Abstract
Scientific advances have altered the nature of primary care medicine. Once the prototypic general practice physician was one who embodied limitless empathy and compassion, who possessed a great deal of common sense about medicine and about life in general, and who often cared for the entire family, whatever the problem might be. Although general practice physicians were an esteemed force dedicated to ensuring the health of their patients, they were often limited in their abilities to have an impact on common diseases affecting their patients. As scientific advances in the latter half of the twentieth century led to an explosion of knowledge in the understanding of many disorders and their therapies, the need for specialists developed. At the same time, these technologic advances led to tremendous increases in the cost of health care and the subsequent development of managed care as an effort to curb the mounting costs.
The emergence of managed care has also helped define the present role of the primary care physician. Primary care physicians have been thrust in the role of gatekeeper and must deftly and adroitly identify and care for a broad spectrum of common maladies in a cost-effective manner. They must know when to use consultants and whom to consult and to coordinate the care of acutely and chronically ill patients, who often are cared for by several consulting physicians. They also must take active roles in disease prevention through immunizations, education, cancer and other disease screening, and risk factor identification and modification.
Although primary care physicians strive for and frequently attain clinical excellence, their performance has been the subject of much debate as care has shifted away from specialists toward primary care physicians. Although primary care physicians have been shown to perform well compared with specialists in the treatment of hypertension and diabetes mellitus,
15
they have not fared well in the interpretation of pulmonary function testing
17
or in the diagnosis and treatment of acute myocardial infarction
1,18
or depression and anxiety.
17
Whether primary care physicians possess the abilities and skills to care for patients with cutaneous disease has generated considerable controversy.
11,16,19,25
The importance of cutaneous disease is underscored by its prevalence: Approximately 6% of outpatient office visits are for diseases of the skin, hair, and nails,
27
and nondermatologists treat almost 60% of these patients.
31
Skin disorders are encountered by 20% to 25% of patients seen in the primary care setting.
2
This article describes studies conducted in the United States that attempted to assess how primary care physicians compare with dermatologists in the diagnosis and treatment of skin disease.
