PRIMARY-CARE PHYSICIANS AS GATEKEEPERS IN MANAGED CARE - PRIMARY-CAREPHYSICIANS AND DERMATOLOGISTS SKILLS AT SECONDARY PREVENTION OF SKIN-CANCER

Background and Design: This study determines (1) the readiness of prim ary care physicians (PCPs) to triage optimally lesions suspicious for skin cancer, (2) the difference in their abilities from those of derma tologists, and (3) whether accurate diagnosis after viewing slide imag es transfers to accurate diagnosis after viewing lesions on patients. Seventy-one primary care residents and 15 dermatologists and resident dermatologists diagnosed and selected a treatment/diagnostic plan for skin lesions suspicious for cancer. The lesions were shown on slides, computer images, and patients. Participants' performance was compared with biopsy results of all lesions. Results: Dermatologists' scores we re almost double those of primary care residents, and primary care res idents' performance was positively associated with previous experience in dermatology. Primary care residents failed 50% of the time to diag nose correctly nonmelanoma skin cancer and malignant melanomas, and 33 % of the time they failed to recommend biopsies for cancerous lesions. Primary care residents failed to diagnose malignant melanomas 40% of the time; dermatologists failed to do so 26% of the time. Both groups performed better using slide images compared with patients. Conclusion s: Primary care residents may not be ready to assume a gatekeeper role for lesions suspicious for skin cancer. Because of the seriousness of missed diagnoses, especially of malignant melanomas, we need to impro ve the triage skills of PCPs. Future studies should evaluate whether p rimary care training allows sufficient time for PCPs to learn the nece ssary skills. Until we can show that PCPs are prepared to triage optim ally, managed care plans should reduce the threshold for referrals to dermatologists of potential skin cancers.