The future of dermatology

May 1, 2014

Until recently, dermatology was an almost universally well-respected medical and surgical discipline. The scope of the specialty appears to be narrowing. If we relinquish the authority to manage skin disorders to concentrate on more lucrative pursuits such as selling products, we will cease to be relevant and our patients will suffer.

At the recent annual meeting of the American Academy of Dermatology, a prominent leader of the organization outlined the many challenges facing dermatology and recommended several means to be used to preserve the specialty and the financial viability of its practitioners. One major component of his strategy was to promote and emphasize the cosmetic aspects of skincare. I assume the idea is that the demand for these services will grow and, as a cash business, will remain very lucrative to the physician in the face of financial pressures from government and insurance carriers. 

At the risk of having live rattlesnakes placed in my Arizona mailbox, I vigorously disagree with these ideas and bemoan the fact that the majority of newly minted dermatologists intend on pursuing this plan of practice.

One brief walk through the technical exhibits at the academy meeting will reinforce the notion that there are myriad ways for the dermatologist to develop a practice with expensive and very sophisticated equipment to be used for the express purpose of caring for the aesthetic needs of the patients. 

Many “cosmeceuticals” or “product lines” are on display and are available for sale in the dermatologist’s office, some of which can be labeled as if they were a private brand. Many of these products would rival the finest that can be purchased at upscale department stores. With these tools, a fully trained dermatologist would no longer need to practice clinical dermatology at all and could still have a waiting room full of people ready for his services.

Complex disease forgotten

In the Japanese system of education, students study extremely hard in preparation for college entrance exams. Based on rigorous testing, the best students are admitted to the most prestigious universities, whereupon the studying ceases and the partying begins. 

Is this the same way that our excellent post-graduate dermatology education is evolving? The most accomplished medical students are accepted into dermatology residency programs that provide them with outstanding educational opportunities. Once the three-year process is complete, the new dermatologists are free to forget much of what they have learned about the complex processes of the skin and proceed to make their fortunes by injecting Botox (onabotulinumtoxinA, Allergan) and fillers. 

Many of these people have advanced degrees in scientific disciplines, have previously done extraordinary biomedical research and have published in major journals. This all falls by the wayside. In my opinion, this is a colossal waste of brainpower and talent.

Is money the driving factor?

Many have made the observation that the cost of medical education is so high and obligations incurred are so onerous that there is great pressure to earn a lot of money quickly in order to pay back these debts. There is no doubt that this is true, but where is it written that physicians are guaranteed a high return on their educational investment?

There are no hidden costs that the unsuspecting student incurs when he or she decides to become a physician. One might assume that he knows exactly what his financial burden will be before he makes the decision to borrow the money to attend medical school.

Perhaps one of the sacrifices of getting a medical education and pursuing post-graduate training is that one’s net income will be diminished for years after training is complete while the debts are paid.

In most other countries, physicians earn only a fraction of what we do in the United States, but the costs of medical education are comparatively low. The physicians choose medicine as a calling rather than as a means to amass great wealth.

I suspect that there are many such individuals in our country who would love to be physicians and practice “real medicine” even if it would mean a somewhat lower standard of living. Perhaps these are the people who should be given the opportunity to train in our residency programs.

The narrowing scope

Until recently, dermatology was an almost universally well-respected medical and surgical discipline, where well-trained practitioners cared for all of the skin-related needs of patients. Our fellow physicians recognized our expertise and appreciated the work that we did. Over the past several years, the scope of the specialty appears to be narrowing.

In a recent academy meeting lecture, John Zone, M.D., related instances where dermatologists in certain communities refused to see patients with complicated cutaneous autoimmune diseases, forcing these patients to be cared for by rheumatologists or other specialists, who often have no idea how to manage these difficult diseases. In my view, that is completely unacceptable.

We all know that pemphigus and other such diseases are not very profitable, but that is what we do for a living. If we relinquish the authority to manage skin disorders to concentrate on more lucrative pursuits such as selling products and enhancing the appearance of the clientele, we will cease to be relevant and our patients will suffer.

Shortage or resource allocation

Many have noted that with the new realities of the healthcare system, there will be a shortage of dermatologists to handle the increased load of patients seeking our care. I disagree with the inevitability of this prediction. It is more a question of allocation of resources rather than a real shortage.

If dermatologists commit themselves to handling the legitimate dermatologic needs of the patients by increasing the number of “medical dermatology” slots over “cosmetic” slots in the schedule, it will go a long way toward meeting the needs that will arise. Will there be those whose incomes will drop? Probably. Will this be better for our patients? Absolutely.