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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Throughout their career and even as early as medical school&#44; physicians are often consulted outside the appointments system&#46; Medical professionals&#44; but particularly dermatologists&#44; can easily recall a situation in which medical advice was informally requested in a street&#44; elevator&#44; corridor&#44; and even in the surgery&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Dermatologists are possibly more likely than other specialists to be asked for informal medical advice&#44; given that the skin is immediately accessible and easily explored&#46; It is this very accessibility&#44; in fact&#44; that leads people to expect the dermatologist to be able to resolve their query immediately&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">With a view to better understanding informal consultations in a hospital setting&#44; we documented 270 consultations between October 2008 and July 2009 in order to profile the individuals who request medical advice&#44; their reasons for consulting&#44; the severity of their complaints&#44; and the dermatologists&#8217; responses&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Objectives</span><p id="par0020" class="elsevierStylePara elsevierViewall">The objectives of the study were to describe the following&#58; &#40;1&#41; the profiles of the consulting individuals&#44; &#40;2&#41; the reasons for consultation&#44; &#40;3&#41; the dermatologist&#39;s diagnosis and treatment&#44; &#40;4&#41; the dermatologist&#39;s assessment of the severity of the complaint&#44; and &#40;5&#41; the dermatologist&#39;s assessment of the care given&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Material and Methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">The data for the study were recorded by dermatologists and resident dermatologists at Hospital Cl&#237;nico San Cecilio de Granada&#44; Spain&#46; Given the lack of similar studies&#44; the dermatologists applied criteria based on their professional experience&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Inclusion criteria for consulting individuals were as follows&#58; they did not have a formal appointment on the day of the consultation&#59; they had not used the emergency service on the day of the consultation &#40;for whatever reason&#41;&#59; they made the consultation within the hospital&#59; and the consultation was about a skin complaint&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Data were collected between October 2008 and July 2009 and analyzed using SSPS statistical software&#44; version 17&#46;0&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Age and sex were recorded&#44; and the consulting individuals were classified in&#160;5 categories&#44; as follows&#58; persons accompanying patients&#44; physicians in other disciplines&#44; hospital workers &#40;excluding physicians&#41;&#44; dermatologist&#39;s family or friends&#44; and medical representatives&#46; The hospital workers were further subdivided into the following groups&#58; administrative workers&#44; nursing auxiliaries&#44; hospital porters&#44; cooks&#44; nurses&#44; cleaners&#44; technical staff&#44; security staff&#44; and others&#46; Information was also collected on whether this was the individual&#39;s first consultation regarding the skin complaint&#44; whether the person had previously consulted for another reason&#44; and whether the person was consulting on their own behalf or on someone else&#39;s&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The reasons for consultation were classified in 13 broad diagnostic groups&#58; dermatitis&#44; eczemas&#44; esthetic&#47;cosmetic complaints&#44; infections&#44; lichens&#44; nail disorders&#44; psoriasis&#44; burns&#44; benign tumors&#44; malignant tumors&#44; skin discoloration&#44; surgery-related complaints &#40;secondary to surgery or lesions&#41;&#44; and undiagnosed complaints&#46; These reasons were further subclassified according to the definitive diagnosis&#44; with the exception of skin complaints that remained undiagnosed due to the need for further tests&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Diagnostic and therapeutic responses were classified as follows&#58; empirical treatment&#44; biopsy for histology study&#44; referral to the family physician or for a formal visit&#44; patient reassurance and information&#44; microbiology study or blood testing&#44; surgical treatment&#44; and other responses&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The dermatologists scored severity on a scale of 1 to 9&#44; with 1 representing a mild complaint&#44; and 9 representing a complaint needing urgent medical attention&#46; The consulting individuals were divided into those whose complaint could or could not be postponed to a formal visit &#40;implying an average wait of 1&#160;month&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The dermatologists&#8217; own assessment of the care provided to these individuals in comparison with their care of formal patients was classified as follows&#58; less care&#59; standard care&#59; or better care&#44; ie&#44; the dermatologist had performed nursing or administrative procedures&#44; or had personally consulted other professionals&#44; and in doing so&#44; had disregarded standard protocols and routine procedures&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Profiles of the Consulting Individuals</span><p id="par0065" class="elsevierStylePara elsevierViewall">A total of 270 informal consultations were documented&#46; More consultations were made by women than by men &#40;63&#37;&#160;vs&#160;37&#37;&#41;&#44; and the mean age was 40&#46;13 years &#40;range&#44; 1-92 years&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Most consultations &#40;50&#37;&#41; were made by hospital workers&#44; followed by other medical specialists &#40;21&#46;9&#37;&#41;&#44; the dermatologist&#39;s family or friends &#40;18&#46;5&#37;&#41;&#44; persons accompanying patients &#40;7&#46;8&#37;&#41;&#44; and medical representatives &#40;1&#46;9&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">The consultations by hospital workers &#40;excluding physicians&#41; were classified according to the following subtypes&#58; nurses &#40;40&#46;7&#37;&#41;&#44; nursing auxiliaries &#40;27&#46;4&#37;&#41;&#44; cleaners &#40;9&#46;6&#37;&#41;&#44; administrative staff &#40;5&#46;9&#37;&#41;&#44; hospital porters &#40;5&#46;9&#37;&#41;&#44; nonidentified occupations &#40;3&#46;7&#37;&#41;&#44; technical staff &#40;3&#46;0&#37;&#41;&#44; security staff &#40;2&#46;2&#37;&#41;&#44; and cooks &#40;1&#46;5&#37;&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Most consulting women were nurses&#44; followed by nursing auxiliaries&#59; and most consulting men were other medical specialists&#44; followed by the dermatologist&#39;s family or friends&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">For 74&#46;4&#37; of the individuals&#44; this was their first consultation regarding the complaint in question&#59; for the remaining 25&#46;6&#37;&#44; the consultations referred to treatment failures&#44; follow-ups&#44; diagnostic test results&#44; etc&#46; The dermatologist had previously been consulted for a different reason by 39&#46;3&#37; of the individuals&#59; for the remaining 60&#46;7&#37;&#44; this was their first dermatology consultation&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">An interesting finding was the number of individuals consulting the dermatologist on behalf of someone else&#46; This was a feature of all the groups with the exception of the group composed of persons accompanying patients&#59; excluding this group&#44; a third &#40;36&#46;1&#37;&#41; of the informal consultations were made on behalf of someone else&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Reasons for Consultation</span><p id="par0095" class="elsevierStylePara elsevierViewall">The highest number of consultations corresponded to the benign tumors group &#40;40&#46;4&#37;&#41;&#44; broken down as follows&#58; acquired melanocytic nevi &#40;10&#46;7&#37;&#41;&#44; seborrheic keratosis &#40;6&#46;7&#37;&#41;&#44; viral warts &#40;6&#46;7&#37;&#41;&#44; and fibromas &#40;3&#46;3&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Dermatitis was the second largest group &#40;17&#37;&#41;&#44; with atopic dermatitis &#40;3&#46;7&#37;&#41; and seborrheic dermatitis &#40;2&#46;6&#37;&#41; heading the list&#46; The third largest group referred to esthetic&#47;cosmetic complaints &#40;8&#46;9&#37;&#41;&#44; with alopecia &#40;all subtypes&#41; accounting for 3&#46;8&#37; of the consultations&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">The remaining groups&#44; in descending order of importance&#44; were as follows&#58; infections &#40;8&#46;5&#37;&#41;&#44; eczemas &#40;5&#46;6&#37;&#41;&#44; malignant tumors &#40;4&#46;4&#37;&#41;&#44; skin discoloration &#40;4&#46;1&#37;&#41;&#44; nail disorders &#40;4&#46;1&#37;&#41;&#44; psoriasis &#40;3&#46;3&#37;&#41;&#44; surgery-related complaints &#40;1&#46;9&#37;&#41;&#44; and lichens&#44; burns&#44; and undiagnosed skin complaints &#40;under 1&#37; each&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The 6 most frequent diagnoses were acquired melanocytic nevi &#40;10&#46;7&#37;&#41;&#44; seborrheic keratosis &#40;6&#46;7&#37;&#41;&#44; viral warts &#40;6&#46;7&#37;&#41;&#44; alopecia &#40;6&#46;7&#37;&#41;&#44; atopic dermatitis &#40;3&#46;7&#37;&#41;&#44; and fibromas and psoriasis &#40;3&#46;3&#37; each&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Diagnostic and Therapeutic Responses</span><p id="par0110" class="elsevierStylePara elsevierViewall">The most frequent dermatologist responses to consultations were as follows&#58; empirical treatment &#40;54&#46;1&#37;&#41;&#44; patient reassurance and information &#40;22&#46;6&#37;&#41;&#44; surgical treatment &#40;13&#37;&#41;&#44; referral for further tests &#40;6&#37;&#41;&#44; referral to the family physician &#40;2&#46;6&#37;&#41;&#44; and histology studies &#40;biopsy&#41; to confirm diagnosis &#40;2&#46;6&#37;&#41;&#46; The remaining categories &#40;microbiology studies&#44; referral to another specialist&#44; referral for an imaging study&#44; etc&#41; accounted for under 2&#37; of the responses&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Severity According to the Dermatologist</span><p id="par0115" class="elsevierStylePara elsevierViewall">The dermatologists rated skin complaint severity on a scale from 1 to 9&#44; with 9 representing the greatest severity&#46; The results largely reflect a descending curve&#44; with 61&#46;1&#37; of complaints receiving a score of 1&#44; 18&#46;5&#37; a score of 2&#44; and 10&#46;7&#37; a score of 3&#44; with the remaining scores &#40;4 to 9&#41; assigned to 3&#46;7&#37;&#44; 2&#46;6&#37;&#44; 1&#46;1&#37;&#44; 0&#46;7&#37;&#44; 1&#46;1&#37;&#44; and 0&#46;4&#37; of the complaints&#44; respectively&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Most of the individuals &#40;87&#37;&#41; were asked to postpone their consultation to a formal visit &#40;an average wait of 1 month&#41;&#44; leaving 13&#37; who were considered to need urgent attention&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Level of Care According to the Dermatologist</span><p id="par0125" class="elsevierStylePara elsevierViewall">The dermatologists rated management and care as similar to that for patients with an appointment for 75&#46;9&#37; of the individuals&#44; and as less scrupulous for 8&#46;5&#37; of the individuals&#46; The remaining 15&#46;6&#37; of individuals were rated as having received better care&#44; given that procedures were followed that were not standard in the dermatologists&#8217; daily routines&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0130" class="elsevierStylePara elsevierViewall">Dermatologists are often asked for a medical opinion in the workplace &#40;in corridors&#44; offices&#44; surgeries&#44; etc&#41;&#46; Such consultations&#44; facilitated by the accessibility of the skin&#44; are not regulated&#44; recorded&#44; or scheduled&#46; They usually imply an investment in terms of time&#44; and occasionally require the use of health care resources&#46; Since our study was conducted in a hospital&#44; consultations with dermatologists outside work were not included&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">The work setting defines certain characteristics of the consulting individual&#46; In our hospital-based study&#44; for example&#44; the typical requester was a female&#44; middle-aged nurse&#44; reflecting the fact that our hospital has more female than male nurses and that its employees are largely middle-aged&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The skin complaints for which medical advice was requested were&#44; in the opinion of the dermatologists&#44; mainly mild&#46; The most frequent complaints were benign tumors&#44; specifically&#44; melanocytic nevi &#40;10&#46;7&#37;&#41;&#44; seborrheic keratosis&#44; and viral warts &#40;6&#46;7&#37; each&#41;&#46; Our findings partially corroborate the study by Tejera-Vaquerizo et al<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> regarding the reasons for additional consultations by dermatology patients &#40;ie&#44; about conditions not covered by the primary care referral&#41;&#58; melanocytic nevi &#40;18&#37;&#41; was the most frequently mentioned complaint &#40;intradermal nevi&#44; 11&#46;5&#37;&#44; and common melanocytic nevi&#44; 6&#46;5&#37;&#41;&#44; followed by eczema &#40;11&#37;&#41;&#44; acne and viral warts &#40;6&#46;8&#37; each&#41;&#44; and seborrheic keratosis and cysts &#40;6&#46;3&#37; each&#41;&#46; The demographic characteristics of the patients have a bearing on the reason for consultation&#46; Half the patients in the study by Tejera-Vaquerizo et al were aged 10 to 40 years&#44; and acne was a frequent motive for consultation &#40;6&#46;8&#37;&#41;&#59; in our study&#44; in contrast&#44; where the mean age was over 40 years&#44; acne &#40;3&#37;&#41; was not among the top 5 complaints&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Informal and nonregulated patient care represents significant savings for the public health system&#46; We used designated costs for dermatology consultations &#40;based on the analytical accountancy system used for Andalusian hospitals and districts &#40;COAN-HyD&#41; and the COAN total costs module&#41;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> to calculate that savings for the Spanish public health system amounted to around &#8364;26&#160;000 for the initial consultations and &#8364;2000 for the follow-up consultations &#40;74&#46;4&#37; and 25&#46;6&#37;&#44; respectively&#44; of the 270 consultations&#41;&#46; Around a fifth of the informal consultations required the use of surgical&#44; histological&#44; laboratory resources&#44; etc&#44; but over half were diagnosed and treated empirically and so did not consume hospital resources&#46; Since a small proportion of requesters &#40;2&#46;6&#37;&#41; was referred to the family physician and so deferred to the formal system&#44; this cost should logically be deducted from the above savings&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Nonregulated informal consultations represent an increased workload for dermatologists&#44; as do the additional consultations referred to in the study by Tejera-Vaquerizo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> They also represent an important proportion of the care activities undertaken by dermatology residents on duty&#46; Obviously&#44; dermatologists who refuse to provide medical advice in this way&#44; or who persuade the requesters to postpone consultation to a formal appointment&#44; do not experience the same degree of overload&#46; According to the dermatologists who participated in this study&#44; additional and nonregulated consultations represent an extra workload of around 25&#37;&#44; to be added to formal appointments and residential duties&#46; Particularly time-consuming are consultations made on behalf of someone else&#58; the requester usually describes the other person&#39;s symptoms in detail&#44; but in most cases&#44; the dermatologist inevitably has to see the person with the skin complaint&#46; The dermatologists agreed that it was not infrequent for them to see 4 to 6 people per day in informal consultations&#44; in addition to 20 to 25 patients with formal appointments &#40;bearing in mind&#44; also&#44; that around 18&#37; of patients miss their appointment according to Tejera-Vaquerizo et al<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#41;&#46; Furthermore&#44; according to the dermatology residents participating in this study&#44; the burden increases substantially during duty shifts&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">The circumstances of informal consultations may suggest poorer medical practice due&#44; for example&#44; to scant attention by the dermatologist&#46; According to the dermatologists in our study&#44; however&#44; care was similar &#40;75&#46;9&#37;&#41; or even better &#40;15&#46;6&#37;&#41;&#46; The advantages of this kind of informal consultation for the requesters are evident&#58; immediacy&#44; no waiting&#44; no cost&#44; etc<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#59; the disadvantages are not so clear&#44; since care is of a quality similar to that provided in formal settings&#46; It would&#44; however&#44; be interesting to know something of the circumstances &#40;lighting&#44; privacy&#44; hygiene&#44; etc&#41; in which such consultations take place&#44; given that many are made in less than ideal conditions in corridors&#44; offices&#44; meeting rooms&#44; etc&#46; The characteristics of this particular kind of consultation&#8212;type of patient&#44; place of consultation&#44; reason for consultation&#44; etc&#8212;led Guberman et al<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> to state that individuals making informal consultations should be called requesters and not patients&#46; From the malpractice perspective&#44; many of these cases&#44; and especially the consultations on behalf of others&#44; reflect what Sanz Rubiales et al<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> call the <span class="elsevierStyleItalic">recommendation syndrome</span>&#46; These authors concluded that many medical errors are the outcome of an attempt to offer more painstaking care to patients to whom the specialist is recommended&#44; with the most important errors occurring due to the patient&#39;s own attitude&#44; inefficient use of health care resources&#44; failure to include data in medical histories&#44; diagnostic test misinterpretations&#44; and changes to standard indications and to treatment&#46; Following appropriate procedures with patients would avoid many such errors&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">In conclusion&#44; our aim was&#44; in the absence of similar studies&#44; to analyze the burden of informal consultations in the routine work of the dermatologist&#46; The requester profile is that of a female middle-aged nurse&#44; who consults for the first time for a benign melanocytic tumor&#46; The dermatologist typically prescribes empirical treatment or reassures and informs the patient&#44; and rates the level of care as similar to that for a patient with a formal appointment&#46; Nonregulated informal consultations increase the workload of dermatologists&#44; but are a particular burden for trainee resident dermatologists in their first steps in patient care&#44; given the great number of trivial complaints&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of Interest</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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              "titulo" => "Profiles of the Consulting Individuals"
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              "titulo" => "Level of Care According to the Dermatologist"
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        8 => array:2 [
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          "titulo" => "Discussion"
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    "fechaAceptado" => "2011-03-22"
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          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec82680"
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            1 => "Workplace"
            2 => "Trivial skin conditions"
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          "clase" => "keyword"
          "titulo" => "Palabras clave"
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          "palabras" => array:3 [
            0 => "Consultas extras"
            1 => "Centro de trabajo"
            2 => "Patolog&#237;a banal dermatol&#243;gica"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Dermatologists are regularly consulted in their place of work by patients without an official appointment &#40;individuals accompanying other patients&#44; doctors from other specialties&#44; hospital workers&#44; etc&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Objectives</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To describe the characteristics of consulting patients&#44; reasons for consultation&#44; severity of complaint&#44; diagnostic and therapeutic approach taken&#44; and level of care provided by the consulted professionals&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The typical patient would be a middle-aged female nurse consulting for the first time for a benign melanocytic lesion&#46; In general&#44; the dermatologist will take an empirical or informative therapeutic approach and consider the care provided to be similar to that offered to patients with an official appointment&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Unofficial appointments&#44; although commonly for trivial complaints&#44; represent an additional workload in daily clinical practice&#46;</p>"
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        "resumen" => "<span class="elsevierStyleSectionTitle">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Los dermat&#243;logos somos demandados a diario&#44; en nuestro centro de trabajo&#44; por pacientes sin cita reglada &#40;acompa&#241;antes de pacientes&#44; m&#233;dicos de otras especialidades&#44; trabajadores del centro&#44; etc&#46;&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Objetivos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Descripci&#243;n de los pacientes demandantes&#44; los motivos de consulta&#44; la gravedad de la patolog&#237;a consultada&#44; la actitud diagn&#243;stico-terap&#233;utica y asistencial de los profesionales demandados&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El paciente modelo ser&#237;a una mujer enfermera de mediana edad que consulta por primera vez por una lesi&#243;n tumoral melanoc&#237;tica benigna&#46; En general el dermat&#243;logo tomar&#225; una actitud terap&#233;utica emp&#237;rica o informadora y considera que la atenci&#243;n prestada es similar a un paciente con cita reglada&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Las consultas no regladas&#44; aunque suelen ser por patolog&#237;a banal&#44; suponen una carga asistencial en la pr&#225;ctica diaria&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Almaz&#225;n-Fern&#225;ndez FM&#44; et al&#46; Estudio de las consultas extraoficiales en un hospital de tercer nivel&#46; Actas Dermosifiliogr&#46;2011&#59;102&#58;805-809&#46;</p>"
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                  \t\t\t\t">Acquired melanocytic nevus&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">Seborrheic keratosis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Alopecia&nbsp;\t\t\t\t\t\t\n
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Original articles
Analysis of Unofficial Consultations in a Tertiary-Level Hospital
Estudio de las consultas extraoficiales en un hospital de tercer nivel
F.M. Almazán-Fernández
Autor para correspondencia
almazanweb@yahoo.es

Corresponding author.
, A. Clemente-Ruiz De Almirón, S. Arias-Santiago, H.H. El-Ahmed, J.C. Ruiz-Carrascosa, R. Naranjo-Sintes
Servicio de Dermatología, Hospital Clínico San Cecilio, Granada, Spain
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    "cabecera" => "<span class="elsevierStyleTextfn">Original articles</span>"
    "titulo" => "Analysis of Unofficial Consultations in a Tertiary-Level Hospital"
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        "autoresLista" => "F&#46;M&#46; Almaz&#225;n-Fern&#225;ndez, A&#46; Clemente-Ruiz De Almir&#243;n, S&#46; Arias-Santiago, H&#46;H&#46; El-Ahmed, J&#46;C&#46; Ruiz-Carrascosa, R&#46; Naranjo-Sintes"
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        "titulo" => "Estudio de las consultas extraoficiales en un hospital de tercer nivel"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Medical advice requester profiles&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Throughout their career and even as early as medical school&#44; physicians are often consulted outside the appointments system&#46; Medical professionals&#44; but particularly dermatologists&#44; can easily recall a situation in which medical advice was informally requested in a street&#44; elevator&#44; corridor&#44; and even in the surgery&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Dermatologists are possibly more likely than other specialists to be asked for informal medical advice&#44; given that the skin is immediately accessible and easily explored&#46; It is this very accessibility&#44; in fact&#44; that leads people to expect the dermatologist to be able to resolve their query immediately&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">With a view to better understanding informal consultations in a hospital setting&#44; we documented 270 consultations between October 2008 and July 2009 in order to profile the individuals who request medical advice&#44; their reasons for consulting&#44; the severity of their complaints&#44; and the dermatologists&#8217; responses&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Objectives</span><p id="par0020" class="elsevierStylePara elsevierViewall">The objectives of the study were to describe the following&#58; &#40;1&#41; the profiles of the consulting individuals&#44; &#40;2&#41; the reasons for consultation&#44; &#40;3&#41; the dermatologist&#39;s diagnosis and treatment&#44; &#40;4&#41; the dermatologist&#39;s assessment of the severity of the complaint&#44; and &#40;5&#41; the dermatologist&#39;s assessment of the care given&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Material and Methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">The data for the study were recorded by dermatologists and resident dermatologists at Hospital Cl&#237;nico San Cecilio de Granada&#44; Spain&#46; Given the lack of similar studies&#44; the dermatologists applied criteria based on their professional experience&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Inclusion criteria for consulting individuals were as follows&#58; they did not have a formal appointment on the day of the consultation&#59; they had not used the emergency service on the day of the consultation &#40;for whatever reason&#41;&#59; they made the consultation within the hospital&#59; and the consultation was about a skin complaint&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Data were collected between October 2008 and July 2009 and analyzed using SSPS statistical software&#44; version 17&#46;0&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Age and sex were recorded&#44; and the consulting individuals were classified in&#160;5 categories&#44; as follows&#58; persons accompanying patients&#44; physicians in other disciplines&#44; hospital workers &#40;excluding physicians&#41;&#44; dermatologist&#39;s family or friends&#44; and medical representatives&#46; The hospital workers were further subdivided into the following groups&#58; administrative workers&#44; nursing auxiliaries&#44; hospital porters&#44; cooks&#44; nurses&#44; cleaners&#44; technical staff&#44; security staff&#44; and others&#46; Information was also collected on whether this was the individual&#39;s first consultation regarding the skin complaint&#44; whether the person had previously consulted for another reason&#44; and whether the person was consulting on their own behalf or on someone else&#39;s&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The reasons for consultation were classified in 13 broad diagnostic groups&#58; dermatitis&#44; eczemas&#44; esthetic&#47;cosmetic complaints&#44; infections&#44; lichens&#44; nail disorders&#44; psoriasis&#44; burns&#44; benign tumors&#44; malignant tumors&#44; skin discoloration&#44; surgery-related complaints &#40;secondary to surgery or lesions&#41;&#44; and undiagnosed complaints&#46; These reasons were further subclassified according to the definitive diagnosis&#44; with the exception of skin complaints that remained undiagnosed due to the need for further tests&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Diagnostic and therapeutic responses were classified as follows&#58; empirical treatment&#44; biopsy for histology study&#44; referral to the family physician or for a formal visit&#44; patient reassurance and information&#44; microbiology study or blood testing&#44; surgical treatment&#44; and other responses&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The dermatologists scored severity on a scale of 1 to 9&#44; with 1 representing a mild complaint&#44; and 9 representing a complaint needing urgent medical attention&#46; The consulting individuals were divided into those whose complaint could or could not be postponed to a formal visit &#40;implying an average wait of 1&#160;month&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The dermatologists&#8217; own assessment of the care provided to these individuals in comparison with their care of formal patients was classified as follows&#58; less care&#59; standard care&#59; or better care&#44; ie&#44; the dermatologist had performed nursing or administrative procedures&#44; or had personally consulted other professionals&#44; and in doing so&#44; had disregarded standard protocols and routine procedures&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Profiles of the Consulting Individuals</span><p id="par0065" class="elsevierStylePara elsevierViewall">A total of 270 informal consultations were documented&#46; More consultations were made by women than by men &#40;63&#37;&#160;vs&#160;37&#37;&#41;&#44; and the mean age was 40&#46;13 years &#40;range&#44; 1-92 years&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Most consultations &#40;50&#37;&#41; were made by hospital workers&#44; followed by other medical specialists &#40;21&#46;9&#37;&#41;&#44; the dermatologist&#39;s family or friends &#40;18&#46;5&#37;&#41;&#44; persons accompanying patients &#40;7&#46;8&#37;&#41;&#44; and medical representatives &#40;1&#46;9&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">The consultations by hospital workers &#40;excluding physicians&#41; were classified according to the following subtypes&#58; nurses &#40;40&#46;7&#37;&#41;&#44; nursing auxiliaries &#40;27&#46;4&#37;&#41;&#44; cleaners &#40;9&#46;6&#37;&#41;&#44; administrative staff &#40;5&#46;9&#37;&#41;&#44; hospital porters &#40;5&#46;9&#37;&#41;&#44; nonidentified occupations &#40;3&#46;7&#37;&#41;&#44; technical staff &#40;3&#46;0&#37;&#41;&#44; security staff &#40;2&#46;2&#37;&#41;&#44; and cooks &#40;1&#46;5&#37;&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Most consulting women were nurses&#44; followed by nursing auxiliaries&#59; and most consulting men were other medical specialists&#44; followed by the dermatologist&#39;s family or friends&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">For 74&#46;4&#37; of the individuals&#44; this was their first consultation regarding the complaint in question&#59; for the remaining 25&#46;6&#37;&#44; the consultations referred to treatment failures&#44; follow-ups&#44; diagnostic test results&#44; etc&#46; The dermatologist had previously been consulted for a different reason by 39&#46;3&#37; of the individuals&#59; for the remaining 60&#46;7&#37;&#44; this was their first dermatology consultation&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">An interesting finding was the number of individuals consulting the dermatologist on behalf of someone else&#46; This was a feature of all the groups with the exception of the group composed of persons accompanying patients&#59; excluding this group&#44; a third &#40;36&#46;1&#37;&#41; of the informal consultations were made on behalf of someone else&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Reasons for Consultation</span><p id="par0095" class="elsevierStylePara elsevierViewall">The highest number of consultations corresponded to the benign tumors group &#40;40&#46;4&#37;&#41;&#44; broken down as follows&#58; acquired melanocytic nevi &#40;10&#46;7&#37;&#41;&#44; seborrheic keratosis &#40;6&#46;7&#37;&#41;&#44; viral warts &#40;6&#46;7&#37;&#41;&#44; and fibromas &#40;3&#46;3&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Dermatitis was the second largest group &#40;17&#37;&#41;&#44; with atopic dermatitis &#40;3&#46;7&#37;&#41; and seborrheic dermatitis &#40;2&#46;6&#37;&#41; heading the list&#46; The third largest group referred to esthetic&#47;cosmetic complaints &#40;8&#46;9&#37;&#41;&#44; with alopecia &#40;all subtypes&#41; accounting for 3&#46;8&#37; of the consultations&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">The remaining groups&#44; in descending order of importance&#44; were as follows&#58; infections &#40;8&#46;5&#37;&#41;&#44; eczemas &#40;5&#46;6&#37;&#41;&#44; malignant tumors &#40;4&#46;4&#37;&#41;&#44; skin discoloration &#40;4&#46;1&#37;&#41;&#44; nail disorders &#40;4&#46;1&#37;&#41;&#44; psoriasis &#40;3&#46;3&#37;&#41;&#44; surgery-related complaints &#40;1&#46;9&#37;&#41;&#44; and lichens&#44; burns&#44; and undiagnosed skin complaints &#40;under 1&#37; each&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The 6 most frequent diagnoses were acquired melanocytic nevi &#40;10&#46;7&#37;&#41;&#44; seborrheic keratosis &#40;6&#46;7&#37;&#41;&#44; viral warts &#40;6&#46;7&#37;&#41;&#44; alopecia &#40;6&#46;7&#37;&#41;&#44; atopic dermatitis &#40;3&#46;7&#37;&#41;&#44; and fibromas and psoriasis &#40;3&#46;3&#37; each&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Diagnostic and Therapeutic Responses</span><p id="par0110" class="elsevierStylePara elsevierViewall">The most frequent dermatologist responses to consultations were as follows&#58; empirical treatment &#40;54&#46;1&#37;&#41;&#44; patient reassurance and information &#40;22&#46;6&#37;&#41;&#44; surgical treatment &#40;13&#37;&#41;&#44; referral for further tests &#40;6&#37;&#41;&#44; referral to the family physician &#40;2&#46;6&#37;&#41;&#44; and histology studies &#40;biopsy&#41; to confirm diagnosis &#40;2&#46;6&#37;&#41;&#46; The remaining categories &#40;microbiology studies&#44; referral to another specialist&#44; referral for an imaging study&#44; etc&#41; accounted for under 2&#37; of the responses&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Severity According to the Dermatologist</span><p id="par0115" class="elsevierStylePara elsevierViewall">The dermatologists rated skin complaint severity on a scale from 1 to 9&#44; with 9 representing the greatest severity&#46; The results largely reflect a descending curve&#44; with 61&#46;1&#37; of complaints receiving a score of 1&#44; 18&#46;5&#37; a score of 2&#44; and 10&#46;7&#37; a score of 3&#44; with the remaining scores &#40;4 to 9&#41; assigned to 3&#46;7&#37;&#44; 2&#46;6&#37;&#44; 1&#46;1&#37;&#44; 0&#46;7&#37;&#44; 1&#46;1&#37;&#44; and 0&#46;4&#37; of the complaints&#44; respectively&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Most of the individuals &#40;87&#37;&#41; were asked to postpone their consultation to a formal visit &#40;an average wait of 1 month&#41;&#44; leaving 13&#37; who were considered to need urgent attention&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Level of Care According to the Dermatologist</span><p id="par0125" class="elsevierStylePara elsevierViewall">The dermatologists rated management and care as similar to that for patients with an appointment for 75&#46;9&#37; of the individuals&#44; and as less scrupulous for 8&#46;5&#37; of the individuals&#46; The remaining 15&#46;6&#37; of individuals were rated as having received better care&#44; given that procedures were followed that were not standard in the dermatologists&#8217; daily routines&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0130" class="elsevierStylePara elsevierViewall">Dermatologists are often asked for a medical opinion in the workplace &#40;in corridors&#44; offices&#44; surgeries&#44; etc&#41;&#46; Such consultations&#44; facilitated by the accessibility of the skin&#44; are not regulated&#44; recorded&#44; or scheduled&#46; They usually imply an investment in terms of time&#44; and occasionally require the use of health care resources&#46; Since our study was conducted in a hospital&#44; consultations with dermatologists outside work were not included&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">The work setting defines certain characteristics of the consulting individual&#46; In our hospital-based study&#44; for example&#44; the typical requester was a female&#44; middle-aged nurse&#44; reflecting the fact that our hospital has more female than male nurses and that its employees are largely middle-aged&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The skin complaints for which medical advice was requested were&#44; in the opinion of the dermatologists&#44; mainly mild&#46; The most frequent complaints were benign tumors&#44; specifically&#44; melanocytic nevi &#40;10&#46;7&#37;&#41;&#44; seborrheic keratosis&#44; and viral warts &#40;6&#46;7&#37; each&#41;&#46; Our findings partially corroborate the study by Tejera-Vaquerizo et al<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> regarding the reasons for additional consultations by dermatology patients &#40;ie&#44; about conditions not covered by the primary care referral&#41;&#58; melanocytic nevi &#40;18&#37;&#41; was the most frequently mentioned complaint &#40;intradermal nevi&#44; 11&#46;5&#37;&#44; and common melanocytic nevi&#44; 6&#46;5&#37;&#41;&#44; followed by eczema &#40;11&#37;&#41;&#44; acne and viral warts &#40;6&#46;8&#37; each&#41;&#44; and seborrheic keratosis and cysts &#40;6&#46;3&#37; each&#41;&#46; The demographic characteristics of the patients have a bearing on the reason for consultation&#46; Half the patients in the study by Tejera-Vaquerizo et al were aged 10 to 40 years&#44; and acne was a frequent motive for consultation &#40;6&#46;8&#37;&#41;&#59; in our study&#44; in contrast&#44; where the mean age was over 40 years&#44; acne &#40;3&#37;&#41; was not among the top 5 complaints&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Informal and nonregulated patient care represents significant savings for the public health system&#46; We used designated costs for dermatology consultations &#40;based on the analytical accountancy system used for Andalusian hospitals and districts &#40;COAN-HyD&#41; and the COAN total costs module&#41;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> to calculate that savings for the Spanish public health system amounted to around &#8364;26&#160;000 for the initial consultations and &#8364;2000 for the follow-up consultations &#40;74&#46;4&#37; and 25&#46;6&#37;&#44; respectively&#44; of the 270 consultations&#41;&#46; Around a fifth of the informal consultations required the use of surgical&#44; histological&#44; laboratory resources&#44; etc&#44; but over half were diagnosed and treated empirically and so did not consume hospital resources&#46; Since a small proportion of requesters &#40;2&#46;6&#37;&#41; was referred to the family physician and so deferred to the formal system&#44; this cost should logically be deducted from the above savings&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Nonregulated informal consultations represent an increased workload for dermatologists&#44; as do the additional consultations referred to in the study by Tejera-Vaquerizo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> They also represent an important proportion of the care activities undertaken by dermatology residents on duty&#46; Obviously&#44; dermatologists who refuse to provide medical advice in this way&#44; or who persuade the requesters to postpone consultation to a formal appointment&#44; do not experience the same degree of overload&#46; According to the dermatologists who participated in this study&#44; additional and nonregulated consultations represent an extra workload of around 25&#37;&#44; to be added to formal appointments and residential duties&#46; Particularly time-consuming are consultations made on behalf of someone else&#58; the requester usually describes the other person&#39;s symptoms in detail&#44; but in most cases&#44; the dermatologist inevitably has to see the person with the skin complaint&#46; The dermatologists agreed that it was not infrequent for them to see 4 to 6 people per day in informal consultations&#44; in addition to 20 to 25 patients with formal appointments &#40;bearing in mind&#44; also&#44; that around 18&#37; of patients miss their appointment according to Tejera-Vaquerizo et al<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#41;&#46; Furthermore&#44; according to the dermatology residents participating in this study&#44; the burden increases substantially during duty shifts&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">The circumstances of informal consultations may suggest poorer medical practice due&#44; for example&#44; to scant attention by the dermatologist&#46; According to the dermatologists in our study&#44; however&#44; care was similar &#40;75&#46;9&#37;&#41; or even better &#40;15&#46;6&#37;&#41;&#46; The advantages of this kind of informal consultation for the requesters are evident&#58; immediacy&#44; no waiting&#44; no cost&#44; etc<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#59; the disadvantages are not so clear&#44; since care is of a quality similar to that provided in formal settings&#46; It would&#44; however&#44; be interesting to know something of the circumstances &#40;lighting&#44; privacy&#44; hygiene&#44; etc&#41; in which such consultations take place&#44; given that many are made in less than ideal conditions in corridors&#44; offices&#44; meeting rooms&#44; etc&#46; The characteristics of this particular kind of consultation&#8212;type of patient&#44; place of consultation&#44; reason for consultation&#44; etc&#8212;led Guberman et al<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> to state that individuals making informal consultations should be called requesters and not patients&#46; From the malpractice perspective&#44; many of these cases&#44; and especially the consultations on behalf of others&#44; reflect what Sanz Rubiales et al<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> call the <span class="elsevierStyleItalic">recommendation syndrome</span>&#46; These authors concluded that many medical errors are the outcome of an attempt to offer more painstaking care to patients to whom the specialist is recommended&#44; with the most important errors occurring due to the patient&#39;s own attitude&#44; inefficient use of health care resources&#44; failure to include data in medical histories&#44; diagnostic test misinterpretations&#44; and changes to standard indications and to treatment&#46; Following appropriate procedures with patients would avoid many such errors&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">In conclusion&#44; our aim was&#44; in the absence of similar studies&#44; to analyze the burden of informal consultations in the routine work of the dermatologist&#46; The requester profile is that of a female middle-aged nurse&#44; who consults for the first time for a benign melanocytic tumor&#46; The dermatologist typically prescribes empirical treatment or reassures and informs the patient&#44; and rates the level of care as similar to that for a patient with a formal appointment&#46; Nonregulated informal consultations increase the workload of dermatologists&#44; but are a particular burden for trainee resident dermatologists in their first steps in patient care&#44; given the great number of trivial complaints&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of Interest</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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              "identificador" => "sec0045"
              "titulo" => "Level of Care According to the Dermatologist"
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            0 => "Unscheduled consultations"
            1 => "Workplace"
            2 => "Trivial skin conditions"
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          "clase" => "keyword"
          "titulo" => "Palabras clave"
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            0 => "Consultas extras"
            1 => "Centro de trabajo"
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      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Dermatologists are regularly consulted in their place of work by patients without an official appointment &#40;individuals accompanying other patients&#44; doctors from other specialties&#44; hospital workers&#44; etc&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Objectives</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To describe the characteristics of consulting patients&#44; reasons for consultation&#44; severity of complaint&#44; diagnostic and therapeutic approach taken&#44; and level of care provided by the consulted professionals&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The typical patient would be a middle-aged female nurse consulting for the first time for a benign melanocytic lesion&#46; In general&#44; the dermatologist will take an empirical or informative therapeutic approach and consider the care provided to be similar to that offered to patients with an official appointment&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Unofficial appointments&#44; although commonly for trivial complaints&#44; represent an additional workload in daily clinical practice&#46;</p>"
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        "resumen" => "<span class="elsevierStyleSectionTitle">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Los dermat&#243;logos somos demandados a diario&#44; en nuestro centro de trabajo&#44; por pacientes sin cita reglada &#40;acompa&#241;antes de pacientes&#44; m&#233;dicos de otras especialidades&#44; trabajadores del centro&#44; etc&#46;&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Objetivos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Descripci&#243;n de los pacientes demandantes&#44; los motivos de consulta&#44; la gravedad de la patolog&#237;a consultada&#44; la actitud diagn&#243;stico-terap&#233;utica y asistencial de los profesionales demandados&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El paciente modelo ser&#237;a una mujer enfermera de mediana edad que consulta por primera vez por una lesi&#243;n tumoral melanoc&#237;tica benigna&#46; En general el dermat&#243;logo tomar&#225; una actitud terap&#233;utica emp&#237;rica o informadora y considera que la atenci&#243;n prestada es similar a un paciente con cita reglada&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Las consultas no regladas&#44; aunque suelen ser por patolog&#237;a banal&#44; suponen una carga asistencial en la pr&#225;ctica diaria&#46;</p>"
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                  \t\t\t\t">Acquired melanocytic nevus&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Psoriasis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Acne&nbsp;\t\t\t\t\t\t\n
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                    0 => array:2 [
                      "titulo" => "Estudio de los motivos de consultas adicionales en una consulta ambulatoria de dermatolog&#237;a&#58; &#171;Doctor&#44; pues ya que estoy aqu&#237;&#8230;&#187;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "A&#46; Tejera-Vaquerizo"
                            1 => "M&#46;C&#46; Huertas-Aguayo"
                            2 => "I&#46; P&#233;rez"
                            3 => "M&#46; Illescas-Est&#233;vez"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Piel"
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                        "paginaFinal" => "543"
                      ]
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              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Estudio de descripci&#243;n de costes sobre el diagn&#243;stico y tratamiento del melanoma cut&#225;neo"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "F&#46;M&#46; Almaz&#225;n-Fern&#225;ndez"
                            1 => "S&#46; Serrano-Ortega"
                            2 => "J&#46;J&#46; Moreno-Villalonga"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Actas Dermosifiliogr"
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                        "volumen" => "100"
                        "paginaInicial" => "785"
                        "paginaFinal" => "791"
                        "link" => array:1 [
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19889300"
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              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Corridor dermatology consultation in passant"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "D&#46; Guberman"
                            1 => "D&#46;A&#46; Vardy"
                            2 => "S&#46;N&#46; Klaus"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Dermatol"
                        "fecha" => "1994"
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                        "paginaFinal" => "234"
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            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "El s&#237;ndrome del recomendado"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "A&#46; Sanz Rubiales"
                            1 => "M&#46;L&#46; Del Valler Rivero"
                            2 => "L&#46;A&#46; Flores P&#233;rez"
                            3 => "S&#46; Hernansanz de la Calle"
                            4 => "C&#46; Garc&#237;a Recio"
                            5 => "F&#46; L&#243;pez-Lara Mart&#237;n"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "An Med Interna"
                        "fecha" => "2002"
                        "volumen" => "19"
                        "paginaInicial" => "430"
                        "paginaFinal" => "433"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12244793"
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    ]
    "agradecimientos" => array:1 [
      0 => array:3 [
        "identificador" => "xack35200"
        "titulo" => "Acknowledgments"
        "texto" => "<p id="par0170" class="elsevierStylePara elsevierViewall">We thank Hospital Cl&#237;nico San Cecilio de Granada dermatologists and especially resident dermatologists&#44; and also participants at the 2009 Dermatology Residents&#8217; Conference in Valencia&#44; Spain&#44; who honored this research with an award&#46;</p>"
      ]
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