Abstract
Introduction
Family physicians (FPs) play a critical role in the early detection of skin cancers. Dermoscopy can improve diagnostic accuracy but its use by FPs in the United States (US) remains understudied.
Objectives
To examine dermoscopy use, factors associated with ever having used (Model 1) and currently using the dermascope (Model 2), and barriers.
Methods
We recruited 705 practicing FPs in-person at conferences and on-line to complete an anonymous, 46 item survey measuring: demographic factors, physician and practice characteristics; confidence in differentiating skin lesions; knowledge and use of dermoscopy; intentions to use; and barriers to use. We conducted bivariate analysis for each outcome and entered the significant predictors into two logistic regressions.
Results
Almost 20% had ever used a dermascope and 8.3% were currently using it. Ever having used a dermascope was associated with being 39 years of age or younger, practicing in academia or community centers, and having higher confidence differentiating skin lesions. Current use was associated with seeing more than 400 patients per month and being 60 years-of-age or older.
Conclusion
Use of dermoscopy by FPs is low. This study is an initial step in understanding its use among US FPs.
Keywords: dermoscopy, dermatoscopy, epiluminescence microscopy, family physicians, primary care
Introduction
As the initial point of contact with the health care system, family physicians (FPs) play a critical role in the early detection of preventable diseases such as skin cancers. FPs routinely screen for skin cancer through visual inspections, which may not be the most optimum strategy [1]. Use of dermoscopy, a relatively inexpensive technology, improves diagnostic accuracy and reduces unnecessary biopsies and referrals to dermatologists [2]. Although studies suggest the dermascope maybe a valuable tool [2,3], little is known about its use among FPs. We examine FP’s use of dermoscopy in the United States (US), factors associated with use, and barriers.
Methods
We recruited 705 practicing FPs in-person at conferences and online to complete an anonymous, 46-item survey measuring demographic factors; physician and practice characteristics; confidence in differentiating skin lesions; knowledge and use of dermoscopy; intentions to use in the next 12 months; and barriers to use (see Survey). We ran descriptive analyses and determined the bivariate associations between key factors and ever having used the dermascope (Model 1) and currently using the dermascope among those who had ever used it (Model 2). For each dependent variable, we ran a logistic regression on the significant factors (p<0.05).
Results
Sample characteristics are described in Table 1. Ever having used a dermascope (Model 1) was associated with being 39 years of age or younger (OR=8.9, CI=4.3–18.6), practicing in academic (OR=2.8, CI=1.3–5.8) or community centers (OR=2.6, CI=1.2–5.5), and having higher confidence differentiating skin lesions (OR=1.7, CI=1.4–2.2). Currently using the dermascope (Model 2) was associated with seeing more than 400 patients per month (OR=8.0, CI=1.6–40.8) and being 60 years of age or older (OR=6.2, CI=1.1–34.6). Both models were highly significant and correctly classified 80.8% (Model 1) and 68.8% (Model 2) of participants. The main barriers were: cost of the equipment (M=3.9, SD=1.2); time and training requirements (M=3.6, SD=1.2); and insufficient reimbursement (M=3.4, SD=1.4) (Table 2).
TABLE 1.
Sample Characteristics
| Characteristics | % of total sample | % that have ever used a dermascope | % currently using of those who have ever used |
|---|---|---|---|
| Age (N*=695) | |||
| ≤39 (n=177) | 25.5 | 36.7 (n=65) | 35.4 (n=23) |
| 40–49 (n=171) | 24.6 | 21.1 (n=36) | 36.1 (n=13) |
| 50–59 (n=181) | 26.0 | 11.6 (n=21) | 57.1 (n=12) |
| ≥60 (n=166) | 23.9 | 6.6 (n=11) | 81.8 (n=9) |
| Ethnicity (N*=702) | |||
| White (n=548) | 78.1 | 19.0 (n=104) | 42.3 (n=44) |
| Black (n=63) | 9.0 | 22.2 (n=14) | 42.9 (n=6) |
| Hispanic/Latino (n=33) | 4.7 | 12.1 (n=4) | 25.0 (n=1) |
| Asian/Pacific Islander (n=45) | 6.4 | 22.2 (n=10) | 50.0 (n=5) |
| Other (n=13) | 1.9 | 23.1 (n=3) | 66.7 (n=2) |
| Gender (N=705) | |||
| Male (n=412) | 58.4 | 17.5 (n=72) | 48.6 (n=35) |
| Female (n=293) | 41.6 | 21.8 (n=64) | 35.9 (n=23) |
| Degree (N=705) | |||
| D.O. (n=532) | 75.5 | 19.4 (n=103) | 43.7 (n=45) |
| M.D. (n=173) | 24.5 | 19.1 (n=33) | 39.4 (n=13) |
| Location (N*=702) | |||
| Urban (n=201) | 28.6 | 20.9 (n=42) | 52.4 (n=22) |
| Suburban (n=306) | 43.6 | 17.0 (n=52) | 38.5 (n=20) |
| Rural (n=186) | 26.5 | 26.3 (n=49) | 30.6 (n=15) |
| Other (n=9) | 1.3 | 33.3 (n=3) | 33.3 (n=1) |
| Type of Medical Practice (N=705) | |||
| Solo (n=190) | 27.0 | 10.0 (n=19) | 63.2 (n=12) |
| Group (n=272) | 38.6 | 19.9 (n=54) | 42.6 (n=23) |
| Hospital-based (n=72) | 10.2 | 16.7 (n=12) | 33.3 (n=4) |
| Academic medicine (n=68) | 9.2 | 33.8 (n=23) | 43.5 (n=10) |
| Community health center (n=72) | 10.2 | 30.6 (n=22) | 31.8 (n=7) |
| Other (n=31) | 4.4 | 19.4 (n=6) | 33.3 (n=2) |
| Time in direct patient care (N=705) | |||
| ≤25% (n=28) | 4.0 | 17.9 (n=5) | 20.0 (n=1) |
| 26%–50% (n=31) | 4.4 | 25.8 (n=8) | 25.0 (n=2) |
| 51%–75% (n=67) | 9.5 | 29.9 (n=20) | 40.0 (n=8) |
| ≥76% (n=579) | 82.1 | 17.8 (n=103) | 45.6 (n=47) |
| Number of patients/month (N*=695) | |||
| ≤100 (n=115) | 16.5 | 18.3 (n=21) | 14.3 (n=3) |
| 101–200 (n=116) | 16.7 | 25.0 (n=29) | 37.9 (n=11) |
| 201–300 (n=149) | 21.4 | 22.1 (n=33) | 45.5 (n=15) |
| 301–400 (n=161) | 23.2 | 15.5 (n=25) | 36.0 (n=9) |
| ≥401 (n=154) | 22.2 | 16.2 (n=25) | 68.0 (n=17) |
| Number of patients/month with suspicious lesions that might be cancerous (N*=689) | |||
| ≤1.5 (n=84) | 12.2 | 16.7 (n=14) | 21.4 (n=3) |
| 1.51–4.99 (n=135) | 19.6 | 20.0 (n=27) | 29.6 (n=8) |
| 5–9.99 (n=132) | 19.2 | 20.5 (n=27) | 40.7 (n=11) |
| 10–19.99 (n=159) | 23.1 | 18.2 (n=29) | 37.9 (n=11) |
| ≥20 (n=179) | 26.0 | 20.0 (n=35) | 65.7 (n=23) |
| Confidence differentiating benign and malignant skin lesions (N*=702) | |||
| Not confident at all (n=15) | 2.1 | 6.7 (n=1) | (n=0) |
| A little confident (n=132) | 18.8 | 16.7 (n=22) | 18.2 (n=4) |
| Neither confident nor unconfident (n=154) | 21.9 | 13.6 (n=21) | 33.3 (n=7) |
| Confident (n=335) | 47.7 | 20.6 (n=69) | 47.8 (n=33) |
| Very confident (n=66) | 9.4 | 34.8 (n=23) | 60.9 (n=14) |
| Heard of a dermascope (N*=702) | |||
| Yes (n=432) | 61.5 | 31.5 (n=136) | 42.6 (n=58) |
| Read about a dermascope (N*=690) | |||
| Yes (n=210) | 30.4 | 41.0 (n=86) | 52.3 (n=45) |
| Used a dermascope (N*=698) | |||
| Yes (n=136) | 19.5 | – | – |
| Currently use a dermascope (N*=698) | |||
| Yes (n=58) | 8.3 | – | – |
| Intentions to incorporate dermoscopy into clinical practice in 12 months (N*=618) | |||
| Yes (n=393) | 63.6 | 22.6 (n=89) | – |
N varies due to missing data
TABLE 2.
Main Barriers to Incorporating Dermoscopy into Clinical Practice
| Mean | Standard Deviation | |
|---|---|---|
| Cost of the equipment | 3.9 | 1.2 |
| Time and training requirements to become proficient in its use | 3.6 | 1.2 |
| Insufficient reimbursement | 3.4 | 1.4 |
Discussion
Despite the benefits of dermoscopy, only 19.5% of participants had ever used it and 8.3% were currently using it. It is not surprising that younger age was the strongest predictor in Model 1, given the increasing availability of dermascopes in current training programs [4]. This could also explain the association with practicing in academia. Since they serve lower socioeconomic status communities, FPs practicing in community centers may be drawn to dermoscopy to reduce costs and improve outcomes. The relationship between greater confidence differentiating lesions and ever having used a dermascope is perplexing. Are FPs with higher diagnostic confidence more likely to have used the dermascope per se, or has experience using the dermascope increased their confidence?
In Model 2, seeing an average of more than 400 patients per month was the strongest predictor of current dermascope use. It could be that FPs who see more patients recognize the need to find tools that increase diagnostic accuracy such as the dermascope. Interestingly, older age, rather than younger age, predicted current use. Since two of the top three barriers to using the dermascope involved financial issues, it could be that older FPs with well-established practices that generate higher revenues have overcome these financial barriers.
Although we recruited participants from 47 states, our sample may not be representative of the US population of FPs. Another limitation was the use of self-report; however, since we were not dealing with sensitive topics, the tendency to provide socially desirable responses was reduced. Last, because many participants completed the survey without direct oversight, there were skip pattern errors and missed responses.
Conclusion
Our study represents an initial step in understanding dermoscopy use among US FPs. Dermoscopy is an underutilized tool that may help FPs promote the health and well being of their patients.
Acknowledgments
We thank the dean of NSU COM and the NSU research fellowship program for the opportunity to conduct this research. We also thank the professional organizations and conference officials who helped us with data collection. Most importantly, we thank all survey participants.
SURVEY
Footnotes
Competing interests: The authors have no conflicts of interest to disclose.
All authors have contributed significantly to this publication.
Funding: Funding for the NSU research fellowship program was obtained by internal university funds.
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