SALT SPRING ISLAND, B.C. – Unable to find a dermatologist to whom he could refer patients in Victoria, family doctor Shane Barclay, located on Salt Spring Island, created a teledermatology program that is available province-wide.
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.
“It’s changed my practice and I think it’s changed the lives of my patents in many cases,” Dr. Barclay told the Times-Colonist newspaper.
The online program Barclay pioneered – based on one for family physicians from Alberta and the Northwest Territories – is used by 700 doctors and 100 nurse practitioners to access the services of 11 dermatologists, according to the Doctors of B.C., formerly the B.C. 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’s a fraction of the 130,845 consultations done just last year by B.C. 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.
“And that’s very good in a situation when time is of the essence,” said Kenny, who has been part of the teledermatology pilot since the start.
“It’s the wave of the future. It’s a new field and we’re just beginning to realize what it can do and how many problems it can solve.”
However, Kenny is quick to caution that “all problems cannot be solved with teledermatology — this is a way to answer a shortage.”
The B.C. 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.
“I thought, ‘This is nuts,’” said Barclay.
Barclay contacted Dr. Jaggi Rao, a dermatologist from the University of Alberta, about building in B.C. the kind of teledermatology system that’s 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 B.C. pilot project.
“I thought, we don’t have to reinvent the wheel, I just had to get the infrastructure set up in B.C.,” Barclay said.
B.C.’s 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 – 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 B.C. 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 B.C., he said, and he sees far too many patients in Victoria with advanced melanomas that should be caught earlier.
“Here in Victoria we see melanomas when they have progressed to a certain stage. They are not of the earliest stage … because people have to wait longer,” Kenny said.
In Australia, where the rate of melanoma in some areas is four times what it is in Canada, 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.
“They can see their patients when the tumour is 0.6 millimetres in depth,” Kenny said. “In Europe, it’s less than 1 millimetre in depth and here it’s 1.43 millimetres in depth by the time we get to see them because access to be seen is not that readily available.”
Between 15 and 20 per cent of people with melanoma die from it, Kenny said. “It’s important that we are able to see people in a timely manner.”
Atypical melanomas that are flesh-coloured or reddish – not the typical “ugly duckling” dark mole – are often missed or misdiagnosed, dermatologists say.
The average family doctor – who may have studied dermatology for only a day or a week in medical school – will likely see few melanomas in their whole career, Kenny said. “I follow close to 1,400 melanoma patients.”
Dr. Wingfield Rehmus, a pediatric dermatologist at B.C. Children’s 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 under-served communities – and even in Vancouver – 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.
“That’s not to say it’s as good as an in-person consultation … but, for some things, it’s really easy to tell on a photograph,” she said.
“I think teledermatology is serving a wonderful role in the instance of people who don’t have access to dermatology care in any other way,” 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.
“The feedback I get back from the GPs is that it is really increasing the GPs’ capability to handle dermatology conditions on their own because they learn so much from each case.”
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’s 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. “They have the best pick-up rate in the world.”
Fees for doctors in the teledermatology pilot project are funded through Shared Care, a partnership between the Doctors of B.C. and the B.C. 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’s electronic record to save time in doctor’s having to input relevant patient background during each consultation.