Help needed
As rural America seeks dermatologists, increasing rural residency tracks may steer them there.
Feature
By Ruth Carol, Contributing Writer, May 1, 2023
Looking to treat grateful patients who present with a mix of diverse and challenging cases? Hoping to offer training opportunities for dermatology residents? Willing to work at a profitable solo practice with a high degree of autonomy? If so, rural America is calling. Dermatologists practicing in rural areas can do all the above; they just haven’t had that many role models demonstrating their success, noted Robert Brodell, MD, FAAD, co-founder of the rural dermatology residency program at the University of Mississippi Medical Center (UMMC) in Jackson. Dr. Brodell, and others, are out to change that. But it’s going to take more than trying to convince dermatology residents from big cities to relocate and embrace hiking, fishing, farming, and the like.
Big city appeal
Recent growth in the number of dermatology residency positions has led to a modest expansion of the workforce, representing a 1.6% annual increase since 2010, according to the most recent dermatology workforce report. Still, dermatologists remain maldistributed across the United States, particularly in rural areas, where the density gap for general dermatologists and Mohs surgeons is expanding. Urban areas have more than 40 times the number of dermatologists per 100,000 citizens compared to rural areas.
Most dermatologists work in single-specialty and multi-specialty private practices — practice models that are concentrated in well-resourced, urban communities. It doesn’t help that recent graduates are more likely to practice in academic settings, which also tend to be in urban areas, and are less likely to practice in solo settings. Barriers to opening a solo practice include significant start-up costs, insurance complexity and billing requirements, and myriad government regulations, Dr. Brodell said. Additionally, studies show that physicians tend to practice in the area where they train.
And then there are the myths of training and practicing in rural communities that keep dermatologists at bay. Among them are that metropolitan areas offer greater professional opportunities, including more diverse and challenging patients, as well as research and teaching opportunities. “We have data showing that the first-year rural dermatology resident does three times more excisions than residents in Jackson,” Dr. Brodell stated. They perform many more procedures than listed in the common training program requirements.
Mary Logue, MD, FAAD, who has been practicing in rural North Dakota for a little more than a year, serves as clinical faculty at the University of North Dakota (UND) and volunteer faculty at the University of New Mexico (UNM) from where she graduated. Dr. Logue leads Nodak Kodaks, quarterly Kodachrome sessions for UNM dermatology residents. She has medical students rotate through her dermatology clinic affiliated with Trinity Hospital and hopes to have dermatology residents do the same someday. Dr. Logue engages in community education, ranging from teaching skin care to pregnant mothers as part of the hospital’s prenatal program, high school students in health class, and grade-school children at the public library, as well as conducting skin cancer screenings. “Living in a rural community has not limited my professional opportunities by any means,” said Dr. Logue, who grew up in rural central Illinois.
“Living in a rural community has not limited my professional opportunities by any means.”
What living in a rural community does limit is patients’ access to dermatologic care, which can have dire consequences. Fewer dermatologists practicing in rural areas may cause patients to postpone or forgo preventive screening or specialty care, leading to treatment delays and disease progression. Studies have shown that increased distance to dermatologic care is associated with a higher number of diagnosed melanomas and thicker Breslow depth at the time of diagnosis as well as increased mortality from melanoma and Merkel cell carcinoma. But even a delay in diagnosis and treatment for common skin diseases, such as psoriasis and eczema, severely decreases a person’s quality of life, Dr. Logue added. Studies suggest that wait times for new patient appointments in rural areas tend to be longer than those for patients in urban or suburban locations.
One program at a time
Although increasing access to dermatologic care in rural areas requires a multi-pronged approach, one successful strategy has been to increase the number of partnerships between existing residency programs and rural regional medical centers that have difficulty recruiting dermatologists.
One such model is the UMMC rural residency program that was established in 2013. Each year, one of five dermatology residents is in the rural track. They spend three contiguous months each year of their training at a satellite clinic run by Adam Byrd, MD, FAAD, in Louisville, Mississippi, and the remaining nine months training in Jackson at “the mothership program,” Dr. Brodell explained. “You can’t train a resident entirely in a rural area because they need exposure to Mohs surgery, cosmetics, pediatrics, complex hospital dermatology, dermatopathology, and hospital consults,” Dr. Byrd said. “You won’t find all of that in a rural area.” Because travel is essential, residents receive a housing stipend to cover costs when they are in Louisville. One resident purchased a recreational vehicle, one lived with a family member, and another stayed in a hotel. About half of the UMMC dermatology residents rotate in Dr. Byrd’s clinic, including those who are not in the rural dermatology track. Rural trainees are expected to serve at least three years at a rural location upon graduation at a site mutually agreed upon by the resident and UMMC.
“These are people we hand pick,” Dr. Brodell said. “They grew up in a rural area and want to return to their roots. Now they’re training with someone who loves working in a rural community. After three years, they can go elsewhere, but why would they?” he asked.
Today, the UMMC program serves 55,000 patients a year, with thousands of Mohs and excisional surgeries and hundreds of patch tests performed annually. The faculty and trainees account for 40% of dermatologists in the entire state. About 4,000 patient visits per year are performed at the rural academic office staffed by Dr. Byrd. Moving forward, the plan is for UMMC to establish a satellite clinic or solo practice in another rural area where residents can work after graduating, Dr. Brodell said.
Dr. Logue finds herself in the ER to treat a special patient
Last July, Dr. Logue met her most memorable patient who turned out to be one of her most challenging cases. That’s when she met “Addi,” a sweet eight-year-old girl who suffered a severe blast injury after fireworks exploded in her face. Addi was referred to Dr. Logue after she received stitches and was stabilized at the nearest rural emergency room by an inexperienced PA. Time was of the essence if Dr. Logue had any chance of minimizing scarring and traumatic tattoos, which become more difficult to remove after 72 hours. She credits her staff with triaging the referral to get Addi to Trinity Hospital as soon as possible. Without a pediatric plastic surgeon in the area to call on, early the next morning, Dr. Logue was in the emergency room (ER) performing a debridement with the help of the hospital’s ER clinicians and staff, who were very accommodating given the unusual nature of the case. “You usually don’t expect a dermatologist to be in the ER,” Dr. Logue said, “but sometimes as a rural dermatologist, you have to work with what you have in a pinch.” Addi needed conscious sedation to tolerate the dermabrasion. “I ended up having to debride 90% of her face to improve scarring and minimize traumatic tattoos,” Dr. Logue said. Following the procedure, Dr. Logue made herself available to Addi’s parents to help navigate her follow-up care with the Mayo Clinic on her road to recovery, and still keeps in touch. In fact, Dr. Logue recently ran into Addi’s mom while out for dinner in their small town.
The secret sauce of the rural dermatology track is a three-way partnership among a university, local hospital, and promising medical student, Dr. Byrd stated. A department chair doesn’t have the authority to buy property and build a clinic on it; trying to obtain approval is nearly impossible due to bureaucracy. Dr. Byrd knows because he tried. On the other hand, a small-town hospital can more easily find the space by either building a clinic or housing it in an existing building. As an example, Dr. Byrd works in a university clinic in a building owned by the local hospital. Hospital administrators know the local high school and college students, he said, so they can identify promising individuals who the university can pay to train.
Until recently, the UMMC program was the only rural one of the 142 accredited dermatology programs in the U.S. But both St. Louis University in Missouri and the University of Alabama at Birmingham (UAB) are starting a rural residency track. This year, they will match their first residents. At UAB, the resident will spend one to three months training at satellite locations in rural/underserved areas and the bulk of the time training at UAB. The resident will receive a housing stipend as part of the rural/underserved residency track, which is sponsored by the Alabama Dermatology Society (ADS). Before training commences in July 2024, the resident will sign an agreement with the ADS promising to work in either a rural or dermatologically underserved area of Alabama for three years following graduation. “We hope when the resident graduates, they will serve as a mentor to the new residents, growing the program exponentially,” noted Lauren Kole, MD, FAAD, director of UAB’s dermatology residency program. “There’s a huge demand for dermatologists in the state,” she said. “The ADS recognized that dermatologists are more heavily concentrated in urban areas, and this was a way for them to help support a rural patient population and encourage dermatologists to work in underserved areas.”
Increasing government funding would enable rural residency training opportunities to proliferate, Dr. Byrd said. So would developing incentives for faculty to train residents in rural areas, Dr. Logue added. She can accommodate residents to rotate in her Minot practice but hasn’t had any yet in large part because UND’s medical school doesn’t have a dermatology program. Her long-term goal is to accommodate dermatology residents from urban programs across the country who are interested in using their elective time to gain experience in rural practice, and just maybe feel inspired to return to a rural community.
Recruit from within
Encouraged that the rural dermatology track may finally be catching on, Dr. Brodell stressed the importance of targeting residents with rural ties. He modeled the UMMC program after the first rural residency program that started in Loma Linda, California, in 2007. The program failed because many residents once they graduated did not follow through on their commitment to practice in rural communities, he said. Lesson learned. “You need to pick people from rural areas whose families are still there and who want to return to their hometown to practice,” Dr. Brodell said.
Dr. Logue concurred. “The evidence we do have consistently shows that those with strong rural ties are the ones who return to their communities, or move to a similar one, to practice,” she said. “But that’s not to say that residents who don’t come from a rural community won’t fall in love with or feel inspired by a small town, but they need the actual exposure for that to happen.”
Recruiting for rural dermatology positions should begin in high school, said Dr. Byrd, speaking from experience. He went to medical school to become a primary care physician (PCP) with a focus on skin disease. Instead, he became double-boarded in internal medicine and dermatology. Dr. Byrd knew he could have a thriving primary care practice in his hometown but wasn’t sure he could have a viable practice as a full-time dermatologist. “If more people knew these opportunities were possible, they would take advantage of them,” Dr. Byrd said.
Are NPs, PAs improving dermatologic access in rural areas?
The Academy has been working on scope of practice issues for the last two decades, noted Lisa Albany, JD, the AADA’s director of state policy. For much of that time, NPs have been seeking independent practice in states across the country. In the last few years PAs, especially in rural states, have joined them.
Their primary argument for being able to practice independently is that they will improve access to dermatologic care. “This argument really resonates with legislators because they want their constituents to have access to health care,” she said. Many legislators don’t necessarily appreciate how significant the differences in education and training are between dermatologists and non-physician clinicians, and how those differences lead to quality care issues and higher health care costs, Albany added.
While NPs and PAs may have been sold as a solution to improving dermatologic care in rural areas, the reality is quite different. According to the geographic mapping initiative of the American Medical Association (AMA), non-physician clinicians are not located in rural or underserved areas, but rather are concentrated in the same geographic areas as physicians. It’s true even in states that allow NPs to work independently. The AMA has studied this in 2013, 2018, and 2020, all with the same results.
Other strategies
When Dr. Brodell joined UMMC nearly 11 years ago, the dean said that it was his responsibility to take care of all Mississippians, not just those in Jackson. Dr. Brodell continues to try innovative ways to reach patients in the most rural parts of the state. Six years ago, UMMC established a university clinic in the Mississippi delta, one of poorest parts of Mississippi, where there aren’t any practicing dermatologists. The dermatology department staff volunteer to see patients at the general medicine clinic housed in the local high school and run by nurse practitioners (NP). They are offered incentive pay to make the six-hour trip because they are unable to see their regular patients on the days they volunteer.
One day, a high school teacher presented with a black asymptomatic lesion that turned out to be a thin melanoma. “She was willing to walk down the hallway to see a dermatologist, but wasn’t willing to travel three hours to Jackson,” he said. That walk saved her life because the melanoma was identified early and removed. This clinic also serves telemedicine patients who require in-person appointments.
In the last few years, UAB also opened satellite dermatology clinics to serve patients on the outskirts of the metropolitan area; one is in Montgomery and two are in suburban locations. Dr. Kole has patients who travel hours to see her not only from Alabama, but the Florida panhandle, eastern Mississippi, western Georgia, and western Tennessee.
Studies suggest that telemedicine can be used to enhance dermatologic care for patients living in rural and underserved areas. Ivy Lee, MD, FAAD, knows that firsthand as she has successfully used store-and-forward teledermatology across California working with PCPs to increase access to dermatologic care. In Southern California, she worked with the Department of Health Services to care for patients in primarily agricultural communities on the outskirts of Los Angeles. Within two months of implementing store-and-forward teledermatology for referrals, wait times dropped substantially and patients who required in-person care were fast-tracked. Instead of waiting, on average, nine months to see a dermatologist, patients received a preliminary diagnosis in 48 hours. Approximately 70% of patients did not require an in-person visit, enabling those who had to be seen to get an appointment at a safety net hospital in seven to 10 days. “Teledermatology helps build our capacity to offer and extend our dermatology expertise to patients who don’t have access to care, helping decrease health disparities and improve health care outcomes,” she said. Dr. Lee prefers store-and-forward teledermatology because it relies less on connectivity, which she acknowledged can be problematic.
Dr. Brodell has had modest success using telemedicine for PCP referrals. Working with PCPs is advantageous, he said, because they know the local pharmacies and how to deal with insurance companies. Knowing how great the demand for dermatologic care is in the area, Dr. Brodell questioned why only 350 telemedicine cases were being generated a year. After surveying the PCPs, he streamlined the process for generating telemedicine consultations and cut the response time to one day. The PCPs are happier with the new approach, which Dr. Brodell is confident will increase telemedicine cases.
Dr. Byrd used telemedicine for a few months in the beginning of the COVID-19 pandemic. But he was not a fan, largely due to connectivity issues. “In rural areas, you can’t assume you will have good cell service,” he said.
Working with NPs and physician assistants (PAs) can play a role in increasing access to care in rural communities if they are working under the supervision of a board-certified dermatologist, Dr. Byrd said. The three NPs at UMMC work well under the supervision of the 14 dermatologists in the practice, Dr. Brodell noted. Last fall, Dr. Logue started training an NP to work in her dermatology practice. To date, she has completed Dr. Boswell’s Derm Boot Camp and is enrolled in the Florida Atlantic University Dermatology Nurse Practitioner Certificate Program with the long-term goal of passing the NP dermatology board exam. Working with her NP has decreased patient wait times and freed up Dr. Logue’s time to treat the more complex patients and see her pediatric patients sooner. The NP’s willingness to invest in so much training to offer high-level care at the mid-level has been an asset to the practice, said Dr. Logue, adding, “we complement each other.” In a state that allows NPs to practice unsupervised, Dr. Logue is all too familiar with NPs who do not have any formal training which has resulted in several cases of significant patient harm.
“Grateful people are happy people, and who doesn’t want to have happy patients?”
Practicing in a rural area can be very intimidating. Patients present with more severe disease because they wait longer to see a dermatologist. There is no safety net of specialists to help with challenging cases. At times, it requires MacGyver-like problem-solving skills to treat a patient. On the other hand, patients in rural communities seem to be more grateful than patients elsewhere, Dr. Brodell said, adding, “Grateful people are happy people, and who doesn’t want to have happy patients?” Rural patients might be a little more trusting of their doctor because there aren’t a bunch of them around, Dr. Byrd added. But Dr. Logue summed it up best when she said, “I have the honor of taking care of the community, but I’m also part of this community.”
