Experience Of Dermatologists Research Articles

Primary Care Physicians as Gatekeepers in Managed Care

This study determines (1) the readiness of primary care physicians (PCPs) to triage optimally lesions suspicious for skin cancer, (2) the difference in their abilities from those of dermatologists, and (3) whether accurate diagnosis after viewing slide images transfers to accurate diagnosis after viewing lesions on patients. Seventy-one primary care residents and 15 dermatologists and resident dermatologists diagnosed and selected a treatment/diagnostic plan for skin lesions suspicious for cancer. The lesions were shown on slides, computer images, and patients. Participants' performance was compared with biopsy results of all lesions. Dermatologists' scores were almost double those of primary care residents, and primary care residents' performance was positively associated with previous experience in dermatology. Primary care residents failed 50% of the time to diagnose correctly nonmelanoma skin cancer and malignant melanomas, and 33% of the time they failed to recommend biopsies for cancerous lesions. Primary care residents failed to diagnose malignant melanomas 40% of the time; dermatologists failed to do so 26% of the time. Both groups performed better using slide images compared with patients. Primary care residents may not be ready to assume a gatekeeper role for lesions suspicious for skin cancer. Because of the seriousness of missed diagnoses, especially of malignant melanomas, we need to improve the triage skills of PCPs. Future studies should evaluate whether primary care training allows sufficient time for PCPs to learn the necessary skills. Until we can show that PCPs are prepared to triage optimally, managed care plans should reduce the threshold for referrals to dermatologists of potential skin cancers.

••• no, just based in the real world

Natalie Tidy has misinterpreted the aims of our study. We fully accept the nurses and SHOs involved had different duration of dermatology experience, but to compare two groups with equivalent experience would be both impractical and irrelevant to real life.

Accuracy in the clinical diagnosis and pattern of malignant melanoma at a dermatological clinic.

The diagnostic pattern of malignant melanoma and clinical suspicion rate has been investigated at a dermatological university clinic. Of 174 histologically proven malignant melanomas, 60 (34%) were not clinically suspected as melanomas. The accuracy of clinical diagnosis increased with level of experience. Physicians with < 1 year experience in dermatology were able to detect malignant melanoma as the first diagnosis in 31% of the cases in contrast to 63% for those with > 10 years experience. Of 50 patients immediately referred from the dermatologic clinic to surgery departments, 12 did not have melanoma.

Should patch testing be restricted to dermatologists only?

Calnan (1) wrote that greatest abuse of patchtesting is failure to use and that number ofdermatologists have never patch tested a patient.However, equally or more serious than this maybe to patch test incorrectly and thus provide er-roneous conclusions (2).Patch testing is, at present, the only practicalscientific procedure for the diagnosis of allergiccontact dermatitis (3). The ease of application ofthe test can mislead the unwary into overlookingthe fact that patch testing is a biological assay witha number of pitfalls. Confidence in results canbe achieved only when appropriate experience hasbeen gained in the indication for the test, its correctapplication, and the reading and interpretation ofits results.Patch testing is indicated when allergic contactdermatitis is suspected and the relevant allergenmust be identified or confirmed. As the only objec-tive assessment of any eczema, it may also serve toexclude a relevant contact sensitivity. Testing isnot a substitute for taking the patient's history orexamination (4). It requires considerable dermatol-ogical experience even to suspect contact allergy orcontact allergy as an aggravating factor in otherskin diseases. Allergic contact dermatitis may beimpossible to differentiate clinically from otherforms of eczema, such as atopic, seborrhoeic, num-mular or dyshidrotic eczema, and these conditionsmay coexist. Taking an appropriate history re-quires time, experience and knowledge of potentialallergens that the patient might have come into* On behalf of the Council of the European Society ofContact Dermatitis (W. Aberer, Austria; K. E. Andersen,Denmark; G. Angeiini, Italy; F. M. Brandao, Portugal;D. P. Bruynzeel, The Netheriands; D. Burrows, NorthernIreland; J. G. Camarasa, Spain; G. Ducombs, France;P. J. Frosch, Germany; N. Hunziker, Switzerland; L.Kanerva, Finland; J.-M. Lachapelle, Belgium; J. E.Wahlberg, Sweden; P. Thune, Norway; I. R. White, Eng-land).contact with at home, in the workplace and duringleisure time. Changing consumer habits, produc-tion procedures, allergen prevalence geographicallyand temporally, and other factors must be con-sidered.The optimal choice of test materials and theirapplication may appear simple. Adequate infor-mation should be given to patients before applyingthe test for legal and practical reasons. The occur-rence of irritant patch test reactions, focal flare ofeczema, active sensitization and other rare side-effects of patch testing need to be dealt with appro-priately (3, 5). The skin ofthe back is the preferredsite for testing; it should be free from eczema andnot have been recently exposed to topical cortico-steroids or UV-radiation. The selection of test sub-stances must be based on the patient's history andwill normally include the current version of thestandard (6). This series must be supple-mented with those substances indicated by the pa-tient's history of exposure. The test de-tects only 50-80% of relevant contact allergens.Only standard concentrations should be used;the potential risk of testing with industrial sub-stances of unknown toxieity must be kept in mindand testing with such materials must be cautious.Test readings should be performed according tothe criteria of the ICDRG (3). Negative, doubtful,positive and irritant well-defined terms. Butthe criteria are of absolutely no value when thephysician is confronted with a relatively weak reac-tion (3); this is frequently the case. The criticalpoint in evaluating a positive test response is nothow severe it is, but the determination of whetherit is a true positive caused by allergy or a non-specific irritant reaction.Accurate interpretation is most important: posi-tive reactions can be positive (allergic) or false-positive (irritant), not relevant to the present der-matitis, relevant to a preceding and/or unrelatedproblem, or be the primary or aggravating cause of

How many GP referrals to dermatology outpatients are really necessary?

In a survey of patients referred to the dermatology outpatients department of a British teaching hospital, 26% of referrals were considered unnecessary by a senior house officer with three months practical dermatological experience. We conclude that better undergraduate and postgraduate education in dermatology is essential. A period spent in dermatology should be included in all vocational training schemes for general practice.

Holistic approach to diagnosis in psychosomatic dermatology

Three decades ago, two psychosomatic skin clinics were established by this author—one at the Hadassah University Hospital (1955) in Jerusalem, Israel, and one at the Cincinnati General Hospital (1957) in the United States, with the close cooperation and assistance of their Department of Dermatology (headed by Dr. Leon Goldman) and the Department of Psychiatry (headed by Dr. Maurice Levine and Dr. W. Donald Ross.) Postgraduate dermatologists, residents, medical students, and nurses were trained in the close relationship and possible interaction of organic and emotional factors in certain dermatoses. The teaching was conducted by the author, a dermatologist trained in psychiatry and psychosomatic dermatology. A psychiatrist was only occasionally consulted in specifically psychiatric cases. The aim was to enable the dermatologist to gain sufficient knowledge and experience in psychosomatic dermatology that he could directly handle his own patients by a holistic approach. Thus, this method was on a one-to-one (dermatologist-patient) basis, as opposed to the conventional two-to-one (dermatologist-psychiatrist-patient) relationship. This led to interesting seminar sessions with the residents, as well as special conferences with the hospital patients, and case presentations. Long experience in teaching convinced us that the greatest difficulty of postgraduate and resident dermatologists was in making the correct diagnosis of psychosomatic dermatosis. The aim of this paper is to guide the dermatologist in achieving this goal. To be able to make a proper diagnosis of psychosomatic skin disorder, the dermatologist must free himself of some misconceptions relating to the term “psychosomatic.”

Dermatologic practice

The problems encountered, diagnostic procedures performed, and treatments prescribed in dermatology were studied in a primary care practice and in a dermatology clinic. Referrals from a primary care practice to a dermatology practice were analyzed. It was determined that nine disease categories accounted for more than 75 percent of the problems encountered in both settings. Only one diagnostic procedure was performed commonly in both the primary care and dermatology practices--skin scraping for fungal infection. Approximately 90 percent of the treatments prescribed in both settings fell within 13 categories. It is proposed that these findings be the basis for designing the curriculum in dermatology for residents in primary care medicine. The curriculum also should provide practical experience in dermatology and familiarity with selected, rarely encountered dermatologic conditions that have important therapeutic implications.

Pruritus vulvae as seen in dermatological practice.

Commonly the term pruritus vulvae is used as a diagnosis, though literally it describes only a symptom rarely seen without excoriation or dermatitis; seldom can the patient tell us which was the primary symptom. Unnecessary confusion results when the term is incorrectly applied, as in the presence of a distinctive dermatosis such as vulvar psoriasis or dermatomycosis. Dermatological experience minimizes this fault, which is commoner among general practitioners, gynecologists, and radiologists. There are various views on this disease, partly owing to the confusion of inaccurate terminology and partly to the viewpoints of the various specialists consulted by the patient, whose choice of physician has depended on the presence of vaginitis or discharge, urinary complaints, involvement of the perianal area, or extensive cutaneous inflammation. Because of such variations and because pruritus vulvae is fairly common and is frequently difficult to treat I have surveyed the literature of the past 10 years

SYNTHETIC TAR PASTE

The efficacy of crude coal tar as a topical application is attested by the favorable clinical experience of dermatologists throughout the world. Patients object to its uncleanliness and staining qualities. Furthermore, different lots of crude coal tar vary materially in composition. Feeling that a preparation free of these objectionable qualities and with equivalent therapeutic effect would be distinctly advantageous, we have elaborated a synthetic tar by ascertaining the average formula of crude coal tar and eliminating inert and irritating substances, a classification which, as will be noted, includes 44.7 per cent pitch. Using these figures as a guide, we have prepared a synthetic tar containing quantities of active ingredients equivalent to those contained in the original coal tar, the ratio being corrected in keeping with elimination of the inert substances and the irritating light oils. The formula just given may be used in various preparations in the same percentages as crude coal tar. The following formula is one we frequently use:

Nursing Experience in Dermatology

Nursing Experience in Dermatology

Nursing Experience in Dermatology

Nursing Experience in Dermatology

BLASTOMYCOSIS OF THE PROSTATE, EPIDIDYMIS AND LEG

Blastomycosis was first described by Gilchrist in 1896. It has since been reported from most countries of the world. In the United States it appears to be of more frequent occurrence in the Mississippi Valley region. It is not infrequent in the experience of dermatologists in St. Louis. The particular interest in the case reported here was the localization of blastomycetes in the prostate and epididymis, and the subsequent course following prostatectomy and the use of iodides. The prognosis of systemic blastomycosis is grave. Our patient made a rapid and complete symptomatic recovery We are aware, however, that localized foci of the organism may still be present, and future trouble from this source is not beyond a possibility. <h3>REPORT OF CASE</h3> In the case reported here the lesions on the skin when one of us was called into consultation consisted of an oval ulcer, 3 by 1½ inches, on the