How far can a maverick journey?
A Career Series in podiatry – Ivan Bristow
Dermatology in focus covers the unique career of Dr Ivan Bristow, both clinician and academic podiatrist. It takes mavericks to change a profession either by stealth, dogged hard graft or by example. In many ways, Ivan has achieved all three.
Dermatology is a subspecialty of medicine and podiatric dermatology is a subset of podiatry. Ivan Bristow is one of the foremost podiatrists with an interest in this area of practice for over 30 years. People say to him, “you’re a dermatologist,” but he is clear he would never call himself a dermatologist. However, the truth is that podiatrists’ interest in dermatology has always been present as it is core to their practice. What has become more evident is the fact that changes in the skin are often not only a guide to a medical condition but may herald the start of something more sinister.
Ivan was a delight to interview bringing warmth and passion to the subject that he has taken from his early days as a student. He discusses how dermatology became his key interest and what he has done since qualifying from his old school, now the University of Northampton.
As a student, he was engaged with orthopaedics which was never particularly high on his list of interests. Rather than enthusing over whether the patient had a hindfoot valgus or varus, he was intrigued by the blemish at the back of his patient’s leg. Now, Ivan was fairly well-read as a student and tried to persuade the lecturer to focus on the skin rather than the shape of the foot.
The lecturer finally conceded after persuasion and let Ivan write a letter to the GP. Three months later, one of the students in another clinic came through because he was in the opposite clinic and said,
“There’s a lady who wants to see you. You saw her a few months back. So, I went to see her and she was the lady who had the mole on the back of her leg. She had a large excision that she’d had done on her leg which had healed up, and she said, I just want to thank you. You probably saved my life. You were right, it was something to worry about. It was a melanoma.”
In 1990, he was in discussion with another lecturer about his plans when he left Northampton. Referring to a book he was reading at the time called Essentials of Dermatology by J. L. Burton. He explained that he was quite interested in dermatology. The conversation went something like this; “Well, no, no, no, that’s not going to work. You see, you’re a podiatrist. You have to be a dermatologist to do dermatology”.
Like a flame to a firework, Ivan decided to prove his lecturer otherwise. Armed with his new religious bible – Burton, he found humour, a new love in the subject and a passion to take it further.
As podiatrists, we often have to climb our way slowly working amongst some specific groups who traditionally were provided with a foot health service. Ivan found himself in the neighbouring county of Oxfordshire but disliked his job dealing with cases of the elderly on long stay wards. He used to walk past the Department of Dermatology and saw the office belonging to Rodney PR Dawber, Consultant Dermatologist, and an author of books he had been introduced to when studying in Northampton. Seeing the door open one day he introduced himself and ended up having a long conversation. Dawber said, “You’re a podiatrist. People like you should be working in our department because our dermatologists don’t like anything below the waist, and we see so much… things on the feet that they’re just not happy about.”
Invited to set up a clinic he went back to his NHS manager who was rather negative and dismissive about the value dermatology could bring. Nonetheless, he let Ivan have one afternoon a month as long as he made up the time elsewhere. Having set up one of the first dermatology clinics with a podiatrist his enthusiasm and future hopes started to emerge with him participating in registrar meetings, using the library and being treated like a registrar more or less. Back in 1978 a young female podiatrist, Joan Mayhew, worked closely with a dermatologist at the time. Ivan would not have known this as she happened to be my own boss at the time and thus could not follow her passion for dermatology. The problem with the earlier podiatrists was that nothing was ever published. Without being committed to paper any clear history remains unrecorded. There is no doubt that podiatrists all over the UK were undertaking seminal work and connecting with senior doctors and consultants, but young Ivan was to be different and his diligence to the field of published work would grow. As a corollary, it is interesting to note that his manager then went around the region telling other managers how useful podiatrists were in dermatology, despite his negative attitude at the outset.
Ivan reflects on his early years and says, “You have to take that step out of your comfort zone and I was facing sometimes conditions I didn’t have a clue what I should do, but nobody else did either. We needed to try and apply our basic podiatry principles across to other areas like epidermolysis bullosa. How would you prevent a foot from blistering? How do you stop a foot from rubbing? How do you prevent skin from drying out? All the different tricks and techniques. That’s how it started, but by the end of it what would happen is that the registrars used to have a rotation through podiatry in the dermatology department consequently to learn about the skills that we had.”
The common theme in all the stories of those who have changed the direction is that the profession has ultimately made sacrifices. As Ivan points out it is easy to undervalue one’s manual skills. Dermatologists are absolutely fascinated by how we can stick a blade down the side of a nail or excise a nail spike painlessly. This group of medical specialists admired our skills.
Ivan threw himself into learning about general dermatology alongside diabetes. He went on to write the first of four books in dermatology with Rod Dawber, and latterly with some of the other dermatology greats, writing with them. So that’s how he got started.
Ivan, now Dr Bristow PhD is critical of the profession. He became a full-time lecturer at the University of Southampton, “dermatology is not well-served within the podiatry curriculum, but that’s also a problem in GP land because GP’s knowledge of dermatology is often on the basic level and so is not served either.” Nonetheless, Ivan believes the vast majority of our profession is interested in dermatology. This is validated by the numbers who sign up for his webinar talks which are highly popular. For those interested, he reflects what was once easy is now harder.
“Years ago, you could just turn up and shadow a dermatologist. These days there are honorary contracts, funding issues and confidentiality. Trusts don’t want people there obviously who may slow up the clinics or impede progress as they try to hit their targets and so on. So, it’s much more tricky.”
As ever, Ivan is full of quotes and says – “Some surgeons say the skin is merely a membrane which impedes the passage down to the deepest structure that requires surgical attention. But actually, it’s a very important membrane.”
How to approach dermatology as a sub-speciality
If something does not exist and yet you are interested then never give up on your goal. Secondly, do not be persuaded by others that you cannot achieve your goal; success and failure fall at your doorstep no one else’s. Lastly, never expect to be given a career on a plate. You have to earn your right of passage. When asking Ivan how he believes you should break into a specialism, dermatology does not have a pathway compared to other areas of podiatry. As he reminds us, the provision in dermatology is poor.
Cardiff University offers a diploma in dermatology and the University of Hertfordshire provides a MSc in dermatology skills and is open to all healthcare professionals from all over the world. It can be done part-time or full time, but it does offer a MSc in dermatology skills. The course marries wound care, offering a good crossover with a lot of entrants because wound care and dermatology are quite closely related.
The difficulty comes in getting the surgical skills because there we are encroaching in the areas of podiatric surgery. But when it comes to biopsies, excisional biopsies, this is a big stumbling block for us because getting people to mentor to do this. At the time of writing a new course has been established through the Royal College of Podiatry from 2021 when 20 experienced podiatrists embarked on undertaking biopsy and excisional skin surgery. The future looks encouraging as podiatric surgeons are slowly involving podiatrists in some of the essential techniques seen in the USA and Spanish podiatry.
Dermoscopy – the skin’s stethoscope
An important part of our work comes is the recognition of skin cancer. As the most common cancer in the world today, outstripping all other types of the disease, it’s a disease that podiatrists should be able to recognise and refer to. Podiatrists are now pushing at the boundaries using a device called a dermatoscope. The technique has primarily been in the hands of dermatologists, but this has made its way into primary care and we’re now seeing GPs use this technique. “With more podiatrists involved, we are detecting cancers earlier and literally saving lives”, Ivan says, which brings him back to the story when he was a student in Northampton.
Ivan has been working with a dermatologist in Southampton, and together they have educated about 350 podiatrists across the UK in basic dermoscopy. As the number of podiatrists using this technique grows, direct referrals to the skin cancer screening clinic may become a reality. This will beneficially impact wait times which traditionally go through GPs. Progress since Ivan and I talked in 2020 show that first contact practitioners will include podiatrists, not least because the effect of the pandemic and covid has affected GP contact numbers. At the time of writing, we still await to analyse the effect of the past 2 years on the national health service. The pundits do not suggest the horizon looks attractive for timely treatment in many areas of health. Ivan is quite direct in that he feels that the priority is to get people trained before cutting bits out because “what is lacking is people don’t know what they’re cutting out. They need the basics before they can move on to decide if this is serious enough to warrant taking it out. We don’t want to end up in a situation where everything gets cut out for the sake of it.”
Ivan no longer works in the university but in his regular private clinic, two out of three of his referred patients turn out to have a melanoma or other forms of skin cancer. “Without the dermoscopy technique it would have taken me longer to conclude that something was wrong”, he says. “Potentially that’s two lives I’ve saved in a year. Multiply that up across the UK”. But what’s curious is the number of podiatrists who’ve done the dermoscopy course and he regularly gets emails saying,
“Thank you so much. I found my first melanoma. I’ve discovered this on a patient”. That’s so good that we’re actually making a difference to the patients and spotting these things earlier and 86 per cent of skin cancer is curable if it’s caught early enough. And that’s a technique podiatrists should be adopting because melanoma occurs on the feet, but they also have the poorest prognosis than melanoma elsewhere on the body. It is so important that this should be integrated down to undergraduate level.”
We chatted about lumps and bumps, skin tumours and psoriasis. The advent of biologics has made a dent in how skin diseases such as psoriasis and eczema can be managed. Biologics are medicines made from living cells. The cells are genetically modified in the lab to make certain proteins. Unlike drugs that work on your whole immune system, biologics block only the parts that are responsible for the overgrowth of skin cells.
Basic skincare is important with older patients. Eczema for example is relatively easy to manage. Fungal infections might appear trivial, but athlete’s foot is a leading cause of cellulitis, and hospital admission. Podiatrists can contribute and make a big difference, it’s important. Dermoscopy can reduce the need to excise lesions because you’re able to discover more benign lesions.
Ivan Bristow brings humour to his talks – no doubt influenced by Burton
Develop an interest in dermatology
Judging by Ivan’s data, his webinars and seminars are popular. Booking a room and thinking 40, 50 people would probably turn up for a dermatology conference, he had over 200 applications for his programme and had to move the lecture room twice. Dermatology sits well with podiatrists. Specialist tools are not required, and the practice fits into the independent sector. “It’s not so mystical as orthopaedics. It’s more black and white. It’s far more medical, and I think that’s the draw. Why do people keep coming back to dermatology updates is because it’s something that can be integrated in practice so easily for many of our members.
Fungal and bacterial infections are important even down to the most mundane of dermatological conditions, i.e. how to use an emollient. How many podiatrists actually say “Are you using an emollient” to their patients? Podiatrists are taught about topical (non-ingestible) medications. Each medication has a carrier or vehicle as well as preservatives. Ivan believes more could be learned about the different emollients given the breadth of the market and patient preferences. He also covers the subject of athlete’s foot and tinea pedis which affects around a third of adult patients. The concern for dry skin broadens to the hidden side effects of common drugs like statins – taken for high cholesterol.
“The statistics say 59% of patients who come into a podiatry clinic will have a diagnosable skin condition on their feet. That’s evidence from a 90,000 patient study across Europe. There is plenty of work out there for anybody who’s interested to wander into that specialism.”
Ivan believes “We don’t have enough dermatologists. This is why dermatology specialist nurses have grown. Nurses are now doing things that the dermatologist used to do.” Of course, dermatology is not the only area where nurse practitioners have grown.
The Primary Care Dermatology Society, (PCDS) was set up because of the shortfall in dermatology education and training for GPs. Now that is an organisation that started with five GPs who wanted to learn more about dermatology. It’s been going on for 20 years. They’ve now got 5000 members across the UK and hold around 40 to 50 meetings a year around the country. Ivan is an honorary life member of the PCDS and the first non-medic in its history to receive that accolade. He holds his own in meetings often scoring higher than his medical colleagues such is his dedication to the subject. If anybody comes to him he says join the PCDS or the British Dermatological Nursing Group (BDNG), which is another professional group of which he is a member of both the PCDS and BDNG are big organisations but fortunately, the material is not all about feet. To learn about dermatology, you can’t just understand what’s below the trouser leg. You need to look at the whole body, just as there’s no point just learning the anatomy of the toe because you want to do toe surgery. You have to go and look a lot further to see and understand what’s going on elsewhere. You can’t treat any part in isolation.
Why not read – Podiatry as a career choice?
Thanks for reading Dermatology in Focus and the work of Podiatrist Ivan Bristow
Published by Busypencilcase Communications Est. 2015 for ConsultingFootPain