Commentary to “patients seen and lessons learned”

Patients seen and lessons learned addition, there were large areas that were warm, tender, and red. The woman had a history of atopic dermatitis and was experiencing a generalized flare of her condition. In addition, several areas were suggestive of secondary impetiginization or cellulitis or both. I discussed my evaluation with the medicine resident who followed my recommendations for treatment: admission to the hospital to receive intravenous antibiotics and topical management with repeated application of a midstrength corticosteroid cream to the involved skin areas. The patient’s condition improved. When she saw me again, she thanked me profusely and mentioned that, bNobody else in the other hospitals seemed to know what I had.Q The diagnosis and management of a patient with a dermatologic disease can be challenging to the primary care physician. The trained eye of a dermatologist may appreciate subtle skin findings that could otherwise be missed or misinterpreted by a physician who has not specialized in cutaneous medicine. Regardless of the severity of the condition, a new or return visit to a dermatologist is more time efficient per visit than a visit to an established primary care provider for treatment of a skin problem.1 The relative difficulty for primary care physicians in managing skin problems is furthermore reflected by their numerous referrals to dermatologists for patients with common skin problems and by the greater likelihood of referral for skin disorders than for other medical disorders.2 Unfortunately, managed care threatens to reduce specialists’ services to save costs.3,4 Potential misdiagnosis and mismanagement could, however, harm the patient and even cause costs to skyrocket rather than decrease. The high rates of referral per episode of care by primary care physicians support the cost-effectiveness of dermatologists in treating skin conditions.2 In some situations, it has been noted that managed care has created a competitive, instead of a collegial, relationship between dermatologists and primary care physicians.5 The placement of financial incentives on primary care physicians as gatekeepers in capitated risk-bearing insurance systems is a potential factor in fostering this unhealthy relationship. Unfortunately, this type of competition between the specialists and generalists usually does not result in a good outcome with regards to patient care.

145 5. Feldman SR, Coates ML, Fleischer Jr AB, et al. Comparing the diagnostic accuracy of dermatologists and nondermatologists. Arch Dermatol 2001;137:1645 - 6.

Jashin J. Wu, MD, was born and raised in Waynesburg, Pa, a small rural town 40 miles south of Pittsburgh, Pa. After graduating from the 7-year BA/MD Honors Program in Medical Education at Northwestern University in Evanston and Chicago, Ill, he completed his internal medicine internship at Baylor College of Medicine and a clinical research fellowship with Dr Stephen K. Tyring in Houston, Tex. Afterward, he completed a clinical research fellowship with Dr Gerald D. Weinstein at the University of California, Irvine, in Irvine, Calif; currently, he is a dermatology resident there. Stephen K. Tyring, MD, PhD, MBA, earned a BA at the Indiana State University, Terre Haute, Ind; MS in Biology/ Chemistry at the Abilene Christian University, Abilene, Tex; PhD in Medical Microbiology at the Texas Tech University, Lubbock, Tex; MD at the University of Texas Medical Branch, Galveston, Tex; and MBA at the Rice University, Houston, Tex. He completed dermatology residency at the University of Alabama in Birmingham, Ala. Dr Tyring is a world-renowned leader and an NIH-supported researcher in viral diseases, focusing on human papilloma virus, oral and genital herpes, and herpes zoster. Dr Tyring has published more than 500 journal articles, book chapters, and books. He is also on the editorial board of several journals. He is currently the medical director of the Center for Clinical Studies, Houston, Tex, and is a Professor of Dermatology at the University of Texas Health Science Center, Houston, Houston, Tex.

Commentary to b patients seen and lessons learnedQ QQ A pair of vignettes is presented by Drs Wu and Tyring. Dr Wu’s career choice and insight into medical management were effected by his interaction with these patients.1 During his fellowship, which was directed by Dr Tyring, Dr Wu had the opportunity to describe the lessons he had learned. Many physicians have been significantly influenced by a mentor or a patient or both. Indeed, the impact of that individual’s relationship to us often persists long after the specific encounter has passed. In addition, it should not be forgotten how physicians can and do influence those with whom they interact—their patients, their colleagues, and their students. Philip R. Cohen, MD Bellaire, TX 77401-2806, USA E-mail address: [email protected]

References 1. Feldman SR, Fleischer Jr AB, Young AC, et al. Time-efficiency of nondermatologists compared with dermatologists in the care of skin disease. J Am Acad Dermatol 1999;40:194 - 9. 2. Feldman SR, Fleischer Jr AB, Chen JG. The gatekeeper model is inefficient for the delivery of dermatologic services. J Am Acad Dermatol 1999;40:426 - 32. 3. Fivenson D, Goldberg Arnold RJ, Kaniecki DJ, et al. The effect of atopic dermatitis on total burden of illness and quality of life on adults and children in a large managed care organization. J Manag Care Pharm 2002;8:333 - 42. 4. Emmet SD. How to survive and thrive under managed care: lessons from U.S. dermatologists. J Dermatol 1999;26:753 - 6.

DOI of original article: 10.1016/j.clindermatol.2006.08.003

Reference 1. Wu JJ, Tyring SK. Patients seen and lessons learned. Clin Dermatol 2007; 25:144 - 5.

Please submit contributions to this section to Philip R. Cohen, MD, E-mail address: [email protected]