Family Physicians Discuss Dermatologic Training

In a recent article in Family Medicine,¹ Fleischer and colleagues offer several interesting comments based on minimal data. Whether family physicians function as gatekeepers or medical sieves, their beliefs are meaningful to specialists, and in this case, skin specialists. The following paragraphs expound on several of the observations made by Fleischer and coauthors.

Family physicians are now required to have a minimum of 60 hours of dermatologic training, although most programs allocate 135 hours. Younger family physicians are superior to their older counterparts in the diagnosis and treatment of skin disorders. Twenty-two percent of family practice residents feel somewhat unprepared to treat skin ailments. Dermatologic problems account for 7.2% of all office visits to family physicians, which is higher than the previous decade. The most common skin disorders diagnosed by these physicians were dermatitis (16.4% of all diagnoses), pyoderma (13.7%), warts (8%), and tinea (5.4%). On the other hand, the most common skin disorders diagnosed by dermatologists were acne (18%), dermatitis (13.1%), actinic keratosis (11.5%), and skin cancer (7.6%).

Fleischer et al assert that family physicians have special needs because "skin disorders diagnosed by family physicians differ considerably from those diagnosed by dermatologists." They feel that it is important to

recognize these dissimilarities to place emphasis on the proper areas of study. . . . The teaching of dermatology to family practice residents should be done by family physicians who are well trained and have excellent experience with skin diseases or by dermatologists who are aware of family physicians' unique needs. ...Family practice residency programs should prepare residents to recognize which of their patients are most likely to present with skin disease, and concentrate on the skin diseases seen most commonly in family practice situations.

These authors envision that 3 areas that family physicians should spend additional time to "specialize" in are melanoma, dermatitis, and psoriasis. In terms of psoriasis, they assert that "its treatment is within the capabilities of the family physicians."

Unequivocally, there is some room for discussion. First of all, I am not convinced that family physicians attend to a different assortment of skin disorders than dermatologists. We just do not converse with identical lingoes. Lichen simplex chronicus to a dermatologist may be termed dermatitis to the family physician. Acne, hidradenitis, and furuncles may represent distinct entities to the skin specialist, and yet the family physician may coin them pyoderma. If my observation is correct, it would negate the bulk of the authors' dissertation.

Their study does not address possible referral restraints imposed by various insurance providers. Although assigning patients to dermatologists is alluded to, they offer no guidelines as to when such an action would materialize. Correspondingly, the carte blanche statements concerning family practice residency training from the scanty information provided in the text could lead to illogical conclusions.

In all medical specialties one must perform at one's level of expertise and comfort. Whether facing a medical or surgical dilemma, if one believes a physician in a different specialty, or even in the same specialty, can perform the service more proficiently, then refer the patient. Listing diagnoses that a family physician should always be qualified to treat without referral appears senseless and not predicated on good patient care standards. On the other hand, if family physicians, by their training, expertise, or interest in a particular field (be it psoriasis therapy or wedge resections on the cheek), desire to treat a condition, no one should constrict them from their efforts. Specialty teaching standards should not obstruct physicians from performing, or not performing, the various acts of medical care. In short, patients will be better served by a coherent team approach. And finally, never let your schooling get in the way of your education or patient care.