Jack S. Resneck

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

BACKGROUND The US dermatology workforce, which is affected by a physician shortage, has reportedly seen a rapid and substantial influx of physician assistants (PAs) and nurse practitioners (NPs). Little is known about which dermatology practices use these practitioners, how they are supervised, and the services they are providing. METHODS We analyzed results of the American Academy of Dermatologys 2007 practice profile survey to learn more about patterns of nonphysician clinician (NPC) use. Of 3965 surveys mailed, responses were obtained from 1243 dermatologists (31% response rate). Comparison data were drawn from previous surveys conducted with a similar methodology in 2002 (35% response rate) and 2005 (30% response rate). RESULTS Overall, 325 responding dermatologists (29.6%) reported using PAs, NPs, or both in their practices in 2007, a 43% increase from the proportion in 2002 (20.7%). PAs were more prevalent than NPs (23% vs 10%). By the year 2010, 36.2% of respondents plan to hire these NPCs. Younger cohorts of dermatologists were significantly more likely to use NPCs (P = .006), as were those in group and academic practices (P < .0001). Respondents seeking to hire additional dermatologists (P < .0001) and those with surgical or cosmetically focused practices (P < .001) were much more likely to use NPCs. Respondents reported supervising their NPCs on-site 92.8% of the time, but 31% were off-site 10% of the time or more. Most dermatologists allowed their NPCs to see new patients and established patients with new problems, and a minority of these patients were formally presented to a physician during extender visits. NPCs spent the majority of their time seeing medical dermatology patients, even if their supervising dermatologist was primarily engaged in surgical or cosmetic dermatology. LIMITATIONS Survey respondents might have inaccurately reported practice characteristics or might not be representative of all US dermatologists. CONCLUSIONS In the setting of persistently long patient wait times and difficulty recruiting new physician staff, dermatologists have rapidly turned to PAs and NPs to help meet patient demand for care. These NPCs are primarily caring for new and established medical dermatology patients under indirect supervision. In the absence of explicit consensus or policy as to how the field should ensure future access to care for patients with skin disease, growth in the use of NPCs has continued, with significant variation in use and supervision patterns.

A gender gap in the dermatology literature? Cross-sectional analysis of manuscript authorship trends in dermatology journals during 3 decades

BACKGROUND Despite a dramatic influx of female dermatologists during the last 30 years, women in academic dermatology departments remain relatively clustered in junior faculty positions. Research in other specialties showing a disparity in the academic productivity of women has led to many hypotheses regarding factors that may place them at a competitive disadvantage. It is unknown, however, whether similar differences in academic productivity might also serve as barriers to advancement in dermatology, or whether any productivity gap actually exists in this specialty that experienced a more substantial entry of women. OBJECTIVE Because publication in peer-reviewed journals is one of the core measures of academic productivity used in the promotion process, we evaluated trends in the prevalence of female authorship in top dermatology journals during the last 3 decades. METHODS We conducted an observational study of trends in the sex distribution of US authors in 3 prestigious general dermatology journals (in 1976, 1986, 1996, and 2006) and 3 subspecialty dermatology journals (in 2006 only). Journals were chosen based on published impact factors and citation half-lives. RESULTS During the last 3 decades, the proportion of women authoring manuscripts in the 3 major general dermatology journals increased from 12% to 48% of US-affiliated first authors (P < .001) and from 6.2% to 31% of US-affiliated senior authors (P < .001). Separate analyses by journal and by article type showed similar increases. The prevalence of female authors in subspecialty journals in 2006 was slightly more variable. LIMITATIONS Although the publications selected for this study capture many of the most respected US journals in dermatology, they may not be representative of all journals in which dermatologists publish. CONCLUSIONS Female dermatologists are authoring publications in growing numbers that match or exceed their prevalence in the academic and overall workforce. This suggests that other factors (differences in productivity outside of the publishing arena, differences in job descriptions or opportunities, differences in career aspirations, a lack of institutional support or flexibility, or gender bias) may be associated with the ongoing reduced advancement of women to senior academic dermatology ranks relative to their male colleagues, and further research is warranted to explore these possibilities.

The burden of skin disease in the United States

&NA; Since the publication of the last US national burden of skin disease report in 2006, there have been substantial changes in the practice of dermatology and the US health care system. These include the development of new treatment modalities, marked increases in the cost of medications, increasingly complex payer rules and regulations, and an aging of the US population. Recognizing the need for up‐to‐date data to inform researchers, policy makers, public stakeholders, and health care providers about the impact of skin disease on patients and US society, the American Academy of Dermatology produced a new national burden of skin disease report. Using 2013 claims data from private and governmental insurance providers, this report analyzed the prevalence, cost, and mortality attributable to 24 skin disease categories in the US population. In this first of 3 articles, the presented data demonstrate that nearly 85 million Americans were seen by a physician for at least 1 skin disease in 2013. This led to an estimated direct health care cost of

Twitter: an opportunity for public health campaigns

75 billion and an indirect lost opportunity cost of

Choice, Transparency, Coordination, and Quality Among Direct-to-Consumer Telemedicine Websites and Apps Treating Skin Disease

11 billion. Further, mortality was noted in half of the 24 skin disease categories.

Pediatric dermatology workforce shortage: Perspectives from academia

www.thelancet.com Vol 384 July 12, 2014 131 F i n a l l y, L a b r o p o u l o s a n d colleagues seem to be dismayed that the SOX trial does not confi rm the assumed benefit of elastic compression stockings suggested by smaller trials. There are many examples of large, properly designed multicenter trials refuting results of earlier smaller trials or cohort studies. The SOX trial is the largest randomised trial so far of elastic compression stockings, overcomes the potential for bias inherent in any open trial by using placebo and double blinding, uses outcome measures used in other clinical trials of post-thrombotic syndrome, and is generalisable because of the large number of centres involved. Further, the estimated compliance rates are consistent with our clinical experience. Many patients find elastic compression stockings intolerable for aesthetic reasons, because they have the potential to cause discomfort, and can be difficult to put on. Although some might find the negative results of the SOX trial disappointing, patients might be relieved to fi nd that they do not routinely need to wear elastic compression stockings for 2 years after deep-vein thrombosis.

Compliance by California tanning facilities with the nation’s first statewide ban on use before the age of 18 years

IMPORTANCE Evidence supports use of teleconsultation for improving patient access to dermatology. However, little is known about the quality of rapidly expanding direct-to-consumer (DTC) telemedicine websites and smartphone apps diagnosing and treating skin disease. OBJECTIVE To assess the performance of DTC teledermatology services. DESIGN AND PARTICIPANTS Simulated patients submitted a series of structured dermatologic cases with photographs, including neoplastic, inflammatory, and infectious conditions, using regional and national DTC telemedicine websites and smartphone apps offering services to California residents. MAIN OUTCOMES AND MEASURES Choice of clinician, transparency of credentials, clinician location, demographic and medical data requested, diagnoses given, treatments recommended or prescribed, adverse effects discussed, care coordination. RESULTS We received responses for 62 clinical encounters from 16 DTC telemedicine websites from February 4 to March 11, 2016. None asked for identification or raised concerns about pseudonym use or falsified photographs. During most encounters (42 [68%]), patients were assigned a clinician without any choice. Only 16 (26%) disclosed information about clinician licensure, and some used internationally based physicians without California licenses. Few collected the name of an existing primary care physician (14 [23%]) or offered to send records (6 [10%]). A diagnosis or likely diagnosis was proffered in 48 encounters (77%). Prescription medications were ordered in 31 of 48 diagnosed cases (65%), and relevant adverse effects or pregnancy risks were disclosed in a minority (10 of 31 [32%] and 6 of 14 [43%], respectively). Websites made several correct diagnoses in clinical scenarios where photographs alone were adequate, but when basic additional history elements (eg, fever, hypertrichosis, oligomenorrhea) were important, they regularly failed to ask simple relevant questions and diagnostic performance was poor. Major diagnoses were repeatedly missed, including secondary syphilis, eczema herpeticum, gram-negative folliculitis, and polycystic ovarian syndrome. Regardless of the diagnoses given, treatments prescribed were sometimes at odds with existing guidelines. CONCLUSIONS AND RELEVANCE Telemedicine has potential to expand access to high-value health care. Our findings, however, raise concerns about the quality of skin disease diagnosis and treatment provided by many DTC telemedicine websites. Ongoing expansion of health plan coverage of these services may be premature. Until improvements are made, patients risk using health care services that lack transparency, choice, thoroughness, diagnostic and therapeutic quality, and care coordination. We offer several suggestions to improve the quality of DTC telemedicine websites and apps and avoid further growth of fragmented, low-quality care.

Online Advertising for Cancer Prevention: Google Ads and Tanning Beds

BACKGROUND The pediatric dermatology workforce has not been systematically evaluated since recent changes in board certification requirements. OBJECTIVE To quantify and characterize the workforce of academic pediatric dermatologists and examine issues related to training, hiring, and retention. METHODS Dermatology chairpersons and residency directors in the United States and Canada completed a 30-question survey. RESULTS Eighty of 132 programs (61%) responded to the survey. More than two thirds of programs (56/80) employed a pediatric dermatologist, and 34 programs were recruiting a pediatric dermatologist. The number of residents that pursue careers in pediatric dermatology is significantly associated with the number of pediatric dermatologists on faculty at their institution. LIMITATIONS Self-reported data, which may have been reflected by recall bias, and 61% response rate. CONCLUSIONS At a majority of academic centers, the current pool of pediatric dermatology faculty is neither adequate to meet academic nor clinical demands. Methods to increase exposure to pediatric dermatology among medical students and residents must be sought.

Contribution of health care factors to the burden of skin disease in the United States

BACKGROUND Exposure to indoor tanning, especially at younger ages, is associated with increased risk of skin cancer. Even in states with parental consent requirements, teenagers used tanning facilities at high rates. In 2011, California became the first state to pass a complete ban on indoor tanning by those younger than 18 years. OBJECTIVE We sought to determine whether tanning facilities in California were in compliance with the new law. METHODS In a cross-sectional study, telephone calls were placed in May 2013 to a statewide random sample of tanning facilities by a study investigator indicating that she was 17 years old. RESULTS Of 600 advertised indoor tanning facilities, 338 met inclusion criteria. A majority of respondents (77%, 95% confidence interval 72%-81%) told the underage caller that she could not use their ultraviolet tanning facility. Most facilities, however, denied any dangers from ultraviolet tanning (61%) and made unlawful claims of specific health benefits, including vitamin-D production (44%), skin disease treatment (22%), prevention of future sunburns (17%), and prevention or treatment of depression (8%). LIMITATIONS Tanning facilities may respond differently to a 17-year-olds request to tan in person versus by telephone. CONCLUSION Given strong evidence linking indoor tanning to skin cancer, and the tanning industrys documented history of marketing specifically to teenagers, this study suggests that laws banning indoor tanning younger than 18 years can meaningfully impact access. Additional enforcement, however, may be required to bring about accurate disclosure of risk and prevent claims of unproven health benefits.

How Health Policy and Health Services Researchers are Compensated: Analysis of a Nationwide Salary Survey

Author Contributions: Dr Yeung had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Yeung. Acquisition, analysis, or interpretation of data: Both authors. Drafting of the manuscript: Yeung. Critical revision of the manuscript for important intellectual content: Both authors. Statistical analysis: Yeung. Administrative, technical, or material support: Yeung. Study supervision: Both authors.