck in the past or focused on the future, then we may not be as able to appreciate and impact the reality of our present moment. My innovation journeys have been exciting, and not without obstacles, which do also bring me joy in my attempt to problem solve through them. Having a firm grasp of the “why” and a clear vision of the big picture, even during the day to day blunders, was critical to providing support to sustain me along these journeys.
None of us are able to achieve success without some help along the way. Is there a particular person who you are grateful towards who helped get you to where you are? Can you share a story about that?
For me, that person is Dr. Albert Yan — a pediatric dermatologist here at The Children’s Hospital of Philadelphia (CHOP). Since the beginning, when I fell in love with pediatric dermatology as a first-year intern in pediatrics, he has been extremely supportive and nurturing and took me under his wing. After my dermatology residency at The University of California, San Francisco, I returned to CHOP as a fellow and Dr. Yan was the chief of pediatric dermatology. He was very supportive when I set out as a junior faculty member to create teledermatology options for our families. Without his guidance and support, many of the things that I’ve done would not have been possible.
Ok wonderful. Let’s now shift to the main focus of our interview. The pandemic has changed so many things about the way we behave. One of them of course, is how doctors treat their patients. Many doctors have started treating their patients remotely. Telehealth can of course be very different than working with a patient that is in front of you. This provides great opportunity because it allows more people access to medical professionals, but it can also create unique challenges. To begin, can you articulate for our readers a few of the main benefits of having a patient in front of you?
Yes, I think this has become more and more apparent with the distance that the pandemic has forced upon us. The rapport and human connection that you have when you have a patient in front of you is really hard to replicate. And, of course, there are benefits to being able to physically touch a patient when you are examining them; there are tests and procedures we would perform that we can’t do if we are not physically in the same location.
On the flip side, can you articulate for our readers a few of the main challenges that arise when a patient is not in the same space as the doctor?
One challenge is the reliance on technology, specifically internet bandwidth and connectivity. We rely on families having digital literacy as well as the doctors and providers being tech savvy enough to use the platforms. The inherent challenges of technology can exacerbate the lack of human connection. Further, the environment the patient and/or providers are in may not be ideal for conducting a patient-doctor encounter. So, because it’s new for all of us, we’re learning how to navigate these challenges. Over the past year these challenges have been highlighted because many who hadn’t used telehealth in this way previously are now thrust into needing to figure out many different platforms.
Fantastic. Here is the main question of our interview. Based on your experience, what can one do to address or redress each of those challenges? What are your “5 Things You Need To Know To Best Care For Your Patients When They Are Not Physically In Front Of You ? (Please share a story or example for each.)
- Set expectations: We must set expectations before a teledermatology encounter begins. We need the families to know how to prepare and what space they should be in. Patients need to understand the workflow of the various telehealth modalities: live-interactive video (synchronous), store-and-forward encounters (asynchronous) and a hybrid approach combining both of these. For instance, we require photos to be submitted prior to a video visit to be able to assess the skin conditions with still photos which is better than video quality, whereas in a store-and-forward encounter, we rely on photos alone and there is no live-interactive video component. It’s difficult because there are so many different platforms and interaction types, and the providers and patients both need to know what to expect. Also, now patients may need to be more aware of the approximate length of their visit — if it’s a 30-minute or a 15-minute encounter. Historically, in medicine we rarely told patients the length of visit times. Theoretically, moving forward, patients could even be able to self-select for doctor visits of varying durations depending on their needs.
- Be patient: Both patients and providers need to employ patience during telehealth encounters. It is helpful to understand that we are relying on the internet connection, and a stable stream of connectivity is sometimes out of our control. It can be difficult, at times, to remain calm as we’re often facing the same difficulties over and over again (i.e., dropping the connection, experiencing glitches, having audio cut out or faces freeze, not knowing to turn the audio on, etc). Instead of becoming frustrated, we need to find new strategies to overcome these problems as well as finding and using the humor in these situations to remain lighthearted when things go awry. We might have to say “can you hear me now” and “let me call you back,” a few times, but we are all in this together. In practice, we’ve had scenarios where the encounter might take longer than it needs to, such as when the patient is a toddler and running around their playroom or thinks it’s funny to hide underneath their bed. You have to laugh at those situations to get through them. We need to learn how to engage and connect with younger patients through these telehealth mediums. As a provider, you may need to start by asking the patient to show you their stuffed animals or by asking about their pet’s name. Now we are peering in to their environment — which is a unique privilege and, truthfully, can be fun. We need to be patient and learn as we go!
- Be honest: It’s important to be truthful in telling the families and patients when the telehealth experience is running up against one of its challenges or shortcomings. For instance, I might say “this is the type of skin lesion that I can’t see well enough (and obviously cannot feel) through video or photograph. For the best experience and outcome, you really need to bring him in.” The families usually understand this, especially if you explain that you could do certain types of tests in the office to give them a more definitive diagnosis. The honesty is appreciated as the patients also know that this isn’t how they’ve had typical medical encounters and we’re all learning which conditions are most appropriate for telehealth and which are not. The openness and honesty of the provider goes a long way and, of course, it’s the right thing to do.
- Be careful: For issues surrounding confidentiality and counseling families and patients, we need to be careful and safe. For instance, if we’re asking a sixteen-year-old about social habits or sexual activity, we’d normally ask the parent to step out of the room to discuss privately in the office. With telehealth, we don’t know if they’re alone, or if their little brother is in the bedroom with them or if their grandmother is sitting across from them in the living room, so we need to ask the patient if this is a space where we can discuss things that are private. Also, as it applies to medical chaperones, in our clinic, we may require another medical provider to be present during sensitive physical examinations for the provider’s legal safety and the patient’s comfort. In a telehealth encounter, we may need to think creatively about replicating medical chaperones. Regarding counseling, we have to be sure that the patients really understand what we’re saying, for example, asking did we drop out halfway through the call? Did we get glitchy? We have to ask them if they heard and understood completely, potentially having them explain the plan back to the provider to ensure they understand correctly.
- Ask for help: We need to be smart as we move forward with telehealth and teledermatology specifically. We need to acknowledge what went well, what didn’t go well, and what could go better in the future. We need to have an eye for optimization and we can’t be afraid to ask for help. Doctors and providers do need support from all sides, not only in the form of time and money spent to improve the platform, but also in terms of access to the same help we would need in clinic. We need the assistance of our staff, medical assistants, and nurses on both the front and back end for things such as making sure the families are set up correctly on the platform and have sent in accurate, high quality photographs. Our team is vital to optimizing the experience, so knowing when to ask for help and keeping an eye out for potential improvements are key as we move forward.
Can you share a few ways that Telehealth can create opportunities or benefits that traditional in-office visits cannot provide? Can you please share a story or give an example?
In a global sense, it is beneficial for providers to see what the patient’s home environment looks like. In the case of patients that are young children who can be anxious in doctor’s offices, they may be more comfortable in their own home knowing they won’t be receiving a shot or undergoing a painful medical procedure. An improved comfort level can help to put the patient at ease and provide a more relaxed experience wherein we may get to know that patient. Another benefit of telehealth is that the provider can see the prescribed and over-the-counter products, creams, and ointments the patient is actually using.
Further, from an outreach perspective, we can use an additional telemedicine offering: the provider-to-provider modality. This occurs via live-interactive video or store-and-forward to help bridge the digital divide when telehealth encounters are facilitated by the referring provider, for instance, in the patient’s primary care clinic. Using this method, we can begin to overcome some healthcare disparities and possibly reach families who never would have been able to drive into the specialist’s clinic, who may have never had access to transportation to come in person, or who might not have had the means to use a smartphone or sufficient digital literacy to navigate a telehealth platform. Now we can use those provider-to-provider modalities to match families to specialists regardless of their location or accessibility and reach underserved urban, suburban or rural areas more equitably. These forms of telehealth may round out the offerings to allow us to reach people in need much more broadly than when we could only see patients in clinic. It is exciting to be potentially reaching a population of patients that were previously unreachable.
We also have to think creatively about the reality of some of these interactions not being billable or reimbursable. There may be grants that we currently have for underprivileged or lower resource populations that we now need to repurpose for telehealth.
Let’s zoom in a bit. Many tools have been developed to help facilitate Telehealth. In your personal experiences which tools have been most effective in helping to replicate the benefits of being together in the same space?
Without a doubt, the development of the smartphone camera and improvement in video capabilities have been absolutely critical. For reference, I started practicing dermatology in 2008 when we had BlackBerrys and poor-quality photos. Of course, soon after, there was this explosion of digital capabilities and families could bring in iPads or iPhones with a clear photo of the rash they were struggling with for months. In 2015, there was a lightbulb moment for me. I began to realize when families would show me pictures four months after the rash began that if they had shown me those exact photos months ago when the rash had started, I could have helped so much earlier.
In the realm of telehealth, there have been new devices, add-ons, and attachments that people can now put on smartphones. There have been developments, specifically in pediatrics, surrounding things like ear infections — we use otoscope tips we can apply to videos so a nurse at a school can send a photograph to a doctor remotely so they can assess for an ear infection. For dermatology, there are dermatoscopes that work like magnifying glasses which can be attached to cameras so we can see a skin lesion more clearly from Africa while working in Philadelphia. We need to continually improve these devices and get them into the hands of people who need them.
If you could design the perfect Telehealth feature or system to help your patients, what would it be?
We have the basics down. We have the ability to connect through video, submit photographs, and respond. But in pediatrics, I think we’re lacking the fun. We need to gamify some of our interactions as kids take very well to games. For instance, if we make a game out of a child applying their acne cream every day for three months, they could then get to the “next level” or become the star patient for the month. We need to have fun platforms so patients can improve their experience and ultimately their outcomes. Further, we can use this system to track them and their progress from afar. We already have systems that do this with avatars for HIV screening and adherence to their treatment regime, so we can start with similarly important conditions to be sure patients are doing what they need to do. We can find a way to make the treatment interactive and fun and not a burden!
Are there things that you wish patients knew in order to make sure they are getting the best results even though they are not actually in the office?
First, in order to get the best results, it’s important to send good photographs. In order to submit a helpful photograph to your doctor, you’ll need to take adequate time to ensure high quality. An hour or more before the appointment, not rushed right before the video encounter, find a way to make sure the patient is as still as possible (I recommend while the child is napping, eating, or playing) and in natural light (next to a window or outside) to give the best picture. For more subtle conditions, doctors may require side lighting (flashlight held obliquely) or extreme close-up shots to show subtle texture changes. Additionally, make sure to send photos of the entire skin condition, not just one portion or one of the areas of concern as doctors need to see where the condition is and where it isn’t in order to put the whole story together. It is important to take the time to review these photos before sending, and retake or refocus if need be to avoid blurriness, to improve your provider’s ability to assess the condition. Additionally, it’s necessary to call in from a place that is conducive to having a conversation.I’ve had families that are out and about in a car, at a soccer game, and even at the hair salon. These situations made it extremely difficult to have a good conversation and examine the skin condition, especially with masks on and other distractions. Patients should take the encounter seriously enough to be in a home or private location so they can get the best possible care.
The technology is rapidly evolving and new tools like VR, AR, and Mixed Reality are being developed to help bring people together in a shared virtual space. Is there any technology coming down the pipeline that excites you?
In dermatology specifically, we are seeing artificial intelligence (AI) technologies start to be tested. While many aren’t ready for primetime yet, the future will bring ways for us to triage skin conditions and have AI offer predictive recommendations, diagnoses, and treatment options for the providers to review. These predictive recommendations will have already been vetted, and while providers will need to use their best judgement, they may help to speed up our everyday interactions and help get patients the best care more efficiently.
Virtual reality (VR) is exciting for the patient experience — we’re already starting to use that in hospitals. One example is using VR to make patients more comfortable, such as when a patient is nervous about the tunnel experience during an upcoming MRI, the VR modality offers the ability to preview what they’ll see in the machine. Also, our Child Life team has been able to use VR immerse the child in an entirely different world during painful or invasive procedures so the child can be distracted and not experience as much anxiety and stress of a procedure.
We also need to figure out a way to make the provider experience mobile-friendly. Many of us are still tied to a desktop or laptop, and if we can find a way to make the doctor’s experience faster and clickable, we can scale to a larger population faster.
Is there a part of this future vision that concerns you? Can you explain?
For me, I’m seeing patients start to act like consumers. Patients are weighing their options and wanting to know what they’re paying for, but I’m worried about patients seeing the experience as a service being provided and not as people trying to care for them. I’m worried that the technological interface will create too much of an impersonal barrier. As providers, we need to understand that our patients are very real people on the other side of the screen just as patients need to understand the same for providers. For instance, patients often expect immediacy in a way that is similar to what they would get in an in-office experience. However, as it stands now, sometimes the turnaround time for a store-and-forward encounter can be a few days (which should be spelled out in the expectations from the start), but if a patient needs a faster turnaround, they should seek out an urgent in-person visit or find a different platform. We all need to have an understanding that we are not just robots behind a screen spitting out information.
As we move forward with these platforms, we have to make sure they relay the same care and emotion of an in-person visit. Instead of remaining stale through tracking metrics and just providing information, providers should aim to make it more personalized. Perhaps for encounters that are not live-interactive, providers can record our recommendations in a video to send back, or provide a video bio or some sort of personal touch to connect to the person behind the screen. While it may take more energy to get that type of connection in this medium, it’s worth finding ways to overcome the challenges.
Ok wonderful. We are nearly done. Here is our last “meaty” question. You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. 🙂
Taking into account everything we’ve learned in the past year around telehealth and medicine, one of the biggest opportunities I think we have is to crowdsource love and support from the collective population. We’ve seen that the internet does have a power for good, and people want to rally around other people in need even if they are perfect strangers. I’m interested in the possibility of developing something, a telehealth platform, that has an option for a donation to be provided for a certain charity. Could we find a way to tap in to our collective charitability and desire for human connection? From a provider standpoint, I think many doctors would be willing to donate some of their time to patients who can’t afford these services and offer pro-bono care as long as we can find a way to mitigate liability concerns. All in all, I’m passionate about finding a way to provide care to people who don’t otherwise have access.
We’re all connected, and telehealth is another way that we’re all connected on a very intimate level. It’s important to make sure that we are still creating emotional connections and spreading gratitude, generosity, love and joy. There may be an opportunity to create a platform to connect families to the appropriate support groups or even a way for patients to reach out with gratitude toward their providers. I’m eager to explore ways to spread and share the feel-good emotions that we sometimes lose in the course of day-to-day life, which we need now more than ever.
How can our readers further follow your work online?
You can keep up with my practice on my LinkedIn and I would love to connect to discuss any collaborations in this space. I am on the brink of a career transition as I am leaving the Children’s Hospital of Philadelphia in June, 2021 after 10 years there and will be joining a local private practice dermatology group in New Jersey named HMGS Dermatology.
To learn more about pediatric dermatology or find a practicing pediatric dermatologist with the Society for Pediatric Dermatology (SPD) near you at www.pedsderm.net.
Thank you so much for the time you spent doing this interview. This was very inspirational, and we wish you continued success.