185 GENERAL DISCUSSION GP training in clinical practice, who themselves may not have been trained sufficiently in taking (dermoscopic) photographs. Nowadays, in the national education plan of future Dutch GPs, there is an increasing focus on using innovative healthcare technology and modern communication techniques to communicate with patients and other healthcare providers [8]. We recommend to further stimulate the use of digital health applications in the GP training program, but also to expand (tele)dermatology and (tele)dermoscopy education in the GP curricula, and promote dermatologist education sessions. In this way, GPs learn to diagnose skin disorders and use digital dermatology care applications earlier and become digitally skilled from the start of their GP career. To support GPs in the diagnosing and treatment of suspicious skin lesions, the Dutch College of General Practitioners (Dutch: Nederlandse Huisartsen Genootschap (NHG)) published a guideline for the management of suspicious skin abnormalities [9]. Experiences in practice demonstrated that GPs did not adhere to the policy recommendations in this standard for each individual patient [10]. For example, when the recommendations do not correspond to the situation of the individual patient or for elderly patients, where treatment choices are made on quality of life rather than on (extended) lifespan [10,11]. Furthermore, the standard’s novelty and the absence of a formalized training program to implement this standard in daily practice are also possible reasons why GPs deviate from this standard [10]. In addition, GPs have a substantial number of diverse tasks to perform, limited time, have to adhere to more than 140 different guidelines and have to collaborate with numerous specialists of many different disciplines [10,12,13]. Moreover, rare skin disorders such as melanoma occur infrequently in general practice and make it difficult for GPs to keep track on this knowledge [10], while correct and timely diagnosis of melanoma enables adequate treatment and may be vital for patients’ survival [14]. These dermatology knowledge gaps of GPs for detection of suspicious skin lesions stimulated the Dutch National Research Agenda for General Practice to investigate which interventions can improve GP diagnosis skills for suspicious skin abnormalities and assess how to train GPs in the evaluation of these abnormalities [15]. This thesis showed that teledermoscopy supports GPs in their decision-making regarding referral of patients with benign, premalignant, or malignant skin lesions. Along with the surplus value of the services for patient management, GPs indicated themselves that they improved their dermatology knowledge while receiving remote advice and feedback from a TD. However, despite GPs indicating that they improved their knowledge, this thesis showed only a small learning curve for GPs after frequent use of digital dermatology. Such a learning curve and transmission of dermatology knowledge might be an internal incentive for GPs to use the service [16], but could also be a reason for the stabilization in the number of digital dermatology consultations performed by experienced GPs. In addition, this thesis and prior studies showed diverse results on the quality of the photographs taken by GPs for the purpose of dermatology consultation [17-20]. However, 8
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