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Dermatologists debate ways to reverse shortage of practitioners


National report - By now, few dispute the existence of a dermatologist shortage in the United States, or the likelihood it will worsen in the future as the population ages and market forces drive many practitioners away from medical dermatology. Opinions differ, however, as to how to solve the problem.

"There's both a quantitative and a qualitative shortage," says Joseph L. Jorizzo, M.D., professor and founding chair, department of dermatology, Wake Forest University School of Medicine, Winston-Salem, N.C. "In other words, we could use more dermatologists (overall)," he says. "There is probably not a perceived shortage from the standpoint of people doing surgical oncology, and there is not a shortage of people to do cosmetic dermatology. But the biggest problem is a shortage on the medical and pediatric side."

Robert T. Brodell, M.D., adds, "Any place away from the big cities and coastal areas either needs or will need more dermatologists. It is amazing to me that inexpensive housing, higher incomes, being a 'big fish in a small pond,' low crime and other incentives of small-town America drive so few dermatologists to areas like my own in Northeast Ohio. It is almost impossible to recruit a dermatologist to a small town when opportunities exist on the coasts and in vacation destinations. Last year at the AAD meeting I stumbled upon a list of dermatologists looking for associates which had hundreds of names. A list of dermatologists looking for positions had only a handful." Dr. Brodell is a solo private practitioner in Warren, Ohio.

"Within the existing manpower," says Dr. Jorizzo, "I estimate there has been a 50 percent shift in effort away from medical and pediatric dermatology. And it is a direct response to managed care dramatically reducing reimbursement. In order for dermatologists to pay their staff and overhead and keep their income where it was, they are having to shift some of their effort towards doing things such as cosmetic dermatology, which are not reimbursed through the managed care system. That has exacerbated the problem that already existed because of there not being enough dermatologists."

About 10 years ago, the federal government froze funding levels provided to hospitals to pay for resident training positions. Along with cost-cutting motives, Dr. Jorizzo says that "in those days, there might have been some sense that there were enough doctors."

Since then, the supply of new dermatologists has not kept pace with marketplace needs.

Practices change "There is no question that my practice is changing," Dr. Brodell says. "I am seeing the average age of my patients grow with me. I'm seeing at least 25 percent more pre-cancers and skin cancers than I was 20 years ago, with more doctors practicing at least some cosmetic dermatology, more women in the field who practice fewer hours during their childbearing years (Jacobson et al. Arch Dermatol 2004;140:191-196), and more specialty-trained surgeons and greater medical dermatology needs."

More specifically, Dr. Brodell says, "I fear that if we cannot produce enough dermatologists to approximate the need, we will have primary care doctors pointing out their 'special interest in dermatology' or even becoming 'board-certified' by boards which most of us would recognize as having no standing."

AAD launches initiative Attempting to prevent such problems, in November 2004 the American Academy of Dermatology (AAD) unveiled a plan to increase the number of dermatologists nationwide by awarding $1 million for each of the next three years toward establishing dermatology residency slots. According to the American Board of Dermatology, there were 342 first-year dermatology residents in 2004.

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