Dermatology practice is thriving post-pandemic, as patients return to clinics for basic and procedural care after many months of lockdowns. With practices now able to see patients, however, the challenge of access to care has actually worsened for people living in rural areas. Robert T. Brodell, MD, FAAD, made a presentation at the 2021 Summer Meeting of the American Academy of Dermatology (AAD) held in Tampa, FL, on the novel approaches taken by the University of Mississippi, Department of Dermatology to address this problem. Most importantly, they have developed a rural residency track designed to attract dermatologists with an interest in practicing in the one of the most rural and impoverished states in the US.
“The well documented problems related to access to care in rural areas are the result of many things,” said Dr Brodell, who attributed it largely to attempts to put square pegs in round holes. “It is impossible to recruit dermatologists to practice in areas where they don’t want to live. Our residency training programs in big cities often attract ‘big city’ medical students who go on to practice in the city. If somebody wants to go to a different Broadway show every night–you can’t do that in rural America.” As a solution, he suggested recruiting medical students from small towns into programs in which they learn dermatology for rural areas, as they are more likely to be comfortable practicing in these same areas.
Limited Rural Access to Traditional Dermatology
Mississippi is largely a rural state, with many people living in areas 2 or more hours from the nearest major city where dermatology centers are located. “The question is, does that make a difference?” Dr Brodell asked. “Well, it turns out that melanomas are often found at a later stage in people from rural areas, as patients tend to ignore symptoms and signs longer when visiting a physician is not convenient. And of course, patients with thicker melanoma are more likely to develop metastatic melanoma, leading to considerable morbidity and mortality. Over and over again in rural Mississippi we see issues related to access to care associated with delayed diagnosis and delayed treatment.”
Serving Rural Communities
Telederamatology was already in use before the pandemic and seems an ideal platform for serving rural patients, but according to Dr Brodell, it has not worked out that way. “When the federal government removed a lot of the rules related to telehealth, it was expected this would lead to a renaissance in caring for people in rural areas, but actually, teledermatology was just not quite ready for primetime.” The same staffing issues exist in teledermatology as in regular in person office visits: someone is needed to check in patients, take histories, and cue multiple patients for the clinician to visit sequentially. “I think that synchronous teledermatology could be quite successful with significantly more support staff. During the pandemic, however, my university went the opposite way. They didn’t know how long it was going to be before we could see patients in the clinic, so we had a hiring freeze to minimize staff expenses during a period when income was reduced,” he said.
Dr Brodell also noted a number of problems that have developed with the unchecked use of direct-to-consumer teledermatology. He cited an article from the University of California, San Francisco1 in which patients who signed on and provided images for evaluation did not know anything about the doctor who provided their care or if the recipient was even a dermatologist, or what country they were practicing from. Many sites were not sending a note to the primary care doctor for follow-up and, in fact, many sites did not even ask the name and address of the patient’s primary care doctor. Diagnoses were frequently based on the images alone, without any knowledge of patient histories.
A Novel Approach to Providing Rural Access
“What we’ve done in Mississippi is store-and-forward telehealth to primary care doctors in rural areas,” Dr Brodell explained, noting that their peak caseload was about 350 a year. The PCs send clinical images along with a brief history to the telehealth department to be entered into EPIC (electronic health record platform), with a consultation report from the dermatologist delivered within 48 hours. “We found that about 80% of the time we could significantly help the primary care physician manage the patient, but 20% of the time we couldn’t.”
So, in Mississippi the approach to rural care became “all of the above.” It started with telehealth, connecting university dermatologists with primary care physicians in rural areas across the state. Other approaches Dr Brodell described included:
· A free clinic staffed once a month in the Delta, the poorest part of Mississippi. For the 20% of teledermatology patients who needed to see the dermatologist, clinicians were in their community on a regular basis to help. A 12-member faculty of physicians and NPs each attend this clinic 1 day per year.
· Project Echo – a program developed in Arizona in which primary care doctors around the state participate in a “grand rounds” style teleconference once a month at lunchtime in their offices. It starts with a 5 to7 minute presentation about 1 of the top 10 dermatologic diseases. The dermatologists then do case reviews using images submitted by the primary care physicians in a collegial and collaborative manner. The idea behind this programs is to train local PCs to take on more of the routine dermatologic screening and patient education to better serve the rural patients and reserve the limited dermatologic services for higher-level needs.
Yet another innovative approach came from a resident who wanted to return home to practice. “About 7 years ago, I got a call from Adam Byrd, MD who was graduating from a dermatology/internal medicine 5-year combined program that allowed him to be double-board eligible. He said he wanted to come home to work in the rural community of Louisville, Mississippi,” said Dr Brodell, who instantly embraced the idea. “We devised a position for him that would make him an academic physician with all the rights and privileges of every other academic dermatologist on my department faculty, only he would be 90 miles from the university.”
Despite the challenges, the program has been enormously successful. “He’s running this practice at about the 96th percentile compared with academic dermatologists in the United States, extending the reach of our academic dermatologists. Picture a busy clinical practice with rotating dermatology residents, family practice residents, internal medicine residents, and medical students learning the highest quality dermatology skills in rural America!”
The last part of “all of the above” is the University of Mississippi Department of Dermatology rural residency track, Dr Brodell continued. “Early in medical school, we talk to medical students in the dermatology interest group and identify students from rural areas who might want to become a dermatologist and then go into practice back home, like Adam Byrd did.” He explained that 1 dermatology resident each year matches into this program with the expressed intent of returning to their rural hometown in Mississippi. They spend 3 months each year during 3 years of training working in the rural academic dermatology office and then commit to 3 years practicing in their home town at the end of their training as a university dermatologist.
The success of the University of Mississippi Medical Center approach has been borne out by the numbers of patients served. The free clinic now sees about 180 patients a year, and the teledermatology store-and-forward program serves another 200 to 350 patients. Project ECHO has been training 8 to 10 primary care doctors around the state to improve their dermatology skills for routine care.
Adam Byrd sees about 5000 patients a year at his Louisville clinic, Dr Brodell said. “Start multiplying this impact by the residents in the rural residency track pipeline. In the next 5 years, there will be 4 more. Five university dermatologists times 5000—means we will soon be seeing 25,000 people/year in rural Mississippi. Now that is a significant impact!”
Resneck JS, Abrouk M, Steuer M, et al. Choice, Transparency, Coordination, and Quality Among Direct-to-Consumer Telemedicine Websites and Apps Treating Skin Disease. JAMA Dermatol. 2016 07 01;152(7):768-75.