The incidence of malignant melanoma is rising concomitantly with dramatic changes in our healthcare system. Primary care physicians (PCPs) are responsible for an increasing number of skin-related healthcare visits. Therefore, PCPs must be on the forefront of early detection of suspicious pigmented lesions. Understanding the PCPs' screening and referral patterns for pigmented lesions is the first step in ensuring that atypical pigmented lesions will be properly evaluated within the confines of the present healthcare system. To develop a better understanding of how PCPs (internists, family practitioners, and pediatricians) manage pigmented lesions in their practice, we mailed a 28-question survey to 999 PCPs in Connecticut. Fewer than half of the 248 respondents indicated they "often" performed full skin examinations. However, when suspicious lesions were found, most PCPs referred patients to a dermatologist for a biopsy of the lesion. PCPs did not feel pressure from managed care companies to limit these referrals. However, many PCPs did not feel highly confident in their ability to recognize melanoma and thought their training was not adequate to prepare them to diagnose and manage pigmented lesions. Family practitioners were more likely than internists and pediatricians to manage suspicious pigmented lesions and to perform a biopsy on their own. Family practitioners also were more confident in performing these tasks and were more likely to think their training in these areas was adequate. Very few PCPs reported sending their biopsy specimens to a dermatopathology laboratory. In fact, many PCPs seemed unaware of who interpreted the histopathology. PCPs do not emphasize full skin examinations in their practice and seem unaware of the advantages inherent in using dermatopathologists in the histopathologic interpretation of pigmented lesions. Furthermore, lack of confidence on the part of PCPs, as well as their concern about adequate training in the management of pigmented lesions, suggest there is need for improvement in the education of primary care residents and physicians.