Pediatric Dermatology Comes Of Age
November 2004
On Oct. 4, nearly 100 skin doctors converged on Deerfield, IL, outside Chicago. The occasion: The first board certification in the field of pediatric dermatology, a small but growing subspecialty that after some three decades is finally getting official recognition.
“Pediatric dermatology has really become a very critical subspecialty,” said Dr. Amy Paller, President of the Society for Pediatric Dermatology, with its 520-some members, and one of the physicians sitting for the board exam.
Is the new certification just another diploma to hang on the office wall?
Advocates of the exam insist not. They believe the testing regime will give added legitimacy to their field, which joins only two other dermatology subfields to be so recognized. Practitioners of the subspecialty, they contend, must acquire a discrete body of knowledge that general skin doctors don’t have if they aren’t focused on childhood conditions. Obtaining board certification, test proponents claim, will not only help point generalists to qualified subspecialists, but it will give patients an extra measure of comfort that the doctors their children are referred to are appropriately trained.
Some dermatologists, however, fear the added hurdle of board certification may worsen an already severe shortage in the availability of skin experts who treat children. But more on that later.
A Subspecialty in Demand
Dr. Paller, head of dermatology at Northwestern University’s Feinberg School of Medicine in Chicago, and one of four pediatric dermatologists at the school’s affiliate hospital, Children’s Memorial, trained for her career the old-fashioned way. As a medical student at Stanford University in the mid-1970s, she studied under the legendary Al Jacobs, “who allowed me to see that this was a specialty,” she said.
Dr. Paller had already done graduate work in medical genetics and thought pediatric dermatology would be a good way to combine her interests. From Stanford she headed to Chicago to train in both pediatrics and dermatology under Nancy Esterly, whom Dr. Paller calls the “mother” of pediatric dermatology.
Pediatric dermatologists are clearly in high demand. “We have four full-time faculty at Children’s, but we continue to have a 4-month waiting list” for appointments, she said. “There just aren’t enough physicians.”
Other hospitals are in the same position. A recent article in the Journal of the American Academy of Dermatology found that almost half of dermatology departments surveyed had a full-time pediatric dermatologist on staff. More than a quarter have tried to recruit one for an average of nearly 1.5 years. And while 10 programs had pediatric dermatology fellowships, only six fellows were in training at the time of the survey.
Dr. Paller said she knows of at least 25 open faculty positions nationally for pediatric dermatologists. “And the numbers just keep going up. It’s an exciting, growing area where the body of knowledge has increased tremendously.”
Who’s Eligible?
The Society for Pediatric Dermatology has laid out the following guidelines for eligibility for subspecialty certification.
These include:
• A current valid license to practice medicine or osteopathy in the state or province of the candidate’s residence in either the United States or Canada. Candidates for certification may be denied if their license has been revoked, suspended, restricted, or surrendered in any jurisdiction, or if they are subject to adverse licensure proceedings.
• Primary certification by the American Board of Dermatology.
• At least 1 year of ACGME-approved residency training in pediatrics, followed by the requisite training and certification in dermatology, and an additional year of fellowship training in pediatric dermatology.
• Acceptable experience can also include an ACGME-approved transitional year or an ACGME-approved broad-based year of residency training in emergency medicine, family practice, general surgery, internal medicine, or obstetrics and gynecology, followed by the requisite training and certification in dermatology. However, candidates who have chosen this route must complete 2 additional years of fellowship training in pediatric dermatology.
• Certification is also open to candidates who have demonstrated a “special interest, experience, and expertise” in pediatric dermatology for at least 5 years. However, this route will no longer be available in 2009, 5 years after the first certification exam.
In the near term, the society will allow doctors with significant experience in pediatric dermatology to sit for the board examination on a case-by-case basis. Eligible physicians are those with no less than 5 years of clinical dermatology practice in which their pediatric patients account for at least half the total caseload. They may also submit papers and invited lectures in the field as evidence of expertise.
Doctors who trained in pediatric dermatology fellowships prior to the development of approved fellowship training programs — in other words, the entire “old guard” — will be eligible for the certification exam on a case-by-case basis.
What Will Candidates Be Tested On?
Dr. Ilona Frieden, Director of Pediatric Dermatology at the University of California, San Francisco Children’s Hospital, chaired the SPD’s test committee. The process of creating the board exam began about 3 years ago, she said, when the committee invited all pediatric dermatologists to submit questions. “We tried to collect a lot of images to go along with the questions, because seeing skin lesions is what we actually do for a living” she added. The test is rich with the kind of dermatology shots that fascinate the layman the way car accidents draw rubberneckers.
The committee winnowed the submissions down to a total of 200 questions for the first certification examination. About a third have pictures to go with them. Test takers had 4 hours to complete the computer-based exam, which was held at a testing facility used by the American Board of Psychiatry and Neurology.
Dr. Frieden said the questions were designed to cover the “walking knowledge” that pediatric dermatologists should possess. “They don’t have to memorize 25,000 genes and diseases they’ll see once in their career.”
While general skincare specialists will be able to answer many of the questions, most refer to the kinds of things that must occur immediately to a pediatric dermatologist when, for example, she sees a child in a newborn nursery with bad blisters.
Although the test committee had no trouble creating the test, the SPD did encounter a bump or two winning approval from the American Board of Medical Specialties — which okays new subspecialty examinations — to offer the board exam in the first place. The initial SPD application (called a COCERT) would have allowed doctors to take the exam if they had done a pediatric residency first, followed by a dermatology residency. The ABMS said “no,” according to Dr. Frieden, because it felt that someone could go through both residencies without accumulating sufficient expertise in what’s considered pediatric dermatology. A compromise was reached: To be eligible for the test, doctors would have to have at least a 1 year of pediatric dermatology fellowship “to consolidate that knowledge,” Dr. Frieden said.
Summing up a Pediatric Dermatologist’s Expertise
Dr. Paller admits that much of what pediatric dermatologists see doesn’t require a special expertise in child medicine: eczema, warts, molluscum, pigmented nevi. [A study in the journal Pediatric Dermatology of the most common conditions pediatric skin specialists in Switzerland treated found that atopic dermatitis was the runaway leader, seen in nearly 26% of patients; followed by 9% with pigmented nevi, and 5% with warts.] “But the special approach to the child and the family and the ability to handle the most difficult cases of common disorders is also part of the expertise of a pediatric dermatologist,” she said.
“In addition, the wide range of genetic disorders, inflammatory ailments, infections and immune diseases that afflict young children that most general dermatologists aren’t familiar with make the expertise of a pediatric dermatologist critical,” she added.
Childhood skin conditions account for nearly one in four (24%) of all pediatric office visits, Dr. Paller said. And while most dermatologists treat both children and adults, there are many disorders better suited to doctors with expertise in pediatrics.
A pediatric dermatologist, for example, should be familiar with Kindler syndrome, a rare, recessive condition that causes rampant blistering and occasionally squamous cell carcinomas in young children. Epidermolysis bullosa, or EB, is another inherited skin disease affecting roughly two in every 100,000 American children, according to the Children’s Skin Disease Foundation. There are more than two dozen forms of EB, with varying degrees of severity.
Even for more conventional skin conditions, a background in pediatrics can be crucial. One reason is technical: When adult patients present with dermatomyositis, doctors should be concerned about accompanying cancers. “But in children we see more calcinosis, and overall the prognosis is better,” Dr. Paller said.
Another key difference affects the intangibles of medical practice. When treating children with skin diseases, Dr. Paller said, “it’s very important to have training that allows you to have a better understanding of the dynamics of families.” Children require more time than adults as patients, she said, and a more sensitive touch. Not just emotionally, but physically, too. Pediatric dermatologists are more hesitant to perform biopsies than are dermatologists who treat adults, Dr. Paller said. “We always think twice about doing procedures that might cause pain or discomfort.”
The American Board of Dermatology intends to offer the new board exam every 2 years. The test is $1,600, and certification is good for 10 years.
Dr. Antoinette Hood, Executive Director of the American Board of Dermatology, and Chair of the Department of Dermatology at Eastern Virginia Medical School in Norfolk, said adding pediatric dermatology to the roster of board-certified subspecialists will have “absolutely no impact” on generalists. “I’m going to still see kids and adolescents, no question about it. But if I have a difficult patient, I would be wise to call on the expertise of my colleagues” who focus on childhood skin diseases. “I have the luxury of having one on campus,” Dr. Hood added.
Dr. Hood, who is helping administer the exam, predicted that the approximately 100 people taking the pediatric boards this year will be a high-water mark for the test because it includes many doctors who are being “grandfathered” and “grandmothered” into the eligibility requirements. As those rules tighten over the next 5 years, the pipeline for potential test takers will narrow, she said.
The new subspecialty at first could create difficulties for patients with insurance. If carriers become more restrictive about coverage decisions for specialists, they may demand that children see pediatric dermatologists instead of general skin doctors, Dr. Paller said. However, while most major medical centers now have a pediatric dermatologist, “until there are more nationally it may be difficult for a patient to see someone without going outside of the health plan.”
On the other hand, Dr. Paller said, the advent of the certification test could deliver a needed spur to managed care companies that they include pediatric dermatologists on their lists of approved providers.
Could Certification Worsen the Shortage of Pediatric Dermatologists?
Dr. Robert Dellavalle, a co-author of the Journal of the American Academy of Dermatology staffing survey, said there’s some concern that introducing a certification process could worsen the shortage of pediatric dermatologists. “By tightening credentialing, we feel it might reduce the number of people” who go into the field, said Dr. Dellavalle, a dermatologist at the University of Colorado Health Sciences Center in Denver.
Already, becoming a pediatric dermatologist is no cheap trick. “It takes as much training as to become a neurosurgeon,” Dr. Dellavalle said.
Two other dermatology subspecialties, dermatopathology and clinical and laboratory dermatological immunology, have certifying examinations, and Dr. Dellavalle believes those tests haven’t exacerbated the general shortage of U.S. skincare specialists. On the other hand, he added, both disciplines are “very lucrative fields compared to pediatric dermatology, so the incomes are much higher and therefore that sort of drives demand of people going into them.”
According to the American Board of Dermatology, roughly 15 doctors take the dermatopathology exam each year, compared with about 340 who take the general dermatology boards. The group hasn’t offered the immunology exam since 2001, when six physicians sat, though the test is still available in theory.
Dr. William Weston was among the first American physicians to lay claim to the field of pediatric dermatology in the early 1970s. “When I started, there were basically three of us,” said Dr. Weston, a Professor of Dermatology and Pediatrics at the University of Colorado Health Sciences Center.
The primary motivation for entering the new and unproven field was educational, Dr. Weston said. Although dermatology was coming into its own scientifically, back then pediatric dermatology was as advanced as Greenland is hot.
“All of realized that this was a real deficiency in our own training. There was a terrible level of knowledge in pediatric dermatology,” Weston said. An example: The only textbook in the subject had been published in the early 1960s, and it was essentially a pharmacy handbook for strange compounds and salves — ointments “that probably in retrospect didn’t work,” he said.
Being first has its advantages. One is the ability to work unfettered of established biases and conventional wisdom, Dr. Weston said.
The budding subspecialty — and others — took a body blow in 1990, when the U.S. government declared that it would stop funding second residencies in its effort to promote primary care. “That really restricted the opportunities for training,” Dr. Weston said. “The government has reversed its decision but the impact was great.”
Dr. Weston has mixed feelings about the new certification process, which he feels may have the perverse effect of driving people away from pediatric dermatology instead of drawing them into the discipline. “I think we want to encourage people to come into the field, and I’m not sure this does,” he said.
For starters, it’s odd to see a hybrid subspecialty exam appear without any hybrid training programs (only the University of Texas at Galveston has a joint pediatrics and dermatology residency, though other programs are considering such a course).
What’s more, trying to foster professional legitimacy by fiat may work, but is it better than simply recognizing established clinical and academic expertise, garnered through years of patient care, research and publishing?
Whatever the case, Dr. Weston believes the certification exam, which he has previewed, won’t be a walkover.
“I don’t know how people will do. It depends on their background and training. If they have not had adequate pediatric training, they may have trouble.”
So, Should Eligible Doctors Take the New Certification Exam?
Dr. Richard Antaya, of Yale University, in New Haven, CT, said “yes.” “I would recommend it, and I did take the boards myself on Oct. 4,” Dr. Antaya said. “I think pediatric dermatology is really quite different than adult dermatology and the knowledge base and skill sets differ from that of adult dermatology in many ways. It will help with recognition of our subspecialty and allow us to proceed in formalizing training and certification.”
Like other physicians, Dr. Antaya doesn’t believe the advent of certification will have much immediate impact on practice.
“My greatest concern is that we have made the criteria so stringent that it will be prohibitively difficult to sit for this subspecialty board exam,” he added. “This is where a coordinated effort will be necessary to train fellows in pediatric dermatology in order to keep the number of candidates at a sufficient level to maintain the numbers of practicing pediatric dermatologists.”
On the other hand, he predicted, patients will come out winners. “This will certainly improve care for children,” Dr. Antaya said. “Overall, general dermatologists will continue to care for children with skin disease, but this exam will provide pediatric dermatologists with the formal recognition as a subspecialty to make other physicians aware of an advanced level of care in situations when general dermatology care is inadequate.”
On Oct. 4, nearly 100 skin doctors converged on Deerfield, IL, outside Chicago. The occasion: The first board certification in the field of pediatric dermatology, a small but growing subspecialty that after some three decades is finally getting official recognition.
“Pediatric dermatology has really become a very critical subspecialty,” said Dr. Amy Paller, President of the Society for Pediatric Dermatology, with its 520-some members, and one of the physicians sitting for the board exam.
Is the new certification just another diploma to hang on the office wall?
Advocates of the exam insist not. They believe the testing regime will give added legitimacy to their field, which joins only two other dermatology subfields to be so recognized. Practitioners of the subspecialty, they contend, must acquire a discrete body of knowledge that general skin doctors don’t have if they aren’t focused on childhood conditions. Obtaining board certification, test proponents claim, will not only help point generalists to qualified subspecialists, but it will give patients an extra measure of comfort that the doctors their children are referred to are appropriately trained.
Some dermatologists, however, fear the added hurdle of board certification may worsen an already severe shortage in the availability of skin experts who treat children. But more on that later.
A Subspecialty in Demand
Dr. Paller, head of dermatology at Northwestern University’s Feinberg School of Medicine in Chicago, and one of four pediatric dermatologists at the school’s affiliate hospital, Children’s Memorial, trained for her career the old-fashioned way. As a medical student at Stanford University in the mid-1970s, she studied under the legendary Al Jacobs, “who allowed me to see that this was a specialty,” she said.
Dr. Paller had already done graduate work in medical genetics and thought pediatric dermatology would be a good way to combine her interests. From Stanford she headed to Chicago to train in both pediatrics and dermatology under Nancy Esterly, whom Dr. Paller calls the “mother” of pediatric dermatology.
Pediatric dermatologists are clearly in high demand. “We have four full-time faculty at Children’s, but we continue to have a 4-month waiting list” for appointments, she said. “There just aren’t enough physicians.”
Other hospitals are in the same position. A recent article in the Journal of the American Academy of Dermatology found that almost half of dermatology departments surveyed had a full-time pediatric dermatologist on staff. More than a quarter have tried to recruit one for an average of nearly 1.5 years. And while 10 programs had pediatric dermatology fellowships, only six fellows were in training at the time of the survey.
Dr. Paller said she knows of at least 25 open faculty positions nationally for pediatric dermatologists. “And the numbers just keep going up. It’s an exciting, growing area where the body of knowledge has increased tremendously.”
Who’s Eligible?
The Society for Pediatric Dermatology has laid out the following guidelines for eligibility for subspecialty certification.
These include:
• A current valid license to practice medicine or osteopathy in the state or province of the candidate’s residence in either the United States or Canada. Candidates for certification may be denied if their license has been revoked, suspended, restricted, or surrendered in any jurisdiction, or if they are subject to adverse licensure proceedings.
• Primary certification by the American Board of Dermatology.
• At least 1 year of ACGME-approved residency training in pediatrics, followed by the requisite training and certification in dermatology, and an additional year of fellowship training in pediatric dermatology.
• Acceptable experience can also include an ACGME-approved transitional year or an ACGME-approved broad-based year of residency training in emergency medicine, family practice, general surgery, internal medicine, or obstetrics and gynecology, followed by the requisite training and certification in dermatology. However, candidates who have chosen this route must complete 2 additional years of fellowship training in pediatric dermatology.
• Certification is also open to candidates who have demonstrated a “special interest, experience, and expertise” in pediatric dermatology for at least 5 years. However, this route will no longer be available in 2009, 5 years after the first certification exam.
In the near term, the society will allow doctors with significant experience in pediatric dermatology to sit for the board examination on a case-by-case basis. Eligible physicians are those with no less than 5 years of clinical dermatology practice in which their pediatric patients account for at least half the total caseload. They may also submit papers and invited lectures in the field as evidence of expertise.
Doctors who trained in pediatric dermatology fellowships prior to the development of approved fellowship training programs — in other words, the entire “old guard” — will be eligible for the certification exam on a case-by-case basis.
What Will Candidates Be Tested On?
Dr. Ilona Frieden, Director of Pediatric Dermatology at the University of California, San Francisco Children’s Hospital, chaired the SPD’s test committee. The process of creating the board exam began about 3 years ago, she said, when the committee invited all pediatric dermatologists to submit questions. “We tried to collect a lot of images to go along with the questions, because seeing skin lesions is what we actually do for a living” she added. The test is rich with the kind of dermatology shots that fascinate the layman the way car accidents draw rubberneckers.
The committee winnowed the submissions down to a total of 200 questions for the first certification examination. About a third have pictures to go with them. Test takers had 4 hours to complete the computer-based exam, which was held at a testing facility used by the American Board of Psychiatry and Neurology.
Dr. Frieden said the questions were designed to cover the “walking knowledge” that pediatric dermatologists should possess. “They don’t have to memorize 25,000 genes and diseases they’ll see once in their career.”
While general skincare specialists will be able to answer many of the questions, most refer to the kinds of things that must occur immediately to a pediatric dermatologist when, for example, she sees a child in a newborn nursery with bad blisters.
Although the test committee had no trouble creating the test, the SPD did encounter a bump or two winning approval from the American Board of Medical Specialties — which okays new subspecialty examinations — to offer the board exam in the first place. The initial SPD application (called a COCERT) would have allowed doctors to take the exam if they had done a pediatric residency first, followed by a dermatology residency. The ABMS said “no,” according to Dr. Frieden, because it felt that someone could go through both residencies without accumulating sufficient expertise in what’s considered pediatric dermatology. A compromise was reached: To be eligible for the test, doctors would have to have at least a 1 year of pediatric dermatology fellowship “to consolidate that knowledge,” Dr. Frieden said.
Summing up a Pediatric Dermatologist’s Expertise
Dr. Paller admits that much of what pediatric dermatologists see doesn’t require a special expertise in child medicine: eczema, warts, molluscum, pigmented nevi. [A study in the journal Pediatric Dermatology of the most common conditions pediatric skin specialists in Switzerland treated found that atopic dermatitis was the runaway leader, seen in nearly 26% of patients; followed by 9% with pigmented nevi, and 5% with warts.] “But the special approach to the child and the family and the ability to handle the most difficult cases of common disorders is also part of the expertise of a pediatric dermatologist,” she said.
“In addition, the wide range of genetic disorders, inflammatory ailments, infections and immune diseases that afflict young children that most general dermatologists aren’t familiar with make the expertise of a pediatric dermatologist critical,” she added.
Childhood skin conditions account for nearly one in four (24%) of all pediatric office visits, Dr. Paller said. And while most dermatologists treat both children and adults, there are many disorders better suited to doctors with expertise in pediatrics.
A pediatric dermatologist, for example, should be familiar with Kindler syndrome, a rare, recessive condition that causes rampant blistering and occasionally squamous cell carcinomas in young children. Epidermolysis bullosa, or EB, is another inherited skin disease affecting roughly two in every 100,000 American children, according to the Children’s Skin Disease Foundation. There are more than two dozen forms of EB, with varying degrees of severity.
Even for more conventional skin conditions, a background in pediatrics can be crucial. One reason is technical: When adult patients present with dermatomyositis, doctors should be concerned about accompanying cancers. “But in children we see more calcinosis, and overall the prognosis is better,” Dr. Paller said.
Another key difference affects the intangibles of medical practice. When treating children with skin diseases, Dr. Paller said, “it’s very important to have training that allows you to have a better understanding of the dynamics of families.” Children require more time than adults as patients, she said, and a more sensitive touch. Not just emotionally, but physically, too. Pediatric dermatologists are more hesitant to perform biopsies than are dermatologists who treat adults, Dr. Paller said. “We always think twice about doing procedures that might cause pain or discomfort.”
The American Board of Dermatology intends to offer the new board exam every 2 years. The test is $1,600, and certification is good for 10 years.
Dr. Antoinette Hood, Executive Director of the American Board of Dermatology, and Chair of the Department of Dermatology at Eastern Virginia Medical School in Norfolk, said adding pediatric dermatology to the roster of board-certified subspecialists will have “absolutely no impact” on generalists. “I’m going to still see kids and adolescents, no question about it. But if I have a difficult patient, I would be wise to call on the expertise of my colleagues” who focus on childhood skin diseases. “I have the luxury of having one on campus,” Dr. Hood added.
Dr. Hood, who is helping administer the exam, predicted that the approximately 100 people taking the pediatric boards this year will be a high-water mark for the test because it includes many doctors who are being “grandfathered” and “grandmothered” into the eligibility requirements. As those rules tighten over the next 5 years, the pipeline for potential test takers will narrow, she said.
The new subspecialty at first could create difficulties for patients with insurance. If carriers become more restrictive about coverage decisions for specialists, they may demand that children see pediatric dermatologists instead of general skin doctors, Dr. Paller said. However, while most major medical centers now have a pediatric dermatologist, “until there are more nationally it may be difficult for a patient to see someone without going outside of the health plan.”
On the other hand, Dr. Paller said, the advent of the certification test could deliver a needed spur to managed care companies that they include pediatric dermatologists on their lists of approved providers.
Could Certification Worsen the Shortage of Pediatric Dermatologists?
Dr. Robert Dellavalle, a co-author of the Journal of the American Academy of Dermatology staffing survey, said there’s some concern that introducing a certification process could worsen the shortage of pediatric dermatologists. “By tightening credentialing, we feel it might reduce the number of people” who go into the field, said Dr. Dellavalle, a dermatologist at the University of Colorado Health Sciences Center in Denver.
Already, becoming a pediatric dermatologist is no cheap trick. “It takes as much training as to become a neurosurgeon,” Dr. Dellavalle said.
Two other dermatology subspecialties, dermatopathology and clinical and laboratory dermatological immunology, have certifying examinations, and Dr. Dellavalle believes those tests haven’t exacerbated the general shortage of U.S. skincare specialists. On the other hand, he added, both disciplines are “very lucrative fields compared to pediatric dermatology, so the incomes are much higher and therefore that sort of drives demand of people going into them.”
According to the American Board of Dermatology, roughly 15 doctors take the dermatopathology exam each year, compared with about 340 who take the general dermatology boards. The group hasn’t offered the immunology exam since 2001, when six physicians sat, though the test is still available in theory.
Dr. William Weston was among the first American physicians to lay claim to the field of pediatric dermatology in the early 1970s. “When I started, there were basically three of us,” said Dr. Weston, a Professor of Dermatology and Pediatrics at the University of Colorado Health Sciences Center.
The primary motivation for entering the new and unproven field was educational, Dr. Weston said. Although dermatology was coming into its own scientifically, back then pediatric dermatology was as advanced as Greenland is hot.
“All of realized that this was a real deficiency in our own training. There was a terrible level of knowledge in pediatric dermatology,” Weston said. An example: The only textbook in the subject had been published in the early 1960s, and it was essentially a pharmacy handbook for strange compounds and salves — ointments “that probably in retrospect didn’t work,” he said.
Being first has its advantages. One is the ability to work unfettered of established biases and conventional wisdom, Dr. Weston said.
The budding subspecialty — and others — took a body blow in 1990, when the U.S. government declared that it would stop funding second residencies in its effort to promote primary care. “That really restricted the opportunities for training,” Dr. Weston said. “The government has reversed its decision but the impact was great.”
Dr. Weston has mixed feelings about the new certification process, which he feels may have the perverse effect of driving people away from pediatric dermatology instead of drawing them into the discipline. “I think we want to encourage people to come into the field, and I’m not sure this does,” he said.
For starters, it’s odd to see a hybrid subspecialty exam appear without any hybrid training programs (only the University of Texas at Galveston has a joint pediatrics and dermatology residency, though other programs are considering such a course).
What’s more, trying to foster professional legitimacy by fiat may work, but is it better than simply recognizing established clinical and academic expertise, garnered through years of patient care, research and publishing?
Whatever the case, Dr. Weston believes the certification exam, which he has previewed, won’t be a walkover.
“I don’t know how people will do. It depends on their background and training. If they have not had adequate pediatric training, they may have trouble.”
So, Should Eligible Doctors Take the New Certification Exam?
Dr. Richard Antaya, of Yale University, in New Haven, CT, said “yes.” “I would recommend it, and I did take the boards myself on Oct. 4,” Dr. Antaya said. “I think pediatric dermatology is really quite different than adult dermatology and the knowledge base and skill sets differ from that of adult dermatology in many ways. It will help with recognition of our subspecialty and allow us to proceed in formalizing training and certification.”
Like other physicians, Dr. Antaya doesn’t believe the advent of certification will have much immediate impact on practice.
“My greatest concern is that we have made the criteria so stringent that it will be prohibitively difficult to sit for this subspecialty board exam,” he added. “This is where a coordinated effort will be necessary to train fellows in pediatric dermatology in order to keep the number of candidates at a sufficient level to maintain the numbers of practicing pediatric dermatologists.”
On the other hand, he predicted, patients will come out winners. “This will certainly improve care for children,” Dr. Antaya said. “Overall, general dermatologists will continue to care for children with skin disease, but this exam will provide pediatric dermatologists with the formal recognition as a subspecialty to make other physicians aware of an advanced level of care in situations when general dermatology care is inadequate.”
On Oct. 4, nearly 100 skin doctors converged on Deerfield, IL, outside Chicago. The occasion: The first board certification in the field of pediatric dermatology, a small but growing subspecialty that after some three decades is finally getting official recognition.
“Pediatric dermatology has really become a very critical subspecialty,” said Dr. Amy Paller, President of the Society for Pediatric Dermatology, with its 520-some members, and one of the physicians sitting for the board exam.
Is the new certification just another diploma to hang on the office wall?
Advocates of the exam insist not. They believe the testing regime will give added legitimacy to their field, which joins only two other dermatology subfields to be so recognized. Practitioners of the subspecialty, they contend, must acquire a discrete body of knowledge that general skin doctors don’t have if they aren’t focused on childhood conditions. Obtaining board certification, test proponents claim, will not only help point generalists to qualified subspecialists, but it will give patients an extra measure of comfort that the doctors their children are referred to are appropriately trained.
Some dermatologists, however, fear the added hurdle of board certification may worsen an already severe shortage in the availability of skin experts who treat children. But more on that later.
A Subspecialty in Demand
Dr. Paller, head of dermatology at Northwestern University’s Feinberg School of Medicine in Chicago, and one of four pediatric dermatologists at the school’s affiliate hospital, Children’s Memorial, trained for her career the old-fashioned way. As a medical student at Stanford University in the mid-1970s, she studied under the legendary Al Jacobs, “who allowed me to see that this was a specialty,” she said.
Dr. Paller had already done graduate work in medical genetics and thought pediatric dermatology would be a good way to combine her interests. From Stanford she headed to Chicago to train in both pediatrics and dermatology under Nancy Esterly, whom Dr. Paller calls the “mother” of pediatric dermatology.
Pediatric dermatologists are clearly in high demand. “We have four full-time faculty at Children’s, but we continue to have a 4-month waiting list” for appointments, she said. “There just aren’t enough physicians.”
Other hospitals are in the same position. A recent article in the Journal of the American Academy of Dermatology found that almost half of dermatology departments surveyed had a full-time pediatric dermatologist on staff. More than a quarter have tried to recruit one for an average of nearly 1.5 years. And while 10 programs had pediatric dermatology fellowships, only six fellows were in training at the time of the survey.
Dr. Paller said she knows of at least 25 open faculty positions nationally for pediatric dermatologists. “And the numbers just keep going up. It’s an exciting, growing area where the body of knowledge has increased tremendously.”
Who’s Eligible?
The Society for Pediatric Dermatology has laid out the following guidelines for eligibility for subspecialty certification.
These include:
• A current valid license to practice medicine or osteopathy in the state or province of the candidate’s residence in either the United States or Canada. Candidates for certification may be denied if their license has been revoked, suspended, restricted, or surrendered in any jurisdiction, or if they are subject to adverse licensure proceedings.
• Primary certification by the American Board of Dermatology.
• At least 1 year of ACGME-approved residency training in pediatrics, followed by the requisite training and certification in dermatology, and an additional year of fellowship training in pediatric dermatology.
• Acceptable experience can also include an ACGME-approved transitional year or an ACGME-approved broad-based year of residency training in emergency medicine, family practice, general surgery, internal medicine, or obstetrics and gynecology, followed by the requisite training and certification in dermatology. However, candidates who have chosen this route must complete 2 additional years of fellowship training in pediatric dermatology.
• Certification is also open to candidates who have demonstrated a “special interest, experience, and expertise” in pediatric dermatology for at least 5 years. However, this route will no longer be available in 2009, 5 years after the first certification exam.
In the near term, the society will allow doctors with significant experience in pediatric dermatology to sit for the board examination on a case-by-case basis. Eligible physicians are those with no less than 5 years of clinical dermatology practice in which their pediatric patients account for at least half the total caseload. They may also submit papers and invited lectures in the field as evidence of expertise.
Doctors who trained in pediatric dermatology fellowships prior to the development of approved fellowship training programs — in other words, the entire “old guard” — will be eligible for the certification exam on a case-by-case basis.
What Will Candidates Be Tested On?
Dr. Ilona Frieden, Director of Pediatric Dermatology at the University of California, San Francisco Children’s Hospital, chaired the SPD’s test committee. The process of creating the board exam began about 3 years ago, she said, when the committee invited all pediatric dermatologists to submit questions. “We tried to collect a lot of images to go along with the questions, because seeing skin lesions is what we actually do for a living” she added. The test is rich with the kind of dermatology shots that fascinate the layman the way car accidents draw rubberneckers.
The committee winnowed the submissions down to a total of 200 questions for the first certification examination. About a third have pictures to go with them. Test takers had 4 hours to complete the computer-based exam, which was held at a testing facility used by the American Board of Psychiatry and Neurology.
Dr. Frieden said the questions were designed to cover the “walking knowledge” that pediatric dermatologists should possess. “They don’t have to memorize 25,000 genes and diseases they’ll see once in their career.”
While general skincare specialists will be able to answer many of the questions, most refer to the kinds of things that must occur immediately to a pediatric dermatologist when, for example, she sees a child in a newborn nursery with bad blisters.
Although the test committee had no trouble creating the test, the SPD did encounter a bump or two winning approval from the American Board of Medical Specialties — which okays new subspecialty examinations — to offer the board exam in the first place. The initial SPD application (called a COCERT) would have allowed doctors to take the exam if they had done a pediatric residency first, followed by a dermatology residency. The ABMS said “no,” according to Dr. Frieden, because it felt that someone could go through both residencies without accumulating sufficient expertise in what’s considered pediatric dermatology. A compromise was reached: To be eligible for the test, doctors would have to have at least a 1 year of pediatric dermatology fellowship “to consolidate that knowledge,” Dr. Frieden said.
Summing up a Pediatric Dermatologist’s Expertise
Dr. Paller admits that much of what pediatric dermatologists see doesn’t require a special expertise in child medicine: eczema, warts, molluscum, pigmented nevi. [A study in the journal Pediatric Dermatology of the most common conditions pediatric skin specialists in Switzerland treated found that atopic dermatitis was the runaway leader, seen in nearly 26% of patients; followed by 9% with pigmented nevi, and 5% with warts.] “But the special approach to the child and the family and the ability to handle the most difficult cases of common disorders is also part of the expertise of a pediatric dermatologist,” she said.
“In addition, the wide range of genetic disorders, inflammatory ailments, infections and immune diseases that afflict young children that most general dermatologists aren’t familiar with make the expertise of a pediatric dermatologist critical,” she added.
Childhood skin conditions account for nearly one in four (24%) of all pediatric office visits, Dr. Paller said. And while most dermatologists treat both children and adults, there are many disorders better suited to doctors with expertise in pediatrics.
A pediatric dermatologist, for example, should be familiar with Kindler syndrome, a rare, recessive condition that causes rampant blistering and occasionally squamous cell carcinomas in young children. Epidermolysis bullosa, or EB, is another inherited skin disease affecting roughly two in every 100,000 American children, according to the Children’s Skin Disease Foundation. There are more than two dozen forms of EB, with varying degrees of severity.
Even for more conventional skin conditions, a background in pediatrics can be crucial. One reason is technical: When adult patients present with dermatomyositis, doctors should be concerned about accompanying cancers. “But in children we see more calcinosis, and overall the prognosis is better,” Dr. Paller said.
Another key difference affects the intangibles of medical practice. When treating children with skin diseases, Dr. Paller said, “it’s very important to have training that allows you to have a better understanding of the dynamics of families.” Children require more time than adults as patients, she said, and a more sensitive touch. Not just emotionally, but physically, too. Pediatric dermatologists are more hesitant to perform biopsies than are dermatologists who treat adults, Dr. Paller said. “We always think twice about doing procedures that might cause pain or discomfort.”
The American Board of Dermatology intends to offer the new board exam every 2 years. The test is $1,600, and certification is good for 10 years.
Dr. Antoinette Hood, Executive Director of the American Board of Dermatology, and Chair of the Department of Dermatology at Eastern Virginia Medical School in Norfolk, said adding pediatric dermatology to the roster of board-certified subspecialists will have “absolutely no impact” on generalists. “I’m going to still see kids and adolescents, no question about it. But if I have a difficult patient, I would be wise to call on the expertise of my colleagues” who focus on childhood skin diseases. “I have the luxury of having one on campus,” Dr. Hood added.
Dr. Hood, who is helping administer the exam, predicted that the approximately 100 people taking the pediatric boards this year will be a high-water mark for the test because it includes many doctors who are being “grandfathered” and “grandmothered” into the eligibility requirements. As those rules tighten over the next 5 years, the pipeline for potential test takers will narrow, she said.
The new subspecialty at first could create difficulties for patients with insurance. If carriers become more restrictive about coverage decisions for specialists, they may demand that children see pediatric dermatologists instead of general skin doctors, Dr. Paller said. However, while most major medical centers now have a pediatric dermatologist, “until there are more nationally it may be difficult for a patient to see someone without going outside of the health plan.”
On the other hand, Dr. Paller said, the advent of the certification test could deliver a needed spur to managed care companies that they include pediatric dermatologists on their lists of approved providers.
Could Certification Worsen the Shortage of Pediatric Dermatologists?
Dr. Robert Dellavalle, a co-author of the Journal of the American Academy of Dermatology staffing survey, said there’s some concern that introducing a certification process could worsen the shortage of pediatric dermatologists. “By tightening credentialing, we feel it might reduce the number of people” who go into the field, said Dr. Dellavalle, a dermatologist at the University of Colorado Health Sciences Center in Denver.
Already, becoming a pediatric dermatologist is no cheap trick. “It takes as much training as to become a neurosurgeon,” Dr. Dellavalle said.
Two other dermatology subspecialties, dermatopathology and clinical and laboratory dermatological immunology, have certifying examinations, and Dr. Dellavalle believes those tests haven’t exacerbated the general shortage of U.S. skincare specialists. On the other hand, he added, both disciplines are “very lucrative fields compared to pediatric dermatology, so the incomes are much higher and therefore that sort of drives demand of people going into them.”
According to the American Board of Dermatology, roughly 15 doctors take the dermatopathology exam each year, compared with about 340 who take the general dermatology boards. The group hasn’t offered the immunology exam since 2001, when six physicians sat, though the test is still available in theory.
Dr. William Weston was among the first American physicians to lay claim to the field of pediatric dermatology in the early 1970s. “When I started, there were basically three of us,” said Dr. Weston, a Professor of Dermatology and Pediatrics at the University of Colorado Health Sciences Center.
The primary motivation for entering the new and unproven field was educational, Dr. Weston said. Although dermatology was coming into its own scientifically, back then pediatric dermatology was as advanced as Greenland is hot.
“All of realized that this was a real deficiency in our own training. There was a terrible level of knowledge in pediatric dermatology,” Weston said. An example: The only textbook in the subject had been published in the early 1960s, and it was essentially a pharmacy handbook for strange compounds and salves — ointments “that probably in retrospect didn’t work,” he said.
Being first has its advantages. One is the ability to work unfettered of established biases and conventional wisdom, Dr. Weston said.
The budding subspecialty — and others — took a body blow in 1990, when the U.S. government declared that it would stop funding second residencies in its effort to promote primary care. “That really restricted the opportunities for training,” Dr. Weston said. “The government has reversed its decision but the impact was great.”
Dr. Weston has mixed feelings about the new certification process, which he feels may have the perverse effect of driving people away from pediatric dermatology instead of drawing them into the discipline. “I think we want to encourage people to come into the field, and I’m not sure this does,” he said.
For starters, it’s odd to see a hybrid subspecialty exam appear without any hybrid training programs (only the University of Texas at Galveston has a joint pediatrics and dermatology residency, though other programs are considering such a course).
What’s more, trying to foster professional legitimacy by fiat may work, but is it better than simply recognizing established clinical and academic expertise, garnered through years of patient care, research and publishing?
Whatever the case, Dr. Weston believes the certification exam, which he has previewed, won’t be a walkover.
“I don’t know how people will do. It depends on their background and training. If they have not had adequate pediatric training, they may have trouble.”
So, Should Eligible Doctors Take the New Certification Exam?
Dr. Richard Antaya, of Yale University, in New Haven, CT, said “yes.” “I would recommend it, and I did take the boards myself on Oct. 4,” Dr. Antaya said. “I think pediatric dermatology is really quite different than adult dermatology and the knowledge base and skill sets differ from that of adult dermatology in many ways. It will help with recognition of our subspecialty and allow us to proceed in formalizing training and certification.”
Like other physicians, Dr. Antaya doesn’t believe the advent of certification will have much immediate impact on practice.
“My greatest concern is that we have made the criteria so stringent that it will be prohibitively difficult to sit for this subspecialty board exam,” he added. “This is where a coordinated effort will be necessary to train fellows in pediatric dermatology in order to keep the number of candidates at a sufficient level to maintain the numbers of practicing pediatric dermatologists.”
On the other hand, he predicted, patients will come out winners. “This will certainly improve care for children,” Dr. Antaya said. “Overall, general dermatologists will continue to care for children with skin disease, but this exam will provide pediatric dermatologists with the formal recognition as a subspecialty to make other physicians aware of an advanced level of care in situations when general dermatology care is inadequate.”
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