Feeling the impact: Shortage of dermatologists getting worse

New Haven, Conn. - The shortage of dermatologists in the United States is getting progressively worse, and patients and practicing dermatologists are being affected.

Only about 300 dermatologists are entering the specialty each year to practice in densely populated urban areas, where development of a subinterest in advanced surgical and cosmetic procedures is feasible. This trend results in a depletion of dermatologists available to the rural population, and it forecasts a virtual absence of replacement of dermatologists outside of urban areas.

According to Marie-Louise Johnson, M.D., Ph.D., clinical professor of dermatology at Yale University, New Haven, Conn., and an epidemiologist, of all patients who consult a doctor for a dermatologic problem, a staggering two-thirds are being seen by a physician who has never had adequate training in dermatology.

"The reason for this is that in medical school and in primary care residencies, dermatology is more or less ignored - a holdover of the unimportance of dermatologic diseases as a contributor to mortality. However, in private practice, primary care physicians are often bewildered by what they call ’the mystery of the rashes,’ and uncertain in detecting malignant lesions, in knowing which of the patient’s many lesions should be biopsied," Dr. Johnson explains.

In a rural area, referral to a local dermatologist is not at best a timely option. The very few dermatologists in the area are overloaded with patients. New patient appointments are scheduled for many months of wait time.

AAD findings

The American Academy of Dermatology (AAD) has investigated the shortage in terms of evaluating the impact on practicing dermatologists. However, solutions for the populations disadvantaged by the increasing shortage need to be addressed as well.

In 2004, the AAD evaluated the impact of the shortage on the practices of 10,000 dermatologists and found that half of the practices sought relief from overload by competing fiercely for the services of the 300 graduating dermatology residents. Another 2004 finding indicated that 4,000 practices had hired physician assistants (PAs) and nurse practitioners (NPs) who saw, on average, 30 to 35 patients per day.

These PAs and NPs have not had adequate prior training; what they receive is informal on-the-job training. However, with their assistance, dermatologists have been able to maintain a national market share that accounts for seeing 30 percent of all visits to physicians for medical dermatologic care.

"Dermatology is laden with medically challenging cases. Seeing patients without the necessary sophistication, sensitivity, knowledge and training clearly diminishes the quality of care patients receive. Dermatology as a specialty is too small to assume responsibility for the cutaneous healthcare of the nation, but I believe that we are responsible for identifying and promoting solutions toward improving patients’ access to informed medical dermatologic care," Dr. Johnson says.

New venture

Dr. Johnson’s solution is both personal and systemic in nature. In 2002, at the age of 75, practicing in a four-county rural service area and unable to recruit a dermatologist, she decided to expand her practice facility into a Yale clinic replicate with Mohs surgery and upscale phototherapy, and to establish, under the aegis of a local American Board of Family Medicine-approved residency program, a Fellowship of Additional Training in Medical Dermatology. She was joined in her effort by the Yale department of dermatology, which provides full participation of fellows in the Yale dermatology residents educational program, one day per week.

Dr. Johnson established a program that would select trainees nominated by their primary care residency directors and serving rural areas who would return to the faculty of their department to practice medical dermatology and to teach and train residents and medical students. Dr. Johnson’s strategy was to be that of training-the-trainer and to have a multiplier effect in improving dermatology training for hundreds of primary care residents and medical students. Physicians planning a private practice are ineligible to apply.

Training

The training given is intensive and varies in length from one to three years, according to the progress of the fellow in satisfying core competencies in practicing and teaching medical dermatology.

Fellows have the unique opportunity of one-on-one learning from a master of dermatology, a long-time experienced teacher, and a member of the National Academy of Sciences Institute of Medicine. A Mohs surgeon and a second medical dermatologist, both medical school voluntary clinical faculty, complete the training staff.

"In many ways, the fellowship program," Dr. Johnson says, "is a renaissance of dermatology’s training by preceptorship, a modal model until the ’50s. Then, as now in our small program, training was directed solely to general dermatology."

Effectiveness

Dr. Johnson cites with great pride the 2007 fellow who returned to the family medicine faculty at State University of New York-Buffalo. There, she teaches and trains 48 residents, classes of medical students and has a family medicine dermatology clinic in four Buffalo hospitals.

Dr. Johnson refers to her efforts as "a demonstration programproviding evidence of the feasibility, efficiency and effectiveness of training highly qualified board-certified primary care specialists in medical dermatology.

"The fellows are interested and quick learners, and the training program uses resources that are readily available in many rural areas - an interested dermatologist clinician/teacher, an institutional sponsor for certification and a supportive medical school department of dermatology.

"To date, we do not have sufficient data to assess effectiveness. However, our program is identical in purpose and implementation to the British National Health Services General Practitioners with a special interest in dermatology. That program has trained over 4,000 primary care physicians and has a score of reported studies on its great effectiveness," Dr. Johnson says.

Looking to the future

Dr. Johnson hopes that her demonstration will give renewed attention to the seminal and essential component of medical dermatology in defining the specialty. Research in medical dermatology is the engine that has brought forth the dawn of the biologics and effective novel treatments for patients with chronic skin diseases.

Dr. Johnson is concerned about the lessening of interest in dermatology training programs and its displacement by cosmetic dermatology, a set of skills outside the unique specialty of dermatology.

She says that many other dermatologists would like to replicate the program but cannot do so in the absence of federal support for the trainees. There is such support for Mohs surgery trainees, and for geriatrics and sports medicine, but as yet none for medical dermatology.

"Hopefully," Dr. Johnson says, "its effectiveness will help to gain support for the program."

In the long run, Dr. Johnson expects that the reticence of dermatologists to encourage the upgrading of non-dermatologists in primary dermatologic care will abate, and it will be seen simply as an improvement in the quality of care to patients that they are unable to see. DT

Disclosure: Dr. Johnson reports no relevant financial interests.