Dermatologists in Kaiser Permanente-northern California. Satisfaction, perceived constrains, and policy options.

BACKGROUND AND DESIGN: A survey was conducted in a large closed-panel health maintainance organization to identify and understand influences on dermatologists' job satisfaction and preferences for policies affecting management of routine dermatologic care. Of the population of 98 dermatologists, 91 (93%) responded. The main variables of interest were current and ideal practice characteristics (time allocations and case mix) and (dis) agreement with 4 statements: (1) I am satisfied with my job; (2) I favour a direct access model over a gatekeeper model for patients seeking dermatologic care; (3) I favour training primary care physicians to evaluate and treat routine dermatologic problems; and (4) I welcome incorporating nurse practitioners and physician extenders into my practice. RESULTS: The dermatologists currently spend 86% of their work time providing patient care. On average, 70% of their caseload involves routine problems; 56% would ideally increase the complexity mix of their patients. The survey reveals gender differences in perceptions of time constraints and opportunities for professional development. Most dermatologists (88%) report they are satisfied with their jobs. Satisfaction correlates strongly with their perceived ability to deliver excellent care, use their skills, and develop new skills (correlations, 0.53-0.59). Although 78% favor retaining direct patient access, at least 60% endorse more cooperative work with primary care physicians and nurse practitioners. These views are related to their satisfaction, interest in challenging cases, development and use of new skills, and perceived relationships with colleagues and support staff. CONCLUSIONS: Understanding the factors that affect physician preferences can help to identify policies that potentially improve efficiency without compromising quality of care or physician satisfaction. If routine problems can be effectively managed in cooperation with other health care providers, this may also lead to the more complex case mix these dermatologists ideally want. Further study might focus on the scheduling and referral processes that influence both cost-effectiveness and continuity in coverage for dermatologic problems.

Cosmetics and contact dermatitis.

A complete work-up of most patients with cosmetic allergies can be performed satisfactorily in a dermatologist's office without expensive equipment. After taking a complete history and performing a thorough examination, a biopsy is seldom required. Examine all the patient's cosmetics, eliminate the strong irritants, and proceed with product patch testing. Patch testing with the AAD allergen test tray at the same time is frequently helpful. When results are doubtful or do not fit with the information obtained from the history and examination, supplemental provocative use tests often clarify what information is clinically relevant. Patch testing with ingredients that dermatologists have obtained from cosmetic manufacturers or other sources often provides a helpful, definitive answer for the patient. Always provide the patient with information about cross-reactions and the official name of the allergen as it will appear on a cosmetic label to prevent recurrences.

Lip cosmetics.

Throughout the centuries, the beauty of lips has been extolled by poets, and painters; and people in many different cultures decorate their lips. Modern cosmetics are designed not only to beautify the lips but also to moisturize and protect them from environmental hazards. Familiarity with the ingredients used in lip cosmetics is essential to recognizing and diagnosing the adverse reactions that are associated with these products.

Cosmetic and dermatology: bleaching creams.

Bleaching creams containing hydroquinone are modestly effective in treating some pigmentary disorders. In 2.0% to 5.0% concentrations, hydroquinone is generally quite safe; allergic contact dermatitis may rarely necessitate stopping therapy. Achieving successful results depends on diligent, long-term treatment by patients who have carefully instructed in methods of use as well as protection from sun exposure. Supplemental use of topical corticosteroids, salicylic acid, or tretinoin, under a physician's supervision, improves the results considerably. However, even with the most persistent and careful management, most patients experience at best only partial improvement.

Evaluation and management of the "red face". Interview by K. Watsky and M. Rothe.

Patients presenting with a "red face" challenge clinicians to consider a broad differential diagnosis that includes contact dermatitis. The diagnosis may be obscured or complicated by underlying actinic damage or rosacea. Unraveling this Gordian knot to arrive at a precise and accurate diagnosis takes patience and practice. The collective experience of our invited group of expert clinicians sheds light on this process.