Diagnosing and managing cutaneous pigmented lesions: primary care physicians versus dermatologists

Abstract

Background: Primary care physicians (PCPs) are often expected to screen for melanomas and refer patients with suspicious pigmented lesions to dermatologists.

Objective: To assess whether there is a difference between dermatologists and PCPs in accurately diagnosing melanoma and appropriately managing (based on decisions to refer/biopsy) suspicious pigmented lesions.

Design, participants: A survey based on a random sample of 30 photographs of pigmented lesions with known pathology was administered to 101 dermatologists and 115 PCPs from October 2001 to January 2003.

Measurements: Likelihoods that a photographed lesion was melanoma and that the lesion should be biopsied/referred were scored on a 1 to 10 scale. Accuracy of melanoma diagnosis and appropriateness of pigmented lesion management were compared between dermatologists and PCPs by using the areas under (AUC) the receiver operating characteristic (ROC) curves.

Results: Dermatologists were superior to PCPs in diagnosing melanomas (AUC 0.89 vs 0.80, P<.001) and appropriately managing pigmented lesions (AUC .84 vs 0.76, P<.001). PCPs who tended to biopsy lesions themselves did better at managing pigmented lesions than PCPs who did not perform biopsies. Dermatology training during residency did not significantly improve the diagnostic accuracy of PCPs nor their management of pigmented lesions.

Conclusions: Dermatologists have both better diagnostic accuracy and ability to manage pigmented lesions than PCPs. Yet, there is a shortage of dermatologists to meet the demand of accurate melanoma screening. More innovative strategies are needed to better train PCPs and enhance skin cancer screening.

FIGURE 1

Average ROC curves for dermatologists and PCPs. Question A: likelihood the lesion should be biopsied/referred. Question B: likelihood the lesion is a melanoma.