FPs Compare Favorably With Dermatologists in Care of Skin Lesions, Study Shows

In a study designed to assess patient-oriented outcomes, such as complaint resolution and overall satisfaction, rather than disease-focused outcomes, patients overwhelmingly reported their skin lesions improved after family physicians diagnosed and treated the conditions, according to a research report in the January issue of The Journal of Family Practice. "How Well Do Family Physicians Manage Skin Lesions?" also noted dermatologists' high levels of agreement with the FPs' diagnoses and treatment plans.

Studies that have suggested dermatologists are superior to primary care physicians in diagnosing skin conditions typically have been based on the use of pathology slides or digital images, not on direct patient contact, said the article's lead author, Daniel Merenstein, M.D., assistant professor and director of research programs in the family medicine department at Georgetown University School of Medicine, Washington, D.C. In contrast with such image-based research, for this study, 53 family physicians in Maryland; Virginia; and Washington, D.C., diagnosed and treated skin lesions in 244 patients, some of whom had more than one lesion. The study, which was funded by a grant from the Joint Grant Awards Program of the AAFP Foundation and the Academy, builds on patients' reports one week, four weeks and 12 weeks after they received initial care.

"When the patient is there in the office and the family physician can look at the lesion and feel it and consult with a colleague about it, family physicians are providing excellent care to their patients," said Merenstein. "Patients' satisfaction levels are high."

One week after seeing a family physician for treatment, 84 percent of reporting patients said their lesions were "better" or "much better." At four weeks, the positive response reached 89 percent, and at 12 weeks, 94 percent.

The study also tracked patients' satisfaction levels on a five-point scale (very satisfied, satisfied, neither satisfied nor unsatisfied, unsatisfied, and very unsatisfied). One week after visiting an FP, 55 percent of reporting patients expressed high satisfaction and 34 percent expressed satisfaction, for a combined satisfaction rate of 89 percent. The combined high satisfaction/satisfaction rate was 93 percent for both the four-week and 12-week reports.

"The satisfaction levels are excellent," said Merenstein, adding that those levels coincided with the high percentage of patients who said their lesions were better or much better a week after visiting the FP. "This study shows family physicians are providing excellent care," Merenstein said. Patients should rest assured, he added, that "when they go to their family doctor, their family doctor will do a good job with their skin lesion."

Two university-based dermatologists concurred with most of the family physicians' diagnoses and treatment plans after reviewing photographs of the skin lesions. Looking only at instances in which the two dermatologists agreed with each other regarding diagnoses and treatment, the dermatologists agreed with the FPs on diagnoses 72 percent of the time and agreed with them on treatment 80 percent of the time.

Moreover, for more common diagnoses, FP/dermatologist agreement rates exceeded 80 percent; for less common diagnoses, agreement rates were 62 percent. Concerning treatment, dermatologists recommended steroids "much more often than family physicians prescribed steroids," said the article.

Among other information the researchers gleaned were the 10 most common types of skin lesions diagnosed at the study sites. Out of 257 lesions, 73 were diagnosed as eczema, 28 as dermatophyte infections, 26 as benign nevi and 14 as bacterial infections. There were fewer instances of seborrheic keratosis, bites, herpes lesions, warts, viral exanthems and actinic keratosis. "Family physicians need to know these 10 conditions; we see them day in and day out," said Merenstein. "It's OK to know some rare things -- 'zebras' -- but these are our bread and butter."

The article noted that the study did not aim to assess family physicians' skills in identifying skin cancers. A much larger sample size would be required for a cancer-related project, said Merenstein, because skin cancer is not as prevalent as the conditions in this study.

Subscribers to The Journal of Family Practice may read the article online.