Dr. Howard I. Maibach is a big believer in science-based practice, or as he puts it, a "deeply orthodox member" of evidence-based medicine. But he went beyond these parameters to draw on his decades of experience as a dermatologist in forecasting where the specialty is headed, based on his keen observations and anecdotal experience.
Dr. Maibach’s predictions for dermatology potentially have huge ramifications for training and clinical practice.
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The development and use of smartphone "apps" will become ubiquitous in 3-5 years, with ever-more-powerful and useful apps, said Dr. Maibach.
For one thing, board examinations will evolve from testing memory to testing how well physicians can look up information and whether they know the right algorithms for when to seek consultations. Current recertification exams are "based upon a system from the 19th century. It’s going to go," he said at the annual meeting of the Pacific Dermatologic Association in San Francisco.
Because of the expansion of knowledge and specialization, medical institutions – especially medical schools – will rely on cooperative teams and silos of excellence to help each other. In some parts of the United States, groups of dermatologists may do consultations only, and no direct care. The specialty will develop algorithms for deciding when to get consultant help early, when to wait, and when a consultant is of no value, said Dr. Maibach, professor of dermatology at the University of California, San Francisco.
Health education of consumers and patients will increase, starting from grades 5 or 6, he suggested. Medical residencies and fellowships will emphasize an introduction to lifelong learning in the subject. And medicine will mimic some other successful industries by instituting months-long sabbaticals every 5 years or so for additional training.
Why does he think this? Here are the trends that Dr. Maibach perceives, and which he believes will underlie the changes ahead. What do you think?
• There is a functional shortage of dermatologists. On Dr. Maibach’s weekly telephone hour, he frequently gets asked for help in arranging for a patient to be seen sooner in places like Kansas, where there’s a 6-month waiting list to see dermatologists, he said. "Clearly, society is going to demand a change."
• Dermatologic knowledge is expanding rapidly, which will lead to greater specialization and changes in training that will include some practitioners who are more specialized than today’s dermatologists and some who are less specialized.
• The development and use of smartphone "apps" will become ubiquitous in 3-5 years, with ever-more-powerful and useful apps. "You’re going to say three words, and all of the stuff that you learned in your residency is going to be updated in moments," he said.
• More and more physician assistants and nurse practitioners will be employed to help deal with the functional shortage of U.S. dermatologists.
• Whole new classes of assistants will be created, some of whom may be certified after 6 weeks of training and some of whom will be uncertified. "Your patients will learn to live with them," Dr. Maibach said. "If you go around the hospitals of California, there are many people acting as nurses who don’t even have an LVN degree and who are doing a wonderful job."
• Aestheticians will increase their role in dermatology practices.
• In all countries of the world, not just the United States, government will play an increasing role in medical care. "Your governments, unless you’re totally cash oriented, are going to be more deeply involved," he said.
• Specialties will increasingly subspecialize. "I predict the major training centers will have 10-15 subspecialties. I could see there will be one porphyria clinic for all of California and Utah in the not-too-distant future," he said.
• There’s enormous room for innovation, especially as evidence-based medicine takes hold, which will continue to change medical practice.
• People will live longer, exacerbating some of these trends and perhaps creating gerontologic dermatologists.
Dr. Howard I. Maibach
• Rationing will grow. "We have it already. We don’t like to talk about it in public, but you’re going to see more and more pseudo- or actual rationing of care," he said.
• Physician assistants and nurse practitioners who practice 10 or 100 miles from their supervising physicians eventually will become freestanding practitioners themselves.
• Younger dermatologists who already are rejecting long work hours will shorten the work week to 30 or 32 hours.
• The nascent use of teledermatology will increase.
• Some medical schools will offer 3-year degrees instead of the traditional 4 years. "It’s already started," Dr. Maibach said.