Pediatric Dermatology: Past, Present, and Future · PDF file2004, followed by the...

Pediatric Dermatology: Past, Present, andFuture

Brea Prindaville, M.D.,* Richard J. Antaya, M.D.,†,‡ and Elaine C. Siegfried, M.D.§,¶

*Department of Dermatology, Children’s Mercy Hospital, Kansas City, Missouri, Departments of †Dermatologyand ‡Pediatrics, School of Medicine, Yale University, New Haven, Connecticut, Departments of §Pediatrics and

¶Dermatology, Saint Louis University School of Medicine, St. Louis, Missouri

Abstract: Up to 30% percent of pediatric primary care visits include askin-related problem, and referrals are hampered by appointment waittimes among the longest of any pediatric subspecialty. Despite the cleardemand for pediatric dermatologists, there has been a long-standingshortage of providers, leaving dermatology as one of the most under-served pediatric subspecialties. Another consequence of the workforceshortage is the limited opportunity for pediatric dermatology training forresidents and postgraduate general pediatricians and dermatologists.This review includes the evolution of the subspecialty from conceptionthrough the present, along with obstacles to workforce expansion andpotential solutions to improve access to care for children with skindiseases.

Between 10% and 30% of pediatric primary carevisits include a skin-related problem (1–4). Thisobvious clinical need was the catalyst for establishingthe subspecialty of pediatric dermatology, beginningwith the first international symposium held in MexicoCity and the founding of the International Society ofPediatric Dermatology in October 1972 (5). TheSociety for Pediatric Dermatology (SPD) wasfounded 18 months later (1). The next decade wit-nessed the launch of the journal Pediatric Dermatol-ogy in 1982 and the creation of an American Academyof Pediatrics (AAP)–sponsored Section on Dermatol-ogy in 1986. Initial interest in the subspecialty washigh. Those who chose to focus their practice on

treating children with skin disease generally com-pleted residency training and earned certification inpediatrics and dermatology (1). Since that time, thefield has evolved. The enormous breadth and depth ofclinical information discovered over the past fourdecades has filled several texts and inspired countlesspublications and conferences. Initial informal fellow-ship training experiences evolved into formal 1- to 2-year programs sponsored by the American Board ofDermatology (ABD). In 2000, the AccreditationCouncil of Graduate Medical Education (ACGME)recognized this unique body of knowledge as asubspecialty of the ABD (6). Subspecialty certificationexaminations have been held every other year since

Address correspondence to Elaine C. Siegfried, M.D., Depart-ment of Dermatology Pediatrics and Dermatology, Saint LouisUniversity, St. Louis, MO 63104, or e-mail: [email protected].

A small portion of the information in this manuscript waspresented by Dr. Siegfried as part of the Founder’s Lecture at theannual SPD meeting on July 13, 2012, in Monterey, CA.

DOI: 10.1111/pde.12362

© 2014 Wiley Periodicals, Inc. 1

REVIEW ARTICLE

Pediatric Dermatology 1–12, 2014

2004, followed by the implementation of a recertifi-cation program. Along with these changes, thedemand for pediatric dermatology services has con-tinued to grow far beyond the available workforce.This article will review the genesis of the field and themost important challenges to the future of thesubspecialty.

Defining the Subspecialty

Surveys conducted in primary care offices in the mid-1980s estimated that 10% to 30% of pediatric clinicvisits included dermatologic concerns. The mostcommon conditions were skin infections, followedby atopic dermatitis, seborrheic dermatitis, contactdermatitis, acne, and infestations (2–4). Along withthis observation, pediatric training programs werenoted to devote “very little time to organized teachingof dermatology” and “house officers’ experiencewith skin problems was likely to be on a hit-or-missbasis” (2).

At this time, when less than two-thirds of pediatricresidencies in the United States offered electives inpediatric dermatology and far fewer had pediatricdermatologists to supervise the electives (7,8), severalstudies were conducted to compare the ability ofpediatricians and dermatologists to evaluate skinproblems. One comparative study assessed residentsfrom seven training programs in the United States byasking them to identify color transparencies ofdermatologic findings in children. Pediatrics residentshad a mean score of 53%, compared with a mean of86% for dermatology residents. A similar studyfocusing on the 20 most common pediatric dermato-ses found that dermatologists made the correctdiagnosis in 96% of cases, whereas pediatricians atthe same institution averaged only 49% correct (9).

Related surveys in other North American countriesyielded similar conclusions. Data collected from theNational Institute of Pediatrics in Mexico Citybetween 1995 and 1999 compared diagnoses madeby pediatric and dermatology residents for more than200 skin findings and found that pediatric residentsmisdiagnosed more than 75% of cases. This inade-quacy was attributed to a lack of dermatologyexposure during training in Mexico, where an averageof 0.8% of the medical student curriculum wasallocated to dermatology, and similar to training inthe United States, where a rotation in dermatologywas optional for pediatric residents, despite a muchgreater prevalence of skin complaints in Mexico (10).

After the founding of Pediatric Dermatology, thedearth of related research and publications began to

improve. Before 1983 only 15% of dermatologicjournal articles focused on pediatrics and only 4% ofpediatric articles focused on skin disease. The greatmajority of these pediatric dermatology articles werecase reports, most often featuring unusual diagnoses.There were few prospective studies (11).

In 1986 the first systematic evaluation of the U.S.pediatric dermatology workforce was published (8).Fifty-seven subspecialists were identified, practicingmainly in large teaching hospitals. More than half ofthe individuals younger than 40 years of age. Halfwere board certified in pediatrics and dermatology,but few of these specialized physicians cared exclu-sively for children. Only 20% of practices followed apatient population that included at least 75% chil-dren, whereas more than half of the patients wereadults in more than 60% of practices. At that time, amajority of hospital administrators stated that theywould like to hire a pediatric dermatologist, althoughfewer than half had available positions, and not all ofthose positions were funded. The article concludedthat employment opportunities were limited forpediatric dermatologists (8).

Despite that discouraging conclusion, significantprogress was made in the 1990s, most notably in thenumber of peer-reviewed journal articles, textbooks,and meetings documenting advances in pediatricdermatology. In 2000 the subspecialty was recog-nized as comprising a unique body of knowledgeand was formally certified by the Committee onCertification, Subcertification and Recertification ofthe ACGME.

The Early Years

Expanding clinical and academic activity launchedprofessional organizations in the United States andabroad, beginning with the International Society ofPediatric Dermatology, founded during the firstinternational symposium

1

in 1973. Drs. Alvin Jacobs,Samuel Weinberg, Nancy Esterly, Sidney Hurwitz,William Weston, and Coleman Jacobson establishedthe SPD (http://www.pedsderm.net) in the UnitedStates in 1975. Seven years later the European Society

1The first international symposium was held in October 1973 inMexico City, Mexico, and was hosted by Ramon Ruiz-Madonado.The 14 participants founded the International Society of PediatricDermatology: Dagoberto Pierini of Argentina, E.J. Moynahan ofGreat Britain, Eva Torok of Hungary, Martin Beare of Ireland,Ferdinando Gianotti of Italy, Kazuya Yamamoto of Japan,Armando Franco and Ramon Ruiz-Maldonado of Mexico, andSidney Hurwitz, Alvin Jacobs, Coleman Jacobson, Guinter Kahn,AndrewMargileth, and Lawrence Solomon of the United States (1).

2 Pediatric Dermatology 2014

was founded. Today, many countries throughoutthe world have their own national societies(Figs. 1 and 2).

Growing Demand

In the 15 years before 2001, the number of physiciansin the United States who identified themselves aspediatric dermatologists nearly tripled, to 151, butcontrary to the 1986 prediction (8), this supply wasinsufficient to meet the demand for clinical care andteaching. In 2002 a survey of dermatology residencyprograms in the United States found that only 48%employed a pediatric dermatologist and 25% wererecruiting, although 75% of chairpersons thought itwas important to have a pediatric dermatologistfaculty member and 70% felt that there was ashortage of pediatric dermatologists (12). Interest inestablishing a career in pediatric dermatology did notreflect the increasing demand. By 2002, 40 pediatri-cians had completed dermatology residency trainingin the previous 5 years, but only 26 were practicingprimarily pediatric dermatology. During that year, 10programs offered pediatric dermatology fellowshippositions. There was no formal match program andonly six positions were filled (12).

A shortage of qualified faculty and institutionalorganization has complicated adequate dermatologytraining for pediatricians. The ABD governs certifi-cation in dermatology and pediatric dermatology,whereas the much larger American Board of Pediat-rics (ABP) certifies pediatricians and nonsurgicalpediatric subspecialists. Pediatric residency trainingprograms that offer a rotation in dermatology havelong done so as a noncore elective. Statistics have notbeen collected on the number of pediatric residentselecting a dermatology rotation. The quality of andaccess to these rotations is variable because many lackpediatric dermatology faculty and a few do not evenhave access to general dermatology faculty. For manypediatricians, the only exposure to dermatology maybe during medical school. A 2008 survey found that93% of U.S. medical schools offered dermatologyelectives for their students, often during the fourthyear (13). The required number of hours for teachingin dermatology was 10 or fewer in half of the 65dermatology residency programs included in thesurvey. For 8% of programs, there was no require-ment. An outcome of this training gap was docu-mented in a 2002–2006 U.S. study that rankedpediatric dermatology third behind only psychiatryand allergy/immunology as subspecialties providinglong-term care to children who primary care providerscould more appropriately serve (14).

A June 2004 survey including all Canadian derma-tology residents ranked pediatric dermatology amongthe top three areas in which training had beeninadequate to support their practice. There was alarge discrepancy between the perceived importanceof pediatric dermatology, which was ranked amongthe highest of several educational components of thecurriculum, and overall satisfaction with training. Thestudy also indicated that “early intervention duringresidency may help foster their involvement inacademic career paths” (15).

During this time the ABD recognized the need forformal certification in pediatric dermatology. Theprocess used to create certification examinations wasalso evolving to address the need for recertification.Pediatric dermatology was included among the threesubspecialty and two general committees establishedto formulate questions for certification and recertif-ication examinations.

The first certifying examination in pediatric der-matology was administered in Deerfield, Illinois, onOctober 4, 2004. Eligibility criteria to sit for thisexamination included ABD certification in generaldermatology plus board certification in pediatrics anddermatology, completion of a pediatric dermatology

Figure 1. International organizations for pediatricdermatology.

Figure 2. International workforce for pediatricdermatology.

Prindaville et al: Pediatric Dermatology 3

fellowship, or “grandfather” experience. “Grand-father” eligibility required documentation of at least5 years of clinical practice that included at least 50%children. Ninety of the 94 registered candidates passedthe 2004 examination. The majority were double-boarded in pediatrics and dermatology. Biennialexaminations were subsequently held every otherOctober, with fewer candidates and a similar veryhigh pass rate (Table 1). During the same interval,ABD diplomates with time-limited certification beganthe process of recertification. This required passing atwo-part examination, including one general derma-tology module and a second among four availablemodules of the candidate’s choice. Between 2004 and2011, fewer than 6% of ABD diplomates chose thepediatric dermatology module for recertification,making it the least popular option among the poolof ABD diplomates taking the recertification exami-nation (Fig. 3), reflecting the decreased interest inpediatric dermatology among general dermatologistsand exacerbating the existing workforce shortage.

International training standards for pediatric der-matology have also been evolving, as documented in a2002 survey (16). In Argentina and Mexico, subspe-cialization follows a pediatric or dermatology resi-dency. In the United Kingdom, pediatric residentssubsequently complete a portion of their dermatologyresidency without an additional fellowship trainingrequirement. In Italy, Belgium, Spain, and Germany,pediatric dermatology has not been a formally recog-nized subspecialty, but is practiced by physicians whocomplete either residency. Dermatology residentsfrom Singapore and Australia have travelled else-where for further pediatric dermatology training. Peruhas not formally recognized the subspecialty (16).

Growing the Subspecialty

Increasing demand for all dermatologists was docu-mented in the September 2011 Physician WorkforceStudy undertaken by the Massachusetts MedicalSociety. These data, collected in anticipation ofgreater demand for physician services with implemen-tation of the federal Patient Protection and Afford-able Care Act, ranked dermatology as one of sixspecialties facing severe shortages for at least fourconsecutive years (17). An increasing number ofunfilled faculty and fellowship positions reflects theshortage of pediatric dermatologists in the UnitedStates (Fig. 4). The SPD newsletter has consistentlyposted more than a dozen faculty positions every yearsince 2004 (Fig. 5). Pediatric dermatology was rankedas the third least accessible subspecialty, behind onlychild psychiatry and developmental pediatrics, in asurvey of general pediatricians. A 2009 NationalAssociation of Children’s Hospitals and RelatedInstitutions (NACHRI) survey documented a 13.2-week average wait time for patients to get anappointment with pediatric dermatology, the longestfor any pediatric subspecialty; the wait time was more

Figure 3. Module chosen among American Board ofDermatology diplomates taking the recertificationexamination.

TABLE 1. Subspecialty Certification of Practicing PediatricDermatologists in the United States

YearNumber (%) completinga fellowship)

Number (%) passingthe exam

2004 24 (25 90 (96)2006 3 (10) 41 (93)2008 18 (58) 31 (91)2010* 24 (63) 34 (92)2012 43 (97)† 37 (86)Total 112 233‡

*Last year for grandfather eligibility.†Two candidates who did not complete a fellowship were repeat testtakers following prior failure to pass.‡Approximately 60% qualified by meeting grandfather criteria.

Figure 4. Available and filled pediatric dermatologyfellowship positions in the United States.


than the 2-week benchmark at 66% of hospitalssurveyed (Fig. 6). Despite the demand, interest in thesubspecialty has been low, with only 2.1% (233) beingboard-certified pediatric dermatologists among morethan 11,000 dermatologists in the United States.

Several forces have discouraged physicians-in-train-ing from pursuing careers in pediatric dermatology. A2010 SPD survey of 100 pediatric dermatologistsindicated that 74%made the decision to pursue a careerin pediatric dermatology during medical school orpediatric residency. Only 17% made this decisionduring dermatology residency. A majority of dermatol-ogy residency applicants begin planning early inmedical school for the highly competitive processrequiring excellent board scores, research, andpublications (18).

For pediatric residents who first discover aninterest in pediatric dermatology during their post-graduate training, it is increasingly too late to qualifyfor a highly competitive dermatology residencyposition. The timeframe and qualifications for secur-ing a dermatology residency are different from thosefor pediatric subspecialty fellowship training, typi-cally done during postgraduate year 2 or 3. There hasalso been a strong financial disincentive for manydermatology programs to accept a candidate withprior postgraduate training since 1999 legislation

limited federal funding for more than one residency(19). Furthermore, four additional years of trainingmay discourage some pediatric residents from pursu-ing a career in pediatric dermatology.

For many dermatology residents, especially forthose with large educational debt, salary discrepanciesmay be the greatest deterrent to pursuing fellowshiptraining in pediatric dermatology. Salaries that gen-eral dermatologists earn, especially dermatologistssubspecializing in procedures, cosmetics, or dermato-pathology, are significantly higher than those ofpediatric dermatologists. Despite the fact that anextra year of training is required to become a pediatricdermatologist, the average salary for pediatric derma-tologists in the United States in 2010 was $203,727,compared with an annual salary for most U.S. derma-tologists ranging from $287,832 to $385,953 (20).

Postgraduate training in pediatric dermatology hasevolved over the past 30 years. Before 1990, mostsubspecialists were board certified in pediatrics anddermatology. Between 1978 and 1985, a few moti-vated dermatology residents chose to enhance theirtraining by completing an informal 3-month precep-torship that one of the founding members of theSPD sponsored. Dr. Esterly offered the first unofficial1-year fellowship, which Dr. Adelaide Hebert com-pleted in 1983. The first ABD-sanctioned fellowshipcurriculum required 12 months for trainees whocompleted at least an internship in pediatrics or24 months for those who had no prior pediatricstraining. Because pediatrics residency programs sel-dom offer a preliminary internship year, few candi-dates were eligible for the 1-year fellowship. Othercandidates were deterred by 2 years of additionaltraining, so a significant number of fellowship posi-tions went unfilled.

To consolidate the time commitment and recruitcandidates at an earlier stage, a 5-year combinedABD-ABP pediatric and dermatology residency wasattempted at three academic centers. Two of theseprograms, sponsored by the University of Californiaat San Francisco and the University of Texas atGalveston, recruited a total of seven residents startingin 2003. By the end of 2012, only four had completedjoint training because of difficulties integrating rota-tions across two different ACGME programs. Thecombined programs are no longer being offeredbecause of overwhelming administrative and sched-uling challenges.

To help mitigate the 2-year fellowship disincentive,the ABD proposed a condensed 1-year program forindividuals without previous pediatric residency expe-rience. On September 19, 2006, the ABMS approved

Figure 6. Average wait time for a pediatric dermatologyappointment across the United States.

Figure 5. Pediatric dermatology positions posted in theSociety for Pediatric Dermatology newsletter since 2002.


the following requirement for board certification: anACGME-approved transitional year or an ACGME-approved broad-based year of residency training inemergency medicine, family practice, general surgery,internal medicine, or obstetrics and gynecology,followed by the requisite training and certification indermatology and then completion of 1 additional yearof fellowship training in pediatric dermatology duringwhich 80% of fellowship time is spent in directpediatric dermatology clinical activity.

Standardization and oversight of the fellowshipprograms also evolved (Fig. 7). Beginning in 2003,fellowship programs were required to apply for ABDaccreditation. During that year, eight pediatric pro-grams were approved. By 2008 the number grew to 17(Fig. 8), but more than half of the positions wentunfilled. The Pediatric Dermatology FellowshipDirectors Committee was established a year later,facilitating uniform training logs and leading to aformal match, implemented in 2009 for fellowshippositions beginning in 2010, using the San FranciscoMatch Program. The first match included 22 pro-grams with 28 fellowship positions. Thirteen (46%) ofthese positions were filled. The next academic year(2011–2012), the match rate improved, with 13 of 19(68%) programs and 18 of 28 (64%) positions filled.With a critical mass of fellowship training programs,application for ACGME accreditation has beenconsidered. ACGME accreditation has provided uni-form standards and enhances oversight for more than100 fellowship programs in dermatopathology andprocedural dermatology, but the majority of pediatricdermatology programs felt that the additional costsand administrative burden outweighed the benefits ofparticipation.

As the workforce shortage became increasinglyevident, eligibility expired for certification in pediatricdermatology via the grandfather pathway. This win-dow of opportunity was originally approved as a 5-year period beginning with the first certificationexamination in 2004. Because examinations were held

biennially, approval for grandfather eligibility waslost after the 2008 examination. A request forACGME permission to extend the window until the2010 examination was rejected in March 2009, butwas granted the following January after an appealthat stressed the need for additional board-certifiedpediatric dermatologists to satisfy the workforceshortage. The grandfather pathway to board eligibil-ity officially expired after the October 2010 examina-tion.

Although the number of graduating fellows hasbeen small, 10 of 12 who completed training in 2008chose academic positions and six (50%) remained attheir training institution. In 2009, 9 of 11 fellows choseacademic positions, and only 1 remained at hertraining institution. A 2008 survey of dermatologydepartments in the United States found that only 31%of dermatology residency programs reported anadequate number of faculty members specializing inpediatric dermatology to satisfy the clinical demand(21). Whereas 25% of programs reported at least oneunfilled pediatric dermatology faculty position in2002, 43% of programs had 34 unfilled facultypositions in 2008, with only 11 fellows in training.The average recruitment time was 4.7 years. Three-fourths of programs considered it difficult to hire orretain pediatric dermatology faculty, citing a shortage

Figure 7. Evolution of the standardization and oversight of pediatric dermatology fellowship programs.

Figure 8. Number of pediatric dermatology fellowshipprograms in the United States and internationally.


of qualified candidates as the most common reason.Resident decisions to choose pediatric dermatology asa career were found to be directly related to thenumber of pediatric dermatologists that their trainingprogram employed (21).

Exacerbating the workforce shortage is a geo-graphic maldistribution of board-certified pediatricdermatologists in the United States, including 15states that have none. Detailed workforce data forABP-certified pediatric subspecialties have been col-lected for decades and most recently updated through2010 (22). This database repeatedly identified pedi-atric rheumatology as one of the most understaffedfields, especially before 2000, which facilitated fund-ing through the Children’s Health Act of 2000 “toevaluate whether the number of pediatric rheuma-tologists is sufficient to address the health care needsof children with arthritis and related conditions”(23). This report acknowledged a prevalence of300,000 rheumatic diseases among children in theUnited States served by fewer than 200 subspecialists,with an average ratio of 0.3 physicians per 100,000children and an average practice capacity of 443children. As of December 2010, the number ofpediatric rheumatologists grew to 270, still less thanthe 337 calculated to meet patient care needs (23).Pediatric neurology is another subspecialty with arecognized workforce shortage, with 904 full-timepractitioners in the United States in 2002, represent-ing 1.27 per 100,000 children. At that time, theaverage wait for a new appointment was 53 days(24). Comparative data for pediatric dermatology arelimited but indicate a much larger number of childrenwith skin disease and a smaller workforce (Fig. 9 andTable 2). A 2007 survey of pediatricians rankedpediatric dermatology among the three most difficultsubspecialty services to access for patient care, withmore than 80% reporting a perceived shortage ofpediatric dermatologists (25). Surveys that NACHRI

and the SPD conducted in 2010 independentlydocumented the wait for a pediatric dermatologyappointment of longer than 60–90 days, longer thanfor any other pediatric subspecialty (26,27).

Although clinical research in the field has beenaccumulating, clinical demands and lack of fundinghave hampered basic research. In 2007, 99% of 70SPD members surveyed reported limitations toresearch. The main reason was lack of time, attribut-able to the high demand for clinical services, aproblem that the workforce shortage exacerbated.More than one-third also cited lack of training and10% cited lack of mentoring as impediments toresearch. Only 43% of pediatric dermatologists feltqualified to act as research mentors to residents andmedical students (28).

Current Challenges

In addition to the challenges detailed above—anabsolute shortage of pediatric dermatologists, inade-quate training of primary care providers and generaldermatologists, limited medical student exposure,postgraduate training obstacles, a paucity of experi-enced mentors, and salary inequity—other challengesexist, including a disproportionate number of under-insured patients.

In 2010 the 196 board-certified pediatric dermatol-ogists represented fewer than 2% of more than 11,000

TABLE 2. Comparative Supply of Pediatric MedicalCaregivers in the United States

U.S. specialty Per capita supply

Dermatologists 30,000 peoplePediatricians 1,500 people <18 years of agePediatric rheumatologists 240,000 people <18 years of agePediatric dermatologists 385,000 people <18 years of age

Figure 9. Comparative densities of pediatric dermatologists and rheumatologists across the United States.


U.S. dermatologists (29). Sixty-eight percent werefemale and 32% male. On a positive note, the averageage of these practicing pediatric dermatologists was 47years (range 32–67 years), representing a slightlyyounger workforce than that of general dermatology(Fig. 10).

Skin diseases in children are common and representa spectrum of conditions different from those inadults. Ideally, primary care physicians should be ableto treat a significant number of these children, but theproportion of pediatric residency training dedicatedto learning about the diagnosis and management ofdermatologic disease does not reflect disease preva-lence. Pediatric residents’ and practicing pediatri-cians’ diagnostic errors have been reported to rangefrom 80% to 90% (10,30). The true number ofincorrect diagnoses may be lower, but each incorrectdiagnosis can lead to inappropriate testing andmanagement, which can result in poorer patientoutcomes and higher medical costs. Severe skindisease is not uncommon and can take a heavy tollon a child’s and family’s quality of life. The pediatricdermatologist workforce shortage most negativelyaffects these patients.

The shortage of clinicians adequately trained to treatskin disease disproportionately affects children of low-income families. As of 2009, 15 million (21%) Amer-ican children lived in households below the federalpoverty line, and 31 million (42%) lived in low-incomehouseholds (31). Thirty-nine percent of hospitalizationsfor children are billed to Medicaid (32), which insures37 million children (33). Studies have shown thatchildren covered by Medicaid face significantly morebarriers to care than children with private insurance.This may be partially because of limitations related tosocioeconomic deprivation, but an important cofactoris that many specialists do not accept Medicaid.

Approximately 80% of general pediatricians acceptMedicaid-insured patients, although the wait time foran appointment may be twice as long, at an average of42 days versus 20 days for those claiming privateinsurance (34). Access to subspecialty care is muchmore limited.A 2011 secret shopper surveyof follow-upappointment access from a pediatric emergency depart-ment in Cook County, Illinois, found a 66%denial ratefor patients claimingMedicaid, comparedwith 11% forprivately insured patients (33). Dermatology wasamong the top three specialties cited as having limitedaccess. InApril 2011 the same technique detected a 19%national acceptance rate among dermatologists willingto schedule a new patient appointment for a Medicaid-insured child with eczema (35).

Fee-for-service reimbursement is one of severalfactors exacerbating the shortage of specialists accept-ing Medicaid. In 2011 the average reimbursement fora level 3 new patient office visit (Current ProceduralTerminology code 99243) was $99.86 from MedicaidChildren’s Health Insurance Program, versus anaverage of $160 from a private insurance company,and wait times for Medicaid payments often farexceed those for payments from private insurancecompanies (33).

Looking Forward

Understanding the broad scope of forces that influ-ence the supply of medical resources can help remedythe shortage of providers and encourage medicaladvances for children with skin diseases. Solutions areunlikely to be found in simple principles of supply anddemand given the complexities of academic and publicpolicy, market forces, and private funding that governhealth care. Important factors include educationalexposure, training requirements, physician-traineeand graduate training program selection bias, medicalcenter mandates to provide care, payer responsibilityto ensure patient access to specialists, relative reim-bursements, and medical advances.

Trainees

Subspecialty exposure and mentorship have been recog-nized as leading factors in career choice. The ABD andABP are organizations with the authority to regulatetraining requirements that can influence these opportu-nities. Given the shortage of pediatric dermatologistsand the elective status of the clinical rotation, fewmedical students get the chance to interact with experi-enced faculty. The most recent ACGME-approvedProgram Requirements for Graduate Medical Educa-

Figure 10. Age distribution for general and pediatricdermatologists in the United States.


tion in Dermatology (2007) include nonspecific require-ments for “adequate” training “to provide knowledgeand competence in four broad categories,” includingpediatric dermatology (36). Although explicit require-ments were also specified for dermatologic surgerytraining to “be directed by a physician with advancedfellowship training in procedural dermatology or itsequivalent” and for dermatopathology training to be“directedby aphysicianwith subspecialty certification indermatopathology, or its equivalent” (36), no suchrequirements were included for pediatric dermatologyfaculty. This document is reviewed every 5 years, but the2013 draft failed to add a requirement for fellowship-trained or certified pediatric dermatology faculty sincethe faculty of many dermatology programs do notcurrently include a pediatric dermatologist. A specificdermatology residency program requirement for facultycertified in pediatric dermatology is essential to ensureadequate mentorship opportunities and a higher level ofinstruction for more trainees. While such a requirementwould put some programs at risk for an ACGMEResidency Review Committee (RRC) deficiency cita-tion, lack of a requirement is a relative disincentive.Only with an adequate number of pediatric dermatol-ogists as academic faculty can the Dermatology RRCimplement more well-defined requirements for derma-tology residents. A subsequent goal would be for themuch larger Pediatric RRC to establish requirementsfor resident rotations in pediatric dermatology, whichcould ultimately facilitate exposure for medical stu-dents. Creation of a standardized electronic curriculumis a realistic alternative to filling faculty positions in allpediatric training programs. The charge of the SPDEducation Committee is to develop an online educationprogram for pediatric residents and pediatricians. Oncethe curriculum is established, a short-term goal is to gainapproval from the Pediatric RRC to require participa-tion in this program for all pediatric residents.

A few funded programs have been established toboost exposure and opportunities for mentorship inpediatric dermatology. These include two mentorshipprograms and two visiting professorships. TheWomen’s Dermatologic Society provides up to$2,000 to cover travel and living costs for eligibledermatology residents or junior faculty to work with asenior faculty mentor (http://www.womensderm.org/grants/mentorship.html). Since the program’s incep-tion in 2001, several of the mentors have beenpediatric dermatologists. Several of the participatingtrainees have gone on to board certification inpediatric dermatology. The SPD founded a Mentor-ship Grant program in 2012, providing up to $4,000 tocover the costs of travel and accommodations to work

with a senior faculty member (http://www.pedsderm.net/sections/mentorship.php).

Visiting professorships were designed to provide2 days of introduction to pediatric dermatology forinstitutions that lack full-time faculty. The AAP Sectionon Dermatology sponsors annual awards honoring Dr.Walter J. Tunnessen, Jr. that fund 2 days of lectures,seminars, and rounds with pediatric residents, medicalstudents, and faculty for two pediatric residency pro-grams annually (http://www2.aap.org/sections/derm/visitprof-derm.htm). The SPD funds two similar Pedi-atric Dermatology Visiting Lectureships every year inhonor of Dr. Nancy Esterly. U.S. or Canadian accred-ited dermatology residency programs without access toan expert in pediatric dermatology are eligible (http://www.pedsderm.net/sections/VisitingLectureship.php).

Many other strategies could support interest inpediatric dermatology among trainees at all levels. AnInternet search for medical student rotations yields onlyindividual program websites. A centralized list ofavailable rotations in pediatric dermatology could helpstudents locate and compare educational opportunitiesat all participating institutions. The most influentialorganizations equipped to post this list include the SPD,ABD, ABP, AAP, and AAD. There are other oppor-tunities to increase medical student exposure. Manyinstitutions host dermatology interest groups for stu-dents contemplating careers in dermatology. Pediatricdermatologists should be proactively involved withthese groups. Likewise, pediatric dermatologists shouldprovide lectures to third-year medical students andencourage participation in clinics during required rota-tions in pediatrics. They should also offer a subspecialtyelective for fourth-year medical students to includeclinical exposure and participation in publication-wor-thy projects (e.g., case reports, reviews, and research).

Given the high proportion of outpatient pediatri-cian visits for skin-related problems, better educationof pediatric residents is critical. Pediatric residencyprograms are not required to provide training inpediatric dermatology. A positive change was imple-mented in 2011, when the Pediatric RRC elevateddermatology to the first tier of outpatient electives forpediatric residents. Although this is an improvement,a dermatology rotation is still not considered arequirement or even a core elective because of therecognized paucity of pediatric dermatologists inpediatric training programs (37). Nevertheless, theprevalence of skin disease in pediatric practicemandates such training. For many programs lackinga pediatric dermatologist, implementing an alterna-tive should be a priority. Novel alternatives areWeb-based curricula or a series of lectures given by


pediatric dermatologists who travel from their homeinstitutions. Core training in the diagnosis and man-agement of the five diagnoses that account for morethan half of all pediatric dermatology consultations(atopic dermatitis, acne, warts, molluscum, vascularbirthmarks) should have the greatest effect.

For centers with pediatric and dermatology train-ing, a relationship between the two would be benefi-cial for both (38). Pediatricians could gain specialtyknowledge from dermatologists, and because mostdermatologists are primarily trained in internal med-icine, dermatologists could gain insight into how tobest approach examinations and communication withchildren and their caregivers. Patients would benefitfrom more accurate diagnoses and better treatment.Such academic centers might consider devoting spe-cific clinic time so that pediatric and dermatologyresidents could see patients together (38). This wouldrequire additional commitment from a supervisingpediatric dermatologist, the willingness of residencyprograms to devote training time (or an RRCrequirement), and cooperation between clinicaldepartments of pediatrics and dermatology.

The dermatology resident selection process repre-sents a strategic opportunity to build the subspecialty.Dermatology training programs that make a con-scious effort to consider applicants with prior grad-uate medical education training in pediatrics or adocumented interest in pediatric dermatology canexpand their faculty from within. Achieving a criticalmass of pediatric dermatologists at a single institutionis a likely contributing factor for training futurepediatric dermatologists and retaining pediatricdermatology faculty. This strategy has proveneffective at several institutions, including the Universityof California at San Diego, Northwestern University,and the Medical College of Wisconsin.

Academic Faculty

The demand for academic pediatric dermatologyfaculty has been high, but more than one-third offellowship positions have gone unfilled, sometimes forseveral years. Although it may be ideal to inspire andmentor candidates during the early years of medicalschool, many physicians-in-training do not commit toa specialty until much later. A significant bottleneck inthe current pathway to a career in pediatric derma-tology is at the point of acceptance into a dermatologyresidency program.

One solution to this problem is to develop fellow-ship or certificate programs that allow ABP diplo-mates to pursue further training in pediatric

dermatology. A fellowship curriculum would reason-ably require 3 years, comparable with all other pedi-atric subspecialty training programs (21). A certificateof added qualifications, similar to that currentlyoffered for sports medicine and medical toxicology,would not produce a fully trained subspecialist, but itwould require less training (likely 1 year) and wouldimprove a general pediatrician’s competence in thediagnosis and management of common pediatric skindiseases, decreasing referrals to pediatric dermatolo-gists. The addition of board-eligible pediatricianswould expand the pool of candidates and providesome flexibility for physicians to choose pediatricdermatology at a later stage of their training. Somehave argued that a resident receiving 3 years oftraining in pediatrics followed by 3 years in a pediatricdermatology fellowship may not have comparableexposure to dermatopathology or procedural derma-tology, but a counter to this argument is the highervalue of additional exposure to pediatric primary care,the spectrum of pediatric subspecialties, inpatient andintensive care, and exclusion of unneeded training inskin cancer surgery and cosmetic dermatology. Fur-thermore, because the salary of a pediatric dermatol-ogist is expected to be higher than that of a generalpediatrician, the additional training provides a greaterfinancial incentive for a pediatrician than for aresident trained in general dermatology.

An additional logistical hurdle to consider withinitiating a new training pathway for pediatricdermatologists is that most ABP-sponsored pediatricsubspecialty training programs require a total of6 years (3 years of fellowship after 3 years of pediat-rics residency), compared with the current 5 years fordermatology board-eligible candidates. Alternativecertification pathways would require joint ABP-ABDsponsorship and raise several challenges, includingfunding sources, competition with current traditionalpediatric dermatology fellowships, and naming anddefining the scope of practice for diplomates trainedvia different pathways. Any training program outsideof the current pathway is controversial, even amongpediatric dermatologists, but the SPD plans toformally evaluate the viability of these options.

After completing a fellowship, physicians whochoose an academic career help satisfy an importantneed. Positions for new faculty in well-establisheddepartments are generally more attractive and moreeasily filled than those as the first or only pediatricdermatologist, but to address the geographic maldis-tribution (Fig. 11), more pediatric dermatologistsmust make the difficult decision to accept facultypositions as solo pediatric dermatologists. Pediatric


dermatologists considering these positions need tonegotiate proactively for sufficient administrative, clin-ical, and investigational infrastructure support to besuccessful in a setting that includes caring for a largenumber of underinsured patients. The SPD hostssessions at its annual meeting designed to educatefellows and junior faculty about the issues related tonegotiating these terms. To underscore the ongoingimportance of this subject, the society’s 2013 StrategicPlan includes establishing a committee for junior facultyand fellows and another for mentorship.

Additional incentives could help to alleviate thelimited access to a dermatologist of Medicaid-insured children. There is current legislation to bringMedicaid payments in line with Medicare. Legisla-tion that extends loan forgiveness to pediatricsubspecialists who practice in underserved areas isanother option that could help mitigate the financialdisincentive. Pediatric dermatology is far morecognitive than procedural and focused on preventa-tive and maintenance care, with the goals of limitingemergency department visits and hospitalizations.But those procedures performed by pediatric derma-tologists are performed more cost effectively in theoffice rather than in the operating room. Data areneeded to document these cost savings. The currentfee-for-service system that compensates for proce-dures at two to three times that of cognitive servicescannot be sustained under the provisions of theAffordable Care Act of 2010. The level of revenue isthe current standard that hospitals and providers useto determine the value of a clinical service. Althoughit is far easier to quantify revenue than cost savings,analysis of the savings that pediatric dermatolo-gists provide would help quantify the value of thesubspecialty.

CONCLUSION

In the four decades since its inception, the field ofpediatric dermatology has witnessed a dramaticevolution and growing clinical demand that has farexceeded the workforce supply. Cultivating interest inpursuing a career in pediatric dermatology to fill thecurrent provider shortage and improve training formedical students and postgraduate physicians-in-training is important for the future of this indispens-able field. Finally, alternative training pathways suchas the development of pediatric dermatology fellow-ships and certificates of added qualifications forpediatricians may be options to meet the pediatricdermatology workforce shortage.

ACKNOWLEDGMENTS

The members of the Executive Board of the Societyfor Pediatric Dermatology reviewed and approvedthis manuscript.

REFERENCES

1. Hurwitz S. The history of pediatric dermatology in theUnited States. Pediatr Dermatol 1988;5:280–285.

2. Tunnessen WW Jr. A survey of skin disorders seen inpediatric general and dermatology clinics. PediatrDermatol 1984;1:219–222.

3. Hayden GF. Skin diseases encountered in a pediatricclinic. a one-year prospective study. Am J Dis Child1985;139:36–38.

4. Krowchuk DP, Bradham DD, Fleischer AB Jr. Der-matologic services provided to children and adolescentsby primary care and other physicians in the UnitedStates. Pediatr Dermatol 1994;11:199–203.

5. Galimberti R, Pierini A, Cervini A, eds. History ofLatin American dermatology. Toulouse, France: Edi-tions Privat, 2007.

6. Feb 2005 American Board of Dermatology newsletter[online]. http://www.abderm.org/docs/pdf/2005News-letter.pdf. Accessed on July 17, 2012.

7. Prose NS. Dermatology training during the pediatricresidency. Clin Pediatr (Phila) 1988;27:100–103.

8. Honig PJ, Burke L. The subspecialty of pediatricdermatology. J Am Acad Dermatol 1986;15:123–126.

9. Ramsay DL, Fox AB. The ability of primary carephysicians to recognize the common dermatoses. ArchDermatol 1981;117:620–622.

10. Soriano-Hern�andez YL, Orozco-Covarrubias L,Tamayo-S�anchez L et al. Exanthems in hospitalizedpediatric patients: concordance between pediatric anddermatological diagnoses. Dermatology 2002;204:273–276.

11. Hayden GF. Continuing education in pediatric derma-tology: the role of pediatric and dermatologic journals.Pediatr Dermatol 1983;1:69–73.

12. Hester EJ, McNealy KM, Kelloff JN et al. Demandoutstrips supply of US pediatric dermatologists: results

Figure 11. Comparative density of pediatric dermatologistsacross the United States with locations of pediatricdermatology fellowship programs highlighted.


from a national survey. J Am Acad Dermatol2004;50:431–434.

13. McCleskey PE, Gilson RT, DeVillez RL. Medicalstudent core curriculum in dermatology survey. J AmAcad Dermatol 2009;61:30–35.e4.

14. Valderas JM, Starfield B, Forrest CB et al. Routine careprovided by specialists to children and adolescents inthe United States (2002–2006). BMC Health Serv Res2009;9:221.

15. Freiman A, Barzilai DA, Barankin B et al. Nationalappraisal of dermatology residency training: a Cana-dian study. Arch Dermatol 2005;141:1100–1104.

16. Oranje AP, Kunz B. Symposium on training demandsin pediatric dermatology 2001. Pediatr Dermatol2002;19:166–176.

17. Massachusetts Medical Society. 2011 Patient Access toHealth Care Study: a survey of Massachusetts physi-cians’ offices [online]. http://www.massmed.org/AM/Template.cfm?Section=Research_Reports_and_Studies2&CONTENTID=54336&TEMPLATE=/CM/Con-tentDisplay.cfm. Accessed on July 17, 2012.

18. Admani S, Caufield M, Kim SS, Siegfried EC, Fried-lander SF. Understanding the pediatric dermatologyworkforce shortage: mentoring matters. J Pediatr2014;164:372–375.e1.

19. Medicare Payment Advisory Commission. Report tothe Congress: Medicare payment policy. MedPAC[online]. http://www.medpac.gov/publications/congres-sional_reports/Mar01%20Ch10.pdf. Accessed on May28, 2012.

20. Society for Pediatric Dermatology. Average salary forpeds derm exceeds $225K in 2011. SPD Review [online].http://www.pedsderm.net/pdfs/SalarySurvey2011.pdf.Accessed on March 2, 2013.

21. Craiglow BG, Resneck JS Jr, Lucky AW et al. Pediatricdermatology workforce shortage: perspectives fromacademia. J Am Acad Dermatol 2008;59:986–989.

22. Althouse LA, Stockman JA. The pediatric workforce:an update on general pediatrics and pediatric subspe-cialties workforce data from the American Board ofPediatrics. J Pediatr 2011;159:1036–1040.e3.

23. Duke EM. The Pediatric Rheumatology Workforce:a study of the supply and demand for pediatricrheumatologists. Report to Congress. Bureau of HealthProfessions. Health Resources and Services Adminis-tration [online]. http://bhpr.hrsa.gov/healthworkforce/reports/pedrheumatology.pdf. Accessed on May 28,2012.

24. Bale JF, Ashwal S, Painter MJ. Specialty care by childneurologists: a workforce analysis. Neurology2005;64:942–948.

25. Pletcher BA, Rimsza ME, Cull WL et al. Primary carepediatricians’ satisfaction with subspecialty care,perceived supply, and barriers to care. J Pediatr2010;156:1011–1015.e1.

26. Wachter K. Wait time for new pediatric derm patients is6–8 weeks. Skin and Allergy News [online]. http://skin.

gcnpublishing.com/fileadmin/content_pdf/archive_pdf/vol40iss8/70364_main.pdf. Accessed on July 17, 2012

27. Groves D. Pediatric subspecialty shortages affect accessto care. National Association of Children’s Hospitalsand Related Information (NACHRI) [online]. http://www.childrenshospitals.net/Content/ContentFolders34/BenchmarkingData/AnnualSurvey/pediatric_subspe-cialty_poster.pdf. Accessed on May 28, 2012.

28. Sugarman JL, Pope E, Lo V et al. Impediments toresearch in pediatric dermatology: the results of asurvey of the members of the Society for PediatricDermatology. Pediatr Dermatol 2010;27:337–340.

29. HiltonL.Pediatric dermatology, a growing subspecialty,faces challenges. Dermatology Times [online]. http://www.modernmedicine.com/modernmedicine/Modern+Medicine+Now/Pediatric-dermatology-a-growing-subspecialty-faces/ArticleStandard/Article/detail/665031. Accessed on September 12, 2011.

30. Pariser RJ, Pariser DM. Primary care physicians’ errorsin handling cutaneous disorders. A prospective survey. JAm Acad Dermatol 1987;1:239–245.

31. Chau M, Thampi K, Wight VR. Basic facts about low-income children 2009: children under age 18. NationalCenter for Children in Poverty [online]. http://www.nccp.org/publications/pub_975.html. Accessed on Sep-tember 21, 2011.

32. Agency for Healthcare Research and Quality. Care ofchildren and adolescents in U.S. hospitals. HealthcareCost and Utilization Project Fact Book No. 4 [online].http://www.ahrq.gov/data/hcup/factbk4/. Accessed onSeptember 25, 2011.

33. Bisgaier J, Rhodes KV. Auditing access to specialty carefor children with public insurance. N Engl J Med2011;364:2324–2333.

34. U.S. Government Accountability Office. Medicaid andCHIP: most physicians serve covered children but havedifficulty referring them for specialty care. Report toCongressional Committees [online]. http://www.aap.org/workforce/GAO_Report_Medicaid_CH_June2011.pdf. Accessed on October 17, 2011.

35. Chaudhry SB, Armbrecht ES, Shin Y et al. Pediatricaccess to dermatologists: medicaid versus private insur-ance. J Am Acad Dermatol 2013;68:738–748.

36. Accreditation Council for Graduate Medical Education(ACGME). ACGME program requirements for grad-uate medical education in dermatology [online]. http://www.acgme.org/acWebsite/downloads/RRC_progReq/080dermatology_07012007.pdf. Accessed on September17, 2011.

37. Accreditation Council for Graduate Medical Education(ACGME). ACGMEprogram requirements for graduatemedical education in pediatrics [online]. http://www.acgme.org/acWebsite/downloads/RRC_progReq/320_pediatrics_07012007.pdf. Accessed on September 18,2011.

38. Katzen D. Benefits of cooperation between pediatricand dermatology staff. Pediatr Dermatol 1983;1:179.


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