Managing Dermatology Remotely with Dr Christos Kasparis

Dane catches up with Dr Christos Kasparis, a consultant dermatologist.

Dane catches up with Dr Christos Kasparis, a consultant dermatologist. They discuss the challenges and advantages of remote dermatology, finding the right tools and platforms to use, how not to miss significant conditions, and the medico-legal aspects of working remotely in dermatology.

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Produced by Arc Health in collaboration with Doctors.net.uk.

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Episode
7
27 mins

Dr Dane Vishnubala:

Hi there, Dane here from Arc Health. Welcome to Remote Consultation Masterclass. This is a podcast where we catch up with leading healthcare professionals to discuss tips and tricks for carrying out remote consultations. As well as bringing you key nuggets of information for your CPD. Now, you can listen to us on Apple Podcasts, YouTube, Spotify, or wherever you get your podcasts from. So I hope you enjoy the episode.

Dr Dane Vishnubala:

Hi there, welcome to Remote Consultation Masterclass series. So our series of podcasts is aiming to dive right into the mind of the experts in the field on a range of medically related topics. So my name is Dane, I'm a GP and a sport and exercise medicine consultant based in Yorkshire. And today I'm joined by Dr. Christos Kasparis, a consultant dermatologist.

Dr Dane Vishnubala:

Today, we're going to be talking about remote dermatology, looking at a range of things from different tools that are available, exploring the challenges and the advantages. Looking at commonly dealt conditions and how not to miss the more significant ones which we all worry about. As well as briefly touching upon medico-legal elements as well.

Dr Dane Vishnubala:

So firstly, Christos, thank you for joining us.

Dr Christos Kasparis:

Thank you, Dane.

Dr Dane Vishnubala:

Before we get started. It's always nice to know a bit more about your background. So tell us a bit about yourself.

Dr Christos Kasparis:

Sure. Thank you for inviting me, Dane. So I am a consultant dermatologist. I'm based in Birmingham, but I work in Wolverhampton mainly. And I've been a consultant dermatologist for about seven years now, having trained in the West Midlands area. But obviously during my career I've been in Yorkshire and Manchester before that. But I have been in a substantive post for about seven years. Just before the pandemic started, I had made a decision to pursue an opportunity abroad for six months. So my plan was to leave my post in May and then go abroad and work abroad. And of course that never materialised due to the travel restrictions and the pandemic. But that in-fact gave me an opportunity to engage in other ways of working, and particularly remote working in dermatology, as at the time, this was the main method and the main way of engaging with patients and offering services at the time.

Dr Dane Vishnubala:

Perfect. Okay. So you're the right man for this podcast anyway. And if you've been doing a lot of remote stuff, clearly there's lots to talk about here. So I guess probably let's start with, there are lots of different ways to work remotely in dermatology. So it'd be useful to find out from you what the different ways are that you are working remotely in dermatology.

Dr Christos Kasparis:

Yes, you're right. There are a number of different ways one can work remotely. This can be via telephone clinics or telephone consultations, video consultations, or they can be using a more tele-dermatology specific platform. I guess, during the pandemic, we've been focusing a lot more on telephone consultations; and some video consultations, but they do have the slight disadvantages I would have to say when it comes to video. But tele-dermatology has been very useful as well because that provides the images which are necessary to make a proper examination.

Dr Dane Vishnubala:

Okay. And so talking about platforms, what do you need in a platform as a dermatologist to do your job well?

Dr Christos Kasparis:

So, the essential things are - we need a platform which will provide all the relevant background medical information of the patient. So this will provide us with a referral, any previous appointments the patient may have had, information on treatments. They may be on both for skin, as well as general medical conditions.

Dr Christos Kasparis:

It should provide some access to photography. And that's very, very important. And there's two ways of doing that. This could either be patients uploading photographs onto the system, or it can be done via a health care person, a healthcare professional, taking the photographs and then uploading them onto the system. However they get it onto the system, we need to have that easy access to photographs at the time of speaking with the patient. Ideally at the time of speaking with the patient.

Dr Christos Kasparis:

Some bonuses would be a platform allowing the clinician to prescribe as well. So those can be done digitally and go directly to the pharmacy. I would say, this is a bonus, it is not essential. But if we're talking about a very comprehensive platform offering comprehensive services, it would be nice to include that as well.

Dr Dane Vishnubala:

Yeah. Perfect. And so getting those images to you easily, and to be able to see them well is important. And in a lot of places we're still emailing images across by email aren't we?

Dr Christos Kasparis:

Yes, absolutely. Dermatology is a visual specialty, so we need to see something to be able to diagnose. Yes, history is very important and we might come to that. But I think getting good quality images is very, very important.

Dr Dane Vishnubala:

Yeah. Okay. So I guess we talked about this in other podcasts, other specialties, but I guess for dermatology specifically, what are the advantages and disadvantages, both for the patients but also yourself, as a clinician of remote working? What have you found?

Dr Christos Kasparis:

So, what I found when it comes to my own work is that working remotely is very flexible. So just to give you an idea, I do a lot of tele-dermatology work, so I will log into the platform, assess images together with histories. And then I will write back to the referring clinicians with an advice. This is done very, very quickly. So from the time we receive the actual referral, we reply within 48 to 72 hours. So that direct, quick access will give a much better patient experience. Because they will get a professional, specialist opinion very quickly. But also probably leads to some upskilling of the referring GPs as well. Because they get direct advice back for a problem they had seen recently, as opposed to having to wait for several months for something they've already forgotten about.

Dr Christos Kasparis:

And flexibility, so I can do these at the comfort of my home. I can stop and start if needed. Equally for patients, they can have a consultation from home, making that work around their own schedules. And again, that leads to good patient experience. I think patients like that, they like that option of having the consultations done from where they need to be that particular day. Rather than having to arrange transport sometimes or having to cancel all their schedules for the day in order to attend an appointment.

Dr Dane Vishnubala:

Yeah, agreed entirely. I think there's lots of stuff. So for me, I work in MSK, and we're finding that there's still a fair amount of things that even for something as practical as MSK that you can do remotely. And patients are quite happy with that result. So, definitely.

Dr Dane Vishnubala:

Well, dermatology, we always ... And I know photographs aren't just your job, but obviously photographs are a big part of dermatology, and particularly from a GP perspective. I'm always thinking about how do I send that picture to the dermatologist. But I guess photographs are obviously a challenge to get right, so do you have any advice around what you tell patients to get the right photograph?

Dr Christos Kasparis:

Yes. So with photographs, we're trying to get the best image, as best as an image or images that will match the actual skin presentation. So, what we need to assess during skin examination is the distribution and the symmetry. And in order to do this, you need to have a distant photograph, a photograph taken from a bit of a distance. So that it gives you an idea of where the rash is, if it is a rash. What the distribution is like, how extensive it is, and whether it's symmetrical or non-symmetrical.

Dr Christos Kasparis:

And then you need a close up. So in order to assess the actual morphology of the rash, which gives you more information about the nature of the rash. For example, there's an eczematous morphology, or a psoriasis morphology or a pityriasis morphology. You need a close-up. So you need both per site. And you need multiple sites sometimes. So we're talking, you need at least eight or 10 good quality photographs in order to be able to confidently assess or make sure that you've seen everything that you need to see.

Dr Christos Kasparis:

Even with that, you may still be missing some key sites that can be important in some examinations, such as the hair, the mouth, or close up of the nails. But if we had these distant and close up photographs for multiple sites, I think that gives you the best chance of making a good assessment.

Dr Dane Vishnubala:

Perfect. And I guess moving on from that slightly, talking about your treatment pathways and treatment decisions that you make, have they changed much during this pandemic in terms of remote working?

Dr Christos Kasparis:

Yes. So, there have been some changes in that. So with the pandemic and with this coronavirus, there's been a lot of uncertainty of what the virus does to the immune system. And a lot of inflammatory skin disease is immune mediated. So the immune system is heavily involved in the pathogenesis. And also the treatments equally suppress the immune system.

Dr Christos Kasparis:

So myself and a lot of my colleagues have had to make some changes in what type of treatments we choose for patients. And I think the trend has been to try and avoid as much as possible immune suppressant medication like methotrexate or cyclosporine for the major inflammatory disease like psoriasis and eczema, and perhaps use alternative ones. I'll give you a simple example, when it comes to using methotrexate or acitretin to treat psoriasis, the trend is to choose acitretin over methotrexate when possible, so that we don't suppress the immune system in those particular patients.

Dr Christos Kasparis:

I guess the other thing that has changed is regarding patients needing a lot of monitoring, whether this is for drug monitoring purposes, needing blood tests every two or three weeks, or they may need to be seen in clinic a lot more frequently due to the medication they're on. So patients who may be shielding, for example, it wouldn't be advisable to have blood tests every two or three weeks, attending a blood service, or the GP practice for that. So again, in those patients, I would personally choose some treatment options which don't rely on frequent monitoring if possible.

Dr Christos Kasparis:

So, this has shifted the way we practice. However, as we're getting more and more information about the effects of the Coronavirus on the immune system, there seems to be a lot of reassuring signs that actually what we have been using all these years is fairly safe. So, I think we're seeing a reverse trend now, going back to our usual ways of dealing with skin disease.

Dr Dane Vishnubala:

Okay. That's good to know because I'm sure many of us who are referring to dermatologists will see a range of different treatments being offered than perhaps we've seen before. So it's good to understand why that's happening as well. Okay. Great. I'm sure the monitoring of methotrexate and the fact that you're using less of it at the moment, it will not be seen as a bad thing to many people anyway.

Dr Christos Kasparis:

Exactly. Exactly.

Dr Dane Vishnubala:

Okay. So I guess the other thing that many doctors I guess worry about, and it doesn't matter what specialty, we always worry about missing that important thing. And I think for me, I guess, in dermatology from a GP perspective, that's always missing the malignant lesion. So if you're working remotely, how do you mitigate these risks, particularly when you're viewing these images?

Dr Christos Kasparis:

Yeah, I think that's a really good question, Dane. So when it comes down to skin cancer risk, I think one of the things that becomes even more important is the history. So focusing on those signs which may suggest malignancy, for example rapid changes in the size, shape or colour of a lesion, new onset of symptoms like bleeding, a strong family history of skin cancer, assessing those risk factors of sunburn, type one skin. Those become very important. And with that, I guess, we are seeing also a lowering of the threshold of patients being referred for a biopsy or for a removal.

Dr Christos Kasparis:

So, those two together, emphasis on good history, focusing on those signs which may suggest malignancy. Secondly, is reducing the threshold of who you refer or who you treat with a biopsy first are important. And thirdly, I would say, good quality images. I cannot stress this enough. With good quality images, you can rule out skin malignancy. If you have an image which is out of focus, it's very hard to tell, so your margin of error then becomes a lot wider. And therefore, you need to lower your threshold of referring for a biopsy or for specialist input. So this would be my key advice with regards to lesions.

Dr Christos Kasparis:

When it comes to rashes or more severe skin eruptions, then again there are some key features in the history that one needs to explore. So when we talk about severe skin dermatosis, which may include severe drug eruptions for example, vasculitis, patients with erythroderma, which means 90% body surface coverage with erythema and inflammation, then the key features here would be to assess whether there's any history of pain in the skin.

Dr Christos Kasparis:

So pain is not common when it comes to skin problems, but when it's there, it may suggest that there is a vasculitic process, something which is causing necrosis on the skin. It may suggest a more acute blistering condition or a severe infection. These are the common things that can present with skin pain acutely.

Dr Christos Kasparis:

The other important clue in the history is whether there is any mouth involvement, so a history of painful mouth, oral mucosa, or eye mucosa, any discharge, exudes, or blistering in these areas, again suggest possibly a more sinister drug or maybe a drug eruption or a more sinister skin eruption. So these are key information from the history.

Dr Dane Vishnubala:

Okay. So, taken from what you've said really, I guess it's the same as in many parts of medicine, but that history is important, but possibly become even more important now.

Dr Christos Kasparis:

Absolutely, absolutely.

Dr Dane Vishnubala:

And that threshold, as you said, it's not going to be as good as being in person, so having a slight lower threshold is probably important here. As much to make sure we don't miss anything key and the patient gets mismanaged.

Dr Christos Kasparis:

Absolutely. So, you're absolutely right. And finding that balance. So if you aren't able to examine that patient face-to-face, and you have to rely on photographs, there needs to be a bit of a trade with a better history in a way to compensate for that lack of that face-to-face assessment.

Dr Dane Vishnubala:

Yeah, that makes sense. And I guess as part of that really, obviously everyone's worried about risk remotely as well. And you've talked about ways of mitigating it here. But I guess there are a range of medico-legal aspects to remote working that people hadn't really considered till they started doing it. And obviously you've been doing that for a while now. Are there are many things you're regularly considering or thinking about while you're consulting now?

Dr Christos Kasparis:

Yes. And this is something that I had to go away and find out myself when I started engaging with more remote working. So I contacted my indemnity, and I asked them for some advice, what do I need to be looking out for when I carry out these remote consultations?

Dr Christos Kasparis:

One of the things which became very clear from the start is that when you do engage in any type of remote working, it's very important to always assess whether remote working is the best way of speaking to that patient or assessing that patient. And that needs to be clearly documented. And this is of course something which if in a few years time something goes wrong, there is a claim, you need to be able to justify why you chose to see that patient remotely or speak to that patient remotely, as opposed to seeing them face-to-face.

Dr Christos Kasparis:

And this may be for a number of reasons. It may be due to the restrictions in access of patients to your GP practice or to the hospital. It may be to do with actual mobility problems or patients shielding at home, which doesn't enable them to come to you for a face-to-face consultation. Or it may be because there's an acute problem, not allowing for the consultation to take place quickly enough face-to-face. But whatever it is, it needs to be clearly documented and justified.

Dr Christos Kasparis:

The indemnities will often say that it's a lot easier dealing with patients remotely if you know those patients already. So again, bear that in mind. So for patients who you've already seen and met and you have a good idea of the background history, it's a lot easier and safer to carry out remote consultations. But for new patients, again, think, can I see that patient face-to-face or is remote consultation the only option?

Dr Christos Kasparis:

The next thing is, I guess it goes without saying, but it's important, always check that you've got the right patient. And we take that for granted when we see patients in clinic, because we've got the receptionist checking that patient first, we've got a healthcare assistant checking again, and then we check again when the patient comes into the room. So there's a safety net. We lose that safety net when we are carrying out the consultations remotely. So, we need to make sure we've got the right patient notes in front of us. And check with the patient that this is the right patient name-wise, date of birth and maybe address. So that's again, another important point.

Dr Dane Vishnubala:

Yeah, no, it happens, doesn't it, you quickly pick up notes because you're busy and you might check the first name or the name, but not everything and it can happen, can't it?

Dr Christos Kasparis:

Absolutely.

Dr Dane Vishnubala:

Okay. So I think there's a range of things you've picked there. I think one of the things I wanted to point out was that you talked about follow-ups being safer online. And that makes sense from what you're saying, because you've probably got a good idea of the diagnosis or you've seen the problem in a face-to-face manner. So the risks are probably mitigated more, aren't they, at this point.

Dr Christos Kasparis:

Yes. Correct. Correct. And I think what we will be seeing, Dane, going forward from this pandemic is that I think everyone's practice will change and we will incorporate more remote working. And I think what a lot of people are doing now are keeping the new patients, patients who we have never seen before as a face-to-face consultation, but keeping follow-ups remotely, as remote consultations. And that seems to work very well.

Dr Christos Kasparis:

So patients who are very stable on medication, you need a catch up, follow up appointment, they don't necessarily need to come in. You can carry out that consultation safely, you know the patient already, there's very little risk in getting that wrong. And it's very unlikely that you will need to intervene in a way that requires a face-to-face. So I think we'll be seeing more of this mixture of face-to-face and remote work in the future.

Dr Dane Vishnubala:

Yeah, I think you're right. And I think that would will be the same for many specialties, won't it?

Dr Christos Kasparis:

Correct.

Dr Dane Vishnubala:

Because I think there's a lot of shared bits around that. So I guess just to finish off really, any final tips and tricks for the people listening in around identifying and managing dermatological issues remotely?

Dr Christos Kasparis:

Yeah. So, I think the things that I have picked up, because it's been a learning curve for me as well as a consultant dermatologist. One, I would say that history becomes very, very important when you carry out remote consultation. So put more emphasis on the history, take a slightly more comprehensive history, focus on those signs which may suggest a more sinister problem would be a very good starting point.

Dr Christos Kasparis:

We talked about dermatology being a visual specialty of course, and we need those photographs at some point to match what we get from the history to what the patient has on the skin. So good quality images, don't settle for anything less than that. Make sure the images are in focus. You get enough images from the different sites which are relevant. And that you have a good distant and close up images to be able to assess the distribution and the morphology of the actual skin rash.

Dr Christos Kasparis:

One of the things that I have had to find out doing these clinics remotely is that you've got a lot of distractions when you're at home. And you need to try and minimise those distractions. Treat these consultations that you carry out at home or remotely as if you were carrying them out in your clinic. So, make sure you're completely isolated. You haven't got anything in the background, TV, children ideally.

Dr Christos Kasparis:

And you need to stay focused because there is a higher risk carrying out remote consultations, not face-to-face, and you need to be sure, you need to be absolutely focused on the job on the day.

Dr Christos Kasparis:

Again, always keep at the back of your mind that you have to assess whether remote engagement with a patient is the best option, or is there an option of face-to-face that you should be carrying out instead. And if you feel unsafe or if you feel that you're not able to carry out an accurate assessment for that patient remotely, then abandon that plan and make alternative plans, so reschedule an appointment or reschedule for a face-to-face appointment. But if you don't feel you're able to give that patient sound advice based on the information that you've got, it is best to abandon and then reschedule.

Dr Dane Vishnubala:

Perfect. Thanks Christos. So just summarising to finish off really, we talked about making sure that the consult is the right consult, should it be face-to-face or should it be remote? We've talked a bit about taking that right history, and actually the history potentially even having more emphasis now, to try and mitigate for some of the things that we can no longer see. We talked about the real value of those images. And you talked about taking it from far away, so you can get a wider picture, and then closer in. And of course the right resolution and lighting to do that. And obviously you've talked about the downsides of working from home as well. And I know that all to well, we've got a 10 week old, so I'm learning quite quickly the distractions in play at home.

Dr Christos Kasparis:

Yes. Yes. And they are difficult to control. I've got a three-year-old and a five-year-old and at any point they can just walk through the door.

Dr Dane Vishnubala:

Yeah. See, I don't have the problem, they're not mobile, he's not mobile yet.

Dr Christos Kasparis:

True. True.

Dr Dane Vishnubala:

Perfect.

Dr Christos Kasparis:

You're still in your grace period.

Dr Dane Vishnubala:

Exactly. Exactly. Perfect. Well, thank you, Christos, really interesting, and thank you for coming on. I know a lot of the listeners wanted to get a podcast in on dermatology. So hopefully you guys found that really helpful. So that is a wrap for our dermatology session. Thank you for listening to our Remote Consultation Masterclass series on dermatology. So I really hope you found it useful.

Dr Dane Vishnubala:

And remember, you can subscribe to our podcast through Apple Podcasts or on Spotify. And we hope to see on the next one. See you soon.

Dr Dane Vishnubala:

Keep in touch with us for future podcasts by subscribing. And you can do this in Apple Podcasts, YouTube, Spotify or wherever you get your podcasts from.

(00:23) Episode introduction

(01.02) Introduction to Dr Christos Kasparis

(02:37) Different ways of working remotely in dermatology

(03:34) What do you need in a platform to do your job well?

(05:34) Advantages and disadvantages of remote working in dermatology

(09:44) How have your treatment pathways and decisions changed during the pandemic

(12:42) How do you mitigate the risks of missing things when working remotely?

(17:00) Are there any medico-legal aspects that you need to consider when carrying out remote consultations?

(21:43) Tips and tricks around identifying and managing dermatological issues remotely

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