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Consensus Statement
ARTICLE IN PRESS
doi:
10.25259/JSSTD_44_2021

Facilitating the practice of dermatology in Kerala – Recommendations by an expert panel of Kerala State Branch of The Indian Association of Dermatologists, Venereologists, and Leprologists

Department of Dermatology and Venereology, Sree Gokulam Medical College and Research Foundation, Thiruvananthapuram, Kerala, India
Department of Dermatology, Baby Memorial Hospital, Kozhikode, Kerala, India
Department of Dermatology and Venereology, Government Medical College, Thrissur, Kerala, India
Corresponding author: Kidangazhiathmana Ajithkumar, Department of Dermatology and Venereology, Government Medical College, Thrissur, Kerala, India. ajisudha@gmail.com
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Simi SM, Martin AM, Ajithkumar K, Asokan N. Facilitating the practice of dermatology in Kerala – Recommendations by an expert panel of Kerala State Branch of The Indian Association of Dermatologists, Venereologists, and Leprologists. J Skin Sex Transm Dis, doi: 10.25259/JSSTD_44_2021

Abstract

Dermatology is a rapidly growing specialty. Dermatology practice has become increasingly complex. The average dermatology practitioner is faced with an explosion of scientific knowledge and would also have to deal with diverse issues such as finance, medicolegal issues, taxation, marketing, and regulatory acts. Updating knowledge and micromanaging clinic-related issues are major concerns for a practicing dermatologist. Kerala state branch of the Indian Association of Dermatologists, Venereologists, and Leprologists can serve the interests of this group of members by helping out in training, faculty development, and research. This document presents a road map for such an initiative.

Keywords

Practitioner
Dermatologist
Kerala
The Indian Association of Dermatologists
Venereologists and Leprologists
Training
Research

INTRODUCTION

Over the years, the perception of dermatology as a specialty has changed considerably. There is an enormous growth in the scientific and technological aspects of knowledge related to the subject. Such changes must get reflected in the practice of dermatology. Although developed countries are way ahead in providing capacity building guidelines for practitioners, there have been limited attempts in India in this regard. To facilitate this, the Kerala branch of the Indian Association of Dermatologists, Venereologists, and Leprologists (IADVL-K) took an initiative to collect opinions from the dermatology practitioners across the state and formulate proposals to strengthen their training and updation of practice.

Objectives

The objective was to develop a policy document to improve the skills and knowledge of the practitioners of dermatology in the state of Kerala, by effective utilization of various resources.

MATERIALS AND METHODS

A three-member committee (including a coordinator) was constituted by the state president of IADVL-K in December 2019 to develop a policy document. This committee prepared a draft document after internal consultations. It was envisaged to conduct a conclave to discuss and gather opinions on the draft prepared by the committee. However, with the onset of the coronavirus disease 2019 (COVID-19) pandemic, it was decided to circulate the draft among dermatology practitioners who were selected by purposive sampling. They included practitioners of different age groups practicing in different regions of Kerala. The document incorporated suggestions received from them. Later, this draft was circulated among all the members of IADVL-K through email and their suggestions were invited. The final document was prepared in May 2020 including suggestions received from them.

RESULTS

The document addressed three domains – training, faculty development, and research. The results are summarized in Tables 1-3.

Table 1:: Recommendations to facilitate practice by providing training to practitioners of dermatology and the role of different agencies in implementing them.
S. No. Issue to be addressed Suggested actions Remarks Agencies to implement
1. To update knowledge of practitioners (i) Contact classes on – recent advances in dermatology, emerging skin diseases and newer treatment guidelines (minimum 20 hours a year)
(ii) To conduct webinars on emerging diseases like COVID-19 as and when it arises
(iii) To develop training modules on issues arising out of emerging diseases like COVID-19
(iv) To provide updates on latest guidelines
This should help the practitioners to be well versed with all recent developments as and when it occurs so that they can take adequate precautions, both for patients and themselves Medical college departments
District dermatology clubs
IADVL-K
2. To develop and increase skills “Hands-on workshop” on current and newer treatment methods (minimum of two 8 hour modules – spaced over a year) This should help practitioners to develop confidence to implement newer treatment methods including esthetic procedures IADVL-K
3 To certify the skills and knowledge obtained “Certificate courses and fellowship programs” with pre- and post-tests and valid training certificates issued by authorized bodies Certification should help to boost the practice, gain more credibility among the patients and discourage patients from turning to non- qualified persons for dermatology procedures Medical colleges, IADVL-K Academy
IADVL-K or State chapters of subspeciality associations like
ISPD, ACSI
4 Training in non-academic matters (i) To set up a panel of successful dermatology practitioners in the state who can provide the necessary guidance and technical knowhow to set up and successfully run a clinic (including purchase and maintenance of equipment, clinical software, taxation, etc.)
(ii) Practitioners are to be motivated to enroll in professional security schemes
(iii) To give adequate training in the conduct of teleconsultation and related medicolegal matters
This should lend a helping hand to the young budding practitioners IADVL-K
5. To interact with fellow practitioners An official online platform/social media group of the practitioners where they can interact among themselves regarding difficult to diagnose/manage cases This should help to disseminate knowledge and to recognize emerging dermatoses IADVL-K Academy,
IADVL-K
6. To train specialists in the fields of venereology, HIV medicine and leprosy Focused training modules on HIV and leprosy need to be prepared for practitioners To update practitioners about new developments in these areas and changes in guidelines of management IADVL-K academy, IADVL-K

IADVL-K: Kerala state branch of The Indian Association of Dermatologists, Venereologists, and Leprologists; COVID-19: Coronavirus disease 2019, ISPD: Indian Society of Pediatric Dermatology, ACSI: Association of Cutaneous Surgeons of India, HIV: Human immunodeficiency virus

Table 2:: Recommendations to facilitate development of faculty and training modules and the role of different agencies in implementing them.
S. No. The issue to be addressed Suggested actions Remarks Agencies to implement
1. To develop competent faculty who can serve as trainers of trainers’ Trainers’ training This is to develop a mix of teachers from medical colleges, renowned trainers as well as practitioners with good academic record and a flair for teaching Central IADVL and IADVL-K, medical college departments, special interest groups of central IADVL
2. To develop training modules for non-dermatologist practitioners in the state of Kerala Dermatology training modules customized for implementation in community dermatology need to be prepared. Broad guidelines need to be circulated among doctors This should ensure downstream teaching and awareness programs for the non-dermatology practitioners by the dermatology specialists IADVL-K academy, medical college departments

IADVL-K: Kerala state branch of The Indian Association of Dermatologists, Venereologists, and Leprologists

Table 3:: Recommendations to facilitate research by practitioners and the role of different agencies in implementing them.
S. No. The issue to be addressed Suggested actions Remarks Agencies to implement
1. To motivate the practitioners to do quality research (i) Research methodology workshops which focus on the special needs of the practitioners can be conducted.
(ii) Practicing dermatologists can be motivated to form small research groups.
This can help them to develop study protocols IADVL-K, IADVL-K Research cell, IADVL-K Academy
IADVL-K, IADVL-K Research cell, IADVL-K Academy
2. To help the practitioners in the conduct of research (i) The faculty in the medical colleges can provide assistance to prepare and improve the protocols and to get the protocols cleared by the Institutional Ethics Committees.
(ii) IADVL-K can hire a research assistant who can help these researchers in data cleaning, analysis, preparation of manuscript, and publication of research article.
Helps guide practitoners interested in research, through mobilisation of expert advise from their peers and technical personnel
This can help them in the smooth and speedy conduct of research
Medical college departments, IADVL-K research cell
IADVL-K
3 To help the practitioners to access funding for research (i) Adequate assistance can be provided to obtain funding from research agencies.
(ii) IADVL-K can directly provide funding to a few promising research projects.
This can motivate them to take up more advanced research which require financial assistance ICMR, Department of Science and Technology, Kerala State, IADVL-K
4. To help the practitioners to publish research papers A separate section (Practitioners’ Column) may be earmarked in the Journal of Skin and Sexually Transmitted Diseases – the official journal of IADVL-K for publishing matters of interest to the practitioners. A forum for practitioners to present and discuss issues unique to them Editorial board, Journal of Skin and Sexually Transmitted Diseases

IADVL-K: Kerala state branch of The Indian Association of Dermatologists, Venereologists, and Leprologists; ICMR: Indian Council of Medical Research

Training

It was proposed that IADVL-K, district dermatology clubs, and/or medical colleges may organize various training programs including contact classes on recent advances in dermatology, emerging, and reemerging skin diseases and newer treatment guidelines for a minimum of 20 hours a year. Dermatology is a specialty that has grown by leaps and bounds and practitioners are constantly bombarded with information from advances in various areas – genetics, immunology, molecular biology, therapeutics, and diagnostics, to name a few. In a busy practice, one needs information that is authentic and backed by sound scientific evidence. The academic division of IADVL-K can work to disseminate information on these subjects in an easy-to-understand capsule format, as ready reckoner pamphlets or as continuing medical education (CME) programmes, intended for capacity building of the practitioners.

New and emerging diseases have skin manifestations that are relevant to clinical practice. Several diseases have emerged in the recent past including dengue, chikungunya, and hand foot and mouth disease and practitioners need to update themselves on the skin manifestations of these diseases as and when they emerge. COVID-19 is a specific case in point (relevant when this document was prepared) in which skin manifestations can trigger suspicion about the disease.

Several dermatological conditions have standardized scoring systems for assessing disease severity and prognosis. Similarly, guidelines have been updated for many conditions. IADVL-K can assist the practitioners in the dissemination of information about these. The development of training modules on human immunodeficiency virus infection and leprosy also was recognized as an important need.

It was also suggested to have “hands-on workshops” on current and newer treatment methods, at least two sessions in a year of about 8 hour duration each, aimed at increasing the confidence of practitioners to use them in their practice. Certificate courses and fellowship programs may be organized by IADVL-K and various subspecialty organizations. If certificates are issued by authorized bodies such as health universities for these courses, it would help to boost practice, gain more credibility among the patients, and to discourage patients from turning to non-qualified persons for dermatology procedures.

IADVL-K can provide training in non-academic topics too – like providing the technical know – how to set up and run a clinic successfully, time management, professional security schemes which are available, effective utilization of teleconsultation, medicolegal aspects of dermatology practice, principles of good clinical practice, and medical ethics. These would help the practitioners, especially the young budding ones. Formation of an official online platform or social media group of the practitioners was also proposed, where they can interact among themselves regarding cases that are difficult to diagnose or manage.

Dermatology practitioners can take lead to develop a network of dermatologists including aesthetic dermatologists, dermatosurgeons, dermatopathologists, rheumatologists, and physicians in the nearby area. This would make cross-consultations easier and more effective thereby providing quality care to the patients and avoiding delay in getting appointments (Table 1).

Faculty development

The development of modules for the practice of community dermatology for dermatology practitioners can equip them to teach non-dermatology practitioners and improve the awareness level of the latter about skin diseases. A mix of teachers from medical colleges, and renowned trainers and dermatology practitioners with good academic record, and a flair for teaching can act as “trainers of trainers” [Table 2].

Research and publication

Helping the practitioners to carry out research is a need of the hour. The research cell of IADVL-K can facilitate research methodology workshops for practitioners and encourage them to form small research groups. The faculty in the medical colleges can help the practitioners to get their protocols cleared by Institutional Ethics Committees. Another suggestion was that IADVL-K can hire a research assistant who can help these researchers to clean and analyze data and in the preparation of manuscript and publication of research papers [Table 3].

Providing funding for research projects and helping practitioners to submit proposals to other funding agencies are two other areas where IADVL-K can support, through its research cell.

The journal of skin and sexually transmitted diseases, the flagship journal of IADVL-K offers an excellent opportunity to the practitioners to get their works of good quality published. The journal may consider earmarking a separate section (practitioners’ column) which can be utilized to publish articles which are of special interest and relevance to the practitioners. Such a section could include case reports, clinical studies, and non-academic practice-related matters.

Future actions

Dermatology has become a more capital-intensive specialty, of late. A dermatology practitioner faces several issues concurrently – such as those related to financial management, taxation, medicolegal issues, ethical issues in practice, and social media usage. It would be good if the senior practitioners can guide entry-level practitioners on such matters in dedicated CME programs and workshops. There is a felt need to have forums to interact and sort out common issues of practitioners. IADVL-K can provide such platforms for practitioners. IADVL-K can form task forces to address specific issues and formulate guidance documents.

Insurance

Many insurance companies reject genuine claims made on dermatological diseases, branding them as cosmetic problems. Furthermore, in conditions such as chronic vesiculobullous disorders and drug reactions, where the patient needs continued monitoring and supportive care, claims are often rejected on flimsy grounds. IADVL-K, through a practitioners’ guild, can take up such matters of concern, with the insurance companies. This is all the more relevant now as treatment of some of these diseases is getting more expensive and reimbursement of medical expenses is a felt need of patients who approach dermatology practitioners for these diseases.

Cost of prescription medicines

There has been a continuous escalation in the price of prescription medicines in dermatology.[1] Many ‘treatable’ chronic diseases remain untreated because the patients cannot afford them. IADVL-K can start a campaign as well as submit representations to the pharmaceutical and regulatory authorities for decreasing the price of at least the life-saving medicines used in dermatology.

DISCUSSION

Practitioners in dermatology have unique issues to be addressed. IADVL-K through its extensive networking can serve as a conduit for facilitating interactions and discussions about them and for providing solutions.

Routine knowledge up-gradation by practitioners in non academic institutions and private clinics may not be easy unless they are motivated and focused. Practice and administrative matters consume much of their time and hence knowledge upgradation takes a back seat. This is in contrast to those in medical colleges who update themselves by association with under graduate and post graduate students and their training programmes. Regularly attending training and certificate courses would help practitioners in non academic streams to update themselves more easily. IADVL-K can be the central forum that promotes robust training programmes for private practitioners.

In a study by Bhat, based on a questionnaire survey of practicing doctors, <50% of doctors were aware of medical-related government regulations.[2] Important regulations – central and state – in Kerala include drugs (price control) order, Pharmacy act, Kerala Clinical Establishments (Registration and Regulation) Act, 2018, and Bureau of Indian Standards Act. Dermatology practitioners need to be made aware of these regulations and IADVL-K should encourage dissemination of information on such topics by expert faculty.

A private practitioner is often like a solo sailor in an unchartered sea. When they encounter certain patient care-related or medicolegal issues, they may long for somebody to seek an opinion from or to rely upon. Formation of informal groups of practitioners would give them an assurance of help in times of need.

Recent studies from India and elsewhere highlight a substantial decrease in the life expectancy of doctors.[3] Increased work pressure, psychological stress related to patient care and in managing one’s clinic, are some possible reasons. Development of guidelines and providing assistance in the running of clinics may help to allay the stress of the practitioners to some extent.

Skin disorders are often misdiagnosed and mismanaged by specialists from other areas and non-specialists, who may feel safe to try their hand in treating them. Use of combination creams containing corticosteroids, antifungals, and antibiotics, without a proper diagnosis is common. Appropriate training given to nondermatologists can curb this menace to some extent. IADVL-K, as an umbrella organization of dermatologists, can help to disseminate scientific information to general practitioners.

It is a paradox that despite having exposure to huge and diverse clinical material, many practitioners seem to have little time and motivation to document and publish. Assistance provided in designing and conducting studies as well as in writing manuscripts should bring about a sea change in the present scenario.

CONCLUSION

Practitioners form a bulk of members of IADVL-K. They contribute immensely to the growth of the organization. IADVL-K, in its commitment to its members of this guild, can build opportunities for training, research, and information dissemination. This document provides a roadmap for this purpose.

Declaration of patient consent

Patient’s consent not required as there are no patients in this article.

Financial support and sponsorship

Nil.

Conflicts of interest

Dr. Neelakandhan Asokan was the president of IADVLKerala when this project was implemented. Dr. Neelakandhan Asokan, Dr. Kidangazhiathmana Ajithkumar and Dr. Abhay Martin are on the editorial board of the Journal.

References

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