Solutions – A project to remedy the lack of a dermatologist in Nièvre

As the departure of Dr. Thierry Poitreneau, the last dermatologist from Nièvre, approaches in December, Dr. Lemoine, president of the Order of Physicians, is looking for solutions. Especially since in neighboring departments, dermatologists are just as overwhelmed and often unavailable for several months. While waiting for a providential arrival, he turns to modern technologies.

1. No artificial intelligence device yet

“Initially, the project was to acquire an artificial intelligence device that would scan the patient’s entire skin and detect any problems,” he explains. Images with these issues had to be sent to a remote dermatologist for analysis. But after discussion with Pr Dincan, dermatologist in Clermont-Ferrand, the president of the Order preferred to change his tune. “He advised us not to use this type of device which is too precise. It detects too many “shady” images, and without the trained eye of a dermatologist, it would too often seek specialist advice. The system would turn against us”.

2. Train general practitioners in Nièvre in the early detection of skin cancers

The doctor is now moving towards the training of voluntary general practitioners. Ten of them, covering the territory, are up for it. Gathered in association, they will be trained in the early detection of skin cancers, by Professor Dincan. They will thus be able to detect really suspicious lesions. They will be equipped with dermatoscopes, and will be able to take macroscopic photos of the lesions, and send the images for expertise to a dermatologist in Clermont or Paris. He will then tell them if the lesion should be monitored, if a biopsy is necessary, if the lesion must be removed (excision) or if cryotherapy should be performed. The ten doctors will also be trained in biopsy and excision. For the most complex cases, local surgeons will take care of it. For facial lesions, it will be ENT. “We have the resources to do it,” says Thierry Lemoine.

3. A room for carrying out minor dermatology surgeries

He wants a room dedicated to the practices of biopsy and excision, in Nevers.

To install minor surgery equipment, and so that doctors have time dedicated to dermatology, without being overwhelmed in their own practice.

“We already know that there will be a lot of requests,” he predicts.

The goal is for us to be more and more autonomous in detection.

Dr Lemoine (President of the Order of Physicians)

The ducal city also has laboratories to quickly analyze biopsies. Dr. Pawin, a Parisian dermatologist who has a house in the Nièvre, will come one day a month to help the general practitioners with the excisions, and to train them as they go along. “The goal is for us to be more and more autonomous in detection, and for dermatologists not to be inundated with requests, because they will not be able to absorb all the management of the Nièvre” .

4. Equip doctors with an application to treat other pathologies

As for inflammatory dermatological pathologies, such as eczema or psoriasis, the solution could also come from Dr. Pawin. “We have been working for several months with him and seven other dermatologists on the development of a tele-expertise application. The GP can take a picture of a rash and send it to these eight dermatologists for expertise. He has a response within five days. We are seven or eight in the department to use it for two months, and I see only advantages. Dermatologists have always answered me within 48 hours. The interface is easy to use, it was created by doctors, for doctors. It takes a bit of time to fill out the patient’s history, his skin phototype, but personally, out of about ten requests, each time, the care has been adequate.

I hope that little by little, all the doctors in Nièvre will equip themselves with this application, because it is serious”.

These solutions do not replace a dermatologist, but it is still better than nothing. We must make up for the deficit.

He agrees that “These solutions are no substitute for a dermatologist, but it’s still better than nothing. We must make up for the deficit. The only obstacle is that the dermatologist will not be able to carry out an exhaustive examination of the patient’s skin. Hence our training. Patients will be asked to dress in undress to have this comprehensive view. Gradually, we will have a more trained eye.

He does not exclude, in a second step, acquiring the artificial intelligence device, which would be dedicated to monitoring people who have developed skin cancer, or who have a high risk of developing one. “But we already have to practice our eyes, so as not to send everything and anything”.

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Dr. Lemoine is writing the file, to request financial assistance from the ARS, for the material and human side. He also wants to solicit the City of Nevers and the Department for the real estate component. He hopes to start this system at the beginning of 2023.

Less medical time, but…

“Yes, with this system, we will lose a little short-term medical time, since general practitioners will not be able to be in their offices and do dermatology. But it’s an investment in the future, because by doing prevention, they will have fewer patients afterwards. And the long-term objective is that with state-of-the-art medical equipment and already trained general practitioners, this will encourage dermatologists to come and set up shop. For the moment, they see a territory where they will be alone: ​​they tell themselves that they are going to live in hell. It is a bet on the future. And maybe if this system works, we can develop it for other specialties in tension…”

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Regulated consultations

The ten volunteer GPs will devote as much time as they can to dermatology: half a day or one day per month, or per week. Dermatology time will therefore be limited. So that the influx of patients does not block the entry system, patients will therefore have to be referred by their attending physician, or it will be up to a secretary to ensure regulation.

What training?

The initial training of the ten doctors will be done face-to-face, then remotely, via questionnaires. “It is based on an Australian practice which has proven that with a year and a half of practice, the differences between the diagnoses of dermatologists and trained general practitioners were not significant”, specifies Dr Lemoine. The intermittent presence of the dermatologist will also ensure ongoing training.

Marlene Martin

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Solutions – A project to remedy the lack of a dermatologist in Nièvre

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