Strategies for Teaching Store-and-Forward Teledermatology: A Survey of U.S. Dermatologists

In the modern practice of medicine, the ability to see a patient's skin condition without being in the same room has become a standard tool, especially for specialists who focus on skin health. This method, known as store-and-forward teledermatology, works by having a local doctor or a patient take a photograph of a skin issue and send it to a specialist. The specialist then reviews the image, makes a diagnosis, and suggests a treatment plan, all without a live video call or an in-person visit. This approach has grown rapidly, particularly after the global health crisis of the early 2020s, as it allows doctors to reach people in remote areas or those who cannot easily travel to a clinic. However, while the technology itself is now common, a significant question remained unanswered: how do experienced doctors teach the next generation of specialists how to use this tool effectively? Medical training has traditionally relied on seeing patients face-to-face, and the shift to reviewing static images requires a different set of skills and a different way of thinking. Without clear guidance, residency programs risk leaving future dermatologists unprepared for a practice that increasingly relies on digital images.

To address this gap, a team of researchers from the University of California, San Francisco, and Stanford University set out to discover how dermatology educators are currently teaching these skills. They focused on the specific moment when a teacher and a student sit down to review a case together, a process called a sign-out. In this setting, the educator and the trainee look at the same image, discuss what they see, and decide on a course of action. The researchers wanted to know which teaching methods worked best. They designed a detailed survey and sent it to 127 dermatologists across the United States who were known for teaching this subject. The survey asked these educators about their programs and, more importantly, about the specific techniques they used to help residents learn. The goal was to move beyond simply asking if teledermatology was being taught and to understand exactly how it was being taught.

The survey reached a wide audience, with responses coming from dermatologists in every major geographic region of the country. In total, 52 doctors participated, representing a diverse mix of academic centers and hospitals, including many that serve veterans. These educators reported that their programs varied widely in how they integrated this technology. Some residents spent only a few hours a week looking at these cases as part of their regular duties, while others dedicated entire months to full-time rotations focused solely on teledermatology. Despite these differences in schedule and setting, the researchers found a striking consistency in the methods the teachers used to educate their students.

The study identified three specific strategies that educators relied on most often, and these same three strategies were also rated as the most effective. The first and most common approach involved asking the trainee to look at the image and propose a list of possible conditions, known as a differential diagnosis, before revealing the final answer. This forces the student to actively engage with the visual evidence rather than passively receiving information. The second key strategy was a detailed review of the physical appearance of the skin condition, or morphology. Teachers would point out specific shapes, colors, and patterns in the image, helping the student learn to recognize the visual language of skin diseases. The third major technique was for the educator to describe their own systematic approach to solving the case. This meant walking the student through the logical steps of how to move from seeing an image to forming a diagnosis and then creating a management plan.

These methods were not just popular; the educators believed they worked. Nearly all respondents who used the strategy of asking for a differential diagnosis rated it as quite or extremely effective. Similarly, the vast majority found that reviewing the specific visual features of the skin and modeling a step-by-step diagnostic process were highly successful ways to teach. In contrast, the study found that one common teaching habit was rarely used and considered less helpful: asking the student to set their own learning goals for that specific session. The researchers suspect this is because the sessions are often driven by the volume of cases that need to be reviewed, leaving little time for individual goal-setting, or because the overall learning objectives are already set by the broader curriculum.

Beyond the mechanics of diagnosis, the study also highlighted how educators are adapting to the reality of treating a diverse population. When asked how they teach students to care for patients with different skin tones, educators described specific techniques. They mentioned reviewing how the same skin conditions look different on darker skin, discussing the barriers that prevent some patients from accessing care, and using specialized resources like digital archives to study cases in people of color. This focus ensures that the training prepares doctors to recognize diseases accurately across the full spectrum of human skin, rather than just on a narrow range of tones.

The researchers acknowledged that their findings come with certain limitations. Because the study relied on what the teachers said they did, rather than directly observing every session or testing the students' knowledge, the results reflect the educators' perceptions. Additionally, the response rate meant that some teaching styles might be underrepresented. However, the consistency of the answers across such a large and varied group of doctors suggests a strong consensus on what works. The study does not claim to have solved every problem in medical education, but it provides a clear, evidence-based starting point. It shifts the conversation from whether to teach teledermatology to exactly how to do it well.

For programs that are just beginning to incorporate this technology, or for those that have been doing so without a structured plan, these findings offer a practical roadmap. The most effective path forward involves engaging students in active reasoning, teaching them to see the details of the image, and showing them how to think through a case systematically. By adopting these proven strategies, medical educators can ensure that the next generation of dermatologists is ready to use this vital tool to care for patients, regardless of where those patients are located or what their skin looks like. The work of these researchers turns a collection of individual teaching habits into a shared standard, helping to build a more consistent and competent future for skin care.