Dermatology: Practical and Conceptual Research | Dermatol Pract Concept 2017;7(4):13 63 DERMATOLOGY PRACTICAL & CONCEPTUAL www.derm101.com Introduction: Family physicians (FPs) play a critical role in the early detection of skin cancers. Der- moscopy can improve diagnostic accuracy but its use by FPs in the United States (US) remains under- studied. Objectives: To examine dermoscopy use, factors associated with ever having used (Model 1) and cur- rently using the dermascope (Model 2), and barriers. Methods: We recruited 705 practicing FPs in-person at conferences and on-line to complete an anony- mous, 46 item survey measuring: demographic factors, physician and practice characteristics; confi- dence 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 com- munity 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. ABSTRACT Introduction As the initial point of contact with the health care system, family physicians (FPs) play a critical role in the early detec- tion of preventable diseases such as skin cancers. FPs rou- tinely 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. Examining the factors associated with past and present dermoscopy use among family physicians Jeffrey B. Morris1, Sarah V. Alfonso1, Nilda Hernandez1, M. Isabel Fernández1 1 College of Osteopathic Medicine, Nova Southeastern University, Ft. Lauderdale, FL, USA Key words: dermoscopy, dermatoscopy, epiluminescence microscopy, family physicians, primary care Citation: Morris JB, Alfonso SV, Hernandez N, Fernández MI. Examining the factors associated with past and present dermoscopy use among family physicians. Dermatol Pract Concept 2017;7(4):63-70. DOI: https://doi.org/10.5826/dpc.0704a13 Received: May 5, 2017; Accepted: July 15, 2017; Published: October 31, 2017 Copyright: ©2017 Morris et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: Funding for the NSU research fellowship program was obtained by internal university funds. Competing interests: The authors have no conflicts of interest to disclose. All authors have contributed significantly to this publication. Corresponding author: M. Isabel Fernández, PhD, Professor and Director NSU COM Research Fellowship Program, 2000 S. Dixie Highway Suite 108, Miami, FL 33133, USA. Tel. 305-860-8710; Fax. 305-860-8742. Email: mariafer@nova.edu mailto:mariafer@nova.edu 64 Research | Dermatol Pract Concept 2017;7(4):13 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) Research | Dermatol Pract Concept 2017;7(4):13 65 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 differ- entiating 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). Discussion Despite the benefits of dermoscopy, only 19.5% of partici- pants 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 diag- nostic confidence more likely to have used the dermascope per se, or has experience using the dermascope increased their confidence? 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 cur- rently 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 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 Characteristics % of total sample % that have ever used a dermascope % currently using of those who have ever used 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 66 Research | Dermatol Pract Concept 2017;7(4):13 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 organi- zations and conference officials who helped us with data col- lection. Most importantly, we thank all survey participants. References 1. Herschorn A. Dermoscopy for melanoma detection in family prac- tice. Can Fam Physician. 2012;58(7):740–745. 2. Menzies SW, Emery J, Staples M, et al. Impact of dermoscopy and short-term sequential digital dermoscopy imaging for the manage- ment of pigmented lesions in primary care: A sequential interven- tion trial. Br J Dermatol. 2009;161(6):1270–1277. 3. Argenziano G, Puig S, Zalaudek I, et al. Dermoscopy improves accuracy of primary care physicians to triage lesions suggestive of skin cancer. J Clin Oncol. 2006;24(12):1877–1882. 4. Terushkin V, Oliveria SA, Marghoob AA, Halpern AC. Use and beliefs about total body photography and dermatoscopy among US dermatology training programs: an update. J Am Acad Dermatol. 2010;62(5):794–803. 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 der- moscopy use among US FPs. Dermoscopy is an underutilized Research | Dermatol Pract Concept 2017;7(4):13 67 — SURVEY — 68 Research | Dermatol Pract Concept 2017;7(4):13 Research | Dermatol Pract Concept 2017;7(4):13 69 70 Research | Dermatol Pract Concept 2017;7(4):13