PracticalDermatology

A recent survey asked board-certified dermatologists (BCDs) their views on whether the American Board of Dermatology (ABD) should police certain areas in determining “professionalism” for BCDs, including “[promoting and maintaining] professional, decorum, and honesty when interacting with or speaking about other medical professionals,” “[avoiding] public comments providing medical recommendations that are untruthful, fraudulent, misleading, or deceptive,” and “[upholding] principles of equity, diversity, and inclusion in the healthcare setting.” Initially, the same survey appeared to include the potential for evaluation of social media posts as they relate to professionalism, but in the latest iteration of the survey (April 22, 2022) this was (encouragingly) not included. One implication was that presence on social media, as well as the other factors, including the diversity of their practices or their clinics, might be considered in the determination of whether a physician was worthy of, or conversely unworthy of, being a BCD. These issues are highly nuanced; the prospect of having this overreach by a board that was created to administer a test of competency in dermatology is concerning. As written, these policies are ill-defined and are at high risk of being misused or misinterpreted, potentially threatening the careers of competent dermatologists. There are several key questions one must answer when evaluating the proposed ABD professionalism policy.

First, what is the ABD’s role in our profession? I have always believed that the ABD’s purpose is to evaluate medical competency. “Professionalism,” on the other hand, should be the purview of state and local governance, as has historically been standard practice. Clearly, in situations where dermatologists have obviously crossed the line, they need to be evaluated for misconduct and disciplined appropriately; this should be the function of the state boards, which are most experienced with handling misconduct issues.

Second, are the policies outlined by the ABD the proper ways to evaluate medical professionalism? From the vague language in the proposed policy, it is unclear whether the ABD plans to include social media in their determination of professionalism, but if they do, there are many considerations. Social media is now an accepted and, possibly, essential component of most dermatology practices. There is no doubt that many medical practitioners, including dermatologists, have been poor stewards of their social media campaigns at times. Clearly we have all seen examples of harmful tweets, Facebook posts, and TikTok videos by colleagues for whom we had more respect prior to seeing these posts. While many younger dermatologists are extremely facile in their use of social media and can run an Instagram account as easily as they do a punch biopsy, there are many dermatologists who delegate these services out to a staff member who is assumed to be more up-to-date in this arena. As the policy is currently written, it is implied that an inappropriate or misguided tweet by a part-time or off-site worker could lead to potential board-certification revocation if reported by a jealous colleague or an unhappy patient.

One other unexpected question in this survey related to whether diversity, equity, and inclusion (DEI) should be a part of the ongoing certification process. While I am a staunch supporter of these initiatives, the policy, at present, fails to provide a definition of what it means to “uphold principles of equity, diversity and inclusion in the healthcare setting.” The proposed policy, for example, does not clarify what criteria would be used to assess this commitment. Many aspects of DEI are still evolving over time, with different interpretations and learning curves by members of our profession that vary based on age, location, and other factors. Just as there is not yet an agreed upon way to teach principles of DEI in medical school and residency, there is no clear way to assess if one is or is not meeting expectations in clinical practice. One can’t help but be heartened by the realization that our specialty, its members, teaching institutions, and journals have taken a strong stance on DEI, with many educational articles and entire sessions at the AAD devoted to it. This is something that all dermatologists will learn to integrate into their lives over time, but it is not something that should determine their board certification status presently. While I believe and hope that all dermatologists will learn to embrace DEI over time, its evaluation in clinical practice remains nebulous.

Third, who should regulate professionalism, and how? The onus has traditionally fallen on state and local medical boards, and I believe it should remain this way. In writing about medical licensure and professionalism, Carlson and Thompson note that, “Medical boards focus on protecting the public, not on punishing physicians…Minor disagreements do not fall under misconduct, nor does poor customer service.”¹ Therefore, while state medical boards typically address physical abuse of patients, inadequate record keeping, improper prescribing of drugs, impaired ability to practice due to addiction, and felony convictions (among several other factors) in determining professionalism, they do not typically include more subjective measures like the ones included in the proposed ABD policy. This is not to say that state and local medical boards are perfect, but they do have a long history of evaluating physician behavior, something that is not currently a part of the ABD duties.

There has been much discussion of this survey by groups such as DermChat (typically more experienced dermatologists) and The Board-Certified Dermatologists’ Facebook Group (typically younger dermatologists). Several thousands of dermatologists are represented between the two groups. Anecdotally (and importantly), among hundreds of posts that I have read in both groups, none supported these measures.

If the ABD truly is representative of the dermatology community, it should strongly consider whether it is best suited to evaluate professionalism while continuing to focus on its core strength: evaluating medical competency. To reiterate: evaluation of professionalism is best left to the state medical boards that are already familiar with these issues and have the broad discretion to discipline those who have made errors that deserve attention.

1. The Role of State Medical Boards. AMA Journal of Ethics 2005, 7(4).