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Comparison of Dermatologic Diagnoses by Primary Care Practitioners and Dermatologists
A Review of the Literature
Daniel G. Federman, MD;
John Concato, MD, MPH;
Robert S. Kirsner, MD
Arch Fam Med. 1999;8:170-172.
ABSTRACT
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Background Cost-containment efforts in the United States have led to a greater emphasis on health care delivery by primary care physicians as opposed to specialists, who are assumed to be more costly. With this approach, it is incumbent on the primary care physician to be able to accurately diagnose and treat common maladies, including skin disease.
Objective To ascertain whether differences in performance were detectable between groups of physicians when presented with color slides or high-quality transparencies.
Design We performed a critical review of published studies.
Results Overall, dermatologists (93% correct) performed better than nondermatologists (52% correct) (P<.001). No difference was appreciable between dermatology residents (91% correct) and practicing dermatologists (96% correct) or between internal medicine residents (45% correct) and family practice residents (48% correct). In addition, family medicine attending physicians (70% correct) performed better than internal medicine attending physicians (52% correct) (P<.001).
Conclusion Primary care physicians should receive more training in the diagnosis of skin disease.
INTRODUCTION
DISEASES OF the skin, hair, and nails are commonly encountered in primary care. Approximately 6% of outpatient visits are for cutaneous disease,1 and nondermatologists treat almost 60% of these patients.2 Whether primary care physicians (PCPs) can correctly diagnose or treat patients with common cutaneous diseases has engendered considerable debate.3-5 This issue has implications not only for managed care but also for the individuals afflicted with skin disease. To better understand the diagnostic capabilities of PCPs when compared with dermatologists, we reviewed the English-language literature and performed a critical review of the published studies.
MATERIALS AND METHODS
Studies comparing dermatologists with nondermatologists in the diagnosis of skin disease were identified through a MEDLINE search using the terms clinical competence, skin diseases/diagnosis, skin neoplasms/diagnosis, melanoma/diagnosis, and dermatology education. The search included only English-language articles that had been published from January 1980 through March 1997. To identify additional articles, the bibliographies of all articles found in the MEDLINE search were reviewed. To be included in our analysis, studies had to (1) be conducted in the United States, (2) be analytic and not descriptive in nature, and (3) be published in a peer-reviewed journal. In addition, we excluded studies that described the performance of only 1 group, either dermatologists or nondermatologists, and studies in which the dermatologist's diagnosis was considered the criterion standard. When possible, we determined the type of practitioner included in each published study as well as the level of training.
To evaluate whether differences in diagnostic abilities between groups could be attributed to chance alone, statistical analysis was performed using  2 tests. We adjusted for multiple comparisons using the Bonferroni procedure with a significance level of P=.005.
RESULTS
We identified 8 studies that met our inclusion criteria (Table 1). Four studies tested participants in the identification of 20 common dermatoses6-9 and 1 tested 7 common dermatoses and 3 less common dermatoses.10 One study showed participants 8 malignant neoplasms and 13 unspecified benign conditions,11 and another study asked participants to examine high-quality color (Kodachrome, Eastman Kodak, Rochester, NY) transparencies, computer images, and actual patients with lesions suggestive of malignancy.12 Using photographs, 1 study examined the ability of participants to identify 3 malignant and 7 benign lesions.13
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Table 1. Peer-Reviewed, Analytic US Studies That Examined Physicians' Ability to Identify Dermatoses
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Test subjects in all studies combined included dermatology residents (n=330), dermatology attending physicians (n=269), internal medicine residents (n=137), internal medicine attending physicians (n=204), family medicine residents (n=603), family medicine attending physicians (n=237), and general physicians (n=43) (Table 2). Only 3 of the studies included more than 100 subjects.6-7,9
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Table 2. Test Subjects for Studies That Fit the Inclusion Criteria
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The diagnostic abilities of all dermatologists, both residents and attending physicians (93% correct), was markedly better than the abilities of all nondermatologists (52% correct) when presented with color slides or high-quality photographs (P<.001). Among practicing physicians, there was a significant difference between the performance of dermatology attending physicians (96% correct) and both internal medicine (52% correct) and family medicine (70% correct) attending physicians (both P<.001). Dermatology residents (91% correct) outperformed both internal medicine (52% correct) and family medicine (70% correct) attending physicians (both P<.001). After accounting for multiple comparisons, no significant difference was found between the performance of dermatology residents (91% correct) and dermatology attending physicians (96% correct) (P=.02).
No significant difference (P=.19) was detected between the performance of internal medicine residents (45% correct) and internal medicine attending physicians (52% correct) or between internal medicine residents (45% correct) and family medicine residents (48% correct) (P=.62). Family medicine attending physicians scored higher (70% correct) than family medicine residents (48% correct) (P<.001). Family medicine attending physicians (70% correct) performed better than internal medicine attending physicians (52% correct) (P<.001).
COMMENT
Studies comparing the abilities of dermatologists and nondermatologists have been criticized for their small size and lack of adjustment for physician specialty. By combining studies, our results confirm that using high-quality color transparencies or high-quality photographs, dermatology residents and attending physicians are superior to internal medicine and family medicine attending physicians in diagnostic ability.
Primary care physicians' poor performance might be attributed to inadequate training originating in medical school. In 1986, Ramsay and Weary4 surveyed US medical schools and found that the mean requirement for education in dermatology was 21 hours, and most teaching was in the first 2 years of medical school, before students acquire experience with clinical medicine. Furthermore, that report found that only approximately one third of medical students were afforded opportunities to rotate through a clerkship in dermatology. We have also previously found that internists have limited postgraduate training in dermatology, which correlates with poor performance in diagnosis.9
Additional evidence supporting the lack of training in skin disease diagnosis as the reason for observed results was the difference between trainees in dermatology and practicing PCPs. Given the frequency of skin disease that practicing PCPs encounter in their daily practice of medicine, it is surprising that their performance was inferior to that of dermatology residents. The value of extensive and concentrated training in dermatology is underscored by the lack of a statistically significant difference between the abilities of dermatology attending physicians and dermatology residents.
Our study also found that among the primary care specialties, family medicine physicians outperformed internal medicine physicians. This result may, in part, be attributable to the broader training experience offered in family medicine residency programs or to other factors occurring after residency training (eg, more hours of graduate training in dermatology or more postgraduate education). The lack of a substantial difference between the family medicine and internal medicine residents suggests that the difference between practicing family medicine and internal medicine attending physicians may be due to a phenomenon that occurs either late in or after residency.
Our critical review assessed differences in diagnostic abilities using high-quality color slides or high-quality photographs. This approach may favor dermatologists since they receive more training than PCPs using these educational tools. Studies using actual patients with cutaneous disease, however, similarly favored the ability of dermatologists to diagnose skin disorders.12, 14
Because many skin diseases resolve spontaneously and are not life-threatening, an important question to be answered in future research is whether outcomes of actual patients with skin disease differ when they are cared for by either dermatologists or nondermatologists. Our critical review did not assess clinical outcomes. Future studies should also include costs of care (both direct and indirect) and should account for incorrect diagnoses, inappropriate testing and biopsies, medications, initial office visits, treatment failures, and the subsequent need for return visits.
AUTHOR INFORMATION
Accepted for publication June 8, 1998.
This study was supported in part by a Career Development Award from the Veterans' Affairs Health Services Research and Development Service (Dr Concato).
Corresponding author: Daniel G. Federman, MD, West Haven Veterans Administration Medical Center (111-GIM), 950 Campbell Ave, West Haven, CT 06516.
From the Department of Medicine, West Haven Veterans Affairs Medical Center, Yale University School of Medicine, West Haven, Conn (Drs Federman and Concato); and the Departments of Dermatology and Cutaneous Surgery and Epidemiology and Public Health, University of Miami School of Medicine, Miami, Fla (Dr Kirsner).
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