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Background Both physician-driven and patient-driven factors influence biopsy decisions. We sought to determine the ratio of benign to malignant melanocytic biopsy findings in our general dermatology practice and to characterize the reasons for biopsy. Methods A retrospective review of institutional records (1 January to 31 December 2005) was undertaken. Results We identified 1398 nevi, 147 invasive and in situ melanomas, and two lesions interpreted as atypical melanocytic proliferations. Prior histories of melanoma, atypical nevi, or nonmelanoma skin cancer were common. Patient concerns about changes or symptoms drove about one-third of the biopsies. Physician concerns more commonly drove biopsies in men and older patients (> 60 years). Physician-directed biopsies more commonly yielded atypical nevi, but there was no difference in the likelihood of melanoma. The ratio of removed nevi to melanomas was 9.2 : 1. Conclusions Both patient-driven and physician-driven indications lead to skin biopsies. We found no standard method of documentation of dermoscopic evaluation, which prevented us from making definitive conclusions about the role of dermoscopy in this cohort. [ABSTRACT FROM AUTHOR]