Skin biopsy indications in primary care practice: a population-based study.

BACKGROUND: To better understand skin biopsy practice among primary care providers, we sought to describe (1) the type and variability of skin lesions biopsied within a defined population, (2) the providers' previous skin cancer experience in clinical practice, and (3) how providers are alerted to the lesions. METHODS: Our study was based upon 1215 skin biopsies done by family physicians, internists, physician assistants, and certified nurse midwives at a health maintenance organization between June 1989 and February 1992. Biopsy reports were reviewed, and providers were both surveyed and interviewed. RESULTS: There were 1004 benign, 89 premalignant, and 122 malignant skin lesions removed for biopsy by 47 primary care providers. The five most frequent biopsy diagnoses were nevi, seborrheic keratoses, actinic keratoses, cysts, and dermatofibromas. Personal interviews indicated that providers noticed lesions based on their experience with pictures, text descriptions, or variation from expected growth, behavior, or response to treatment. Seventy percent of providers interviewed stated that most often the patient brought the lesion to the attention of the provider. CONCLUSIONS: Among the skin lesions examined by biopsy in this primary care setting, 82.6 percent were benign, 7.3 percent were premalignant, and 10.0 percent were malignant. Worthy educational objectives suggested by this study include (1) meeting primary care providers' need for information about early detection of skin cancers, (2) increasing provider access to visual dermatology resources, and (3) increasing patient awareness of skin cancers.

Skin cancer diagnosis in a primary care setting.

BACKGROUND: Primary care providers are in a good position to detect sk in cancers early, but their current involvement in diagnosis and referral of patients with skin cancer is unknown. Some managed care settings utilize a primary care case manager approach to health care. OBJECTIVE: The purpose of this study was to assess the incidence and demographic associations of skin cancer in a managed care population served by primary care providers. METHODS: this study analyzed 1215 skin biopsy specimens obtained by family physicians, internists, and supervised certified physician assistants within an eastern Washington health maintenance organization and the 69 biopsy specimens obtained by referral specialists and confirmed by pathologic consultation. RESULTS: Internists, family physicians, and their physician assistants performed 94.7% of the biopsies on 87% of all malignancies. Dermatologists and surgeons performed the rest. Primary care providers and dermatologists detected malignant melanomas at a rate comparable to a similar study from British Columbia but lower than other previous investigations. CONCLUSION: Melanomas were diagnosed in this managed care system at a rate comparable to a similar system in Canada. Lower rates for other skin cancers are probably because of methodologic differences from other studies, but variation in histologic diagnoses between pathologists and differences in skin cancer detection cannot be excluded.

Reliability of skin biopsy pathology.

BACKGROUND: The diagnosis of skin disease by histologic examination is regarded as the reference standard upon which therapy and follow-up are determined. Our study investigated the reliability of skin biopsy diagnosis requested by family physicians and physicians' assistants. METHODS: Biopsy diagnoses by a community-based pathology group were reinterpreted by our study dermatopathologist on a sample of 119 skin biopsies randomly selected from the 1844 biopsies performed by family physicians and physicians' assistants at a large Washington State health maintenance organization during a 4 1/2-year period. RESULTS: There were 107 exact matches and 3 mismatches of premalignant lesions and 6 mismatches of benign diagnoses. In addition, two melanomas diagnosed by the community-based pathologists were interpreted as benign by our study dermatopathologist. A third melanoma diagnosed by the community-based group was interpreted as a poorly differentiated squamous cell cancer by the university dermatopathologist. The weighted kappa, 0.83, indicated excellent interrater agreement. CONCLUSION: Although our study showed excellent interrater concordance of skin biopsy interpretation, there was disagreement about three melanomas between a community-based general pathology group and our study dermatopathologist. The melanoma disagreement is consistent with previous studies that found poor interrater agreement for early melanomas. The community-based pathologists were uncertain about two of these melanomas, and as part of their quality control and review procedures requested confirmation by an expert pathologist, who agreed with the melanoma diagnosis. Family physicians are justified in requesting a second opinion (if not automatically requested by a community laboratory) when the histopathologic diagnosis is not in concordance with the clinical history or impression or when the pathologist is unsure of the diagnosis.

Patient sex role and preference for a male or female physician.

A study was undertaken to test whether a patient's sex role, as measured by the Bem Sex Role Inventory, is associated with preference for a male or female physician. One hundred ninety-three patients completed a physician preference survey and the Bem Sex Role Inventory. Thirty-six percent of patients preferred a physician of a specific sex. For women, sex role was associated with preference for a female physician (chi 2 = 16.14, P less than .01). Women with an androgynous sex role who gave a preference always chose a female physician; three fourths of women with an undifferentiated sex role who gave a preference always chose a female physician. Regardless of sex role, men who gave a preference always chose a male physician. For women, these findings support the hypothesis that sex role is associated with preference for a female physician.

Physicians treating their own spouses: relationship of physicians to their own family's health care.

Fifty-one family physicians and a comparable group of 65 lawyers were surveyed to determine how each group treated the medical problems of their spouses. There was no significant difference between physician and lawyer controls in the treatment of headaches, sore throats, vomiting, depression, pregnancy, and warts. In fact, the controls treated back pain and stomachaches more often. The physicians treated earaches and deep lacerations more often. The physicians more frequently took a symptom history and examined their spouse. Both groups treated their spouses' headaches, sore throats, and stomachaches at a high rate. This study supports the impression from a literature review and case studies that unique multiple interacting factors determine whether a physician will treat his or her spouse. These factors are feeling of responsibility to answer a request for treatment, cost, convenience, confidentiality, lack of confidence, emotional involvement or detachment, ego needs, and legal considerations. It is concluded that (1) physicians do not generally treat their spouses more often, but they do evaluate their spouses' symptoms more often than do nonphysicians, and (2) the decision to treat by the physician may compromise good care for his or her spouse. It is recommended that physicians and their spouses have an alternative, nonrelated physician to care for their health.