148 CHAPTER 7 dermatology consultation was no longer used by GPs solely for difficult-to-assess skin complaints but also for easy-to-assess skin complaints sent in by patients that were usually assessed in GP practice. However, digital dermatology home consultation requires that patients have the appropriate equipment and technical literacy to engage the service on their own. Despite that most patients had access to a mobile phone or smartphone [32], they were not trained to take photographs of their skin condition. Therefore, GPs in our study reported images of mostly inadequate quality taken by patients. This shows that the external pressure of the pandemic pushed the use of remote dermatology care by (new and untrained) people; however, the fact that these users had insufficient knowledge about the requirements for taking appropriate photographs led to problems with the clinical assessment of the photographs. Future studies could investigate whether the skin disorders in the remote store-and-forward digital dermatology care population changed in comparison with the prepandemic period. A Spanish study during the pandemic confirmed that patients had limited photography skills [33]. They found that only half (52.1%) of the images captured by patients and directly sent to the dermatologist were of adequate quality. Furthermore, in approximately onefourth of these cases, poor image quality of these patient-submitted images was the reason why the teledermatologist could not provide a diagnosis. A prepandemic American study showed that a slightly higher percentage (62.2%) of the images sent by a patient to a dermatologist via teledermatology were with sufficient quality, whereas dermatologists perceived only half of the total images as having sufficient quality for decision-making [34]. Besides the remarks of GPs in our study about the photography skills of the patients, GPs also reported that they received constructive or complimentary feedback from dermatologists about the quality of their photographs. Previous studies about image quality of photographs taken in primary care for digital dermatology consultation also have demonstrated diverse results [10,35-39]. Poor photograph quality in these studies was, similar to our study, caused by out-of-focus images or missing overview or dermoscopic images of a patient’s skin lesions. Digital dermatology consultations can be performed using current technologies, but many of the pictures are of unacceptable quality, and the training of health care providers and patients in taking images should thus be considered [21]. In the Dutch GP training curriculum, GPs are, in general, not trained to use digital services [40]. Only 5% (3/66) of GPs in our study indicated that they received training for taking (dermoscopic) photographs in their GP training curriculum. Owing to this lack of training in the GP curriculum, the telemedicine organization (Ksyos) organizes personal training sessions about the use of the digital dermatology service for all newly operating GP practices. Despite this introductory training, only about half (30/66, 45%) of the GPs in our study reported that they opted for this training or instruction about taking (dermoscopic) photographs from the telemedicine organization. This indicates that GPs did not experience this introductory training as an official education or instruction moment but solely as an installation or demonstration. In addition, a few GPs in our
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