By Jan Bowers, contributing writer, October 01, 2013
What do other physicians think of dermatologists? Are their perceptions off the mark, or is there a grain of truth there? And why should dermatologists care?
The AAD tackled the first question in 2011 when it commissioned a research firm to query senior staff and elected physician leaders at 13 medical associations. The researchers asked a broad range of open-ended questions touching on perceptions regarding different aspects of how dermatologists practice (e.g., whether they treat serious conditions or diseases), how they interact with colleagues, their contributions to patient care and medical research, and whether they give back to society.
The results of the interviews revealed that dermatologists are perceived as valuable colleagues who make significant contributions in the prevention and treatment of skin cancer and controlling chronic disease. Among the negative perceptions, five key concerns emerged: access to dermatologists is limited, both for hospital inpatient consults and outpatient referrals; dermatologists are hesitant or unwilling to treat routine medical conditions, favoring surgical cases; dermatologists are unwilling to accept insurance; dermatologists are shifting their focus to cosmetic-related services; and, dermatologists do not tend to be visible or engaged in their local communities and medical societies. [pagebreak]
The AAD convened an ad hoc task force to address the perception issues raised by the interviews and explore solutions that can be undertaken by the Academy and by individual dermatologists. Dermatologists’ reputation among their colleagues matters a great deal, said the task force chair, because the health care environment of the future may likely include new models of team care with primary care physicians as gatekeepers. “If we as dermatologists are going to have the opportunity to be a part of some of these new medical care practices, it will be important for us as a group and, more importantly, as individuals to have a good reputation and respect within our community,” said Lisa A. Garner, MD, vice president of the AAD, clinical professor of dermatology at the University of Texas Southwestern Medical School, and chair of the task force. That sentiment was echoed by task force member Brent R. Moody, MD, a dermatologist in private practice in Nashville, who noted that other physicians “may not understand who we are and the value of what we do. It’s up to us to stay engaged and show them. I’m concerned about dermatologists being marginalized, and perhaps not being afforded the opportunity to be integral players in any future delivery models.”
Although all the task force members contacted said they do inpatient consults, it nevertheless is “a significant issue,” Dr. Garner said. “There are certainly many areas, even some urban areas, where there are hospitals that can’t get a dermatologist to see an inpatient.”
One factor underlying some dermatologists’ reluctance to do inpatient consults is the logistical barriers that can make it frustrating and time-consuming. “It’s difficult now because every hospital has its own EHR system, which you might not be trained on,” said task force member Barbara M. Mathes, MD, clinical associate professor of dermatology at the Perelman School of Medicine at the University of Pennsylvania. “Many institutions require that you log in onsite every so often to change your password; you can’t do it from an outside computer. These are not intended to be obstacles, but they are for a dermatologist who goes to the hospital infrequently, and some dermatologists think it’s just not worth the hassle.” The task force is exploring ways to work with organizations, such as the American Hospital Association, that might encourage hospitals to make it easier for consulting physicians to navigate the EHR requirements, Dr. Garner said. [pagebreak]
In the meantime, she maintained, “an individual dermatologist can try to negotiate with their hospital. They like to tell us that these things are set in stone, but they’re often not.” In Nashville, “hospitals understand the logistical problems, and they make it really easy for me,” Dr. Moody said. “In general, if dermatologists are willing to do consults, the medical staff will appreciate that and accommodate their needs.”
Another reason for not doing inpatient consults is low reimbursement, Dr. Mathes said. Compound this with logistical and inconvenience factors (few dermatologists have offices in hospitals, making it difficult to see consults during a short break in one’s schedule), and the possibility that the patient’s problem is not urgent and could be managed in the office, she said, and one can understand why dermatologists may not consider hospital consults a priority.
Getting patients access to a dermatologist’s office “is probably one of the biggest issues for other health care providers when they think of dermatology,” Dr. Mathes said. “There is a distribution issue. Some parts of the country are underserved; even within the same city, there are clusters of dermatologists in some areas and few or no dermatologists in other areas.” This is a challenge, she said, as is the problem of large geographic areas that are wholly without a dermatologist.
One approach to alleviating the problem is educating primary care physicians to evaluate dermatologic conditions “so that only patients who really need the dermatologist to diagnose or manage their care are referred to a dermatologist,” Dr. Mathes said. “I teach dermatology at the annual meeting of the American College of Physicians — I’ve been doing it probably more than 20 years — and typically it’s about very common skin conditions that they see, ways they can manage those conditions appropriately, and which are the critical conditions that must go to a dermatologist.” With more appropriate referrals, she said, “dermatologists are more likely to say, I’m happy to do that.’” [pagebreak]
Teledermatology is another tool that dermatologists can use to address both the inpatient and outpatient sides of the access issue. “Penn dermatologists pioneered a program (led by Dr. Carrie Kovarik) using the Academy’s [AccessDerm] program in areas of Philadelphia where no dermatologists are on staff, and in community health centers where it’s unlikely they’ll have dermatologists seeing patients,” Dr. Mathes said. “There are obstacles — issues related to state regulations and compensation; I think there are only a few states that allow you to bill patients for doing medicine in this way. But I don’t think any of the obstacles are insurmountable.” Indeed, the Academy has appointed an ad hoc task force on telemedicine to address these issues and the Board approved a pilot project at its August meeting that will help demonstrate how teledermatology can increase dermatologists’ ability to provide inpatient consultations.
The task force on perception has been brainstorming strategies that very busy practices can use to enable dermatologists to accept more referrals from other physicians, Dr. Garner said (see sidebar). But one approach the task force sees as “problematic” is that some practices put emergency referral appointments on the schedules of nurse practitioners or physician assistants without oversight or evaluation by the dermatologist, she noted. “When you’re referred an emergency patient from another physician, we believe it can appear to show indifference if the patient is put on the PA or NP schedule and not seen by the dermatologist,” Dr. Garner said. “The referring physician might well say, Hey, that’s not what I was asking for.’”
When a dermatologist does see a referral, it’s not just best for the patient but also good business and good manners to follow up with the referring physician, said several task force members. “One of our challenges is to make sure we’re communicating,” said Julie Hodge, MD, a solo practitioner and assistant clinical professor at University of California — Irvine School of Medicine. “Every time a patient tells me who their primary care physician is, and certainly every time I treat a referral, I send the primary or referring physician a note about what I’ve done,” Dr. Hodge added. Bethanee J. Schlosser, MD, PhD, assistant professor of dermatology at Northwestern University’s Feinberg School of Medicine and chair of the AAD’s Young Physicians Committee, insists that the simple step of keeping the primary care physician informed “increases the presence of dermatology, which is always a benefit in building a practice; it says you’re responsive and communicative, which is only beneficial in terms of personal and professional relationships; and I think it says that we want to be part of the bigger house of medicine.” [pagebreak]
Confronting the myths
While access is clearly an issue that is broadly recognized and already being addressed by dermatology, perceptions of dermatologists relating to insurance and specialization in surgical procedures or cosmetic treatment may reflect a complex set of circumstances that vary according to region. “The majority of dermatologists participate in Medicare, but we hear all the time that dermatologists don’t take Medicare,” Dr. Mathes said. “Rarely do physicians in any specialty get paid the amount billed to the insurer. If you’re in an area covered by insurers that pay notoriously low reimbursements, you may not be participating with those insurers. And frankly, other docs in your community probably are not participating either.” Forging relationships with primary care providers, and occasionally reducing or waiving the fee for their low-income patients in need of care, can go a long way toward improving the misperception, Dr. Mathes said, adding that “we have to demonstrate, make the case, that we are better than the myths about us.”
The notion that dermatologists are hesitant or unwilling to treat non-surgical cases is another misperception, Dr. Mathes said. “There certainly are some non-Mohs dermatologic surgeons who only want to excise or do other procedures, but I don’t think that’s common. Now, if there are a limited number of derms in your community, and you refer all the [medical dermatology] cases to your PA, then the perception may be correct in that particular case. But I don’t think that is universal across dermatology.” On the other hand, Dr. Schlosser noted, “the reimbursement system today favors procedural intervention, and that’s not unique to dermatology. In the end, people do have to sustain a living and make it viable for their staff.” In addition, “in some areas they’re so busy fighting the epidemic of skin cancer, it doesn’t leave a lot of room for other things. And the aging population is only going to contribute to that further.” [pagebreak]
The Academy’s own practice survey data contradicts the stubborn myth of dermatologists’ focus on cosmetic treatment. In 2009 and 2012, time spent on patient care broke down as 67 percent medical, 25 percent non-cosmetic surgical, and 8 percent cosmetic. “One of our problems is the only time you see dermatology ads, they’re all for cosmetic procedures, and there’s often a medi-spa associated with the practice and the advertisement,” Dr. Garner said. “That’s what people see, so they begin to believe that all dermatology practices are only interested in cosmetic dermatology patients. I’m not quite sure what to do about that misperception.” Dr. Hodge said her own experience reinforced that interpretation, and prompted her to change her website. “I was surprised I was perceived that way, because I do 70 percent medical dermatology, and I always have,” she noted. “But then I looked at the things I had done marketing-wise, and it was in that [cosmetic] arena. I like to do some [cosmetic procedures], but I also realize they are important to the bottom line because they allow me to do the other things and not worry about it.” She doesn’t see a clear separation between medical and cosmetic dermatology, she added, because “anyone who has a skin problem has a cosmetic problem. And I’ve always seen that as the case, and I feel it’s my responsibility to take care of everybody. I don’t have different slots for medical and cosmetic patients or different waiting rooms. I try to address the medical and cosmetic needs of all my patients. I don’t want anyone to feel like a second class citizen. Dermatologists are lucky to be in a position to balance a mix of patient problems and procedures. This is what I love about being a dermatologist.” Dr. Mathes again emphasized the importance of maintaining strong relationships within the medical community: “We need to make clear to our colleagues in medicine, as well as to the community, that patients coming in for cosmetic medicine may also be getting a dermatologic evaluation for other things, particularly skin cancer. It’s an education thing, but also a relationship issue.”
Engagement the key
The theme that underlies both the misperceptions of dermatologists and the path to correcting them, said the task force members, is engagement — with the hospital staff, with individual primary care physicians, with the community, and with local and state medical societies. At the leadership level, Dr. Garner said, the task force is “trying to interact with larger national primary care organizations to find out what they see as their greatest needs that we could address. What does their leadership see as a way to improve our interaction, how can we do a better job at providing what their members need from dermatology? We don’t really know what that is.” Dr. Mathes emphasized the importance of interaction among specialties, noting that “everyone wants to hear dermatologists talk. We should encourage our members to speak at local, regional, and national meetings. But we should also invite them into our house so that we have mutual respect for each other. I think if this is done on the leadership level, it will demonstrate the importance and the commitment we have as a specialty society.” [pagebreak]
One area of focus should be the hospital, Dr. Moody said. “Part of our problem is our success in treating patients in the outpatient setting,” he explained. “This is wonderful for patients, and cost-effective, but the downside is lack of visibility in the hospitals. The dermatologist who is engaged in some type of hospital activity, such as taking a committee assignment, is helping to counteract some of those negative perceptions people have of us being disengaged or unavailable or uninterested.”
The Young Physicians Committee is actively “trying to encourage broader participation by dermatologists in the house of medicine,” Dr. Schlosser said. “Sitting on various hospital committees, participating not just in state and local dermatology societies but also state and county medical societies. By doing that you are automatically saying that dermatology cares about more than just itself. And, from a self-preservation standpoint, if we’re not sitting at the table, we will not have a voice in decisions about licensure requirements, certification, scope of practice issues — people will be making those decisions for us.” The youngest member of the task force, Karolyn Wanat, MD, who recently completed a dermatopathology fellowship at the University of Pennsylvania and joined the faculty at the University of Iowa as a clinical assistant professor, remarked that “creating a culture” of engagement among dermatology residents involves promoting volunteerism and activism, and “establishing relationships with primary care physicians in the area so that they can help get patients in when they need to. It will require all of dermatology to help improve that perception. I think it starts with the individual, but then it has to continue to grow so that others are aware of what we can accomplish together as dermatologists.” [pagebreak]
Strategies to improve access to the dermatologist’s office
A key concern among dermatologists’ physician colleagues is the difficulty they face in getting their patients in to see a dermatologist, particularly urgent or emergent cases. Two members of the AAD’s ad hoc task force addressing the perceptions of dermatology by others in the house of medicine have suggested steps that dermatologists can take now to alleviate the problem.
Suzanne M. Connolly, MD, emeritus professor of dermatology at Mayo Clinic in Scottsdale, Ariz., noted that dermatologists can:
- Keep some slots open, preferably at the beginning or end of the morning and afternoon session. Don’t fill them until 24 hours ahead, reserving one or two until eight hours ahead.
- If you know a staff shortage will be occurring, set aside a few slots in addition to those normally reserved.
- For established patients who call in concerned about one “spot,” arrange to see these patients early in the morning, before other patients.
- Utilize teledermatology within the institution to facilitate triaging patients who are more urgent.
- Group patients who share a condition (such as sore mouth or dermatitis) for general education regarding the disorder and its management and workup. You will still need to see these patients individually for history, exam, and finally summary session, but group education may free up some slots.
Leonard J. Swinyer, MD, a dermatologist in private practice in Salt Lake City, described four different types of “hold” appointments, noting that “whether or not we put any or all of these into an individual provider’s schedule depends on how far out they are scheduling and how busy they are.”
- Emergency appointments are meant to be filled on the day of the appointment only, and are reserved for patients who must be seen the same day. Generally, one is in the later morning and one is in the afternoon; if they’re not filled by 9 a.m., they’re released for general scheduling.
- Consult appointments are given to patients whose physician offices call directly for appointments. There is usually one per day on the schedule; they are released to general scheduling if they’re not filled a week before the appointment date.
- “Hold” appointments are for the use of the front desk receptionists who are scheduling patients as they leave. There are usually three or four on the schedules of the busiest providers; they allow the provider to see a patient in two to three weeks when the regular schedule is four to six weeks out.
- Surgical appointments are 45- to 60-minute slots set aside for surgical procedures. The practice normally blocks out one or two per day to ensure that excisions can be accommodated. If they’re not filled a week before the appointment date, they are released for general scheduling.