Re: Expert Consensus Statement on Proficiency Standards for Dermoscopy Education in Primary Care

To the Editor: The article “Expert Consensus Statement on Proficiency Standards for Dermoscopy Education in Primary Care” (J Am Board Fam Med 2023;36:25–38)¹ raises more questions than it answers. Only 14 family physicians who are regular users of dermoscopy for early skin cancer detection were part of this expert consensus panel (representing 0.000014% of ABFM diplomates), yet the authors suggest that the dermatoscope could become part of the physician’s toolbox alongside the ophthalmoscope, otoscope, and stethoscope. As with other instrumental skills such as dilated funduscopic examination and cardiac auscultation—proficiency in which by many accounts is declining among medical students and physicians,^2⇓–4 maintenance of skill requires frequent application. A better comparison to the acquisition of dermoscopy skills would be to colposcopy, colonoscopy, and endoscopy, which a subset of family physicians has chosen to make a regular part of their practice.

Despite the expert panel’s implicit goal of increasing the use of dermoscopy by family physicians and the panel’s stated goal for dermoscopy training initiatives—namely, “to decrease patient morbidity and mortality from skin cancer, especially in regions without convenient access to dermatology specialists”—the panel dodges the question of whether teledermatology with a dermatologist (or “teledermoscopy,” to coin a phrase) could better address geographical disparities in early skin cancer detection. Further, the panel inadvertently suggests that the key to early diagnosis of skin cancer with dermoscopy in underserved areas might not be family physicians but rather “advanced practice practitioners,” such as physicians assistants and nurse practitioners. This would be analogous to the roles of allied health professionals like emergency medical technicians and nurse anesthetists.

Although dermoscopy was introduced more than 25 years ago, its most promising use has been in the diagnosis of melanoma. Rather than compile a lengthy list of skin conditions (many of which are uncommon) that dermoscopy can help diagnose, the panel would have better served family physicians by providing a list of skin conditions that we should be able recognize by means of a history, physical examination, and inspection with a hand lens and a good light. For that matter, the recommendations by an expert panel of the most useful textbooks and websites would also be helpful.

Would not a greater emphasis in family medicine residency education—and by the ABFM—in better history-taking and mastery of the diagnosis of common dermatologic conditions be preferable to advanced training in dermoscopy? And who is to say that, given the rapid advances in artificial intelligence, there will not soon be an electronic scanning dermatoscope that will print out a diagnosis, much as our EKG machines now do, albeit imperfectly?

Although dermoscopy can be an asset in the early detection of melanoma, its addition to the primary care toolbox is far from proven. Family physicians should not be made to feel a fear of losing out for not incorporating dermoscopy into their practice.