Newswise — The United States of America has vast populated land areas where inhabitants have poor or limited access to healthcare.  Several domains define the term “medical desert” and include limited or absent access to inpatient and outpatient care, emergency facilitates, primary care providers, and pharmacies.  The causes of inadequate access are protean and can occur in areas with small populations distributed over expansive terrain, or in crowded inner cities that have maldistribution of deployed healthcare workers and facilities.  Rural areas comprising 97% of US surface area contain only 1/5 of the population.1 As a specialty, dermatologists are irregularly distributed across the country; some metropolitan areas have over forty times the number of dermatologists per 100,000 citizens compared to rural areas.2 3,4,5 Conversely, crowded inner-city neighborhoods with disadvantaged socioeconomic demographics including marginalized populations, have limited access to dermatology services.6,7,8

Vulnerable populations in rural and inner-city areas have a “mortality penalty” due to obstacles in availability, accommodation, and appropriateness of healthcare facilities and providers, and health literacy deficits such as ability to perceive, seek, reach, and engage with health care systems.9 As a consequence, rural populations suffer 134.7 excess deaths per 100,000 population. 9 In underserved areas with under or uninsured patient populations, ample data suggests substantially poorer outcomes for health measures such as blood pressure and glucose control (diabetes) and excess mortality from diabetes and breast cancer compared to non-marginalized insured patients.  Dermatologic care is particularly emblematic of “access to care” issues in our country.

Specifically:

  • Increased distance to dermatologic care is associated with an increased number of diagnosed melanomas as well as a thicker Breslow depth at the time of diagnosis 10, 11
  • Decreased dermatologist density is associated with increased mortality from Merkel cell carcinoma and melanoma.12,13
  • Wait times for new patient appointments in rural areas are up to 40% longer than metropolitan or suburban counterparts;14
  • Patients’ perceptions of care may be impacted by race of provider.15, 16 Race concordance may improve patient engagement, education, outcomes and satisfaction in some, but not all, situations.17,18,19,20,21
  • Racial and ethnic minorities and rural citizens are disproportionally uninsured and under-insured and face issues with access to care and diagnostic and treatment delays with an adverse impact on clinical outcomes 22-27
  • Racial and ethnic minorities present with more advanced stages of disease and higher morbidity and mortality despite lower incidence.28-41  This includes women of color with skin cancers such as melanoma, squamous cell carcinoma, and Merkel cell carcinoma33. 
  • Black patients perceive gaps in dermatologists’ specific knowledge of black skin and hair, interacting with Black patients, and inclusion of Black patients in dermatology research.44
  • Inflammatory skin conditions, such as atopic dermatitis, psoriasis, and hidradenitis suppurativa, are more severe and less well controlled in racial and ethnic underserved populations.45-49 [

Providing improved access to Dermatology care in rural and urban clinical settings is the keystone to ensuring sustainable, quality dermatologic care in underserved areas. One noteworthy effort in this regard is the expanding use of teledermatology within the large Department of Veterans Affairs health system with the goal of providing access to all eligible veterans nationwide to dermatology evaluation within 7 days of referral. The most effective approaches to increasing the number of rural health practitioners may include greater exposure to rural medicine in medical school and residency, and increasing the number of medical students reared in rural settings who are more likely to return to these underserved areas.50 In that vein, African-American medical students are more likely to practice in underserved urban areas after their training.51-56  Primary care visits by Black patients as compared to visits by white patients were 39.9 times more likely to be with a Black physician.  Hispanic and Black physicians tend to work in minority communities.54 This suggests that increasing physician diversity might decrease disparities in access to care.  Of course, patients from any background should be made to feel comfortable seeking care from physicians of all backgrounds.  There should be no expectation that individuals selected for dermatology residency are committed to working in a particular area unless a service requirement is part of the program they have selected. 

Specific recommendations include:

  • Physicians should be trained to deliver care within the framework of knowledge of each patient’s personal experiences with regard to their skin, hair and nail disorders
  • Offer patients a choice of physicians who strive to improve communication skills as well as skills in implicit bias and social determinants of health.
  • Provision of state and federal government funding and infrastructure support to facilitate dermatology services in Rural Health Clinics (RHCs) and underserved urban areas
  • Increase payments by Medicare and Medicaid which are often the main insurer in urban and rural communities
  • Provide broader tuition assistance for undergraduate and medical school students from rural areas and health care deserts.
  • Enhance loan forgiveness programs for board certified dermatologist-led teams in medical deserts or underserved areas for meaningful periods of time.
  • Advance admissions and selection processes for medical school and residencies that account for prior education and life experiences that can enrich training programs, and add perspective across the clinical evaluation and care plans for the entirety of society’s patients.
  • Recruit and support under-represented-in-medicine (African descent, Hispanic/Latino, Indigenous American, Native Alaskan, and Pacific Islander descent) medical students to enhance the pool from which dermatology residents are chosen.56-59 Recruitment for medicine and science, technology, engineering, and math (STEM) related fields may need to start at all points throughout the educational process (in primary school, high school, college and beyond).
  • Establish more university-based rural dermatology outreach to care for patients and train residents and medical students in underserved areas.60,61
  • Expand the number of academic dermatology departments providing Dermatology ECHO (Extension for Community Health Outcomes) programs to enhance and support dermatologic care provided by primary care providers 62,63.
  • Utilize physician-led team-based care in rural and urban clinics where physician leaders work with non-physician providers (e.g. nurse practitioners, physician assistants, registered nurses, licensed practical nurses, and medical assistants).
  • Invest in, and encourage the use of, technological advances in digital information tools thereby assisting equitable care delivery in rural and urban dermatology. This includes clinical decision software, telemedicine, patient education technology and artificial intelligence to improve education and clinical care delivery.
  • Partner with health care systems to support and finance these initiatives.
  • Heighten awareness of disparities through continued research 64

The American Dermatological Association affirms the pressing need to address the defects that exist in the current medical infrastructure which prevent equal access, and consequently equitable medical outcomes, for all patients with dermatologic disorders.  Issues limiting access to dermatology care are highlighted here and should urgently be addressed.

 

 

References:

 

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