Background: Health care reform is not dead but merely on hiatus. The vehicle for the reform is managed care, in particular health maintenance organizations (HMOs). HMOs employ primary care physicians as gatekeepers to act as regulators and points of entry into the health care system. It is through these gatekeepers that most dermatologic care is rendered. Objective: Our purpose was to assess (1) the level of dermatology training of family practice physicians compared with dermatologists and (2) the impact on the delivery of quality dermatology services. Methods: A national study of university residency programs was undertaken. Twenty color Kodachromes of typical cutaneous diseases were analyzed by the two physician groups. A questionnaire was used to evaluate the average formal dermatology training received, the number of primary dermatology patients examined by family practitioners, the correct response rates to the questions, and the dermatologic procedures performed by family practitioners. A total of 723 family practice physicians and 443 dermatologists responded. Results: Our results indicate that, in comparison to dermatologists, primary care physicians significantly are deficient in their ability to recognize common and serious dermatoses. Conclusion: This study provides data emphasizing the need for reevaluation of the dermatology curriculum in medical schools and family practice residencies. Most important, it suggests that direct access to dermatologists provides better quality of care to members of HMOs and hence indirectly is most cost effective for the provision of dermatology services.