For decades, dermatology has been fighting the battle of not having a clear image as a serious specialty, not only in the house of medicine but with patients, insurers, and especially three-letter word agencies like CMS, RUC, and FDA (really four letter words, just sayin’). Take a step back and think about patients you secretly wanted to scream at because they went to an urgent care clinic or someone with very little training in dermatology who misdiagnosed them with zoster, scabies, or some dermatophytosis (aka the primary care triad of “shingles/scabies/fungus.”) There is nothing wrong with covering the conditions that could be contagious or have serious consequences if untreated, but what happened to the referral or even a call to ask us to see if their patient can be seen sooner than the next cosmetic consult? Most every other specialist gets that referral…but for skin problems it’s the George Costanza philosophy: “Stick some aloe on it and move on!”
Just this week, I saw a 23-year-old whose chief complaint was “follow-up shingles.” I nearly lost it when she told me that whomever wore the white coat at urgent care barely saw the rash and gave her a pre-stamped acyclovir prescription. The treatment plan? “It’s probably shingles, but in case it doesn’t go away, treat it with cortisone and you’ll be fine,” Not “Go see a dermatologist now!” I was thinking about this young, healthy patient carrying around a diagnosis of herpes zoster on her medical record and its effect on her insurance premiums, what would happen if the she really did have it or needed the vaccine, on top thinking about how to start treatment of PHN and what other risks there are for her. All of this as she looked confused as to why nobody sent her to the dermatologist in the first place. Of course her “zoster” is a patch of xerotic eczema and I talked her (and myself) off the dermatomal ledge.
Thanks to the internet, media, DTC ads, and our non-derm colleagues, diseases like herpes zoster, warts, and onychomycosis have been dumbed down to “shingles, HPV, and nail fungus”; treatment consequences far outweigh the benefits. These are the misconceptions that not only make it harder to treat patients as they progress, but make us waste time undoing this brainwashing that marginalizes us from being taken seriously as a medical specialty.
Another good case this month was the patient who had an IPL treatment from the local medi-spa. She was excessively red, assumed she got burned, and said this wasn’t “the reaction she was hoping for.” You can imagine how that conversation went: “Did you go back to the spa to get treated? No they didn’t help me; Did you speak to the medical director of the spa? No he wasn’t there; Did they give you a post-treatment plan? No they said it would get better; Did it occur to you to get treated by a dermatologist in the first place? I didn’t know you did these treatments.” Amazing…and yet the minute she walked in the door, I am on the hook for the management and outcome for the botched spa work, all because the state of California (among many) allows it. But even worse, the lack of an image of the dermatologist to these patients was clear…come see us when it is too late, not when it is time.
In the past few years, state dermatology societies and organizations that represent dermatologists, like the AAD, ASDS, and WDS, have made great efforts to show that we are more than just “pimple poppers.” The AAD’s Council on Communications recently created an aggressive campaign on Specialty Positioning to help bring dermatology back into focus for patients and other medical specialties. This began with several years of collecting surveys of how we are perceived, and the answers were not new: “Access to dermatologists is horrible; dermatologists don’t come to the hospital and aren’t involved with medical societies; dermatologists only care about cosmetics and procedures.” However, surveys from 2013 have been encouraging, showing that 4 out of 5 potential patients know to come to a dermatologist for skin/hair/nail diseases and that the vast majority of patient encounters with dermatologists are positive. So see, we aren’t so bad.
This year the AAD’s Specialty Positioning campaign, led by Drs. Karen Edison and Elizabeth Martin is in high gear. The SPOT campaign will continue to move forward for skin cancer awareness in conjunction with new ads on melanoma, which emphasize the need for full body skin checks and the dangers of tanning. Internet and social media campaigns will promote the specialty to re-energize our image across medicine and to patients, but also to remind insurers, hospital systems, and healthcare policymakers. Think for a second about the “healthcare dollars” potentially spent on that 23-year-old misdiagnosed with zoster!
So it is up to us to do our part: Send a few reminder letters to your referral base, local urgent care clinic, and ER that you can get their patients in earlier for emergencies; poke your head in the lounge at the hospital if you go there; attend a grand rounds or medical society meeting; and do a skin cancer screening at a health fair. For the specialty, it can be completing RUC surveys, giving to SkinPAC, or showing up every few years at the AAD Legislative Conference. Most of all, by doing what we are trained to do, we can create awareness with a very simple phrase: “My Dermatologist is great, go see him/her; I had no idea I could get better.” n
—Neal Bhatia, MD,
Chief Medical Editor