No rash referrals

There was a push to reduce the need for specialists, with primary care physicians taking on more responsibility. With the growth of gatekeeper HMOs during that decade, in many areas primary care practitioners had to exhaust practically all treatment options before referring patients with difficult medical conditions to the appropriate specialists.

Dermatology possibly suffered more than many other specialties, due to an assumption that anyone can treat skin problems. Dermatologists were portrayed in a famous "Seinfeld" episode as "not really doctors,"but as practitioners who just treated "pimples and warts."

On Call talked to a number of dermatologists around the country to see if primary care physicians are still treating patients with skin problems longer than they should.

We asked how dermatologists handle that, and how it affects the care of their patients.

In general, the dermatologists who spoke to On Call say general practitioners (GPs) are much less likely now than in the past to hold on to patients beyond their ability to treat them, but that this can be problematic when GPs don't make timely referrals.

Jean-Denis J.D. Boucher, M.D., F.A.A.D., in San Antonio, says, "It's very few primary care physicians who will try to keep patients as long as they can, but we do have a general practitioner here who advertises that he does dermatology. I don't know where he was trained, but I've seen some of his patients who hadn't worked out."

Dr. Boucher says he doesn't pay much attention to the types of conditions non-dermatologists try to treat too long, but contends it's the patients' responsibility to report these physicians to their state medical boards.

"I'm not the doctor police, and I won't go out of my way to call the general practitioners and tell them they've made a mistake," he says. "It's up to the patient to complain, although I did call a doctor once who had prescribed tigazon for a young woman of child-bearing years. Fortunately, when she got pregnant, the baby had no complications, but I was really upset and I called that doctor."

"My biggest concern is seeing biopsies done that are just not appropriate or properly done - for example, performing shave biopsies on pigmented lesions - because then we aren't able to determine the Breslow, Clark level.

"Although procedures are sometimes reimbursed at a higher level, I hope the primary care doctors aren't doing it for the money. The problem is, they feel they need to be able to do everything for a patient. Then, when the biopsy comes back showing something like a melanoma, they realized that they've stepped out of their comfort zone and now need to refer the patient, when they really should have referred one step before."