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Table 1. Patient Confidence in a Primary Care Provider* 
Table 1. Patient Confidence in a Primary Care Provider*
Table 1. Patient Confidence in a Primary Care Provider*
Table 2. Patient Confidence in a Dermatologist* 
Table 2. Patient Confidence in a Dermatologist*
Table 2. Patient Confidence in a Dermatologist*
Table 3. Preferences for Care of Skin Disease* 
Table 3. Preferences for Care of Skin Disease*
Table 3. Preferences for Care of Skin Disease*
1.
Feldman  SRFleischer Jr  ABWolford  PMWhite  RByington  R Increasing utilization of dermatologists by managed care: an analysisof the National Ambulatory Medical Care survey, 1990-1994. J Am Acad Dermatol. 1997;37784- 788Article
2.
Branch Jr  WTCollins  MWintroub  BU Dermatologic practice: implications for a primary care residency curriculum. J Med Educ. 1983;58136- 142
3.
Greenfield  SRogers  WMangotich  MCarney  MFTarlov  AR Outcomes of patients with hypertension and non–insulin-dependentdiabetes mellitus treated by different systems and specialties: results fromthe Medical Outcomes Study. JAMA. 1995;2741436- 1444Article
4.
Eisenberg  L Treating depression and anxiety in primary care: closing the gap betweenknowledge and practice. N Engl J Med. 1992;3261080- 1084Article
5.
Ayanian  JZHauptman  PJGuadagnoli  EAntman  EMPashos  CLMcNeil  BJ Knowledge and practices of generalist and specialist physicians regardingdrug therapy for acute myocardial infarction. N Engl J Med. 1994;3311136- 1142Article
6.
Donohoe  MT Comparing generalist and specialty care: discrepancies, deficiencies,and excesses. Arch Intern Med. 1998;1581596- 1608Article
7.
Ramsay  DLFox  AB The ability of primary care physicians to recognize the common dermatoses. Arch Dermatol. 1981;117620- 622Article
8.
Solomon  BACollins  RSilverberg  NBGlass  AT Quality of care: issue of oversight in health care reform? J Am Acad Dermatol. 1996;34601- 607Article
9.
Kirsner  RSFederman  DG Lack of correlation between internists' ability in dermatology andtheir patterns of treating patients with skin disease. Arch Dermatol. 1996;1321043- 1046Article
10.
Clark  RARietschel  RL The cost of initiating appropriate therapy for skin diseases: a comparisonof dermatologists and family physicians. J Am Acad Dermatol. 1983;9787- 796Article
11.
Wagner Jr  RFWagner  DTomich  JMWagner  KDGrande  DJ Diagnoses of skin disease: dermatologists vs. nondermatologists. J Dermatol Surg Oncol. 1985;11476- 479Article
12.
Gerbert  BMaurer  TBerger  T  et al.  Primary care physicians as gatekeepers in managed care: primary carephysicians' and dermatologists' skills at secondary prevention of skin cancer. Arch Dermatol. 1996;1321030- 1038Article
13.
Dolan  NCMartin  GJRobinson  JKRademaker  AW Skin cancer control practices among physicians in a university generalmedicine practice. J Gen Intern Med. 1995;10515- 519Article
14.
Federman  DGHogan  DTaylor  JRCaralis  PKirsner  RS A comparison of diagnosis, evaluation, and treatment of patients withdermatologic disorders. J Am Acad Dermatol. 1995;32726- 729Article
15.
Owen  SAMaeyens Jr  EWeary  PE Patients' opinions regarding direct access to dermatologic specialtycare. J Am Acad Dermatol. 1997;36250- 256Article
16.
Cassileth  BRClark Jr  WHLusk  EJ  et al.  How well do physicians recognize melanoma and other problem lesions? J Am Acad Dermatol. 1986;14555- 560Article
17.
Smith  ESFleischer Jr  ABFeldman  SR Nondermatologists are more likely than dermatologists to prescribeantifungal/corticosteroid products: an analysis of office visits for cutaneousfungal infections, 1990-1994. J Am Acad Dermatol. 1998;3943- 47Article
18.
Federman  DGKirsner  RS Skin biopsies, cutaneous disease, and primary care [letter]. Ann Intern Med. 1999;130617Article
19.
Federman  DGConcato  JKirsner  RS Comparison of dermatologic diagnoses by primary care practitionersand dermatologists: a review of the literature. Arch Fam Med. 1999;8170- 172Article
Study
January 2001

The Primary Care Provider and the Care of Skin DiseaseThe Patient's Perspective

Author Affiliations

From the Department of Internal Medicine, Yale University School ofMedicine, New Haven, Conn, and the Veterans Affairs Connecticut Health CareSystem, West Haven (Drs Federman, Reid, and Greenhoe); the Department of Dermatology,Westwood-Squibb Center for Dermatology Research, Wake Forest University Schoolof Medicine, Winston-Salem, NC (Dr Feldman); and the Departments of Dermatologyand Cutaneous Surgery and Epidemiology and Public Health, University of MiamiSchool of Medicine, Miami, Fla (Dr Kirsner).

Arch Dermatol. 2001;137(1):25-29. doi:10.1001/archderm.137.1.25
Abstract

Objective  To ascertain the patient's perspective on dermatologic care providedby primary care providers (PCPs) or dermatologists.

Design  Cross-sectional survey of patients drawn from primary care and dermatologyclinics.

Setting  Academic Veterans Affairs medical center.

Patients  Convenience sample of patients in either a primary care or a dermatologyclinic.

Intervention  Survey questionnaire.

Main Outcome Measures  Patients' confidence in having their skin problems cared for by PCPsand dermatologists and satisfaction with previous care rendered.

Results  A total of 137 patients in the primary care clinic (group 1) and 100patients in the dermatology clinic (group 2) participated. Patients (N = 237)expressed confidence in their PCP's ability to treat rashes (62%), diagnoseskin cancer (65%), perform skin biopsies (60%), "freeze" lesions with liquidnitrogen (50%), and perform cutaneous surgery (46%). Group 2 patients weresignificantly less likely to have confidence in their PCP than group 1 patientsfor all measures other than the use of liquid nitrogen. High levels of confidencewere expressed in a dermatologist's ability for all 5 measures: 92%, 91%,92%, 83%, and 85%, respectively. Patients were more confident in dermatologists'abilities to perform these procedures compared with PCPs (P<.001 for all comparisons). Of patients previously treated forskin disorders, there was a high rate of satisfaction with the treatment renderedby PCPs (81% for group 1 and 75% for group 2) and by dermatologists (92% forgroup 1 and 90% for group 2). However, patient satisfaction was higher fordermatology vs primary care for the treatment of skin disease (P<.001). Direct access to dermatologists was preferred.

Conclusions  Although patients have confidence in their PCP to care for their skindisease, they have greater confidence in the care provided by dermatologists.Among patients previously treated for skin disease, satisfaction was higherwith care rendered by dermatologists vs PCPs. Most patients prefer directaccess to dermatologists should they develop a skin problem.

PATIENTS WITH skin disorders are extremely common. Approximately 6%of visits to all physicians entail a problem of the skin, hair, or nails;however, only approximately 40% of these patients are seen by dermatologists.1 In primary care settings, the proportion of patientvisits involving dermatologic complaints is even higher, where up to one fourthof visits involve skin disorders.2 As manyhealth care systems have adopted a "gatekeeper" system, whereby a patientmust first see his or her primary care provider (PCP), who then determineswhether the patient is in need of specialty care, information is clearly neededregarding the quality of dermatologic care delivered by PCPs.

Several studies36have evaluated how PCPs compare with specialists in the diagnosis and/or treatmentof disease. Although PCP care may be comparable to that of specialists forcertain disorders (eg, hypertension and type 2 diabetes mellitus), such isnot the case for skin disease. Researchers714have demonstrated that dermatologists provide greater accuracy in diagnosisand more appropriate treatment of skin disorders compared with PCPs.

Another important aspect of quality of care is patient satisfaction,since ultimately, patients are the purchasers of health care resources. Littleis known, however, about patients' preferences for the evaluation and treatmentof skin disorders. One previous study15 conductedin a dermatology practice suggested that patients were more satisfied withdermatologist care for their skin disease compared with PCP care, and thatdirect access to dermatologists was important. However since the study participantswere enrolled in a dermatologist's office, a referral bias in favor of dermatologiccare could have been introduced, as the study sample likely included individualswho were "PCP failures." In contrast, patients successfully treated by theirPCPs for a given skin disorder—and who may have a more favorable opinionof the care provided by PCPs—would have a lower probability of beingreferred for specialty evaluation. To test this hypothesis, we surveyed patientsin dermatology and primary care clinics and determined their confidence inPCPs' and dermatologists' abilities to diagnose and treat skin disease.

PATIENTS AND METHODS
STUDY SITE AND POPULATION

The West Haven Veterans Affairs Medical Center, West Haven, Conn, providescare for more than 29 000 veterans who are older (average age, 61 years)and predominantly male (91%). Patients are enrolled in primary care, and referralto subspecialty clinics must be made by patients' PCPs. Primary care clinicsare staffed by internal medicine attending physicians, nurse practitioners,physician assistants, and internal medicine residents (who work under thesupervision of the attending physicians). Dermatology clinics are staffedby dermatology attending physicians and dermatology residents, who work undertheir supervision. The attending physicians and residents in the dermatologyand primary care clinics are affiliated with the Yale University School ofMedicine, New Haven, Conn.

STUDY SAMPLE

Eligible patients were those veterans in the waiting rooms of the primarycare and dermatology clinics awaiting scheduled appointments. Subjects wererecruited on 14 clinic days during a 2-month period. A trained research assistantadministered the study questionnaires to a convenience sample of patientsbefore their primary care or dermatology clinic appointment.

SURVEY PROCEDURE AND QUESTIONNAIRE

All participants were asked to rate their level of confidence in theirPCP's ability to: (1) care for any rashes or skin conditions that might develop,(2) diagnose skin cancer, (3) perform skin biopsies, (4) "freeze" skin lesionswith liquid nitrogen, and (5) perform cutaneous surgery. Study subjects wereasked identical questions regarding their confidence in a dermatologist, andthey were asked if they had ever been treated by dermatologists and/or PCPsfor skin conditions and about their satisfaction with the treatment.

Possible responses to questions regarding patient confidence were "stronglyagree," "agree," "neither agree nor disagree," "disagree," and "strongly disagree."For analysis, the responses "strongly agree" and "agree" were combined, whilethe 3 remaining categories were also combined into an "all others" category.Subjects who had received previous treatment for a skin problem were askedto rate how satisfied they were with previous care. The responses "very satisfied"and "somewhat satisfied" were combined, while the 3 remaining responses ("neithersatisfied nor dissatisfied," "somewhat dissatisfied," and "very dissatisfied")were combined.

Subjects were also asked where they preferred to have their skin problemscared for and should they develop a skin problem, whether they preferred tohave direct access to dermatologists without having to be seen by their PCP.

Demographic information, including participants' age, sex, level ofeducation, and self-reported health status, was obtained at the interview.

To assess for potential differences between the groups, we used a χ2 or Fisher exact test for categorical variables and t tests for dimensional variables. P<.05(2-tailed) was considered significant.

The study protocol was approved by the local investigational reviewboard.

RESULTS
PATIENTS

A total of 311 patients were asked to participate: 177 in the primarycare clinic and 134 in the dermatology clinic. Of these, 237 patients completedthe questionnaire, for an overall participation rate of 76%. Rates of participationdid not vary by clinic site: 133 (75%) of the 177 general medicine clinicpatients (group 1) agreed to participate, compared with 100 (75%) of the 134dermatology clinic patients (group 2). Subjects' average age was 65.7 years(65.8 years for group 1 vs 65.6 years for group 2), and 95% were male (group1 vs group 2, 94% vs 96%). There was no difference between the groups foreducational level or perception of self-rated health status (data not shown).

PATIENT CONFIDENCE IN CARE BY A PCP

Subjects (N = 237) reported confidence in their PCP's ability to takecare of any rashes or skin conditions that develop, to diagnose skin cancer,to perform skin biopsies, to freeze skin lesions with liquid nitrogen, andto perform surgery on their skin. When the responses of groups 1 and 2 werecompared (Table 1), group 2 subjectswere less likely than group 1 participants to be confident in their PCP'sability to take care of any skin condition that might develop, to diagnoseskin cancer, to perform skin biopsies, and to perform cutaneous surgery.

PATIENT CONFIDENCE IN CARE BY A DERMATOLOGIST

Patients reported confidence in a dermatologist's ability to take careof any skin conditions that might develop, to diagnose skin cancer, to performskin biopsies, to freeze lesions with liquid nitrogen, and to perform cutaneoussurgery. No statistical difference was detected between groups 1 and 2 forany of these outcomes (Table 2).Subjects were significantly more confident in a dermatologist's ability toperform these procedures or measures than a PCP's ability (P<.001 for each comparison).

PREVIOUS TREATMENT BY PCPs AND DERMATOLOGISTS FOR SKIN CONDITIONS

Thirty-five percent of group 1 (47/135) and 40% of group 2 (40/100)participants reported having been treated by their PCP for a skin condition(P = .41). Among this subgroup, 68 (78%) reportedsatisfaction with the previous treatment of their skin problem by their PCP.There was no significant difference in satisfaction with care by their PCPbetween the 2 groups (81% for group 1 and 75% for group 2; P = .50). In addition, among group 1 subjects, there was no differencein satisfaction with the care rendered by their PCP, whether they were alsoenrolled in a dermatology clinic (P = .33).

A total of 90 group 1 and 78 group 2 participants had previously beentreated by dermatologists for skin conditions. There was no difference inreported satisfaction between groups for the care rendered by dermatologists(92% vs 90%; P = .80). Patient satisfaction withdermatologist care was higher than that rendered by PCPs (P<.001).

PATIENT PREFERENCES

Subjects were asked whom they would prefer to take care of their skinproblems (Table 3). Of the 234respondents, 181 preferred dermatologists, 29 preferred their PCP, 6 preferredother physicians, and 18 had no preference. Of the 134 group 1 respondents,26 preferred PCP care for their skin problems, while only 3 of the 100 group2 participants preferred PCP care. Similarly, 91 group 1 patients preferredthat a dermatologist care for their skin problems, while 90 group 2 patientspreferred a dermatologist.

Ninety-one (66%) of the 137 group 1 patients vs 79 (79%) of the 100group 2 patients agreed with the statement that they would prefer to see adermatologist directly without having to see their PCP should they developa skin problem (P<.001).

ROLES OF VARIOUS PCP TYPES

We looked to see if the type of PCP influenced patient satisfaction.Of the patients who had known PCPs, 151 were cared for by attending physiciansin general internal medicine, 23 by internal medicine house staff, and 52by nurse practitioners or physician assistants. For all measures other thanconfidence in PCP's ability to perform a biopsy (P= .03), no significant differences were detected between attending physiciansand other providers (house staff, nurse practitioners, and physician assistants).

COMMENT

The results of our survey further contribute to the growing literatureregarding the quality of care for patients with skin disorders. Previous studieshave demonstrated that dermatologists were superior to PCPs for the diagnosisand treatment of common dermatoses,712the ability to recognize lesions suggestive of malignant neoplasms,13,16 and the appropriate use of topicalantifungal therapy.17

We found that although patients were more likely to have confidencein a dermatologist than their PCP for the care of skin disorders, they werestill confident in the abilities of their PCP. This was true not only fordiagnosis and treatment but for the performance of more invasive procedures,such as skin biopsy, the application of liquid nitrogen, and cutaneous surgery.This finding has important quality-of-care ramifications, since PCPs are beingtrained in these techniques.18 Despite evidencesuggesting that the care of skin disease may be better served by dermatologists,717patients may not be entirely averse to having their PCP assume a greater rolein the delivery of this care.

We also found that among those who had been treated previously for askin disorder by their PCP, there was a high satisfaction rate, although thiswas significantly less than the satisfaction rate of subjects treated by dermatologists(78% vs 90%). In addition, no significant difference in satisfaction was detectedwhether they were questioned in the dermatology or primary care clinic. Forprevious treatment, we therefore could not confirm the potential bias introducedin the study of Owen et al,15 the first tolook at patient opinion with respect to who cares for their skin disease.However, we found that primary care patients were more likely to express confidencein their PCP and prefer PCP treatment of their skin problems than those questionedin the dermatology clinic.

Owen et al15 reported that 64% of patientsin their study who had been treated by a PCP for a skin condition were satisfiedwith the care rendered, which is comparable to, but slightly lower than, the78% we found. Possible explanations for the lower PCP satisfaction rate foundin their study include the finding that 11% of participants had previouslyseen 2 or 3 physicians for their condition, which raises the possibility thattheir patients had either higher expectations or more severe illness thanwe encountered. Furthermore, the skills of the university-affiliated physiciansin our study might be different from those of the PCPs in the study of Owenet al. Interestingly, while the physicians in our study were all trained ininternal medicine, there was a high percentage of family physicians and generalpractitioners among the PCP group in their study. Previous research19 has suggested that family physicians and generalpractitioners are superior to internists when tested on diagnostic abilitieswith respect to skin disease.

How can we reconcile the findings of previous studies that suggest thatPCPs are inferior to dermatologists in the diagnosis and treatment of skindisorders with the high rate of satisfaction and confidence in PCP care foundin our study? It is possible that since most skin conditions are not lifethreatening and often are self-limiting, they may spontaneously improve regardlessof the therapy rendered. Alternatively, patients may harbor positive feelings,in general, toward their PCP, who is involved in such broadly encompassingmedical endeavors as chronic disease management, disease prevention, cancerscreening, patient education, and overall coordination of care, and with whompatients have developed a longitudinal relation.

Our study has several possible limitations. Because our study populationconsisted largely of older, male veterans, our results may not be generalizableto other health care systems. In addition, patient satisfaction with dermatologycare may be different in other systems due to the reliance of dermatologyresidents in training at our facility. However, in our study, with the exceptionof only one measure, the performance of skin biopsies, patient confidencein their PCP was no different whether the PCP was an attending physician.Whether these findings could be replicated in traditional managed care organizationsshould be the subject of future investigation.

Patient satisfaction is clearly an important measure of quality of care.Despite patient confidence in and satisfaction with PCP care of skin problems,patients reported a higher degree of confidence in and satisfaction with dermatologists.Furthermore, most patients prefer having direct access to a dermatologistfor the care of their skin disease. The greater patient satisfaction engenderedby direct access may provide dividends to managed care systems by making themmore attractive to health care consumers.

Future studies should also evaluate whether the outcomes of care, financialand clinical, rendered by PCPs and dermatologists differ, which would furtherhelp shape health care policy. Until these studies are completed, managedcare organizations should consider incorporating patient preferences and expectationsinto policy as logistical constraints permit.

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Article Information

Accepted for publication September 12, 2000.

This study was supported by Career Development Awards from the Departmentof Veterans Affairs Health Services Research and Development Service, Washington,DC, and the Robert Wood Johnson Foundation, Princeton, NJ (Dr Reid); a grantfrom Bristol-Myers Squibb, Wallingford, Conn (Dr Feldman); and the DermatologyFoundation's Clinical Career Development Award in Health Care Policy (Dr Kirsner).

We thank Sue Kancir, RN, for her assistance with data analysis and JoanneHart for her assistance with manuscript preparation.

Corresponding author: Daniel G. Federman, MD, Veterans Affairs ConnecticutHealth Care System (11 ACSL), 950 Campbell Ave, West Haven, CT 06516 (e-mail: FEDERMAN.DANIEL_G+@WEST-HAVEN.VA.GOV).

References
1.
Feldman  SRFleischer Jr  ABWolford  PMWhite  RByington  R Increasing utilization of dermatologists by managed care: an analysisof the National Ambulatory Medical Care survey, 1990-1994. J Am Acad Dermatol. 1997;37784- 788Article
2.
Branch Jr  WTCollins  MWintroub  BU Dermatologic practice: implications for a primary care residency curriculum. J Med Educ. 1983;58136- 142
3.
Greenfield  SRogers  WMangotich  MCarney  MFTarlov  AR Outcomes of patients with hypertension and non–insulin-dependentdiabetes mellitus treated by different systems and specialties: results fromthe Medical Outcomes Study. JAMA. 1995;2741436- 1444Article
4.
Eisenberg  L Treating depression and anxiety in primary care: closing the gap betweenknowledge and practice. N Engl J Med. 1992;3261080- 1084Article
5.
Ayanian  JZHauptman  PJGuadagnoli  EAntman  EMPashos  CLMcNeil  BJ Knowledge and practices of generalist and specialist physicians regardingdrug therapy for acute myocardial infarction. N Engl J Med. 1994;3311136- 1142Article
6.
Donohoe  MT Comparing generalist and specialty care: discrepancies, deficiencies,and excesses. Arch Intern Med. 1998;1581596- 1608Article
7.
Ramsay  DLFox  AB The ability of primary care physicians to recognize the common dermatoses. Arch Dermatol. 1981;117620- 622Article
8.
Solomon  BACollins  RSilverberg  NBGlass  AT Quality of care: issue of oversight in health care reform? J Am Acad Dermatol. 1996;34601- 607Article
9.
Kirsner  RSFederman  DG Lack of correlation between internists' ability in dermatology andtheir patterns of treating patients with skin disease. Arch Dermatol. 1996;1321043- 1046Article
10.
Clark  RARietschel  RL The cost of initiating appropriate therapy for skin diseases: a comparisonof dermatologists and family physicians. J Am Acad Dermatol. 1983;9787- 796Article
11.
Wagner Jr  RFWagner  DTomich  JMWagner  KDGrande  DJ Diagnoses of skin disease: dermatologists vs. nondermatologists. J Dermatol Surg Oncol. 1985;11476- 479Article
12.
Gerbert  BMaurer  TBerger  T  et al.  Primary care physicians as gatekeepers in managed care: primary carephysicians' and dermatologists' skills at secondary prevention of skin cancer. Arch Dermatol. 1996;1321030- 1038Article
13.
Dolan  NCMartin  GJRobinson  JKRademaker  AW Skin cancer control practices among physicians in a university generalmedicine practice. J Gen Intern Med. 1995;10515- 519Article
14.
Federman  DGHogan  DTaylor  JRCaralis  PKirsner  RS A comparison of diagnosis, evaluation, and treatment of patients withdermatologic disorders. J Am Acad Dermatol. 1995;32726- 729Article
15.
Owen  SAMaeyens Jr  EWeary  PE Patients' opinions regarding direct access to dermatologic specialtycare. J Am Acad Dermatol. 1997;36250- 256Article
16.
Cassileth  BRClark Jr  WHLusk  EJ  et al.  How well do physicians recognize melanoma and other problem lesions? J Am Acad Dermatol. 1986;14555- 560Article
17.
Smith  ESFleischer Jr  ABFeldman  SR Nondermatologists are more likely than dermatologists to prescribeantifungal/corticosteroid products: an analysis of office visits for cutaneousfungal infections, 1990-1994. J Am Acad Dermatol. 1998;3943- 47Article
18.
Federman  DGKirsner  RS Skin biopsies, cutaneous disease, and primary care [letter]. Ann Intern Med. 1999;130617Article
19.
Federman  DGConcato  JKirsner  RS Comparison of dermatologic diagnoses by primary care practitionersand dermatologists: a review of the literature. Arch Fam Med. 1999;8170- 172Article
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