Stronger networking between dermatologists and primary care providers can improve care patients receive
By Ruth Carol, contributing writer, November 01, 2012
As the demand for dermatologic care grows and the number of dermatologists doesn’t, dermatologists will likely find themselves working more closely with their primary care colleagues. Dermatologists and primary care physicians agreed, though, that with a few simple steps, among which education is key, dermatologists can put their best collaborative foot forward.
Millions more people are expected to join the ranks of the insured through state-based insurance exchanges and the expansion of Medicaid as the Affordable Care Act rolls out. Add to that the aging of the population and growing skin cancer epidemic. Throw into the mix the creation of innovative care delivery systems and payment models such as patient-centered medical homes and accountable care organizations (ACOs). What is the result? A demand for services that couldn’t possibly be met by a specialty that is already experiencing an average national wait time of more than 29 days for new patient appointments and approximately 16 days for established patient appointments, according to the AAD’s 2012 Dermatology Practice Profile Survey.
But dermatologists can help fill the care gaps by strategically working with primary care physicians (PCPs), general internists, family physicians, and the like. [pagebreak]
Common skin conditions PCPs treat
Randall Roenigk, MD, the Robert H. Kieckhefer Professor in the department of dermatology at Mayo Clinic in Rochester, Minn., points out that PCPs already treat many common dermatologic conditions such as acne, warts, and dermatitis. “They are usually willing to initiate therapy for common problems, but happy to refer complex cases,” he said.
Primary care physicians are quite capable of treating eczema, psoriasis, and acne as long as they are not severe or refractory cases, according to Robert Sidbury MD, MPH, associate professor in the department of pediatrics and chief of the division of dermatology at Seattle Children’s Hospital. The same is true for hives, warts, and molluscum lesions because if those are missed initially, they are not life-threatening and will become apparent soon enough. In fact, some dermatologists prefer that PCPs treat common skin conditions so that they can focus on their more complicated patients. Any conditions with pigmented lesions, however, should be treated with caution by PCPs because such lesions could be melanoma, he added.
Every PCP has his or her own comfort level in terms of diagnosing and treating dermatological conditions, noted Nerissa Collins, MD, an internist at Mayo Clinic. That comfort level is based on one’s knowledge of skin diseases and the availability of necessary equipment and supplies to diagnose and treat them. Minor and limited skin conditions can usually be handled within the realm of the PCP, she said. But skin conditions that are more generalized and widespread, or moderate to severe, as well as changing pigmented lesions or ones that have an unusual appearance, should be referred to a dermatologist, she said. Similarly, a patient who has a bullous disease, systemic symptoms in conjunction with a skin disease, or any condition that requires treatment with phototherapy or immunosuppressants should be sent straight to the dermatologist, Dr. Collins said. [pagebreak]
Karen Edison, MD, chair of the department of dermatology at the University of Missouri, agrees that the type of skin conditions PCPs treat depends on their training, comfort level, and experience. “I know a PCP who has taught herself a lot about dermatology. She refers only the most acute cases or difficult-to-treat patients. I also know several other PCPs who admittedly don’t know much about dermatology and refer pretty much everything.”
Internists and PCPs who haven’t rotated in dermatology are at a disadvantage when they go into practice, noted Dr. Edison, who routinely asks family and internal medicine graduates what they wished they had learned more about in training. “When asked what field they would like to know more about, dermatology is typically the first or second answer,” she said.
Because doctors are finding themselves poorly equipped to deal with skin issues once they graduate, there is a push to increase the number of medical students doing a dermatology rotation and to have residents do more dermatology training, Dr. Sidbury said. At the practice level, dermatologists can conduct focused continuing medical education lectures for primary care practices. “It’s a short-term outlay in terms of time, but it will have a long-term benefit because you will become the go-to person in the group,” he said. [pagebreak]
Dr. Edison concurs. “This might be a good time to dust off those lectures you have on basic dermatology and volunteer to give a lecture at your staff meeting,” she said. Dermatologists tend to practice in solo or small groups and therefore are not as connected to the larger health care community. “It’s a good time to be seen as a part of the team and willing to educate others. It’s a good time to get out of the office and be more visible to the other medical staff, and remind others that we’re valuable physicians with a unique expertise. One of the easiest ways to do that is to give a lecture.” Dr. Edison, who also chairs the AAD’s Workforce Task Force, suggested asking referring physicians what they would like to know about dermatology and create a lecture around that topic.
At Advocate Physician Partners, a system-based health care organization, educational sessions presented by dermatologists for family physicians about treating minor dermatologic conditions and providing follow-up care have been well received, noted Debra O’Connor, DO, a family physician at Glenview, Ill.-based Advocate Medical Group and medical director for Advocate Physician Partners at two medical centers. The sessions address up-to-date treatment options and medications as well as recommendations for when referrals are appropriate. It’s not uncommon for a family physician to spot a more serious dermatologic problem, such as a skin cancer or atypical mole(s). The trick is for him or her to recognize when a referral to a dermatologist is appropriate, she added.
Dermatologists at Mayo Clinic not only help educate primary care residents about recognizing and treating skin diseases, but also teach them how to perform simple punch and shave biopsies and use cryotherapy to treat precancerous lesions and warts, Dr. Collins said. She noted that the AAD’s Medical Student Core Curriculum is an excellent resource. The updated curriculum, posted online at www.aad.org/mscc in March, includes 34 modules on a variety of dermatologic topics. Each module has been peer-reviewed, is based on the best available evidence, and includes clinical vignettes and questions providing a practical framework for learning. The information can also be used to generate lectures like the ones Dr. Edison recommends giving. [pagebreak]
Other ways to collaborate
“Instead of just dictating treatment plans for referral cases, consider having a referring PCP spend time in your clinic,” Dr. Sidbury suggested. Although the latter requires more time on the dermatologist’s behalf, the PCP will gain a lot more knowledge about skin conditions. This scenario could also benefit medical students and residents. Another option is to designate one morning a week, for example, to schedule same-day referral appointments, he said. That will require ongoing communication with referring physicians and help build relationships.
As patients and physicians alike get more comfortable with technology, dermatologists can use teledermatology to triage patients, consult, and/or provide direct care, Dr. Edison said. In her experience, PCPs learn basic dermatology quickly from using teledermatology. Consider doing hospital consults, she recommended, if not in-person then by using teledermatology or reviewing high-quality digital photographs.
Dermatologists should think about how to help foster preventive care, such as asking patients if they have a PCP, she said. If they don’t, Dr. Edison provides a list of PCPs who are taking new patients. “That has built more good will with my primary care colleagues than anything else that I have done,” she noted. Be sure to see referred patients in a timely fashion and provide prompt and clear communication back to the referring provider, she said. [pagebreak]
ACOs reward new kinds of consultations, treatment patterns
It’s important to educate PCPs, but sometimes that creates more questions and referrals, noted Alexa Boer Kimball, MD, MPH, a dermatologist at the Medical Dermatology Clinic of Massachusetts General Hospital, which is a founding member of Partners HealthCare, an integrated health care delivery system-turned-ACO. She also points out that there is an impending shortage of PCPs and other physicians. “So simply shifting business from one type of provider to another may not be a particularly efficient way to solve the problem,” she said.
At Massachusetts General, providers are exploring different types of consultative models to manage dermatologic care. “If the patient only has a skin condition, I’m not sure that the PCP’s office is the right place to go because a visit to the PCP charges the system the same as a visit to the dermatologist. Where you start to see the efficiencies is when a patient’s simple dermatologic problem can be managed as part of the routine visit to the PCP,” Dr. Kimball explained. The latter translates into one less visit to the system. One option being explored is the use of teledermatology to evaluate batch cases, as opposed to doing live teledermatology. Providing feedback to the PCPs has already resulted in a substantial improvement in the referral of urgent patients, she added.
One advantage of being in an ACO is that it allows exploration of alternative ways of managing patients that aren’t tied to the current fee-for-service model, Dr. Kimball said. For example, telephone or telederm follow up can be compensated, especially if it replaces what would otherwise require an in-person visit. Decreasing the regulatory burden is another alternative worth exploring, she said: if documentation requirements that did not affect the quality of care were reduced, for example, then physician time per patient could also be reduced and the expense per patient to the system would decrease.
Similarly, Dr. Roenigk maintains that payment mechanisms, such as global payment systems, foster collaboration among providers. “When dermatologists and PCPs work in the same health system there are no competitive issues,” he said. “At Mayo, we have elaborate care process models and an integrated referring system so patients get to the right doctor in a timely fashion.” [pagebreak]
Dermatologists and PCPs have worked together to create criteria for how patients with acne, psoriasis, and dermatitis are best managed. In addition, they developed a nursing protocol to treat warts. Once the provider makes the diagnosis, the patient is seen by the nurse who treats the warts per the protocol. Helping PCPs by suggesting a care plan for common skin conditions, for example, will make them more likely to refer the complex cases or assist in providing follow-up care once the condition is under control, Dr. Roenigk added.
Additionally, dermatologists use electronic health records to perform virtual consultations to assist PCPs after the latter have performed biopsies, thus eliminating an extra consult, he explained. For example, if the PCP performs a biopsy that indicates a lesion is basal cell carcinoma, the dermatologist reviews the biopsy and pathology report electronically to determine how best to remove it, whether by excision, Mohs surgery, or electrodessication and curettage. Using a combination of protocols and electronic health records, the patient is scheduled for the right procedure in a timely manner, he noted. If the patient has an ongoing problem, then he or she should be scheduled to see a dermatologist. If not, the patient returns to the PCP for follow-up care. [pagebreak]
Virtual consults, Dr. Roenigk said, are simply an attempt to make the care more efficient. “We are all on salary so there is no financial incentive for us to do this or anything else. The only incentive is getting the patient to the right doctor and not waste another visit or consult. It takes very little time for the MD to review the medical record but it saves the patient a lot of time. I can do three virtual visits in the time I do one face-to-face visit for a skin cancer check, and I can do it on my own time. The PCPs at Mayo who use this system do not abuse it, either, so it is not an onerous task and they, along with the patient, appreciate getting appropriately triaged to the right place.”
“Primary care physicians will be increasingly treating skin conditions,” Dr. Edison said. “We have a role in making sure that they know how to diagnose and treat basic dermatologic conditions. The most important thing is to start the dialogue with your PCPs and other referring providers to find out how you can best collaborate moving forward.” [pagebreak]
When dermatologists refer
Even a seasoned dermatologist may need to refer to a colleague who has a subspecialty or an area of expertise. Referral networks for dermatologists may include PCPs, family medicine physicians, and internists; other dermatologists; Mohs surgeons; plastic surgeons; oncologists; and ear, nose, and throat specialists.
Nerissa Collins, MD, an internist at Mayo Clinic, has received referrals from dermatologists to determine the cause of a patient’s itch when there are no skin findings. Skin conditions can be the manifestation of underlying disease, such as cancers, autoimmune disorders, or infections, she noted.
As a pediatric dermatologist, Robert Sidbury, MD, MPH, associate professor in the department of pediatrics and chief of the division of dermatology at Seattle Children’s Hospital, receives many referrals from pediatricians and dermatologists alike. “The latter typically refer when the children are very young or they are concerned that the condition is related to a congenital syndrome. They may not have seen enough of the latter to be comfortable treating the patient,” he said.
Regarding melanoma, patients with either Stage III or Stage IV disease should be referred to an oncologist as they may be eligible for adjuvant therapy or clinical trials, according to Michael Ming, MD, director of the Pigmented Lesion Clinic at the Hospital of the University of Pennsylvania in Philadelphia. Patients with a melanoma that is confined to the skin, but with unfavorable prognostic characteristics, could be considered for referral to a melanoma specialist to discuss the possibility of having a sentinel lymph node procedure. Also, “if the pathology diagnosis is ambiguous, or if the management plan is unclear, those would be circumstances where one might refer to a melanoma specialist,” he added.
When PCPs should refer
Robert Sidbury, MD, MPH, associate professor in the department of pediatrics and chief of the division of dermatology at Seattle Children’s Hospital, suggested that certain questions could trigger a referral. For example, if the PCP answers “yes” to any of the following questions, he or she should refer the patient to a dermatologist:
- Is the differential diagnosis list long?
- Does the diagnosis involve morbidity or mortality?
- Has the patient failed initial therapy?
- Does the treatment have a significant risk of adverse effects?
If the PCP is uncertain of the diagnosis, then he or she should refer the patient, as well.