Addressing Disparities in Atopic Dermatitis Through Teledermatology

"We need to assume that we don't know everything. We need to cast aside our fragility and realize that we only know what we know, and we have to engage with community stakeholders to better understand what the needs are, and how to best deliver actual items for those needs, the way that will be best received by that community," said Adam Friedman, MD, FAAD.

Friedman took part in a mini-symposium at this weekend's Revolutionizing Atopic Dermatitis (RAD) conference in Washington, DC, where he discussed teledermatology and disparities in atopic dermatitis care. Dermatology Times® spoke with Friedman following the conference's conclusion to discuss the biggest takeaways and highlights from his talk, as well as best practices for addressing disparities and racism in atopic dermatitis care.

Friedman: I'm Adam Friedman. I'm professor and chair of dermatology and residency program director at GW [George Washington University] School of Medicine and Health Sciences.

Dermatology Times: What are a few take-home points from your session, "Using Teledermatology to Reduce Disparities in Atopic Dermatitis?"

Friedman: So RAD being a conference dedicated to all things atopic dermatitis, and certainly this has been needed for so long given the prevalence of the disease affecting 30 million folks in the US, forgetting even worldwide, it was really nice to round out the conference that hit on every facet from diagnostic criteria to treatment and long term treatment and clearance with unique and specific issues we need to consider as it relates to disparities in care. And I think 1 of the things that the pandemic really unearthed, not invented, but it's always been there, is both structural and institutional racism, which really translated across many demographics in the house of medicine, and how that affects the patient, how it affects the workforce, how it even affects drug development. Even as you think about clinical trial design, how all these things really percolate and interfere with our ability to do right, ultimately, by the patient. And so I think atopic dermatitis being first and foremost such a common skin condition, the second most common inflammatory skin condition, there's no way you're going to avoid it in terms of both seeing the disease but also these issues affecting patients suffering. And so my part was part 3 of a 3-part panel focusing on what are of the things we can actually do about it? And I like to always consider that there are silver linings even with utter, complete dumpster fires, like the pandemic, and I think one of those silver linings was 1: the recognition of these issues, but 2: the rapid utilization of certain approaches that really weren't accessible to us in the past, and then that would be the kind of, you know, unroofing of any restrictions on legalization of telemedicine in health care. Now, teledermatology has always been there. Actually, I was just fortunate enough to work on a project when I was at the Albert Einstein College of Medicine as faculty with one of the current residents there, Jules Lipoff, for a telehealth project that was being done. This was probably over 10 years ago, and we know some very big names in teledermatology, like Carrie Kovarik at Penn, but our ability to really, you know, intersperse it in our day-to-day has been limited due to restrictions in terms of licensure in the state where the patient resides, reimbursement issues, you name it. So it was kind of niche, but the pandemic, given the lack of access, inability, from one day to the next, literally to be able to come into the office, demanded the need for it. And so we in dermatology, I can only speak to the experience at GW, you know, literally the next day converted our visits to telemedicine, at that time using Zoom, ultimately using our EMR capacity. But we were able to still see patients effectively, and certainly there was a learning curve, but we were able to maintain it, because a lot of what we can do, it's visible inspection, and talking, and eliciting a history, and being detectives. However, in this excitement, and this ability to keep going and evaluating the patient experience, what we noticed is the patients who were utilizing this approach, very few came from certain areas of DC, where already there were gaps identified in terms of areas like Ward 7 and 8, where there's not a single dermatologist, this is a, you know, on 1 hand, a very low socioeconomic population, Ward 8 especially, the residents, about 92%, self identify as Black. And then if we kind of think about atopic dermatitis, where our data shows that those who identify as Black tend to have more atopic derm, have more severe disease, but make up fewer of the appointments seen by a dermatologist for this condition. Now we're adding the mix of, while telemedicine enhances access, the people who are at the greatest need, the divide is furthered. And so that's what I've kind of realized is that, well, yes, this allows access during a time of pandemic, the divide was widened, not just because there was a health desert, but now there's a technology desert as well. And so that really inspired, and timing's always everything, inspired a project that we submitted a grant application we submitted, there was a call for applications, a quality improvement project by Pfizer, looking at how telemedicine can improve access to care. And it's like 1 of those things where like the stars align, we're thinking about this, I see this email, which usually I ignore because they send so many, and I'm like, 'wow, look at that,' like, you know, fireworks are going off in my brain. I'm like, 'We got this,' and we did. We got it, and we established not just a clinic, but we established a telehealth help desk at a church in Ward 8, Temple of Praise Church, which is a massive church, has a huge congregation. It's in a residential area, so hoping to kind of pull in those who live in the area. We set up a unit that 1: got folks in our system, 2: allowed for an opportunity to educate those how to best optimize telemedicine with their device in real time and also gave education on best practices, 3: educated on atopic dermatitis, so that was the focus of this clinic. And then, the individuals who came to this clinic underwent a free telehealth visit with 1 of our dermatology residents back at GW. So they went through the experience of a telemedicine visit. So if there was any concern that 'Oh my, I don't want to do this,' you know, demystify the illusion that this is something difficult, and they were armed with a telehealth coordinator in the room with them. So by the time they walked out, we made a follow up appointment, they got samples for products for over the counter products, and they did some research surveys to better understand the experience. And this approach rapidly was successful. You know, we went from maybe having a couple patients to being maxed out on patients we could see. I'm very happy to report that this 1-year grant, this funding, has actually been extended, and now others are jumping in the fray so we have support frp, Pfizer and Lilly to continue this program at Temple of Praise, now focusing both on both atopic dermatitis and alopecia areata. But I think there are a lot of lessons learned from this. I think that it's not enough to say, 'Oh, well we do telehealth. People can come to us.' That assumption in itself, I hate to say it, is racist, in that it doesn't consider beyond the blinders we have on for our own experiences and our own environment. We have to think about how do other communities learn about these opportunities? What comfort do they have, and actually, can they even access these opportunities? And what barriers prevent them from getting the care they need? Even if they can get that care wherever they are, there could be both perception issues, technological issues, you know, fund of knowledge and comfort issues. So I think that we need to assume that we don't know everything. We need to cast aside our fragility and realize that, you know, we only know what we know. And we have to engage with community stakeholders to better understand what the needs are, and how to best deliver actual items for those needs, the way that will be best received by that community.

Dermatology Times: What are a few highlights from the panel discussion that followed your session?

Friedman: So there were some really great questions that followed, and we closed it down. We were the last session. And one of the questions that resonates was, 'Right in this moment, what can we do to combat racism in dermatology?' And it's not like, alright, what programs can we create? What pipeline programs, and what educational resources? Of which there are many, and actually, you know, as an aside, 1 of the elements with this telehealth program was also educational, from the physician side that we had medical students and residents participating, which is an opportunity to also become comfortable with telemedicine from that side, but also to be able to see patients from wide demographic areas and also patients with varying skin tones, which we know there are gaps in that as well, which translate into issues of proper care. But that's all like, you plan that out. That's over time. What in this single moment? And that's not an easy question to answer. And the way I answered it, was kind of in line with what I said a moment ago, is: recognize our implicit biases. You know, we are products of our upbringing, of our society, and there's so many things that go into it, family, friends, and we have picked up on certain ways of viewing the world. We look through a certain lens that is inadvertent. It's just automatic. It's like breathing. And that's okay. I think people are so concerned about being labeled a certain title. And I think if you accept that you have these implicit biases, and you remind yourself that they're there, and you refuse to allow them to dictate your behavior, and how you treat others, and how you think about, in this case, skin disease, then that's the approach. Like in this moment, just asking that question, recognizing your own personal limitations, accepting your shortcomings, and saying, 'I'm not going to let this dictate how I how I act on a day-to-day basis,' that's the most immediate thing I think you can do. Long-term is, of course, addressing those gaps, you know, making sure that you feel comfortable and you have mastery over, you know, every, in this case, dermatologic disease from every angle. So when we say dermatology, when we say skin diseases, 3000-plus skin diseases, the assumption is that we know how to recognize and treat it in all skin tones and all demographics. And we know that there are limitations in how true that is for everyone. Probably were happenstance, anything, the resources, where you train. So acknowledging that and saying, 'Alright, well, I'm going to do something about it.' That is really the immediate course of action, is acknowledging the issue, and not just saying you acknowledging, but actually choosing to do something about it.

[Transcript has been edited for clarity.]