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Primary Care Physicians as Gatekeepers
Primary care physicians are increasingly required to act as gatekeepers in managed care systems. This can have a huge impact on dermatology referrals and raises the question of whether patients with a variety of skin problems will receive appropriate, timely, and cost-effective care. This study evaluated the ability of 71 primary care residents versus 15 dermatologists (residents and attendings) to correctly diagnose and manage a variety of lesions suspicious for skin cancer. The participants viewed skin lesions on patients, slides, and computer images and then made a diagnosis and selected a treatment plan. The lesions were biopsied to confirm diagnostic accuracy.
Dermatologists' overall scores were nearly twice as high as those of primary care residents. Among the primary care residents, scores correlated with increasing experience in dermatology, such as in clinical rotations. Primary care residents failed to diagnose melanoma 40% of the time, as did dermatologists 26% of the time, and misdiagnosed nonmelanoma skin cancers 50% of the time. The primary care residents did not recommend a biopsy in 33% of the cases where it was appropriate. For diagnosis, primary care physicians did significantly better with slides and computer images than with actual patients. For treatment and diagnostic planning, they performed equally well with all three methods. Dermatologists performed equally well with all three methods for diagnosis but had better scores with slides than with patients for treatment and diagnostic planning.
Comment: The authors conclude that primary care residents are not ready to serve as gatekeepers for dermatology. However, this study compared primary care residents at all levels of training with dermatology residents and attendings; it would be interesting to see how experienced primary care physicians (the true gatekeepers) would perform. As the authors point out, the gatekeeper system is unlikely to disappear anytime soon, so we must improve the skills of our primary care colleagues. It appears that slides and computer images can be used effectively for teaching.
— K Wiss
Published in Journal Watch Dermatology January 1, 1997
Citation(s):
Gerbert B et al. Primary care physicians as gatekeepers in managed care. Arch Dermatol 1996 132
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