A relatively new subset of dermatology hopes to make its mark in the hospital setting by establishing a different type of inpatient practice – one that focuses on education, research, development of new treatment algorithms, and identification of emerging patterns in disease.
The small number of dermatologists who are hoping to make this all happen banded together a few years ago, creating the Society for Dermatology Hospitalists (SDH) as a subsection of the American Academy of Dermatology. There are about 20 members, all of whom spend at least half their time practicing in the hospital, said Dr. Daniela Kroshinsky, who was a cofounder of the Society.
The Society aims to reestablish dermatologists as members of the hospital team, said Dr. Kroshinsky of Harvard Medical School and director of inpatient medical education and research at Massachusetts General Hospital, Boston.
Also, by sharing information, the members of the SDH can identify emerging dermatologic conditions and create best practices, said Dr. Lindy Fox, also a cofounder of the Society from the department of clinical dermatology at the University of California, San Francisco.
The Society members have conference calls every quarter or so, and they conduct consults for the AAD. They also usually present as a group at AAD meetings, Dr. Fox said in an interview.
"We are able to recognize emerging patterns of cutaneous disease," she said.
The aim also is to be able to publish based on their collective experience.
For instance, Dr. Fox and her colleagues helped identify cutaneous conditions that resulted from taking cocaine that was tainted with levamisole. The cutaneous conditions were a tip-off that the drug was perhaps contaminated with some other substance. The Drug Enforcement Administration (DEA) eventually determined through its own testing that a large amount of seized cocaine contained levamisole, an agent approved to deworm livestock, which is often used as a cutting agent. Because of the levamisole, users are susceptible to neutropenia and vasculitis. The dermatologists’ article was published online at the Journal of the American Academy of Dermatology’s website in March 2010 (doi:10.1016/j.jaad.2010.01.055).
Another SDH participant, Dr. Jonathan Cotliar, said that the Society is helping to formalize medical dermatology in the hospital, and that it will ultimately improve patient care. "There’s such a void of evidence-based criteria for treating a lot of the cases we see in the hospital," Dr. Cotliar said in an interview. "The No. 1 goal is to pool our resources and patients to come up with evidence-based treatment recommendations," said Dr. Cotliar of the department of dermatology and internal medicine at Northwestern University, Chicago.
Dr. Cotliar said he basically "stumbled into" inpatient dermatology. He completed a dual internal medicine and dermatology residency and, when he began his career, decided he wanted to continue to care for patients in the hospital. He joined the faculty in 2004 at the University of California, Los Angeles, and began directing the inpatient consult service.
At UCLA, he quickly became known as the go-to guy for inpatient dermatology issues, he said. In 2010, when he went to Chicago, he continued the inpatient practice. Now, he focuses on the cutaneous complications of stem cell transplantation and chemotherapy.
The need for such consults is likely to grow. There is an increasing number of patients who are experiencing adverse drug reactions as well as complications from chemotherapy, say the Society members. Although something like Stevens-Johnson syndrome or toxic epidermal necrolysis might be rare, the reactions are becoming more common, especially with newer medications, said Dr. Kroshinsky. Having dermatology hospitalists at an institution means that these often-fatal syndromes are recognized sooner. And patterns of causation can be more easily determined.
Dr. Kroshinsky said that dermatology hospitalists are also called to consult on birthmarks, surgical complications, and patients admitted with aggressive cases of such underlying dermatologic diseases as psoriasis. "It’s a very interesting day," she said.
And there are enough consults to keep physicians busy, she said. Dr. Kroshinsky sees clinic patients in the morning and inpatients in the afternoon.
Dr. Fox started working in the hospital in 2005, after completing a year-long career development award at Yale University, New Haven, Conn. She implemented the program at UCSF, which consists of three primary dermatology attending physicians. They do consults for the primary inpatient physicians at the hospital and also manage patients admitted for their derm-related conditions. And they have a resident who rounds with an attending each month.
Having a new resident each month helps make the inpatient dermatology practice work, said Dr. Fox. It allows the dermatologists time for both inpatient and clinic responsibilities.