Primary Care Providers as Allies in Dermatology

The United States is currently experiencing a shortage of dermatologists to meet patient demand.^1,2 Over 40 percent of the US population lives in areas that are underserved by dermatologists, translating to long wait times for patients regardless of the urgency of their condition.³ Multiple studies place the average wait to see a dermatologist at over 35 days, with 25 percent of practices reporting wait times exceeding 60 days.^2,4 The current workforce shortage has also had a palpable effect on dermatologists, many of who report working longer hours than they would prefer.²

The relative shortage of the dermatology workforce has been partially alleviated by primary care physicians, who have been imparted with an increasing responsibility to care for patients with dermatological complaints. Board-certified dermatologists see only a third of all skin-related cases, the rest of which are cared for in the primary care setting.⁵ However, primary care physicians lack confidence in their ability to diagnose cutaneous disorders, rating their own abilities as only “mediocre.”⁶ These attitudes are consistent with studies demonstrating that primary care physicians fare poorly in the ability to accurately diagnose benign and malignant skin conditions.^5,7-12 In addition, primary care physicians have been shown to prefer overly conservative approaches to cutaneous therapeutic management, leaving patients at risk of repeated treatment failure and increased costs.^13-16

While these shortcomings may be attributed to a variety of factors, they are likely to be a reflection of insufficient time devoted to teaching dermatology to medical students and residents, as well as a scarcity of postgraduate educational opportunities for practicing primary care physicians.^6,17-19 Primary care physicians’ abilities in dermatology have been shown to correlate with the amount of dermatology education received during medical school and in residency.6 In addition, several studies have demonstrated the positive long-term impact of postgraduate training courses with a focus on medical dermatology, particularly with regard to reducing the rate of unnecessary biopsies and referrals by primary care physicians.^17-19 These findings suggest that even minimal increases in dermatology training at the medical school level or beyond may have a measureable impact on primary care physicians’ abilities in dermatology.

Based on national surveys conducted in 2009, medical schools currently require a median of 10 hours of total dermatology instruction, representing less than 0.3 percent of the total four-year curriculum.²⁰ Educational opportunities pertaining directly to dermatology are equally inadequate in most primary care residencies. While the Accreditation Council for Graduate Medical Education (ACGME) mandates exposure to dermatology as part of the core Family Medicine residency curriculum, no such requirement exists for Internal Medicine residents, except for topics related to signs of internal disease such as lupus and celiac disease.^21,22 Consequently, only 14 percent of internal medicine residents receive at least one month of clinical dermatology training.¹⁶ For physicians who have completed residency training, Continuing Medical Education courses with a focus on dermatology tend to cater to busy primary care physicians interested in enhancing their income. Many of these courses are geared towards teaching cosmetic procedures rather than enhancing the participant’s understanding of cutaneous disease.²³

The field of dermatology must strive to ensure access to high quality healthcare for all patients with cutaneous complaints. Decreased focus on the basic medical sciences and increasing competition from other specialties have limited the role of academic dermatologists in medical school and residency curriculum design.²⁴ Given the correlation between exposure to dermatology instruction and primary care physicians’ abilities to care for patients with skin disorders, dermatology educators must continue to pursue opportunities to influence curricula for medical students, primary care residents, and primary care physicians. However, given that 85 percent of medical schools reported the same or reduced time available to teach dermatology to medical students over a five-year period, it is unlikely that these educational deficiencies can be fully addressed by claiming more curricular time for dermatology.²⁰ Rather, dermatology educators must focus on novel ways of influencing medical school education that are both more feasible and reflective of the current learning environment.

At all levels of medical education, online learning has proven to be both effective and preferred over any other teaching modality.²⁵ The main benefit of online learning is that access is asynchronous, meaning that students may access content at their own convenience, without the need for additional lecture time. Dermatology educators have already taken great strides with this medium in the form of the American Academy of Dermatology Basic Dermatology Curriculum, which has proven to be an effective teaching tool among medical students, residents, and practicing primary care physicians.^26,27 According AAD data on file, the curriculum had a total of 450,000 page views in 2014, with each lecture downloaded between 6,000 and 20,000 times. Dermatology educators should work to increase awareness about the growing availability of online resources, and encourage the incorporation of these resources into required medical school and primary care residency curricula.

Dermatologists should also work to increase access to clinical dermatology rotations among both medical students and primary care residents. Other than students hoping to pursue dermatology as a profession, only a minority of medical students enroll in clinical dermatology rotations during the third and fourth years of medical school. Though it is unknown what percentage of medical students desire to take a dermatology elective but cannot because of limited access, few medical schools in the US require a dermatology clinical experience prior to graduation. Often, dermatology electives are filled between July to December, but unfilled between January and May. This is likely due to the nature of students interested in dermatology as a career enrolling in clerkships prior to submitting residency applications. Encouraging higher enrollment in clinical dermatology clerkships for medical students would likely have substantial benefits on future primary care physicians’ abilities in dermatology. While experiences in academic dermatology settings are preferred, private dermatologists should also be encouraged to accept medical students and primary care residents as rotators in their offices, in a fundamentally important volunteer effort to improve the skin care of the entire population.

Alongside immediate efforts to innovate the presentation of dermatology topics to medical students and residents, dermatology educators must have a long-term focus on changing the existing attitudes of medical students and residents towards the field of dermatology. Medical student behavior is in large part driven by the content of test questions, particularly those within the United States Medical Licensing Exam (USMLE). There are currently no dermatologists actively working on USMLE question writing. Dermatology educators may greatly influence the medical student mindset on cutaneous disease through increased involvement in USMLE question preparation.

Among residents, rotations in dermatology are often viewed as periods of relaxation due to lighter work schedules, leading to a truncated exposure to the field in relation to the length of the experience. Lasting cultural changes will require concerted effort and time by dermatology educators, but are likely to result in a primary care workforce that is better equipped to treat patients with dermatologic complaints.

Through these ongoing efforts, dermatologists can ensure that primary care physicians are adequately trained to serve as trusted allies in the care of patients with cutaneous disorders. This will benefit patients, who will experience more accurate and cost-effective dermatological care in the primary care setting, as well as the field of dermatology, which will be rewarded with improved outcomes and more prompt referral of patients requiring specialized care. n

No funding was received for this article. The authors have no conflict of interest to declare.

Kourosh Beroukhim is a medical student at the David Geffen School of Medicine at UCLA currently doing research at the Psoriasis, Phototherapy & Skin Treatment Clinic at UCSF under Dr. John Koo, Los Angeles. • Melissa Danesh, Department of Dermatology, University of California, San Francisco, San Francisco. • Catherine Nguyen, Department of Dermatology, University of California, Irvine, Irvine, CA. • Benjamin Farahnik, Department of Dermatology, University of Vermont, Burlington, VT. • Jashin J. Wu, MD, Department of Dermatology, Kaiser Permanente Los Angeles Medical Center, Los Angeles. • John Koo, MD, Director of the Psoriasis, Phototherapy, and Skin Treatment Clinic, Dept. of Dermatology, University of California, San Francisco, San Francisco.

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