As we go through our workdays, each of us is faced with a myriad of patients who have concerns about a spot or mole being malignant.  Indeed, with the incidence of basal cell carcinoma outnumbering all other cancers combined, and with the incidence of melanoma now being the sixth most common malignancy, there are plenty of people walking around with something that should be treated. 

Problem is, there are so many people and so few dermatologists.  It would be nice to have a little help in a least separating the worried well from those with a bona fide malignancy, so we could concentrate on those who truly need our expertise.

Taking the time to actually look at the skin is still the best way to detect cutaneous malignancies.  Patients and doctors alike know that a sore that doesn’t heal or a changing mole is a sign to get it checked out.  It is something axiomatic to dermatologists.

Recently, the US Prevention Services Task Force concluded that there was insufficient evidence to recommend that primary care practitioners conduct full-body skin examinations for the detection of skin cancer. 

Specifically, there was no evidence to show that full body skin examinations improved outcomes in patients with skin cancer, nor does the early detection of skin cancer reduce morbidity or mortality.  Furthermore, there was no evidence to show whether patient self-examination was better or worse than examinations performed by their doctors.  In fact, one study quoted by USPSTF indicated that patients were better than their doctors in detecting skin cancer.  The keystone for these conclusions lies with the lack of  well-constructed, adequately powered randomized control trials in the area.

After first reading the report, I was skeptical that the authors had even thought this through.  How can it be possible that screening someone for one of the most common cancers of all time be such a waste of time? 

However, after reviewing it again (after a few glasses of fine Cabernet), there are two issues that deserve further examination.  First, despite the lack of very large RCTs, there is substantial evidence that primary care physicians have difficulty in recognizing skin cancer lesions. 

Second, even while the risks for harm caused by the biopsy, potential for over-diagnosis and the anxiety produced during the wait for the diagnosis was small, the USPSTF felt that it would take the average primary care physician over 10 minutes to do a full body skin examination.  Apparently, the 10 minutes spent on the skin examination was an opportunity cost that prevented a discussion on smoking cessation or dietary counseling. 

If we want our primary care colleagues to help shoulder the burden, we must provide them with the proper tools.  Unfortunately, dermatology training in the undergraduate curriculum and in postgraduate training is almost extinct. 

Even if we cannot get more face time with the students and residents, perhaps we can focus on the preceptors, those with whom the students spend most of their time.  A one-hour lecture with students cannot compare with a long-term exposure and application of proper examination skills performed by one of their mentors in the clinic.  A kind of "Train the Trainer" model that has been successful in other areas.

The second issue of examination time is a little more ponderous.  While it is conceivable that if you don’t know what you are looking for, it could take you a long time to do it.  However, a study by Zalaudek published in the Archives of Dermatology shows that a cutaneous skin examination performed by a dermatologist takes about 70 seconds, and almost 3 minutes if using a dermatoscope.  While dermatologists are much more facile in doing CSEs, it is not difficult to think that primary care physicians can learn to inspect the skin in zones within the same timespan.  To dismiss the value of skin examinations based on the fact it may take too long is not defensible. 

Is there anything that we as dermatologists can do to ensure that this valuable procedure is not denied to our patients?  The precious RCT will not be forthcoming.  It is estimated that it would take over 800,000 patients to drive a sufficiently powered study to explore the utility of skin examinations.  Even in Australia, where the incidence of skin cancer is much higher than in North America, over 400,000 patients would need to be recruited.

Instead of a large scale approach, perhaps a more subtle, intimate and subversive approach would be more useful.  Call up your local university or postgraduate training program, and find out who the key preceptors are in the institution.  Invite them to meet with you to outline your concerns that their primary care residents are not learning a valuable skill, and teach these preceptors the skills to provide a thorough skin examination in an efficient and effective way.  Then touch base occasionally to offer your assistance to reinforce the skills.  In this way, you can start your own little revolution, and help to elevate the quality of care in their patients.

At least that’s the way it looks from up here.