Dr Charbel Skayem
email: charbelskayem@hotmail.com

Hassan Rostom

Gaelle Hirsch

Tu Anh Duong

Teledermatology: the perspective of French general practitioners

Funding sources: None

Conflicts of interest:

Dr. Charbel Skayem and all other authors declare no conflict of interest Keywords: teledermatology, dermatology, general physician, primary care physician, request, education Abbreviations:

Teledermatology (TD)
General physician (GP) Cutaneous problems are the most common reason for consulting primary care physicians [START_REF] Schofield | Skin conditions are the commonest new reason people present to general practitioners in England and Wales[END_REF]. In 2012, teledermatology (TD) was integrated in the French health care system to extend access and decrease lead times for dermatological care [START_REF] Tesnière | Remote dermatological advice: a survey in three French regions[END_REF]. Despite late financial remunerations in 2019 for both dermatologists and requesting physicians, several pilot programs enabled store-and-forward TD between general physicians (GPs) and dermatologists. In 2016, the dermatological emergency department of Henri Mondor University Hospital started using the TELDERM platform to provide rapid dermatological advice for non-specialist practitioners. We naturally wished to assess GPs' experience and reasons for using TD, their satisfaction and future expectations, and the challenges that TD helped them overcome.

An anonymous online survey was sent to all 94 GPs who submitting a TELDERM request from January to August 2017. The response rate was 62% (n=58). Twenty-five GPs (43%) had requested TD between 2 and 5 times, and 22% more than 5 times. The reasons for use of TD were as follows: 91% to resolve diagnostic doubts, 33% for emergencies, and 64% due to long waiting times for dermatology appointments. After receiving a reply to the TD request, 98% of GPs contacted their patient to pass on the dermatologist's response, and in most cases, GPs were able to re-assess their patient. GPs very largely expressed maximum satisfaction (5/5) about the clarity of the answer given (81%), the quick response time for proper management (70%), and the fact that the TD procedure itself took up no additional time (69%). Regarding future use of TD, over 50% of GPs would prefer a mobile platform, and only 36% believed that they should receive any additional fee for completing the TD request and inserting the dermatological findings. The key issues successfully resolved by TD and the numbers of GPs reporting them were as follows: providing patients with a rapid diagnosis (93%), improving management of dermatological conditions (88%), reducing waiting times for dermatology appointments (85%), and providing medical education about common cutaneous diseases (71%).

This study was conducted before the French national insurance started reimbursing teleconsultations, although both the specialist and the requesting GP currently receive fees. Surprisingly, most physicians did not previously consider additional fees necessary, and their main use of TD was to resolve diagnostic doubts. This situation reflects the importance of including dermatology in the medical school curriculum, since GPs are regularly confronted with numerous dermatological conditions [START_REF] Mohan | Store and forward teledermatology improves dermatology knowledge among referring primary care providers: A survey-based cohort study[END_REF]. TD was very often used to overcome the impossibility of rapidly arranging a dermatology appointment, which underscores the major shortage of dermatologists in France. Serious measures need to be taken. In most cases, GPs passed on the dermatologist's response and re-assessed their patient accordingly. This shows that TD is a platform that allows follow-up when needed and emphasizes its usefulness in building patient care pathways [START_REF] Mcafee | Store-and-forward teledermatology improves care and reduces dermatology referrals from walk-in clinics: A retrospective descriptive study[END_REF]. The fact that those GPs satisfied with TD were more likely to respond might have led to overestimation of the satisfaction results. It remains important to note that TD for GPs also has limitations such as disturbance of the workflow, apprehension related to new technologies, and inadequate computer skills [START_REF] Ridard | Indicators in teledermatology: A literature review[END_REF][START_REF] Bowns | Telemedicine in dermatology: a randomised controlled trial[END_REF]. However, our findings reinforce the important role of TD in building networks between dermatologists and primary care practitioners, and in preventing diagnostic errors [START_REF] Mohan | Store and forward teledermatology improves dermatology knowledge among referring primary care providers: A survey-based cohort study[END_REF][START_REF] Cheeley | Consultative teledermatology in the emergency department and inpatient wards: A survey of potential referring providers[END_REF]. Interestingly, our findings also show that since TD enhances patient safety and GPs' dermatology management skills, financial remuneration does not appear to be the main reason for recourse to TD by GPs.

GPs are the most frequent users of TD. At a time where unexpected events are forcing us to replace in-person consultations by TD [START_REF] Skayem | Teledermatology for COVID-19 cutaneous lesions: substitute or supplement?[END_REF], it is necessary to reveal the feedback of the widest users of this approach.

Acknowledgement: Patricia Thion