Comparing preferences for skin cancer screening: AI-enabled app vs dermatologist.

BACKGROUND AND AIM: Skin cancer is a major public health issue. While self-examinations and professional screenings are recommended, they are rarely performed. Mobile health (mHealth) apps utilising artificial intelligence (AI) for skin cancer screening offer a potential solution to aid self-examinations; however, their uptake is low. Therefore, the aim of this research was to examine provider and user characteristics influencing people's decisions to seek skin cancer screening performed by a mHealth app or a dermatologist. METHODS: Two forced-choice conjoint experiments with Nmain = 1591 and Nreplication = 308 participants from the United States were conducted online to investigate preferences for screening providers. In addition to the provider type (mHealth app vs dermatologist), the following provider attributes were manipulated: costs, expertise, privacy policy, and result details. Subsequently, a questionnaire assessed various user characteristics, including demographics, attitudes toward AI technology and medical mistrust. RESULTS: Outcomes were consistent across the two studies. The provider type was the most influential factor, with the dermatologist being selected more often than the mHealth app. Cost, expertise, and privacy policy also significantly impacted decisions. Demographic subgroup analyses showed rather consistent preference trends across various age, gender, and ethnicity groups. Individuals with greater medical mistrust were more inclined to choose the mHealth app. Trust, accuracy, and quality ratings were higher for the dermatologist, whether selected or not. CONCLUSION: Our results offer valuable insights for technology developers, healthcare providers, and policymakers, contributing to unlocking the potential of skin cancer screening apps in bridging healthcare gaps in underserved communities.

Decision-making in dermatologic surgery.

Good clinical decision-making is important in dermatologic surgery. Experience and knowledge help considerably, but take time to acquire. However, how the clinician thinks is also a significant contributory factor. How we think is influenced by many factors, including our beliefs, prejudices, confidence and variables like how we are feeling at that moment physically and emotionally. Thought process can be either fast and subconscious or slow and analytical. Fast thinking contributes to the majority of decision-making and is especially prone to a range of biases which may contribute to suboptimal clinical outcomes. We wish to highlight and illustrate common biases in thinking encountered by the dermatologic surgeon.

What do patients and dermatologists prefer regarding low-risk basal cell carcinoma follow-up care? A discrete choice experiment.

BACKGROUND: Follow-up after low-risk basal cell carcinoma (BCC) is being provided more frequently than recommended by guidelines. To design an acceptable strategy to successfully reduce this 'low-value' care, it is important to obtain insights into the preferences of patients and dermatologists. OBJECTIVE: To determine the preferences and needs of patients and dermatologists to reduce low-risk BCC follow-up care, and the trade-offs they are willing to make. METHODS: A questionnaire including a discrete choice experiment was created, containing attributes regarding amount of follow-up, continuity of care, method of providing addition information, type of healthcare provider, duration of follow-up visits and skin examination. In total, 371 BCC patients and all Dutch dermatologists and dermatology residents (n = 620) were invited to complete the questionnaire. A panel latent class model was used for analysis. RESULTS: Eighty-four dermatologists and 266 BCC patients (21% and 72% response rates respectively) completed the discrete choice experiment. If the post-treatment visit was performed by the same person as treatment provider and a hand-out was provided to patients containing personalised information, the acceptance of having no additional follow-up visits (i.e. following the guidelines) would increase from 55% to 77% by patients. Female patients and older dermatologists, however, are less willing to accept the guidelines and prefer additional follow-up visits. LIMITATIONS: The low response rate of dermatologists. CONCLUSION: This discrete choice experiment revealed a feasible strategy to substantially reduce costs, while maintaining quality of care, based on the preferences and needs of BCC patients, which is supported by dermatologists.

Teledermatology: current indications and considerations for future use.

Telemedicine is one of the most consequential technologies in modern healthcare. In certain situations, it allows for the delivery of care with high quality and minimal difficulty. This is particularly true in dermatology, in which many dermatological conditions can be treated remotely. The burden on dermatology patients has been greatly reduced for certain pathologies due to telemedicine. Health care providers also achieve improved job satisfaction following the convenience of meeting their patients. This paper details select dermatological conditions, and subsequently divides them into those treatable by telemedicine appointments, and those requiring face to face appointments.

Attitudes on Prophylactic Antibiotic Use in Dermatologic Surgery: A Survey Study of American College of Mohs Surgery Members.

BACKGROUND: Antibiotic prescriptions associated with dermatologic surgical visits are increasing and prescribing practices vary among surgeons. OBJECTIVE: To describe dermatologic surgeons' attitudes and practices regarding prophylactic antibiotic use for surgical site infection (SSI), to compare current prescribing practices to those of a 2012 survey, and to determine surgeons' interest in clinical trial data on the utility of prophylactic antibiotics. MATERIALS AND METHODS: This was a cross-sectional online survey of the American College of Mohs Surgery (ACMS) members. Survey items were adapted from a 2012 survey of ACMS members. RESULTS: The survey was initiated by 101 ACMS members. 75.25% (76/101) of surgeons reported routinely prescribing prophylactic antibiotics to reduce SSI risk. The use of prophylactic antibiotics varied with clinical scenario. Most providers (84.21%, 64/76) prescribe postoperative antibiotics, with an average course of 6.56 days. 40.21% (39/97) of respondents were uncertain if prophylaxis prevents SSI, and up to 90.63% (87/96) indicated interest in clinical trial data evaluating the efficacy of oral antibiotics for SSI prevention. CONCLUSION: Dermatologic surgeons continue to report varied attitudes and practices for SSI prophylaxis. Evidence from clinical trials is desired by surgeons to guide clinical practice.

Impact of clinical photographs on the accuracy and confidence in the histopathological diagnosis of mycosis fungoides.

BACKGROUND: The histopathological diagnosis of MF is challenging, and there is significant overlap with benign inflammatory processes. Clinical features may be relevant in the assessment of skin biopsies. METHODS: We provided photomicrographs to board-certified dermatopathologists and one hematopathologist with and without accompanying clinical photographs and assessed accuracy and confidence in diagnosing MF. RESULTS: We found that access to clinical photographs improved diagnostic accuracy in both MF and non-MF (distractors); the degree of improvement was significantly higher in the non-MF/distractor category. Across all categories, diagnostic confidence level was higher when clinical images were available. CONCLUSION: These findings suggest that clinical images are useful in making an accurate diagnosis of MF, and may be particularly helpful in ruling it out when an inflammatory disorder is clinically suspected.

The Importance of Incorporating Human Factors in the Design and Implementation of Artificial Intelligence for Skin Cancer Diagnosis in the Real World.

Artificial intelligence (AI) algorithms have been shown to diagnose skin lesions with impressive accuracy in experimental settings. The majority of the literature to date has compared AI and dermatologists as opponents in skin cancer diagnosis. However, in the real-world clinical setting, the clinician will work in collaboration with AI. Existing evidence regarding the integration of such AI diagnostic tools into clinical practice is limited. Human factors, such as cognitive style, personality, experience, preferences, and attitudes may influence clinicians' use of AI. In this review, we consider these human factors and the potential cognitive errors, biases, and unintended consequences that could arise when using an AI skin cancer diagnostic tool in the real world. Integrating this knowledge in the design and implementation of AI technology will assist in ensuring that the end product can be used effectively. Dermatologist leadership in the development of these tools will further improve their clinical relevance and safety.

Xanthomas Can Be Misdiagnosed and Mistreated in Homozygous Familial Hypercholesterolemia Patients: A Call for Increased Awareness Among Dermatologists and Health Care Practitioners.

Background: Familial hypercholesterolemia (FH) is an autosomal dominant inherited genetic disorder and results in the development of coronary artery disease (CAD). Clinical diagnosis of homozygous HH patients is usually straightforward because persistent hypercholesterolemia can produce xanthoma and corneal arcus. However, xanthoma may also be misdiagnosed as skin lesions and could therefore be mistreated. The aim of this case study report is to highlight the plight of patients with FH as means of raising awareness of the condition among dermatologists and health care practitioners, also to determine the genotype-phenotype correlation in severely affected homozygous FH proband patients. Methods: Genetic screening of FH associated genes was performed by Ion Torrent next-generation sequencing and cascade screening by capillary sequencing. Results: We present two clinical cases with prominent skin lesions seen in a dermatology clinic that were referred to plastic surgery for excision. Genetic testing was performed later, and confirmed common single nucleotide deletion variant (c.2027delG) in the LDLR alleles consequent to a frameshift mutation p.(G676Afs*33). In addition to the LDLR variant, two possibly damaging APOB variants p.(L3313I) and p.(L1212M) and three damaging variants p.(R19*), p.(G83Q) and p.(S474*) in APOC3, PON2 and LPL genes respectively were identified. The PON2 gene variant p.(G83Q) was found to be novel, while others have been previously reported. Both patients were refractory to pharmacological therapies and are currently on lipoprotein apheresis (LA). Conclusions: The present report indicates the need for increased awareness of FH, among the public and healthcare practitioners and supports the need for diagnostic screening and cascade genetic testing of this high-risk condition, which could ultimately lead to better prevention of CHD in this lethal condition.

Patient-centered management of actinic keratosis. Results of a multi-center clinical consensus analyzing non-melanoma skin cancer patient profiles and field-treatment strategies.

Introduction: Actinic keratosis (AK) is a chronic skin condition that can be a precursor to cutaneous squamous cell carcinoma. AK can recur and patients are likely to undergo multiple treatments. It is important that AK lesions are managed appropriately, and that patients are involved in treatment decisions.Materials and methods: The Supporting Professional Expertise in AK (SPEAK) program aims to facilitate this patient-centered care by identifying patient needs and aiding healthcare practitioners (HCPs) in selecting optimal treatment and communication strategies for different types of patients. Twenty-two dermato-oncologists with established expertise in the treatment of AK collaborated to describe commonly encountered psychosocial patient profiles, and to develop respective communication and treatment strategies.Results and conclusion: Six patient profiles were defined based on different psychosocial characteristics and were used to develop appropriate management approaches. We provide a systematic way of identifying these patient profiles in clinical practice and we outline communication strategies tailored to the primary needs of each type of patient. In addition, we provide recommendations for potential field-treatments that may be best suited for each profile. The recommendations provided here may help improve the communication and relationship between patients and HCPs, resulting in higher treatment adherence and improved patient outcomes.

Attitudes and practice among dermatologists regarding indoor tanning.

The aim of this study was to explore dermatologists' practices and attitudes related to educating and counseling their adolescent patients about indoor tanning. An online survey was carried out with a convenience sample of 100 dermatologists. Findings indicated that the majority of the dermatologists are actively engaged in discussing tanning bed use and sun protection with their adolescent patients. Most expressed positive attitudes toward educating patients on the risks of tanning bed use. Limited time was the most commonly reported barrier for the lack of discussion regarding indoor tanning. Of note, more than half of the dermatologists (65%) had patients suffering from tanning addiction. For tanning-addicted patients, dermatologists can encourage lifestyle changes, the use of sunless tanning products, and referrals when the patient's needs extend beyond the scope of the dermatologist.

Visual perception, cognition, and error in dermatologic diagnosis: Key cognitive principles.

Dermatologic diagnosis relies on vision primarily and auditory and verbal input secondarily. Accurate dermatologic diagnosis is predicated on seeing and perceiving a skin finding, categorizing and naming the finding correctly, and comparing the visual data and data obtained from the totality of the clinical encounter (ie, from other sensory modalities) with one's working mental database of dermatologic diagnoses. The baseline assumption-which is false-is that a dermatologist is an expert at each of the aforementioned steps and transitions sequentially between them seamlessly in an error-free fashion. Each of these steps has inherent challenges, and the transitions between steps can also be problematic. In part 1 of this 2-part report, we describe the pitfalls associated with visual recognition. In part 2, we discuss cognitive heuristics as they relate to the dermatologic diagnostic process and prevention of diagnostic error.

Automated decision support in melanocytic lesion management.

An automated melanocytic lesion image-analysis algorithm is described that aims to reproduce the decision-making of a dermatologist. The utility of the algorithm lies in its ability to identify lesions requiring excision from lesions not requiring excision. Using only wavelet coefficients as features, and testing three different machine learning algorithms, a cohort of 250 images of pigmented lesions is classified based on expert dermatologists' recommendations of either excision (165 images) or no excision (85 images). It is shown that the best algorithm utilises the Shannon4 wavelet coupled to the support vector machine, where the latter is used as the classifier. In this case the algorithm, utilising only 22 othogonal features, achieves a 10-fold cross validation sensitivity and specificity of 0.96 and 0.87, resulting in a diagnostic-odds ratio of 261. The advantages of this method over diagnostic algorithms-which make a melanoma/no melanoma decision-are twofold: first, by reproducing the decision-making of a dermatologist, the average number of lesions excised per melanoma among practioners in general can be reduced without compromising the detection of melanoma; and second, the intractable problem of clinically differentiating between many atypical dysplastic naevi and melanoma is avoided. Since many atypical naevi that require excision on clinical grounds will not be melanoma, the algorithm-in contrast to diagnostic algorithms-can aim for perfect specificities without clinical concerns, thus lowering the excision rate of non-melanoma. Finally, the algorithm has been implemented as a smart phone application to investigate its utility in clinical practice and to streamline the assimilation of hitherto unseen tested images into the training set.

Knowledge and attitudes of family doctors, dermatologists, and endocrinologists on sun exposure and vitamin D.

OBJECTIVES: Vitamin D is an important component of bone metabolism. Skin cells synthesize vitamin D when exposed to the sun. However, prolonged sun exposure damages the skin and increases the risk for skin cancer. The objective is to evaluate and compare the attitudes and recommendations of family doctors, dermatologists, and endocrinologists on exposure to the sun and vitamin D. METHODS: In a cross-sectional study, a questionnaire was completed by personal interview in a study population of 78 family doctors, 21 dermatologists, and 22 endocrinologists. RESULTS: On a scale of 1-10, the mean score for recommendations to reduce sun exposure was 4.7 for dermatologists, 4.2 for endocrinologists, and 6.4 for family doctors (p < 0.001). Family doctors recommended a mean daily exposure to the sun of 67.4 min compared to 41.4 by dermatologists, and 47.1 by endocrinologists (p = 0.007). Dermatologists and endocrinologists were more likely to recommend protective measures such as hats and long sleeves during sun exposure than family doctors (p < 0.0001). There were no statistically significant differences between male and female doctors for the entire study population. CONCLUSIONS: There is little consensus among these medical practitioners, whether specialists or primary care doctors, concerning sun exposure. Further studies should evaluate the optimal duration and intensity of sun exposure and doctors' recommendations should be based on the findings.

Practice Patterns and Job Satisfaction of Mohs Surgeons.

BACKGROUND: There is a paucity of data on Mohs surgery workforce patterns. OBJECTIVE: To identify if gender differences exist in practice patterns of Mohs surgeons, factors that influence these differences, and factors influencing job satisfaction among Mohs surgeons. MATERIALS AND METHODS: An electronic survey was distributed to dermatology organizations targeting members of the American College of Mohs Surgery (ACMS), from October 2015 to April 2016. RESULTS: Two hundred twenty-seven ACMS members responded; 37% were women. Twenty-five percent of women and 19% of men work part time. Thirty-seven percent of women practice in academia versus 22% of men. Forty-three percent of women and 23% of men identified children as a factor affecting their ability to work full time. Gender comparisons for current job satisfaction show 57% of men and 35% of women being very satisfied. Supervision/feedback/recognition adds to satisfaction at a higher rate for women (53%) than for men (29%). For both genders combined, work content, patient base, and autonomy had the highest average job satisfaction ratings. CONCLUSION: Gender differences exist in practice patterns and job satisfaction of Mohs surgeons. This study demonstrates factors that could influence job satisfaction among female Mohs surgeons-knowledge that is important to individuals who lead, mentor, or supervise female Mohs surgeons.

A 30-Minute, Monthly, Live, Webinar-Based Journal Club Activity Alters the Self-Reported Behaviors of Dermatologic Surgeons.

BACKGROUND: Journal clubs provide a way to communicate advances in recent literature. In outpatient surgical subspecialties, such as dermatologic surgery, physicians may face challenges in finding or attending meetings pertinent to their practice. OBJECTIVE: To assess the utility of a live web-based journal club in dermatologic surgery. MATERIALS AND METHODS: Monthly 30-minute journal club sessions covering 5 to 6 scholarly articles. Anonymous surveys were used to evaluate the utility and self-reported learning associated with each meeting. RESULTS: From December 2012 to February 2015, 117 articles were reviewed. Survey data were acquired monthly, apart from 5 months of missing data. On average, the survey response rate was 37% (range: 7%-82%), with an average of 17 participants per monthly session (range: 9-25). The mean monthly usefulness score was 83.7 (101-point scale), with participants scoring their likelihood of returning in the future as 96.2 (0 = not likely, 100 = extremely likely). At each session, a mean of 68% of participants felt that at least one article would change their practice of medicine. CONCLUSION: A monthly online and telephonic journal club may be a practical and effective way to inform dermatologic surgeons of new developments in high impact literature and may influence improvements in individual practice.