Primary care in dermatology
Authors: Daniel G. Federman, Robert S. Kirsner
Journal: Journal of the American Academy of Dermatology (1997)

We laud the efforts of the Journal in attempting to convey the two conflicting sides of the contentious debate over who should render primary care for patients with cutaneous disease in the articles entitled “Primary Care in Dermatology: Whose Role Should It Be?” (J Am Acad Dermatol 1996;35:1005-8) and “The Dermatologist’s Role in Primary Care: A Primary Care Physician’s View” (J Am Acad Dermatol 1996;35:1009-11). We disagree with Dr. Hainer’s position that, because health outcomes for patients with hypertension and diabetes do not differ whether or not they are treated by generalists or subspecialist physicians, primary care physicians should continue to care for patients with dermatologic problems. Clearly, primary care physicians receive extensive training during medical school and residency in the care of patients with these common conditions, in contradistinction to training in dermatology. 1Kirsner RS Federman DG Lack of correlation between internists’ ability in dermatology and their patterns of treating patients with skin disease.Arch Dermatol. 1996; 132: 1043-1046Crossref PubMed Google Scholar Although, as Dr. Hainer points out, many of the studies cited by Drs. Ramsay and Weary suffer from inherent flaws and biases, the preponderance of evidence suggests that primary care physicians’ performance in diagnosing and treating skin disease is suboptimal. One study not cited by either author examined the cost of care and concluded that the average cost of initiating care was less expensive when rendered by a dermatologist than a family physician. 2Clark RAF Rietschel RL The cost of initiating appropriate therapy for skin diseases: a comparison of dermatologists and family physicians.J Am Acad Dermatol. 1983; 9: 787-796Abstract Full Text PDF PubMed Scopus (64) Google Scholar Outcomes research is critically needed to ascertain whether or not the care rendered by the two groups differ in cost (both direct and indirect), patient satisfaction, and ultimately patient outcome. 3Kirsner RS Federman DG Managed care: the dermatologist as a primary care provider.J Am Acad Dermatol. 1995; 33: 535-537Abstract Full Text PDF PubMed Scopus (21) Google Scholar It is our position that primary care physicians possess considerable expertise in a wide variety of clinical areas and are essential for comprehensive and cost-efficient care. Whether it is due to a lack of training or other factors, however, there is considerable concern over their performance in the dermatologic arena. Until evidence from outcomes research becomes available, patients with cutaneous disorders should continue to be treated by dermatologists, and primary care practitioners should receive significantly more training in the management of patients with cutaneous disorders. At the core of this issue is physician access. We believe that on the basis of current data with respect to skin disease, access should not be limited. Analysis of the relative merits of care rendered by either primary care practitioners or dermatologists will ultimately drive the development of health care delivery systems. Therefore we also believe that the optimal research will be generated from evaluating and examining various health care delivery systems with regard to outcomes. This should be the focus for further research endeavors.