Why do dermatologists resist hospital consults?

Norman Levine, M.D.

Recently, a young family practice resident was spending some time in my office trying - somewhat unsuccessfully - to learn a little dermatology. In the course of our conversation, he remarked how surprised he was that I was caring for patients with cutaneous lupus erythematosus. He thought that was the purview of rheumatologists. He pictured physicians in our specialty being experts in acne, warts and cosmetology. I have heard this many times from patients, but having a fellow physician express this view forced me to think about why dermatology is falling off the radar as a legitimate medical discipline. One reason may be that we have become almost invisible in the inpatient setting. Part of the reason for this is that patients are now seldom admitted to the hospital for the care of skin diseases.

A significant additional factor, however, is that dermatologists have become extremely reluctant to participate in hospital activities such as evaluating in-patients as consultants, serving on hospital committees, and participating in educational activities in the hospital.

Examining our reluctance

Of these three explanations, the most troubling is our resistance to see patients at the hospital bedside. There are a number of apparently legitimate excuses for the failure of dermatologists to visit the hospital wards.

First, it is very difficult to leave a busy office during the workday and drive to the hospital to care for a single patient. It is a  poor allocation of our time. Second, many hospitals are now utilizing electronic  medical records, which are complex and difficult to master, especially when a physician needs to place entries in the record only occasionally (I have to relearn the process EVERY time I have to perform  a hospital consultation).

Third, reimbursement for hospital consultations is so poor that it makes no financial sense to perform this task. And fourth, it is often a waste of effort, since many of the problems for which one is consulted could be better handled in the office after the patient is discharged since all of the equipment and nursing assistance is optimally available.

Fifth, the high cost to the physician in maintaining hospital privileges does not seem fair since the hospital is getting the benefit of the doctor coming to the hospital. Why should we be charged for that privilege?

There is only one major reason for the dermatologist to answer requests for hospital consults, which counterbalances all of the rationalizations for not participating in this activity: Patients may derive  great benefit from one’s expert opinion.

At the hospital where I attend, if the hospitalist cannot persuade a dermatologist  to see a patient, the infectious disease service is called to fill the breach. This means that an inordinate number of skin problems are ultimately diagnosed as infections, whether this is correct or not. This is not in the patient’s best interest. Most community-based hospitalists have little knowledge or understanding of complex skin problems. If they were forced to act on their own, we would suddenly see an epidemic of Stevens-Johnson syndrome, a common concern of these physicians in any patient with a rash. When we come on the scene and assure the patient and his medical provider that she does not have a potentially lethal condition, we perform an extremely valuable service to all concerned.

I understand that we dermatologists do not derive much personal benefit and that it is pretty annoying to drive all the way to the hospital to see what turns out  to be a simple drug reaction or a seborrheic keratosis. The value to others, however, may be incalculable, which makes the whole exercise worthwhile.

Coming full circle

This brings us back to the initial issue, the perception that dermatologists have disappeared as an integral part of medical care. We must remain relevant in order to continue to be a part of the mainstream medical delivery system. There is no better means of accomplishing this than by providing inpatient hospital services when asked to do so. Patients and their caregivers will appreciate it.

In addition, for young doctors just starting out in practice, there is no better way to endear yourself to primary care physicians than to be ready and willing to inconvenience yourself a bit in order to provide important care to their patients. DT