Over the past few decades, dramatic changes in

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1 Getting inside the heads of current and potential patients shows dermatologists how to best market their unique skills and stand out as the provider patients choose. By Katherine L. Brown, MD, MPH and Alexa Boer Kimball, MD, MPH Over the past few decades, dramatic changes in the field of medicine have impacted the practice of dermatology. During the 1990 s, the expansion of managed care, 1 with its emphasis on primary care providers, and the passage of significant legislation increasing the scope of practice of non-physician clinicians 2 (i.e., nurse practitioners and physician assistants), have contributed to the management of many dermatologic illnesses by non-dermatologists. 3 In 1995, only 33 percent of visits for skin disease in the United States were to dermatologists. Likewise, the numbers of osteopathic doctors and physician assistants entering dermatology increased by 9.2 percent and 49 percent between 2000 and 2004, respectively. Today, physician assistants and nurse practitioners comprise over 20 percent of the dermatology workforce. 4 With the growth of non-physician clinicians outpacing the growth of dermatologists, there will be an increasing need to study the practice trends of these alternate dermatologic providers and identify factors influencing the public s perception of the role of dermatologists, as well as the factors that shape their choices in selecting a provider. Possible factors shaping patients provider preferences may include issues like expense (e.g. insurance coverage), wait times for appointments, patients experience and rapport with past providers, and public perceptions about the level of expertise and training afforded by various dermatologic providers. We are currently researching these complex questions, and while additional studies are needed, our initial investigation (See Research Note ) revealed some surprising findings that have important implications for individual dermatologists as well as for the specialty. Patient Preferences for Skincare Most dermatologists likely perceive themselves as the premier caretakers of skin. In recent years, public awareness campaigns by professional organizations have helped reinforce this view. However, results of our recent survey reveal that (although dermatologists are clearly favored for chronic and flaring skin conditions), in the public s eye, there are a number of areas in which dermatologists are falling short particularly, the perception of dermatologists as skincare providers for non-emergent and emergent skin conditions, changing moles, yearly skin checks, and cosmetics. Respondents prefer PCPs for non-emergent skin conditions. Overall, respondents preferred primary care providers for non-emergent skin conditions regardless of respondent characteristics. Although most respondents preferred to see a PCP (62.2 percent) for non-emergent skin problems, people with a history of a skin problem were more inclined to see a dermatologist for non-emergent problems than those without 36 Practical Dermatology September 2006

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3 Patient Preferences Table 1. Preferred Provider by Reason for Visit Yearly Skin Check Chronic Skin Condition Cosmetics 20% 7% 19% 40% 57% 77% 44% 16% 13% Changing Mole Flaring Skin Condition 23% 23% Dermatologist Primary Care Physician Non-Medical Skin Care Provider Plastic Surgeon N/A Other 72% 72% (44.2 percent vs. 25 percent, p=0.04). Respondents who never had seen a dermatologist preferred a PCP for yearly skin checks (61.7 percent vs percent, p<0.001) and were equally divided between PCPs and dermatologists for changing moles (p<0.001). When a dermatologist is unavailable, most respondents (91.5 percent) prefer to see a primary care physician for their skin problems. Dermatologists do seem to develop patient loyalty. Previous experience with a dermatologist seems to positively influence patient preference for dermatologic care, but preference for PCPs remains higher for non-emergent issues. When data were stratified by the type of skin caregiver patients had consulted for previous dermatologic problems, 100 percent of those seen by PCPs preferred to see PCPs and 62.3 percent of those treated by dermatologists preferred to see dermatologists for non-emergent problems. Regarding annual skin exams, most PCP patients (64.3 percent) would go to a PCP for a yearly skin check, but dermatologists were the first choice of patients who had seen a dermatologist (77.4 percent) for past skin conditions. A majority (72.6 percent) of those reporting a history of having a skin problem saw a dermatologist. Of the remainder, 14 (19.2 percent) went to a PCP and six (8.2 percent) did not seek care. Patients prefer dermatologists for emergent skin conditions. Overall, most patients prefer a dermatologist for emergent skin problems (38.6 percent), yearly skin checks (57.3 percent), changing moles (74.7 percent), flaring skin conditions (71.8 percent), chronic conditions (77.8 percent), and cosmetic services (45.0 percent) regardless of gender, age, education, or personal history of a skin problem (Tables 1 & 2). For emergent problems, dermatology patients were least likely to present to the ER than other patients (10.0 percent vs percent). Male respondents were more likely to pres- 38 Practical Dermatology September 2006

4 Patient Preferences ent to the ER for emergent problems (35.3 percent vs percent of women). Dermatologists outpace PCPs but not plastic surgeons for cosmetic issues. For cosmetic issues, patients preferred to see plastic surgeons (36.4 percent) followed by dermatologists (29.5 percent) and PCPs (22.7 percent). Although the majority of study respondents selected dermatologists as the practitioner they would see for cosmetic skin issues (55.7 percent), preferences were less clear amongst those who had never seen a dermatologist (36.4 percent plastic surgeon vs percent dermatologist vs percent PCP). It is interesting that primary care providers were ranked so highly among non-dermatology patients for cosmetic procedures, given their generalist scope and training while dermatologists 5-8 and plastic surgeons clearly have more training in advanced surgical and cosmetic skills. Sex may influence selection of dermatologists. Female respondents were more likely to have seen a dermatologist (84.2 percent vs percent), whereas men were more likely to not seek help from a skincare provider (17.1 percent vs. 0.0 percent, p=0.04). Of all patients who had seen a dermatologist, 82.9 percent saw their dermatologist once a year or less, and most reported their wait times for dermatology appointments as comparable to those for PCPs or other specialists (57.6 percent). With regard to patient preferences for their provider s sex, 73.5 percent of respondents did not have a preference. Of those with a preference for their skin-caregiver s sex, most preferred a female rather than a male (83.7 percent vs percent). When data were stratified further by various respondent characteristics, 100 percent of female respondents and 67 percent of male respondents preferred female providers. Although female providers were favored across all levels of patients education, the magnitude of this difference generally decreased as education increased. Sixty percent of PCP patients and 100 percent of dermatology patients preferred a female provider (p=0.04). Patients are very satisfied with dermatologists. The good news for dermatology is high patient satisfaction. Patients who had seen a dermatologist in the past favored seeing a dermatologist for most skin problems. In addition, these patients appear less likely to present to the emergency department for dermatologic issues, a trend that could improve utilization of healthcare resources. Current and Future Implications Data from this pilot study show dermatologists were clearly favored for chronic and flaring skin conditions. While further studies are needed, these initial findings suggest opportunities for dermatologists to:

5 Capitalize on our role as experts in diagnosis. Overall, there appears to be insufficient public awareness about the role and expertise of dermatologists. Our findings may indicate a need for more public education about the training and expertise afforded by various skincare providers, since reported preferences for dermatologic providers appeared to be independent of these factors and were most influenced by patients familiarity with the types of providers they had encountered in the past. The fact that patients prefer dermatologists for emergent, chronic, and flaring conditions, as well as for assessment of changing moles, suggests that patients recognize dermatologists expertise in diagnosis of cutaneous disease. With regard to other skin problems, however, respondents tended to be loyal to the type of skincare provider they had seen in the past, regardless of the amount of training or expertise afforded by the various types of providers. Attract and retain new patients. Respondents who had never seen a dermatologist were more inclined to go to a PCP for yearly skin checks and non-emergent skin conditions, present to the ER or a PCP for emergent skin conditions, choose a plastic surgeon for cosmetic services, and were equally divided between PCPs and dermatologists for changing moles. By contrast, those who had previously seen a dermatologist seemed to favor a dermatologist for emergent and non-emergent skincare. Countering restricted access to dermatologists (whether through insurance gatekeepers, practitioner shortage, or any other factor) may permit growth in the number of first-time patients to dermatologists and, subsequently, the cultivation of loyal dermatology patients. Emphasize the specialty s cost-efficiency. Dermatologists have an advantage over other care providers in that they may help contain healthcare costs and decrease utilization noncost-efficient services. Patients who had seen a dermatologist were less likely to report to ERs for skin complaints. Furthermore, primary care physicians typically have limited training in dermatology and have been shown to be less proficient in diagnosing and treating skin disease than are dermatologists According to one systematic review, dermatologists performed better than family practitioners (93 percent vs. 52 percent correct, p<0.001) in proper diagnosis of fairly common dermatoses. 14 In addition, 24 percent of surveyed PCP s (n=7015) reported that the scope of care they were expected to provide was greater than it should be. 15 These are all facts that dermatologists should be familiar with and that the specialty should cite in dialogues with insurers. Increase public awareness around cosmetic services. Although dermatology continues to embrace cosmetic services, opportunities to increase public awareness exist. Patients Table 2. Preferred Provider by Problem Acuity Non-Emergent 2% Emergent Dermatologist Primary Care Physician Non-Medical Skin Care Provider Other Emergency Room 39% 62% 32% 34% 27% Respondent Characteristics n Percent Male % Age, mean (s.d.) Education No high school diploma 2 1.2% High school diploma/g.e.d % College (Associate, Bachelor) % Advanced Degree (Master, Doctor) % History of skin problem % Have seen a dermatologist % September 2006 Practical Dermatology 41

6 Patient Preferences continue to more strongly associate these services with plastic surgeons than with dermatologists, and a significant proportion say they would seek services from a PCP. Continue investigating and adapting. Professional delineation across various dermatologic providers will be important for workforce identity and for better utilization of healthcare resources as more non-dermatologists offer skincare services. Determining factors that influence patient decisions for various dermatologic providers is key to this process. Experience with past providers appears to be a highly important factor, as respondents provider preferences often demonstrated loyalty for past skincare providers. Of note, patients preferences for providers were independent of their perceptions of comparative wait times for appointments to see PCPs, dermatologists, and other specialists. In addition, future studies investigating trends in practice patterns and health outcomes data about the quality of dermatologic care imparted by various skincare providers will be important for validating appropriate professional delineations and scopes of practice across various dermatologic providers, and for effecting better patient care and more efficient use of healthcare resources. Dr. Brown has disclosed that she has received fellowship funding from the Connetics Corporation. Research Note: Our Methodology One hundred sixty seven American individuals attending the Head of the Charles Regatta (Boston, MA) in October 2005 completed the survey. This event attracts more than 7,000 athletes from around the world and up to 300,000 spectators over the course of a weekend. Survey questions focused on patient preferences for various dermatologic providers based on the nature of the chief complaint, as well as their experiences with skin disease and wait times for appointments. This survey study and its analyses (using Stata 8.0) were performed with approval from Partners IRB, Boston, MA. Mean values and only data with significant p-values are reported unless otherwise specified. Of the 167 respondents, 91 (54 percent) were male, 151 (90 percent) had at least a college education, 77 (47 percent) reported a history of a skin problem, and 105 (63 percent) had seen a dermatologist in the past. The average age was 44 years, with a range from 18 to 88 (Table 1). A notable limitation of this pilot study is the catchment population. With 90 percent having a college education or greater, this sample is not representative of the greater public. It is likely that individuals in this study might have higher expectations relative to other citizens and better access to care. As a result, larger studies are needed for analyzing patient preferences and the factors influencing their choices for skincare providers. 1. Stern RS. Managed care and the treatment of skin disease, Continued growth and emerging. Arch Dermatol 1998;134: Druss BG, Marcus SC, Olfson M, Tanielian T, Pincus HA. Trends in care by nonphysician clinicians in the United States. NEJM 2003;348(2): Thompson TT, Feldman SR, Fleischer ABJ. Only 33percent of visits for skin disease in the US in 1995 were to dermatologists: is decreasing the number of dermatologists the appropriate response? Dermatol online J 1996;4:3. Available from URL: 4. Based on membership and survey data from the AMA (Physician Characteristics and Distribution in the US, 2005), AOA, AAPA (2004 Physician Assistant Census Report), and AANP (Nurse Practitioner Workforce Data Survey, 2004) 5. Wu JJ, Markus RF, Orengo IF. The increased competitiveness of mohs micrographic surgery training. Dermatol Online J 2002;8(2):24. Available at Last accessed 3/22/ Nguyen JC, Jacobson CC, Rehmus W, Kimball AB. Workforce characteristics of mohs surgery fellow. Dermatol Surg 2004;30(2 Pt 1): Coleman WP, Hanke CW, Orentreich N, Kurtin SB, Brody H, Bennett R. A history of dermatologic surgery in the United States. Dermatol Surg 2000;26(1): Ringel EW. The morality of cosmetic surgery for aging. Arch Dermatol 1998;134: Federman DG, Concato J, Kirsner RS. Comparison of dermatologic diagnoses by primary care practitioners and dermatologists: a review of literature. Arch Fam Med 1999;8: Federman D, Hogan D, Taylor R, Caralis P, Kirsner RS. A comparison of diagnosis, evaluation, and treatment of patients with dermatologic disorders. J Am Acad Dermatol 1995;32(5): Whited JD, Hall RP, Simel DL, Horner RD. Primary care clinicians performance for detecting actinic keratoses and skin cancer. Arch Int Med 1997;157: Gerbert B, Maurer T, Berger T, Pantilat S, McPhee SJ, Wolff M, et al. Primary care physicians as gatekeepers in managed care: primary care physicians and dermatologists skills at secondary prevention of skin cancer. Arch Dermatol 1996;132: Kirsner RS, Federman DG. Lack of correlation between internists ability in dermatology and their patterns of treating patients with skin disease. Arch Dermatol 1996;132: Clark RA, Rietschel RL. The cost of initiating appropriate therapy for skin diseases: a comparison of dermatologists and family physicians. J Am Acad Dermatol 1983;9: St. Peter RF, Reed MC, Kemper P, Blumenthal D. Changes in the scope of care provided by primary care physicians. N Engl J Med 1999;341: Practical Dermatology September 2006