Who Will Take Care of the Patients?

My last student confirmed it: Derm is indeed white hot. Only the very brightest dare apply, she told me, and even they face long odds. One of her top classmates who failed to match in dermatology has taken a year off to do the research he needs to buff his resume.

An earlier column that told of my experience hiring a physician assistant (PA) drew some strenuous responses ("Associates," September 2002, p. 10). A few of these accused dermatologists like me who engage so-called physician extenders—PAs and nurse-practitioners (NPs)—of irresponsible venality.

When my PA gave unexpected notice last year, I considered taking on a graduating dermatology resident. Directors at nearby training programs agreed to post my opportunity but said they weren't sure how many in their graduating cohort actually planned to enter practice. I got no bites.

Shortly after that I spoke with a consultant, who shared some statistics that I quote without being able to guarantee. He said the number of trainees sitting for the dermatology boards each year roughly approximates the number of practitioners who retire, but residents intending to practice are in fact much fewer. The rest, he said, "are interested in laser and Mohs."

Later in the year I had a chance to confirm these comments, if only anecdotally. Interviewing two men about to finish their training, I learned that several of their fellow residents were indeed heading for careers other than practice: cosmetic or Mohs fellowships, or leaves of absence for family reasons.

Attracting such applicants is indeed cause for optimism that a new generation of this caliber may make discoveries that will benefit patients and society at large. A small doubt, however, nags.

Caring for patients with everyday conditions offers many rewards and demands special skills, but high-octane intellect and entrepreneurial moxie are perhaps not among them.

If I am a super-bright young dermatologist with research credentials and interest, how will I view the quotidian task of managing acne, warts, and eczema?

Several trends therefore seem to point to this problem: If trainees see dermatology as an avenue to do exciting research, learn sophisticated technical skills, or advance lucrative cosmetic careers, then who will take care of the patients?

This is not a rhetorical question. In other countries dermatologists function as secondary or even tertiary consultants. Primary care of skin disease is the province of other practitioners. In principle, there is no reason internists, family physicians, and pediatricians shouldn't manage basic skin problems in the United States as well, but those of us who field referrals from these groups are continually amazed—and appalled—at what a poor job they often do.

The near absence of dermatology teaching in medical school explains a lot of this, of course; the standard curriculum imparts not just limited skin knowledge but an implicitly dismissive attitude toward caring for the banal complaints of ordinary people.

There should thus be no surprise at the burgeoning of "physician extenders" (a barbarous term that conjures up "Hamburger Helper"). Dermatology PAs have for some time had a vigorous organization, the Society of Dermatology Physician Assistants. Dermatology NPs are likewise getting their act together. Near Boston the prestigious Lahey Clinic Medical Center has a new training program for dermatology NPs.

What distinguishes such practitioners is that they actually want to do clinical work. They view caring for patients with everyday problems not as a distraction from their main career, but as its fulfillment. In light of evolving trends in dermatology training and practice, perhaps our profession ought to support and guide the proliferation of dermatology NPs and PAs rather than decrying or ignoring it.

If research provides new treatments, who will administer them? When patients need help, who will take care of them?

My last student confirmed it: Derm is indeed white hot. Only the very brightest dare apply, she told me, and even they face long odds. One of her top classmates who failed to match in dermatology has taken a year off to do the research he needs to buff his resume.

An earlier column that told of my experience hiring a physician assistant (PA) drew some strenuous responses ("Associates," September 2002, p. 10). A few of these accused dermatologists like me who engage so-called physician extenders—PAs and nurse-practitioners (NPs)—of irresponsible venality.

When my PA gave unexpected notice last year, I considered taking on a graduating dermatology resident. Directors at nearby training programs agreed to post my opportunity but said they weren't sure how many in their graduating cohort actually planned to enter practice. I got no bites.

Shortly after that I spoke with a consultant, who shared some statistics that I quote without being able to guarantee. He said the number of trainees sitting for the dermatology boards each year roughly approximates the number of practitioners who retire, but residents intending to practice are in fact much fewer. The rest, he said, "are interested in laser and Mohs."

Later in the year I had a chance to confirm these comments, if only anecdotally. Interviewing two men about to finish their training, I learned that several of their fellow residents were indeed heading for careers other than practice: cosmetic or Mohs fellowships, or leaves of absence for family reasons.

Attracting such applicants is indeed cause for optimism that a new generation of this caliber may make discoveries that will benefit patients and society at large. A small doubt, however, nags.

Caring for patients with everyday conditions offers many rewards and demands special skills, but high-octane intellect and entrepreneurial moxie are perhaps not among them.

If I am a super-bright young dermatologist with research credentials and interest, how will I view the quotidian task of managing acne, warts, and eczema?

Several trends therefore seem to point to this problem: If trainees see dermatology as an avenue to do exciting research, learn sophisticated technical skills, or advance lucrative cosmetic careers, then who will take care of the patients?

This is not a rhetorical question. In other countries dermatologists function as secondary or even tertiary consultants. Primary care of skin disease is the province of other practitioners. In principle, there is no reason internists, family physicians, and pediatricians shouldn't manage basic skin problems in the United States as well, but those of us who field referrals from these groups are continually amazed—and appalled—at what a poor job they often do.

The near absence of dermatology teaching in medical school explains a lot of this, of course; the standard curriculum imparts not just limited skin knowledge but an implicitly dismissive attitude toward caring for the banal complaints of ordinary people.

There should thus be no surprise at the burgeoning of "physician extenders" (a barbarous term that conjures up "Hamburger Helper"). Dermatology PAs have for some time had a vigorous organization, the Society of Dermatology Physician Assistants. Dermatology NPs are likewise getting their act together. Near Boston the prestigious Lahey Clinic Medical Center has a new training program for dermatology NPs.

What distinguishes such practitioners is that they actually want to do clinical work. They view caring for patients with everyday problems not as a distraction from their main career, but as its fulfillment. In light of evolving trends in dermatology training and practice, perhaps our profession ought to support and guide the proliferation of dermatology NPs and PAs rather than decrying or ignoring it.

If research provides new treatments, who will administer them? When patients need help, who will take care of them?

My last student confirmed it: Derm is indeed white hot. Only the very brightest dare apply, she told me, and even they face long odds. One of her top classmates who failed to match in dermatology has taken a year off to do the research he needs to buff his resume.

An earlier column that told of my experience hiring a physician assistant (PA) drew some strenuous responses ("Associates," September 2002, p. 10). A few of these accused dermatologists like me who engage so-called physician extenders—PAs and nurse-practitioners (NPs)—of irresponsible venality.

When my PA gave unexpected notice last year, I considered taking on a graduating dermatology resident. Directors at nearby training programs agreed to post my opportunity but said they weren't sure how many in their graduating cohort actually planned to enter practice. I got no bites.

Shortly after that I spoke with a consultant, who shared some statistics that I quote without being able to guarantee. He said the number of trainees sitting for the dermatology boards each year roughly approximates the number of practitioners who retire, but residents intending to practice are in fact much fewer. The rest, he said, "are interested in laser and Mohs."

Later in the year I had a chance to confirm these comments, if only anecdotally. Interviewing two men about to finish their training, I learned that several of their fellow residents were indeed heading for careers other than practice: cosmetic or Mohs fellowships, or leaves of absence for family reasons.

Attracting such applicants is indeed cause for optimism that a new generation of this caliber may make discoveries that will benefit patients and society at large. A small doubt, however, nags.

Caring for patients with everyday conditions offers many rewards and demands special skills, but high-octane intellect and entrepreneurial moxie are perhaps not among them.

If I am a super-bright young dermatologist with research credentials and interest, how will I view the quotidian task of managing acne, warts, and eczema?

Several trends therefore seem to point to this problem: If trainees see dermatology as an avenue to do exciting research, learn sophisticated technical skills, or advance lucrative cosmetic careers, then who will take care of the patients?

This is not a rhetorical question. In other countries dermatologists function as secondary or even tertiary consultants. Primary care of skin disease is the province of other practitioners. In principle, there is no reason internists, family physicians, and pediatricians shouldn't manage basic skin problems in the United States as well, but those of us who field referrals from these groups are continually amazed—and appalled—at what a poor job they often do.

The near absence of dermatology teaching in medical school explains a lot of this, of course; the standard curriculum imparts not just limited skin knowledge but an implicitly dismissive attitude toward caring for the banal complaints of ordinary people.

There should thus be no surprise at the burgeoning of "physician extenders" (a barbarous term that conjures up "Hamburger Helper"). Dermatology PAs have for some time had a vigorous organization, the Society of Dermatology Physician Assistants. Dermatology NPs are likewise getting their act together. Near Boston the prestigious Lahey Clinic Medical Center has a new training program for dermatology NPs.

What distinguishes such practitioners is that they actually want to do clinical work. They view caring for patients with everyday problems not as a distraction from their main career, but as its fulfillment. In light of evolving trends in dermatology training and practice, perhaps our profession ought to support and guide the proliferation of dermatology NPs and PAs rather than decrying or ignoring it.

If research provides new treatments, who will administer them? When patients need help, who will take care of them?