Fed up after hitting a dead end in trying to find a dermatologist in Victoria to take his patients, a family doctor on Salt Spring Island used technology to build a route around it.
Dr. Shane Barclay created a teledermatology program that is available provincewide. The pilot program offers a simple process in which a family doctor takes a photo of a skin lesion and sends it electronically to a dermatologist for a diagnosis. The turnaround is usually 48 hours.
鈥淚t鈥檚 changed my practice and I think it鈥檚 changed the lives of my patents in many cases,鈥� Barclay said.
The online program Barclay pioneered 鈥� based on one for family physicians from Alberta and the Northwest Territories 鈥� is used by 700 doctors and 100 nurse practitioners to access the services of 11 dermatologists, according to the Doctors of sa国际传媒, formerly the sa国际传媒 Medical Association.
Since its inception in 2011, the program known as BCConsultDerm has been used for more than 2,000 consultations, the association says. But that鈥檚 a fraction of the 130,845 consultations done just last year by sa国际传媒 dermatologists.
The new approach offers speedy assessments of skin problems, said Dr. Patrick Kenny, a Victoria dermatologist who focuses exclusively on melanoma, the most serious and deadly skin cancer.
鈥淎nd that鈥檚 very good in a situation when time is of the essence,鈥� said Kenny, who has has been part of the teledermatology pilot since the start.
鈥淚t鈥檚 the wave of the future. It鈥檚 a new field and we鈥檙e just beginning to realize what it can do and how many problems it can solve.鈥�
However, Kenny is quick to caution that 鈥渁ll problems cannot be solved with teledermatology 鈥� this is a way to answer a shortage.鈥�
Dr. Evert Tuyp, president of the dermatology section of Doctors of sa国际传媒, agrees, noting that teledermatology does not address the critical shortage of dermatologists in the province.
鈥淚t鈥檚 laughable to talk about this,鈥� Tuyp said. 鈥淵es, it鈥檚 a wonderful, great program and it鈥檚 a great idea, but we need more dermatologists.鈥�
Teledermatology could be rolled out across the province to address the shortage in all remote communities, Tuyp said. One dermatologist could do nothing but teledermatology for remote communities, he suggested.
鈥淚t is something we should be doing on a huge scale 鈥� the technology is there 鈥� but again what is missing is the dermatologists,鈥� Tuyp said.
The sa国际传媒 teledermatology program is the result of an experience Barclay had in 2010.
At his Kings Lane Medical Clinic on Salt Spring Island, Barclay was told none of the dermatologists in Victoria were taking new patients. He was advised to send them to Vancouver, which had a year-long wait-list.
鈥淚 thought, 鈥楾his is nuts,鈥櫶�� said Barclay, 61.
Barclay contacted Dr. Jaggi Rao, a dermatologist from the University of Alberta, about building in sa国际传媒 the kind of teledermatology system, already in operation in Alberta.
Another Salt Spring doctor, Paula Ryan, who had experience with teledermatology while working in the Northwest Territories, was also brought in to participate in the sa国际传媒 pilot project.
鈥淚 thought, we don鈥檛 have to reinvent the wheel, I just had to get the infrastructure set up in sa国际传媒,鈥� Barclay said.
Telehealth 鈥� the delivery of health-related services and information through telecommunications technologies 鈥� has been used successfully in sa国际传媒 for many years. It can be as simple as two health professionals discussing a patient鈥檚 case over the phone or wildly sophisticated.
sa国际传媒鈥檚 teledermatology pilot project allows family doctors to take a photograph of a skin condition and upload it, along with a description and relevant patient information, to a secure website. The Salt Spring doctors say the quality of the photographs from a tablet, smartphone or even pocket camera is excellent.
Looking at a photo on the site, a dermatologist can diagnose and offer treatment possibilities 鈥� typically within about 48 hours.
In another form of teledermatology, the doctor and patient can take part in a video conference with a dermatologist.
Doctors of sa国际传媒 say teledermatology is not recommended for pigmented lesions (melanomas).
Studies show the diagnostic capabilities from the photographs of various skin diseases in teledermatology are comparable to face-to-face exams in 80 to 90 per cent of cases, Kenny said.
There are about 800 new melanomas a year in sa国际传媒, he said, and he sees far too many patients in Victoria with advanced melanomas that should be caught earlier.
鈥淗ere in Victoria we see melanomas when they have progressed to a certain stage. They are not of the earliest stage 鈥� because people have to wait longer,鈥� Kenny said.
In Australia, where the rate of melanoma in some areas is four times what it is in sa国际传媒, those cancers are caught much earlier because patients have access to more dermatologists and skin-cancer screening centres where family doctors do nothing but screening, Kenny said.
鈥淭hey can see their patients when the tumour is 0.6 millimetres in depth,鈥� Kenny said. 鈥淚n Europe, it鈥檚 less than 1 millimetre in depth and here it鈥檚 1.43 millimetres in depth by the time we get to see them because access to be seen is not that readily available.鈥�
Between 15 and 20 per cent of people with melanoma die from it, Kenny said. 鈥淚t鈥檚 important that we are able to see people in a timely manner.鈥�
Atypical melanomas that are flesh-coloured or reddish 鈥� not the typical 鈥渦gly duckling鈥� dark mole 鈥� are often missed or misdiagnosed, dermatologists say.
The average family doctor 鈥� who may have studied dermatology for only a day or a week in medical school 鈥� will likely see few melanomas in their whole career, Kenny said. 鈥淚 follow close to 1,400 melanoma patients.鈥�
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Dr. Wingfield Rehmus, a pediatric dermatologist at sa国际传媒 Children鈥檚 Hospital in Vancouver, works in outreach clinics in Prince Rupert, Prince George and Terrace. She has also done about 60 teledermatology consultations since the pilot began.
Rehmus said she sees patients in underserved communities 鈥� and even in Vancouver 鈥� waiting far too long to see a dermatologist.
She is undaunted by looking at photos to diagnose a skin lesion because medical students spend years learning about very rare skin conditions from photos in text books.
鈥淭hat鈥檚 not to say it鈥檚 as good as an in-person consultation 鈥� but, for some things, it鈥檚 really easy to tell on a photograph,鈥� she said.
鈥淚 think teledermatology is serving a wonderful role in the instance of people who don鈥檛 have access to dermatology care in any other way,鈥� Rehmus said. It can eliminate the need to travel great distances to see a specialist, which is especially helpful for the elderly and people who are less mobile, she said.
鈥淭he feedback I get back from the GPs is that it is really increasing the GPs鈥� capability to handle dermatology conditions on their own because they learn so much from each case.鈥�
In February, eager to help their Salt Spring Island patients further, doctors Barclay and Ryan bought dermatoscopes and took a course to learn to use the them.
A dermatoscope, traditionally used by dermatologists, is a lit magnifying lens that illuminates the skin at a low angle in all directions, making the skin鈥檚 upper layers more transparent, allowing a doctor to distinguish deeper pigment patterns and structures. The aim is to distinguish between a benign and a malignant cancerous lesion. Dermatoscopes can cost anywhere from $400 to $1,000.
The Salt Spring doctors expect to soon receive a dermatoscope that affixes to an iPad or iPhone. It will allow the physicians to photograph a skin lesion through the dermatoscope and send the images to dermatologists via the teledermatology system.
In Australia, where skin cancer screening is robust, most family doctors use dermatoscopes with iPads and send photos to dermatologists using their own version of teledermatology, Barclay said. 鈥淭hey have the best pick-up rate in the world.鈥�
Fees for doctors in the teledermatology pilot project are funded through Shared Care, a partnership between the Doctors of sa国际传媒 and the sa国际传媒 Ministry of Health. Negotiations are underway to secure fees under the Medical Services Plan for teledermatology consultations by dermatologists.
The Salt Spring Island doctors say the next step in the pilot will be to try to integrate teledermatology with a patient鈥檚 electronic record to save time in doctor鈥檚 having to input relevant patient background during each consultation.
