Telehealth Best Practices: Dr Lily Talakoub Of Derm to Door On How To Best Care For Your Patients When They Are Not Physically In Front Of You

An Interview With Dave Philistin

Everyone needs an in-person evaluation if the condition is not improved within a small window. Make sure the patient is tied into a in person office even in the future to reevaluate if not improved. Many dermatologic conditions are temporary and curable. There are some that are not. Like skin cancers. A small basal cell skin cancer can look like a pimple that doesn’t heal. Having a dermatologist network to refer a patient to and give them a follow up appointment is crucial, so they know if the condition or lesion does not improve in a short period of time, they at least have a chance to see someone in eros or further testing.

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. Lily Talakoub.

Dr. Lily Talakoub is a board-certified dermatologist, a fellow of the American Board of Dermatology, and Founder of Derm to Door, an app that uses AI to diagnose skin issues. Prior to starting her own practice, McLean Dermatology & Skincare Center in 2009, she served in the Office of the U.S. Surgeon General. Regularly leveraged as an industry expert in the media, Dr. Lily is a frequent guest on local and national television networks and contributes to a variety of national publications including Allure, Glamour, VOGUE, InStyle, Marie Claire, Harper’s Bazaar, BRIDES, Shape, Parenting, Self, and more.

Can you share the most interesting story that happened to you since you began your career?

When I started my career, I didn’t have any money or a job and decided to start my own practice. I walked to every doctor’s office in my town, knocked on the door and asked if I could sublease one room one day a week. No one called me back other than one Gyn who let me use a half a day a week in her pink office that had tables with stirrups. I took it. I got a cell phone and a laptop and made cards at the local FedEx copy shop. From there I took my one-year-old to the park every day and gave my card out to any mom I met. I had no staff, answered my phones myself, did all the notes and billing myself. I used a tool cart from Home Depot which I stored in the back office closet to hold my supplies and kept that with me for 4 years until I had enough patients to finally open my own space and hire my first employee. There were many tears, many failures and life lessons. However, I know how to do everything myself. I know how to do the front desk, the assisting, the ordering, how to set up any of the systems. If no one were to show up one day to work, I could do everything myself. That’s an important part of who I am. There is nothing beneath me.

Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?

If you have risen, send the elevator back down

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?

I had a mentor once that told me do what you love, just one thing and do it really well. Just one thing. It was an important lesson because particularly in my field most doctors try to be great at everything and have their hands in everything to diversify. I always tried to simplify, really be a master of one thing. You build a following and integrity when you are the expert.

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?

There is so much you can obtain from an in-person encounter that just cannot be absorbed from a photo or video. The way a person walks, their speech, their demeanor, their family that accompanies them. Whether they look upset, tried, not able to care for themselves, their gait (the way they walk). It is also important to build a rapport and trust with patients which is very hard to do remotely.

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?

Remote health monitoring or Tele medicine is an amazing accessible tool to help patients that cannot be seen. However, it has its limitations as only the area in the frame or photo can be evaluated. In the case of dermatology if you have an acute rash and need to be seen asap, it would be nearly impossible to see a dermatologist on short notice, but a quick tele dermatologist appointment and you could be better in hours. However, there are other conditions that need an in-person exam. One example is that some diseases have different presentations. A patient can take a photo of their rash on their abdomen but based on what it looks like it comes across to me as a rash that can also be present in the inside of the mouth, however it is very difficult to see or even take a photo of the inside of the mouth. There are benefits and limitations and it’s important that patients know both.

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.)

1. Questions matter. How you ask the questions, what questions you ask can make a huge difference in your diagnosis or treatment. For instance, if I see a patient with an itchy rash that erupted all over their body. Their intake form says what medications they are on. If I don’t follow up sometimes the culprit is not found. I have usually asked what medications, herbals, supplements they take by mouth and often people say none. But then if I inquire further and say did you take ANYTHING by mouth in the last two weeks including Motrin, Advil, Tylenol, gummy vitamins patients often remember they took medications that they wouldn’t have ordinarily mentioned. That’s a difficult point to get across remotely.
2. At home routines need to be discussed. Whether they wash their face, shower, or have an at home routine that needs to be reviewed may make a difference. In the case of dermatology that is a difficult point to get across also in an intake form. I usually have to discuss what they do, what they put on their face and body.
3. It is hard to assess skin issues if you can’t see them in person, feel them, measure them. Rashes particularly serious ones can be scaly, can feel inflamed, can have blisters etc. I have seen many rashes that look like a red sunburn but when I feel them in person, I can feel the deep part of the skin is inflamed and that may be a more serious concern.
4. The normal procedures that help you are not available. You cannot biopsy, scrape, do a culture of a bump or do a blood test or look at their skin under a microscope. As diagnostic tools are not accessible remotely your ability to look and diagnose through a screen becomes very important. You need to be able to feel comfortable making the diagnosis from just a photo but also know when NOT to diagnose something if you are not 100% sure and request that the patient be seen in person for further evaluation.
5. Everyone needs an in-person evaluation if the condition is not improved within a small window. Make sure the patient is tied into a in person office even in the future to reevaluate if not improved. Many dermatologic conditions are temporary and curable. There are some that are not. Like skin cancers. A small basal cell skin cancer can look like a pimple that doesn’t heal. Having a dermatologist network to refer a patient to and give them a follow up appointment is crucial, so they know if the condition or lesion does not improve in a short period of time, they at least have a chance to see someone in eros or further testing.

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?

Our app on the iOS store or on dermtodoor.com give you the ability to do a “store and forward” visit with a board-certified dermatologist as well as making an online video visit with a dermatologist for a more detailed video visit.

If you could design the perfect Telehealth feature or system to help your patients, what would it be?

We did! Direct access from our desktop or your phone (this is a unique feature) as well as 24/7 online chat with a dermatologist and skin expert team.

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?

Make sure you know exactly what you need help with, don’t come to the visit with 10 different problems, choose one or two conditions you need help with immediately. Show up on time, bring your list of medications or supplements, bring out the screen your skincare your use daily.

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?

Artificial intelligence is amazing for dermatology. Our AI technology and facial scan in our app can diagnose 11 different skin conditions and is 98% accurate making these diagnoses.

Is there a part of this future vision that concerns you? Can you explain?

I worry that people that do not get better do not seek out in person visits and it is NOT to be used for emergency conditions like chest pain, shortness of breath, severe symptoms etc. In those cases, one should call 911 and not try to get acute care from a video visit.

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. :-)

In my career I have taken women with no training, education or skill set and trained and promoted them to higher careers in science. I feel as though our young have very little career direction. So much of our educational system is abstract. Very little concrete vocational skills are taught, very little about our political system or civics are taught early on, no money management, no investment education, no financial training. I believe in taking our youth, helping them learn what skill sets they have and training and developing those skills into careers.

How can our readers further follow your work online?

Dermtodoor.com @dermtodoor @drlilyt

Thank you so much for the time you spent doing this interview. This was very inspirational, and we wish you continued success.