It is more than just a play on words to say that dermatologists represent the changing face of the medical profession. As this issue of Virtual Mentor demonstrates, the advances dermatologists have embraced in their clinical practice and professional milieu place them at medicine's "cutting edge."
Practicing at medicine's cutting edge is fraught with ethical questions and challenges to professionalism. This month's clinical cases and commentary examine three situations that raise ethical red flags. The use of isotretinoin for treating severe acne is one example because the drug can cause birth defects if taken during pregnancy. The FDA-approved iPLEDGE program for managing this risk is so burdensome to physicians, patients, pharmacists and manufacturers that its critics fear dermatologists will refuse to prescribe the treatment despite its demonstrated efficacy. The dilemma of how onerous regulations can be before they become disincentives to valuable therapy is also explored in the policy forum and health law sections of the journal.
As the number of conditions physicians can diagnose and treat effectively increases, so do the number of tests available. Dermatologists are high-volume users of pathology services for diagnosis of cutaneous melanoma, other skin cancers and nonmalignant skin lesions. As such, they are courted by large interstate pathology labs that offer bargain prices (at times, lower than the amount insurers will reimburse) to dermatology clinics and practices that maintain a certain volume of business. Case two discusses the ethical dilemma these offers pose. Physicians who are being squeezed by high malpractice liability premiums on one side and generally low reimbursements on the other may be tempted to bill insurers for as much as they will pay, even if it exceeds the lab charges.
With a burgeoning market for cosmeceuticals and a variety of other enhancing products, dermatologists and dermatologic surgeons are well-positioned to contribute to the debate about the ethics of enhancement. How do we quantify the value of increased self-confidence or an improved sense of personal identity? How should physicians handle medical enhancements for minors? This month's third clinical case examines the guidelines for ethical sales of cosmeceuticals from a physician's practice, and a poignant and thoughtful op-ed challenges the wisdom of parental decisions to alter the facial characteristics of their children with Down syndrome through plastic surgery.
Dermatologists also confront questions about the role of the specialty within the larger profession. Long before 2003 when resident work hours were limited to 80 hours per week, dermatology was known for offering and respecting quality of life—both at work and at home. As the importance of balance in the life of physicians rose to the forefront of professional concerns in the 1990s, so did the rate of residency applications for dermatology, to the point that this specialty is now widely considered one of the most competitive. As the author in the medicine and society section explains, the cause and effect relationship between quality of life and selection of medical specialty is more complicated than it first appears.
In addition to analyzing the state of the specialty, contributors to this issue demonstrate that dermatology continues to push the envelope. Two medical education articles defend opposing positions on dermatology's experimental attempt to ameliorate residency shortages by accepting support from the pharmaceutical industry. The journal discussion elaborates on an article about managing the increased liability that dermatologists incur when they delegate clinical responsibilities to nonphysician health care professionals in their practices. The answers tested here may one day supply a fix for a labor shortage in other specialties.
A chapter from dermatology's past is retold in the history of medicine section and represents the downside of being a leader in the field. Clinical trials of new skin products were conducted starting in the 1950s and continuing into the 1970s at the Holmesburg prison in Pennsylvania. The inmates who volunteered and were paid for their participation in the studies were not fully informed about the risks involved in the experiments. These trials contributed to the growing awareness of the ethical hazards inherent in using members of vulnerable populations in research and led to the codification of protections for human research subjects. Finally, a fictional cautionary tale, Nathaniel Hawthorne's "The Birthmark," is explicated in the medical humanities section.
Yes, practicing at the cutting edge of medicine can be precarious. One of the best tools for improving the likelihood of benefit from an experiment is open and honest debate about the risks and rewards, background of the research and conflicts of interest, (real and potential). The authors in this issue contribute significantly to the important ethical debates arising from the professional and clinical "trials" facing dermatology today.