Dermatology Online Journal

Dermatology and medical practice: Options for the millennium
Daniel Siegel MD
Dermatology Online Journal 4(1): 12

The article in this issue by Thompson and co-workers is very thought provoking. Each reader, from his or her own perspective, may interpret this article differently. From the perspective of the practitioner in the oversupplied urban area where full page newspaper ads prominently announce the abilities of dermatologists to remove fat and wrinkles, there may well be a large surplus. On the other hand, from the perspective of the patient in the rural community whose nearest dermatologist is an hour or more away, there is a desperate shortage.

Objective reality is somewhere is the middle and the credit (or blame) can be squarely placed on the heads of the academicians who expanded training programs to meet institutional service needs, without considering the long term consequences of this act. Meltdown seemed far away as recently as the mid 1980's, before the onslaught of the managed care juggernaut.

More residents meant more prestige, prestige meant power and power meant more residents. This cycle persists to this day in many specialties and some have already developed problems, such as anesthesiology, where a few years back many slots went unmatched as the previous graduating class could not all find jobs; and ophthalmology, where permanent employment and partnership are becoming increasingly rare (personal communications) because supply far exceeds demand.

In dermatology, we have succeeded in keeping demand high by creating new services, many of which are cosmetic in nature. In some settings, this is at the expense of developing skills in classical dermatology, putting us in danger of losing this valuable clinical art. While anyone can "treat" acne or psoriasis, only a skilled clinician can "manage" individuals with these and other skin diseases. Unfortunately, the ability to recite trivia for examinations and the ability to manage patients do not seem to correlate, so that many patients may well be seeking care from less empirical but more "understanding" generalists.

For many years, sexually transmitted diseases, leprosy and connective tissue diseases were primarily the province of the dermatologist. We have given up much to other specialities as we, instead of maintaining our unique abilities, try to emulate and overlap with other specialities who are also often in surplus situations.

A radical transition may allow dermatology to survive as a unique speciality meeting our own needs and those of our patients.

One approach could be to place a moratorium on new training programs and alter some current programs so that instead of three clinical years followed by private practice (the most common scenario, despite almost every applicant having had a three to six month rotation in a "name brand" lab), applicants with a research orientation should enter six year programs, with the first residency year a standard clinical year, while years two through five are spent obtaining a PhD or doing post doctoral work as appropriate, with a small but meaningful clinical continuity commitment. The sixth and last year would be a combined research -chief resident year, where administrative and teaching skills can be honed and plans for the future (hopefully in academia) will be made.

Applicants with a clinical orientation and analytic minds would also spend six years, but for them years two through five would be spent obtaining some combination of MBA, management and/or public health training, culminating in skills and credentials that will enable them to become leaders in both dermatology and medicine. The sixth year would be a chief resident year with institutional teaching responsibility aimed at sharing their business and public health knowledge.

Pure clinical applicants would also do a six year stint, with years four through six spent in subspecialty training in pediatric dermatology, dermatologic surgery, dermatopathology, pigmented lesions, connective diseases, immunodermatology or other specialities as they arise. These individuals will then have a "special skill" to offer their patients which they otherwise would not have. These last three years could be spent in one or more of these areas.

Lengthening the pipeline may discourage some applicants, but those dedicated to dermatology as a speciality would still take the plunge.

Other solutions may exist and it would benefit the specialty to air them and find one or more that will bring us into the next millennium in a strong position to survive whatever befalls medicine.

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© 1998 Dermatology Online Journal