93 TO REFER OR NOT TO REFER IN TELEDERMOSCOPY as biopsies are underrepresented in the Dutch medical and GP training curriculum [18]. GP residents must obtain this dermatological knowledge from their GP educators during the medicine internships, and this knowledge transfer might be limited. Furthermore, in the Netherlands, most patients from GP primary care are referred to dermatology secondary care [19]. This again addresses the importance of teledermoscopy as a tool to support GPs in primary practice in recognizing and gaining knowledge about skin lesions and by receiving instructions on patient management. Due to data migration and limitations in the Ksyos database, we could not check if both of our teledermoscopy studies concerned the same GP population. Over the years, some GPs might have learned from the TD advice and applied teledermoscopy less often. It is also possible that GPs who recently started applying the teledermoscopy service frequently change their referral decisions. In any case, the frequently changing referral decisions of GPs emphasize the surplus value and need of teledermoscopy to support GPs in their referral decisions of patients with skin lesions. In an Italian study, GPs were also asked to assess photographed skin lesions and decide whether they would refer the patient to a dermatologist [3]. The authors of that study did not specify who took the photographs. After a 4-hour training on the classification and management of skin lesions, GPs were again asked about their referral decision for the same set of clinical images of skin lesions. GPs had to base their referral decision solely on the set of submitted clinical images without physically seeing the patients and skin lesions in their GP practice. Furthermore, the GPs did not receive a diagnosis or advice from the TD on which they could base their referral decision. In this Italian study, the number of nonmelanocytic benign skin lesions of patients whom GPs intended to refer to a dermatologist decreased significantly after training on the classification and management of skin lesions. This type of training could consist of e-learning, refreshers, and courses in the GP education programs regarding both taking dermoscopic images and recognizing pigmented skin lesions. Therefore, continuous training of GPs in the Dutch teledermoscopy setting could potentially help reduce the number of referrals of patients with benign skin lesions [1]. Strengths and limitations The strengths of this large retrospective study include that teledermoscopy consultations were conducted in daily GP practice and were not simulated in a study setting. The GP referral decisions were noted both before and after the teledermoscopy consultation, which allowed us to verify whether GPs adjusted their initial referral decisions after the teledermoscopy consultation. In doing so, we gained insight into GP referral decisions for different diagnosis groups after the TD assessment in daily GP practice. On the other hand, the first limitation of our study is that the TDs did not always report their diagnosis in the teledermoscopy system and that we omitted data on the differential diagnosis. This might have resulted in an underestimation of the absolute 5
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