Acceptance of Teledermatological Practices: A Cross-Sectional Study of Practicing Saudi Dermatologists

Background: The increase in demand for Telemedicine globally has continued to rise in recent months, showing remarkable success in a variety of medical fields. As dermatology shows one of the most prolific rates of success, having a clear national picture of practitioner opinion on the subject is important. In this study we aimed to quantify the overall level of acceptance and satisfaction of Saudi dermatologists towards the practice of teledermatology. Design and setting: Data was collected by means of a survey which included demographic data and level of exposure and overall satisfaction towards Telemedicine in their field. Results: A total of 102 questionnaires were returned of which 57.8% had engaged in at least one teleconsultation. Of these, 71.2% showed support for the technology, with negative responses being associated with poor infrastructure or implementation in the workplace. Conclusion: The acceptance of dermatologists to teledermatology consultations in Saudi Arabia shows a positive tendency, with the majority of those who engaged in the practice saying they would do so again and find it satisfactory. Creating more reliable and robust tools and greater training in their use would be beneficial for its further incorporation.


Introduction
The practice of telemedicine is drastically changing healthcare services delivery due to its flexibility and easy integration into a multitude of areas and specialties [1]. As an emerging practice, telemedicine is loosely described as a medical consultation provided via a remote channel, usually via video-conference software and associated equipment [2,3] in which the most salient attributes are cost-effectiveness for both parties and overall emphasis on comfort and privacy afforded by avoiding public facilities [4].
Dermatology and its various conditions are commonly primarily visually assessed by a dermatologist. As telemedicine is a purely visual medium of communication, it has potential of achieving the highest rates of adoption and acceptance worldwide [5]. In a single teleconsultation, an assessing physician may, by means of instructions and detailed questioning of symptoms and medical history, effectively and accurately diagnose a significant number of conditions and pathologies [6]. This can be further augmented by the ability to prescribe treatment and issue follow-ups without any need for intermediaries or delays [7].
The global level of satisfaction towards teledermatology is not homogenous, however. Although its adoption in many parts of the globe is relatively high, there is still some resistance by physicians in certain areas, most notably developing countries [8,9]. Studies into this matter largely attribute this to a technological barrier, as these countries rarely possess the resources and technical knowledge to correctly implement the necessary infrastructures, and qualified staff to raise awareness and teach local practitioners on its uses [10].
Patient views on the practice is of equal importance and, to this end, awareness campaigns and active promoting of the service and its benefits to the individual have been conducted in many countries [11]. The overall result of these efforts has been a visible increase in levels of adoption and satisfaction on part of patients, which has been shown to closely correlate with their level of understanding of the service [12,13].
This study was conducted with the aim of determining the relative level of acceptance and satisfaction of telemedicine in the eyes of practicing dermatologists which reside and conduct their work in Saudi Arabia.

Study design
This was a cross-sectional qualitative study carried out in Saudi Arabia. Only licensed and actively practicing dermatologists were taken into consideration when gathering data.

Data collection
A self-administered survey was distributed after validation to as many dermatologists as possible, containing questions on basic demographic information, practical experience in the field, and questions on telemedicine participation history and degree of approval. These were supplemented by questions on the reasons behind their level of approval and what they considered to be the limiting factors for further increase. The possible answers to these questions varied from Strongly Disagree to Strongly Agree at the ends of the spectrum, and Slightly Agree/Disagree and Neutral as the other three possible stances (see the questionnaire in the appendix).

Statistical analyses
Demographic categorical data were expressed as percentages. Numerical scores were expressed in terms of their means ± sd were used to describe numerical variables. To assess whether a positive response to the questions on satisfaction relating to the practice, systems and patient acceptance of telemedicine had any correlation with demographic variables, each response above neutral was attributed a score of 1, and the sum for each separate question was used as a comparison basis using a one-way analysis of variance (ANOVA).
Statistical significance was set at p-value<0.05. The software package used for testing was Statistical Package for Social Sciences (SPSS) version 26 (IBM Corp., Armonk, NY, USA).

Validation of the questionnaire
Validation of the questions included in this questionnaire was carried out through Cronbach's alpha test. Validation for each section was performed separately followed by validation of the questionnaire as a whole. It has been shown that Cronbach's alpha for attitude section was 0.707.

Ethical considerations
Institutional ethics board approval was acquired before conducting any study procedure. Dermatologists were informed that their participation was entirely voluntary, and that all information was made anonymous and maintained strictly as confidential.

Results
A total of 102 questionnaires were returned and used as the base sample size (n=102). Demographic data can be viewed below. Of all the demographic information, only gender could be seen to have a significant bias towards male practitioners, comprising 70% of the total sample ( Table 1).  Of the 102 participants, a total of 59 (57.8%) had engaged in at least one instance of telemedicine comprise the sample size for any questions relating to service views and overall satisfaction.

Reasons for not practicing tele-dermatological consultations
Of the 43 participants that responded as having never engaged in telemedicine, the most common reason (16.3%) given was a distrust or experienced failure in the technology necessary for its practice. The least common reasons were equally patient refusal to participate and lack of proper facilities, both at 2.3%. The majority (60.7%) of this sample group gave multiple reasons for not engaging in telemedicine ( Figure 1).

Assessment of demographic data on engagement in telemedicine
Analysis on whether gender or years of practice had any effect on whether the participant had engaged in a telemedicine consultation found no correlation for either group (p-value=0.282; p-value=0.307 respectively) ( Table 2).
Have you practiced a full teledermatology consultation?

Opinions of dermatologists who practiced telemedicine
Of the 59 participants in this category, most responses were of the positive category (either Strongly agree or Agree) or the neutral category. The negative categories never comprised more than 11.9% of the total, most remaining around 5% or less ( Table 3).

Overall satisfaction of dermatologists with telemedical practices
Of the 59 participants who had engaged in telemedicine, over half were expressed satisfaction with the outcome (65.9%), the system framework and reliability (64.4%), and with reported patient satisfaction (78%). The number of negative or neutral responses was always of negligible amount (

COVID-19 as a factor on response
When asked if the current coronavirus disease 2019 (COVID-19) pandemic had affected their acceptance and overall opinion of telemedicine, 71.2% agreed that their views were affected in some way by the current pandemic, with the remaining 18.6% stating it had had no bearing on their responses ( Figure 2).

Assessing positive response with demographic variables
The average score for positive responses was 1.3±1.9, ranging from 0 to 7. No significant difference between acceptance and demographics was found for any of the variables ( Table 5).

Discussion
Digital technologies are increasingly prevalent in medicine as they have been shown to have a mostly positive impact on patient care and overall outcome [14]. This gradual integration was drastically accelerated by the COVID-19 pandemic of 2020 which forced medical practices to adapt to a world where face-to-face consultation was not legally permissive unless it in emergency situations [15]. Telemedicine in particular has seen a rapid increase in implementation on a global scale, and dermatology, relying mostly on visual assessment for diagnosis, ranks highly among those adopting the practice [16]. Whether or not the physicians themselves approve of this integration is still not clear, however [17]. It was in view of assessing these views that this study was conducted.
Similar to other studies [18][19][20], we found that telemedicine is indeed seeing a high level of adoption and overall acceptance in the field of dermatology, with over half the participants stating they had engaged in a session at least once. Of those who hadn't, the reasons given were mostly related to technical limitations such as insufficient infrastructures or unreliable tools and software platforms, and not the poor perception of telemedicine as an addition to available medical practices.
When assessing demographic variables on the level of acceptance, no meaningful relation or correlation could be established, indicating that whatever opinion the participant expressed, it was not influenced by their age, gender or how long they had practiced in their field. This is encouraging as it suggests that possible stereotypical pressures on expected behaviors and responses were not a meaningful factor, and that other factors must therefore be responsible.
When reviewing similar studies for possible reasons for acceptance or distrust of telemedicine, one possible factor shown to have a significant impact was level of awareness of physicians concerning the technology, its applications, and its benefits [18,19].
It is of interest that most participants stated that the current pandemic had a decided impact on their views and adoption of telemedicine as a medical practice. It will be of considerable interest to see if this remains the same after the situation is resolved.
The findings of Trettel et al. [18] support the outcomes of the present study, where the acceptance rate of teledermatology was relatively low, with an average score of 1.3±1.9. Additionally, only 57.8% had practiced a full teledermatology consultation previously, while dermatologists who did not practice teledermatology were mainly because of the service's absence or it did not work.

Conclusions
The practice of telemedicine applied to dermatology in Saudi Arabia is increasing at a rapid pace and, overall, the perception and opinions for its future as a tool in medical practice is a positive one. The lack of infrastructure and awareness are indicated as the areas in which improvements can be made to further this integration. An assessment into whether these findings remain true after the pandemic would be of great value in assessing how its effect on daily life may have impacted long-established practices and beliefs

Limitations
The present study suffered from a relatively small sample size, a factor that was considered during data interpretation. Furthermore, the study was entirely reliant on participant honesty and objectivity in answering the questions as there was no way to guarantee or monitor these factors. It is therefore advised that appropriate caution and critical assessment be used when interpreting our findings.

Appendices
A survey of dermatologist's acceptance of telemedicine: Based on your perception about telemedicine visit, how satisfied are you with telemedicine outcome?
Based on your perception, what is your overall satisfaction with the telemedicine system for this telemedicine visit?
What is your perception about overall patient satisfaction with telemedicine visit?

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.