L ast year, when it came to light that dermatology was suffering from a serious shortage of physicians, concerned dermatologists sprang into action to try to solve the problem before the specialty was left in a real crisis situation. One of the initiatives that was planned to help combat the shortage was to support a number of new residency positions with a blend of association and pharmaceutical industry money — a plan that proved too controversial to last. Just several weeks ago, the board of the American Academy of Dermatology (AAD) voted to not move forward with its plan to support extra dermatology residencies in this manner. But now many questions remain: How will the number of practicing dermatologists be increased to overcome the shortage? How will a new plan be funded? And now, an even more important issue is under discussion: Is there really a shortage? If so, what kind of shortage is it, and how should it be addressed? A Look Back at a Controversial Plan Before delving into the current state of the issue further, it’s important to revisit the workforce initiative and how and why it was created. The workforce initiative was intended to combat what the board believed to be a serious shortage of dermatologists, and in particular medical dermatologists, in the United States. The Dermatology Workforce Initia-tive, as the plan was initially called, would have combined funds from the Academy and pharmaceutical companies to create up to nearly 100 additional residency spots over the next decade. The estimated cost: $1 million. News of the workforce plan quickly spread throughout the Academy membership, and many doctors were deeply unhappy. Some objected to the idea of using pharmaceutical company money to train residents, a practice with obvious potential conflicts of interest, at least on the surface. Others argued that the physician shortage was a mirage, while some took offense at the way the board went about its decision — from the top down without consulting the body politic. In response, several hundred members signed a petition urging a change in the AAD bylaws. But more on that in a moment. Board members seemed taken off-guard by the AAD members’ reactions to the workforce initiative, and so they subsequently scaled back the plan. The more modest proposal called for only 10 residency slots a year over 3 years, although it still blended Academy and industry funds. Fast forward to today: Ten trainees are slated to receive funding this July, mostly from industry grants. If the Academy ultimately decides to stop the program entirely, that money — $100,000 — could be cut off. The decision to abandon the larger workforce plan was made in early April, and it was cemented at a Dallas summit Clay Cockerell, M.D., President of the American Academy of Dermatology, convened several weeks ago in mid-April. Following the summit, the board has concluded that instead of a shortage of dermatologists, there is more a “misallocation” of doctors than a general dearth. Dr. Cockerell said the Academy is “going to revisit the entire initiative and look at it from the standpoint of a misallocation.” As a result, he added, “We have elected not to continue training residents at this time.” Discussing the Overall Shortage David Pariser, M.D., an AAD board member and a proponent of the residency plan, said workforce issues have been deemed important by most Academy members, even if some doctors dispute the notion of a shortage. In a recent survey, “86% of our members felt dealing with workforce issues is something the Academy should do.” However, Dr. Pariser, a Professor of Dermatology at Eastern Virginia Medical School in Norfolk, acknowledges that many dermatologists view the workforce situation the way parents view public schools: The system in general might be broken, but my kid’s school is fine. “Everybody agrees [there’s a problem] nationally, but locally only a third say ‘yes,’” he said. Reflected in that split response is almost certainly a measure of flank guarding. After all, Dr. Pariser said, any Academy-sponsored residency program would be training the competition — especially if those new doctors went to areas well served by skin specialists. After the initial workforce initiative was put into action, a “fairly vocal minority” raised that concern, Dr. Pariser said. “Frankly, that was something that we didn’t anticipate as much as we should have.” Dr. Pariser is part of the camp that believes the shortage is real. “There is by almost any measure a shortage in most areas. Not everyplace, but even in areas with the highest numbers of dermatologists per capita there still may be a 2- to 3-month wait to get an appointment with a medical dermatologist. That’s unacceptable for patient care.” Although new doctors are entering the field, they’re less likely than ever to practice medical dermatology — preferring instead pediatric dermatology, dermatopathology, or, more likely, cosmetic dermatology, Dr. Pariser explained. What’s more, physician extenders are increasingly common. So, too, is the practice of non-dermatologists treating patients for skin conditions. Then there’s the growing number of women in practice. Surveys show that women dermatologists work fewer hours, on average, than their male counterparts, as they try to balance family demands. So Why Not Support the Plan to Increase Dermatology Residents? Orin Goldblum, M.D., a Pittsburgh dermatologist who was outspoken about the workforce proposal, said the plan suffered two major blemishes. The first involves the ethical sniff test: “It created a potential for significant conflicts of interest,” he said. Then there’s the more practical issue of whether the system was even necessary. Dr. Goldblum, in other words, never believed that the much-mentioned shortage in skin specialists was real to begin with. And he has some numbers to support his skepticism. According to figures from the National Resident Matching Program, the total number of dermatology training positions in the United States rose from 246 in 1998 to 294 in 2004 — an increase of nearly 20%. The number of slots for 2005 is 315, including the 10 funded by the industry-Academy program. The Journal of the American Medical Association shows somewhat different statistics, but the overall trend is the same: There were 281 first-year dermatology residents in 1996, and 315 in 2003. The total number of dermatology residents rose from 850 to 994 during that period. As with the figures from the National Resident Matching Program, the JAMA numbers do not show a steady climb over time. Rather, some years have more slots and trainees than others. But the trend over time is clearly an increase, said Dr. Goldblum, a member of the attending staff at the University of Pittsburgh Medical Center South Side. Of course, an increase in the absolute number of residency slots and apprentice dermatologists says nothing about the demand side of the matter. Nor does it speak to attrition in the field. If more people are seeking dermatologic services while the rate of retiring physicians is high, it’s easy to see how the growth in residencies could fail to keep up. Still, Dr. Goldblum agreed that the situation was more local than systemic. “It’s really not a shortage but a maldistribution,” he said, echoing the board’s freshly revised position. “Dermatologists tend to be distributed in populated areas, not in less populated areas.” Getting Everyone on Board with the Plan There happens to be another reason Dr. Goldblum is upset about the residency funding plan, one of a more political nature. He and many of his colleagues — if petition signatures reflect mindset — did not appreciate the way the Academy board created the program. The workforce initiative came out of board meetings and not the Academy membership, Dr. Goldblum said. “The board never surveyed the membership on whether the members felt that money should come from both the Academy and industry.” When Dr. Goldblum and others complained, he said, the board ignored their concerns. So he drafted a petition calling for the Academy’s bylaws to be amended in such a way that any form of workforce initiative would have to be voted on by the membership. The petition needed 2.5% of the Academy’s voting members, or around 300 signatures. “We got well over 400,” he said. The petition was presented at a board meeting in February and will now go to the organization’s bylaws committee. If the bylaws committee decides to adopt the measure, then it must then go back to the board, which has the final authority on the measure. For Michael Franzblau, M.D., a Clinical Professor of Dermatology at the University of California, San Francisco, the workforce initiative was unpalatable — but not because of the prospect of tainted residents. “If we as a society decide that we want to increase the number of residencies, then as a society we should be willing to pay the cost of it. To ask an industry that has a vested interest to do this is the poorest of public policy,” he said. “I don’t believe we should lean on any third party.” Sandra Read, M.D., a Washington, DC, dermatologist who sits on the Academy’s workforce committee, agreed in principle with that position. However, Dr. Read said, the Academy cannot rely on lobbying efforts alone to protect the skin specialty. “We can’t count on the government to do the right thing. We may have to be a little more proactive than that.” Dr. Read called the board’s actions regarding the workforce plan “well motivated” and rooted in a desire to “create incentive programs to serve areas of need. They were looking at that as part of our responsibility to provide health care for patients.” On the other hand Dr. Read said, many physicians felt the board acted too hastily, and without ample input from Academy members — concerns she considers “legitimate.” For some, said Dr. Read, it was a “very drastic step” not only to accept at face value the existence of a dermatologist shortage but to make the leap to using industry money as a solution to that problem. “The issue had not been proven to the satisfaction of some members,” she said, while “some people feel drug companies have way too much control of our medical practice.” Perhaps the most salient critique of the proposal, Dr. Read said, is that there’s no guarantee that it would have produced more medical dermatologists. “You can’t force someone to do something. This is not like the public health service.” Dr. Cockerell said he “wasn’t totally surprised” by the outcry from the Academy membership, although he still believes the workforce plan “is not a bad idea from 35,000 feet.” But he now takes a somewhat more philosophical view. “Trying to get the feel for a group of 15,000 people is hard to do. I think maybe the degree of upset was not expected; but we thought that if we didn’t get something going now, then it would be harder to do it later. I think there was a sentiment that we probably needed to act sooner rather than later, and maybe we should have acted later rather than sooner.” Some Possible New Directions During the mid-April summit meeting called by Dr. Cockerell, some 120 dermatologists attended to participate in an all-day brainstorming session to discuss possible solutions with regard to addressing the misallocation of dermatologists. Even though the sponsorships for extra residencies were scrapped, several new approaches were discussed. “My idea this year was to take the more difficult problems and put people in a room” to hash them out, explained Dr. Cockerell. An emphasis on telemedicine was one idea that emerged from the summit, Dr. Cockerell said. Another idea that won wide approval was linking board certification for residents to brief service in dermatologist-scarce regions. “The problem is you have the need for dermatologists in areas where a lot of dermatologist don’t want to go,” places such as rural Mississippi and west Texas, Dr. Cockerell explained — a problem that is widespread among medical specialties and even family practice. Such a system obviously would require the approval of the American Board of Dermatology, Dr. Cockerell noted. This would offer a good starting point for an issue about which many dermatologists are clearly passionate.
Is There Really a Shortage of Dermatologists?
L ast year, when it came to light that dermatology was suffering from a serious shortage of physicians, concerned dermatologists sprang into action to try to solve the problem before the specialty was left in a real crisis situation. One of the initiatives that was planned to help combat the shortage was to support a number of new residency positions with a blend of association and pharmaceutical industry money — a plan that proved too controversial to last. Just several weeks ago, the board of the American Academy of Dermatology (AAD) voted to not move forward with its plan to support extra dermatology residencies in this manner. But now many questions remain: How will the number of practicing dermatologists be increased to overcome the shortage? How will a new plan be funded? And now, an even more important issue is under discussion: Is there really a shortage? If so, what kind of shortage is it, and how should it be addressed? A Look Back at a Controversial Plan Before delving into the current state of the issue further, it’s important to revisit the workforce initiative and how and why it was created. The workforce initiative was intended to combat what the board believed to be a serious shortage of dermatologists, and in particular medical dermatologists, in the United States. The Dermatology Workforce Initia-tive, as the plan was initially called, would have combined funds from the Academy and pharmaceutical companies to create up to nearly 100 additional residency spots over the next decade. The estimated cost: $1 million. News of the workforce plan quickly spread throughout the Academy membership, and many doctors were deeply unhappy. Some objected to the idea of using pharmaceutical company money to train residents, a practice with obvious potential conflicts of interest, at least on the surface. Others argued that the physician shortage was a mirage, while some took offense at the way the board went about its decision — from the top down without consulting the body politic. In response, several hundred members signed a petition urging a change in the AAD bylaws. But more on that in a moment. Board members seemed taken off-guard by the AAD members’ reactions to the workforce initiative, and so they subsequently scaled back the plan. The more modest proposal called for only 10 residency slots a year over 3 years, although it still blended Academy and industry funds. Fast forward to today: Ten trainees are slated to receive funding this July, mostly from industry grants. If the Academy ultimately decides to stop the program entirely, that money — $100,000 — could be cut off. The decision to abandon the larger workforce plan was made in early April, and it was cemented at a Dallas summit Clay Cockerell, M.D., President of the American Academy of Dermatology, convened several weeks ago in mid-April. Following the summit, the board has concluded that instead of a shortage of dermatologists, there is more a “misallocation” of doctors than a general dearth. Dr. Cockerell said the Academy is “going to revisit the entire initiative and look at it from the standpoint of a misallocation.” As a result, he added, “We have elected not to continue training residents at this time.” Discussing the Overall Shortage David Pariser, M.D., an AAD board member and a proponent of the residency plan, said workforce issues have been deemed important by most Academy members, even if some doctors dispute the notion of a shortage. In a recent survey, “86% of our members felt dealing with workforce issues is something the Academy should do.” However, Dr. Pariser, a Professor of Dermatology at Eastern Virginia Medical School in Norfolk, acknowledges that many dermatologists view the workforce situation the way parents view public schools: The system in general might be broken, but my kid’s school is fine. “Everybody agrees [there’s a problem] nationally, but locally only a third say ‘yes,’” he said. Reflected in that split response is almost certainly a measure of flank guarding. After all, Dr. Pariser said, any Academy-sponsored residency program would be training the competition — especially if those new doctors went to areas well served by skin specialists. After the initial workforce initiative was put into action, a “fairly vocal minority” raised that concern, Dr. Pariser said. “Frankly, that was something that we didn’t anticipate as much as we should have.” Dr. Pariser is part of the camp that believes the shortage is real. “There is by almost any measure a shortage in most areas. Not everyplace, but even in areas with the highest numbers of dermatologists per capita there still may be a 2- to 3-month wait to get an appointment with a medical dermatologist. That’s unacceptable for patient care.” Although new doctors are entering the field, they’re less likely than ever to practice medical dermatology — preferring instead pediatric dermatology, dermatopathology, or, more likely, cosmetic dermatology, Dr. Pariser explained. What’s more, physician extenders are increasingly common. So, too, is the practice of non-dermatologists treating patients for skin conditions. Then there’s the growing number of women in practice. Surveys show that women dermatologists work fewer hours, on average, than their male counterparts, as they try to balance family demands. So Why Not Support the Plan to Increase Dermatology Residents? Orin Goldblum, M.D., a Pittsburgh dermatologist who was outspoken about the workforce proposal, said the plan suffered two major blemishes. The first involves the ethical sniff test: “It created a potential for significant conflicts of interest,” he said. Then there’s the more practical issue of whether the system was even necessary. Dr. Goldblum, in other words, never believed that the much-mentioned shortage in skin specialists was real to begin with. And he has some numbers to support his skepticism. According to figures from the National Resident Matching Program, the total number of dermatology training positions in the United States rose from 246 in 1998 to 294 in 2004 — an increase of nearly 20%. The number of slots for 2005 is 315, including the 10 funded by the industry-Academy program. The Journal of the American Medical Association shows somewhat different statistics, but the overall trend is the same: There were 281 first-year dermatology residents in 1996, and 315 in 2003. The total number of dermatology residents rose from 850 to 994 during that period. As with the figures from the National Resident Matching Program, the JAMA numbers do not show a steady climb over time. Rather, some years have more slots and trainees than others. But the trend over time is clearly an increase, said Dr. Goldblum, a member of the attending staff at the University of Pittsburgh Medical Center South Side. Of course, an increase in the absolute number of residency slots and apprentice dermatologists says nothing about the demand side of the matter. Nor does it speak to attrition in the field. If more people are seeking dermatologic services while the rate of retiring physicians is high, it’s easy to see how the growth in residencies could fail to keep up. Still, Dr. Goldblum agreed that the situation was more local than systemic. “It’s really not a shortage but a maldistribution,” he said, echoing the board’s freshly revised position. “Dermatologists tend to be distributed in populated areas, not in less populated areas.” Getting Everyone on Board with the Plan There happens to be another reason Dr. Goldblum is upset about the residency funding plan, one of a more political nature. He and many of his colleagues — if petition signatures reflect mindset — did not appreciate the way the Academy board created the program. The workforce initiative came out of board meetings and not the Academy membership, Dr. Goldblum said. “The board never surveyed the membership on whether the members felt that money should come from both the Academy and industry.” When Dr. Goldblum and others complained, he said, the board ignored their concerns. So he drafted a petition calling for the Academy’s bylaws to be amended in such a way that any form of workforce initiative would have to be voted on by the membership. The petition needed 2.5% of the Academy’s voting members, or around 300 signatures. “We got well over 400,” he said. The petition was presented at a board meeting in February and will now go to the organization’s bylaws committee. If the bylaws committee decides to adopt the measure, then it must then go back to the board, which has the final authority on the measure. For Michael Franzblau, M.D., a Clinical Professor of Dermatology at the University of California, San Francisco, the workforce initiative was unpalatable — but not because of the prospect of tainted residents. “If we as a society decide that we want to increase the number of residencies, then as a society we should be willing to pay the cost of it. To ask an industry that has a vested interest to do this is the poorest of public policy,” he said. “I don’t believe we should lean on any third party.” Sandra Read, M.D., a Washington, DC, dermatologist who sits on the Academy’s workforce committee, agreed in principle with that position. However, Dr. Read said, the Academy cannot rely on lobbying efforts alone to protect the skin specialty. “We can’t count on the government to do the right thing. We may have to be a little more proactive than that.” Dr. Read called the board’s actions regarding the workforce plan “well motivated” and rooted in a desire to “create incentive programs to serve areas of need. They were looking at that as part of our responsibility to provide health care for patients.” On the other hand Dr. Read said, many physicians felt the board acted too hastily, and without ample input from Academy members — concerns she considers “legitimate.” For some, said Dr. Read, it was a “very drastic step” not only to accept at face value the existence of a dermatologist shortage but to make the leap to using industry money as a solution to that problem. “The issue had not been proven to the satisfaction of some members,” she said, while “some people feel drug companies have way too much control of our medical practice.” Perhaps the most salient critique of the proposal, Dr. Read said, is that there’s no guarantee that it would have produced more medical dermatologists. “You can’t force someone to do something. This is not like the public health service.” Dr. Cockerell said he “wasn’t totally surprised” by the outcry from the Academy membership, although he still believes the workforce plan “is not a bad idea from 35,000 feet.” But he now takes a somewhat more philosophical view. “Trying to get the feel for a group of 15,000 people is hard to do. I think maybe the degree of upset was not expected; but we thought that if we didn’t get something going now, then it would be harder to do it later. I think there was a sentiment that we probably needed to act sooner rather than later, and maybe we should have acted later rather than sooner.” Some Possible New Directions During the mid-April summit meeting called by Dr. Cockerell, some 120 dermatologists attended to participate in an all-day brainstorming session to discuss possible solutions with regard to addressing the misallocation of dermatologists. Even though the sponsorships for extra residencies were scrapped, several new approaches were discussed. “My idea this year was to take the more difficult problems and put people in a room” to hash them out, explained Dr. Cockerell. An emphasis on telemedicine was one idea that emerged from the summit, Dr. Cockerell said. Another idea that won wide approval was linking board certification for residents to brief service in dermatologist-scarce regions. “The problem is you have the need for dermatologists in areas where a lot of dermatologist don’t want to go,” places such as rural Mississippi and west Texas, Dr. Cockerell explained — a problem that is widespread among medical specialties and even family practice. Such a system obviously would require the approval of the American Board of Dermatology, Dr. Cockerell noted. This would offer a good starting point for an issue about which many dermatologists are clearly passionate.
L ast year, when it came to light that dermatology was suffering from a serious shortage of physicians, concerned dermatologists sprang into action to try to solve the problem before the specialty was left in a real crisis situation. One of the initiatives that was planned to help combat the shortage was to support a number of new residency positions with a blend of association and pharmaceutical industry money — a plan that proved too controversial to last. Just several weeks ago, the board of the American Academy of Dermatology (AAD) voted to not move forward with its plan to support extra dermatology residencies in this manner. But now many questions remain: How will the number of practicing dermatologists be increased to overcome the shortage? How will a new plan be funded? And now, an even more important issue is under discussion: Is there really a shortage? If so, what kind of shortage is it, and how should it be addressed? A Look Back at a Controversial Plan Before delving into the current state of the issue further, it’s important to revisit the workforce initiative and how and why it was created. The workforce initiative was intended to combat what the board believed to be a serious shortage of dermatologists, and in particular medical dermatologists, in the United States. The Dermatology Workforce Initia-tive, as the plan was initially called, would have combined funds from the Academy and pharmaceutical companies to create up to nearly 100 additional residency spots over the next decade. The estimated cost: $1 million. News of the workforce plan quickly spread throughout the Academy membership, and many doctors were deeply unhappy. Some objected to the idea of using pharmaceutical company money to train residents, a practice with obvious potential conflicts of interest, at least on the surface. Others argued that the physician shortage was a mirage, while some took offense at the way the board went about its decision — from the top down without consulting the body politic. In response, several hundred members signed a petition urging a change in the AAD bylaws. But more on that in a moment. Board members seemed taken off-guard by the AAD members’ reactions to the workforce initiative, and so they subsequently scaled back the plan. The more modest proposal called for only 10 residency slots a year over 3 years, although it still blended Academy and industry funds. Fast forward to today: Ten trainees are slated to receive funding this July, mostly from industry grants. If the Academy ultimately decides to stop the program entirely, that money — $100,000 — could be cut off. The decision to abandon the larger workforce plan was made in early April, and it was cemented at a Dallas summit Clay Cockerell, M.D., President of the American Academy of Dermatology, convened several weeks ago in mid-April. Following the summit, the board has concluded that instead of a shortage of dermatologists, there is more a “misallocation” of doctors than a general dearth. Dr. Cockerell said the Academy is “going to revisit the entire initiative and look at it from the standpoint of a misallocation.” As a result, he added, “We have elected not to continue training residents at this time.” Discussing the Overall Shortage David Pariser, M.D., an AAD board member and a proponent of the residency plan, said workforce issues have been deemed important by most Academy members, even if some doctors dispute the notion of a shortage. In a recent survey, “86% of our members felt dealing with workforce issues is something the Academy should do.” However, Dr. Pariser, a Professor of Dermatology at Eastern Virginia Medical School in Norfolk, acknowledges that many dermatologists view the workforce situation the way parents view public schools: The system in general might be broken, but my kid’s school is fine. “Everybody agrees [there’s a problem] nationally, but locally only a third say ‘yes,’” he said. Reflected in that split response is almost certainly a measure of flank guarding. After all, Dr. Pariser said, any Academy-sponsored residency program would be training the competition — especially if those new doctors went to areas well served by skin specialists. After the initial workforce initiative was put into action, a “fairly vocal minority” raised that concern, Dr. Pariser said. “Frankly, that was something that we didn’t anticipate as much as we should have.” Dr. Pariser is part of the camp that believes the shortage is real. “There is by almost any measure a shortage in most areas. Not everyplace, but even in areas with the highest numbers of dermatologists per capita there still may be a 2- to 3-month wait to get an appointment with a medical dermatologist. That’s unacceptable for patient care.” Although new doctors are entering the field, they’re less likely than ever to practice medical dermatology — preferring instead pediatric dermatology, dermatopathology, or, more likely, cosmetic dermatology, Dr. Pariser explained. What’s more, physician extenders are increasingly common. So, too, is the practice of non-dermatologists treating patients for skin conditions. Then there’s the growing number of women in practice. Surveys show that women dermatologists work fewer hours, on average, than their male counterparts, as they try to balance family demands. So Why Not Support the Plan to Increase Dermatology Residents? Orin Goldblum, M.D., a Pittsburgh dermatologist who was outspoken about the workforce proposal, said the plan suffered two major blemishes. The first involves the ethical sniff test: “It created a potential for significant conflicts of interest,” he said. Then there’s the more practical issue of whether the system was even necessary. Dr. Goldblum, in other words, never believed that the much-mentioned shortage in skin specialists was real to begin with. And he has some numbers to support his skepticism. According to figures from the National Resident Matching Program, the total number of dermatology training positions in the United States rose from 246 in 1998 to 294 in 2004 — an increase of nearly 20%. The number of slots for 2005 is 315, including the 10 funded by the industry-Academy program. The Journal of the American Medical Association shows somewhat different statistics, but the overall trend is the same: There were 281 first-year dermatology residents in 1996, and 315 in 2003. The total number of dermatology residents rose from 850 to 994 during that period. As with the figures from the National Resident Matching Program, the JAMA numbers do not show a steady climb over time. Rather, some years have more slots and trainees than others. But the trend over time is clearly an increase, said Dr. Goldblum, a member of the attending staff at the University of Pittsburgh Medical Center South Side. Of course, an increase in the absolute number of residency slots and apprentice dermatologists says nothing about the demand side of the matter. Nor does it speak to attrition in the field. If more people are seeking dermatologic services while the rate of retiring physicians is high, it’s easy to see how the growth in residencies could fail to keep up. Still, Dr. Goldblum agreed that the situation was more local than systemic. “It’s really not a shortage but a maldistribution,” he said, echoing the board’s freshly revised position. “Dermatologists tend to be distributed in populated areas, not in less populated areas.” Getting Everyone on Board with the Plan There happens to be another reason Dr. Goldblum is upset about the residency funding plan, one of a more political nature. He and many of his colleagues — if petition signatures reflect mindset — did not appreciate the way the Academy board created the program. The workforce initiative came out of board meetings and not the Academy membership, Dr. Goldblum said. “The board never surveyed the membership on whether the members felt that money should come from both the Academy and industry.” When Dr. Goldblum and others complained, he said, the board ignored their concerns. So he drafted a petition calling for the Academy’s bylaws to be amended in such a way that any form of workforce initiative would have to be voted on by the membership. The petition needed 2.5% of the Academy’s voting members, or around 300 signatures. “We got well over 400,” he said. The petition was presented at a board meeting in February and will now go to the organization’s bylaws committee. If the bylaws committee decides to adopt the measure, then it must then go back to the board, which has the final authority on the measure. For Michael Franzblau, M.D., a Clinical Professor of Dermatology at the University of California, San Francisco, the workforce initiative was unpalatable — but not because of the prospect of tainted residents. “If we as a society decide that we want to increase the number of residencies, then as a society we should be willing to pay the cost of it. To ask an industry that has a vested interest to do this is the poorest of public policy,” he said. “I don’t believe we should lean on any third party.” Sandra Read, M.D., a Washington, DC, dermatologist who sits on the Academy’s workforce committee, agreed in principle with that position. However, Dr. Read said, the Academy cannot rely on lobbying efforts alone to protect the skin specialty. “We can’t count on the government to do the right thing. We may have to be a little more proactive than that.” Dr. Read called the board’s actions regarding the workforce plan “well motivated” and rooted in a desire to “create incentive programs to serve areas of need. They were looking at that as part of our responsibility to provide health care for patients.” On the other hand Dr. Read said, many physicians felt the board acted too hastily, and without ample input from Academy members — concerns she considers “legitimate.” For some, said Dr. Read, it was a “very drastic step” not only to accept at face value the existence of a dermatologist shortage but to make the leap to using industry money as a solution to that problem. “The issue had not been proven to the satisfaction of some members,” she said, while “some people feel drug companies have way too much control of our medical practice.” Perhaps the most salient critique of the proposal, Dr. Read said, is that there’s no guarantee that it would have produced more medical dermatologists. “You can’t force someone to do something. This is not like the public health service.” Dr. Cockerell said he “wasn’t totally surprised” by the outcry from the Academy membership, although he still believes the workforce plan “is not a bad idea from 35,000 feet.” But he now takes a somewhat more philosophical view. “Trying to get the feel for a group of 15,000 people is hard to do. I think maybe the degree of upset was not expected; but we thought that if we didn’t get something going now, then it would be harder to do it later. I think there was a sentiment that we probably needed to act sooner rather than later, and maybe we should have acted later rather than sooner.” Some Possible New Directions During the mid-April summit meeting called by Dr. Cockerell, some 120 dermatologists attended to participate in an all-day brainstorming session to discuss possible solutions with regard to addressing the misallocation of dermatologists. Even though the sponsorships for extra residencies were scrapped, several new approaches were discussed. “My idea this year was to take the more difficult problems and put people in a room” to hash them out, explained Dr. Cockerell. An emphasis on telemedicine was one idea that emerged from the summit, Dr. Cockerell said. Another idea that won wide approval was linking board certification for residents to brief service in dermatologist-scarce regions. “The problem is you have the need for dermatologists in areas where a lot of dermatologist don’t want to go,” places such as rural Mississippi and west Texas, Dr. Cockerell explained — a problem that is widespread among medical specialties and even family practice. Such a system obviously would require the approval of the American Board of Dermatology, Dr. Cockerell noted. This would offer a good starting point for an issue about which many dermatologists are clearly passionate.
