A Picture is Worth More Than a Thousand Words

OBJECTIVE: In addition to the assessment and the management of patients with skin diseases, a considerable portion of dermatology residency involves examining clinical images and generating differential diagnoses from these images. This training, though helpful for recognizing manifestations of rare disorders, goes unused by most practicing dermatologists after certification. In contrast, dermatology residents learn and master verbal descriptions of skin diseases and continue to use this skill throughout their careers. However, problems arise when a dermatologist is not available and a non-dermatologist attempts to verbally describe a skin condition. An accurate description of a cutaneous disorder can facilitate effective triage management of a patient when a dermatologist is not available. Unfortunately, an inaccurate description by the referring provider can lead to diagnostic bias and ineffective, or even harmful, initial treatment. In recent years, digital photography has facilitated the electronic transfer of clinical images over distances. However, despite the promise that this technique shows in providing teledermatologic services to specialty-underserved areas and the availability of low-cost digital cameras, telephone consultation is still the standard of care when a dermatologist is not available. The purpose of this study is to compare the reliability of dermatologic consultations that use the telephone with that of dermatologic consultations that use both the telephone and digital images. DESCRIPTION: After patient approval, an acute care provider randomly assigned patients with skin disorders of unclear etiology to two groups, with and without digital images. The acute care provider then performed an exam and took the patient's history. Telephone data, with or without digital images, were then presented to the consulting dermatologist, who formulated a pre-physical exam differential diagnosis and treatment plan. The consulting dermatologist immediately examined the patient in person and refined the diagnosis and management. The confidence in diagnosis, both before and after the in-person exam, was compared in the patient group with digital images and in the patient group without digital images using a five-point scale (1 = no confidence, 5 = most confident). DISCUSSION: The consulting dermatologist evaluated 12 patients (six with digital images and six without digital images). In the patient group with digital images, the consulting dermatologist's confidence in diagnosis varied very little from before to after the in-person exam (from no change in five cases to a one-point increase in the sixth case). In the patient group without digital images, the consulting dermatologist's confidence level increased significantly from before to after the in-person exam. This led to therapy changes for three of the six patients in the patient group without digital images, versus two of the six patients in the patient group with digital images. This study indicates that an acute care provider's verbal description of a skin condition may be less reliable compared with a provider's verbal description combined with digital images. Telephone-only descriptions may also lead to management discrepancies more frequently than telephone descriptions with digital images. This has at least two implications for medical education: (1) need for support of formal teaching of the language of dermatology to non-dermatologists and (2) justification of the time spent in two-dimensional clinical image interpretation by dermatology residents in light of digital image technology.