Is dermatology abdicating to other specialties?

Since his dermatologic practice would best be characterized as being medically oriented, his concern initially seemed out of character to me. After further thought and discussion, however, I began to understand why he called. Although he was not particularly interested in personally offering his patients any of the procedures being promoted by these independent, unsupervised, unlicensed non-physicians, he was interested in preserving the right of dermatologists to provide their patients with the highest quality medical, surgical and cosmetic therapies that they are trained to perform. His motivation was not financial, but rather an attempt to develop a defense strategy to help preserve our specialty for the future.

Remarkable changes If one looks back over the past 50 years of dermatologic training and patient care, it should come as no surprise that our specialty has undergone some rather remarkable changes.

Difficult to explain However, some of the other changes that have occurred in dermatology are more difficult to explain and have come at some rather significant costs to the specialty.

One of those changes is that dermatologists rarely admit patients to the hospital anymore. Instead, even patients with primary skin diseases like extensive psoriasis, exfoliative erythroderma, pemphigus, lupus, severe atopic or contact dermatitis are now typically admitted to the hospital's medicine service and the dermatologist may only be asked to provide consultative assistance. When did dermatologists stop receiving training in the management of patients with these skin disorders? When did dermatologists routinely stop providing care for patients with these disorders? When did dermatologists abrogate our responsibilities to patients with these types of diseases and give them over to internists? Are we avoiding hospitalizing patients with skin disease because they take too much time to care for or have we simply gotten lazy? While it is more difficult and time-consuming to go to the hospital before or after office hours, see inpatients, write progress notes and review the laboratory results and other studies than it is to stay in our office and see ambulatory outpatients all day long, I believe that many of us would still be willing to do this work.

Not a question of laziness However, I think that much of this change is not a result of lack of training, incompetence or laziness, but rather a direct result of managed care organizations dictating to us what patients with which diseases require hospitalization and who should manage them.

In addition, there is also no doubt in my mind that some of this change is a reflection of improved technology in drugs and devices that allows better management of patients with certain skin diseases in the outpatient setting instead of requiring hospitalization. I believe that most dermatologists would agree that using PUVA to treat severe psoriatics as outpatients and allowing them to continue to work and live at home is certainly far better than the old days of Goeckerman therapy that required two to three weeks of hospitalization for application of topical stinky tar ointments.

Psoriatics first to go? New technologies may come at some risk to the patient and the physician.