The Primary Care Provider and the Care of Skin Disease

Abstract

Objective: To ascertain the patient's perspective on der-matologic care provided by primary care providers (PCPs) or dermatologists. Design: Cross-sectional survey of patients drawn from primary care and dermatology clinics. Setting: Academic Veterans Affairs medical center. Patients: Convenience sample of patients in either a primary care or a dermatology clinic. Intervention: Survey questionnaire. Main Outcome Measures: Patients' confidence in having their skin problems cared for by PCPs and dermatologists and satisfaction with previous care rendered. Results: A total of 137 patients in the primary care clinic (group 1) and 100 patients in the dermatology clinic (group 2) participated. Patients (N=237) expressed confidence in their PCP's ability to treat rashes (62%), diagnose skin cancer (65%), perform skin biopsies (60%), "freeze" lesions with liquid nitrogen (50%), and perform cutaneous surgery (46%). Group 2 patients were significantly less likely to have confidence in their PCP than group 1 patients for all measures other than the use of liquid nitrogen. High levels of confidence were 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 for skin disorders , there was a high rate of satisfaction with the treatment rendered by PCPs (81% for group 1 and 75% for group 2) and by dermatologists (92% for group 1 and 90% for group 2). However, patient satisfaction was higher for dermatology 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 skin disease, they have greater confidence in the care provided by dermatologists. Among patients previously treated for skin disease, satisfaction was higher with care rendered by dermatologists vs PCPs. Most patients prefer direct access to dermatologists should they develop a skin problem. Arch Dermatol. 2001;137:25-29 P ATIENTS 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 patient visits involving derma-tologic complaints is even higher, where up to one fourth of visits involve skin disorders. 2 As many health care systems have adopted a "gatekeeper" system, whereby a patient must first see his or her primary care provider (PCP), who then determines whether the patient is in need of specialty care, information is clearly needed regarding the quality of dermatologic care delivered by PCPs. Several studies 3-6 have evaluated how PCPs compare with specialists in the diagnosis and/or treatment of disease. Although PCP care may be comparable to that of specialists for certain disorders (eg, hypertension and type 2 diabetes melli-tus), such is not the case for skin disease. Researchers 7-14 have demonstrated that dermatologists provide greater accuracy in diagnosis and 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. Little is known, however, about patients' preferences for the evaluation and treatment of skin disorders. One previous study 15 conducted in a dermatology practice suggested that pa-STUDY