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Parable: What is this noise?

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Parable: What is this noise?
Mauricio Goihman-Yahr MD PhD
Dermatology Online Journal 15 (9): 17

Professor(E) of Dermatology and Immunology, Vargas School of Medicine, Central University of Venezuela, Caracas, Venezuela.

Disclaimer: Opinions expressed in this paper are the author's. They do not represent nor pretend to represent those of Central University of Venezuela nor those of Dermatology Online Journal.

On January 27, 1942, just before the fall of Singapore, engineers blew up the causeway that connected the island to the mainland. The British principal at Raffles College asked boys who were passing by what the noise was. One answered, "That is the end of the British Empire." The boy was Lee Kuan Yew, who grew up to be President of the Republic of Singapore. Today's reader is surely amazed at the future President's quick grasp of the situation and its likely consequences. Yet, the British Empire did not fall in 1942. First, the Japanese Empire fell in 1945 under American and British attack. The British Empire crumbled progressively after 1945; England's wealth and human resources had been spent after two World Wars. The ruling Labour Party did not or could not stave off the downfall. The historian could certainly visualize a different outcome for this Empire had Churchill stayed in power and if Roosevelt's policy had been different towards the British Raj.

Many of us can now discern two impending danger signs to the future of Dermatology. I will analyze two of them.

The first is the increasing abandonment of hospitals and hospital care by dermatologists. There is no question that a great deal of common skin diseases can be well treated outside hospitals. Yet teaching, research, and therapy of serious conditions are often better handled within the hospital setting where the patient can receive multidisciplinary care. The creation of a subgroup of hospital-based dermatologists may be a short-term solution, but it is self-defeating. The strength and life of Dermatology lies in a flowing interaction with all other branches of Medicine; all practitioners require these interactions, not just the few designated hospitalists.

The second is the use of Physician Assistants as direct providers of dermatology care. The concept of physician-extenders grew out of the need for employing lay assistants to treat leprosy or other scourges in underdeveloped countries with a dearth of physicians. This was needed and unavoidable under certain circumstances such as in the case of the "barefoot doctors" in Mao's China. In the USA the use of such assistants in private offices to provide primary medical care and diagnosis is extremely dangerous. Who determines what is an "efficient use of doctor's time?" Is this determined by the amount of reimbursement that can be obtained? I am not going against the age-old use of nurses or others to do some procedures, help in others, or provide some initial scanning. However, I am against the practice of doing surgical procedures, diagnosing, and providing therapy without actual direct participation of the specialist. Dermatologists are paid to provide quality care in their field and this should be above and beyond the level of care that could be administered even by a full-fledged medical doctor who is not a specialist. Doing otherwise is bad practice and might lead to the decay of Dermatology as an independent discipline in Medicine.

© 2009 Dermatology Online Journal