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Practice Gaps
January 17, 2011

Need to Improve Skin Cancer Screening of High-Risk Patients: Comment on “Skin Cancer Screening by Dermatologists, Family Practitioners, and Internists”

Author Affiliations

Author Affiliations: Department of Dermatology, Boston University School of Medicine (Dr Garg and Mr Geller), and Department of Society, Human Development, and Health, Harvard School of Public Health (Mr Geller), Boston, Massachusetts.

Arch Dermatol. 2011;147(1):44-45. doi:10.1001/archdermatol.2010.385

In their study, Oliveria et al reveal a practice gap in which more than 3 of 10 primary care physicians (PCPs) and 1 of 10 dermatologists report not screening more than half their high-risk patients for skin cancer. While a knowledge gap in identifying high-risk patients may be a contributing factor, time constraints, competing morbidities, and patient embarrassment/reluctance were cited as the strongest barriers to performing a full skin examination (FSE).

The continued existence of barriers to PCPs performing skin cancer screenings is not unexpected in the context of a shortage of PCPs coupled with a predicted health care overhaul that will provide first-time health care for millions of patients. To narrow this gap, dermatologists can train current and future PCPs to identify patients at the highest risk of advanced melanoma (white men older than 50 years) and devote more time to screening patients with multiple risk factors while limiting efforts toward low-risk patients. Although performing the FSE should remain within the province of PCPs and dermatologists, other specialists who see high-risk patients may improve early detection rates by integrating a focal skin examination into the specialty visit. For instance, the scenario in which the cardiologist, trained in the FSE during medical school and residency, examines the skin of the chest and back and finds an “ugly duckling” nevus while auscultating heart and lung sounds in a 65-year-old man with congestive heart failure is not unimaginable. The success of such an integrated examination requires that specialists make an additional effort to inspect the skin and be trained in recognizing and triaging suspicious lesions. After witnessing a short film (available upon request) illustrating the concept of the integrated skin examination, undifferentiated medical students perceived the integrated skin examination to take less time than initially thought, and they expressed strong intentions to incorporate the integrated skin examination into their routine visit regardless of specialty choice.1 This integrated approach underscores the importance of training medical students and residents to appreciate early on the relevance of the skin cancer screening and to recognize suspicious lesions. Currently, most graduating medical students fail to meet established American Association of Medical College guidelines for competency in dermatology. Improved competency in identifying skin cancer may be achieved through integrating novel experiential-based teaching strategies (ie, moulage) into core curricula and longitudinally integrating these with structured practical learning activities.

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