When I first saw a paper discussing this topic, I thought that’s a daft question! Of course, but then the evidence-based mind track kicked in and said well, is there any research looking at this? So, in this short blog, I will look at two recent papers presented at the British Association of Dermatologists Conference in Manchester (July 2024).
A change in role
Following the pandemic, reduced access to primary care services have meant that many health care practitioner roles have changed, both unofficially and officially. From my own practice I continue to be asked by patients about health care services outside of my scope of practice owing to the difficulties of accessing general practitioners, for example.
Melanoma rates are increasing across the world but generally we are seeing a levelling of mortality rates in many countries. There are a few possible reasons for this, but one explanation is that awareness of the disease is increasing, and suspicious lesions are being spotted earlier, improving the prognosis for patients. So, it could be asked which healthcare professionals are responsible for discovering these and referring them for diagnosis?
A study of non-medical practitioner’s referrals to skin cancer clinics
A joint study between the UK and Australia published in the British Journal of Dermatology posed this question – looking at referrals to skin cancer clinics by non-medical professionals [1]. Data was collected prospectively from patients referred to a dermatology department under the 2-week wait system. This included ascertaining the original referral source (from the letter and by asking the patient). The ultimate diagnosis was also matched to the referral.
The study included 753 patients, and of these just under a third (29%) were ultimately defined as having a skin cancer. 88.7% were GP referred versus 11.3% by a non-medical practitioner. Where identified, most of the referrals were made by nurses (73%), paramedics (24%) and physician associates (4%). Interestingly, the data showed that non-medical practitioners were equally as likely to correctly identify a skin cancer as a GP (29% v 29.3%).
The study was conducted within the UK, but no specific mention of podiatry is made in the work although nearly a quarter of non-medical referrals were not listed as any being from any one particular profession it’s possible that it could be within that data.
Melanoma awareness amongst Podiatrists
Although the study did not specifically refer to podiatrists, a second recent paper examines podiatry specifically. A study from Ireland, has focussed more on podiatrists awareness of melanoma [2]. In a survey of 400 Irish podiatrists a 18-item questionnaire explored the awareness and knowledge of practitioners towards melanoma. There were 247 responses (62% response). Podiatrists reported seeing on average 30 patients a week. Just over two-thirds (58%) had been asked to examine suspicious lesions, many on numerous occasions. Over 175 (71%) reported observing a suspicious lesion which warranted referral back to the general practitioner or recommending a dermatology review.
The downsides were that 81.9% of podiatrists received no feedback on the outcome/diagnosis following referral. Of more concern, over a third 34% did not feel comfortable making a referral back to the GP. Similarly discussing sun protection with patients was difficult for just over half of respondents (55%). Ultimately 81% felt they were ill-equipped in their undergraduate training around melanoma knowledge.
Non-medics can recognise skin cancer as frequently as GP’s
Collating the findings from these two studies, one can gain insight into melanoma recognition amongst non-medics and podiatrists. Firstly, the research suggests that non-medical practitioners can be equally as good at spotting skin cancer as GP’s. Secondly, podiatrists frequently examine suspect lesions on the lower limb as part of their daily workload, however, many feel inadequately trained to do this.
As authors in both studies suggest that more research, education and supervision be directed towards this group with accreditation of training pathways to capitalise on this increasingly important cohort of referrers. A sentiment which most podiatrists would strongly endorse. A previous study has shown how valuable dermoscopy training can be for podiatrists in increasing awareness and early recognition of acral melanoma [3]. With the training and the tools there is no reason why we cannot routinely take on this role.
Finally, I think it is time to revisit the referral pathways. It seems a waste of time and resources referring patients to the GP’s when a melanoma is suspected. A direct referral route would be more beneficial. Moreover, with podiatrists making these referrals themselves to dermatology, one would envisage correspondence back to the referring podiatrist with the results which would help with learning and demonstrate the value in what we do.
References
1. Anderson, A.D.G., et al., P024 Skin cancer referrals by non-medical practitioners: a prospective observational study. British Journal of Dermatology, 2024. 191 (Supplement 1): p. i25-i25.
2. Nolan, B., C. O’Connor, and M. Murphy, P049 Best foot forward: awareness of melanoma of the foot among podiatrists. British Journal of Dermatology, 2024. 191 (Supplement 1): p. i37-i37.
3. Serra-Garcia, L., et al., Dermoscopy training course improves podiatrists’ accuracy in diagnosing lesions suggestive of acral melanoma: A cross-sectional study. Australas J Dermatol, 2021.63(1): p. e44-e48.
