What will dermatology look like in 2020?
The March issue of Dermatology World asks what the future holds for the specialty — how practices will be organized, how providers will be reimbursed, how care will be delivered, and what treatments will be available.

In this online-only feature, DW asked several dermatologists to answer a broader question: “What will dermatology look like in 2020?” Click through the slideshow below to see their answers.

Want to add your own response? Write to dweditor@aad.org. Please:

  • Limit your answer to 250 words.
  • Include a digital headshot suitable for publication with your answer.
Responses may be edited to conform with DW style.

Jeffrey Dover, MD

In 2020 we will take a more global approach to anti-aging; instead of fixing this line or that hollow, there will be ways to a slow the aging process. The earliest effective systemic agents may be available to slow or reverse the aging process. 

These will be the first of a group of topical agents which using gene therapy will alter our appearance in subtle and positive ways. These agents will down regulate the phenotypic expression of telangiectasia, lentigines, wrinkles, and skin sagging. And there’s no reason why we won’t eventually have products that can be applied to the skin to stop pattern baldness from ever developing. Lasers and energy-based devices will continue to get smaller, less expensive, and safer but especially more effective.

W. Patrick Davey, MD, MBA

We are going to have a team approach. It will be a team of dermatologists and it may be sort of a virtual team that we have, with a surgeon in one area working with a medical dermatologist in another. It’s going to be a team that may be part of a larger multispecialty team. 

We will really have to look at not only cost, but also at the quality of the services that we provide. We’re not going to be able to get away with not providing quality services.

What will every dermatologist need to do? Well, they really need to keep educating themselves. The Academy is a good resource to keep up-to-date with the latest treatments. Dermatologists need to begin thinking about things in terms of outcomes. The outcome of what they’re doing — not just diagnosis, but treatments and outcomes — and eventually being able to document their results.

Brett Coldiron, MD

I think you’ll see more nurse practitioners and physician assistants who profess to specialize in dermatology. Right now, there’s about 6,000. I’d say that in seven years, you’ll see 10,000.

By 2020 there will be more large dermatology groups and more dermatologists employed by large multispecialty groups, at lower incomes. Many young dermatologists will belatedly realize they have signed poor contracts that pay for their productivity based on work relative value units, not realizing that practice expense relative value units comprise 2/3 of dermatology RVUs. 

The specialty will further its concentration in surgical dermatology in response to the skin cancer epidemic and aesthetic dermatology in response to stagnant payment for medical dermatology.

I think you’ll see fewer dermatology residencies. I would expect you’ll see a cut of 30 or 40 percent in the number of residency slots. The remaining dermatologists will be utilized even more, and the academic programs in some of the larger cities will be forced to merge. I believe Mount Sinai just merged with a couple of the residencies in New York. It’s already happening. 

In seven years you’ll see a year of medical school cut out, which I think is a good idea, and maybe even cut a year of residency out. You’ll see less training, because the bar is lowered when an NP can go out after seven years and practice like a doctor.

Karen Edison, MD

Whether we like it or not, dermatology will be part of a changed health care landscape in 2020. Our training programs may expand some, but political realities will prevent the expansion of the workforce needed for our expanding and aging patient population. Consequently, dermatology practice will be increasingly multidisciplinary and team-based and our time and expertise will largely be reserved for patients and conditions where our higher level of training is most needed. We will need to increase collaboration with others, especially primary care providers. In addition, medical schools will need to improve and expand general dermatology education.

Because payment structures will trend toward rewarding quality patient outcomes and patient satisfaction rather than volume of services, dermatologists will be more mindful of high value patient-centered care, leading to the expanded use of teledermatology. All forms — telederm triage, telederm consultation, and telederm direct care — will be more commonplace than they are today. There will also be a push toward cost-conscious dermatology and we will continually need to show others the value of our services.

In spite of the external forces molding our specialty, the fundamentals of the practice of dermatology will not change. As the science evolves, I am most excited about the development of meaningful treatments for and even the cure of advanced melanoma.

Alexa Kimball, MD, MPH

Everyone has ideas about telemedicine and teledermatology, and our specialty is an obvious place to play that out. Obviously the funding and reimbursement mechanisms haven’t really facilitated that. One thing we may see in this new era is that our ability to do these is enabled dramatically. But there is something different about the way that dermatologists see pictures rather than see people. I think we have to be mindful, as we see these tools develop, that they may only be appropriate for certain patients under certain conditions.  The appropriate use of how to be effective and efficient is important to demonstrate. I hope we see more of it, and that we are judicious about it along the way.

Mark Lebwohl, MD

I fear that the practitioners out there by themselves will be struggling. Some of the not-so-good things that happen in other countries will occur here, where a high portion of the population goes to either large groups or hospitals or academic centers. They get care, but that care is offered in a scenario that pushes through too many patients in an hour. You’ll have a lot of care provided by nurse practitioners and physician assistants, and the quality of care will be a lot less than what we’re used to now.

Private practice will still exist, as it does in many countries that have socialized medicine, but patients who can afford to will go to private practitioners to get care that’s faster and access to whatever physician or medicine they want; but they’ll have to pay for it. In 2020, we will start to simulate the kind of care that is offered in many other countries. And it will be challenging to maintain the quality of care we’ve offered in the past.

Randall Roenigk, MD

I think that dermatology is still going to be desirable. A lot of dermatologists will be happy doing their practice for a variety of reasons. Dermatology is in high demand by patients, and is more valued by folks than it ever used to be. Doctors can do lots of different things — medical, cosmetic, surgical, pathology, pediatrics. You can work a lot, you can work a little. I think there will be a strong interest in dermatology, because the demand for care means that you can always get a good job.

Brent Moody, MD

On a positive note, our treatments will become even more precise and effective. Eventually, we will find a cure for chronic conditions, like psoriasis or atopic dermatitis, that we currently can only manage. New treatments for advanced melanoma are already changing the mortality curve for that condition and we will see continued gains. From a clinical standpoint, I am excited about the near-term future. 

The practice of dermatology will look very different in the near future. The loss of solo and small group practices will accelerate. The exciting clinical advances could very well be restricted by cost issues. I see less need for physician-level dermatologists. The current perceived shortage in dermatology workforce will be replaced by a glut of providers as care is more tightly integrated. The use of non-physician providers will continue to expand. 

A few dermatologists will be able to totally opt-out of governmental or other third-party payers, but the market limit of this practice model is untested. Most dermatologists will not want or be able to practice in a pure cash model. There is greater likelihood of dermatologists maintaining a blended service offering, accepting insurance, Medicare and the like, but offering enhanced options similar to other concierge practices. 

We are certainly entering a brave new world, where neither physician nor patient can really know what to expect. My current strategy is to continue to provide the best possible care to my patients that I can. 

Mark Kaufmann, MD

A lot hangs in the balance with the SGR “fix” that Congress is currently considering. If you take a look at the bill that’s been introduced in both houses, it may have more to do with what will happen to dermatology in the next 10 to 20 years than anything else. The bill will consolidate meaningful use, quality reporting, and the new value-based modifier and bundle them together into a single system. If you don’t practice the way they think you should be practicing, they’re only going to pay you 90 percent of the fee schedule. It may take more than that, but they’ll eventually find the right number to achieve compliance. They want fewer independent, small group, and solo practices, because it’s a lot easier to control the output of centralized health care. 

The bottom line is that fee-for-service is on its way out; the only question is what the time span will be. Is it five years? Ten years? Certainly from the way it looks, both houses would like to get rid of fee-for-service as soon as possible. That’s probably the most reasonable way to think of the specialty in the future — a lot fewer independent practitioners and more centralization of health care.

Barbara Gilchrest, MD

I practice at Boston Medical Center, Massachusetts’ largest safety net hospital and a living laboratory for Romneycare/Obamacare. A very dedicated leadership team and medical staff deliver “Exceptional Care, Without Exception” (our institutional mission statement) to a remarkable degree. However, BMC Dermatology works with a very restrictive formulary, endless prior authorization requirements and denials of coverage, and patients who often forgo treatment if their limited insurance won’t cover it. Reimbursements for care provided often do not cover the cost of physician and staff time, clinic supplies, and billing, a shortfall presently met through philanthropy and politicking... 

I agree with many of the opinions expressed in other posts. By 2020, I predict that numbers of NPs, PAs, and physician expanders practicing dermatology will increase at least threefold, that dermatologists will increasingly join large practices or health care organizations that decrease their autonomy, and that fee-for-service will all but disappear. I would like to think that teledermatology will assume a much larger role, although it is discouraging that it is taking so long to overcome third-party resistance. Hospital-sponsored dermatology residency slots will surely decrease and there will likely be the resurgence of unpaid residents because, as noted by Dr. Roenigk, dermatology will remain an attractive specialty for many. I also agree dermatology will evolve into a two-tier system, similar to that in the countries with universal coverage, in which many patients will elect to pay out-of-pocket for services, both medically necessary and cosmetic, in a more traditional private practice setting.

Bruce Deitchman, MD

I now fear that our ability to influence the business of dermatology is rapidly fading, and that the entire field of medicine may have slipped out of the doctors’ control. In 2020, the choices we have will bear little resemblance to the ones we have today, and may even bear little resemblance to what we can today imagine. Surely, rises in physician extenders, decreases in solo practices, and far less independence in decision making than we are used to. Dermatologists will be more employee than employer, and the punishing burden of regulation and requirement may make, with some exceptions, the private office and even the concept of private doctor, an anachronism.

I hope that the practice of dermatology, that doctors who specialize in the detection and treatment of cutaneous malignancies and treat the myriad manifestations of skin conditions which cause so much morbidity and disability, will be unchanged despite the changed business climate. That is in our control — to maintain professionalism, dignity, and patient trust as the world we know is rearranged. It will be our challenge to remain doctors and overcome our resentments and angers.

Carrie Kovarik, MD

I think that teledermatology is going to be more widely adopted, not just practiced by our teledermatology specialists. Right now, people don’t always understand what the options are or just how it’s done. Medical students will learn about telemedicine, and residents will begin to use it as it becomes more commonplace. Primary care doctors will have easy portals to access specialists and we will be able to keep a high standard of quality in the medical home.

Right now, people have one primary care doctor and go to many specialists that may be at different locations. Specialty care is often very scattered. The patients who will be able to get their care through a PCP and access specialty care through telemedicine will have a better record and history. There are going to be answers at the tips of your fingers.

Daniel Siegel, MD

Better living through technology! 

On the up side, imaging technology that allowa a combination of visual, dermoscopic, confocal, optical coherence tomography, multispectral analysis, and ultrasound with software that will let us eliminate the need for most biopsies will be just around the corner. (Not yet “Bones” McCoy from Star Trek’s tricorder but darn close.) Google Glass will evolve into unobtrusive eyes-up displays so you can fill your EMR with a mix of eye movements and audio commands. Corticosteroids lacking atrophy and tachyphylaxis concerns will be coming to market.

On the down side, documentation requirements will include 6474 data points that will be required by the IPEB. (IPAB will have been phased out by 2018; “Advisory” will have been replaced “Execution.” Cost containment as the government’s primary motivation for health care reform will have been leaked by Edward Snowden and both sides of the aisle decide to “shoot the chefs.” ) Medicare will be able to call for drone strikes on non-participating physicians. All mind altering drugs will be legalized for recreational use so the government can step up detection of foreign-made tetracycline, doxycycline, isotretinoin, and botulinum toxins being smuggled into the country. President Bill DeBlasio will nationalize the practice of medicine…

Hopefully, with support of each and every dermatologist in practice we will see the upside while the downside will only remain a bad nightmare, fueled by low SkinPAC donations and apathy. 

Timothy Abrahamson, MD

I wonder about the push toward non-physician clinicians acting as “specialists.” I think there will be two or three levels of care. Will you see the nurse practitioner or physician assistant first, and then go on to the next level? That seems to be the way things are trending…though I hope that’s not the case. Also, with an extender’s lesser level of training and academic requirements (formal and informal), will insurances and patients demand to pay less for their services? I would think this would only make sense. Even 85 percent of specialty physician rate feels excessive when you are seeing someone with considerably less training than a general practitioner (physician with one year of residency training).

As dermatology is a visual specialty, some form of teledermatology will be more commonplace. My hope is that telemedicine would allow us to triage rural patients and inpatients better. This would increase these two populations’ access to a board-certified dermatologist in a timely manner. Within telemedicine, regular telemedicine remains very inefficient; store-and-forward will need to become the norm. The military uses it extensively because they don’t have to use a payment model. I think the Academy’s work will advance this cause, and that patients will have better and timelier access to care through the system to help triage care. Telemedicine, in any form, cannot replace physically seeing the patient but will become a way to triage care to rural and in-patient populations that currently have little to no access. 

As a solo practicing dermatologist, my hope is that restraint-of-trade laws will protect us from needing to join a big group. Even with this, connection to ACOs and/or hospital networks will become necessary to achieve equal funding. I don’t see anyone practicing without a certified electronic record system as penalties will force the need to be computerized.

Cosmetically, we will continue to see an evolution of fillers along with injectable agents to address adipose tissue. The expanding field of fractionation along with new radiofrequency and ultrasound devices will continue to expand as well as picosecond lasers for tattoos. Tissue growth and inhibitor factors will likely be used in wound healing and keloids. We will likely see numerous biologics available well beyond our current choice list. Therapies that help metastatic melanoma patients will likely be firmly established. Also, an increasing number of pathway inhibitors in basal cell carcinoma will likely change the treatment paradigm. Digital photography algorithms will likely have improved enough to allow patients to use photography to monitor for changes to their moles at home improving early detection.

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