Top Derm Looks Forward to Educating DermPAs Who Are “Rigorous in Their Thinking”

As the practice of medicine evolves, lifelong learning is required to remain a proficient health care professional. Anyone practicing dermatology has witnessed a dramatic evolution in treatments with the advent of Janus kinase inhibitors and expansion of biologic therapy over the last decade. Continuing medical education (CME) is understandably required to maintain national and state licensing for most health professions. As a physician assistant(PA) for nearly 20 years, I relish the benefit of learning from experts and applying their knowledge to my practice. In fact, I enjoy attending Society of Dermatology Physician Assistants (SDPA) conferences because of the caliber of faculty they attract. For example,I recently had the pleasure of speaking with Arash Mostaghimi, MD,MPA, MPH, conference medical director for the SDPA Annual Summer Dermatology Conference in Boston, MA, June 22–25, 2023. Dr Mostaghimi, director of inpatient dermatology services at Brigham and Women’s Hospital, is a Harvard Medical School professor who serves as codirector of the complex medical dermatology fellowship program. Below is an excerpt from our recent conversation on SDPA’s upcoming CME conference.

Medical Stewardship

The World Health Organization defines stewardship as “the careful and responsible management of the well-being of the population.”Many of us became keenly aware of the importance of stewardship of health care resources during the COVID-19 pandemic when we faced mask and personal protective equipment shortages. I asked Dr Mostaghimi to apply this lesson to medication stewardship in our daily practices with patients. “Medication stewardship is a concept that was completely disregarded when I was in training. We had the general concept that you do not want to overuse certain types of antibiotics, but the rest of the time you were taught that you literally only focus on the patient in front of you when you are seeing them and nobody else. While I do agree that individual patient care is each clinician’s primary responsibility, it has increasingly become clear that we need to keep in mind population-level impacts when thinking about drug safety and costs."

Dr Mostaghimi went on to explain, “What we do and how we think about our patients has implications not just for the patient in front of us, but for all our patients. Individual choices about care impact costs and access to care for everyone. For example, when I tell a patient to come back in 3 months, I am indirectly saying that I want that patient to return and not someone else in that slot, because my clinic is going to be 100% booked. From a patient care standpoint, it is not appropriate to say that you do not want your patient to come back solely so you can save a slot for someone else. But from a stewardship standpoint, you can examine that decision closely. Sure, the patient needs to come back, but do I really need to see them in 3 months? If not, would 4 months or 6 months do? These simple changes may lead to access for many more patients. For example, we put a lot of people on yearly skin checks. Is a yearly skin check necessarily all that different from every 14 months or 16 months? Probably not. We certainly do not have data to suggest that it is. Instead of squeezing in patients before or after clinic because we do not have access, let’s work smarter and expand access across the population. That takes a different part of our brain—it is a new way of examining the world. If you are doing what is 100% appropriate for the person in front of you but it also has some benefits for the society at large, why not take the win-win?”

Growing Demand for Skin Health

The demand for dermatology providers is growing throughout the United States. A 2016 analysis predicted a substantial shortage of dermatologists in the next 30 years that could negatively impact 25% of anticipated demand.¹ Dr Mostaghimi reports, “While we do have a buildup of dermatology physicians in certain cities, even in cities such as Boston, where we have the highest per capita of dermatologists, it still can still take up to 6 months to get in to see someone.We are still dealing with pent-up demand after COVID and staffing shortages, which can make it hard to run a clinic efficiently. How do we deal with this as dermatologists? How can we work to build back a robust system for as many people as we can? These are the questions that are going to define our field over the next decade.”

Benefits of SDPA Conferences

Dr Mostaghimi’s response to my question about the value of attending SDPA conferences made me proud to be a PA. “What I really loved about participating in the 2021 LA SDPA conference [SDPA’s 19th Annual Fall Dermatology Conference in Los Angeles,CA] and what I think may be a cultural difference between PAs and physicians is...I write a lot of papers and do a lot of research that challenges our current practice and the decisions we make and how we do it. Whenever I write something that is particularly evocative, I get 2 sets of responses. One group of people will say, ‘Thank you for publishing this, it was great. I have known this for years and it has been my practice, and this supports it.’ Another group of people will say, ‘I do it totally differently, and I disagree.This is not consistent with how I like to practice.’ That is a view-point, not something based on facts. At SDPA, whether it is differences in training, or outlook, or the type who become PAs, the interactions and responses were different. I was really excited to talk to a group of people who were rigorous in their thinking and who were looking for better and more creative ways of doing things. For me, it was joyful and made me excited about engaging with SDPA in a deeper fashion for the upcoming conference in Boston.”

Addressing Dermatopathology

In my opinion and experience as an educator and provider, pathology is lacking in most PA’s training, mainly due to the condensed nature of our schooling. As such, I was excited to learn that Dr Mostaghimi will discuss dermatopathology at SDPA 2023 in Boston. When asked if he has any tips for resources or approaches for PAs to help fill the knowledge gap in this field, Dr Mostaghimi responded, “My secret is this: I am not a dermatopathologist, right? I think that puts me in a unique position to give that talk because my focus will be, ‘How do you partner with your dermatopathologist to help you make the best choices and decisions?’ ...From my perspective, while having a baseline literacy of understanding how different disease morphology is reflected in biopsy specimens and vice-versa, it is most important to correlate what you see visually with what is reflected in the biopsy. Dermatopathology is not always a gold standard—when we get a result, the next step is not to shutdown our thinking and assume that the read is the ‘answer’ but to incorporate the data into an overall assessment of the patient. Instead of dermatopathology being the answer, it is more akin to any other laboratory result that I get.” Dr Mostaghimi’s lectures on dermatopathology include “Introduction to Dermatopathology: Understanding the Pathology Report” and “Basic Biopsy Tips and Advanced Dermatopathology: Beyond the H&E.”

The Crystal Ball

Dr Mostaghimi will deliver a highly anticipated lecture on the future of dermatology, where he will tap into his deep expertise to share his thoughts on years to come. When asked about the future of advanced practice providers (APPs) and specifically PAs in dermatology, Dr Mostaghimi prefaced his response with, “The greatest thing about giving a talk about the future of something is that people can always point out how you were wrong a few years later.” He went on to discuss how he sees the future of dermatology focusing on 2 stories, including the “reprise of the role of APPs” with a focus on proper training, education, and support and dermatology’s interface with artificial intelligence (AI). He sees a future in which AI will play a role in making decisions around triage, screening, and surveillance. “What it means for us is that we must choose how we deal with this new technology. While I think most clinicians will fight it or ignore it, my philosophy on these types of larger, more existential changes is that you embrace it. When APPs entered dermatology, many physicians chose to fight their inclusion or ignore them altogether. I embrace the APP community and I want you to learn as much as possible to take the best care of patients. Similarly, we need to get in on the ground floor with the introduction of augmented reality and AI to make sure that we build, validate, and implement these technologies in a thoughtful manner that provides value and care for the patient in a way that we want.” After this preview of the SDPA Annual Summer Dermatology Conference, I am ready to embrace more learning and ask more questions. As Indira Gandhi said, “The power to question is the basis of all human progress.”

Reference

1. Sargen MR, Lucy S, Hooker RS, Chen SC. The dermatology workforce supply model: 2015–2030. Dermatol Online J. 2017; 23(9):1-7.