Education
Dermatology training and practice in Australia Deshan F. Sebaratnam, MBBS, M Clin Epi, and Dedee F. Murrell, MA, BMBCh, MD, FACD
Department of Dermatology, St. George Hospital and University of New South Wales, Sydney, NSW, Australia Correspondence de e F. Murrell MA, BMBCH, MD, De Department of Dermatology St. George Hospital Gray Street, Kogarah, Sydney, NSW 2217 Australia E-mail: [email protected]
Abstract Background Dermatology is a relatively young discipline in Australia compared to other specialities within the medical fraternity. From its humble beginnings, the profession has evolved significantly over the decades and is now represented by the Australasian College
FACD
of Dermatologists which is charged with training the next generation of dermatologists and advocating for and advancing the profession. Methods The authors reviewed and describe the history of dermatology training and practice in Australia. Results Despite the progress in education, there are only 415 dermatologists serving a population of 23.3 million (1 per 58 000) and yet it has the highest incidence and prevalence of skin cancer in the world. Conclusions The scope of clinical practice is wide in Australia, with clinicians well versed
Conflicts of interest: none.
in medical and procedural dermatology. It is hoped that Australian dermatology will continue to bolster the dermatology profession globally.
A brief history of dermatology in Australia Dermatology in Australia is a relatively young discipline when compared to Europe where the study of cutaneous pathology can be traced back to the 18th century.1 The earliest records of dermatology in Australia date to 1883 when William Moore was appointed Surgeon-in-charge of the Skin Department in Melbourne Hospital. Eight years later, dermatology was recognized as a specialty at Sydney Hospital and, in 1899, a dermatology clinic was established at the Royal Prince Alfred Hospital in Sydney.2 In the early twentieth century, despite Australias federation of states and territories (becoming an independent nation from Great Britain in 1901) nearly all medical practitioners belonged to the British Medical Association and specialists to Royal Colleges. Doctors were appointed as dermatologists to a teaching hospital, usually based on some form of European qualification, though this was not always mandatory. Essentially, any medical practitioner could become a dermatologist and any practicing dermatologist could become a member of the British Association of Dermatology.3 There was no uniformity in qualification and the specialty was held in low regard within the wider medical fraternity.4 John Belisario identified the need for specialized postgraduate training within Australia and with the support of the British Association of Dermatology, he established the Diploma in Dermatological Medicine at the University of Sydney in 1947.5 It was said to encompass a wider variety of subjects than any other medical training course ª 2014 The International Society of Dermatology
in Australia or Great Britain and remained the national standard of dermatology training for nearly 20 years.6 With an academic benchmark established, the next milestone in Australian dermatology was the formation of the Dermatological Association of Australia in 1949, again championed by Belisario. The organization aimed to provide a representative voice for Australian dermatology and one of its first actions was the inception of the Australasian Journal of Dermatology.7 The Dermatological Association of Australia later evolved into the Australasian College of Dermatologists (ACD) in 1966 with a more physical role in training and advocacy. As the DDM was only available at the University of Sydney, it precluded doctors located in other states from training in dermatology. It was decided that the ACD would create a uniform standard of training with national examinations and accredit teaching hospitals in every state to provide this with registrars trained through the hospital-salaried system in line with other specialties. However, as training moved into the public hospital system, it became apparent that there was a limited capacity to assemble the necessary concentration of patients and dermatologists to foster a milieu conducive to teaching and advancing the profession. To overcome this challenge, Kenneth Paver and his colleagues established the Skin and Cancer Foundation Australia (SCFA) in 1976.8 The SCFA was founded as a charity, modeled on the honorary system in which doctors donated their services to the Foundation (half a day each week) with the income generated used to sustain the organization financially.9 International Journal of Dermatology 2014, 53, 1259–1264
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The SCFA provided a nucleus in which dermatologists could collaborate together, offer a concentration of patients for teaching, complete clinical research, engage postgraduate education, and shape the future of dermatology within Australia.10 In the succeeding decades, the ACD has grown from strength to strength, now consisting of 415 practicing fellows and 90 trainees (Fig. 1).11 It remains the only representative body for dermatology in Australia charged with responsibilities relating to teaching, advocacy, and professional development of medical practitioners within the specialty of dermatology and the broader medical community.12 Specialist training in dermatology Selection into the ACD training program is intensely competitive. To be eligible, Australian medical graduate candidates must be registered for medical practice in Australia and have completed a minimum of 2 years of postgraduate training in a teaching hospital.13 Given the intensely competitive nature of selection into the program, successful candidates are generally in their third or more postgraduate year, with no single path to entry into the program; rather, those selected are pooled from a diverse range of backgrounds, including all specialties within medicine as well as research. Currently, applicants may nominate two states within Australia in which they would like to pursue their training. The candidates are shortlisted for interviews according to a standardized
Sebaratnam and Murrell
written application and verbal referee reports to a human resources consultant. Those selected for a national interview, are assessed by a committee consisting of a panel of dermatologists and a psychologist, completing structured behaviorally based interviews to determine a candidates congruency with selection criteria. Candidates are then ordered on a merit list with ACD State Faculty Chairs matching candidates preferences and their rankings. The number of training positions available each year varies, but for the past 5 years, there have been approximately 20 registrar positions available nationally each year. For international medical graduates who have already obtained qualifications in dermatology overseas with proficiency comparable or partially comparable to the ACD training program, there is a streamlined pathway available through which they may apply to have their qualifications assessed by the College. They are required to pass the test of English as a foreign language to a level required by the medical licensing authority and undergo up to two further years of training as international medical graduates before sitting the Part II examinations.14 The training program covers a comprehensive curriculum run over 4 years during which registrars rotate annually through a variety of institutions, including public hospitals, the Skin and Cancer Foundation Australia, and private practices.15 Registrars have to complete regular clinical evaluations with their supervisor throughout their training as well as a formal pharmacology examination and a series of learning modules covering the basic
Figure 1 Distribution of dermatologists and dermatology trainees in Australia according to state in 2013 International Journal of Dermatology 2014, 53, 1259–1264
ª 2014 The International Society of Dermatology
Sebaratnam and Murrell
Figure 2 The dermatology team at St. George Hospital, Sydney consists of consultants, registrars, research fellows and students, and overseas trained doctors participating in exchange programs
sciences. They must have two publications in peerreviewed journals and two conference proceedings at dermatology meetings to satisfy the research requirements of their degree. Once these prerequisites have been met, they are capable of sitting the fellowship examination in their fourth year of training, which involves a written examination, a combined laboratory dermatology, dermoscopy, short case viva examination and a long case viva, and a procedural dermatology examination. In recent years the pass rates for both the final written and clinical examinations has been approximately 80%. If candidates pass through all components of the fellowship examination, they are inducted as Fellows of the Australasian College of Dermatologists. Dermatology practice in Australia Australians and permanent residents have universal healthcare under the Medicare system in which the government provides a basic level of health care.16 Patients eligible for Medicare may attend any dermatology clinic operating in teaching hospitals free of charge with procedures such as excision of cutaneous lesions also provided without cost to the patient. Patients pay for their own ª 2014 The International Society of Dermatology
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medications, which vary in price, particularly depending upon whether or not they are listed on the Pharmaceutical Benefits Scheme (PBS) (in which case they are subsidized by the government and incur a maximum price currently of AUD$28.90 if the patient satisfies an appropriate indication, with further discounts available for pensioners or those eligible for other concessions).17 Currently about one-third of Australians have private health insurance. This only covers accommodation, hospital fees, some procedures in a hospital or accredited day surgery facilities, and some of the cost towards non-PBS drugs. It does not cover the gap between the Medicare reimbursement and the doctors fees in private clinics or hospitals, unlike traditional health insurance overseas. This out of pocket payment limits escalation of medical fees. Hospital-based dermatology services are largely outpatient based18 although the specialty still plays an important role in the care of patients presenting to the Emergency Department19 and to inpatients.20 There are a number of subspecialty clinics, including multidisciplinary epidermolysis bullosa clinics in Sydney (Sydney Childrens Hospital and St George Hospital), Melbourne, Adelaide, and Brisbane,21 autoimmune blistering disease clinics in Sydney and Melbourne,22 melanoma clinics, cutaneous lymphoma clinics in Sydney and Melbourne,23 vitiligo and HIV clinics at SCFA, contact dermatitis clinics in Melbourne,24,25 vulvar dermatology clinics in Sydney,26 and biologics clinics for patients with severe psoriasis across the nation.27 Sexually transmitted disease clinics are run by sexual health doctors who have a separate training program and are affiliated with the Australasian Chapter of Sexual Health Medicine. There is limited funding within hospitals for both salaried dermatologists and dermatology trainees. The vast majority of practicing dermatologists in Australia work full-time in private practice with a portion working a clinic per week in public hospitals.28 Most dermatologists (and public hospitals) are located in the more populous urban centers along the coast of Australia with fewer services available to inland populations. As the skin cancer capital of the world,29 Australian dermatologists are well versed in the management of cutaneous malignancy. Dermoscopy is a routinely employed tool30 and the majority of dermatologists are highly skilled in procedural dermatology. The burden of skin cancer is so great that general practitioners routinely complete full skin examinations and complete basic procedures and general practitioner operated skin cancer clinics are a common occurrence. Given the prevalence of skin cancer and limited access to dermatologists, these services help to address some of the deficiencies that exist within the healthcare system; however, there are also concerns regarding the proficiency of International Journal of Dermatology 2014, 53, 1259–1264
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such practices given the lack of formal training or qualifications in dermatology.31–33 Mohs micrographic surgery (MMS) was first introduced to Australia in 1978, and there are over 40 Mohs surgeons in clinical practice nationally. Dermatologists wanting to perform MMS are required to have completed a fellowship, either in Australia or abroad. The average volume of MMS cases performed annually by Mohs surgeons is between 200 and 300 patients; lower compared to other countries such as the USA where the average is approximately 1000 patients per year.34 MMS is becoming increasingly available and from the perspective of the Australian healthcare system, MMS has been shown to be a cost-effective option for the treatment of specific nonmelanoma skin cancer.35 As elsewhere in the world, knowledge of cosmetic dermatology is part of the armamentarium of at least the younger generation of Australian dermatologists. Botulinum toxin injections, injectable fillers, epilation, and laser resurfacing36 are all commonly sought after procedures. Australia is unique though, in that given patients often present with concomitant photoaging and actinic dysplasia, and ablative modalities such as photodynamic therapy or ablative laser can be employed to treat these two conditions synchronously.37 One of the challenges facing Australia is the limited access to dermatologists, particularly in rural areas.38 Approximately one-third of Australians live outside major cities and access to healthcare is a significant issue for rural populations.39 The proportion of the population who are Indigenous Australians also increases with remoteness. Indigenous Australians have specific dermatological issues, with a greater incidence of communicable diseases40,41 but also non-communicable pathologies,42 and specialized clinics often run as outreach programs to improve access to dermatology services.43 Dermatology is uniquely placed within medicine in that teledermatology is a particularly promising avenue that may bridge some of the disparity facing rural populations with a number of pilot programs showing promising results.44–46 This is still an emerging field in Australia and debate regarding the best delivery of this service is ongoing.47–49 Compared to other countries, there are relatively few institutions dedicated to academic dermatology in Australia. However, the nation still boasts a robust research profile with institutions including the SCFA, St George Hospital (Fig. 2), Melanoma Institute of Australia, Dermatology Research Centre, Sydney Melanoma Diagnostic Centre, Centenary Institute, and Occupational Dermatology Research & Education Centre making regular contributions to the dermatology literature with clinical trial research being increasingly conducted in the private setting. The Australasian Society for Dermatology Research International Journal of Dermatology 2014, 53, 1259–1264
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was established in 2003 and has an annual meeting that focuses predominantly on the basic sciences50 with the ACD Annual Scientific Meeting the major forum for clinical research. The ACD ran a very successful ILDS World Congress in 1997 in Sydney, Dermoscopy World Congress in Brisbane in 2012 and will be hosting the International Society of Dermatologys 2021 World Congress in Melbourne.51 With its breadth of dermatological experience, Australia is a popular destination for international exchange programs and this a promising avenue through which international collaboration can propagate.52 Conclusion From humble beginnings, dermatology has established itself firmly as an important discipline of medicine within Australia. The profession has evolved over the decades with the ACD now charged with the responsibility of training the next generation of dermatologists in Australia and advocating for and advancing the profession. The scope of clinical practice is wide with clinicians well versed in medical and procedural dermatology and it is hoped that Australian dermatology will continue to bolster the profession globally. References 1 Paver K, Pettit P. Behind the Skin & Cancer Foundation: Unseen Dermatology. Sydney: Mini-Publishing, 2009. 2 Belisario JC. Inaugural oration. Australasian College of Dermatologists. Australas J Dermatol 1967; 9: 5–15. 3 Paver K, Pettit P. A history of the institutions of Australian dermatology. Australas J Dermatol 1998; 39: 52–56. 4 Linn LW. Dermatology: cinderella or princess? Aust J Dermatol 1956; 3: 109–114. 5 Johnson A, Becke R, Kocsard E. Obituaries. John Colquhoun Belisario, C.M.G., C.B.E., E.D. Australas J Dermatol 1976; 17: 127–129. 6 Georgouras KE. Australian dermatology: the past. Australas J Dermatol 1997; 38: 226–228. 7 Belasario J. Introduction. Australas J Dermatol 1951; 1: 5–6. 8 Regan W. William Kenneth Amedee Paver. Australas J Dermatol 2011; 52: 309–310. 9 Paver K. The early history of the skin & cancer foundation of NSW. Australas J Dermatol 1991; 32: 121–123. 10 Paver K, Pettit P. A philosophy for the skin and cancer foundation. Australas J Dermatol 1998; 39: 76–80. 11 Australasian College of Dermatologists. 2013. Australasian College of Dermatologists Annual Report 2013 (WWW document). http://www.dermcoll.asn.au/ public/publications.asp (accessed on November 7, 2013). ª 2014 The International Society of Dermatology
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12 Singh DG, Boudville N, Corderoy R, et al. Impact on the dermatology educational experience of medical students with the introduction of online teaching support modules to help address the reduction in clinical teaching. Australas J Dermatol 2011; 52: 264–269. 13 Australasian College of Dermatologists. 2013. Become a dermatologist (WWW document). http://www.dermcoll. asn.au/public/become_a_dermatologist_trainee_selection. asp (accessed on November 7, 2013). 14 Australasian College of Dermatologists. 2012. Specialist recognition pathway (WWW document). http://www. dermcoll.asn.au/downloads/IMG_specialist_recognition_ pathway_Feb2012.pdf (accessed on November 7, 2013). 15 Australasian College of Dermatologists. 2013. Training Program Handbook (WWW document). http://www. dermcoll.asn.au/downloads/130624TPH2013V15.pdf (accessed on November 7, 2013). 16 Australian Government Department of Human Services. 2013. Medicare website (WWW document). http://www. humanservices.gov.au/customer/information/welcome medicare-customers-website (accessed on November 7, 2013). 17 Australian Government Department of Health. 2013. Pharmaceutical Benefits Scheme (WWW document). http://www.pbs.gov.au/pbs/home (accessed on November 7, 2013). 18 Heyes C, Chan J, Halbert A, et al. Dermatology outpatient population profiling: indigenous and non-indigenous dermatoepidemiology. Australas J Dermatol 2011; 52: 202–256. 19 Wallet A, Sidhu S. Management pathway of skin conditions presenting to an Australian tertiary hospital emergency department. Australas J Dermatol 2012; 53: 307–310. 20 Bale J, Chee P. Inpatient dermatology: pattern of admissions and patients characteristics in an Australian hospital. Australas J Dermatol 2013; doi 10.1111/ajd. 12097 [Epub ahead of print]. 21 Murrell DF. Epidermolysis bullosa in Australia and New Zealand. Dermatol Clin 2010; 28: 433–438. 22 Daniel BS, Dermawan A, Murrell DF. The autoimmune blistsering diseases in Australia: statuses and services. Dermatol Clin 2011; 29: 687–690. 23 Prince HM, McCormack C, Ryan G, et al. Management of primary cutaneous lymphomas. Australas J Dermatol 2003; 44: 227–242. 24 Blumettil T, Wells J, Hertzberg M, et al. Two years of cutaneous lymphoma clinic at westmead hospital. Australas J Dermatol 2011; 52: S18. 25 Tizi S, Nixon R. Patch testing in Australia. Australas J Dermatol 2013; 54: S5. 26 Fischer GO. The commonest causes of sympomatic vulvar disease: a dermatologists perspectives. Australas J Dermatol 1996; 37: 12–18. 27 Baker C, Mack A, Cooper A, et al. Treament goals for moderate to severe psoriasis: an Australian consensus. Australas J Dermatol 2013; 54: 148–154.
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28 Taft E. How many dermatologists? – 1973 revisited. Australas J Dermatol 1988; 29: 61–71. 29 Fransen M, Karahallos A, Sharma N, et al. Non-melanoma skin cancer in Australia. Med J Aust 2012; 197: 565–568. 30 Venugopal SS, Soyer HP, Menzies SW. Results of a nationwide dermoscopy survey investigating the prevalence, advantages and disadvantages of dermoscopy use amongst Australian dermatologists. Australas J Dermatol 2011; 52: 14–18. 31 Commens C. Skin cancer: changing paradigms of practice and medical education. Med J Aust 2007; 187: 207–208. 32 Chia AL, Shumack S. Skin cancer clinics in Australia: workload profile and performance indicators from an analysis of billing data. Med J Aust 2006; 185: 239. 33 Wilkinson D, Askew DA, Dixon A. Skin cancer clinics in Australia: workload profile and performance indicators from an analysis of billing data. Med J Aust 2006; 184: 162–164. 34 Rutherford T, Elliot T, Vincuillo C. Mohs surgery in Australia: a survey of work practices. Australas J Dermatol 2011; 52: 98–103. 35 Sebaratnam D, Fern andez Pe~ nas P, Morton R, et al. Cost-effectiveness analysis of Mohs micrographic surgery vs traditional surgical excision for head and neck basal cell carcinoma in Australia. J Am Acad Dermatol 2013; 68: AB159. 36 Stewart N, Lim AC, Lowe PM, et al. Lasers and laser-like devices: part one. Australas J Dermatol 2013; 54: 173–183. 37 Sebaratnam DF, Lim AC, Lowe PM, et al. Lasers and laser-like devices: part two. Australas J Dermatol 2014; 55: 1–14. 38 Kurzydlo A, Casson C, Shumack S. Reducing professional isolation: support scheme for rural specialists. Australas J Dermatol 2005; 46: 242–245. 39 Australian Government Australian Institute of Health and Welfare. 2013. Rural Health AIHW (WWW document). http://www.aihw.gov.au/rural-health/ (accessed on November 7, 2013). 40 Currie BJ, Carapetis JR. Skin infections and infestations in Aboriginal communities in northern Australia. Australas J Dermatol 2000; 41: 139–145. 41 McMeniman E, Holden L, Kearns T, et al. Skin disease in the first two years of life in Aboriginal children in East Arnhem Land. Australas J Dermatol 2011; 52: 270–273. 42 Heyes C, Tait C, Toholka R, et al. Non-infectious skin disease in Indigenous Australians. Australas J Dermatol 2013; doi: 10.111/ajd.12106 [Epub ahead of print]. 43 Scrace M, Margolis SA. The Royal Flying Doctor Service primary care skin cancer clinic: a pilot program for remote Australia. Rural Remote Health 2009; 9: 1048. 44 See A, Lim AC, Le K, et al. Operational teledermatology in Broken Hill, rural Australia. Australas J Dermatol 2005; 46: 144–149. 45 Lim D, Oakley AM, Rademaker M. Better, sooner, more convenient: a successful teledermoscopy service. Australas J Dermatol 2012; 53: 22–25.
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46 Tait CP, Clay CD. Pilot study of store and forward teledermatology services in Perth, Western Australia. Australas J Dermatol 1999; 40: 190–193. 47 Lim AC, Egerton IB, Shumack SP. Australian teledermatology: the patient, the doctor and their government. Australas J Dermatol 2000; 41: 8–13. 48 Mahar P, Baker C, Mar A, et al. Protecting the role of clinical photography in dermatology. Australas J Dermatol 2013; 54: 238–239. 49 Kunde L, McMeniman E, Parker M. Clinical photography in dermatology: ethical and medico-legal
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considerations in the age of digital and smartphone technology. Australas J Dermatol 2013; 54: 192–197. 50 Barnetson R, Halliday GM, Sinclair R. The Australasian society for dermatology research: a new player on the team. J Invest Dermatol 2009; 129: 1843–1844. 51 Murrell DF. International Society of Dermatology Connection. Summer 2014. 52 Murrell DF, Handog EB. International exchange programs for dermatology: a prescription for the present, a hope for the future. Dermatol Clin 2008; 26: 203–219.
ª 2014 The International Society of Dermatology
Dermatology training and practice in Australia Deshan F. Sebaratnam, MBBS, M Clin Epi, and Dedee F. Murrell, MA, BMBCh, MD, FACD
Department of Dermatology, St. George Hospital and University of New South Wales, Sydney, NSW, Australia Correspondence de e F. Murrell MA, BMBCH, MD, De Department of Dermatology St. George Hospital Gray Street, Kogarah, Sydney, NSW 2217 Australia E-mail: [email protected]
Abstract Background Dermatology is a relatively young discipline in Australia compared to other specialities within the medical fraternity. From its humble beginnings, the profession has evolved significantly over the decades and is now represented by the Australasian College
FACD
of Dermatologists which is charged with training the next generation of dermatologists and advocating for and advancing the profession. Methods The authors reviewed and describe the history of dermatology training and practice in Australia. Results Despite the progress in education, there are only 415 dermatologists serving a population of 23.3 million (1 per 58 000) and yet it has the highest incidence and prevalence of skin cancer in the world. Conclusions The scope of clinical practice is wide in Australia, with clinicians well versed
Conflicts of interest: none.
in medical and procedural dermatology. It is hoped that Australian dermatology will continue to bolster the dermatology profession globally.
A brief history of dermatology in Australia Dermatology in Australia is a relatively young discipline when compared to Europe where the study of cutaneous pathology can be traced back to the 18th century.1 The earliest records of dermatology in Australia date to 1883 when William Moore was appointed Surgeon-in-charge of the Skin Department in Melbourne Hospital. Eight years later, dermatology was recognized as a specialty at Sydney Hospital and, in 1899, a dermatology clinic was established at the Royal Prince Alfred Hospital in Sydney.2 In the early twentieth century, despite Australias federation of states and territories (becoming an independent nation from Great Britain in 1901) nearly all medical practitioners belonged to the British Medical Association and specialists to Royal Colleges. Doctors were appointed as dermatologists to a teaching hospital, usually based on some form of European qualification, though this was not always mandatory. Essentially, any medical practitioner could become a dermatologist and any practicing dermatologist could become a member of the British Association of Dermatology.3 There was no uniformity in qualification and the specialty was held in low regard within the wider medical fraternity.4 John Belisario identified the need for specialized postgraduate training within Australia and with the support of the British Association of Dermatology, he established the Diploma in Dermatological Medicine at the University of Sydney in 1947.5 It was said to encompass a wider variety of subjects than any other medical training course ª 2014 The International Society of Dermatology
in Australia or Great Britain and remained the national standard of dermatology training for nearly 20 years.6 With an academic benchmark established, the next milestone in Australian dermatology was the formation of the Dermatological Association of Australia in 1949, again championed by Belisario. The organization aimed to provide a representative voice for Australian dermatology and one of its first actions was the inception of the Australasian Journal of Dermatology.7 The Dermatological Association of Australia later evolved into the Australasian College of Dermatologists (ACD) in 1966 with a more physical role in training and advocacy. As the DDM was only available at the University of Sydney, it precluded doctors located in other states from training in dermatology. It was decided that the ACD would create a uniform standard of training with national examinations and accredit teaching hospitals in every state to provide this with registrars trained through the hospital-salaried system in line with other specialties. However, as training moved into the public hospital system, it became apparent that there was a limited capacity to assemble the necessary concentration of patients and dermatologists to foster a milieu conducive to teaching and advancing the profession. To overcome this challenge, Kenneth Paver and his colleagues established the Skin and Cancer Foundation Australia (SCFA) in 1976.8 The SCFA was founded as a charity, modeled on the honorary system in which doctors donated their services to the Foundation (half a day each week) with the income generated used to sustain the organization financially.9 International Journal of Dermatology 2014, 53, 1259–1264
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The SCFA provided a nucleus in which dermatologists could collaborate together, offer a concentration of patients for teaching, complete clinical research, engage postgraduate education, and shape the future of dermatology within Australia.10 In the succeeding decades, the ACD has grown from strength to strength, now consisting of 415 practicing fellows and 90 trainees (Fig. 1).11 It remains the only representative body for dermatology in Australia charged with responsibilities relating to teaching, advocacy, and professional development of medical practitioners within the specialty of dermatology and the broader medical community.12 Specialist training in dermatology Selection into the ACD training program is intensely competitive. To be eligible, Australian medical graduate candidates must be registered for medical practice in Australia and have completed a minimum of 2 years of postgraduate training in a teaching hospital.13 Given the intensely competitive nature of selection into the program, successful candidates are generally in their third or more postgraduate year, with no single path to entry into the program; rather, those selected are pooled from a diverse range of backgrounds, including all specialties within medicine as well as research. Currently, applicants may nominate two states within Australia in which they would like to pursue their training. The candidates are shortlisted for interviews according to a standardized
Sebaratnam and Murrell
written application and verbal referee reports to a human resources consultant. Those selected for a national interview, are assessed by a committee consisting of a panel of dermatologists and a psychologist, completing structured behaviorally based interviews to determine a candidates congruency with selection criteria. Candidates are then ordered on a merit list with ACD State Faculty Chairs matching candidates preferences and their rankings. The number of training positions available each year varies, but for the past 5 years, there have been approximately 20 registrar positions available nationally each year. For international medical graduates who have already obtained qualifications in dermatology overseas with proficiency comparable or partially comparable to the ACD training program, there is a streamlined pathway available through which they may apply to have their qualifications assessed by the College. They are required to pass the test of English as a foreign language to a level required by the medical licensing authority and undergo up to two further years of training as international medical graduates before sitting the Part II examinations.14 The training program covers a comprehensive curriculum run over 4 years during which registrars rotate annually through a variety of institutions, including public hospitals, the Skin and Cancer Foundation Australia, and private practices.15 Registrars have to complete regular clinical evaluations with their supervisor throughout their training as well as a formal pharmacology examination and a series of learning modules covering the basic
Figure 1 Distribution of dermatologists and dermatology trainees in Australia according to state in 2013 International Journal of Dermatology 2014, 53, 1259–1264
ª 2014 The International Society of Dermatology
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Figure 2 The dermatology team at St. George Hospital, Sydney consists of consultants, registrars, research fellows and students, and overseas trained doctors participating in exchange programs
sciences. They must have two publications in peerreviewed journals and two conference proceedings at dermatology meetings to satisfy the research requirements of their degree. Once these prerequisites have been met, they are capable of sitting the fellowship examination in their fourth year of training, which involves a written examination, a combined laboratory dermatology, dermoscopy, short case viva examination and a long case viva, and a procedural dermatology examination. In recent years the pass rates for both the final written and clinical examinations has been approximately 80%. If candidates pass through all components of the fellowship examination, they are inducted as Fellows of the Australasian College of Dermatologists. Dermatology practice in Australia Australians and permanent residents have universal healthcare under the Medicare system in which the government provides a basic level of health care.16 Patients eligible for Medicare may attend any dermatology clinic operating in teaching hospitals free of charge with procedures such as excision of cutaneous lesions also provided without cost to the patient. Patients pay for their own ª 2014 The International Society of Dermatology
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Education
medications, which vary in price, particularly depending upon whether or not they are listed on the Pharmaceutical Benefits Scheme (PBS) (in which case they are subsidized by the government and incur a maximum price currently of AUD$28.90 if the patient satisfies an appropriate indication, with further discounts available for pensioners or those eligible for other concessions).17 Currently about one-third of Australians have private health insurance. This only covers accommodation, hospital fees, some procedures in a hospital or accredited day surgery facilities, and some of the cost towards non-PBS drugs. It does not cover the gap between the Medicare reimbursement and the doctors fees in private clinics or hospitals, unlike traditional health insurance overseas. This out of pocket payment limits escalation of medical fees. Hospital-based dermatology services are largely outpatient based18 although the specialty still plays an important role in the care of patients presenting to the Emergency Department19 and to inpatients.20 There are a number of subspecialty clinics, including multidisciplinary epidermolysis bullosa clinics in Sydney (Sydney Childrens Hospital and St George Hospital), Melbourne, Adelaide, and Brisbane,21 autoimmune blistering disease clinics in Sydney and Melbourne,22 melanoma clinics, cutaneous lymphoma clinics in Sydney and Melbourne,23 vitiligo and HIV clinics at SCFA, contact dermatitis clinics in Melbourne,24,25 vulvar dermatology clinics in Sydney,26 and biologics clinics for patients with severe psoriasis across the nation.27 Sexually transmitted disease clinics are run by sexual health doctors who have a separate training program and are affiliated with the Australasian Chapter of Sexual Health Medicine. There is limited funding within hospitals for both salaried dermatologists and dermatology trainees. The vast majority of practicing dermatologists in Australia work full-time in private practice with a portion working a clinic per week in public hospitals.28 Most dermatologists (and public hospitals) are located in the more populous urban centers along the coast of Australia with fewer services available to inland populations. As the skin cancer capital of the world,29 Australian dermatologists are well versed in the management of cutaneous malignancy. Dermoscopy is a routinely employed tool30 and the majority of dermatologists are highly skilled in procedural dermatology. The burden of skin cancer is so great that general practitioners routinely complete full skin examinations and complete basic procedures and general practitioner operated skin cancer clinics are a common occurrence. Given the prevalence of skin cancer and limited access to dermatologists, these services help to address some of the deficiencies that exist within the healthcare system; however, there are also concerns regarding the proficiency of International Journal of Dermatology 2014, 53, 1259–1264
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such practices given the lack of formal training or qualifications in dermatology.31–33 Mohs micrographic surgery (MMS) was first introduced to Australia in 1978, and there are over 40 Mohs surgeons in clinical practice nationally. Dermatologists wanting to perform MMS are required to have completed a fellowship, either in Australia or abroad. The average volume of MMS cases performed annually by Mohs surgeons is between 200 and 300 patients; lower compared to other countries such as the USA where the average is approximately 1000 patients per year.34 MMS is becoming increasingly available and from the perspective of the Australian healthcare system, MMS has been shown to be a cost-effective option for the treatment of specific nonmelanoma skin cancer.35 As elsewhere in the world, knowledge of cosmetic dermatology is part of the armamentarium of at least the younger generation of Australian dermatologists. Botulinum toxin injections, injectable fillers, epilation, and laser resurfacing36 are all commonly sought after procedures. Australia is unique though, in that given patients often present with concomitant photoaging and actinic dysplasia, and ablative modalities such as photodynamic therapy or ablative laser can be employed to treat these two conditions synchronously.37 One of the challenges facing Australia is the limited access to dermatologists, particularly in rural areas.38 Approximately one-third of Australians live outside major cities and access to healthcare is a significant issue for rural populations.39 The proportion of the population who are Indigenous Australians also increases with remoteness. Indigenous Australians have specific dermatological issues, with a greater incidence of communicable diseases40,41 but also non-communicable pathologies,42 and specialized clinics often run as outreach programs to improve access to dermatology services.43 Dermatology is uniquely placed within medicine in that teledermatology is a particularly promising avenue that may bridge some of the disparity facing rural populations with a number of pilot programs showing promising results.44–46 This is still an emerging field in Australia and debate regarding the best delivery of this service is ongoing.47–49 Compared to other countries, there are relatively few institutions dedicated to academic dermatology in Australia. However, the nation still boasts a robust research profile with institutions including the SCFA, St George Hospital (Fig. 2), Melanoma Institute of Australia, Dermatology Research Centre, Sydney Melanoma Diagnostic Centre, Centenary Institute, and Occupational Dermatology Research & Education Centre making regular contributions to the dermatology literature with clinical trial research being increasingly conducted in the private setting. The Australasian Society for Dermatology Research International Journal of Dermatology 2014, 53, 1259–1264
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was established in 2003 and has an annual meeting that focuses predominantly on the basic sciences50 with the ACD Annual Scientific Meeting the major forum for clinical research. The ACD ran a very successful ILDS World Congress in 1997 in Sydney, Dermoscopy World Congress in Brisbane in 2012 and will be hosting the International Society of Dermatologys 2021 World Congress in Melbourne.51 With its breadth of dermatological experience, Australia is a popular destination for international exchange programs and this a promising avenue through which international collaboration can propagate.52 Conclusion From humble beginnings, dermatology has established itself firmly as an important discipline of medicine within Australia. The profession has evolved over the decades with the ACD now charged with the responsibility of training the next generation of dermatologists in Australia and advocating for and advancing the profession. The scope of clinical practice is wide with clinicians well versed in medical and procedural dermatology and it is hoped that Australian dermatology will continue to bolster the profession globally. References 1 Paver K, Pettit P. Behind the Skin & Cancer Foundation: Unseen Dermatology. Sydney: Mini-Publishing, 2009. 2 Belisario JC. Inaugural oration. Australasian College of Dermatologists. Australas J Dermatol 1967; 9: 5–15. 3 Paver K, Pettit P. A history of the institutions of Australian dermatology. Australas J Dermatol 1998; 39: 52–56. 4 Linn LW. Dermatology: cinderella or princess? Aust J Dermatol 1956; 3: 109–114. 5 Johnson A, Becke R, Kocsard E. Obituaries. John Colquhoun Belisario, C.M.G., C.B.E., E.D. Australas J Dermatol 1976; 17: 127–129. 6 Georgouras KE. Australian dermatology: the past. Australas J Dermatol 1997; 38: 226–228. 7 Belasario J. Introduction. Australas J Dermatol 1951; 1: 5–6. 8 Regan W. William Kenneth Amedee Paver. Australas J Dermatol 2011; 52: 309–310. 9 Paver K. The early history of the skin & cancer foundation of NSW. Australas J Dermatol 1991; 32: 121–123. 10 Paver K, Pettit P. A philosophy for the skin and cancer foundation. Australas J Dermatol 1998; 39: 76–80. 11 Australasian College of Dermatologists. 2013. Australasian College of Dermatologists Annual Report 2013 (WWW document). http://www.dermcoll.asn.au/ public/publications.asp (accessed on November 7, 2013). ª 2014 The International Society of Dermatology
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12 Singh DG, Boudville N, Corderoy R, et al. Impact on the dermatology educational experience of medical students with the introduction of online teaching support modules to help address the reduction in clinical teaching. Australas J Dermatol 2011; 52: 264–269. 13 Australasian College of Dermatologists. 2013. Become a dermatologist (WWW document). http://www.dermcoll. asn.au/public/become_a_dermatologist_trainee_selection. asp (accessed on November 7, 2013). 14 Australasian College of Dermatologists. 2012. Specialist recognition pathway (WWW document). http://www. dermcoll.asn.au/downloads/IMG_specialist_recognition_ pathway_Feb2012.pdf (accessed on November 7, 2013). 15 Australasian College of Dermatologists. 2013. Training Program Handbook (WWW document). http://www. dermcoll.asn.au/downloads/130624TPH2013V15.pdf (accessed on November 7, 2013). 16 Australian Government Department of Human Services. 2013. Medicare website (WWW document). http://www. humanservices.gov.au/customer/information/welcome medicare-customers-website (accessed on November 7, 2013). 17 Australian Government Department of Health. 2013. Pharmaceutical Benefits Scheme (WWW document). http://www.pbs.gov.au/pbs/home (accessed on November 7, 2013). 18 Heyes C, Chan J, Halbert A, et al. Dermatology outpatient population profiling: indigenous and non-indigenous dermatoepidemiology. Australas J Dermatol 2011; 52: 202–256. 19 Wallet A, Sidhu S. Management pathway of skin conditions presenting to an Australian tertiary hospital emergency department. Australas J Dermatol 2012; 53: 307–310. 20 Bale J, Chee P. Inpatient dermatology: pattern of admissions and patients characteristics in an Australian hospital. Australas J Dermatol 2013; doi 10.1111/ajd. 12097 [Epub ahead of print]. 21 Murrell DF. Epidermolysis bullosa in Australia and New Zealand. Dermatol Clin 2010; 28: 433–438. 22 Daniel BS, Dermawan A, Murrell DF. The autoimmune blistsering diseases in Australia: statuses and services. Dermatol Clin 2011; 29: 687–690. 23 Prince HM, McCormack C, Ryan G, et al. Management of primary cutaneous lymphomas. Australas J Dermatol 2003; 44: 227–242. 24 Blumettil T, Wells J, Hertzberg M, et al. Two years of cutaneous lymphoma clinic at westmead hospital. Australas J Dermatol 2011; 52: S18. 25 Tizi S, Nixon R. Patch testing in Australia. Australas J Dermatol 2013; 54: S5. 26 Fischer GO. The commonest causes of sympomatic vulvar disease: a dermatologists perspectives. Australas J Dermatol 1996; 37: 12–18. 27 Baker C, Mack A, Cooper A, et al. Treament goals for moderate to severe psoriasis: an Australian consensus. Australas J Dermatol 2013; 54: 148–154.
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28 Taft E. How many dermatologists? – 1973 revisited. Australas J Dermatol 1988; 29: 61–71. 29 Fransen M, Karahallos A, Sharma N, et al. Non-melanoma skin cancer in Australia. Med J Aust 2012; 197: 565–568. 30 Venugopal SS, Soyer HP, Menzies SW. Results of a nationwide dermoscopy survey investigating the prevalence, advantages and disadvantages of dermoscopy use amongst Australian dermatologists. Australas J Dermatol 2011; 52: 14–18. 31 Commens C. Skin cancer: changing paradigms of practice and medical education. Med J Aust 2007; 187: 207–208. 32 Chia AL, Shumack S. Skin cancer clinics in Australia: workload profile and performance indicators from an analysis of billing data. Med J Aust 2006; 185: 239. 33 Wilkinson D, Askew DA, Dixon A. Skin cancer clinics in Australia: workload profile and performance indicators from an analysis of billing data. Med J Aust 2006; 184: 162–164. 34 Rutherford T, Elliot T, Vincuillo C. Mohs surgery in Australia: a survey of work practices. Australas J Dermatol 2011; 52: 98–103. 35 Sebaratnam D, Fern andez Pe~ nas P, Morton R, et al. Cost-effectiveness analysis of Mohs micrographic surgery vs traditional surgical excision for head and neck basal cell carcinoma in Australia. J Am Acad Dermatol 2013; 68: AB159. 36 Stewart N, Lim AC, Lowe PM, et al. Lasers and laser-like devices: part one. Australas J Dermatol 2013; 54: 173–183. 37 Sebaratnam DF, Lim AC, Lowe PM, et al. Lasers and laser-like devices: part two. Australas J Dermatol 2014; 55: 1–14. 38 Kurzydlo A, Casson C, Shumack S. Reducing professional isolation: support scheme for rural specialists. Australas J Dermatol 2005; 46: 242–245. 39 Australian Government Australian Institute of Health and Welfare. 2013. Rural Health AIHW (WWW document). http://www.aihw.gov.au/rural-health/ (accessed on November 7, 2013). 40 Currie BJ, Carapetis JR. Skin infections and infestations in Aboriginal communities in northern Australia. Australas J Dermatol 2000; 41: 139–145. 41 McMeniman E, Holden L, Kearns T, et al. Skin disease in the first two years of life in Aboriginal children in East Arnhem Land. Australas J Dermatol 2011; 52: 270–273. 42 Heyes C, Tait C, Toholka R, et al. Non-infectious skin disease in Indigenous Australians. Australas J Dermatol 2013; doi: 10.111/ajd.12106 [Epub ahead of print]. 43 Scrace M, Margolis SA. The Royal Flying Doctor Service primary care skin cancer clinic: a pilot program for remote Australia. Rural Remote Health 2009; 9: 1048. 44 See A, Lim AC, Le K, et al. Operational teledermatology in Broken Hill, rural Australia. Australas J Dermatol 2005; 46: 144–149. 45 Lim D, Oakley AM, Rademaker M. Better, sooner, more convenient: a successful teledermoscopy service. Australas J Dermatol 2012; 53: 22–25.
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1264
Education
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46 Tait CP, Clay CD. Pilot study of store and forward teledermatology services in Perth, Western Australia. Australas J Dermatol 1999; 40: 190–193. 47 Lim AC, Egerton IB, Shumack SP. Australian teledermatology: the patient, the doctor and their government. Australas J Dermatol 2000; 41: 8–13. 48 Mahar P, Baker C, Mar A, et al. Protecting the role of clinical photography in dermatology. Australas J Dermatol 2013; 54: 238–239. 49 Kunde L, McMeniman E, Parker M. Clinical photography in dermatology: ethical and medico-legal
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considerations in the age of digital and smartphone technology. Australas J Dermatol 2013; 54: 192–197. 50 Barnetson R, Halliday GM, Sinclair R. The Australasian society for dermatology research: a new player on the team. J Invest Dermatol 2009; 129: 1843–1844. 51 Murrell DF. International Society of Dermatology Connection. Summer 2014. 52 Murrell DF, Handog EB. International exchange programs for dermatology: a prescription for the present, a hope for the future. Dermatol Clin 2008; 26: 203–219.
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