Response to: Impact of Dermoscopy Training on Diagnostic Accuracy,and Its Association with Biopsy and Referral Patterns Among Primary Care Providers: A Retrospective and Prospective Intervention Study

Dear Editors,

With interest, we read Middleton et al’s manuscript: Impact of Dermoscopy Training on Diagnostic Accuracy, and Its Association with Biopsy and Referral Patterns Among Primary Care Providers: A Retrospective and Prospective Intervention Study. ¹ This work describes an educational intervention using the Triage Amalgamated Dermoscopic Algorithm (TADA) to facilitate dermoscopy training in the primary care setting. The authors sought to determine the impact of TADA training on classroom and clinical identification of benign and malignant skin growths. Middleton et al state “no studies have been conducted to analyze the impact of TADA with PCPs beyond standardized testing and 1 study evaluating NNB.” Indeed, while most TADA-related clinical outcomes have focused on number needed to biopsy (NNB), we have also studied and reported other post-TADA metrics. When we complemented TADA workshops with spaced-review using a monthly Dermatology Project ECHO (Extension of Community Health Outcomes) virtual training platform, we demonstrated not only knowledge retention and improved ability to accurately identify images of skin cancer, but also consistent use of dermoscopy in clinical practice. ² More than 6 months after TADA training, 96% of our participants (27 PCPs) continued using dermoscopy on a regular basis. ² Furthermore, as Middleton et al have noted, educational interventions do not necessarily lead to meaningful improvements in patient outcomes. However, we were able to demonstrate a powerful shift in the likelihood of skin biopsy results being benign versus malignant following TADA training for PCPs in Maine. ³ As a noted limitation in their study, Middleton et al report outcomes for only 13 PCPs for 1 year following the TADA training. We studied all PCPs (more than 150) in the MaineHealth system for 2 years following TADA workshops, Dermatology ECHO, and tele-mentoring with store-and-forward electronic consultations (eConsult). The percentage of benign growths being biopsied in the primary care setting dropped to 68% and there was a greater than 50% reduction in the NNB to detect a melanoma in the primary care setting.^3.4

We commend Middleton et al for their work on the impact of dermoscopy training in the primary care setting and we suggest when teaching dermoscopy to PCPs, educators consider offering longitudinal training programs which might include patient-centered tele-mentoring such as eConsult with dermoscopy and ongoing dermoscopy training to provide spaced-review with virtual platforms such as Project ECHO. These additional training modalities provide opportunities for discussion of topics not covered by TADA, such as actinic keratoses—which were a diagnostic challenge for the PCPs in the Middleton et al study. Ongoing sessions and access to eConsult strengthen the bond between PCPs and specialists and foster positive collaborations allowing for the transfer of knowledge not patients. These multi-modal efforts result in more enduring practice change and improved patient outcomes when compared to isolated workshops. Lastly, to facilitate dermoscopy training at other institutions, it would be helpful for the authors to share their educational content with the readers.

Respectfully,

Elizabeth V. Seiverling MD, Hadjh Ahrns MD, and Peggy Cyr MD