The inevitability of change
Section snippets
Era of “old school”
Although used often in conversation with colleagues and patients, the expression old school has a fluid definition depending on context and subject under discussion. As per the Merriam-Webster Dictionary, the definition of old school is: “Adhering to traditional policies or practices with characteristics evocative of an earlier or original style, manner, or form.” Other names applied include “antique,” “old-fashioned,” “old time,” and “obsolete,” to name a few. The expression old school likely
Era of the business elites
With the turn of the twenty-first century, dermatology continued to be a growing field for private practices as well as for large multispecialty groups and academic institutions. These were exciting times, as dermatology was attracting many young physicians to a specialty that now encompassed subspecialties of clinical and hospital dermatology, research, pathology, and dermatologic surgery with a very attractive future for the new subspecialty of cosmetic dermatology. This was an opportunity
The business of medicine
Health care dollars were consuming a larger portion of the gross national product than ever; hence, government intervention grew. Instead of physicians or physician-led organizations seeking their own solutions to upcoming interventions, they instead hired consultants who were often less concerned about patient care to advise them. Physicians were trained to bill correctly and to understand invented health care codes, rather than focusing their primary attention on their patients’ skin health
The dermatology hospitalist
With the advent of managed reimbursement and government interventions in the late 1990s,[4], [5] the hospital presence of dermatologists as well as phototherapy2 decreased considerably to where we have very few dermatologists caring for our most sick hospitalized dermatology patients. Diseases such as lymphomas, as well as immunobullous and autoimmune diseases are much more difficult to teach in residency programs given the minimal involvement with hospitals.[7], [8] Newer dermatologic
Procedural dermatology
Dermatologic surgery and cosmetics grew rapidly over the past 3 decades and is continuing to grow until today. The reasons for the expansion were multifactorial but may be related to the rising numbers of skin cancers and a growing interest in surgery and cosmetics. It also was more appealing to a new generation that preferred avoidance of “on call” specialties, quality of life, time spent with family, and perhaps a much higher financial reward.
Most in dermatology have supported this growth and
Shortage of dermatologists
One of the unintended consequences of this shift of dermatologists’ work to cosmetics and surgery, in addition to many working part-time, is a relative shortage of dermatologists nationwide.[20], [21], [22], [23], [24], [25], [26], [27], [28] As a result, there has been a large infusion of midlevel providers to fill this gap and the gradual but predictable takeover of dermatologic subspecialties by other medical specialties, similar to the loss of sexually transmitted diseases to infectious
Era of optimism: The future of science and technology
It would seem that the changes previously described will never revert; but they will change, as they always do. There could be many drivers for this change, but one major driver is technology. Technology is moving at such a fast pace that it is difficult to get a handle on it. Going beyond targeted drugs, which have changed our treatment protocols for many diseases especially in oncology, there are many different avenues arising that behold a very optimistic view for medicine as a whole. Given
Telemedicine
Due to the manpower challenges discussed previously, remotely offering care has become a popular idea. The art and science of taking care of patients, when there is a large distance between provider and the patient, is now a specialty referred to as telemedicine. Currently, we have teleconsults, telepathology (Figure 1), and teleradiology, the latter of which is more mature and now widely used, e-consults over the Internet and even telerobotic surgery which will probably be widely available in
Regenerative medicine
Transplant surgery has grown so much of late to include almost every organ, including limbs, face, and internal organs. The main drawback has been the required use of immunosuppressive agents for life. Is there a way to avoid it? By using one’s own stem cells, can we regenerate our dying organs? The field of regenerative medicine and 3-dimensional (3D) printing will be the future of transplants. Using stem cells growing in cell culture, it has been shown that these cells can become pluripotent
Nanotechnology
Dermatologists know nanotechnology, as it has allowed us to make excellent sunscreens.44 The transformation of titanium to tiny, less than 100 nm in size molecules, can change its properties from opaque to transparent yet maintain the sun-screening ability. This has led to an inert, nonallergenic sunscreen. Nanotechnology is now used in many fields of engineering and medicine. For example, the gadolinium that is used as a dye in MRI and the chemotherapeutic agent doxorubicin are both
Genetics
One of the emerging fields where dermatologists should be active is genetics. New targeted medications are being directed to edit the DNA or to halt a stop codon. A great development is gene editing technology known as CRISPR (clustered regularly interspaced short palindromic repeats). Also known as CRISPR-Cas, this technology utilizes a part of the bacterial immune system known as the defense genes (Figure 3). With this as a source of the synthetic guide, RNA and the enzyme Cas that can split
Artificial intelligence (AI)
Everyone knows about AI, but we do not know how it would fit in our lives. For example, there is a hotel in Japan run totally by AI, from manager to cook to cleaning and room services. The only humans are the guests! Does this mean in the future there will be no jobs for hotel personnel? How will AI change dermatology? Generally, in order for an AI to be a provider of health care it first needs to be educated. This is the most important step where dermatologists should be involved, assuming we
Conclusions
Do we need to be nervous about all this rapidly evolving technology? I think yes, we should be nervous! Our residents who are the smartest in their classes graduating with honors need to be engaged and mentored in basic science or technological research. We need academics and researchers who can work with everything from telemedicine to AI to genetic editing. If we do not do this for dermatology and our patients, who will? Our academic centers must be teaching these technologies and learning
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