Disparities in the geographic distribution of dermatologists appear to be increasing throughout the United States. Reducing these gaps is critical to improving outcomes in patients who require care from these specialists.


 

The demand for dermatologic care throughout the United States has increased due to a variety of reasons, including increased life expectancy, a higher incidence of skin cancer and complex inflammatory skin disorders, and a growing market for surgical and non-invasive dermatology procedures. “Research shows that dermatologists tend to be concentrated in cities and there is a shortage of these specialists in rural areas, but little is known about trends over time,” explains Hao Feng, MD, MHS. “A better understanding of these trends is needed to address workforce disparities that can negatively affect outcomes for patients living in underserved areas.”

 

Increasing Gaps

For a study published in JAMA Dermatology, Dr. Feng and colleagues analyzed nationwide longitudinal trends on dermatologist density and urban-rural disparities using a standardized classification scheme. They examined county-level data for 1995 to 2013 to evaluate demographic and environmental factors associated with the geographic distribution of dermatologists. Results showed that the overall dermatologist workforce density increased by 21% over the study period, rising from 3.02 to 3.65 per 100,000 people. However, the gap between the density of dermatologists in urban and other areas increased from 2.63 to 3.06 per 100,000 people in non-metropolitan areas and rose from 3.41 to 4.03 per 100,000 individuals in rural areas.

“Dermatologists were distributed unevenly and were consistently located in well-resourced communities,” says Dr. Feng. The study notes that given the increased interest in surgical and cosmetic dermatology among younger dermatologists, several factors may be driving dermatologists to metropolitan communities, such as market forces in urban areas with higher procedural and elective cosmetic demands, patient demographics, and economic prosperity.

 

Other Key Variables

From 1995 to 2013, the proportion of dermatologists older than 55 increased by 75% in non-metropolitan and rural areas and by 170% in metropolitan areas when compared with those younger than 55. The number of young dermatologists increased in metropolitan counties but decreased in non-metropolitan and rural counties. “The age of dermatologists in rural areas appeared to be increasing more quickly due to younger dermatologists preferring to live and work in urban areas,” Dr. Feng says. Older dermatologists retiring in the next decade or two will likely affect non-urban areas more heavily.

For counties with at least one dermatologist, several variables had a significantly positive association with dermatologist density, including the density of advanced practice registered nurses and primary care physicians, median household income, the percentage of patients without insurance or those older than 65, and population per square mile. Few dermatologists were practicing in areas without systems support. Percentages of urban, unemployed, and white people were identified as variables inversely associated with dermatologist density (Table).

 

Assessing Implications

Dr. Feng says poor access to dermatologic care may increase already long wait times and worsen clinical outcomes and quality of life, especially for patients in rural areas. “For example, early detection is critical to patient outcomes when treating skin diseases like melanoma,” he explains. “Difficulty with or an inability to gain access to dermatologists can lead to delays in care for melanoma, which may result in worse outcomes, including fatalities.”

Concerted efforts are needed to attract dermatologists to rural and underserved areas. “All fields of medicine—not just dermatology—face similar issues with physicians being concentrated in urban locations,” says Dr. Feng. “As such, physicians and other stakeholders need to have serious discussions and work collaboratively to address this workforce disparity. Several approaches may help, including targeted financial incentives, alternative healthcare delivery models, and recruiting students of rural origin and diverse backgrounds to enter medical school and the specialty. Improved physician recruitment strategies, increasing the role of non-physician practitioners, and telemedicine are other approaches that should be explored to help close the workforce gap and bring about positive changes in dermatologic care in the U.S.”

References

Feng H, Berk-Krauss J, Feng PW, Stein JA. Comparison of dermatologist density between urban and rural counties in the United States. JAMA Dermatol. 2018;154:1265-1271. Available at: https://jamanetwork.com/journals/jamadermatology/fullarticle/2698667.

Kosmadaki MG, Gilchrest BA. The demographics of aging in the United States: implications for dermatology. Arch Dermatol. 2002;138:1427-1428.

Resneck JS Jr. Dermatology workforce policy then and now: reflections on Dr Peyton Weary’s 1979 manuscript. J Am Acad Dermatol. 2013;68:338-339.

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