Elsevier

Clinics in Dermatology

Volume 37, Issue 1, January–February 2019, Pages 4-11
Clinics in Dermatology

The inevitability of change

https://doi.org/10.1016/j.clindermatol.2018.09.003Get rights and content

Abstract

Change is an absolute so long as time does not stand still. We should expect it, embrace it, and try to predict its direction. Dermatology, as a specialty practice, has been changing rapidly over the past 30 years concurrent with the changes in medicine. What are these changes, how did they come about, and what may be the consequences? The goal of this review is to follow the march of time, as we move from one era to the other in step with what is happening in the world as a whole and the United States in particular. The growth of our specialty, Dermatology, is divided into 3 eras which are quite different in generational cultures. The first era spanning the 1980s and 1990s is dubbed as “old school.” The second era begins with the new century, 2000 until today. This era will forever be remembered as the business era, the rise of elite cultures, and the losses and threats to academia. The third era begins now; it is that of technology which is fast progressing into the future. One can theoretically project what may occur during this technologic revolution and the directions in medicine as a whole. Dermatology can be at the forefront of this era or it could be lost as a whole if we do nothing to keep up. These eras are based on my personal experience as a dermatologist in a large academic institution in the United States and may not apply to other communities or societies elsewhere. The United States serves as a good example of a western technologically oriented society that is often emulated by others.

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

References (67)

  • J.S. Resneck et al.

    Challenges facing academic dermatology: Survey data on the faculty workforce

    J Am Acad Dermatol

    (2006)
  • J.S. Resneck

    Dermatology workforce policy then and now: Reflections on Dr Peyton Weary’s 1979 manuscript

    J Am Acad Dermatol

    (2013)
  • J.S. Resneck et al.

    Who else is providing care in dermatology practices? Trends in the use of nonphysician clinicians

    J Am Acad Dermatol

    (2008)
  • Y. Huang et al.

    Telepathology consultation for frozen section diagnosis in China

    Diagn Pathol

    (2018)
  • S. Sau et al.

    Multifunctional nanoparticles for cancer immunotherapy: A groundbreaking approach for reprogramming malfunctioned tumor environment

    J Control Release

    (2018)
  • M. Damian et al.

    A crisper look at genome editing: RNA-guided genome modification

    Mol Ther

    (2013)
  • H.A. Haenssle et al.

    Man against machine: Diagnostic performance of a deep learning convolutional neural network for dermoscopic melanoma recognition in comparison to 58 dermatologists

    Ann Oncol

    (2018)
  • F.F. Costa

    Big data in biomedicine

    Drug Discov Today

    (2014)
  • M.D. Brennan

    Professionalism

    Int J Dermatol

    (2010)
  • J.G. Hancox et al.

    Limited availability of psoriasis and phototherapy care: An analysis of advertisements

    Dermatol Online J

    (2005)
  • F.D. Scutchfield et al.

    Managed care in the United States

    J Public Health Med

    (1997)
  • T.E. Miller

    Managed care regulation: In the laboratory of the states

    JAMA

    (1997)
  • J.S. Resneck

    Dermatology practice consolidation fueled by private equity investment: Potential consequences for the specialty and patients

    JAMA Dermatol

    (2018)
  • S. Dogra

    Fate of medical dermatology in the era of cosmetic dermatology and dermatosurgery

    Indian J Dermatol Venereol Leprol

    (2009)
  • R. el-Azhary et al.

    The dermatology hospitalist: creating value by rapid clinical pathologic correlation in a patient-centered care model

    Int J Dermatol

    (2012)
  • R.H. Weenig et al.

    The role of the hospital dermatologist in the diagnosis and treatment of calciphylaxis and nephrogenic systemic fibrosis

    Semin Cutan Med Surg

    (2007)
  • E.R. Storan et al.

    Filling a critical practice gap: Experience with a dermatology day treatment center at Mayo Clinic

    Int J Dermatol

    (2015)
  • E.R. Storan et al.

    Pediatric hospital dermatology: Experience with inpatient and consult services at the Mayo Clinic

    Pediatr Dermatol

    (2013)
  • Micheletti RG, Chiesa-Fuxench Z, Noe MH, et al. Stevens-Johnson syndrome / toxic epidermal necrolysis: A multicenter...

  • The future of dermatology. Dermatology Times

  • S.J. Reck et al.

    Assessment of residents’ loss of interest in academic careers and identification of correctable factors

    Arch Dermatol

    (2006)
  • S. Maguiness et al.

    The Canadian Dermatology Workforce Survey: Implications for the future of Canadian dermatology—who will be your skin expert?

    J Cutan Med Surg

    (2004)
  • J.S. Resneck et al.

    An analysis of dermatologist migration patterns after residency training

    Arch Dermatol

    (2011)

    • Cited by (7)

    • Healthcare students’ knowledge, attitudes, and perspectives toward artificial intelligence in the southern Vietnam

      2023, Heliyon

    • Deep Learning and Mathematical Models in Dermatology

      2020, Actas Dermo-Sifiliograficas

    • Commentary

      2019, Clinics in Dermatology

    • Digital Tools for Assessing Disease Severity in Dermatology

      2022, Indian Dermatology Online Journal

    • Artificial Intelligence in Medicine: A Multinational Multi-Center Survey on the Medical and Dental Students' Perception

      2021, Frontiers in Public Health

    • Artificial Intelligence Applications in Dermatology: Where Do We Stand?

      2020, Frontiers in Medicine
    View all citing articles on Scopus
    View full text
    © 2018 Elsevier Inc. All rights reserved.