Over 200 years ago, in 1798, Robert Willan, a British physician, published his masterpiece, On Cutaneous Diseases, which organized and categorized skin lesions by small differences in morphology. Sorting out the definitions of the various lesions has been called "one of the great achievements of the dermatology of the nineteenth century."3 In 1799, the first hospital devoted to dermatology opened in France. In the United States, the first dermatologic hospital ward opened in Massachusetts General Hospital in 1870. At this time, dermatology was actually an inpatient-based specialty with patients who were managed for prolonged periods of time in the hospital. Now, only 2% of patients admitted to the hospital for dermatologic diseases are managed by dermatologists.4
Much has occurred since Willan's time to expand professional knowledge about the morphology and distribution of skin lesions. Today's body of dermato-logic knowledge is both wide and deep. In addition to the study of the morphology and distribution of skin lesions, the histopathology of skin lesions has become of paramount importance in understanding these diseases. The nature of dermatology has also changed dramatically over the past couple of decades. In what was once a male-dominated field, in which students often trained in internal medicine before dermatology, at least 50% of today's would-be dermatologists, if not more, are women.
Despite the growth of dermatologic specialization, primary care physicians are playing an increasing role in the treatment of dermatologic maladies. More than one quarter of Americans seen by their primary care physician have a skin-related complaint, and dermatologic disorders account for 6% of all chief complaints.5 Primary care physicians are becoming more comfortable in treating basic and uncomplicated dermatologic diseases such as acne and fungal infections. (The use of isotretinoin, which can cause birth defects, for the treatment of acne remains within the control of the dermatologists.) Many patients prefer dermatologists for these problems because they can offer patients advice on general skin care as well as prescribe medicine. Some dermatologists welcome the involvement of primary care physicians for basic needs and have consequently shifted their practices to focus on more special needs such as oncological, surgical, and cosmetic procedures.
The accuracy of nondermatologists diagnosing dermatologic diseases has been called into question. In a study designed to quiz physicians on dermatologic diagnoses using slides and high-quality transparencies, dermatologists performed better than nondermatologists (93% versus 52% correct).6 However, family practice physicians did perform better than internal medicine specialists (70% versus 52%). This study suggests that when something goes wrong with the skin, a consultation with a dermatologist is in order.
In the twentieth century, the microscope revolutionized the practice of dermatology. For today's medical student, the digital camera may change the practice of dermatologists in the twenty-first century. Teledermatology, or the practice of dermatology using digital cameras, is a hot topic. This type of dermatology can be practiced in two ways: (1) the patient and the dermatologist have a real-time conversation via camera or (2) the patient's skin is photographed and viewed at a later time (store and forward method) in conjunction with a clinical history. Proponents of teledermatology argue that these services allow for equitable service to those patients in remote areas who may not have access to centers of excellence in dermatology. Also, studies have shown that teledermatology is an accurate and reliable way of diagnosing disease. Although teledermatolgy has been seen as a useful mode of communication for patients, the greatest concern has been the lack of relationship between physician and patient.7
While dermatologists must master the basics of medicine, they also must understand the interactions of various cells and the interplay between disease processes in the skin, for example, inflammation, immunology, oncology, and infection. The diagnostic process is fascinatingly rich—with an infinite arrangement of colors, patterns, and textures. It is this complexity that defines the field.
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