Donning many hats

By Andrea Niermeier, Contributing Writer, March 1, 2024

As medicine is constantly evolving, so are the roles of physicians providing the latest treatments to patients. Dermatology is no exception: before it became its own specialty in the 1960s, residents pursued the degree as a subspeciality following internal medicine. Dermatologists had a strong presence in the hospital before the shift to managed care in the 1990s, moving dermatology more to an outpatient setting. Daniela Kroshinsky, MD, MPH, FAAD, president of the Society of Dermatology Hospitalists, commented, “At the same time, the acuity of illnesses coming into the hospital — the extensive skin disease presenting as a result of more complicated management plans for patients around oncology or cutaneous complications of other medications — meant that patients were coming into the hospital sicker. It really generated this conversation for more dermatology access and expertise.”

In 2009, a small group of academic dermatologists with the expertise and interest to manage medically complex patients in the hospital setting came together to coin the term “dermatology hospitalist” and form the Society of Dermatology Hospitalists. Lindy Fox, MD, FAAD, immediate past president of the Society of Dermatology Hospitalists, noted, “It began as a casual group doing the same things and recognizing similar barriers and areas of interest. It was a way for us to communicate around interesting or difficult cases and discuss advocating for this as a subspeciality of dermatology. We found other recent graduates and people practicing who were also interested, taking us from a robust group to a full-fledged society.” Since then, the organization has grown to over 190 members, and inpatient dermatology has become a subspeciality of dermatology, offering physicians the opportunity to develop expertise in the acute management of severe skin disease, increasingly varied therapeutics, and comorbid disorders to deliver high-level care to hospitalized patients.

Teacher, student, collaborator

While dermatology hospitalists differ from other kinds of hospitalists in that they are often a consultative service rather than a primary service in the hospital, the role offers opportunities for multidisciplinary collaboration, research, learning, and teaching. Dr. Fox explained, “As part of expanding the knowledge base in hospital dermatology, physicians can report on observations they have seen, study interventions to improve how care is delivered to patients, and collaborate between institutions to pull information together about a particular disease.” In addition, inpatient dermatology presents the unique opportunity to work with doctors from other specialties within the hospital. Lauren Madigan, MD, FAAD, assistant professor of dermatology at the University of Utah, highlighted, “I’ve had the opportunity to engage in many multidisciplinary publications and research projects with internists, pathologists, endocrinologists, rheumatologists, and oncologists among others. We also lecture to each other’s departments, and it is all because we know each other, work with each other, and respect each other.” Not only is this collaboration beneficial to patients and doctors but also to medical students and dermatology residents. “We regularly sit down with consulting teams in person to discuss patients holistically and are thoughtful in terms of how the skin is impacting their overall health; we also weigh the risks and benefits of treatments in terms of their overall condition. Residents and medical students get to participate in these vital discussions, and it is highly educational.”

Expert in medically complex skin disease

Dr. Madigan emphasized that this dermatologic expertise in medically complex patients is important because of the sheer amount and burden of skin disease that exists in the hospital setting. A 2019 retrospective cohort study that looked at the 2014 National Inpatient Sample revealed over 600,000 hospitalizations principally for skin disease in adults, costing the health care system over $5 billion. Additionally, skin disease was diagnosed in one out of every eight hospitalized adults as either a primary or secondary diagnosis. The most common final diagnoses rendered by dermatology hospitalists each year are high-burden conditions that fall into five categories. These include severe cutaneous drug eruptions such as Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (SJS-TEN), and drug-induced hypersensitivity syndrome (DIHS). Also frequently diagnosed are cutaneous infections such as cellulitis, chronic dermatoses like psoriasis and eczema, contact dermatitis, and vascular disorders including calciphylaxis.

With thousands of dermatologic diagnoses, dermatology hospitalists are trained to understand and recognize all of them, offering diagnostic accuracy that many, like Dr. Kroshinsky, feel cannot be underscored enough. Dr. Madigan mentioned that oftentimes when a hospital dermatologist is called for a consultation, the base description is listed as unknown or rash. “Our colleagues are not only consulting us for procedures and treatment recommendations, they are enlisting our help to formulate an appropriate differential.” Also notable are concordance rates; in only 22-52% of cases does the initial differential match the final diagnosis rendered by the dermatology team, with dermatologist consultants changing treatments in 60-80% of cases. “Fundamentals like getting the right diagnosis and treatment plan are — at its core — the crux of what leads to good outcomes in hospitals,” Dr. Kroshinsky added.

Asset to hospital and patient outcomes

The valuable expertise provided by dermatology hospitalists provides better outcomes for both the patient and the hospital. Misha Rosenbach, MD, FAAD, Paul R. Gross Professor of Dermatology at the University of Pennsylvania, pointed to the data regarding dermatology hospitalists and cellulitis. A cohort study in 2017 found that early dermatology consultation for presumed cellulitis decreased rates of unnecessary antibiotic use by 74.4% and unnecessary hospitalization by 85% in patients with pseudocellulitis. “If dermatology sees these patients, we know that they can give the correct diagnosis, help patients avoid being admitted, reduce complications from antibiotics, and lower costs. The gold standard of diagnosis of cellulitis should include dermatologists because they help improve care.” This better care, in turn, means better management of hospital resources. The same study noted that dermatology-led screening could eliminate 97,000 to 256,000 unnecessary hospitalization days, protect 34,000 to 91,000 patients from unnecessary antibiotic exposure, and save $80 to $210 million annually.

Dr. Rosenbach also recognized inpatient dermatology’s positive effect on emergency department wait times and readmissions. “Patients with hidradenitis suppurativa often come to the emergency department for care. They are told it is an abscess, have procedures to drain it, and are admitted for antibiotics. They may temporarily get better but later have to return to the emergency department. With a dermatology consult, the patient is correctly diagnosed, put on the correct medicine, and does not return to the emergency department.” This is corroborated by a 2017 study of dermatology hospitalists that found improvement in both hospital length of stay and one-year readmission rates for patients with inflammatory skin conditions.

Perhaps no population benefits more from the expertise of dermatology hospitalists than patients undergoing cancer treatment. When a patient under care develops a rash, a medical team has to determine whether the rash is directly related to the cancer, secondarily related to the cancer, or related to the treatment. A physician’s first response might be to suspect drug rash and stop treatment. An oncologist may prescribe steroids to help the patient. However, Dr. Rosenbach explained that a dermatology hospitalist has the experience to know if, when, and how the rash should be addressed, especially for a patient receiving anti-cancer agents. With checkpoint inhibitors, not only can stopping the drugs have a negative impact on outcome, but adding a steroid can further reduce the immune system’s ability to fight the cancer. A dermatology hospitalist helps the medical team determine if a rash is not only tolerable, but a sign that cancer treatment is working. “One of the benefits of in-patient care is you are caring for the patient as one person, but also you are caring for the consulting team. If the team is spending even 20 minutes a day worrying about a patient’s rash, they are not spending 20 minutes a day taking care of the patient’s cancer. We support the team taking care of the patient.”

Researcher on emerging diseases

While hospital dermatologists help medical teams with known diseases, they also play an integral role in developing knowledge on emerging diseases. Dr. Rosenbach recalled the importance of in-patient consults during the peak of the COVID-19 pandemic. Dermatology hospitalists were very involved in identifying that some patients with COVID would get purpura and be at increased risk of clotting. They also recognized that children with even mild cases of COVID were getting multi-system inflammatory syndrome and helped by describing what that looked like based on skin morphology.

At the same time as the COVID-19 pandemic, dermatology hospitalists were essential in characterizing the mpox outbreak in the United States. The first U.S. case was staffed by Dr. Kroshinsky. Dr. Madigan emphasized, “During the height of the mpox surge in our community, we acutely triaged and accepted all consults for suspected cases. In the beginning, we were only able to send a limited number of swabs to the health department for confirmatory testing. We helped the infectious disease department by serving as a gateway for which patients were tested, helping to conserve and better allocate this limited resource.” When Dr. Madigan and her colleagues retrospectively looked at the data, the team’s success was clear: when comparing the consulting service’s differential with the inpatient and acute care dermatology clinic’s differential, her team had correctly determined which cases were most likely mpox (and which were not) with 100% accuracy.

Problem solver to improve patient access

With an overwhelming amount of data and anecdotal evidence establishing the value of inpatient dermatology, the question becomes: how does the field of dermatology improve patient access to this vital hospital care? Dr. Fox stated, “When I started 20 years ago, not many people were seeing patients in the hospital as part of their career and defining their career based on it. Years later, we have convinced academic dermatology programs that they should invest in having someone see their hospitalized patients with skin disease because it is better for patient care, teaching, and outcomes.” Dr. Madigan credits this increase in popularity to those at the core of the movement who have demonstrated the value of inpatient consultation while educating and mentoring others.

Dr. Kroshinsky agrees that the number of dermatology hospitalists has increased and hopes a wide net of resources for academic medical centers and an established core group of faculty can expand access to patients who live farther from these centers and to colleagues who do not have an affiliation with one. “As we think through 2024 and 2025, a focal point is helping interested parties to partner with community hospitals to set up robust programs that can stand alone but also take our established expertise and expand our reach.”

One potential way to accomplish this is utilizing teledermatology, which surged in popularity during the COVID-19 pandemic. Dr. Kroshinsky acknowledged, “While I think dermatology hospitalists would rather see a patient in person, a number of papers came together during COVID to demonstrate the safety and efficacy of inpatient teledermatology. Using this technology, we can at least triage patients, guide our colleagues, and move care in the right direction.” Setting up this support system can be especially valuable in remote areas or places with workplace shortages by helping medical teams determine if a patient needs to be transferred to an academic center with inpatient dermatology. Dr. Rosenbach also highlighted the opportunity teledermatology can provide to those dermatologists who work in a clinic but also want to support their local hospital.

While emerging technology may be part of broadening the impact of dermatology hospitalists, a key component is eliminating hurdles that potentially make practicing inpatient dermatology difficult. Some of these barriers include learning new EHR software, inputting patient data, and obtaining hospital credentialing. Dr. Kroshinsky explained that advancing technology and partnerships may help lessen the difficulty for dermatology hospitalists. As more practices fall under larger academic networks and more major medical centers affiliate or incorporate with private practices, it’s easier to understand multiple EHRs. She added, “I think groups are coming to the table with a lot more willingness to find creative and flexible ways to make it work. This may include the dermatology hospitalist providing expertise and having someone else take care of orders and documentation.”

This flexibility and creativity may also help alleviate some of the largest barriers to practicing inpatient dermatology: time and appropriate compensation. While larger academic hospitals or departments may salary a full-time dermatology hospitalist, many physicians who do inpatient consultations also work in out-patient practices and clinics. According to a 2017 survey of dermatology hospitalists, half spent 41 to 52 weeks on service and 37% spent between 11 and 30 weeks. Each day, consultation services saw approximately 3.7 new inpatients and 4.2 follow-up inpatients, with rounds lasting approximately 2.6 hours. In addition, during this service they staffed an average of four outpatient clinics per week.

Dr. Madigan explained the importance of value-based financial support. “If a community physician has a very busy out-patient practice and is seeing a high volume of patients each day, it can be very challenging to set aside or block out time to perform inpatient consults. The opportunity cost can be great, particularly if they are partnering with a hospital system that has less consistency in terms of the frequency of consults.” In addition, billing and reimbursement for consulting on medically complex cases can be complicated. Dr. Fox acknowledged, “While the onus may be on community hospitals not affiliated with an academic hospital or dermatology program to put someone on staff, we have not gotten there yet.”

Lindsay Ackerman, MD, FAAD, founder of Medical Dermatology Specialists, a private practice in Phoenix, agrees that dermatology hospitalists need to be paid appropriately for cutting clinic hours and/or providing after-hours services for inpatient consults. “One of my primary interests as a dermatologist has always been to be able to offer our expertise to our most vulnerable patients. One of the very early lessons I learned as I set out to do this in my practice 15 years ago was how much we were not only helping patients, but our colleagues, and the evident ‘value-add’ to the financial stewardship of the health care system,” she said. “Aside from the direct benefit to patients’ outcomes, assisting the primary inpatient team and other consultants, dermatology hospitalists are saving money for our health care system, and most especially for the hospital. Simply put, we provide consultative care that enhances the accuracy of diagnoses, reduces the risks of adverse outcomes arising within a hospital stay, and allow for earlier discharge, all things that directly demonstrate value. This work-value is measurable objectively, as is the loss of revenue we experience by giving up time in what would otherwise be reimbursable work in our busy outpatient clinics. Hospital systems, benefiting from our time and expertise, may need to be educated on our value, but should compensate us for our availability. While appropriately compensating dermatology hospitalists helps them efficiently use their time and expertise, providing this service also requires other novel solutions, compatible with both community health care systems and physicians’ needs, to make the consultative work one with an efficient workflow.”

Dr. Ackerman has problem-solved a number of time-related challenges as a dermatology hospitalist with her own community practice. Wanting to be integrally involved with hospital dermatology care, she built her practice within blocks of the hospital so that she and other physicians saved time commuting. As her private office is located in close proximity to an academic hospital center that does not have a dermatology residency, she has partnered with and offered her outpatient practice as an educational rotation for internal medicine residents at the institution in which she consults. She and her partners all share the consultation call, having each of them responsible every third week. Residents on rotation are responsible for covering consultations, getting a ‘first look’ and documentation into the medical record, requiring minimal additional documentation by the attending dermatologist.

“Having the residents’ assistance greatly diminishes the time requirement for us after hours, as well as helps in providing necessary inter-specialty communication during the normal business day. In addition, we store resources in the hospital’s central supply chain (we have fully stocked tackleboxes with everything needed for bedside procedure) so that a quick call ensures supplies are bedside when she arrives. We have created an infrastructure that works. When I take down my shingle, I want to look back and know that it has meant something — for me, being able to serve patients who are systemically ill with dermatologic diseases requiring hospitalization has been an enormous privilege.”

As the role of the dermatology hospitalist grows and evolves, the Society of Dermatology Hospitalists is committed to building research as well as fostering a supportive community that mentors residents pursuing hospital dermatology and empowers dermatologists to navigate inpatient care in their area’s health care systems. Drs. Kroshinsky and Fox both encourage those interested in inpatient care to connect with the society or access the expert resource group available on the AAD website. Dr. Fox highlighted the priceless value of a dermatology hospitalist — student, teacher, researcher, collaborator, problem solver, and healer. “At the end of the day, you can really measure the impact that you have had on someone’s life and disease.”

Additional DermWorld Resources