Staying on Top in Dermatology: Title and subTitle BreakWhy We Must Act Now to Address the Capacity Challenge

The dermatology profession is currently facing an intriguing problem: business is booming. Dermatologists are in great demand, and although this might not sound like cause for complaint, our capacity to provide care for dermatology patients is now being critically stretched. The surge in demand is no matter of chance but rather the result of changing epidemiology, ethnographic trends, and skilled advertising. Despite recent advances in care, our core clinical conditions remain without curative treatments. Furthermore, old enemies are fighting back; both melanoma and nonmelanoma skin cancer incidences are on the rise. The World Health Organization estimates that half of all cancers in the United States are skin related.¹ At the same time, the demographic shift in the US population means that we are caring for an aging population with multiple medical dermatology needs. In addition, a sustained, high-profile advertising campaign by organized dermatology over the past 15 years has fueled demand by educating, or reminding, the public that “there are thousands of reasons to see a dermatologist.”²

It is certainly true that there are many more reasons to see a dermatologist now than in years past. In addition to the growing demand for medical dermatology care, the US market for antiaging products and services, estimated at $45 billion in 2004, has been growing 9.5% per year and is estimated to hit nearly $72 billion by 2009.³ Consequently, the number of dermatologists hungry to grab a piece of this lucrative pie is growing as well.

Rising demand is primarily an issue, however, because we have made no concerted effort to increase our capability to supply dermatology care. As a profession, we have the privilege, and the responsibility, of self-regulating our numbers, yet we have been extremely cautious about increasing the supply of dermatologists. Dermatology training numbers have remained relatively constant over the past decade, whereas the dermatology needs of the US population have continued to grow. Although this undoubtedly limits our ability to respond, closer analysis reveals that how we work may be just as important as how many of us there are. Generational differences in practice predict increasing problems going forward. Older dermatologists currently perform a larger share of care delivery, working more sessions per week and spending more time practicing medical dermatology, than their younger colleagues.⁴ Growing interest in flexible working arrangements means that 1 trainee no longer offsets 1 retiring dermatologist, and the powerful pull of cosmetic practice further constrains the effective supply of dermatologists addressing the medical dermatology needs of patients.

The armchair economists reading this article may not be unduly concerned. Surely the short supply of dermatologists makes us a valuable commodity, able to name our price and work as we choose. This logic is faulty and assumes that only 1 group of individuals has the capabilities to provide those services in short supply. The reality is that other practitioners are stepping in to fill the void. Primary care physicians, nurse practitioners, and physician assistants (collectively described as providers) currently deliver a large proportion of medical dermatology care, and cosmetic services and procedures are being performed by an ever-greater variety of specialists, many of whom are prepared to directly compete with dermatologists. Although many patients consider us their preferred providers,⁵ our supply constraints, in combination with the low entry barriers to delivering dermatology care, will likely lead us to lose market share and potentially threaten our role as specialists.

It may seem surprising that some patients choose to receive skin care from those with little or no formal training in the specialty rather than see a board-certified dermatologist. The reality is that the health care consumer is forced to make decisions with limited data points to guide them. Wait time and location may be the only metrics available to help them decide between 2 health care providers. They may well have a hunch that a dermatologist knows more about skin disease than the average physician, but they have insufficient evidence to lead them to a different conclusion about whom to receive care from. Despite our own conviction that we are the best people for the job, we lack adequate evidence from performance measurements to objectively substantiate this claim.

In summary, it seems that we may be facing a future in which dermatologists increasingly choose to spend time on cosmetic practice, a large proportion of both medical and nonmedical dermatology is delivered by nondermatologists, and patients are left confused and their illnesses potentially mismanaged. If this scenario is accurate, even in part, then surely we are compelled to ask how the dermatology profession should respond to the challenges we currently face.

We only have 2 options: to stand back and let this happen or choose to act now to shape our professional fate. The opportunity to act will not remain open indefinitely: alternative providers are not waiting for our permission to take on dermatology cases, and payers are not going to postpone making changes to reimbursement models just because we are not ready. The onus is on us to demonstrate our value as providers and our collective capacity to organize and deliver an efficient, high-quality service for patients.

Although taking action to preserve and strengthen our place in the medical community seems the obvious course of action, this will require a new attitude among our ranks. Over the past decades, dermatologists have already relinquished, in large part, our role as a valued, trusted partner in care for patients with infectious diseases (including human immunodeficiency virus), sexually transmitted diseases, connective tissue diseases, and even dermatology inpatients. Are we really prepared to give up our role as the primary providers of medical dermatology care? Although cosmetic practice has proved an alluring distraction, continuing to narrow our activities may leave us professionally marginalized.

So, what actions should we take? If we fundamentally believe that dermatologists are the best people to deliver skin care, then we must address 2 issues. First, we need to demonstrate that we are the premium providers of this service, and second, we need to act to increase our capacity to deliver this care.

To counter the challenges to our profession, we must take strong action to demonstrate our position as leaders in the delivery of skin care. Through educational efforts, we have been very successful in driving the general demand for dermatology services. We must now shift the focus toward educating people on why we are the preferred providers of those services. Positioning our specialty as academic leaders in the field is necessary, relatively easy, but sadly insufficient. To truly demonstrate that we deliver superior care requires embracing performance measurement.

Unfortunately, dermatology is currently well behind other specialties in the development of an agreed-on set of quality metrics. The health care environment is rapidly shifting from a fee-for-service to a pay-for-performance model. Quality-based reimbursement models are already in use by many of the commercial payers and are in development by Medicare. Physicians providing care for patients with diabetes mellitus are now required to demonstrate not only that their patients have undergone appropriate screening but also that a significant proportion are meeting recommended blood pressure and hemoglobin A_1c targets. Failing to meet these standards frequently carries a financial penalty for physicians or the institutions within which they practice. As the self-proclaimed experts in our area, we should regard performance measurement as a friend not a foe. We have the opportunity to define excellence in our specialty, set ambitious targets, and measure our performance. We can then hold ourselves and, importantly, hold other providers, accountable to these standards.

Simply measuring performance is not enough. Appropriate channels through which to communicate our findings to patients and payers must be developed. Creating a solid brand for the dermatology profession with patients and payers will not only secure our position at the core of dermatology care but will also offer us an opportunity to differentiate ourselves from other providers. This will also prove useful in any efforts to increase training numbers, maintain or increase payment levels, and lobby for funding to support novel models of care delivery.

Being the best at what we do is meaningful only if we can couple our skills with our ability to deliver. Current capacity constraints mean that many patients do not have appropriate access to dermatology care, and we must explore solutions to address this issue. Policy measures to build capacity can be split into those that increase the effective size of the dermatology workforce (how many of us), those that address how we spend our time (what do we do), and those that change the way in which we deliver care (can we be more efficient) (Table).

Increasing the number of trainees is an important step in matching our capacity to deliver care with the demand for dermatology services. Such a move requires us to adopt a less protectionist stance and instead start lobbying to grow the profession. Any expansion of dermatologist numbers must be accompanied by thoughtful workforce planning. It is critical to factor in the proportion of dermatologists planning to work part-time or to pursue academic careers because both lead to fewer hours spent in patient care activities. Our specialty can support flexible working practices, but these considerations need to be incorporated into workforce projections for the future.

However, even if there is agreement to increase our numbers, then difficult questions still remain. How should we approach growing our numbers? Does a steady annual growth rate really make more sense, or should we be seeking to match our supply to meet current demand? And exactly what demand for services should we be trying to match: the demand for medical services or the demand for both medical and cosmetic services? The answer to both these questions dramatically alters our workforce planning.

Regardless of the approach we take, increasing our numbers is an imperative and may, ironically, ultimately offer dermatology far more protection from other providers than our current approach does.

Simply increasing trainee numbers, however, does nothing to address the issue of how these new dermatologists spend their time once fully trained. Is it reasonable to request additional funding for trainees from Medicare to train the cosmetic dermatologists of the future?

Developing training programs, or reserving program slots, specifically for candidates committed to a career in medical dermatology might address this issue. Although we congratulate the fledgling efforts under way at several training centers to provide combined training in internal medicine and dermatology, at their current scale these programs will not solve the capacity problem. In addition, such programs do not place any restrictions on the trainee's subsequent career choices. Incentives, such as tuition reimbursement, could be offered to those prepared to commit to a career in medical dermatology or at least make a multisession, multiyear commitment to serve this patient group. If even a proportion of posts was allocated to this subset of trainees, workforce planning might become more straightforward. Ultimately, it may become necessary to offer 2 separate training tracks, requiring applicants to choose between certification in medical or cosmetic dermatology to preserve choice for physicians while allowing growth of the specialty in a way that best serves the needs of the population.

Reexamining how we work is not just an issue for trainees. Although current estimates suggest that cosmetic practice occupies only approximately 10% of dermatologists' time, we need to question, given the current demand for our medical services, is this too much? It is impossible to say what the “right amount” of time is to spend on these activities; however, when most dermatologists feel patient wait times for appointments are too long and evidence suggests waits may be longer for those with serious symptoms than for those seeking a cosmetic procedure, it seems fair to say that the status quo is far from optimal.^{6 - 7}

Motivating physicians to change their work practice may be a critical component to successfully solving our capacity challenge but in reality is challenging to achieve. Realigning financial incentives from cosmetic to medical practice would be likely to shift provider practice patterns accordingly, but in the current era, in which insurer-based payments are shrinking rather than growing, increased reimbursement for medical dermatology cases seems unlikely. A shift may still occur if the number of providers in the cosmetic space continues to grow. There may come a time when excess supply results in a drop in price for these services: cosmetic practitioners may eventually kill their golden goose.⁸

Leaders in our specialty might have an impact on physician behavior by challenging the dermatology profession to question and define its identity. Do we have a responsibility to ensure that our patients and communities have access to high-quality skin care? In the words of Samuel Moschella, MD, are we at risk of becoming “beauticians rather than clinicians” (written communication, August 2007), and if so, do we care? Strong leadership is required to ask and attempt to address these tough questions. The answers should be used to develop community standards in departments across the country, allowing us to shape a future state more consistent with our professional goals and values.

Dermatologists who focus on medical practice are not exempt from reevaluating their activities. Given that we are running a constrained service, it is necessary to ensure that dermatologists primarily deal with cases in which they can offer high-value input. Although a dermatologist is the most appropriate provider for some patients, our input is by no means necessary in every skin-related consultation that occurs. For this reason, another way to increase our reach is to reexamine our relationship with alternative providers. Strengthening links between primary and secondary providers through education, training, and support networks could generate a collaborative rather than competitive environment. The usual objection raised to this suggestion is that if we train and support alternative providers we will do ourselves out of a job. Conversely, by improving awareness of our value and expertise among other providers we may generate more appropriate and timely patient referrals.

In conjunction with reexamining whom we treat, we can also use new technology to change how we deliver care. A quiet technological revolution is under way, one that could potentially transform health care practice in a similar way to what has happened in the retail, travel, and banking industries in the last 10 years. Dermatology has in some regards been a forerunner in this field, and remote patient care using video links or store-and-forward technology has been repeatedly shown to increase efficiency and improve patient access. Although these approaches initially required an intermediary physician to connect the dermatologist and patient, the field is rapidly moving toward a model in which the patient can directly interact with a dermatologist from his or her own home or workplace. The technologies required to deliver care remotely, such as digital cameras and secure e-mail, are inexpensive and pervasive. Furthermore, patients seem keen to adopt new methods of communicating with their physicians.⁹ The challenge is not one of technology but rather in establishing a standard of care (“What constitutes a visit if we never meet?”) and a robust reimbursement model. A demonstration project between Partners Healthcare and Blue Cross Blue Shield of Massachusetts has piloted remote, asynchronous follow-up care for patients with acne at a reimbursement rate that closely parallels reimbursement for a similar service provided in an office setting: both physicians and patients seem highly satisfied with this method of care delivery.¹⁰ Communications technologies, when thoughtfully deployed, allow for improved access and quality but also—and this is important to this discussion—improved efficiency. Asynchronous communications break barriers of both time and distance and in doing so provide opportunities to improve work flow.¹¹

In many ways, the dermatology profession is currently in an enviable position. We have an abundance of patients seeking our services and the opportunity to pursue rewarding clinical work. We do, however, have important choices to make regarding where we see ourselves in the future and how best to ensure we get there. Our failure to meet demand, to sensibly address our competing priorities and the growing presence of other providers put us at risk of a fall. These issues are complex, and the potential solutions to address our capacity challenges require energy and bravery. We need to engage with our own colleagues, departments, payers, and policy makers over quality metrics, reimbursement, training numbers, and technology implementation. Many of these subjects fundamentally relate to the role that we decide dermatologists should play in society. Strong leadership, both by individuals and as a profession, is mandatory to unite us in our thinking and firmly establish our preeminent position in the delivery of dermatology care now and in the future.

Correspondence: Dr Kvedar, 25 New Chardon St, Ste 400D, Boston, MA 02114 (jkvedar@partners.org).

Financial Disclosure: None reported.

Additional Information: Drs Watson and Kvedar are with the Departments of Dermatology at Massachusetts General Hospital and Harvard Medical School, Boston.