Experts: Medical Dermatology Is Losing Ground

By 2020, the practice of dermatology will likely be narrower in scope, be less medically oriented, and place greater emphasis on dermatologic surgery and cosmetic interventions, according to two medical dermatologists.

These trends will apply worldwide but will be most pronounced in the United States, where they are already far more advanced. The dermatologists also predicted that European dermatologists will continue to practice a more traditional style of dermatology that includes inpatient care for severely ill patients.

"Cosmetic and procedural dermatology will no doubt continue to grow. You can see it growing at virtually every meeting you go to in the U.S. Why? There’s immediate gratification, and it’s the path of least resistance. You’re basically on your own, in business for yourself," said Dr. Stephen I. Katz, a dermatologist and director of the National Institute of Arthritis and Musculoskeletal and Skin Diseases.

What he finds particularly worrisome, he said, is that most cosmetic and procedural dermatology is not science based. These fields are thriving at a time of exciting advances in understanding the biologic basis of skin diseases, with the discoveries having far-reaching implications for both diagnosis and treatment. Yet aesthetic dermatology and dermatologic surgery are not pulling their fair share of the load, he said.

"With few exceptions, cosmetic and procedural dermatology is not accompanied by a research base. It’s absolutely ridiculous, for example, that we don’t have a robust research interest in wound healing," said Dr. Katz.

In an interview, Dr. Joel Schlessinger, a dermatologist in private practice in Omaha, Neb., said that although he too laments the lack of basic science research in cosmetic dermatology, he believes there is room for hope.

"Recently, over 100 residents competed for selective positions as adjunct faculty at the Third Annual Cosmetic Surgery Forum by submitting research on cosmetic dermatology," said Dr. Schlessinger.

And although several university programs have undertaken research on collagen fillers and collagen formation, "until the federal government realizes the importance that cosmetic dermatology [plays] in patients' lives, no significant basic science research will be funded at the university level. It is understandable, but not practical, for all research dollars to be in life-and-death disease states. Hopefully, the paradigm will change among strategic decisions at the government and university [levels], thereby allowing more serious research in cosmetic dermatology," he added.

"Somehow, I think, we've lost our way," said Dr. Katz. "Our specialty has already lost STDs, connective tissue disease, psoriasis, eczema, melanoma, wound healing – they’re already gone. Yes, there are psoriasis centers, but rheumatology is taking over much of psoriasis because rheumatologists are more comfortable with the more complicated biologic therapies."

The Marginalization of Academic Dermatology in the U.S.

He said that he had hoped academic dermatology would play a leadership role in keeping the specialty on track as a broad-based discipline that encompasses a wide range of subspecialty interests, but in this he has been disappointed. Academic dermatology, in his view, has undergone marginalization and trivialization.

"In the U.S., many dermatology programs are struggling to continue an academic focus. They’re basically no more than practices that happen to be located at a university, trying to meet their financial overhead with very little in the way of an academic dimension. Still, there are maybe 10-15 programs in the U.S. that have continued to focus on generating new knowledge in the university setting, often with PhD scientists leading the way," said Dr. Katz.

The National Institutes of Health now awards far more grant money for research into skin biology and skin disease to PhD scientists than to either MD or MD/PhD scientists. "The PhD scientists are so successful because they’re not encumbered by seeing patients," Dr. Katz said during a panel discussion at the World Congress of Dermatology in Seoul, South Korea.

His fellow panelist, Dr. Georg Stingl, reported that a substantial reduction in the number of hospital beds reserved for dermatology is ongoing throughout Europe, but those beds "have not yet disappeared."

"I predict the scope of dermatology in continental Europe 10 years from now will remain broader than that in the U.S., [the United Kingdom], and Asia, but it will be subject to territorial battles with other disciplines. Yet if our discipline is shrinking, it’s not the fault of others. It’s our own fault. It’s because of what we are doing," said Dr. Stingl, professor of dermatology and chairman of the division of immunology, allergy, and infectious diseases at the Medical University of Vienna.

Traditional fields of European dermatology that are now at risk of being lost to other specialties include venereology, dermato-oncology, type 1 allergy, and dermatopathology. Phlebology has already been largely taken over by vascular surgeons. On the other hand, European dermatology will see expansion of genodermatology, aesthetic dermatology, and dermatologic surgery, he added.

Dermatologic Role Changing in Japan

In Japan, as elsewhere throughout the world, the traditional dermatologic role as caregiver for severely ill patients is being taken over by other specialties.

"Traditional dermatologists are an endangered species," said Dr. Masayuki Amagai, professor of dermatology at Keio University, Tokyo. For example, Japanese dermatologists traditionally have cared for melanoma patients with terminal disease as well as for those who have early-stage disease. Now, however, more patients with advanced melanoma are being seen in integrated oncology centers.

Following the same model, it is likely that the near future will bring a new sort of integrated immunologic disease center for patients with Crohn’s disease, rheumatoid arthritis, psoriasis, and other conditions that share common inflammatory mechanisms. Dermatologists who hunger to take on the most interesting and challenging cases will want to become a part of such centers, where they will work alongside rheumatologists and gastroenterologists, Dr. Amagai said.

The good news in the United States, according to Dr. Katz, is that the recent skin biology discoveries will eventually translate into major clinical advances. And dermatology continues to attract the best and brightest medical school graduates, he said. In 2004-2007, 5.8% of U.S. dermatology residency positions were held by MD/PhDs, a rate nearly threefold greater than the average for other residency programs.

His wish list for the dermatology specialty includes a better-organized research agenda, including research programs in the cosmetic and procedural aspects of the specialty. He would also like to see the development of a clinical research consortium in dermatology, similar to the way pediatric research is conducted. "Dermatology departments are just too small to not work together," said Dr. Katz.

More effort should be placed on educating dermatologists about health services research, comparative effectiveness studies, and clinical outcomes research.

"These are areas we're not very good at. We need to be part of that whole scenario because reimbursement is going to be based on these types of studies," he said.

The speakers declared having no financial conflicts.

By 2020, the practice of dermatology will likely be narrower in scope, be less medically oriented, and place greater emphasis on dermatologic surgery and cosmetic interventions, according to two medical dermatologists.

These trends will apply worldwide but will be most pronounced in the United States, where they are already far more advanced. The dermatologists also predicted that European dermatologists will continue to practice a more traditional style of dermatology that includes inpatient care for severely ill patients.

"Cosmetic and procedural dermatology will no doubt continue to grow. You can see it growing at virtually every meeting you go to in the U.S. Why? There’s immediate gratification, and it’s the path of least resistance. You’re basically on your own, in business for yourself," said Dr. Stephen I. Katz, a dermatologist and director of the National Institute of Arthritis and Musculoskeletal and Skin Diseases.

What he finds particularly worrisome, he said, is that most cosmetic and procedural dermatology is not science based. These fields are thriving at a time of exciting advances in understanding the biologic basis of skin diseases, with the discoveries having far-reaching implications for both diagnosis and treatment. Yet aesthetic dermatology and dermatologic surgery are not pulling their fair share of the load, he said.

"With few exceptions, cosmetic and procedural dermatology is not accompanied by a research base. It’s absolutely ridiculous, for example, that we don’t have a robust research interest in wound healing," said Dr. Katz.

In an interview, Dr. Joel Schlessinger, a dermatologist in private practice in Omaha, Neb., said that although he too laments the lack of basic science research in cosmetic dermatology, he believes there is room for hope.

"Recently, over 100 residents competed for selective positions as adjunct faculty at the Third Annual Cosmetic Surgery Forum by submitting research on cosmetic dermatology," said Dr. Schlessinger.

And although several university programs have undertaken research on collagen fillers and collagen formation, "until the federal government realizes the importance that cosmetic dermatology [plays] in patients' lives, no significant basic science research will be funded at the university level. It is understandable, but not practical, for all research dollars to be in life-and-death disease states. Hopefully, the paradigm will change among strategic decisions at the government and university [levels], thereby allowing more serious research in cosmetic dermatology," he added.

"Somehow, I think, we've lost our way," said Dr. Katz. "Our specialty has already lost STDs, connective tissue disease, psoriasis, eczema, melanoma, wound healing – they’re already gone. Yes, there are psoriasis centers, but rheumatology is taking over much of psoriasis because rheumatologists are more comfortable with the more complicated biologic therapies."

The Marginalization of Academic Dermatology in the U.S.

He said that he had hoped academic dermatology would play a leadership role in keeping the specialty on track as a broad-based discipline that encompasses a wide range of subspecialty interests, but in this he has been disappointed. Academic dermatology, in his view, has undergone marginalization and trivialization.

"In the U.S., many dermatology programs are struggling to continue an academic focus. They’re basically no more than practices that happen to be located at a university, trying to meet their financial overhead with very little in the way of an academic dimension. Still, there are maybe 10-15 programs in the U.S. that have continued to focus on generating new knowledge in the university setting, often with PhD scientists leading the way," said Dr. Katz.

The National Institutes of Health now awards far more grant money for research into skin biology and skin disease to PhD scientists than to either MD or MD/PhD scientists. "The PhD scientists are so successful because they’re not encumbered by seeing patients," Dr. Katz said during a panel discussion at the World Congress of Dermatology in Seoul, South Korea.

His fellow panelist, Dr. Georg Stingl, reported that a substantial reduction in the number of hospital beds reserved for dermatology is ongoing throughout Europe, but those beds "have not yet disappeared."

"I predict the scope of dermatology in continental Europe 10 years from now will remain broader than that in the U.S., [the United Kingdom], and Asia, but it will be subject to territorial battles with other disciplines. Yet if our discipline is shrinking, it’s not the fault of others. It’s our own fault. It’s because of what we are doing," said Dr. Stingl, professor of dermatology and chairman of the division of immunology, allergy, and infectious diseases at the Medical University of Vienna.

Traditional fields of European dermatology that are now at risk of being lost to other specialties include venereology, dermato-oncology, type 1 allergy, and dermatopathology. Phlebology has already been largely taken over by vascular surgeons. On the other hand, European dermatology will see expansion of genodermatology, aesthetic dermatology, and dermatologic surgery, he added.

Dermatologic Role Changing in Japan

In Japan, as elsewhere throughout the world, the traditional dermatologic role as caregiver for severely ill patients is being taken over by other specialties.

"Traditional dermatologists are an endangered species," said Dr. Masayuki Amagai, professor of dermatology at Keio University, Tokyo. For example, Japanese dermatologists traditionally have cared for melanoma patients with terminal disease as well as for those who have early-stage disease. Now, however, more patients with advanced melanoma are being seen in integrated oncology centers.

Following the same model, it is likely that the near future will bring a new sort of integrated immunologic disease center for patients with Crohn’s disease, rheumatoid arthritis, psoriasis, and other conditions that share common inflammatory mechanisms. Dermatologists who hunger to take on the most interesting and challenging cases will want to become a part of such centers, where they will work alongside rheumatologists and gastroenterologists, Dr. Amagai said.

The good news in the United States, according to Dr. Katz, is that the recent skin biology discoveries will eventually translate into major clinical advances. And dermatology continues to attract the best and brightest medical school graduates, he said. In 2004-2007, 5.8% of U.S. dermatology residency positions were held by MD/PhDs, a rate nearly threefold greater than the average for other residency programs.

His wish list for the dermatology specialty includes a better-organized research agenda, including research programs in the cosmetic and procedural aspects of the specialty. He would also like to see the development of a clinical research consortium in dermatology, similar to the way pediatric research is conducted. "Dermatology departments are just too small to not work together," said Dr. Katz.

More effort should be placed on educating dermatologists about health services research, comparative effectiveness studies, and clinical outcomes research.

"These are areas we're not very good at. We need to be part of that whole scenario because reimbursement is going to be based on these types of studies," he said.

The speakers declared having no financial conflicts.

By 2020, the practice of dermatology will likely be narrower in scope, be less medically oriented, and place greater emphasis on dermatologic surgery and cosmetic interventions, according to two medical dermatologists.

These trends will apply worldwide but will be most pronounced in the United States, where they are already far more advanced. The dermatologists also predicted that European dermatologists will continue to practice a more traditional style of dermatology that includes inpatient care for severely ill patients.

"Cosmetic and procedural dermatology will no doubt continue to grow. You can see it growing at virtually every meeting you go to in the U.S. Why? There’s immediate gratification, and it’s the path of least resistance. You’re basically on your own, in business for yourself," said Dr. Stephen I. Katz, a dermatologist and director of the National Institute of Arthritis and Musculoskeletal and Skin Diseases.

What he finds particularly worrisome, he said, is that most cosmetic and procedural dermatology is not science based. These fields are thriving at a time of exciting advances in understanding the biologic basis of skin diseases, with the discoveries having far-reaching implications for both diagnosis and treatment. Yet aesthetic dermatology and dermatologic surgery are not pulling their fair share of the load, he said.

"With few exceptions, cosmetic and procedural dermatology is not accompanied by a research base. It’s absolutely ridiculous, for example, that we don’t have a robust research interest in wound healing," said Dr. Katz.

In an interview, Dr. Joel Schlessinger, a dermatologist in private practice in Omaha, Neb., said that although he too laments the lack of basic science research in cosmetic dermatology, he believes there is room for hope.

"Recently, over 100 residents competed for selective positions as adjunct faculty at the Third Annual Cosmetic Surgery Forum by submitting research on cosmetic dermatology," said Dr. Schlessinger.

And although several university programs have undertaken research on collagen fillers and collagen formation, "until the federal government realizes the importance that cosmetic dermatology [plays] in patients' lives, no significant basic science research will be funded at the university level. It is understandable, but not practical, for all research dollars to be in life-and-death disease states. Hopefully, the paradigm will change among strategic decisions at the government and university [levels], thereby allowing more serious research in cosmetic dermatology," he added.

"Somehow, I think, we've lost our way," said Dr. Katz. "Our specialty has already lost STDs, connective tissue disease, psoriasis, eczema, melanoma, wound healing – they’re already gone. Yes, there are psoriasis centers, but rheumatology is taking over much of psoriasis because rheumatologists are more comfortable with the more complicated biologic therapies."

The Marginalization of Academic Dermatology in the U.S.

He said that he had hoped academic dermatology would play a leadership role in keeping the specialty on track as a broad-based discipline that encompasses a wide range of subspecialty interests, but in this he has been disappointed. Academic dermatology, in his view, has undergone marginalization and trivialization.

"In the U.S., many dermatology programs are struggling to continue an academic focus. They’re basically no more than practices that happen to be located at a university, trying to meet their financial overhead with very little in the way of an academic dimension. Still, there are maybe 10-15 programs in the U.S. that have continued to focus on generating new knowledge in the university setting, often with PhD scientists leading the way," said Dr. Katz.

The National Institutes of Health now awards far more grant money for research into skin biology and skin disease to PhD scientists than to either MD or MD/PhD scientists. "The PhD scientists are so successful because they’re not encumbered by seeing patients," Dr. Katz said during a panel discussion at the World Congress of Dermatology in Seoul, South Korea.

His fellow panelist, Dr. Georg Stingl, reported that a substantial reduction in the number of hospital beds reserved for dermatology is ongoing throughout Europe, but those beds "have not yet disappeared."

"I predict the scope of dermatology in continental Europe 10 years from now will remain broader than that in the U.S., [the United Kingdom], and Asia, but it will be subject to territorial battles with other disciplines. Yet if our discipline is shrinking, it’s not the fault of others. It’s our own fault. It’s because of what we are doing," said Dr. Stingl, professor of dermatology and chairman of the division of immunology, allergy, and infectious diseases at the Medical University of Vienna.

Traditional fields of European dermatology that are now at risk of being lost to other specialties include venereology, dermato-oncology, type 1 allergy, and dermatopathology. Phlebology has already been largely taken over by vascular surgeons. On the other hand, European dermatology will see expansion of genodermatology, aesthetic dermatology, and dermatologic surgery, he added.

Dermatologic Role Changing in Japan

In Japan, as elsewhere throughout the world, the traditional dermatologic role as caregiver for severely ill patients is being taken over by other specialties.

"Traditional dermatologists are an endangered species," said Dr. Masayuki Amagai, professor of dermatology at Keio University, Tokyo. For example, Japanese dermatologists traditionally have cared for melanoma patients with terminal disease as well as for those who have early-stage disease. Now, however, more patients with advanced melanoma are being seen in integrated oncology centers.

Following the same model, it is likely that the near future will bring a new sort of integrated immunologic disease center for patients with Crohn’s disease, rheumatoid arthritis, psoriasis, and other conditions that share common inflammatory mechanisms. Dermatologists who hunger to take on the most interesting and challenging cases will want to become a part of such centers, where they will work alongside rheumatologists and gastroenterologists, Dr. Amagai said.

The good news in the United States, according to Dr. Katz, is that the recent skin biology discoveries will eventually translate into major clinical advances. And dermatology continues to attract the best and brightest medical school graduates, he said. In 2004-2007, 5.8% of U.S. dermatology residency positions were held by MD/PhDs, a rate nearly threefold greater than the average for other residency programs.

His wish list for the dermatology specialty includes a better-organized research agenda, including research programs in the cosmetic and procedural aspects of the specialty. He would also like to see the development of a clinical research consortium in dermatology, similar to the way pediatric research is conducted. "Dermatology departments are just too small to not work together," said Dr. Katz.

More effort should be placed on educating dermatologists about health services research, comparative effectiveness studies, and clinical outcomes research.

"These are areas we're not very good at. We need to be part of that whole scenario because reimbursement is going to be based on these types of studies," he said.

The speakers declared having no financial conflicts.