Dermatologists Should Provide Primary Care For Skin Disease, Wake Forest Study Shows

August 01, 1998

WINSTON-SALEM, NC -- Though many managed care systems steer patients with skin problems to primary care doctors on the supposition that they will get comprehensive care as well, a new study indicates patients with skin problems get no more comprehensive care than they would from dermatologists.

But they would miss the dermatologist's special expertise in treating skin conditions.

A study by researchers at Wake Forest University School of Medicine's Westwood-Squibb Center for Dermatology Research showed that primary care doctors focused on the skin problem without providing comprehensive care.

According to data collected in 1996 through the National Ambulatory Medical Care Survey, 95 percent of the patients who were treated for skin disease by primary care doctors received none of 5 preventive exams listed in the survey, said Steven R. Feldman, associate professor of dermatology and the director of the Westwood-Squibb Center.

Of those patients going to dermatologists, 98 percent received no preventive exams. These figures excluded blood pressure checks, which are routine in many medical offices.

"The data don't support the idea that in cases of skin problems, patients should see their primary care provider because that doctor will also address their comprehensive care needs," Feldman said, the primary author of the study that was published today (Aug. 1) in the August issue of the Journal of the American Academy of Dermatology.

"These findings have important implications," Feldman said. "First, they disprove the presumption by many HMOs that giving patients direct access to dermatologists will result in less effective overall patient care. In fact, despite the evidence that dermatologists are best able to met the needs of patients with skin disorders at no additional cost, most visits for skin disease are being treated by non-dermatologists.

"This suggests that HMOs would do better both by their patients and their shareholders by giving patients greater access to dermatologists."

Under managed care, patients are assigned a primary care doctor who monitors blood pressure and other indicators of overall health, and who counsels patients on health issues such as diet and exercise. This system assumes that the primary care doctor will function as an "early warning system" to detect health problems other than that which brought the patient in to see the doctor in the first place. Primary care doctors do, in fact, provide this comprehensive care for most of the conditions that they see -- but apparently not for skin conditions.

The survey also records data on 12 types of counseling, such as cholesterol levels, tobacco use and diet. The survey showed no counseling in 91 percent of the visits to primary care doctors and 94 percent of the visits to dermatologists.

"These results show that the standard of care for the primary care of skin disease, based on the actual practices of primary care physicians, is attention to the skin problem itself, and not comprehensive medical screening," Feldman said. "Part of the reason may be they're under pressures from managed care to see patients quickly and may not be able to do all the preventive care they would like."

Feldman said that primary care physicians do check blood pressure -- a simple way to check for hypertension -- significantly more often than dermatologists do. But he said it would be a simple enough matter for dermatologists to incorporate blood pressure checks into their routine examination.

Given that the standard of care for skin disease visits is focused on the skin problem, dermatologists are the logical choice for treating these patients, he said. Previously published studies have shown that dermatologists not only are more accurate in diagnosing and effectively treating skin disease, but also are just as cost-effective as primary care physicians.
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Wake Forest Baptist Medical Center

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