Commentary: 'Big tent' approach to dermatology

May 1, 2009

A few months ago, I wrote an editorial for Dermatology Times on the subject of Mohs micrographic surgery and its potential abuses. I noted that while the procedure is very beneficial, it is sometimes overused for questionable indications.

Key Points

Among the responses to the editorial team was one from the head of an academic department who accused me of being "condescending" - I really didn't understand that - and "cannibalistic." That I understood very well. He was saying that by allegedly speaking ill of other dermatologists, I was devouring our own, to the detriment of the specialty.

One of the famous aphorisms developed by Ronald Reagan was the "11th Commandment," which said something to the effect that Republicans should never speak ill of fellow Republicans. This may be effective in politics but, in my view, it represents a potential disaster for medicine.

'Big tent' approach

There are many examples in which organized dermatology seems to have decided on a "big tent" approach, whereby just about anything a dermatologist does is acceptable.

The best example of this is the effort to develop practice guidelines for certain skin disorders.

In theory, this is an excellent initiative, under which experts review the available evidence and decide upon worthwhile therapies. Unfortunately, the product of these efforts often looks more like a political statement, which includes almost every possible treatment - even those with only a marginal benefit at best.

Although I have no idea what the deliberations looked like, based on the final report, I can envision a group of experts discussing the consequences of including or excluding treatment modalities based - in part - on who will be offended and who will be more vulnerable to lawsuits if any given treatment is excluded from the list of acceptable therapies.

The argument has been made that individual practitioners have the right to practice in any way that they wish, because, after all, who is better at determining what is best for the patient than the physicians on the front line? Thus, these "guidelines" should be as broad as possible to legitimize honest differences in treatment approaches.

I would agree with this general principle when decisions made by physicians are totally removed from what is in the best interest of the physician himself. Unfortunately, this is not what happens in some instances.

The American Academy of Dermatology (AAD) is the pivotal organization to move the specialty forward in ways that are beneficial to our patients. The AAD was never meant to be a policing body for its members, but it certainly can set some standards of practice that are up-to-date and realistic.

Perhaps ad hoc boards of inquiry could be organized and include individuals without a particular agenda who could carefully review the pertinent data and submit a detailed report of their findings. If a treatment for a given disease does not work, or if it is not cost-effective in comparison to other therapeutic options, this should become public knowledge.

Some are concerned that third-party payers will use these types of reports to limit the scope of practice that they will reimburse. That is not necessarily a bad thing if it results in better medical decision-making.

Others worry that malpractice lawyers will use these findings in the court of law to vilify physicians who practice outside of the standard guidelines. I am certain that this will happen, but it may ultimately lead to improved practice habits and to fewer lawsuits.

Outliers

One of the time-honored social mores in this country is that nobody likes a whistleblower ("snitch"), and one shouldn't "rat" on one's friends, family, neighbors or colleagues.

We all know that there are a few outliers in our profession who practice dishonest and/or substandard medicine. These people should not be under the big tent of dermatology, and it would be in everybody's best interest if there was a mechanism by which these practitioners could be publicly scrutinized. I know that this is the role of state medical boards, but these are often erratic and unfair.

Under the general heading of "totally impractical suggestions," I would propose that the academy have some mechanism of identifying those few physicians who are not serving their patients' interests in one way or another and who are actually diminishing the reputation of the specialty.

One means by which this could be accomplished would be to have the ethics committee of the academy produce guidelines of practice behavior, with some enforcement mechanisms that might result in a reasonable level of deterrence.

Our specialty is expansive enough to accommodate many diverse individuals and ways of practicing. There are limits to this, however, and we owe it to our patients to examine these issues - which may ultimately improve the care that we give them.