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    Pediatric dermatology, a growing subspecialty, faces challenges

    EDITOR'S NOTE: Pediatric dermatology is an up-and-coming subspecialty. But it faces start-up challenges: The number of certified practitioners isn't growing appreciably. In this issue, we look at some of the reasons why the subspecialty may not be a big draw, and why already-certified pediatric dermatologists say they're so satisfied. We also examine evolving training requirements (see p. 24). Our Special Report (see p. 39) focuses on clinical advances.

    National report — Pediatric dermatology has achieved important milestones in recent years, including board certification. However, the small dermatology subspecialty stands at a crossroads in 2010.


    Dr. Eichenfield
    Faced with a significant shortage of physicians choosing a career in pediatric dermatology, those committed to the subspecialty's survival are searching for solutions.

    "The field has really matured to a field that has specialty certification, and its own journal, Pediatric Dermatology," says Ilona J. Frieden, M.D., professor of dermatology and pediatrics, University of California, San Francisco.


    Dr. Siegfried
    "It went from just one or two textbooks in pediatric dermatology to numerous multi-authored textbooks," she says. "We have had the growth of the Society for Pediatric Dermatology (SPD) and now have multiple fellowships around the country. All those are signs ... of the maturation of a subspecialty."

    The international scope and collaborative efforts within the subspecialty have also blossomed, says Lawrence F. Eichenfield, M.D., chief, pediatric and adolescent dermatology and professor of pediatrics and medicine (dermatology), Rady Children's Hospital, San Diego.


    Dr. Frieden
    "The international scope of influence of pediatric dermatologists in the U.S. is greater than ever," Dr. Eichenfield says. "The SPD traditionally meets twice a year. ... One of the differences, however, is that SPD members regularly meet at lots of other different venues, as we collaborate on research, political advocacy and educational (issues) throughout the country and the world."

    Numbers lacking

    Still, for all the good, the subspecialty also is experiencing its share of growing pains. One challenge is that the supply of pediatric dermatologists has not met the growing demand.

    Board-certified pediatric dermatologists currently make up only about 1.5 percent of the dermatology specialty, and the number of fellowship programs approved by the American Board of Dermatology — currently 21, and growing slowly — far exceeds the number of dermatologists opting for the specialized training.

    The banner year for certifying pediatric dermatologists was the first year the qualifying exam was offered by the American Board of Medical Specialties: 2004, when 90 physicians passed. The number of eligible candidates earning certification dwindled to 41 in 2006 and to only 31 in 2008.

    Today, there are 162 board-certified pediatric dermatologists.

    And while there was a slight upswing in the fellowship matching program for 2010/2011 — when 13 fellows were placed, versus eight in 2009/2010 — there is a concern that the numbers may fall again after this year, says Elaine C. Siegfried, M.D., professor of pediatrics and dermatology, Saint Louis University, Cardinal Glennon Children's Medical Center, St. Louis.

    A "grandfather" provision contributed to the larger numbers in earlier years, she says.

    "In the beginning, we had a lot of people who were eligible for certification via the grandfather clause," Dr. Siegfried says. "These diplomates did not complete fellowship training but rather were double-boarded in pediatrics and dermatology, and practicing pediatric dermatology full-time."

    The small but rich resource of physicians who met the requirements for being grandfathered will soon dry up, according to Robert Silverman, M.D., a pediatric dermatologist who practices in Fairfax, Va., serves on the board of the American Board of Dermatology and has an academic appointment in the department of pediatrics at Georgetown University Hospital, Washington.

    "This is the last year that anyone can petition the board to take the test without being in an official board-certified fellowship training program," he says.

    Struggling for attention

    One possible reason for the relatively low interest in the subspecialty: Pediatric dermatology gets little exposure during traditional medical training. Residents spend much more time in procedural and cosmetic dermatology.

    This is a problem even at institutions that have certified fellowship programs for pediatric dermatology, according to Dr. Siegfried.

    "Dermatology training is 36 months. In my institution, the residents spend just two months (three for some) doing a dedicated pediatric dermatology rotation, in addition to a one-half-day-per-month continuity clinic, during their 36-month dermatology residency," she says. "They spend six months doing surgical dermatology, five months doing cosmetic dermatology and three months doing derm path."

    Not a cash cow

    Another key challenge: Salaries are comparatively lower for pediatric dermatologists, largely because the subspecialty is less procedure-based, according to Dr. Siegfried.

    The Association of American Medical Colleges, citing the 2008 Physician Compensation Survey in Modern Healthcare, reports that the annual salary for dermatologists ranges from $287,832 to $385,953. The average salary for a pediatric dermatologist, according to the SPD's 2008 benefits and compensation survey, is $203,727.

    "We're certainly not as procedure-based as general dermatology. Reimbursement for cognitive services is far, far lower than it is for procedural services. So, the income potential is not as high as for general dermatology, or certainly dermatologic surgery and dermatopathology," Dr. Frieden says.

    "I think that if the incomes were equal, these shortage problems would be much less, because pediatric dermatology is incredibly interesting and fun."

    Pediatric dermatologists in private practice earn the highest salaries, according to SPD: an average $291,000, versus academic salaries, which average $193,522. Still, most of the board-certified pediatric dermatologists in this country, as indicated by 50 of the 80 who responded to the survey, are in academia.

    Pediatric dermatologist James Treat, M.D., assistant professor of pediatrics and dermatology at Children's Hospital of Philadelphia, was in private practice for one year before going into academia.

    "Private practice was enjoyable in terms of the patients, but I generally found that the diseases were not as stimulating, and that is actually one of the reasons that I switched to pediatric dermatology," he says.

    Nevertheless, the high demands of academia are driving some pediatric dermatologists into private practice. Pediatric dermatologist Alanna F. Bree, M.D., recently left a faculty position at Baylor College of Medicine, Houston, to go into private practice in Bellaire, Texas. She did it, she says, to achieve a better work-life balance.

    "I still practice exclusively pediatric dermatology, but with a few modifications: I work part-time; I have privileges at an ambulatory surgery center for my surgical and laser cases," Dr. Bree says.

    Demand remains

    Dr. Siegfried says there is a need to train primary care doctors to treat pediatric patients with severe skin disease because dermatology isn't a required rotation in medical school, and because there are so few pediatric dermatologists.

    Skin problems are the chief complaint for 10 percent of pediatric visits to a primary care physician's office. A diagnosis of dermatitis in infants alone accounts for 256 visits per 1,000 population per year, according to the National Ambulatory Medical Care Survey and National Hospital Ambulatory Care Survey databases. Atopic dermatitis accounts for more than 1 million pediatric outpatient visits per year.

    Despite these numbers, a significant number of primary care providers receive little or no training in dermatology, Dr. Siegfried says. "There is as significant need to train primary care doctors as to evaluate and treat pediatric patients with severe skin disease," she says.

    Mapping the future

    One answer to the subspecialty's numbers problem may lie with pediatricians, Dr. Siegfried says.

    "There is a much larger pool of pediatricians than dermatologists, and I believe that a significant number ... would be interested in pursing additional training in pediatric dermatology," she says. "I would like to pursue the option of credentialing an alternate training route for pediatricians."

    A next stage for the subspecialty is an increased focus on collaborative research, Dr. Eichenfield says. This would involve developing individual physician researchers and then using a collaborative network to establish a more scientific basis for diagnostic and therapeutic work.

    Lisette Hilton
    Lisette Hilton is president of Words Come Alive, based in Boca Raton, Florida.

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