Diagnostische Strategien, Therapieziele und Kooperation mit Spezialisten bei dermatologischen Erkrankungen. Eine qualitative Untersuchung.

Background: Skin diseases are a common reason for consulting the general practitioner (GP). Many of these dermatological patients are treated by the GP while others, mainly suffering from chronic disorders, will be referred to a dermatologist. This regular occurrence stands in contrast to lack of knowledge and training at the GPs side. Although a highly relevant topic, there is virtually no research on dermatology in primary care. Consequently, little is known about GPs diagnostic approaches in these patients. Research questions: We therefore aimed to analyse how GPs approach patients presenting with skin disease and to explore their different diagnostic approaches. Furthermore, we aimed to identify strategies how GPs handle diagnostic uncertainty as well as the way they cooperate with dermatologists, the use of cortisone in daily practice, their opinion towards skin cancer screening and what areas GPs would identify for further research and training. Material and methods: In semi-structured interviews (20 to 40 minutes), 14 GPs were asked to describe, among other topics, their personal diagnostic approaches in 2-3 of their patients with acute or chronic skin problems they had prospectively identified (stimulated recall). Interviews were taped and transcribed verbatim. Qualitative analysis was conducted by two independent raters using a deductive-inductive approach. Results: We identified several aspects of a complex decision making process in GPs’diagnostic management of patients with dermatological problems. In the general diagnostic workup, GPs used a broad spectrum of different strategies like spot diagnosis, stepwise refinement, pattern recognition trigger or test of treatment. GPs reduced diagnostic uncertainty through identification of red flags, application of the test of time, therapeutic trials and asking for further advice including patient referral. Regarding the cooperation with der dermatologist, GPs were faced with the difficulty to get a timely appointment and complained about the lack of professional feedback. Furthermore, we could identify three different ways how GPs use steroids in daily practice. In regard to skin cancer screening, GPs showed quite different opinions ranging from total acceptance to strict rejection. Conclusions: GPs encounter a broad range of dermatological problems in their daily work using a variety of strategies in the work up of these patients. However, in a significant number of patients, there remains diagnostic uncertainty that is reduced mainly by specialist referral. Cooperation between GPs and dermatologists can still be optimized, especially concerning communication and division of work. GPs would clearly profit by distinct recommendations regarding steroid therapy for common skin diseases. Internationally established approaches such like tele dermatology or regular sessions of a dermatologist GPs’ practices could be established as model projects. In addition, regular training diagnosis and treatment of common dermatological diseases should be offered to all GPs.