Who Will Advise Patients About Matters Dermatological in the New Millennium?

Dermatologists have been accused of thinking that they are the only people who know about skin diseases and that they are the only people sufficiently qualified to treat them. How true is this, and is it likely that dermatologists are going to be the major sources of advice on dermatological matters in the new millennium?

To answer these questions, one only has to look at the developing countries to appreciate the fact that there is a problem. In these regions of the world, whose populations constitute more than two thirds of the world population, the vast majority of people live in rural communities where skin diseases are predominantly infective-parasitic.¹ In contrast, in those countries the vast majority of medical practitioners are situated in cities and provide care to a relatively small proportion of the total population.

In addition, there is a mismatch in training between dermatological professionals and work requirements in developing countries. A very large proportion of the diseases in these countries could either be prevented by relatively simple structural measures or, when required, if they were treated without the need for highly specialized medical experts. In other words, dermatologists might not even be required for the vast majority of skin problems. Care could be provided by primary care health workers (not necessarily medical practitioners), including nurses or other allied health workers who have received some basic and satisfactory dermatological teaching and training. In the new millennium, no doubt, a broad view will be required to develop a public health approach that is appropriate to their needs.

So much for dermatologists being the major providers of advice about skin problems in the developing world. What about dermatological care in the developed world, in which more than 90% of the world's dermatologists practice and from whence have come the most wonderful scientific and technological advances in the last century? Who will need dermatological care in this more advanced part of the world in the new millennium? What sort of problems will those patients have, and who will provide the advice for either preventing their problems or treating them if they occur?

In contrast to the developing world, very large proportions of the population in developed countries are urban, living in or very close to the city. Also in contrast to the developing world, there is a greater proportion of the population in the older age range. In the developing world, around 45% of people are under the age of 15 years compared with 20% to 25% in the developed countries. There is a clear difference in prevalence of various cutaneous diseases related to age.

What are the common diseases in the developed countries? Every dermatologist will tell you that they are acne, warts, tinea, dermatitis (eczema) of various types, psoriasis, and skin tumors. These may vary in relative proportions to a certain extent according to geographic location and demographic characteristics of particular populations.

Unfortunately, the exact frequency of these diseases in most developed countries is unknown. Despite the huge amounts of money poured into basic scientific and technological research in dermatology, remarkably little by comparison is devoted to determining the frequency of the diseases for which most scientific research money is being spent. Even less money is devoted to accurately recording morbidity in the community related to these conditions. The latest population-based national study on the incidence of nonmelanoma skin cancers, reportedly the most common malignant tumors in the United States, was undertaken in 1977-1978.² The last population-based national study on the frequency of other common skin diseases in the United States was undertaken in 1971-1974, more than 25 years ago.³ The amount of data published on the epidemiology of cutaneous diseases in the developed countries is not dramatically different from the amount published on the developing ones.

The data we do have tend to confirm the impression of dermatologists that the most common skin problems in developed countries are indeed those listed above. However, they are not always in the proportions in the general populations that dermatologists might expect based on their experience in practice. There are major traps in suggesting that what is going on in the population at large is accurately represented by the sample of patients being seen in the offices of dermatologists or other medical practitioners. Two recent examples will suffice.

In Maryborough, a Central Victorian city in Australia with a mixed rural-industrial occupation spread, we interviewed over several weeks on 2 different occasions in the year people who entered the pharmacies and purchased a skin-related product.⁴ The proportion of skin diseases they reported (ie, the reason for purchasing a skin-related product) was substantially different from the proportion of the same conditions that was seen in the medical practices in the area during the study period. Of the 729 products purchased over the counter (OTC) (ie, without a medical prescription), only 10% were recommended by a doctor, 39% were recommended by the pharmacy staff, and 27% were recommended by someone in the subject's family.

The second example relates to a telephone survey of a randomized selection of 443 adults from Maryborough (94% response rate), in which interviewees were asked to report skin problems they had experienced during the last 2 weeks and the last 6 months. They were also asked from whom they sought treatment advice.⁵ Only 49% ever saw a medical practitioner about their skin condition. Pharmacists provided advice and treatment for 19% of the people who were interviewed, while 6% received advice from family and friends, and 7% received advice from a variety of other sources, including beauty therapists and naturopaths.

In summary, these 2 examples confirm that relying on data from surveys of medical practice will not reveal the true frequency or relative proportions of cutaneous disease in any given community. They also highlight very clearly that neither general medical practitioners nor dermatologists are the sole players in providing advice about the management of skin diseases in the general population.

Concern has been expressed about the lack of dermatologically trained practitioners in developing countries—90% of skin diseases in these areas are currently treated by people with little or no training in dermatology. It is ironic that in our Maryborough pharmacy study, 55% of people who sought advice and purchased a skin-related product within the pharmacy were seen only by the junior sales staff, not by the pharmacist or any other person there who might at least have some training in OTC pharmaceutical products and their use. Not necessarily so different from the situation in developing countries.

With concern about the rapidly rising costs of health care, particularly when provided by highly trained specialists, governments and other health care providers in most developed countries are looking at ways of underwriting less costly and, of course, less qualified providers of dermatological care. One only has to watch the debate about managed care and "gatekeepers" in the United States to appreciate this. The recent increase in availability of highly efficacious OTC products for cutaneous diseases in most countries and moves towards an increasing role for pharmacists in diagnosing and managing the common conditions is another example.⁶ Although the situation in developed countries is several orders of magnitude away from the situation in developing countries, one could almost make a case for saying that they are running in parallel in regard to the methods being recommended to provide dermatological care in the future. Certainly the rhetoric in both situations sounds very familiar.

What about the role of health promotion and screening in prevention and early diagnosis of cutaneous disease? The outstanding success of the skin cancer programs in Australia at the end of the 20th century has been applauded, and they are now being emulated by many countries in the world. But these programs, although involving medical practitioners to varying degrees, are largely run by public health practitioners, such as health educators and others, not by medical practitioners. These programs have had a major impact on one group of common cutaneous diseases, and in the future, no doubt, there will be others that could benefit from similar public health problems focusing on primary prevention and early detection. This is analogous to Axiom VIII of Dr Grossman's article on developing countries, which states that "The majority of skin diseases in these countries are not only preventable but also curable with simple, cheap and effective medications." This is particularly the case if they can be detected early in their course. Thus, the public health approach to cutaneous disease will no doubt be an important part of the future in both the developing and developed world.

Finally, I come to what might be of most interest to the readership of the ARCHIVES. Will there be a role for the dermatologist, that clinically and scientifically highly trained fighting machine, in the new millennium? The answer is, of course, yes. But it is a qualified affirmative. I predict that the role of the dermatologist may not be as dominant as it was in the 20th century. That time may well be looked back upon, wistfully, as the heyday of our discipline.

I suspect that in the new millennium we will be the tip of the iceberg of all those people providing dermatological advice and care to the community, both in the developed and in the developing world. There will be an increase in the proportion of less highly qualified medical practitioners, pharmacists, nurses, and other allied health practitioners taking this role. Our data show that already a large proportion of the community, even in developed countries, seeks advice from people who have no medical training whatsoever, let alone any training in the management of cutaneous disease. No doubt in the new millennium there will be plenty of unqualified people promoting themselves and competing with what are considered orthodox health practitioners, a situation that is deplored in both developing and developing countries currently.

The role of the dermatologist in the increasing pool of practitioners providing cutaneous advice is likely to be one of leadership. By becoming the teachers and trainers of the other reputable people to whom the community turns for cutaneous advice, and by always remaining available for help when a person's problem becomes too severe or complex, dermatologists will continue to play an important part in ensuring that care is provided to those for whom they are there to serve (ie, people in the community with diseases affecting their skin). In this way, the dermatologist's future, even though the role may be a changing and indeed challenging one, will be assured.