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Genital warts in children indicate the possibility of sexual abuse. If sexual child abuse is recognized or suspected, then the law in all states requires that the physician report this to the appropriate authority. The dermatologist may be the first person to suspect the problem and can be of great help in protecting the child from future harm.
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The NAMCS provides a wealth of information on use of PAs in all practices, including dermatology. Two important points regarding the NAMCS and SDPA data are addressed here: the number of visits to PAs for dermatologic symptoms and the expected growth of PA use in dermatologists' offices. Dermatologic symptoms were evaluated frequently by PAs, accounting for 14% of PA visits. These statistics do not address the number of referrals those PAs made to dermatologists. Perhaps PAs as a group should be targeted for increased dermatologic education, particularly stressing the need for appropriate referral to a dermatologist. PAs could increase the number of dermatology referrals from primary care offices with improved understanding of the importance of the dermatologist in the management of patients' overall skin health. At projected growth rates, the number of PAs employed by dermatologists should exceed 500 by the end of 2000. Most of this growth has been in private practices and rarely in HMOs or in large multispecialty clinics. There are a number of reasons for this growth, as follows: A PA may help reduce the patient load on the dermatologist, especially with sameday appointments and drop-ins. Some dermatologists are moving away from clinical dermatology into cosmetics, which not only leaves a vacuum in clinical dermatology, but also creates job opportunities for PAs in cosmetic dermatology. Regarding managed care growth, PAs can have a positive impact on the problem of having to see more patients for less money. PAs are cost-effective. In the 1998 SDPA survey, the ratio of billings generated (production) to gross income for the average dermatology PA ranged from 3:1 to 6:1. Even with inexperienced PAs new to dermatology, this ratio was usually at least 2:1 at the end of the first year. PAs can cover satellite offices, allowing for practice expansion. Effective with the new Medicare laws of January 1, 1998, PAs can now see new Medicare patients or Medicare patients with new conditions without the physician being on site, opening up the possibility for satellite offices in remote areas. Just as dermatologists may move toward specialization in surgery, cosmetics, or medical dermatology, PAs may do the same, filling a niche in a particular practice. As in other specialties, patient acceptance of seeing dermatology PAs has not been a significant problem. Continued access to the dermatologist remains unfettered, but, over time, many patients become willing to see either. Are PAs likely to become future competitors of dermatologists? Genuinely concerned dermatologists worry that a dermatology-trained PA will become part of a gatekeeper system that impedes patient access to dermatologists. This is not happening and is not at all likely to become a trend, for a number of reasons. First, primary care cannot compete with dermatology practices in remuneration for PAs. Just as financial benefits in high-production specialty practices entice physicians, the same benefits entice PAs as well. Second, according to member surveys of the SDPA, virtually 100% of fellow members work with dermatologists. Although PAs can work in any type of practice and evaluate dermatologic symptoms just as a general practitioner would, PAs who specialize in dermatology primarily practice with dermatologists, a collegial association most PAs seek out. PAs have steadfastly maintained their dependent, noncompetitive relationship with physicians and would not have it any other way. Although PAs see a good number of patients (2.8 million) with dermatologic symptoms, the NAMCS data indicate that most (72%) of these patients are also seen by a physician. Third, physicians are ultimately responsible for the actions of their PA employee. A general practitioner not trained to perform excisions or manage certain dermatologic conditions should not allow a PA to perform such duties. Similar to much of medicine, the PA profession continues to evolve, with many members moving awa
Change within dermatology as a clinical discipline is expected and inevitable. However dermatology may change as a medical specialty in the new millennium, there will still be patients with medical dermatologic disease whose optimal care will depend on skin disease specialists' having the highest level of training and experience in medical dermatology. Dermatologists who have subspecialized in medical dermatology will provide the role models for new generations of dermatologists, perform the patient-oriented research, and care for the more complicated patients. Thus, if during its evolution, dermatology loses the ability to train and support medical dermatologists, it will be weakened as the discipline that can best care for skin disease. Clearly, the loss of talented academicians such as the person whose career was outlined in the case report presented at the beginning of this article should be a huge warning sign that the future of medical dermatology as a specialty is uncertain. The Medical Dermatology Society hopes to develop a coalition with all other leadership organizations within dermatology to deal with this problem effectively. There is a need for a broader discussion within organized dermatology of the growing crisis in this area and how all dermatology leadership organizations working together can develop an action plan for effectively dealing with this important but challenging problem. Dermatology must ask itself what it wants to look like as a medical specialty in the future. Without an steady stream of young clinician-investigators focused on the many challenging problems in medical dermatology, dermatology will not exist as the specialty it is today.
BACKGROUND: In 1993, the General Medical Council recommended that all medical schools should revise their curricula for undergraduate medical education and foster more interdisciplinary collaboration in teaching. In accordance with these recommendations, new curricula have been introduced in U.K. medical schools. OBJECTIVES: To assess the impact of changes in medical curricula on the teaching of dermatology to medical undergraduates. METHODS: A questionnaire was sent to the dermatologists responsible for organizing the teaching of undergraduate dermatology in each of the 24 medical schools in England, Scotland, Wales and Northern Ireland. RESULTS: Replies were received from all schools. Nineteen of the 24 schools had already introduced integrated curricula and the others were changing more slowly. Some dermatology was included in the core curriculum in all schools. Dermatologists in 14 schools contributed to the teaching of basic science and students in 18 schools were able in years 1 and 2 to see patients in primary care (14) and/or the hospital (13). In nine of these schools, students could meet dermatology patients in these early clinical sessions. Nine schools used some problem-based learning (PBL) in addition to other teaching methods, but PBL predominated in four schools and in two of these schools most students never met a dermatologist. Dermatology was a compulsory clinical attachment in 21 schools, but the length of attachments varied and was less than 5 days in four schools. Students had to pass a dermatology assessment at the end of the clinical attachment in 14 schools and there was assessment of knowledge of dermatology in final examinations in all schools. Students had an early opportunity to explore a dermatology topic in depth in 17 schools, and 20 schools offered or were planning to introduce special study modules in dermatology. Interdisciplinary teaching links were common. Resources for out-patient teaching were inadequate in 16 schools and university support poor in 10 schools. Few departments had direct access to the considerable health service funding that is paid to National Health Service Trusts to reimburse the costs of teaching medical students. CONCLUSIONS: In general, dermatology has maintained a reasonable profile in the new undergraduate curricula, but dermatology experience is inadequate in four schools. Dermatologists should maximize opportunities for introducing dermatology into the curriculum by familiarizing themselves with the forces that are driving curriculum reform, participating in curriculum development, keeping abreast of changes in medical education and using opportunities for interdisciplinary teaching.
BACKGROUND AND DESIGN: Dermatologic practice occurs mainly in the outpatient setting. The reasons for, frequency, and impact of inpatient dermatologic consultation are largely unstudied. In this report, we prospectively studied dermatologic consultation in the major teaching hospital complex of a medical school. Over a period of 8 months, we prospectively recorded the demographics of the patients for whom consultation was requested, the provisional dermatologic diagnosis of the referring service, the final diagnosis of the dermatologic service, and the tests necessary to arrive at a final diagnosis. RESULTS: During a period of slightly over 8 months, dermatologic consultation was requested and delivered to 591 patients who were either hospitalized or being evaluated in the emergency department or other urgent care settings. The services requesting consultation most frequently were medicine (39%), pediatrics (14%), surgery (12%), psychiatry (6%), and neurology (3%). In 51% of consultations, the patients were younger than 45 years of age. Diagnostic tests, including Tzanck smear and potassium hydroxide preparation, confirmed the clinical diagnosis in up to 50% of cases. Dermatologic consultation changed dermatologic diagnosis and treatment in more than 60% of the patients. Generally, the dermatologic diagnoses most frequently missed by the referring service were common conditions with established treatment. CONCLUSIONS: Dermatologic consultation in the hospital setting improves dermatologic diagnosis and has an impact on treatment.
BACKGROUND AND DESIGN: We determine whether a subset of internists exist who are better at diagnosing skin disease and therefore select themselves to treat the majority of patients with dermatologic disorders. A survey was conducted in which internists reported their self-perception regarding their abilities in dermatology, the amount of dermatology training they had received, and the percentage of patients they encounter with and treat for skin diseases. This was correlated with results from an objective photographic (Kodachrome) examination assessing their diagnostic abilities in dermatology. The setting was university and private practices in Miami, Fla, and New Haven, Conn. The participants were general internists, medical subspecialists, and medical residents. After completing a self-administered questionnaire, each physician then participated in an examination where they were shown 20 color photographs of common skin disorders. We correlate the relationship between the survey variables and the results of the photographic examination. RESULTS: Eighty-four internists diagnosed 50.5% of the diseases correctly. Internists perceive themselves as mediocre in dermatology (2.6, on a scale of 1-5, 5 being the best), which correlated with their poor performance on the photographic evaluation (P = .04). Internists reported having limited education or training in dermatology (> 85% having < 1 month of training in or after medical school). There was a trend toward a correlation between the amount of training internists received and their ability in dermatology (P = .07). Notably , there was no correlation between internists' ability in dermatology and the percentage of patients they encounter with and treat for skin disease. CONCLUSIONS: Internists receive limited training and have resultant poor performance in diagnosing skin disease. Internists are aware of their limited ability in dermatology as demonstrated by their mediocre self-perceived ability. Notably, no correlation was found between internists' abilities in dermatology and the percentage of patients they encounter and treat for skin disease. Therefore, we did not demonstrate a subset of internists, superior at dermatology, who treat the majority of patients with skin disease. This suggests patients with skin disease may be better served by dermatologists.
AIM: The aim of the study was to establish prevalence and type of dermatologic symptoms in patients with mental disorders, treated with psychotropics drugs, and comparison of the frequency and type of dermatologic disorders after typical psychotropics and new psychotropic drugs, and assessment of relationships between diagnosis of mental disorders and type of dermatologic symptoms. METHOD: In the study 4041 patients hospitalized and treated with psychotropic drugs in a psychiatric hospital took part. Dermatologic consultation was conducted in 340 patients, but only 98 were in monotherapy. This group was assessed with a next procedure: questionnaire regarding demographic dates, early and family dermatologic disorders, treatment with other than psychotropics--drugs, diet, addictions and analysis of medical documentation (psychiatric and dermatologic diagnosis, actual pharmacotherapy). RESULTS AND CONCLUSIONS: 8.4% of the subjects had dermatologic symptoms, which were consulted by dermatologists. 1/2 of this group had their first treatment with psychotropics. Dermatologic symptoms appeared more often in patients treated with more than 2 psychotropics than in patients in monotherapy, usually in the first weeks of pharmacotherapy. Nearly 1/3rd of these subjects had allergic disorders. In subjects treated with psychotropics the most frequent dermatologic symptoms (allergic diseases, psoriasis and psoriasislike disorders) were noted after therapy with antipsychotics, next anxiolytics. In 3/4 patients treated with antidepressants had vascular diseases of the skin. In the whole group, dermatologic disorders appeared most frequently after treatment with BZD, phenothiazines and butyrophenones. New psychotropic drugs caused less dermatologic symptoms than typical antipsychotics and antidepressants.
OBJECTIVES: To examine attitudes toward evidence-based medicine and evidence-based dermatology and to assess evidence-based training in US internal medicine and dermatology residency programs. METHODS: A 1-page self-administered questionnaire was mailed to residency training directors and chief residents at 104 dermatology and 103 internal medicine residency programs from the same or affiliated medical centers. RESULTS: Questionnaires were returned by respondents from 70 (68%) of 103 internal medicine programs and 86 (83%) of 104 dermatology programs. Most respondents (91% internal medicine and 70% dermatology) strongly agreed or agreed that evidence-based internal medicine/dermatology is valuable and should be included in residency training (93% internal medicine and 70% dermatology). Respondents from internal medicine programs agreed more strongly with both statements than respondents from dermatology programs (P =.001). Dedicated evidence-based curricula were in place at significantly more internal medicine programs (50 [71%] of 70) than dermatology programs (20 [23%] of 86) (P<.001). Curricula at internal medicine programs offered significantly more evidence-based medicine training sessions (24 vs 6; P<.001) and biostatistics sessions (10 vs 2.3; P =.03), and internal medicine programs more frequently evaluated the curricula using clinical question applications (56% vs 30%; P =.04). CONCLUSION: Despite favorable attitudes toward evidence-based dermatology, compared with internal medicine programs, dedicated evidence-based training is underdeveloped in dermatology programs.
OBJECTIVES: To provide the first comprehensive assessment of dermatology residency training in Canada based on the residents' perspective; to examine and elucidate trends in current residents' envisioned career paths and aspirations. DESIGN: A national survey conducted in June 2004. PARTICIPANTS: All Canadian dermatology residents. MAIN OUTCOME MEASURES: Cross-sectional analysis of (1) satisfaction with and importance placed by the trainees on the various curriculum components as measured by a 5-point Likert-type scale and (2) current residents' career and practice plans. RESULTS: One hundred percent of dermatology residents across the country (n = 48) responded to the survey. The greatest discrepancies between ranked importance and corresponding satisfaction were observed for the teaching from faculty (both didactic and clinic based) and for the practice management exposure and training. Residents were most satisfied with dermatopathology education (score, 4.4 of 5.0) and least satisfied with cosmetic dermatology (2.7 of 5.0) and dermoscopy training (2.8 of 5.0). Men indicated more interest than women in academics (71% [n = 12] vs 45% [n = 14]), research (41% [n = 7] vs 16% [n = 5]), and teaching (71% [n = 12] vs 42% [n = 13]), while female residents were more inclined toward pediatric dermatology (42% [n = 13] vs 29% [n = 5]) and cosmetic dermatology (48% [n = 15] vs 29% [n = 5]). An overall trend of decreased interest in academic and hospital-based practice was noted with progression through residency training. CONCLUSIONS: This study provides a current picture of dermatology postgraduate education in Canada from the residents' perspective. Above all, dermatology residents desire more teaching (clinic, didactic, and practice management) and mentorship from their faculty. Recruitment and retention of women in academic dermatology may benefit from early intervention during residency. The data are intended to assist dermatology programs with development, evaluation, and improvement of their curricula and can serve as a reference point to gauge future trends.
BACKGROUND: Problems in some advertisements in medical journals, including dermatology journals, have been identified in various studies. Examples have included poorly supported claims, failure to balance claims of efficacy with potential adverse effects of a drug, and slogans that recommend prescribing a drug for groups of patients different from those assessed in a referenced study. OBJECTIVE: We sought to assess dermatology journals' and dermatology journal editors' policies, practices, and attitudes toward prescription-medicine advertising in dermatology journals. METHODS: We searched dermatology journals' paper copies and World Wide Web sites for statements of advertising policy and sent surveys to dermatology journal editors. RESULTS: Of 22 journals, 8 (36.4%) had an advertising policy published in a paper copy or a World Wide Web site. Of 17 editors (70.8%) from 17 journals (77.3%) who responded to the survey, 3 reported having an advertising policy; these policies were also identified in searches of paper copies or World Wide Web sites. Two editors whose journals each had a published policy reported not having one. In all, 7 editors (41.2%) reported that they or other physician members of the editorial board reviewed advertisements before publication in the previous year. A total of 8 editors (47.1%) agreed somewhat or strongly that advertisements in medical journals, including dermatology journals, generally present information that is accurate, and 12 (70.6%) agreed somewhat or strongly with the same statement regarding advertisements appearing in their own journal. In all, 12 editors (70.6%) agreed somewhat or strongly that advertisements should be reviewed for accuracy by the editorial staff before publication, and 3 (17.6%) agreed somewhat or strongly that advertisements should be reviewed for accuracy before publication in a peer-review process similar to that used for submitted manuscripts. LIMITATIONS: This study did not assess processes by which editors or other members of editorial or publishing staffs review advertisements before publication. CONCLUSIONS: Policies, practices, and attitudes toward advertising vary among dermatology journals and dermatology journal editors. Journals, especially those without a policy, should consider establishing policies to separate and, therefore, minimize conflicts of interest between editorial and business aspects of publication.