#AI in dermatology: Imag(in)ing a future

“…to promote the rapid and accurate reading of … skin lesions.”

That was part of the answer Dr. Eric Topol gave in a recent New York Times interview when asked where Artificial Intelligence (AI) shows the most promise in medicine.

Dr. Topol expands on this in the first part of his new book Deep Medicine dealing with AI in medicine where he describes dermatologists, along with radiologists and pathologists, as “doctors with patterns” or those who rely heavily on images in their work. He said such doctors could potentially benefit from AI algorithmic support.

“Many,” he writes “were frankly surprised by what deep learning could accomplish: studies that claim AI’s ability to diagnose some types of skin cancer as well or perhaps even better than board-certified dermatologists”. However, he also noted that the work done with deep learning and AI to diagnose melanomas represent computer-based validation rather than using AI support in a real clinical environment.

The complexities involved in doing just that and the hope it held for dermatologists who fear losing out to technology formed the backbone of two standing-room only sessions at the recent American Academy of Dermatology(AAD) meeting in Washington DC in early March where AI was formally on the agenda for the first time. While the ability of algorithms to identify melanomas as well if not better than dermatologists has been grabbing headlines for a couple of years, the subject matter was still novel enough at the world’s premier gathering of dermatologists that a portion of each session was needed to discuss the basics of exactly what was being talked about.

Dermatologists were also chastised by one of their own for doing a lousy job of what is needed to fundamentally support the use of AI to support a pattern-based specialty – namely taking and a categorizing images of skin lesions.

Dr. Allan Halperin, is head of the dermatology service at Memorial Sloan Kettering Cancer Centre at president of the International Skin Imaging Collaboration, a group that has pioneered the collection of dermoscopy images to develop algorithms to diagnose melanoma. “Frankly its embarrassing that, as a specialty, we are far behind what can be done already,” he said, commenting on the image-gathering capabilities of dermatologists.  “We’re not taking images of enough things in a standardized enough way to make them available in a pipeline to the computer scientists to build an AI.”

Dr. Roger Ho, assistant professor of dermatology at NYU Langone Health in New York, agreed. In a news release he noted “hundreds of thousands of photos that have been confirmed as benign or malignant are used to teach the technology to recognize skin cancer, but all of these images were captured in optimal conditions – they’re not just any old photos snapped with a smartphone.”

To address these issues, Dr. Curiel said community-based dermatologists need to be involved in building the databases that will inform machine learning for melanoma. It was also noted that how the databases are compiled will depend to a degree on who will be making use of the data – patients, primary care physicians or dermatologists.

Dr. Ho and others – including the incoming president of the AAD Dr. George Hruza feel that even if the use of deep learning and AI is optimized for use with skin lesions, dermatologists will always be needed to properly interpret the findings and counsel patients. In his address to the meeting, Dr. Hruza said he was excited to imagine that when it comes to AI, dermatologists will have a “seat at the table and will not be on the menu.”

“The future of augmented dermatology is an opportunity not a threat,” said Dr. Clara Curiel, director of the dermatology program at the University of Arizona.  “AI should reinforce clinical skills.”

It remains to be seen whether this almost universally expressed optimism holds true for a specialty already facing inroads from numerous other pretenders in the art and science of diagnosing and managing skin conditions.

(Photo: Patterns of light and dark at AAD meeting, Washington DC)

 

 

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Teledermatology: Every picture tells a story (#AAD17)

One can imagine the era of modern telemedicine beginning with dermatology.

“Hey, I have this rash. Mind if I e-mail you a picture so you can tell me how to deal with it”?

While teledermatology can actually be a far more complex and sophisticated interaction between patient and doctor, that core ability to send an image of the key diagnostic feature is what has led some dermatologists to be involved in telemedicine for almost two decades now.

And with telemedicine and virtual medicine now entering prime time, it is not a surprise that more dermatologists are focusing on teledermatology as a way to allow more people to access quality care.

What is somewhat more surprising is that fact that after two decades of practice, the dermatology specialty still lacks a good remuneration model and more importantly agreed upon standards for how quality care should be delivered.

The recent annual meeting of the American Academy of Dermatology (#AAD17) meeting in Orlando provided a snapshot, if you will, of all these issues. Not only was teledermatology the focus of at least two educational sessions, it was also the subject of one of the plenary named lectures.

In her plenary presentation, Dr. Carrie Kovarik (@carriekovarik), associate professor of dermatology at the University of Pennsylvania and a

teledermatology pioneer, gave a blunt assessment of telemedicine in her specialty.

“There are people in the middle who see teledermatology as a good thing when it is used to provide quality care and provide access,” she said in an interview published in the conference newsletter. “Unfortunately, there are also people on one end of the spectrum who think this is a way to make a lot of money and sell products. Then there are people at the opposite end who are afraid that telemedicine is eventually going to take away their patients.”

If that was the bleak overview of telemedicine within the speciality, Kovarik’s assessment of how unprofessional and unethical websites are exploiting patients by offering teledermatology services was worse. “We have businesses that have scaled-up teledermatology using non-dermatologists, anonymous apps and apps where the patients have to self-diagnose.”

Despite the potential value of teledermatology for improving access to underserviced areas and populations through the U.S., in her speech Kovarik noted only 12 States currently reimburse specialists for the “store forward” approach in which pictures of a patient are assessed after they are taken.

Another challenge is that in many instances the patient’s primary care provider receives no payment for helping facilitate the process by, for example, taking high-quality images of the patient for the dermatologist to assess.

However at the end of the day, despite all these challenges, Kovarik predicted it would be harder and harder for dermatologists to avoid telemedicine.

The key she said was to ensure the quality of care provided is the same as that seen in a face-to-face encounter.