Guideposts for the Future of Medical Dermatology
“Dermatology” was perhaps once synonymous with the medical specialty of physicians who focused on diseases of the skin, hair, and nails. It is one of the most difficult medical residency positions to obtain through the match, involves some of the most diverse and stimulating medical content, and patients actually get better in dermatology.
But our specialty is under fire. Ahead, I outline considerations to assure the future of medical dermatology.
Patients are Not Consumers.
In the eyes of today’s patients, known now as consumers, “Dermatology” is interchangeable with various other, less-specific terms. “Skin Care Clinic,” “Skin Specialist,” and many synonyms used for marketing have diluted the perception of the practice of dermatology. Today “dermatology” is also being “practiced” by non-physicians from many levels of training, supervision, and quality assurance…and in some cases, none of the above.
The notion of the “healthcare consumer” is not derived solely from the fee-for-service model of aesthetic medicine. Even there, the notion is misleading. Surely patients can be empowered to be partners in their own care, but we should not equate receiving medical care with shopping, dining, or house repairs.
Doris Day, MD weighs in: Patients are not consumers and doctors are not providers. We are physicans and the people we see are our patients. We take care of them to keep them healthy and to help them heal when they are ill. We go through four years of medical school where we learn about the entire body, from conception to death. We then have to select a specialty and hope we match in that specialty. Once we specialize, we take our board exam and then are generally expected to practice within the scope of that specialty. We pass board exams, do CME, do MOC, re-certify every 10 years. Either this matters or it doesn't.
If it matters, then the public needs to be aware of the differences. If it doesn't, then we need to eliminate the requirements and maybe even medical school altogether. As a PA you graduate after two years of school, no residency or further training required ,and with that you can now select your specialty and change your mind and switch specialties at any time. You can be a dermatologist one day or for a year and then work as a psychiatrist next. If you don't like it, no worries, try pediatrics. There is very little truth in advertising, and the boards of the NPs and PAs are investing in marketing and advertising while dermatologists are too busy fighting for mere survival and reimbursement as well as prescription drug coverage for our patients. We need to open our eyes and see where we have played a role in the present situation and make changes to help protect our patients as well as the future of dermatology.
Physicians are Not Providers.
There is nothing elitist or insensitive about using our hard-earned titles. Sometimes for expediency and sometimes for more questionable reasons, middle management of healthcare systems, the pharmaceutical industry, the media, and others have marginalized what a dermatologist either can do or is perceived to be able to do, distilling them down to “providers,” equivalent to those with far less training or acumen for patient care.
If we do not continuously emphasize and defend our status as physicians who are board certified in dermatology, and do nothing to promote our value to the medical community, then patients will not fully appreciate our training, expertise, and proficiency in patient care…with potentially devastating results.
Micheal Gold, MD weighs in: I agree whole-heartedly with Dr. Bhatia here – we have been lessened over the years and this is something that we need to correct. I find it amazing that as a medical dermatologist that I can walk into an exam room where a patient has a “bizarre” rash and I know what it is instantly and already am working on a treatment plan in my mind. Often, the patient is amazed and dumbfounded that after seeing this doctor or that practitioner and not knowing what is going on – whether skin only or from an internal cause – that we can diagnose and treat skin concerns better than any other group of doctors. That is because our training programs demand that we learn as much as we can and that we are proficient in disease awareness. On the cosmetic front, I also think we are better than what some give us credit for – we are the ones who brought most of the non-invasive and minimally invasive therapies to cosmetic dermatology. We should be the leaders – we should not just be a provider.
We Can—and Should—Partner with Industry.
In 2019, the relationship between dermatologists and the pharmaceutical industry—once a strong partnership—has been diminished so that pharma is left to focus on their new favorite volume customers: non-physician prescribers.
More dermatologists seem to come out of residency training with contempt for the pharmaceutical industry. This likely stems from the fact that most programs forbid interaction between residents and industry, and some mentors are hostile toward pharma. And the result? Dermatologists are learning less and less about new innovations, new vehicles, and even worse, deprived of the education of how to make a decision on ethical relationships, since those decisions are made for them, despite their being some of the smartest graduates from medical school.
But if dermatologists don’t partner with industry, where will the next crop of speakers/educators, advisors, and innovators come from? Is it better to let pharmaceutical companies work with non-physician prescribers, who will only speak at sponsored presentations, which must be on-label and company approved? That might work for pharma, since these “speakers” lack the scientific knowledge to go off the script, and therefore avoid the penalties for promoting their products off-label or adding their own two cents.
Let’s also keep in mind that pharmaceutical companies support our societies and society meetings. Where will we find funding if we alienate pharma? Do we have enough support from generic drug manufacturers to promote medical education for our residents and our colleagues? And who will pay for the increase in membership dues and meeting registrations when pharma decides that there is no return on their investment to support a specialty that looks with contempt on their existence based on philosophy?
Stefan Weiss, MD weighs in: Across the large cap pharmaceutical and biotechnology companies, immunology has become one of the key business priorities. Because most dermatologic diseases are immunologic in nature, we, as dermatologists, have an opportunity to advocate for these budgets to be directed towards therapies addressing unmet needs in cutaneous medicine. But, if we abscond from this responsibility, other specialists will lobby to direct these scarce resources towards diseases in their respective fields of medicine.
Hidradenitis suppurativa, vitiligo, and alopecia areata, previously without any FDA approved therapies are undergoing a renaissance in research. None of these disease states represent multi-billion dollar markets, the traditional threshold for a project moving forward. As such, they fail to register among the commercial organizations of these companies. But, by building relationships with dermatology divisions of companies, we have the opportunity to educate industry colleagues on how the late-stage science can be directed and what early-stage science is promising.
In the end, our obligation to our patients does not end at the exam room door. Nor can we consider ourselves successful patient advocates if all we do is offer the therapies currently in existence. Rather, we need to stimulate research driven pharmaceutical companies to explore therapies for the diseases for which we have no options. We have all applied immunosuppresants off label in an effort to combat immunologically mediated diseases. We have all faced the vitiligo patient heartbroken as we explain the lack of proven options. The future is bright for new therapies and much like this generation of dermatologists can treat psoriasis with a success unapproachable by the previous generation, there is a real possibility that the next generation of dermatologists will not be as limited with these rarer, but devastating diseases. However, in the end, the leadership of dermatologists in steering research towards that goal, by partnering and engaging with our colleagues in industry, is a necessary ingredient.
We Must Also Promote Traditions.
Already we see that non-physicians diagnosing and treating patients in dermatology are knowledgeable about the commonly used prescription drugs but may be unfamiliar with long-used and still-effective dermatology remedies. Biologics, isotretinoin, or other complex therapeutic regimens may well be the best bet for a given patient, but many supervising dermatologists stand by methotrexate, precipitated sulfur, intramuscular steroids, and even Grenz Rays.
We Should Drive the Dialogue.
Can Physician Assistants and Nurse Practitioners help increase patient access to dermatology care? Of course—with proper training and working appropriately along with a board-certified dermatologist. However (perhaps as a result of dermatologists’ own unwillingness to take a unified approach to the issue), NPs and PAs in dermatology are representing themselves to the public without our involvement. Sure, they often make reference to partnership with dermatologists, but we might better reflect the importance of collaboration if we collaborated on messaging, too!
Additionally, some Nurse Practitioners and PAs (not all, and not necessarily in dermatology) are now being called “Doctor” by obtaining degrees, often outside of accredited medical schools. Yes, a PhD is referred to as “Doctor,” but in a clinical setting, this creates confusion for patients. Just as vexing, in a nationwide media campaign, a PA from a large venture capital-based practice referred to herself as a “Board-Certified Derm PA.” No such thing exists…to date, there is no board certification in dermatology for PAs, and the AAD made sure that they were aware of their infraction. But how many more of these scope of practice and marketing violations occur? If the practitioner is not truly a doctor of medicine, should the title “doctor” enter the clinic arena?
Dr. Gold weighs in: I am in favor of having NPs and PAs working in our offices under our supervision. We can teach them and guide them in the nuances of how we practice our chosen craft and they can help us deliver appropriate care. We must be willing to teach them and we must have them work with us – not against us as more and more extenders are entering the work place. We can never let them replace us and we cannot let them refer to themselves as Board Certified Derm PAs – this we need to stop.
On the other hand, we exclude them from coming to our specialty meetings and participating in our courses. You may think this is a good thing – but I want my extenders to learn from our thought leaders and this is not always easy. Are we scared of them – some are – I am not. I think they have been a wonderful addition to my practice and I encourage mutual learning and teaching so that they can be the best they can be.
Dr. Day weighs in: More and more I'm seeing patients who have come in after having had adverse reactions from treatments, or misdiagnoses, who tell me they saw a "dermatologist" when, upon further questioning, I find out they did not actually see an MD. Patients are trained to think of anyone in a white coat as a doctor. They are often not corrected when they call an NP or PA “doctor,” even when those individuals don't have an MD; and those who have PhD rather than MD don't seem to mind misleading patients by calling themselves “Doctor.” Yet these individuals know that the term refers to MD in the patient’s mind, not PhD.
We need truth in advertising where they must wear their title not “Dr.” as a prefix but instead use their name and degree as a suffix. We as medical doctors, dermatologists, need to find a way to do a much better job of educating the public on what it means to be a doctor and the value of the training we get. Finally, some of this is self-inflicted pain, as many within our specialty employ mid-levels as if they are doctors and provide little to no oversight of their work.
We Must Advocate.
Medical Dermatology is basically on life support as many dermatologists are disillusioned by endless regulation, beat downs by pharmacies, insurance, the cursed prior authorization, and the declining reimbursements associated with actually being a doctor.
Non-physician prescribers don’t carry the same burdens of liability, Sunshine Act reporting, or even the challenges of practice ownership and management that dermatologists do.
In 2019, dermatologists have continued to show that they have lost control of the specialty. These shifts are not only in full motion, they are going to lead to the eventual phasing out of dermatologists as too expensive, unable to collaborate, and too afraid of their own shadows.
Fig. 1 Rates of EHR Adoption
Sources: J Am Acad Dermatol 2017;77:746-52 and The Office of the National Coordinator for Health Information Technology
Fig. 2. % of Dermatologists Employing PAs or NPs
Source: J Am Acad Dermatol 2017;77:746-52.
Fig. 3. PAs in Medicine (darker shade) and PAs in Dermatology
Sources: NCCPA Statistical Profiles and AAPA Salary Surveys
Fig. 4. Prior Authorizations
Source: JAAD, in Press and AMA 2018 AMA Prior Authorization (PA) Physician Survey
Look to the Future
All is not lost. Dermatology has a rich history and retains an established and respected place in the house of medicine. It should be noted that other medical specialties face many—but perhaps not all—of the challenges that dermatology does. If we remain dedicated to advocating for ourselves and for our patients, then we can continue to be a vibrant and successful specialty.
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