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Dr. Tarbox: Hello and welcome to "Skincast," the podcast for people who want to learn how to take the very best care of the skin they're in. My name is Michelle Tarbox, and I'm an associate professor of dermatology and dermatopathology at Texas Tech University ÐÇ¿Õ´«Ã½ Sciences Center in beautiful, sunny Lubbock, Texas. And joining me is . . .

Dr. Johnson: Hey, hey. This is Dr. Luke Johnson. I'm a pediatric dermatologist and general dermatologist with the University of Utah.

Dr. Tarbox: So today we're going to talk about virtual visits and how to make the most of them. So what are the different types of virtual visits, Luke?

Dr. Johnson: Virtual visits are when you use some kind of technology to communicate with your health care provider, instead of seeing them face to face in person like in an exam room. So even something like a phone call or an electronic message could count as a virtual visit. But normally, when we talk about virtual visits these days, we break them into two main categories. There's the live video version where you're talking to somebody like Skype, or Zoom, or FaceTime, or whatever. You're talking to your doctor that way. And there's the what we call the store and forward type, which basically means you send us information. In dermatology, that information usually includes photographs because we like to see stuff on the skin. And of course, as we all know, since the pandemic has been chugging along for a couple of years now, especially at the beginning, a lot of doctor visits that could move to virtual did and some of them have sort of hung around. So there's a lot more virtual visits happening now than they were five years ago, for example.

Dr. Tarbox: And the types of visits can also be modified by whether or not they're self-operated. So sometimes a virtual visit has a facilitator, a person at the remote site that helps with the videography as well as with communication and documentation. The other type of virtual visit that is a live interaction would just be patient-directed. So this is the Zoom phone call or FaceTime with your healthcare provider that you facilitate the technology of. Similarly, store and forward can be self-facilitated or can have a facilitator where somebody might take the photographs maybe even using a special kind of camera, or a special kind of tool like a dermatoscope to send forward for analysis versus a picture you might take with your own phone and send to the physician to review.

Dr. Johnson: Some of this might be happening behind the scenes. So, for example, your primary doctor might take a picture of your mole or your rash and then send it to a dermatologist to get a consult about what to do.

Dr. Tarbox: And sometimes it might be something that's arranged ahead of time when you're having the facilitator of communication as well. Sometimes there's also backend communication that happens with the facilitator. So what are the ways to optimize these visits, Luke?

Dr. Johnson: So out of all of those things that can happen, I think by far the most common thing that actually does happen is a live video. I was going to say chat, but it's more than just a chat. It's an experience between you and your healthcare provider from wherever you happen to be. And the doctor is usually in their office, though, not all the time. So I certainly do plenty of video visits like this, and there's a lot of things that you can do to make it the best possible experience for your overall health. So, for example, the first thing to do is make sure you are in a spot that is conducive to you having this virtual visit. So your house would be a pretty good example, but I have had video visits with patients doing all kinds of things. They are actively commuting, driving in a car, they're parked in a car, they're in a parking garage, they're at another doctor's appointment. So . . .

Dr. Tarbox: I had some . . . I actually had a couple in a drive-thru, it was really funny.

Dr. Johnson: A drive-thru?

Dr. Tarbox: We had to compete with the person at the window.

Dr. Johnson: And people have been on break from work like in a break room and stuff. And of course, if you can make it happen in a safe way and this is just what you have to do because of your schedule, then they normally work out okay, but a calm environment like your house would be a pretty good idea.

Dr. Tarbox: Yeah. I tell my patients to try to make the space that they're in as much like the space I usually see them in in my office as possible. So, of course, in my office, each patient is in their own room with perfect privacy so that there's not somebody else listening to their conversation or seeing them, especially if there's any state of undress. But the most important part is making sure that you can see the patient. So we talk about the importance of lighting and how they sort of brighter broad-spectrum light like a fluorescent light or if you have accessible sunlight can be beneficial for the interpretation, although not direct sunlight because sometimes that wipes out the whole camera lens.

Dr. Johnson: Right. You don't want to be backlit either. And we should be able to see your skin. So, for example, you might want to wear clothes that are easy to move out of the way to show the appropriate area. I have a number of teenagers who wear skinny jeans, for example, and they just can't pull up their pant leg for me to look at the rash on their leg. And then it's like weird for them to actually take their pants off, especially if their mom is also there or something. So maybe they should have just worn shorts.

Dr. Tarbox: Yeah. I think that that pre-planning is really important in terms of the visit as well. Sometimes people get a little bit of stage fright. This is a weird thing to have to do. Here, I'm going to talk to my doctor, we're in a separate space, I may be in some state of undress. Sometimes people get a little anxious or nervous and actually forget what they wanted to ask.

Dr. Johnson: Yes. So I think this is true if you're coming in person to the doctor too. It helps to write down any questions that you might have in advance. But it's more important in a virtual visit, I think because after you hang up, it's not like you can turn around and go back into the office and say, "Oh, yeah. I forgot to ask the doctor something."

Dr. Tarbox: That's right. And I do have a percentage of my patients that will think of something that they'd forgotten to ask while I was in the room after their visit has concluded. Of course, we always try to answer those questions for the patients before they leave. But you're absolutely right. Once you're out of a virtual encounter, it's really hard to get back into one. You might have to schedule another appointment. So definitely writing those questions ahead of time is a good idea. I know myself, personally, I'm not my own best camerawoman. How about you, Luke?

Dr. Johnson: I am my best camerawoman.

Dr. Tarbox: So if you are excellent at taking videos or photos of yourself, you might not need this help. Or if you don't have it accessible, you do the best you can. But if somebody can assist you with holding the camera, making sure that you can be seen through the video interface, that might create a little bit more of a conducive environment to a good exam.

Dr. Johnson: If you've got a virtual appointment coming up, answer your phone. Usually, our staff will give you guys a call ahead of time to say, "Hey, I see you're scheduled for a virtual appointment with Dr. Johnson. Can we go ahead and get that started? Here are the technical details of how you would get into the platform." So I know there's so much spam these days in terms of phone calls. But if you've got a virtual visit like the next half hour, answer your phone, even if it's a phone number you don't recognize.

Dr. Tarbox: Another thing people might not think about is that things in their environment may also react to the virtual visit. One thing that I saw happen a lot was people would have a pet in the room with them. And as soon as a new voice came on to the interface, the pets got excited about that and made a bit of a distraction that made it hard to communicate with the patient.

Dr. Johnson: I do think it's kind of fun to see people's pets. But if they're going to be a significant distraction, then you might want to put them in another room or go in another room yourself. I've also seen televisions just running in the background, which makes it difficult to have a conversation. Children, you got to do what you got to do. But children running around and being loud and tapping on the screen, not conducive. So just do what you can.

Dr. Tarbox: Many people are using the same device they would use to take pictures to do the virtual visit. So it might be a good idea to take some good photos with good lighting and good focus ahead of the appointment so that if the doctor asks for a picture to be emailed to a secure and compliant email address, you can do that without taking a lot of bandwidth away from your phone. For some people's phones, that actually turns off the video while they're doing anything else in the phone's operating system. So having those in advance might save you some time and also help make sure that you have as much information for the doctor as possible.

Dr. Johnson: Because of technology, usually, the video images that we see are much less crisp than a photograph that might be taken. So, especially in dermatology, it's nice if we just see an actual photograph sometimes rather than seeing it all on video. So, as you say, if you take a picture or two of the concerning rash or whatever it is, or this is what my acne looks like today and send it to us ahead of time, that's great. A lot of academic and other institutions have what we refer to as patient portals, which are ways for you to interact with your healthcare staff virtually. So it's basically just sending us a glorified email. So, for example, here at the University of Utah, we use a medical record system called Epic and it supports this patient portal that's called MyChart. And so people can log into their MyChart, they can see their lab results in their visit notes and things, and then you can also send us a message. And just like with an email, you can attach a photograph to that. So if you wanted to do that ahead of time, it can help us out.

Dr. Tarbox: Absolutely. Now, some people don't have a very good internet connection at home or have no internet connection at all. So there have been some people who have proposed that there might be special spaces set up for telehealth in public spaces like libraries that would have virtual access.

Dr. Johnson: That would be nice if such a thing exists. In terms of technology, you do want to be in a place where you've got a good, stable internet connection. So this is one of the problems with like commuting or doing it in a parking lot or something. You want to have a piece of technology with a good camera. And the technology is not super complicated but not 100% simple either. So if you're not feeling particularly comfortable with technology, it might be helpful if your helper could be there to help you out in terms of getting on the platform. And you could even consider just trying it. If you're like, "Okay. I really want to get the most out of this virtual visit that's in two hours. I'll set things up now and let me just try ahead of time to make sure the video looks good and the lighting is good and all that." Like a rehearsal.

Dr. Tarbox: Exactly. I love that. Now, certain conditions are more conducive to being well treated by telehealth than others. What are some things you think are easy to treat by telehealth?

Dr. Johnson: So, in dermatology, I think it's a little different than some other medical fields. But the best candidates for a virtual visit are patients who have a known condition. So we already know that you have eczema or acne or psoriasis, or something like that, and we've already met you at least once and we've put you on a treatment plan and now you're following up. Hemangioma is a common birthmark. That's another good example. So I don't need to make my patients who have tiny babies drive three hours to see me basically, just to make sure things are going okay and adjust their dosing. I can do that via virtual visit. So those conditions, we can usually get a pretty good handle on seeing them in the video, especially if a photograph or two is sent ahead of time. And we can adjust treatment as necessary that way. It's a lot harder to look at all of somebody's skin over a virtual visit to make sure none of their moles are concerning.

Dr. Tarbox: I totally agree. I think that if you have an unknown condition, it's really better to see the physician in person. There are some entities that can look very, very similar in photographs without being able to examine the patient completely, and also even touch the skin, we call that palpating the skin. Sometimes the feel of the skin gives us some information, sometimes the overall distribution of a rash gives us some information. And while people are generally comfortable showing an arm or maybe a leg or something on a webcam, presenting yourself in a greater state of undress, potentially close to not wearing any clothes at all, might be much more uncomfortable for some patients. And so our determination of the volume, the distribution actually of the condition might be harder. There's conditions that look very similar like eczema can overlap clinically with cutaneous T-cell lymphoma and can overlap with psoriasis, all of which can have different treatment protocols.

Dr. Johnson: Speaking of being uncomfortable with getting undressed on the camera, some people have a concern that doing this in this sort of technology can allow hackers or some malicious people to somehow get in there and either see your information or actually see the video stream itself. And I won't say that's impossible because I don't know enough about the technology, but the platforms that we use are considered to be safe and secure. So they are HIPAA compliant. And that's why we generally can't just do it on FaceTime or whatever, you have to use a special platform like through this MyChart thing, or if there's one we use called doxy.me as well that are secure in that sense.

Dr. Tarbox: The most important thing is that you're able to get the care that you need in a way that you're comfortable getting it. So I think that telehealth can be a great option for certain conditions. And hopefully, it will help us expand our services to the patients who need to see us.

Dr. Johnson: And if you just can't get to our office physically because you live seven hours away or there's a ton of snow and you can't make it or you're worried about the pandemic and coming out of your house or whatever, a virtual visit is better than nothing, which I know is not a high bar. But even if you have a wart or you have a funny rash and we look at it and we say, "Well, we can't treat your wart physically because you're not here," we can at least give you some advice about warts." And even if we say, "Well, it would be really nice if you were here in person so we can look at the rash more closely and maybe even take a biopsy or something," we can at least give it our best shot. So I know mejor que nada, as you say. Nothing is not, again, not a high bar, but we are better than nothing. So keep that in mind if you just can't make it out.

Dr. Tarbox: Yeah. Especially if you have a suspicious lesion, getting it looked at and triaged is very important. And while we might not be able to make a concrete specific diagnosis through telemedicine for a changing or new spot, we can at least help to determine how concerned we are about it being a dangerous spot for you. And if we do find that it's a high concern, we'll work our backsides off to get you in as quickly as possible.

Dr. Johnson: Thanks to our institutions. Thanks to the University of Utah for supporting the podcast and thanks to Texas Tech for lending us Michelle. If you would like to hear more of us talk, you can listen to our other podcast.

Dr. Tarbox: Our other podcast is called "Dermasphere." It's a little bit longer than this podcast. Each episode is about an hour, and it's actually directed at people who take care of skin problems and other patients. So this is the podcast by dermatologists for dermatologists and the dermatologically curious. And we welcome anyone to come and learn more about the skin.

Dr. Johnson: Thanks again for hanging out with us today and we'll see you virtually or otherwise next time.