News — 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:

 

  1. Ratliffe M, Burd, C, Holder K and Fields A.   Defining rural at the US Census Bureau: American Community Survey and Geography Brief. (2016) United States Census Bureau, US Department of Commerce, Economics and Statistics Administration. 

 

  1. Feng H, Berk-Krauss J, Feng PW, Stein JA. Comparison of dermatologist density between urban and rural counties in the United States. JAMA Derm. 2018;154(11):1265-1271.

 

  1. Feng H; Belkin D Geronemus, RG. Geographic distribution of U.S. Mohs micrographic surgery workforce. Dermatologic surgery. 2019 Jan;45(1):160-163.

 

  1. Sinha S, Lin G, Zubkov M, Wu R, Feng H. Geographic distribution and characteristics of the pediatric dermatology workforce in the United States. Pediatr Dermatol. 2021 Nov; 38(6):1523-1528.

 

  1. Ashrafzadeh S, Peters GA, Brandling-Bennett HA, Huang JT. The geographic distribution of the US pediatric dermatologist workforce: A national cross-sectional study. Pediatr Dermatol. 2020 Nov;37(6):1098-1105.

 

  1. Cyr ME, Etchin AG, Guthrie BJ et al. Access to specialty healthcare in urban versus rural US populations: a systematic literature review. BMC Health Serv res 2019; 19:974.

 

  1. Vaidya T, Zubritsky L, Alikhan A, et al. Socioeconomic and geographic barriers to dermatology care in urban and rural US populations. J Am Acad Dermatol. 2018 Feb;78(2):406-408.

 

  1. Sedghi T, Gronbeck C, Feng H. Comparison of socioeconomic and demographic characteristics of counties with and without Mohs micrographic surgeons: a cross-sectional medicare analysis. Dermatol Surg. 2021 Dec 1;47(12):1655-1657.

 

  1. Cosby AG, McDoom-Echebiri MM, James W, Khandekar H, Brown W, Hanna HL. Growth and persistence of place-based mortality in the united states: The rural mortality penalty. Am J Public Health. 2019;109(1):155-162.

 

  1. Stitzenberg KB, Thomas NE, Dalton K, et al. Distance to diagnosing provider as a measure of access for patients with melanoma. Arch Dermatol. 2007;143(8):991-998.

 

  1. Parisi R, Huppertz J, Potolski A, Tracey V. Distance to diagnosing dermatology provider as a predictor of multiple melanoma diagnoses. J Am Acad Dermatol. 2021 Aug 3:S0190-9622(21)02214-3.

 

  1. Criscito MC, Martires KJ, Stein JA. A population-based cohort study on the association of dermatologist density and Merkel cell carcinoma survival.  J Am Acad Dermatol. 2017;76(3):570-572. doi: 10.1016/j.jaad.2016.10.043.

 

  1. Aneja S, Aneja S, Bordeaux    Association of increased dermatologist density with lower melanoma mortality.  Arch Dermatol. 2012;148(2):174-178. doi:10.1001/archdermatol.2011.345.

 

  1. Kimball AB, Resneck Jr JS. The US dermatology workforce: a specialty remains in shortage. J Am Acad Dermatol. 2008;59(5):741-745.

 

  1. Gorbatenko-Roth K, Prose N, Kundu RV, et al. Assessment of black patients’ perception of their dermatology care. JAMA Dermatol 2019; 155:1129-1134.

 

  1. Gray B, Soddard JJ. Patient-Physician Pairing: Does racial and Ethnic Congruity Influence Selection of a Regular Physician? J of Community Health 2019; 22:247-259.

 

  1. Harvey, V.M., Ozoemena, U., Paul, J., Beydoun, H.A., Clemetson, N.N. and Okoye, G.A., 2016. Patient-provider communication, concordance, and ratings of care in dermatology: results of a cross-sectional study. Dermatology online journal, 22(11).

 

  1. Schoenthaler A, Ravenell J. Understanding the patient experience through the lenses of racial/ethnic and gender patient-physician concordance. JAMA Network Open. 2020 Nov 2;3(11): e2025349.

 

  1. Takeshita J, Wang S, Loren AW, et al. Association of racial/ethnic and gender concordance between patients and physicians with patient experience ratings. JAMA Netw Open. 2020 Nov 2;3(11): e2024583. doi: 10.1001/jamanetworkopen.2020.24583.

 

  1. Hamel LM, Moulder R, Ramseyer FT, Penner LA, Albrecht TL, Boker S, Eggly S. Nonverbal Synchrony: An Indicator of Clinical Communication Quality in Racially-Concordant and Racially-Discordant Oncology Interactions. Cancer Control. 2022 Jan-Dec;29:10732748221113905. doi: 10.1177/10732748221113905. PMID: 35801386; PMCID: PMC9272474.

 

  1. Oguz T. Is Patient-Provider Racial Concordance Associated with Hispanics' Satisfaction with Health Care? Int J Environ Res Public Health. 2018 Dec 24;16(1):31. doi: 10.3390/ijerph16010031. PMID: 30586847; PMCID: PMC6338960.

 

  1. Adamson AS, Zhou L, Baggett CD, et al. Association of delays in surgery for melanoma with insurance type. JAMA Dermatol. 2017 Nov 1;153(11):1106-1113. doi: 10.1001/jamadermatol.2017.3338.

 

  1. Alghothani L, Jacks SK, Vander Horst A, et al. Disparities in access to dermatologic care according to insurance type. Arch Dermatol. 2012 Aug;148(8):956-7. doi: 10.1001/archdermatol.2012.804.

 

  1. Huq F, Nakamura M, Black K, et al. Association of dermatology wait times with insurance coverage in Michigan. Am J Manag Care. 2020 Oct;26(10):432-437. doi: 10.37765/ajmc.2020.88501.

 

  1. Resneck J Jr, Pletcher MJ, Lozano N. Medicare, Medicaid, and access to dermatologists: the effect of patient insurance on appointment access and wait times. J Am Acad Dermatol. 2004 Jan;50(1):85-92. doi: 10.1016/s0190-9622(03)02463-0.

 

  1. Abudu B, Cook KA, Gershenwald JE, Cohen PR, Geller AC. Quantitative associations between health insurance and stage of melanoma at diagnosis among nonelderly adults in the United States. Cancer. 02 2020;126(4):775-781. doi:10.1002/cncr.32587.

 

  1. Tripathi R, Archibald LK, Mazmudar RS, et al. Racial differences in time to treatment for melanoma. J Am Acad Dermatol. Sep 2020;83(3):854-859. doi:10.1016/j.jaad.2020.03.094.

 

  1. Blumenthal LY, Arzeno J, Syder N, Rabi S, Huang M, Castellanos E, Tran P, Pickering TA, Dantus EJ, In GK, Soriano T. Disparities in nonmelanoma skin cancer in Hispanic/Latino patients based on Mohs micrographic surgery defect size: A multicenter retrospective study. Journal of the American Academy of Dermatology. 2021 Oct 5

 

  1. Lackland D.T. Racial differences in hypertension: Implications for high blood pressure management (2014) American Journal of the Medical Sciences, 348 (2):135-138.

 

  1. Breast Cancer Prevention Partners; .

 

  1. US Department of Health and Human Services Office of Minority Health. .

 

  1. gov

 

  1. Davis DS, Robinson C, Callender VD. Skin Cancer in Women of Color: Epidemiology, Pathogenesis and Clinical Manifestations. Int J Women’s Derm 2021; 7:127-134.

 

  1. Qian Y, Johannet P, Sawyers A, Yu J, Osman I, Zhong J. The ongoing racial disparities in melanoma: An analysis of the Surveillance, Epidemiology, and End Results database (1975-2016). J Am Acad Dermatol. Jun 2021;84(6):1585-1593. doi:10.1016/j.jaad.2020.08.097.

 

  1. Cormier JN, Xing Y, Ding M, et al. Ethnic differences among patients with cutaneous melanoma. Arch Intern Med. Sep 2006;166(17):1907-14. doi:10.1001/archinte.166.17.1907.

 

  1. Byrd KM, Wilson DC, Hoyler SS, Peck GL. Advanced presentation of melanoma in African Americans. J Am Acad Dermatol. Jan 2004;50(1):21-4; discussion 142-3. doi:10.1016/s0190-9622(03)02091-7.

 

  1. Higgins S, Nazemi A, Chow M, Wysong A. Review of Nonmelanoma Skin Cancer in African Americans, Hispanics, and Asians. Dermatol Surg. 07 2018;44(7):903-910. doi:10.1097/DSS.0000000000001547.

 

  1. Trofymenko O, Zeitouni NC, Kurtzman DJB. Factors associated with advanced-stage Merkel cell carcinoma at initial diagnosis and the use of radiation therapy: Results from the National Cancer Database. J Am Acad Dermatol. Oct 2018;79(4):680-688. doi:10.1016/j.jaad.2018.03.019.

 

  1. Trofymenko O, Zeitouni NC. Association of patient demographic characteristics with dermatofibrosarcoma protuberans tumour size at diagnosis in the U.S. National Cancer Database. Br J Dermatol. 10 2017;177(4):e103-e104. doi:10.1111/bjd.15357.

 

  1. Weinstock MA, Gardstein B. Twenty-year trends in the reported incidence of mycosis fungoides and associated mortality. Am J Public Health. Aug 1999;89(8):1240-4. doi:10.2105/ajph.89.8.1240.

 

  1. Mills PK, Shah P. Cancer incidence in California farm workers, 1988-2010. Am J Ind Med. 2014 Jul;57(7):737-47. doi: 10.1002/ajim.22338. PMID: 24954888.

 

  1. Huang AH, Kwatra SG, Khanna R, Semenov YR, Okoye GA, Sweren RJ. Racial Disparities in the Clinical Presentation and Prognosis of Patients with Mycosis Fungoides. J Natl Med Assoc. Dec 2019;111(6):633-639. doi:10.1016/j.jnma.2019.08.006.

 

  1. Desai M, Liu S, Parker S. Clinical characteristics, prognostic factors, and survival of 393 patients with mycosis fungoides and Sézary syndrome in the southeastern United States: a single-institution cohort. J Am Acad Dermatol. Feb 2015;72(2):276-85.

 

  1. Gorbatenko-Roth k et al. assessment of Black patients’ perception of their dermatology care. JAMA Dermatol 2019;155(10):1129-1134.

 

  1. Davis CM, Apter AJ, Casillas A, Foggs MB, Louisias M, Morris EC, Nanda A, Nelson MR, Ogbogu PU, Walker-McGill CL, Wang J, Perry TT. Health disparities in allergic and immunologic conditions in racial and ethnic underserved populations: A Work Group Report of the AAAAI Committee on the Underserved. J Allergy Clin Immunol. 2021 May;147(5):1579-1593. doi: 10.1016/j.jaci.2021.02.034. Epub 2021 Mar 10. PMID: 33713767. [see section on Atopic Derm for relevance to derm].

 

  1. Abrouk M, Lee K, Brodsky M, et al. Ethnicity affects the presenting severity of psoriasis. J Am Acad Dermatol. 07 2017;77(1):180-182. doi:10.1016/j.jaad.2017.02.042.

 

  1. Soliman YS, Hoffman LK, Guzman AK, Patel ZS, Lowes MA, Cohen SR. African American patients with hidradenitis suppurativa have significant health care disparities: a retrospective study. J Cutan Med Surg. 2019 May/Jun 2019;23(3):334-336. doi:10.1177/1203475418803077.

 

  1. Thomas C, Rodby KA, Thomas J, Shay E, Antony AK. Recalcitrant hidradenitis suppurativa: an investigation of demographics, surgical management, bacterial isolates, pharmacologic intervention, and patient-reported health outcomes. Am Surg. Apr 2016;82(4):362-8.

 

  1. Kilgour JM, Li S, Sarin KY. Hidradenitis suppurativa in patients of color is associated with increased disease severity and healthcare utilization: a retrospective analysis of 2 U.S. cohorts. JAAD Int. Jun 2021;3:42-52. doi:10.1016/j.jdin.2021.01.007.

 

  1. Chan BT, Degani N, Crichton T, et al. Factors influencing family physicians to enter rural practice: does rural or urban background make a difference? Can Fam Physician. 2005;51(9):1246-1247.

 

  1. Imam M. Xierali, PhD and Marc A. Nivet, EdD MBA. The racial and ethnic composition and distribution of primary care physicians. J Health Care Poor Underserved 2018;29(1):556-570.doi: 10.1353/hpu.2018.0036.

 

  1. Lyndonna M. Marrast, MD; Leah Zallman, MD, MPH; Steffie Woolhandler, MD, MPH. Minority physicians’ role in the care of underserved patients diversifying the physician workforce may be key in addressing health disparities. JAMA Internal Med 2014;174(2):289-290.

 

  1. Komaromy M, Grumbach K, Drake M, Vranizan K. The role of Black and Hispanic physicians in providing health care for underserved populations. N Engl J Med 1996; May 16;334(20):1305-10.doi: 10.1056/NEJM199605163342006.

 

  1. Raynard Kington. Increasing racial and ethnic diversity among physicians: an intervention to address health disparities? In: Smedley BD, Stith AY, Colburn L, et al The right thing to do, the smart thing to do: enhancing diversity in the health professions: summary of the symposium on diversity in health professions in honor of Herbert W. Nickens, M.D..; Institute of Medicine (US). Washington (DC): ; 2001.

 

  1. Bach PB et al. Primary care physicians who treat blacks and whites. N Engl J Med 2004; 351:57.

 

  1. Powers BW et al. Race-conscious professionalism and African American representation in academic medicine.  Academic Medicine.  91(7);913-5.

 

  1. Marrast LM, Zallman L, Woolhandler S, Bor DH, McCormick D. Minority physicians’ role in the care of underserved patients: diversifying the physician workforce may be key in addressing health disparities. JAMA Intern Med.2014;174(2):289–291. doi:10.1001/jamainternmed.2013.12756.

 

  1. Nguyen B, Bray FN. Access to dermatologic care in Indiginous American communities. J Am Acad Dermatol. 2022 Apr 23:S0190-9622(22)00691-0. doi: indian10.1016/j.jaad.2022.04.026. Epub ahead of print. PMID: 35472325.

 

  1. Hooper J, Shao K, Feng H. Racial/Ethnic Health Disparities in Dermatology in the United States Part 1: Overview of Contributing Factors and Management Strategies. J Am Acad Dermatol. 2022 Feb 7:S0190-9622(22)00194-3. doi:

 

 

  1. (accessed 9/15/22)

 

  1. (accessed 9/15/22)

 

  1. Becevic M, Smith E, Golzy M, Bysani R, Rosenfeld A, Mutrux ER, Hoffman K, Wallach E, McElroy JA, Edison K. Melanoma extension for community healthcare outcomes: A feasibility study of melanoma screening implementation in primary care settings. Cureus. 2021 May 29;13(5).

 

  1. Bridges C, Morris C, McElroy JA, Quinn K, Dyer J, Becevic M. Utility of dermatology extension for community healthcare outcomes (ECHO) sessions in the adult and paediatric population. Journal of telemedicine and telecare. 2021 Jul;27(6):376-81.

 

  1. Shao K, Hooper J, Feng H. Racial/Ethnic Health Disparities in Dermatology in the United States Part 2: Disease-specific Epidemiology, Characteristics, Management, and Outcomes. J Am Acad Dermatol. 2022 Feb 7:S0190-9622(22)00195-5. doi: 10.1016/j.jaad.2021.12.062

 

 

 

 

 

 

 

 

MEDIA CONTACT
Register for reporter access to contact details
TYPE OF ARTICLE
Policy
SECTION
CHANNELS
Health Disparities Dermatology Healthcare Rural Issues Race and Ethnicity
KEYWORDS
Dermatology Healthcare
COMMENTS | COMMENTING POLICY