Gerbert B, Maurer T, Berger T, Pantilat S, McPhee S J, Wolff M, Bronstone A, Caspers N
Division of Behavioral Sciences, School of Dentistry, University of California-San Francisco, USA.
Arch Dermatol. 1996 Sep;132(9):1030-8.
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.
本研究旨在确定（1）基层医疗医生（PCP）对疑似皮肤癌病变进行最佳分诊的准备情况，（2）他们与皮肤科医生在能力上的差异，以及（3）在查看幻灯片图像后做出的准确诊断是否能转化为在查看患者病变后的准确诊断。71名基层医疗住院医师以及15名皮肤科医生和皮肤科住院医师对疑似癌症的皮肤病变进行诊断并选择治疗/诊断方案。病变以幻灯片、计算机图像和患者身上的形式呈现。将参与者的表现与所有病变的活检结果进行比较。
皮肤科医生的得分几乎是基层医疗住院医师的两倍，且基层医疗住院医师的表现与之前的皮肤科经验呈正相关。基层医疗住院医师在诊断非黑色素瘤皮肤癌和恶性黑色素瘤时，有50%的时间诊断错误，并且有33%的时间他们未能对癌性病变建议进行活检。基层医疗住院医师在40%的时间里未能诊断出恶性黑色素瘤；皮肤科医生在26%的时间里未能做到。与查看患者身上的病变相比，两组在查看幻灯片图像时表现更好。
基层医疗住院医师可能尚未准备好对疑似皮肤癌的病变承担把关人的角色。由于漏诊的严重性，尤其是恶性黑色素瘤的漏诊，我们需要提高基层医疗医生的分诊技能。未来的研究应评估基层医疗培训是否能为基层医疗医生留出足够时间来学习必要的技能。在我们能够证明基层医疗医生已准备好进行最佳分诊之前，管理式医疗计划应降低将潜在皮肤癌患者转诊至皮肤科医生的门槛。
