untitled CORRESPONDENCE RESEARCH LETTERS The Utility of Clinical Photographs in Dermatopathologic Diagnosis: A Survey Study D ermatopathologists receive skin biopsy speci-mens accompanied by requisition slips that helpdirect their diagnoses. Owing to busy clini- cian’s time constraints and the increasing frequency with which the paperwork is completed by physician extend- ers rather than physicians, the requisition slips often do not contain adequate information. In some cases, this makes diagnosis more challenging. Prior reports have emphasized the importance of clini- copathologic correlation and the usefulness of clinical pho- tography as an aid in diagnosis.1,2 The present study ex- amines (1) how often photographs are currently being used as an aid in dermatopathologic diagnosis, (2) in which situations they are most likely to be helpful, and (3) whether dermatopathologists want to receive pho- tographs more frequently. Methods. After approval from the institutional review board at Eastern Virginia Medical School, Norfolk, and the American Society of Dermatopathology (ASDP) board of directors, an anonymous, voluntary, Web-based sur- vey was e-mailed to all board-certified dermatopatholo- gist members of the ASDP. In November 2009, the e-mail invitation was sent to all 816 members who provided their e-mail addresses to the ASDP; 34 of the e-mail addresses were considered invalid because an error message was received in response. The survey remained available for responses for 30 days, and a reminder was sent during the final week. In addition to multiple choice answers, respondents were given the opportunity to write addi- tional comments and feedback on the topic. Statistical analysis was performed using SAS computer software, ver- sion 9.2 (SAS Institute Inc, Cary, NC). Results. There were 135 complete responses and 13 par- tial responses from all regions of the United States from both dermatology- and pathology-trained individuals. At least 2 respondents had completed both dermatology and pathology residencies. There were 4 international re- sponses. Current frequency of photography usage is sum- marized in the Table. Analysis with the Cochran-Mantel- Haenszel statistic revealed no significant difference in frequency of use among geographic regions. Ninety- four percent of dermatopathologists stated that they would like to receive photographs more frequently. More respondents stated that clinical photography is ben- eficial in the evaluation of inflammatory skin diseases (92%) than in pigmented lesions (73%) or nonmelanocytic tu- mors and growths (56%). By Fisher exact test, we found no significant difference between pathology- and derma- tology-trained dermatopathologists with regards to find- ing clinical photography useful in any category. Ninety- one percent of respondents stated that they were able to provide a more specific diagnosis with the aid of clinical photographs. For pigmented lesions, respondents stated that photography and history with measurements were help- ful when only a portion of the lesion was biopsied. Oth- erwise, sampling error might lead to a misdiagnosis of mela- noma. One respondent found photographs useful in reporting margins in complex surgical cases. The most preferred methods of photograph delivery included printed-out photographs (54%) and en- crypted e-mail (50%) followed by posting on a secure Web site (21%) and images on compact disc (10%). In addi- tion, several respondents suggested integration into elec- tronic medical records when available. Respondents were also given the opportunity to write open-ended comments. Several dermatopathologists stated that clinical photographs are particularly useful when the specimen is submitted by a nondermatologist who pro- vides a limited history and differential diagnosis. A po- tential drawback to photography mentioned is the time and cost that it takes for clinicians to take the photograph and send it to the dermatopathologist. In addition, pho- tographs provided in a cumbersome format (compact disk or flash drive) may slow down sign-out for the dermato- pathologist; a printed-out photograph attached to the req- uisition slip was the most preferred method of delivery for this reason. Furthermore, several people emphasized that clinical photographs should not replace a good history. Comment. Limitations of this study include an inability for respondents to state that they were trained in both pathology and dermatology residencies prior to obtain- ing a dermatopathology fellowship. Two respondents in- cluded this information in the comment section. In ad- dition, physicians who felt strongly about the beneficial use of clinical photography might have been more likely See Practice Gaps at the end of this letter Table. Frequency of Receiving Clinical Photographs Frequency, Times/y, No. Dermatopathologists, No. (%) (n = 135) 0 18 (13) 1-5 42 (31) 6-12 26 (19) �12 49 (36) (REPRINTED) ARCH DERMATOL/ VOL 146 (NO. 11), NOV 2010 WWW.ARCHDERMATOL.COM 1307 ©2010 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 to respond to the survey, thus creating response bias and overestimating the beneficial effect of photography. Overall, this survey study revealed that dermatopa- thologists find clinical photography most beneficial in the diagnosis of inflammatory skin diseases, and they would like to receive photographs more frequently. They prefer a convenient method of delivery, most commonly a printed- out photograph attached to the requisition slip. Accepted for Publication: June 4, 2010. Author Affiliations: Department of Dermatology (Drs Mohr and Hood) and Epidemiology and Biostatistics Core (Mr Indika), Eastern Virginia Medical School, Norfolk. Correspondence: Dr Mohr, Department of Dermatology, Eastern Virginia Medical School, 721 Fairfax Ave, Ste 200, Norfolk, VA 23507 (melinda.mohr@gmail.com). Author Contributions: All authors had full access to all of the data in the report and take responsibility for the in- tegrity of the data and the accuracy of the data analysis. Study concept and design: Mohr and Hood. Acquisition of data: Mohr. Analysis and interpretation of data: Mohr, In- dika, and Hood. Drafting of the manuscript: Mohr and In- dika. Critical revision of the manuscript for important intel- lectual content: Hood. Statistical analysis: Indika. Study supervision: Hood. Financial Disclosure: None reported. Additional Contributions: We thank the members of the ASDP who participated in this study and the Epidemiol- ogy and Biostatistics Core at Eastern Virginia Medical School, Norfolk, and Old Dominion University, Norfolk, for assisting with statistical analysis. 1. Fogelberg A, Ioffreda M, Helm KF. The utility of digital clinical photographs in dermatopathology. J Cutan Med Surg. 2004;8(2):116-121. 2. Kutzner H, Kempf W, Schärer L, Requena L. Optimizing dermatopathologic diagnosis with digital photography and internet: the significance of clinico- pathologic correlation [in German]. Hautarzt. 2007;58(9):760-768. PRACTICE GAPS Submitting Clinical Photographs to Dermatopathologists to Facilitate Interpretations A dvances in immunohistochemical stains, molecu-lar analysis, and laboratory technology have fa-cilitated dermatopathologic diagnostic accuracy. Nevertheless, patients and clinicians are often frustrated when dermatopathologists render nonspecific diagnoses, which may lead to diagnostic and/or therapeutic uncer- tainty. Given the importance of clinicopathologic correla- tion (CPC), a practice gap exists between what dermato- pathologists desire and what the clinicians provide.1,2 Mohr et al point out that one of the most important tools used to assist accurate dermatopathologic diagno- sis is the information supplied on the dermatopathology form accompanying tissue specimens. They also report that dermatopathologists find the addition of a clinical photograph useful in rendering a microscopic diagno- sis, especially when dealing with inflammatory skin dis- eases. The use of clinical photographs may be particu- larly helpful when dermatopathologists receive specimens with an inadequate clinical description on the dermato- pathology form, which may be more of a concern with specimens submitted by nondermatologists who have less CPC experience. Although clinical photographs are desired, it is ex- tremely infrequent for a dermatopathologist to be pro- vided with one. Barriers to sending clinical photographs with biopsy specimens include the time it takes to create and implement standard operating procedures (SOP), which include identifying the body region to be photo- graphed, obtaining consent from the patient, taking the digital photograph, downloading the photographic file, la- beling the photograph, and either printing or electroni- cally sending the picture to the pathologist. Other barri- ers are limited computer file storage space; costs of obtaining 1 or more digital cameras for the physician office; and com- pliance with the secure data transfer standards of the Health Insurance Portability and Accountability Act and Health Information Technology for Economic and Clinical Health. It is also possible that some patients may object to pho- tography, particularly of specific body parts. This gap between what dermatopathologists desire and what the clinicians provide can be narrowed by improv- ing the quality of information supplied by the clinician to the dermatopathologist. Education directed at office efficiency should include instruction on efficient pro- cesses to incorporate patient photography. Mohr et al un- derscore that patient care will benefit when clinicians im- prove the quality and quantity of the information provided, and they encourage incorporation of photog- raphy as part of routine biopsy procedures. Develop- ment of a more comprehensive way of communicating information to dermatopathologists is needed. Clinician- friendly pathology forms and reminder systems to in- clude clinical photographs may help. Considering patient volume and increasing time limi- tations of office visits, it would optimal for clinicians to train an assistant to take and process the photographs for relevant patients. The SOP should be defined for this process to assist personnel in implementation without loss of efficiency. Creating an SOP for a proper and com- plete provision of information including completion of requisition forms and taking clinical photographs will help establish uniformity of photographic information to the dermatopathologist. Hard copies of photographs are not always neces- sary. Digital technology provides a variety of media to safely transmit images, including secure Internet con- nections and storage on compact discs and flash drives, to protect the confidentiality of patient photographic in- formation, usually considered personal health informa- tion. Data transfer between dermatologists and derma- topathologists can be optimized to maximize the quality of dermatopathology diagnosis. Melinda R. Mohr, MD S. H. Sathish Indika, MS Antoinette F. Hood, MD Alejandra Vivas, MD Robert S. Kirsner, MD, PhD (REPRINTED) ARCH DERMATOL/ VOL 146 (NO. 11), NOV 2010 WWW.ARCHDERMATOL.COM 1308 ©2010 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021