How well do family physicians manage skin lesions?
Results of this prospective cohort study put them on a par with their dermatologist colleagues.
Family physicians can feel comfortable that most patients whom they treat with skin disorders improve (B).
The bite of a brown recluse spider is dangerous, leading to necrosis and possibly death, right? That supposition is widely held and backed by studies.1,2 In fact, conventional wisdom says if a person is bitten by a brown recluse spider, serious complications are the norm and the best course of action is aggressive treatment in a hospital.
The studies supporting this view, however, were conducted in tertiary care settings, which do not always represent primary care settings.3,4 When Cacy and Mold5 examined the characteristics of brown recluse spider bites in outpatient settings, they found that 43% of patients healed within 2 weeks and only 1 in 149 patients required hospitalization.
Is it likely other skin disorders seen in primary care also have clinical courses more favorable than when seen in tertiary care centers? This was one of our hypotheses, and we structured our study to determine the percentage of the skin lesions that improved after evaluation and management by family physicians.
How do FPs compare with dermatologists?
Dermatology literature boasts about the superiority of the dermatologist in diagnostic ability, cost savings, and cancer prevention when compared with primary care physicians.6-10 Studies have evaluated the skill level of primary care physicians compared with dermatologists in identifying skin disorders when tested with color transparencies, computer images, and slides—however, rarely with actual patients.7,9-16 Some studies have suggested a higher rate of referral for skin problems than for other non-dermatologic conditions.14,17,18
Often the outcome of interest in these studies is disease-oriented, judging a physician’s diagnostic ability, rather than examining a patient-oriented outcome, such as resolution of lesion or patient satisfaction.
Thus, the secondary aims of our study were to observe how family physicians diagnose and treat the lesions, and to gauge their concordance with dermatologists’ assessments and plans. We hypothesized that, in an office setting, family physicians would provide effective and efficient treatment for most patients who present with new skin lesions, and that there is high diagnostic concordance between the 2 specialties.
We first share our study findings, and then provide details of our Methodology and Results.
Family physicians excel at dermatologic care
Our study demonstrates that most skin conditions diagnosed and managed by family physicians improve. At day 7, 84% of patients who were contacted reported their skin lesions were “better” or “much better.” Moreover, patients said they were highly satisfied with their care. Referrals to subspecialists were infrequent.
These findings counter those from previous studies questioning primary care physicians’ care of dermatologic conditions. We believe it is likely that patients in previous studies reflected different populations than are typically seen by family physicians.18-20 Another difference may be that family physicians used other resources to assist with their diagnosis and treatment decisions. As we hypothesized, family physicians had good correlation with dermatologists in both diagnosis and treatment, and skin lesions improved.
Important study limitations
We relied on patient reports of improvement. While-self impression of degree of improvement is a patient-centered outcome, there may be instances in which inappropriate or insufficient treatment may produce temporary symptomatic relief and mask true improvement.
Although the patients’ primary care physicians were not involved in the follow-up process, it is possible they felt some social pressure to report higher levels of improvement or satisfaction.
Though we attempted to enroll all eligible patients, some patients seen for skin conditions may not have been captured. As we met our planned enrollment rates, we believe we captured most of the eligible encounters.
Some studies have questioned primary care physicians’ abilities to properly diagnose skin cancers.21,22 Our study was not designed or powered to detect skin cancers or the number, if any, of missed diagnoses of skin cancer.
Cues for teachers of family medicine
Most diagnoses fell within a limited set of diagnostic categories that probably reflect a distribution of skin disorders more typical within family medicine than in dermatology clinics. This range of disease defines a set of diagnostic skills, information resources, and treatment plans required to make these diagnoses and manage these conditions in family practice settings. This information should help physicians involved in training family physicians to concentrate on these common categories of diagnoses. Most important, our study conducted with actual patients found that family physicians manage skin lesions effectively and efficiently, with high patient satisfaction.
Methods
Study design and participants
We conducted a multisite, 3-state (Maryland, Virginia, and Washington, DC) prospective cohort study under the auspices of the Capital Area Practice Based Research Network (CAPRICORN). Between May 24 and August 13, 2004, all patients with new skin lesions who were seen by participating physicians were expected to enter into the study. Institutional Review Board approval was obtained from Georgetown University prior to the study. Written informed consent was obtained from all physicians and patients.
