ORIGINAL
ARTICLES
Public perception of dermatologists and comparison with other medical specialties: Results from a national survey Elizabeth A. Brezinski, MD,a Caitlin T. Harskamp, BSN, RN,a Lynda Ledo, BS,a and April W. Armstrong, MD, MPHb Sacramento, California, and Aurora, Colorado Background: The public’s perception of dermatologists in the United States is unknown. Objective: We sought to determine the US public’s perception of how dermatologists spend time professionally and to compare the public’s perception of dermatologists with physicians from other medical specialties. Methods: We administered a telephone survey to the US public using the validated random digit dialing method. Results: We made 2353 telephone calls to randomly selected active numbers from 10 US area codes. A total of 800 adults (34%) completed the telephone survey. Overall, 46% of participants perceived that dermatologists spend a majority of their time managing skin cancer. Of respondents, 27% perceived that dermatologists spend a majority of their time performing cosmetic procedures. Compared with dermatologists, primary care physicians were perceived to have a more critical profession by 63% of participants, a more difficult job by 54% of respondents, and work longer hours by 92% of those surveyed. Similar findings were observed when dermatologists were compared with cardiologists. The public perceived dermatologists to earn more than primary care physicians but less than cardiologists or plastic surgeons. Limitations: Potential differences may exist between responders and nonresponders. Conclusions: Educational efforts are necessary to better inform public understanding and perception of dermatologists’ expertise. ( J Am Acad Dermatol 2014;71:875-81.) Key words: cardiology; cosmetic dermatology; dermatologists; dermatology; medical dermatology; perception; plastic surgery; primary care physicians; public opinion; public perception.
he perception of medical and surgical specialties by the general US public is not well characterized in the literature. Few prior studies on the perception of various medical specialties focused on input from health care professionals.1-4 The perception of medical specialists by the general public has a significant effect on a multitude of issues ranging from how patients seek health care from specialists, health policy development and implementation, and research
T
funding allocation. Therefore, examining the public’s perception of dermatologists is the foundation for identifying opportunities to inform the general public regarding the diversity and nature of dermatologists’ expertise. An informed public will be better able to make health care decisions concerning their skin care and gain a renewed understanding of dermatologists’ skill sets. Although investigations of the public’s perception of dermatologists are scarce, several studies have
From the Departments of Dermatology at University of CaliforniaeDavisa and University of ColoradoeDenver.b Funding sources: None. Conflicts of interest: None declared. Accepted for publication July 6, 2014. Correspondence to: April W. Armstrong, MD, MPH, Department of Dermatology, University of ColoradoeDenver, School of Medicine,
12801 E 17th Ave, Mail Stop 8127, Aurora, CO 80045. E-mail: [email protected]. Reprint requests: [email protected]. Published online September 4, 2014. 0190-9622/$36.00 Ó 2014 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2014.07.019
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examined the perceived hierarchy of medical dermatologists’ contributions to health care. The specialties from the perspective of US medical public’s perception also may influence policy professionals.1-3 In a 1958 study, of 12 medical decisions regarding resource allocation for clinical specialties, medical students and physician faculty care and research. The objectives of this study are to ranked surgery, internal medicine, and neurology as determine the general US public’s perception of the top-3 most prestigious fields, and they ranked dermatologists’ professional responsibilities and dermatology last.1 In a 1973 study, of 22 medical how dermatologists compare with physicians from specialties, physicians and other medical fields. medical staff perceived CAPSULE SUMMARY neurosurgery, internal mediMETHODS cine, and general surgery Study procedures The US public’s perception of to be the most prestigious To obtain a representative dermatology is unknown. subspecialties, and they US public perception of derThe US adult population perceives ranked dermatology 18th in matologists, we performed a dermatologists to spend more time on prestige.2 In a 1975 study, of population-based, telephone cosmetic procedures than the published 40 medical specialties, physisurvey using a multidiworkforce data would indicate. cians and medical students mensional sampling method ranked internal medicine, with random digit dialing. Dermatologists need to educate the family medicine, and general We used a validated method public and other stakeholders, including practice in the top ‘‘most for random digit dialing payers and health policy constituents, on attractive fields to practice.’’3 to obtain a representative their medical and surgical expertise In this study, dermatology sampling of US adults because the public’s perception may was ranked 28th by male ($ 18 years old).6-8 This influence health policy development, physicians and 7th by female study was approved by clinical care, and research. physicians.3 the Institutional Review One study investigated Board at the University of the perceptions of expertise in cutaneous surgery CaliforniaeDavis on July 8, 2010 (201018257-1). and cosmetic procedures from the perspective of To obtain a representative sample of the US medical residents in primary care training fields.4 population to administer our survey, we randomly The medical residents perceived dermatologists as selected 10 US cities by telephone area code. Sets of 3 the most qualified specialist to evaluate and digits were randomly generated using a random biopsy worrisome lesions on the face, perform skin number generator (randomizer.org) to correspond cancer surgery, inject botulinum toxin, inject with the 3 digits in a US area code.9 An online search fillers, and perform laser procedures as compared was performed after each 3-digit set was generated with physicians from other specialties including to confirm that it was a valid US city area code. The plastic surgeons, otolaryngologists, and ophthalmorandomly selected US cities were Abilene, TX; Cedar logists. Plastic surgeons were perceived as the Rapids, IA; Dayton, OH; Lakeland, FL; Lexington, most qualified specialist to perform liposuction, KY; Macon, GA; Newark, NJ; San Diego, CA; face-lift surgery, and a hair transplantation Santa Ana, CA; and Waco, TX. The 10 selected cities procedure.4 One survey found that physician with their estimated population, the number of and nonphysician leaders of 13 nondermatology respondents, and the percentage of respondents physician organizations perceive dermatologists are shown in Fig 1. to be making significant a contribution to the In the US, telephone numbers comprise 3 comprevention and treatment of skin cancers and ponents. The first 3 digits make up the area code, the chronic skin diseases; however, the same physician second 3 digits make up the prefix number, and the and nonphysician leaders also perceive dermatolast 4 digits are randomly generated.8 To obtain the logists as difficult to access, hesitant or unwilling to prefixes for each of the randomly selected cities, we treat routine medical conditions, and focusing more used the National Pooling World Wide Web site on cosmetic procedures.5 (nationalpooling.com).10 We randomly selected 10 To date, there are no published assessments of prefixes for each city. To generate a random assortthe US public’s perception of dermatology from a ment of the last 4 digits of the telephone numbers, nationally representative sample of the US populawe used a random number generator (randomizer. tion. Determining the public’s perception of org) to produce different 4-digit combinations.9 dermatologists is critical because these perceptions After compiling the data for eligible telephone represent a facet of the perceived importance of numbers, telephone calls were made using the area d
d
d
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Fig 1. Ten randomly selected US cities with each city’s population estimate, number of respondents, and percentage of respondents. From the US Department of the Interior. National atlas. Available from: http://nationalatlas.gov.13 Accessed February 28, 2014. xPopulation estimates are based on the 2010 US Census data (http://factfinder2.census.gov/faces/nav/jsf/ pages/index.xhtml).14
code of a randomly selected city, a randomly selected prefix for that city, and one of the randomly generated 4-digit sets. If the initial number that we dialed was connected to either a residence or a cell phone, we continued making calls using the clustered unit of telephone numbers. A clustered sampling unit of telephone numbers contains telephone numbers that have the same area code, same prefix, and same first 2 digits of the last 4-digit number.7 The variations within a cluster are the last 2 digits of the telephone number, which range from 00 to 99. For example, the telephone number (555) 555-5555 would have a cluster ranging from (555) 555-5500 to (555) 555-5599. If the first several numbers within a cluster were not connected with residences or cell phones, we would randomly select another prefix and 4-digit set for the randomly selected area code and begin a different clustered sampling unit. This method was repeated for all 10 area codes. Data were collected from July 13, 2010, to July 7, 2011. Outcomes ascertainment and analysis We collected demographic information from respondents including age, gender, race, income bracket, and employment status. The primary outcome of this study was to ascertain the public’s
perception of the type of skin conditions that dermatologists spent the majority of their time managing. The secondary outcomes included public’s perception of dermatologists in comparison with primary care physicians, cardiologists, and plastic surgeons with regards to perceived responsibilities and difficulties of the profession, work hours, and income level. Primary care physicians and cardiologists were chosen because these medical specialties were perceived highly by health care professionals in previous studies.1-3 In addition, primary care physicians offered a comparable outpatient-based medical practice. Plastic surgery was selected as a comparison group because of the perceived similarities to dermatology in certain practice areas. The survey data were summarized descriptively. All analyses were performed using Stata 13 (StataCorp LP, College Station, TX).
RESULTS From the 2353 telephone calls to working telephone numbers, 800 US adults (34%) completed the telephone survey. The baseline characteristics of the respondents were summarized and compared with the demographics of the US population in Table I. The majority of adults surveyed were white
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Table I. Population characteristics Characteristic
Age, y, mean 6 SD Male gender Race
Ethnicity Employment status
Annual income
No. of dermatologist visits in past 5 y, median
Survey study results (n = 800)
US population (n = 308,745,538)*
46.4 6 12.7 44.6% White, 72% Black or African American, 12% Asian or Pacific Islander, 8% American Indian or Alaska Native, 0.1% Other race, 8% Hispanic or Latino, 19% Not Hispanic or Latino, 81% Employed (including self-employment), 64% In school, 6.3% Retired, 13.6% Unemployed, 15.9% \$50,000, 23% $50,000-$100,000, 43% $100,000-$150,000, 12% [$150,000, 1% Declined to answer, 21% 1 (25th quartile = 0, 75th quartile = 1)
37.2 (median) 49.2% White, 72% Black or African American, 12% Asian or Pacific Islander, 5% American Indian or Alaska Native, 0.9% Other race, 9% Hispanic or Latino, 16% Not Hispanic or Latino, 84% Employed (self-employment NR), 58.2% In school, 27% Retired, NR Unemployed, 9.3%y \$50,000, 47% $50,000-$100,000, 30% $100,000-$150,000, 13% [$150,000, 9% Declined to answer, NRy NR
NR, Not reported. *Population estimates are based on the 2010 US Census (http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml).14 y Employment status and annual income estimates are based on the US Census Bureau, 2008-2012 American Community Survey (http:// factfinder2.census.gov/faces/nav/jsf/pages/searchresults.xhtml?refresh=t).15
(72%) and employed (64%) with a median of 1 visit to the dermatologist in the past 5 years. Perception of how dermatologists spent time professionally The participants were asked their perception of how dermatologists spend the majority of their time professionally. Overall, 46% of surveyed US adults perceived that dermatologists spend a majority of time managing skin cancer. In addition, 27% of respondents perceived that dermatologists spend a majority of the time performing cosmetic procedures, 21% perceived that dermatologists spend a majority of their time treating rashes, and 6% of the participants believed that dermatologists spend a majority of their time treating benign growths. Perception of dermatologists compared with other medical and surgical specialists When comparing primary care physicians with dermatologists, 63% (95% confidence interval [CI] 60%-66%) of survey respondents selected a primary care physician to have a more critical profession (Table II). Of participants, 54% (95% CI 51%-57%) perceived primary care physicians to have a more difficult job; 92% (95% CI 90%-94%) of respondents perceived that primary care physicians work longer hours. Overall, 99.6% (95% CI 99.2%-100%) of the US
general public surveyed perceived dermatologists to earn a higher income on average compared with primary care physicians. Of note, 72% (95% CI 69%-75%) of the respondents believed that primary care physicians should be paid more than dermatologists. Similar results were found when the participants were asked their perceptions of dermatologists compared with cardiologists. Among those surveyed, 99.5% (95% CI 99%-100%) perceived cardiologists to have a more critical profession, 99.5% (95% CI 99%-100%) believed cardiologists have a more difficult job, 99.75% (95% CI 99.4%-100%) selected cardiologists as the profession that works longer hours, and 74% (95% CI 71%-77%) perceived that cardiologists earn a higher income than dermatologists. Overall, 99.5% (95% CI 99%-100%) reported that cardiologists should be paid more than dermatologists. The US public’s perception of dermatologists compared with plastic surgeons was also elicited. Among survey respondents, 56% (95% CI 53%-59%) perceived dermatologists to have a more critical profession and 53% (95% CI 50%-56%) believed dermatologists have a more difficult job compared with plastic surgeons. However, plastic surgeons were perceived to work longer hours by 88% (95% CI 86%-90%) of respondents. Overall, 81%
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Table II. Survey study results and evidence-based data Comparison specialty physician group
Primary care physicians
Cardiology
Plastic surgery
Dermatology
Questions
Has a more critical profession Has a more difficult job Works longer hours Earns more income on average Should be paid more
Has a more critical profession Has a more difficult job Works longer hours Earns more income on average Should be paid more Has a more critical profession Has a more difficult job Works longer hours Earns more income on average Should be paid more NA
Evidence-based data for the comparison specialty physician group12
Dermatologists Specialists
37%
63%
Internists, family practitioners Yearly compensation: $185,000, $173,000 d 48% and 49% Believe they are fairly 54% 92% compensated d The largest percentage sees patients between 0.4% 30-40 h/wk (29%, 39%) d The majority sees patients for # 45 h/wk (64%) 72% and # 40 h/wk (62%) d 8% and 3% Spend [65 h/wk seeing patients 99.5% d Yearly compensation: $357,000 d 42% Believe they are fairly compensated 99.5% d The largest percentage sees patients between 99.75% 45-50 h/wk (17%) d The majority sees patients for # 50 h/wk (59%) 74% d 14% Spend [65 h/wk seeing patients 99.5% d Yearly compensation: $317,000 44% d 41% Believe they are fairly compensated d The largest percentage sees patients between 47% 88% 30-40 h/wk (28%) d The majority sees patients for # 45 h/wk (74%) 81% d 3% Spend [65 h/wk seeing patients 52% d Yearly compensation: $306,000 NA d 65% Believe they are fairly compensated d The largest percentage sees patients between 30-40 h/wk (52%) d The average amount of time spent seeing patients was 37 h/wk11 d The majority sees patients for # 40 h/wk (80%) d 1% Spend [65 h/wk seeing patients d
46% 8% 99.6% 38%
0.5% 0.5% 0.25% 26% 0.5% 56% 53% 12% 19% 48% NA
NA, Not applicable.
(95% CI 78%-84%) of participants perceived plastic surgeons to earn a higher income on average compared with dermatologists. However, 48% (95% CI 45%-51%) of respondents indicated that dermatologists should be paid more than plastic surgeons.
DISCUSSION To our knowledge, this is among the first studies using a nationally representative US cohort to examine the public’s perception of dermatologists and how dermatologists compare with physicians from other medical specialties. The study findings have identified specific areas where the public’s perception does not align with actual dermatology workforce data. These findings provide the foundation for advocacy and educational efforts aimed at informing the public regarding dermatologists’ expertise and contributions to health care.
This study showed that 27% of respondents perceived dermatologists to spend a majority of their time performing cosmetic procedures. The public’s perception that dermatologists spend a majority of their time performing cosmetic procedures is not supported by the dermatology workforce data.11 In a 2007 survey of dermatologists, respondents reported spending 63% of their patient care hours managing medical dermatology conditions.11 The survey of dermatologists also found that the second largest amount of patient care time was spent performing surgery (27%) and the least number of direct patient care hours was spent on cosmetic dermatology (10%).11 The gap between the public’s perception of the dermatologist’s job and the reported practices of dermatologists is likely multifactorial. Innovations have continued to grow in cosmetic procedures and devices over the past decade. These cosmetic innovations may appeal to a larger audience and receive greater public attention in the print, online,
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and television media. In addition, the general public may not have sufficient appreciation for dermatologists’ role in managing chronic inflammatory skin diseases that significantly impact patients’ lives, such as psoriasis, atopic dermatitis, or immunobullous diseases. For example, primary care physicians may be the first-line providers for patients with acne or atopic dermatitis in many communities, and therefore the patients are not as aware of dermatologists’ expertise or other types of common skin diseases. Important opportunities exist to inform the general public regarding the burden of many chronic inflammatory skin diseases and dermatologists’ expertise in treating these conditions. From this study, the public perceived that primary care physicians, cardiologists, and plastic surgeons work longer hours compared with dermatologists, and this perception is accurate when compared with the reported work hours seeing patients by physicians in each of these specialties.12 A study of 21,878 US physicians across 25 specialties reported that the majority of cardiologists saw patients for 50 hours or less per week (59%), the majority of plastic surgeons and internists saw patients 45 hours or less per week (74% and 64%, respectively), and the majority of family practitioners and dermatologists saw patients for 40 hours or less per week (62% and 80%, respectively).12 A minority of practitioners from all specialties spent more than 65 hours per week treating patients: 14% of cardiologists, 8% of internists, 3% each of family practitioners and plastic surgeons, and 1% of dermatologists.12 However, the literature shows that, despite the relatively fewer hours per week seeing patients compared with some medical specialties, dermatologists have a greater volume of patient encounters or visits per week. For example, although the number of patient encounters per week varies significantly among dermatologists, dermatologists most commonly complete 100 to 136 patient encounters per week nationally.11,12 This is more than the 76 to 99 encounters per week for family practitioners and 50 to 75 encounters per week for internal medicine physicians.12 Thus, many dermatologists face demanding, high-volume clinic schedules where they are expected to provide high-quality care within a short period of time. The public perceived that cardiologists and plastic surgeons earned a higher income on average compared with dermatologists and that dermatologists earned more than primary care physicians. The public perception of earned physician income by specialty is consistent with the literature.12 According to the 2012 yearly
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compensation report, the average yearly compensation was $357,000 for cardiologists, $317,000 for plastic surgeons, $306,000 for dermatologists, $185,000 for internists, and $173,000 for family practitioners.12 Among the physicians surveyed, a greater percentage of dermatologists believed they were fairly compensated, compared with medical professionals in the other 4 specialties.12 In this study, the public perceived that cardiologists, plastic surgeons, and primary care physicians should be paid more than dermatologists. The question of who should earn more is complex. Factors affecting a physician’s income may include length of training, number of hours worked, the volume of patients seen, the number and types of procedures performed, degree of contribution to scholarship and research grants, practice setting (academic vs community group practice vs private), and the perceived quality of care by patients. Although the public accurately perceives earned physician income, educating the general population on the dermatologist’s skill set and the diversity of skin conditions managed by dermatologists is critical. In this study, the public perceived dermatology to be a more critical profession and perceived that dermatologists had a more difficult job compared with plastic surgeons. One possible explanation for this perception may be related to the public’s awareness of dermatologists’ key role in treating skin cancers. The results of this study need to be interpreted in the context of the study design. As with all survey data, potential differences may exist between responders and nonresponders. The telephone survey study was also only conducted in English, which precluded non-English-speaking respondents from participating in the survey. The randomization process was used to eliminate selection bias; however it would have been more ideal to have a greater number of randomly selected regions to conduct the survey. To our knowledge, this is among the first studies that examined the general US public’s perception of dermatology. The perceived importance of dermatology may influence health policy decisions, payer policies, and allocation of research funding. This study showed that a significant proportion of the US public perceives that dermatologists spend most of their time performing cosmetic procedures, which is not corroborated by actual workforce data. The study findings suggest that ample opportunities exist to educate the public regarding the diversity of dermatologists’ expertise and the associated contributions towards improving patients’ physical well-being and their
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quality of life. Educational strategies need to occur at both local and national levels to increase awareness of dermatologist expertise among the public and other stakeholders, including payers and health policy constituents. REFERENCES 1. Reader GG. Development of professional attitudes and capacities. J Med Educ 1958;33:164-85. 2. Schwartzbaum AM, McGrath JH, Rothman RA. The perception of prestige differences among medical subspecialties. Soc Sci Med 1973;7:365-71. 3. Gough HG. Specialty preferences of physicians and medical students. J Med Educ 1975;50:581-8. 4. Ibrahimi OA, Bangash H, Green L, Alam M, Armstrong AW, Eisen DB. Perceptions of expertise in cutaneous surgery and cosmetic procedures: what primary care physicians think. Dermatol Surg 2012;38:1645-51. 5. Bowers J. How dermatologists are viewed by other physicians and what they can do about it. Dermatology World. Available from: http://www.aad.org/dw. Accessed June 5, 2014. 6. Cummings KM. Random digit dialing: a sampling technique for telephone surveys. Public Opin Q 1979;43:233-44. 7. Waksberg J. Sampling methods for random digit dialing. J Am Stat Assoc 1978;73:40-6.
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8. Hartge P, Brinton LA, Rosenthal JF, Cahill JI, Hoover RN, Waksberg J. Random digit dialing in selecting a population-based control group. Am J Epidemiol 1984;120:825-33. 9. Urbaniak GC, Plous S. Research Randomizer (Version 4.0). [Computer software]. Available from: http://www.randomizer. org/. Accessed June 2, 2010. 10. Neustar, Inc. National Number Pool Administration. Available from: http://www.nationalpooling.com/. Accessed June 2, 2010. 11. Kimball AB, Resneck JS Jr. The US dermatology workforce: a specialty remains in shortage. J Am Acad Dermatol 2008;59: 741-5. 12. Medscape. Physician compensation report 2013. New York: WebMD LLC; c1994e2014. Available from: http://www. medscape.com/sites/public/physician-comp/2013. Accessed February 20, 2014. 13. The National Atlas of the United States (2014). Available from: http://www.nationalatlas.gov/. Accessed February 28, 2014. 14. US Census Bureau, American Fact Finder (2010). Census 2010 Total Population. Available from: http://factfinder2.census. gov/faces/nav/jsf/Q9pages/index.xhtml. Accessed February 11, 2014. 15. US Census Bureau. American Fact Finder (2012). S2301 Employment Status, 2008e2012 American Community Survey 5-Year Estimates. Available from: http://factfinder2.census. gov/faces/nav/jsf/pages/searchresults.xhtml?refresh=t. Accessed February 11, 2014.
ARTICLES
Public perception of dermatologists and comparison with other medical specialties: Results from a national survey Elizabeth A. Brezinski, MD,a Caitlin T. Harskamp, BSN, RN,a Lynda Ledo, BS,a and April W. Armstrong, MD, MPHb Sacramento, California, and Aurora, Colorado Background: The public’s perception of dermatologists in the United States is unknown. Objective: We sought to determine the US public’s perception of how dermatologists spend time professionally and to compare the public’s perception of dermatologists with physicians from other medical specialties. Methods: We administered a telephone survey to the US public using the validated random digit dialing method. Results: We made 2353 telephone calls to randomly selected active numbers from 10 US area codes. A total of 800 adults (34%) completed the telephone survey. Overall, 46% of participants perceived that dermatologists spend a majority of their time managing skin cancer. Of respondents, 27% perceived that dermatologists spend a majority of their time performing cosmetic procedures. Compared with dermatologists, primary care physicians were perceived to have a more critical profession by 63% of participants, a more difficult job by 54% of respondents, and work longer hours by 92% of those surveyed. Similar findings were observed when dermatologists were compared with cardiologists. The public perceived dermatologists to earn more than primary care physicians but less than cardiologists or plastic surgeons. Limitations: Potential differences may exist between responders and nonresponders. Conclusions: Educational efforts are necessary to better inform public understanding and perception of dermatologists’ expertise. ( J Am Acad Dermatol 2014;71:875-81.) Key words: cardiology; cosmetic dermatology; dermatologists; dermatology; medical dermatology; perception; plastic surgery; primary care physicians; public opinion; public perception.
he perception of medical and surgical specialties by the general US public is not well characterized in the literature. Few prior studies on the perception of various medical specialties focused on input from health care professionals.1-4 The perception of medical specialists by the general public has a significant effect on a multitude of issues ranging from how patients seek health care from specialists, health policy development and implementation, and research
T
funding allocation. Therefore, examining the public’s perception of dermatologists is the foundation for identifying opportunities to inform the general public regarding the diversity and nature of dermatologists’ expertise. An informed public will be better able to make health care decisions concerning their skin care and gain a renewed understanding of dermatologists’ skill sets. Although investigations of the public’s perception of dermatologists are scarce, several studies have
From the Departments of Dermatology at University of CaliforniaeDavisa and University of ColoradoeDenver.b Funding sources: None. Conflicts of interest: None declared. Accepted for publication July 6, 2014. Correspondence to: April W. Armstrong, MD, MPH, Department of Dermatology, University of ColoradoeDenver, School of Medicine,
12801 E 17th Ave, Mail Stop 8127, Aurora, CO 80045. E-mail: [email protected]. Reprint requests: [email protected]. Published online September 4, 2014. 0190-9622/$36.00 Ó 2014 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2014.07.019
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876 Brezinski et al
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examined the perceived hierarchy of medical dermatologists’ contributions to health care. The specialties from the perspective of US medical public’s perception also may influence policy professionals.1-3 In a 1958 study, of 12 medical decisions regarding resource allocation for clinical specialties, medical students and physician faculty care and research. The objectives of this study are to ranked surgery, internal medicine, and neurology as determine the general US public’s perception of the top-3 most prestigious fields, and they ranked dermatologists’ professional responsibilities and dermatology last.1 In a 1973 study, of 22 medical how dermatologists compare with physicians from specialties, physicians and other medical fields. medical staff perceived CAPSULE SUMMARY neurosurgery, internal mediMETHODS cine, and general surgery Study procedures The US public’s perception of to be the most prestigious To obtain a representative dermatology is unknown. subspecialties, and they US public perception of derThe US adult population perceives ranked dermatology 18th in matologists, we performed a dermatologists to spend more time on prestige.2 In a 1975 study, of population-based, telephone cosmetic procedures than the published 40 medical specialties, physisurvey using a multidiworkforce data would indicate. cians and medical students mensional sampling method ranked internal medicine, with random digit dialing. Dermatologists need to educate the family medicine, and general We used a validated method public and other stakeholders, including practice in the top ‘‘most for random digit dialing payers and health policy constituents, on attractive fields to practice.’’3 to obtain a representative their medical and surgical expertise In this study, dermatology sampling of US adults because the public’s perception may was ranked 28th by male ($ 18 years old).6-8 This influence health policy development, physicians and 7th by female study was approved by clinical care, and research. physicians.3 the Institutional Review One study investigated Board at the University of the perceptions of expertise in cutaneous surgery CaliforniaeDavis on July 8, 2010 (201018257-1). and cosmetic procedures from the perspective of To obtain a representative sample of the US medical residents in primary care training fields.4 population to administer our survey, we randomly The medical residents perceived dermatologists as selected 10 US cities by telephone area code. Sets of 3 the most qualified specialist to evaluate and digits were randomly generated using a random biopsy worrisome lesions on the face, perform skin number generator (randomizer.org) to correspond cancer surgery, inject botulinum toxin, inject with the 3 digits in a US area code.9 An online search fillers, and perform laser procedures as compared was performed after each 3-digit set was generated with physicians from other specialties including to confirm that it was a valid US city area code. The plastic surgeons, otolaryngologists, and ophthalmorandomly selected US cities were Abilene, TX; Cedar logists. Plastic surgeons were perceived as the Rapids, IA; Dayton, OH; Lakeland, FL; Lexington, most qualified specialist to perform liposuction, KY; Macon, GA; Newark, NJ; San Diego, CA; face-lift surgery, and a hair transplantation Santa Ana, CA; and Waco, TX. The 10 selected cities procedure.4 One survey found that physician with their estimated population, the number of and nonphysician leaders of 13 nondermatology respondents, and the percentage of respondents physician organizations perceive dermatologists are shown in Fig 1. to be making significant a contribution to the In the US, telephone numbers comprise 3 comprevention and treatment of skin cancers and ponents. The first 3 digits make up the area code, the chronic skin diseases; however, the same physician second 3 digits make up the prefix number, and the and nonphysician leaders also perceive dermatolast 4 digits are randomly generated.8 To obtain the logists as difficult to access, hesitant or unwilling to prefixes for each of the randomly selected cities, we treat routine medical conditions, and focusing more used the National Pooling World Wide Web site on cosmetic procedures.5 (nationalpooling.com).10 We randomly selected 10 To date, there are no published assessments of prefixes for each city. To generate a random assortthe US public’s perception of dermatology from a ment of the last 4 digits of the telephone numbers, nationally representative sample of the US populawe used a random number generator (randomizer. tion. Determining the public’s perception of org) to produce different 4-digit combinations.9 dermatologists is critical because these perceptions After compiling the data for eligible telephone represent a facet of the perceived importance of numbers, telephone calls were made using the area d
d
d
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Fig 1. Ten randomly selected US cities with each city’s population estimate, number of respondents, and percentage of respondents. From the US Department of the Interior. National atlas. Available from: http://nationalatlas.gov.13 Accessed February 28, 2014. xPopulation estimates are based on the 2010 US Census data (http://factfinder2.census.gov/faces/nav/jsf/ pages/index.xhtml).14
code of a randomly selected city, a randomly selected prefix for that city, and one of the randomly generated 4-digit sets. If the initial number that we dialed was connected to either a residence or a cell phone, we continued making calls using the clustered unit of telephone numbers. A clustered sampling unit of telephone numbers contains telephone numbers that have the same area code, same prefix, and same first 2 digits of the last 4-digit number.7 The variations within a cluster are the last 2 digits of the telephone number, which range from 00 to 99. For example, the telephone number (555) 555-5555 would have a cluster ranging from (555) 555-5500 to (555) 555-5599. If the first several numbers within a cluster were not connected with residences or cell phones, we would randomly select another prefix and 4-digit set for the randomly selected area code and begin a different clustered sampling unit. This method was repeated for all 10 area codes. Data were collected from July 13, 2010, to July 7, 2011. Outcomes ascertainment and analysis We collected demographic information from respondents including age, gender, race, income bracket, and employment status. The primary outcome of this study was to ascertain the public’s
perception of the type of skin conditions that dermatologists spent the majority of their time managing. The secondary outcomes included public’s perception of dermatologists in comparison with primary care physicians, cardiologists, and plastic surgeons with regards to perceived responsibilities and difficulties of the profession, work hours, and income level. Primary care physicians and cardiologists were chosen because these medical specialties were perceived highly by health care professionals in previous studies.1-3 In addition, primary care physicians offered a comparable outpatient-based medical practice. Plastic surgery was selected as a comparison group because of the perceived similarities to dermatology in certain practice areas. The survey data were summarized descriptively. All analyses were performed using Stata 13 (StataCorp LP, College Station, TX).
RESULTS From the 2353 telephone calls to working telephone numbers, 800 US adults (34%) completed the telephone survey. The baseline characteristics of the respondents were summarized and compared with the demographics of the US population in Table I. The majority of adults surveyed were white
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Table I. Population characteristics Characteristic
Age, y, mean 6 SD Male gender Race
Ethnicity Employment status
Annual income
No. of dermatologist visits in past 5 y, median
Survey study results (n = 800)
US population (n = 308,745,538)*
46.4 6 12.7 44.6% White, 72% Black or African American, 12% Asian or Pacific Islander, 8% American Indian or Alaska Native, 0.1% Other race, 8% Hispanic or Latino, 19% Not Hispanic or Latino, 81% Employed (including self-employment), 64% In school, 6.3% Retired, 13.6% Unemployed, 15.9% \$50,000, 23% $50,000-$100,000, 43% $100,000-$150,000, 12% [$150,000, 1% Declined to answer, 21% 1 (25th quartile = 0, 75th quartile = 1)
37.2 (median) 49.2% White, 72% Black or African American, 12% Asian or Pacific Islander, 5% American Indian or Alaska Native, 0.9% Other race, 9% Hispanic or Latino, 16% Not Hispanic or Latino, 84% Employed (self-employment NR), 58.2% In school, 27% Retired, NR Unemployed, 9.3%y \$50,000, 47% $50,000-$100,000, 30% $100,000-$150,000, 13% [$150,000, 9% Declined to answer, NRy NR
NR, Not reported. *Population estimates are based on the 2010 US Census (http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml).14 y Employment status and annual income estimates are based on the US Census Bureau, 2008-2012 American Community Survey (http:// factfinder2.census.gov/faces/nav/jsf/pages/searchresults.xhtml?refresh=t).15
(72%) and employed (64%) with a median of 1 visit to the dermatologist in the past 5 years. Perception of how dermatologists spent time professionally The participants were asked their perception of how dermatologists spend the majority of their time professionally. Overall, 46% of surveyed US adults perceived that dermatologists spend a majority of time managing skin cancer. In addition, 27% of respondents perceived that dermatologists spend a majority of the time performing cosmetic procedures, 21% perceived that dermatologists spend a majority of their time treating rashes, and 6% of the participants believed that dermatologists spend a majority of their time treating benign growths. Perception of dermatologists compared with other medical and surgical specialists When comparing primary care physicians with dermatologists, 63% (95% confidence interval [CI] 60%-66%) of survey respondents selected a primary care physician to have a more critical profession (Table II). Of participants, 54% (95% CI 51%-57%) perceived primary care physicians to have a more difficult job; 92% (95% CI 90%-94%) of respondents perceived that primary care physicians work longer hours. Overall, 99.6% (95% CI 99.2%-100%) of the US
general public surveyed perceived dermatologists to earn a higher income on average compared with primary care physicians. Of note, 72% (95% CI 69%-75%) of the respondents believed that primary care physicians should be paid more than dermatologists. Similar results were found when the participants were asked their perceptions of dermatologists compared with cardiologists. Among those surveyed, 99.5% (95% CI 99%-100%) perceived cardiologists to have a more critical profession, 99.5% (95% CI 99%-100%) believed cardiologists have a more difficult job, 99.75% (95% CI 99.4%-100%) selected cardiologists as the profession that works longer hours, and 74% (95% CI 71%-77%) perceived that cardiologists earn a higher income than dermatologists. Overall, 99.5% (95% CI 99%-100%) reported that cardiologists should be paid more than dermatologists. The US public’s perception of dermatologists compared with plastic surgeons was also elicited. Among survey respondents, 56% (95% CI 53%-59%) perceived dermatologists to have a more critical profession and 53% (95% CI 50%-56%) believed dermatologists have a more difficult job compared with plastic surgeons. However, plastic surgeons were perceived to work longer hours by 88% (95% CI 86%-90%) of respondents. Overall, 81%
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Table II. Survey study results and evidence-based data Comparison specialty physician group
Primary care physicians
Cardiology
Plastic surgery
Dermatology
Questions
Has a more critical profession Has a more difficult job Works longer hours Earns more income on average Should be paid more
Has a more critical profession Has a more difficult job Works longer hours Earns more income on average Should be paid more Has a more critical profession Has a more difficult job Works longer hours Earns more income on average Should be paid more NA
Evidence-based data for the comparison specialty physician group12
Dermatologists Specialists
37%
63%
Internists, family practitioners Yearly compensation: $185,000, $173,000 d 48% and 49% Believe they are fairly 54% 92% compensated d The largest percentage sees patients between 0.4% 30-40 h/wk (29%, 39%) d The majority sees patients for # 45 h/wk (64%) 72% and # 40 h/wk (62%) d 8% and 3% Spend [65 h/wk seeing patients 99.5% d Yearly compensation: $357,000 d 42% Believe they are fairly compensated 99.5% d The largest percentage sees patients between 99.75% 45-50 h/wk (17%) d The majority sees patients for # 50 h/wk (59%) 74% d 14% Spend [65 h/wk seeing patients 99.5% d Yearly compensation: $317,000 44% d 41% Believe they are fairly compensated d The largest percentage sees patients between 47% 88% 30-40 h/wk (28%) d The majority sees patients for # 45 h/wk (74%) 81% d 3% Spend [65 h/wk seeing patients 52% d Yearly compensation: $306,000 NA d 65% Believe they are fairly compensated d The largest percentage sees patients between 30-40 h/wk (52%) d The average amount of time spent seeing patients was 37 h/wk11 d The majority sees patients for # 40 h/wk (80%) d 1% Spend [65 h/wk seeing patients d
46% 8% 99.6% 38%
0.5% 0.5% 0.25% 26% 0.5% 56% 53% 12% 19% 48% NA
NA, Not applicable.
(95% CI 78%-84%) of participants perceived plastic surgeons to earn a higher income on average compared with dermatologists. However, 48% (95% CI 45%-51%) of respondents indicated that dermatologists should be paid more than plastic surgeons.
DISCUSSION To our knowledge, this is among the first studies using a nationally representative US cohort to examine the public’s perception of dermatologists and how dermatologists compare with physicians from other medical specialties. The study findings have identified specific areas where the public’s perception does not align with actual dermatology workforce data. These findings provide the foundation for advocacy and educational efforts aimed at informing the public regarding dermatologists’ expertise and contributions to health care.
This study showed that 27% of respondents perceived dermatologists to spend a majority of their time performing cosmetic procedures. The public’s perception that dermatologists spend a majority of their time performing cosmetic procedures is not supported by the dermatology workforce data.11 In a 2007 survey of dermatologists, respondents reported spending 63% of their patient care hours managing medical dermatology conditions.11 The survey of dermatologists also found that the second largest amount of patient care time was spent performing surgery (27%) and the least number of direct patient care hours was spent on cosmetic dermatology (10%).11 The gap between the public’s perception of the dermatologist’s job and the reported practices of dermatologists is likely multifactorial. Innovations have continued to grow in cosmetic procedures and devices over the past decade. These cosmetic innovations may appeal to a larger audience and receive greater public attention in the print, online,
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and television media. In addition, the general public may not have sufficient appreciation for dermatologists’ role in managing chronic inflammatory skin diseases that significantly impact patients’ lives, such as psoriasis, atopic dermatitis, or immunobullous diseases. For example, primary care physicians may be the first-line providers for patients with acne or atopic dermatitis in many communities, and therefore the patients are not as aware of dermatologists’ expertise or other types of common skin diseases. Important opportunities exist to inform the general public regarding the burden of many chronic inflammatory skin diseases and dermatologists’ expertise in treating these conditions. From this study, the public perceived that primary care physicians, cardiologists, and plastic surgeons work longer hours compared with dermatologists, and this perception is accurate when compared with the reported work hours seeing patients by physicians in each of these specialties.12 A study of 21,878 US physicians across 25 specialties reported that the majority of cardiologists saw patients for 50 hours or less per week (59%), the majority of plastic surgeons and internists saw patients 45 hours or less per week (74% and 64%, respectively), and the majority of family practitioners and dermatologists saw patients for 40 hours or less per week (62% and 80%, respectively).12 A minority of practitioners from all specialties spent more than 65 hours per week treating patients: 14% of cardiologists, 8% of internists, 3% each of family practitioners and plastic surgeons, and 1% of dermatologists.12 However, the literature shows that, despite the relatively fewer hours per week seeing patients compared with some medical specialties, dermatologists have a greater volume of patient encounters or visits per week. For example, although the number of patient encounters per week varies significantly among dermatologists, dermatologists most commonly complete 100 to 136 patient encounters per week nationally.11,12 This is more than the 76 to 99 encounters per week for family practitioners and 50 to 75 encounters per week for internal medicine physicians.12 Thus, many dermatologists face demanding, high-volume clinic schedules where they are expected to provide high-quality care within a short period of time. The public perceived that cardiologists and plastic surgeons earned a higher income on average compared with dermatologists and that dermatologists earned more than primary care physicians. The public perception of earned physician income by specialty is consistent with the literature.12 According to the 2012 yearly
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compensation report, the average yearly compensation was $357,000 for cardiologists, $317,000 for plastic surgeons, $306,000 for dermatologists, $185,000 for internists, and $173,000 for family practitioners.12 Among the physicians surveyed, a greater percentage of dermatologists believed they were fairly compensated, compared with medical professionals in the other 4 specialties.12 In this study, the public perceived that cardiologists, plastic surgeons, and primary care physicians should be paid more than dermatologists. The question of who should earn more is complex. Factors affecting a physician’s income may include length of training, number of hours worked, the volume of patients seen, the number and types of procedures performed, degree of contribution to scholarship and research grants, practice setting (academic vs community group practice vs private), and the perceived quality of care by patients. Although the public accurately perceives earned physician income, educating the general population on the dermatologist’s skill set and the diversity of skin conditions managed by dermatologists is critical. In this study, the public perceived dermatology to be a more critical profession and perceived that dermatologists had a more difficult job compared with plastic surgeons. One possible explanation for this perception may be related to the public’s awareness of dermatologists’ key role in treating skin cancers. The results of this study need to be interpreted in the context of the study design. As with all survey data, potential differences may exist between responders and nonresponders. The telephone survey study was also only conducted in English, which precluded non-English-speaking respondents from participating in the survey. The randomization process was used to eliminate selection bias; however it would have been more ideal to have a greater number of randomly selected regions to conduct the survey. To our knowledge, this is among the first studies that examined the general US public’s perception of dermatology. The perceived importance of dermatology may influence health policy decisions, payer policies, and allocation of research funding. This study showed that a significant proportion of the US public perceives that dermatologists spend most of their time performing cosmetic procedures, which is not corroborated by actual workforce data. The study findings suggest that ample opportunities exist to educate the public regarding the diversity of dermatologists’ expertise and the associated contributions towards improving patients’ physical well-being and their
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quality of life. Educational strategies need to occur at both local and national levels to increase awareness of dermatologist expertise among the public and other stakeholders, including payers and health policy constituents. REFERENCES 1. Reader GG. Development of professional attitudes and capacities. J Med Educ 1958;33:164-85. 2. Schwartzbaum AM, McGrath JH, Rothman RA. The perception of prestige differences among medical subspecialties. Soc Sci Med 1973;7:365-71. 3. Gough HG. Specialty preferences of physicians and medical students. J Med Educ 1975;50:581-8. 4. Ibrahimi OA, Bangash H, Green L, Alam M, Armstrong AW, Eisen DB. Perceptions of expertise in cutaneous surgery and cosmetic procedures: what primary care physicians think. Dermatol Surg 2012;38:1645-51. 5. Bowers J. How dermatologists are viewed by other physicians and what they can do about it. Dermatology World. Available from: http://www.aad.org/dw. Accessed June 5, 2014. 6. Cummings KM. Random digit dialing: a sampling technique for telephone surveys. Public Opin Q 1979;43:233-44. 7. Waksberg J. Sampling methods for random digit dialing. J Am Stat Assoc 1978;73:40-6.
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8. Hartge P, Brinton LA, Rosenthal JF, Cahill JI, Hoover RN, Waksberg J. Random digit dialing in selecting a population-based control group. Am J Epidemiol 1984;120:825-33. 9. Urbaniak GC, Plous S. Research Randomizer (Version 4.0). [Computer software]. Available from: http://www.randomizer. org/. Accessed June 2, 2010. 10. Neustar, Inc. National Number Pool Administration. Available from: http://www.nationalpooling.com/. Accessed June 2, 2010. 11. Kimball AB, Resneck JS Jr. The US dermatology workforce: a specialty remains in shortage. J Am Acad Dermatol 2008;59: 741-5. 12. Medscape. Physician compensation report 2013. New York: WebMD LLC; c1994e2014. Available from: http://www. medscape.com/sites/public/physician-comp/2013. Accessed February 20, 2014. 13. The National Atlas of the United States (2014). Available from: http://www.nationalatlas.gov/. Accessed February 28, 2014. 14. US Census Bureau, American Fact Finder (2010). Census 2010 Total Population. Available from: http://factfinder2.census. gov/faces/nav/jsf/Q9pages/index.xhtml. Accessed February 11, 2014. 15. US Census Bureau. American Fact Finder (2012). S2301 Employment Status, 2008e2012 American Community Survey 5-Year Estimates. Available from: http://factfinder2.census. gov/faces/nav/jsf/pages/searchresults.xhtml?refresh=t. Accessed February 11, 2014.
