An analysis of patients presenting to primary and secondary care with dermatological conditions in south-east Scotland with reference to the dermatological training of general practitioners

• Main Author: Kerr, Olga Ann
• Published: University of Edinburgh 2012
• Online Access: http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.735482

Cutaneous disease is thought to account for 10-15% of patient consultations with general practitioners, but relatively little is known about the demography of dermatological conditions in primary care. The primary care study aims were to assess the proportion and diagnostic profile of dermatological conditions seen in primary care in the southeast of Scotland, and to draw comparisons with secondary dermatological care. General practitioners in 13 general practices serving a population of approximately 104,621 were asked to note all skin-related consultations during a two-week period. The case notes of these patients were reviewed, and diagnosis and treatment was recorded. Patients who had consulted for the same skin disorder on >/ =3 occasions during the previous year were invited for assessment by a consultant dermatologist. Where possible, the case notes from 10% of all consultations during the two-week study period were examined to assess accuracy of recording. The percentage of consultations relating to cutaneous disorders varied between practices, ranging from 3% to 18.8 %, with a mean of 8.4 %. Eczema accounted for 22.5 %, infections 20.3 %, and benign tumours for 11.4% of consultations with a dermatological basis. In contrast, in secondary care, benign tumours accounted for 23.8 %, malignant tumours 16.4% and eczema 16.3% of dermatological consultations. Dermatological disorders make up a significant proportion of general practitioners workload. The diagnostic profile of primary-care dermatology differs markedly from that of hospital practice. General practitioners may benefit from training specifically tailored to the common primary-care dermatological conditions. In order to plan appropriate delivery of dermatology services we need to periodically assess the type of work we undertake in secondary care and to examine changing trends in the numbers and type of referrals and the workload these referrals generate. The secondary care study aims were to quantify outpatient workload in hospital- based and private practice; to assess reasons for referral to secondary care and to examine the changes over 25 years in the diagnostic spectrum of conditions referred. During November 2005, all outpatient dermatological consultations in the south-east of Scotland were recorded. Demographic data, source of and reason for referral, diagnoses, investigations performed, treatment administered and disposal were recorded, and comparisons made with four previous studies. During the 1-month study, attendances were recorded for 2118 new and 2796 review patients (new/ review 1:1.3, female / male 1.3:1, age range 0-106 years). Eighty-nine per cent of new referrals came from primary care and 11% from secondary care. Fifty-seven per cent of referrals were for diagnosis and 38% for management advice. Benign tumours accounted for 33.4 %, malignant tumours 11.6 %, eczema 16% and psoriasis 7.4% of new cases. For return patients, 20% had skin cancer, 16.5% eczema, 13.4% psoriasis and 9% acne. The referral rate has risen over 25 years from 12.6 per 1000 population in 1980 to 21 per 1000 in 2005, with secondary care referrals increasing from 61 in Nov 1980 to 230 in November 2005. Attendances for benign and malignant skin tumours have increased six-fold since 1980. Patients with eczema and psoriasis account for one third of clinic visits. New referrals have risen by 67 %, with those from other specialities almost quadrupling since 1980 to 11% of the total in 2005. The following chapter examined the dermatological training received by local general practitioners. There is an absence of compulsory vocational training in dermatology for general practitioners and the core medical curriculum in some UK universities is lacking in adequate dermatology training. An anonymous postal questionnaire was circulated to 583 Lothian GPs, with a response rate of 67 %. A qualitative approach was used to detail GPs' experience of dermatology training in the locality both at undergraduate and postgraduate levels, and a quantitative approach to determine: (i) how important doctors consider postgraduate training in dermatology relative to training in other specialities, some of which are compulsory during their vocational training; (ii) what factors prevent doctors from pursuing post- graduate training in dermatology; (iii) how do GPs perceptions of the importance of dermatology training relate to their basic characteristics (type of GP, length of experience as a GP and gender): and (iv) how do GPs experience of their own competence in managing dermatology conditions relate to the length and type of training they have received. From all of these questions, an attempt was made to make some recommendations regarding the future of dermatology training for general practitioners. In total, 71% concluded that dermatology was not only an essential part of the medical core curriculum but should also be taught at postgraduate level. Most GPs concluded that dermatology training at postgraduate level was very important (40.3 %) or important (56.6 %), and 79.5% suggested that clinical training during ST years followed by regular (e.g. 5- yearly) updates would be optimum. GPs rate dermatology on a par with other specialities that are compulsory attachments for their vocational training. No statistical reason for failure to pursue postgraduate training was isolated. GPs' perception of the importance of dermatology was not significantly predicted by their individual characteristics. Receiving postgraduate training in dermatology was positively associated with doctors' perceptions of their own competence at managing skin conditions. Men felt more competent than women. Dermatology should remain an essential part of the undergraduate medical curriculum it should be encouraged as a useful clinical attachment during GP vocational training. Good clinical teaching ran perhaps jointly by a dermatologist and general practitioner should be our aspiration.