COMMENTARY

Expanding Dermatologic Care in Rural Areas

Vincent A. DeLeo, MD; Robert T. Brodell, MD; Cindy Firkins Smith, MD; Alexandra Streifel, MD

Disclosures

March 02, 2021

This interview was based on an article published in Cutis, Rural Residency Curricula: Potential Target for Improved Access to Care? The transcript has been edited for clarity.

Hello, and welcome to Dermatology Weekly, the official podcast of MDedge Dermatology, where we discuss issues that most affect the specialty. I'm MDedge editor Elizabeth Mechcatie. And now, your host for this week's Peer to Peer, Dr Vincent DeLeo.

Vincent A. DeLeo, MD: Today we're talking to Dr Robert Brodell, Dr Cindy Smith, and dermatology resident Dr Alexandra Streifel. Welcome to all of you. Can you please introduce yourselves for our listeners?

Cindy Firkins Smith, MD: Hi, everyone. I'm Cindy Firkins Smith. I'm a dermatologist in Willmar, Minnesota. I also am a clinical professor at the University of Minnesota in Minneapolis, and I serve as the vice president for rural health in CentraCare Health.

Robert T. Brodell, MD: I'm Bob Brodell. I'm chairman of the department of dermatology at the University of Mississippi Medical Center. I am a professor of dermatology and pathology. I do dermatopathology in my spare time. At the University of Mississippi, we have a big interest in access to care.

Alexandra Streifel, MD: My name is Alexandra Streifel. I am a 2020 graduate of the University of North Dakota and I will be completing my dermatology residency starting next year at Louisiana State University. I'm a very interested prospective rural dermatologist.

DeLeo: Thank you all for joining us today. Let's get started. Why has access to dermatologic care in rural areas become such a growing problem?

Brodell: It turns out that there is an increase in the number of dermatologists per capita in urban and rural areas. However, the rural increase is much smaller than the urban increase. The difference in the ability to access a dermatologist is a growing rural problem.

DeLeo: Thinking about this, what factors influence some young physicians to establish clinical practice in geographically isolated rural areas? Wouldn't that help?

Firkins Smith: The best way to secure a rural dermatologist is actually to start with someone who grew up in a rural area. The data clearly suggest that rural people move back to rural areas. We have found out that rural dermatologists tend to be born and not made.

Having said that, there aren't enough rural-born dermatologists. We need to rely on people who are born in suburban and urban areas to come out and join us in rural dermatology as well. The way we found success in that is to ensure that they have the opportunity to experience rural dermatology, by coming out as medical students or as residents to see how wonderful it is to practice dermatology in a rural geography.

Brodell: That's been our experience in Mississippi, too. We have an academic rural office in Louisville, Mississippi. I'm going to say it's in the middle of nowhere, but I may get in trouble with Dr [Adam] Byrd, who runs that office. It is 90 miles from the mother ship.

We have rural residents who commit to 3 months of training each of their 3 years in general dermatology in Louisville. We also have other residents who elect to do a month here and a month there in rural Mississippi. They all absolutely love it. They say that they do more surgery. They see very interesting patients, often people for whom access-to-care issues have led them to wait to get to the dermatologist.

[The residents] love going to the dermatologist's house for dinner at the end of practice. They love pheasant hunting on the weekend, duck hunting, going to the creek and knocking out the beaver dam that's flooding some farmland, and many other experiences, including hiking, fishing, and shooting. There are so many things that make it seem that a rural life can be a very wonderful life.

We really need to hear from Alexandra, who's maybe had her own experiences.

Streifel: Yes. I'd echo a lot of what Dr Smith and Dr Brodell said. I'm a proud, multigenerational North Dakotan. Really, I would say our density of dermatologists is pretty low for our state because it's very spread out. We have a lot of rural surrounding states. Growing up, I, as a patient, experienced the lack of access to specialty care, as do my family and friends.

When I was a medical student, I was interested in dermatology, but thought that maybe I'd do something different down the line. When I was doing my rotations, I got the opportunity to rotate through a lot of rural sites. I really was drawn to the kind of generalist challenge of being in rural medicine that you're kind of it. You have to be prepared to see anything that walks through the door. You have to be, I think, very resourceful because of the lack of other specialists in the area.

That was a big motivating factor for me. Deciding where I would like to end up, I want to be somewhere I know I'm going to make a big difference and help my community, and also somewhere where I'll be challenged to really employ all of my faculties to help my patients.

As Dr Brodell said, there is definitely a beauty in rural life that you can't get in a city. I love the outdoors. All the things that you mentioned in Mississippi are things we like doing in North Dakota as well. Those are all the factors that really came into play in my decision to pursue dermatology in a rural area when I'm in practice.

Brodell: I just want to say one other thing, Alexandra: Come to Mississippi.

Firkins Smith: No, Alexandra, come to Minnesota. We are happy to share rural dermatologists all across the country. Dr Brodell mentioned Adam Byrd, who is now a rural dermatologist in Mississippi. He actually rotated with me on a rural rotation when he was a resident at the University of Minnesota. Ultimately, if she ends up in rural dermatology anywhere in this country, we'll be thrilled.

DeLeo: Having been born and raised in White Castle, Louisiana, a town of 1200 people, I'm embarrassed to say that I've spent my career in New York City and Los Angeles. But I still appreciate it.

Brodell: Everyone should realize that I spent 28 years in Warren, Ohio, a small town in the middle of nowhere in northeastern Ohio, and loved it. Only the lure of academic medicine made me jump ship and try something else.

DeLeo: I think that's probably how a lot of us rural people end up in cities, because we are interested in academics and teaching. That fulfills it by taking us out of that area.

Firkins Smith: Wait a second, Vince — I'm still in academics and in rural medicine, so you can have it both ways. And so is Adam. It's not an either/or.

DeLeo: Recently, the three of you published an incredible research paper about a review that you guys did. You review the curricula related to rural dermatology and telemedicine experiences at all of the accredited residency programs across the country. Can you highlight some of the key findings for us?

Streifel: Absolutely. Our research, as you stated, Dr DeLeo, was focused on viewable online curricula and assessing rural opportunities for residency training from each ACGME-accredited program.

Our findings were that there is only one program with a specialized rural track training for residency trainees interested in rural medicine. We also looked at population size for each program, as working with a rural population while in training may influence eventual rural practice selection. A small percentage of programs were based in rural areas.

We also looked at possibly elective options that could be used to do a month of rural medicine for resident trainees who are interested.

DeLeo: That's very interesting. I would suggest that readers go to the incredible table that you guys put together with the results of this. You also asked about telemedicine, and I know that the Veterans Health Administration has extensive telemedicine experience. Can you talk about what you found when you looked at telemedicine training and the curricula of all these residency programs?

Streifel: Absolutely. How we analyzed telemedicine, knowing that the Veterans Health Administration is one of the biggest providers of telemedicine in the country, was to examine which programs had affiliations with VA hospitals, which is a big component in analyzing dermatology resident training.

I think it's interesting, in the age of COVID, how telemedicine will be a factor in dermatology residency. I foresee that it's going to become even more of an important component of residency education. I think having the Veterans Health Administration and seeing how broadly available it was for residency trainees is really only going to increase interest. I wonder how that's going to translate as well to rural access.

DeLeo: I think that's a great point, Alexandra, and I would suggest that 2 years from now, you redo this study looking at telemedicine and see how that's changed in the curricula of residency programs because of what we're all doing in telemedicine.

Finally, what do dermatology residency programs need to do to attract more students willing to pursue clinical practice in rural areas?

Firkins Smith: Well, Vince, I think that is really easy and I have a strong bias. I think you need to recruit people who come from rural areas. The best way to get someone to go to a rural area and stay there is to make sure that they love it to begin with. That's number one.

Number two is to ensure that they have rural opportunities so they can get out into rural areas and do a rotation, and do all of the wonderful things from a life standpoint that Dr Brodell already spoke to.

Number three, and the most innovative, is to do what Dr Brodell has done at the University of Minnesota and create a rural residents residency track where you recruit rural people right into a rural residency, set them up, and set them on the path to a successful rural career.

I'd be interested in anything else Dr Brodell might add to that.

Brodell: I might add to number one, with regard to recruiting, that the Match is somewhat of a barrier to this. We're talking about making a big investment, maybe starting in a student's first year of medical school, mentoring them, training them, writing papers with them, getting them to do rural rotations. We can rank them high, but when they're in the Match, it is somewhat difficult to decide exactly what's going to happen to them in the end.

I think we may make a big enough investment that there are ways to convince the Match to take a slot out for this sort of thing. It's good for the students and good for us.

Firkins Smith: Ultimately, it's good for patients because the rural areas are tremendously underserved. As already has been said, people are waiting months to get appointments. If we can increase the number of rural dermatologists, it's primarily good for patients, and that's our purpose.

Brodell: Maybe the fourth thing I could add is that at the University of Mississippi, we take an approach to access to care that I call "all of the above." Anything that anyone is doing around the country, we want to do it in Mississippi. We study it and try to figure out how to fit them into the mix.

We do Project Echo, where once a month we're educating primary care doctors from rural areas around Mississippi to learn dermatology and take care of the 10 or 15 most common conditions.

We have a free clinic in the delta, the poorest part of the state. We have a free clinic in the inner city of Jackson to take care of underserved people. We have the office I mentioned that's an academic office in rural Mississippi. We do store-and-forward teledermatology, which my faculty love, because in 5 or 10 minutes they get a lot of RVUs at night.

We don't have the barrier of payment because in the state of Mississippi, all insurance companies here must offer teledermatology and pay at the same rate as they pay for regular visits. We have a barrier getting primary care doctors to take 15 minutes to send the teledermatology consult. Just saying, anything we can do to expose our residents to the problem and potential solutions, we hope is going to stand them in good stead to carry on in the future.

DeLeo: I want to thank all of you for this really interesting discussion today, and I'm hopeful that it will engender greater thought by many people about approaching this underserved minority in small towns and rural areas all around the country.

I will leave you with one personal experience. We were interviewing resident applicants this week at USC in big Los Angeles, and we interviewed a young man, who will go unnamed, from South Carolina. We ask every one of them in the group, "If you had one day off and you could do whatever it is you wanted to do, what would you do?"

The answers are usually "be with my family," "go to a museum," etc. He said, "I'd go duck hunting." I think he may come to USC, but my guess is he's going back to South Carolina.

I thank you all for being with us. Anything else anyone wants to add?

Brodell: If anybody wants to email me at rbrodell@umc.edu, I would love to talk to you, day or night, to tell you how we do our efforts and access to care, and the great feeling of accomplishment we get from that — and maybe encourage others to do the same.

Firkins Smith: Bob's way ahead of us on rural dermatology residencies. In rural Minnesota, we are committed to rural health in all areas. Part of what I do is promote rural health in every way possible. I'm always interested in talking to people about what they can do to expand care to the people we serve in rural areas who are desperately in need.

My email is Cindy.Smith@CentraCare.com, and I'm happy to answer your questions and get feedback and ideas on how we can better serve the people that we are here to serve.

DeLeo: Thank you all once again. Have a good day.

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