Dr. Krakowski is chief medical officer for DermOne and co-director of the dermatology residency at Campbell University, in North Carolina. He is also a practicing pediatric dermatologist with a specialty in scar treatment and revision. He may be reached at AndrewKrakowski@DermOne.com.
What did 2016 mean for the dermatology community?
This past year has been filled with tremendous novelty, ranging from new treatment strategies for complex conditions like epidermolysis bullosa to the emergence of private equity’s seemingly ubiquitous interest in all things dermatology-related. For this reason, I believe 2016 will be remembered as a year of “dynamic transformation” within our specialty.
Were there any breakthrough treatments, procedures or studies that helped move the needle forward?
Every day brings tremendous breakthroughs and different perspectives — any number of which could be identified as game-changers within their respective sub-specialties. As a pediatric dermatologist, I am probably most excited at the prospect of reprogramming or transplanting a patient’s own cells to genetically correct conditions like recessive dystrophic epidermolysis bullosa or Goltz syndrome. Likewise, the identification of novel immunomodulators for atopic dermatitis and their developing role in the pediatric population seems promising.
Medicine’s general frame shift to “clinical outcomes” is also especially noteworthy. The idea that, for example, a group of psoriasis experts would convene, agree on a set of metrics to evaluate the success or failure of treatment, and publish guidelines as clinical best practices has the potential to truly help us become better clinicians and patient advocates. Dermatologists in the trenches want to do what is best for their patients, and we also try to keep a vigilant eye on the overall burden we place on the heath care system. Such expert recommendations help us to better define our treatment targets and reach them in a more time-sensitive, cost-efficient manner. Similar projects have also been accomplished for acne and atopic dermatitis, for example, and several are underway for scar management, wound care — you name it and there is likely a group of experts working on their respective guidelines! I believe we will see this trend continue because, quite frankly, our specialty demands the clinical excellence such recommendations seek to achieve.
Health care delivery is about to change again. Any thoughts on what these changes may mean for dermatologists?
Many dermatologists — both newly graduated residents and seasoned professionals — are exploring new models of clinical care delivery, either because they willingly seek a change or because they feel that, ultimately, they must. It is no accident that this growing sentiment coincides with a rise in regional and national dermatology groups seeking to transform the specialty from within. By removing day-to-day inefficiencies and streamlining the administrative processes, these groups promise dermatologists the ability to focus more on patient care and less on the distractions that would otherwise bog us down as clinicians.
What is most interesting to me is the potential for such models to improve the public’s overall access to quality dermatologic care. In some ways, this trend represents an evolution of the traditional “big city” dermatology center of excellence paradigm. By participating in a regional hub and spoke model, a single private practice dermatologist can provide an entire community with access to a number of dermatological services that it might not otherwise be able to sustain on its own; for example, top-notch dermatopathology, Mohs micrographic surgery, pediatric dermatology, and reconstructive/aesthetic dermatology. The individual physicians, in turn, enjoy being supported by a larger group of expert colleagues and an experienced, financially sound administration team.
Done correctly, with the needs of the individual dermatologists and patients kept paramount, I think we will continue to see this model build momentum and challenge the dogma that you must work in an academic center if you want to practice academic-level dermatology.
What technologies have been implemented this year or recently that help physicians practice dermatology?
We are witnessing some major step-changes in the way dermatologists practice clinical medicine right now. The desire for more rewarding patient encounters, for example, has led to my increased use of clinical scribes. Having now had a taste of what it is like to converse with a patient face-to-face instead of a video screen, I do not think I can (or will!) ever go back to being a computer jockey. Likewise, we have started to merge our electronic health records into larger databases, like the American Academy of Dermatology’s own DataDerm registry. This allows us to aggregate “big data” and should, ultimately, facilitate the identification of clinical trends, as needed, in real-time.
Teledermatology also continues to evolve as a powerful clinical tool - so much so that, at this point, you are no longer “cutting edge” if you utilize teledermatology, you have simply managed to keep up with Dr. Jones. The rise of direct-to-consumer dermatology websites, in particular, signifies an interesting trend. Like them or not, these sites serve as a bellwether that certain patient populations are absolutely willing and able to access their skin care through technology. We must, as a specialty, acknowledge the factors (e.g., cost, convenience, anonymity, etc.) that lead a patient to want to “log in” instead of “pop in” to see a local dermatologist and then work toward addressing our patients’ specific needs.
What are some of the bigger trends that practices have seen in terms of what patients want in the past year?
Patients continue to grow savvier and, perhaps rightly so, continue to demand more from us as providers. People have in their minds an expectation for an ideal patient experience, and they are willing to travel until they find it. This may be the consequence of imperfect technologies like online physician review websites or it may simply be an attempt to get more out of their annual deductibles.
Either way, gone are the days when “Doctor [paternalistically] knows best.” Today’s patients routinely come in with self-diagnoses – some of which are actually correct! – that they gleaned using Google Images combined with a basic keyword search (“This rash is either shitake mushroom toxicity or a classic case of parastratiosphecomyia stratiosphecomyioides; so, which is it, Doc?”). Similarly, patients have become adept at understanding even complex skin disease processes, and they are sometimes just as versed as we are in describing the risks and benefits of cutting-edge therapies. Consequently, we as dermatologists must recognize this phenomenon, take a deep breath, and remember that we are now being evaluated on a case-by-case, patient-by-patient basis. Now more than ever, we have to leave our own baggage at the clinic door, and we must continue to evolve to meet the growing expectations and increasing sophistication of the patients we treat.
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