In this treacherous time in our country’s history, there are many ways to cope. I often turn to wishful thinking and whimsy to get through the day. With all of the potentially ominous changes that may soon occur in American medicine, I have chosen to paint myself a brighter scenario by creating an alternate universe, where I make the rules for anything related to our specialty. Here are some of my ideas in this regard.
If I ruled the (dermatology) world, the specialty would return to its roots as a true medical subspecialty. Dermatologists would all be interested in caring for patients with complicated combined medical/dermatologic conditions such as lupus erythematosus, dermatomyositis, vasculitis and pyoderma gangrenosum. They would be an integral part of the team that cares for hospitalized patients. They would have the expertise and inclination to use aggressive systemic therapies when necessary without having to refer tough cases to internists or pediatricians.
If I ruled the (dermatology) world, the term “cosmetic dermatology” would become an oxymoron. If someone were interested in pursuing a career in aesthetics, that person would not take a dermatology residency, but rather would seek training by some other means. Thus, the specialty of dermatology would be divorced from the discipline of cosmetology or aesthetic plastic surgery.
If I ruled the (dermatology) world, the concept of “thought leader” would disappear. No longer would drug and medical technology companies be allowed to hire academic dermatologists or others as advertisers for their products and call them anything other than “company spokespersons.” Free dinner “seminars” would be required to be renamed as “infomercials experienced over dinner.”
If I ruled the (dermatology) world, the FDA mandate would be changed to require that before new medications are approved, they must be tested against existing drugs (preferably generics) and shown to be at least comparable if not superior to them. Thus, many expensive new “me-too” agents would never clutter the pharmacy shelves.
If I ruled the (dermatology) world, there would never be limited access to dermatologists for whatever reason. Closed provider panels would become a thing of the past. On the other hand, dermatologists would not be allowed to pick and choose which insurance plans with which they would contract. This would require some upward adjustment in reimbursement rates by many plans covering low-income patients to make it financially feasible for practitioners to provide services for these people.
If I ruled the (dermatology) world, a medical education system similar to that operative in many European countries would be organized. In these systems, the costs associated with training to become a physician are largely covered by the government, so that new doctors are not crippled by extraordinary debts after finishing school. As in Europe, physicians would have an obligation to care for patients in underserved areas for three to five years at a living wage, but not one to make one rich. Unlike the European system, my plan would mandate that specialists would be included in this arrangement. For areas of the country that lack adequate numbers of dermatologists, this would be a terrific service, and for the newly-minted dermatologists, it would be a great opportunity to give back something to the society and to perfect the practice of cost-effective medicine, since there would be no financial incentive to do otherwise.
If I ruled the (dermatology) world, there would be a major shift in the way dermatologists would avail themselves of continuing medical education. It would become much more individualized and flexible than the present system which often revolves around one’s physical presence at a meeting site. As many modern medical schools have already learned, a large percentage of learning can take place without one being present in large lecture halls listening to professors repeat what is already either in print or online. Dermatology still relies to some extent on giant meetings with hundreds of presentations as a major portion of continuing education. So many sessions occur simultaneously, it is almost impossible to see and hear all of what one would desire. As a start, I would insist that all future American Academy of Dermatology meetings be recorded in their entirety and be made available for all members on a subscription basis. Perhaps the cost of subscribing to the entire menu of lecture options would be similar to what it would cost to register for the meeting as an on-site attendee. Thus, for those who would prefer to learn at home, there would be ample opportunity to remain up to date on all aspects of our specialty. I have little doubt that this would be a major logistic and financial challenge for the Academy and a disappointment to the technical exhibitors at the meetings, but the cost of the production could be defrayed in part by advertising that could accompany the online lectures.
After reading my musings, it is likely that many of you will be relieved that I will never rule the (dermatology) world. That does not stop me from dreaming of that day.