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Future of dermatology will bring greater demand, more physician extenders

EDITOR'S NOTE: What's the outlook for the specialty of dermatology over the coming years? In this issue, we look at physicians' concerns about the major trends that will impact the field, including healthcare reform. We also examine changes in credentialing for Mohs surgeons (see "Mohs surgeons wrestle with increasing skin cancer rates, scrutiny by insurers").

National report — The key concerns that dog dermatology today — healthcare reform, workforce woes and the impact of cosmetic dermatology — aren't going to disappear soon, sources say. Nevertheless, they say, the specialty will survive, although probably with more nonphysician clinicians delivering dermatologic care.

Healthcare reform ranks high among many dermatologists' worries for the immediate future.

Dr. Pariser
In the next three to five years, "We're going to have to see how healthcare reform shakes out and what that's going to do to medicine as a whole and (to) dermatology specifically," says David M. Pariser, M.D., immediate past president of the American Academy of Dermatology (AAD).

Dr. James
Current AAD President William D. James, M.D., says the academy is "trying to anticipate and influence how health system reform is going to impact us." Although regulators have sketched plans broadly, he says, there's room for interpretation in still-unsettled details.

Dr. James says the American Academy of Dermatology Association (AADA) will continue to work in collaboration with others in the medical community to influence the scope and speed of planned reforms.

Another major and related concern is the need for a long-term fix for Medicare's sustainable growth rate (SGR) formula, Dr. James says. At press time, the AADA expressed hope for legislators to find a long-term solution before the current Band-Aid expires Nov. 30, opening the door to a 23 percent cut in reimbursements.

Influx of patients

Healthcare reform will add an estimated 30 million patients to an already strained system, Dr. Pariser says. That will exacerbate what is already a shortage of dermatologic care, he says.

"Not only will it be harder to get appointments, but care will be delivered more by nonphysician clinicians (NPCs) than directly by physicians, particularly in dermatology," Dr. Pariser says. Nondermatologist physicians also may pick up some of the slack, he predicts.

"We can argue about what the quality of care will be, but that's going to be a fact of life," he says.

Extending the workforce

Dr. Kvedar
In some ways, dermatology is a victim of its own success, says Joseph Kvedar, M.D., associate professor of dermatology, Harvard Medical School, Boston.

Consumers continue to express a robust desire for aesthetic treatments, he says, while dermatologists have done "an amazing job of educating people about the value of skin exams and skin cancer prevention. Those two trends have filled our offices in ways that I'm not sure we anticipated."

The burgeoning demand has led to long wait times for patient appointments.

AAD practice profile surveys indicate that in 2009, established patients waited 33.9 days, on average, to see their dermatologists (versus 33.2 days in 2007), while new patients waited 17.9 days (versus 19.5 days in 2007).

Meanwhile, the number of dermatology residency slots is expanding only slowly, Dr. Kvedar says, which means "The mismatch continues to grow."

U.S. institutions offered 360 dermatology residency slots in 2010, versus 338 in 2009 and 306 in 2006, according to data from the 2010 National Resident Matching Program.

To date, "I haven't seen any appetite in organized dermatology to do something bold like double the number of trainees," Dr. Kvedar says.

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