Do dermatologists overutilize procedures?

Denver - Dermatology can be the target of some unnecessarily negative attitudes from other medical specialties regarding revenue. But some "questionable behavior" by some in the specialty should cause others to more closely scrutinize what procedures they are selecting to perform, according to the incoming president of the American Academy of Dermatology.

Attempting to explain the disrespectful - if not hostile - attitude toward dermatology among some other medical specialties, says incoming AAD President Brett Coldiron, M.D., "We appear to make more money. But we really don't, after our office overhead. If anybody ever asks you about that, say, 'I have an ambulatory surgery center right in my office,'" with all the attendant expenses. Dr. Coldiron spoke at the 72nd Annual Meeting of the American Academy of Dermatology.

In fact, Dr. Coldiron says, two-thirds of the typical dermatologist's practice income goes toward his or her practice expenses, which is not the case in hospital-based specialties such as neurosurgery.

However, "We do have questionable behavior in our midst. We need to talk about that, because every time some scandal hits, (regulators) take away a little of our freedom. And it's not good for patient care."

A study he co-authored analyzed Mohs surgery utilization by state (Donaldson MR, Coldiron BM. Dermatol Surg. 2012;38(9):1427-1434).

"There were dramatic differences," not all of which could be explained by differing skin cancer rates. When they examined Mohs surgery of the trunk and extremities by provider, Dr. Coldiron says, "Many practitioners were doing very few cases. And at the other extreme, there were a few guys doing impossible numbers. How you do 2,400 Mohs cases a year? I don't know. I'm fast, but I can't do half that many. We suspect there were small tumors at the extremes that may not have needed Mohs surgery."

To counteract pressure from the American Medical Association (AMA)/Specialty Society Relative Value Scale Update Committee (RUC), Dr. Coldiron spearheaded the development of appropriate use criteria for Mohs surgery. They're less restrictive than what the government was proposing, he says.

"This is one way for us to police ourselves that preserves the procedure for patients who need it," Dr. Coldiron says.

Dermatologists must apply a similarly aggressive eye to other procedures such as biopsies, he adds, so that a small handful of unscrupulous dermatologists don't ruin it for the rest.