We all have secretly held opinions which run counter to what has been labeled “conventional wisdom.” For a variety of reasons, we are reluctant to act on those beliefs. That is usually a wise decision. However, as one gets older and it matters less if others think of him as eccentric, ill-informed, out of touch or just plain weird, expressing unpopular views or putting these notions into action becomes much easier.
I am now in the later stages of my professional career and have had years to solidify my biases about much having to do with dermatology. Having absolutely nothing to lose, I am now ready to share a partial list of my most unpopular views publicly with other dermatologists.
Dermatologists are overpaid for the services that they render
It is not as if we are doing something illegal, but it so happens that the current system rewards us too generously for performing often unnecessary exams and procedures. An example would be a patient with a history of actinic keratosis who returns every three months for an exam. We are paid each time we perform a complete skin evaluation in this person, even if it is probably overkill to repeat this type of evaluation that frequently. If we happen to see a solitary seborrheic keratosis and one actinic keratosis, we can bill for the visit as well as the treatment of the AK. The whole process takes under 10 minutes and the fee is at least $120. Sorry, but I do not feel like I have provided $120 worth of service. A much better system would be to be paid for the time spent with a given patient rather than for the individual procedures performed. That system might end what most of us do on occasion, searching for a billable procedure during the examination.
I freely admit that I enjoy a comfortable income level which allows me to take my extended family on nice vacations and to buy useless electronic gadgets. Somehow, it does not seem completely right to me. Soon, others with authority to make public policy will agree and our incomes will fall. I am trying to prepare psychologically and financially before the inevitable takes place. Perhaps you should make similar plans.
Sometimes it is better not to treat at all
A wizened old gynecologist once advised my medical school class that his secret to success with patients is that every patient received some form of therapy before leaving the office. I couldn’t disagree more. There are times when the fear of being unpopular with our patients or being pressured by them to “do something” drives us to use treatments that we know are not beneficial. I am aware that it takes longer to explain that no treatment is therapeutic than to simply write a prescription for a harmless (and useless) potion. Dissatisfied patients often will write scathing reviews on Yelp complaining that the doctor did not do anything, or worse, that he refused to treat at all. Recently, a person literally threw me out of the exam room after I had informed her that there was no medical remedy for her severely sun damaged skin. This patient aside, most individuals ultimately want a realistic evaluation of their situation. This can include a recommendation against any treatment for certain ailments.
Dermatology is reverting back to anecdotal medicine
Many years ago, there was a newsletter, the Schoch Letter, devoted to reports based on success stories seen in one or two patients. I recall vividly a pharmaceutical representative touting the efficacy of topical acyclovir in herpes simplex virus infections based on a brief comment in this publication. The dermatology community seemed to have largely gone beyond this type of data during the succeeding glory years of new scientific discovery and improvements in residency training programs which emphasized the scientific method.
I fear that the pendulum has begun to swing back toward clinical decision making by anecdote. In part this is driven by social media, where physicians share information without an editorial filter. Chat groups and Facebook pages devoted to dermatology have proliferated and have, I fear become the main sources of information for many of our colleagues. I understand that these web sites are fun to read and easy to digest, and that digging deeper for reliable data is time-consuming and often challenging. However, patients often are often not well-served by these quick-hitting recommendations that result in unhelpful or even dangerous therapeutic decisions on the part of their dermatologists.
What can busy practitioners do to keep up with the latest reliable clinical information? The most valuable source remains the excellent major dermatology journals that often publish very valuable review articles which summarize vast amounts of data. These journals also include articles which perform meta-analyses or Cochrane reviews which draw conclusions from evaluating many studies. There are also independent newsletters such as Practice Update,1 which summarize articles of interest with commentary by respected physician editors. The Medical Letter2 is a highly authoritative newsletter which critically evaluates new treatment modalities. Lastly, there are informative blogs, such as one maintained by Dr. Warren Heymann,3 which carefully analyze subjects of interest to dermatologists without a particular pre-existent point of view.
I have enjoyed my years as a dermatologist and greatly respect the practitioners in the field. In my view, our specialty has drifted down from the high level of scientific discourse that characterized it in the past. I am hopeful that we can maintain our reputation as one of the most knowledgeable and caring specialties in American medicine.