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Table 1.  Active Physician Density by Specialty and Yeara
Active Physician Density by Specialty and Yeara
Table 2.  Logistic Regression Results for Determining the Presence of at Least 1 Dermatologist in a County Based on Demographic and Environmental Variables
Logistic Regression Results for Determining the Presence of at Least 1 Dermatologist in a County Based on Demographic and Environmental Variables
Table 3.  Multivariate Linear Regression Results for the Association of Demographic and Environmental Variables and Dermatologist Density in Counties With at Least 1 Dermatologist
Multivariate Linear Regression Results for the Association of Demographic and Environmental Variables and Dermatologist Density in Counties With at Least 1 Dermatologist
1.
Dall  TM, Gallo  PD, Chakrabarti  R, West  T, Semilla  AP, Storm  MV.  An aging population and growing disease burden will require a large and specialized health care workforce by 2025.  Health Aff (Millwood). 2013;32(11):2013-2020. doi:10.1377/hlthaff.2013.0714PubMedGoogle ScholarCrossref
2.
Kosmadaki  MG, Gilchrest  BA.  The demographics of aging in the United States: implications for dermatology.  Arch Dermatol. 2002;138(11):1427-1428. doi:10.1001/archderm.138.11.1427-aPubMedGoogle ScholarCrossref
3.
Donaldson  MR, Coldiron  BM.  No end in sight: the skin cancer epidemic continues.  Semin Cutan Med Surg. 2011;30(1):3-5. doi:10.1016/j.sder.2011.01.002PubMedGoogle ScholarCrossref
4.
Resneck  JS  Jr.  Dermatology workforce policy then and now: reflections on Dr Peyton Weary’s 1979 manuscript.  J Am Acad Dermatol. 2013;68(2):338-339. doi:10.1016/j.jaad.2012.09.035PubMedGoogle ScholarCrossref
5.
Kimball  AB, Resneck  JS  Jr.  The US dermatology workforce: a specialty remains in shortage.  J Am Acad Dermatol. 2008;59(5):741-745. doi:10.1016/j.jaad.2008.06.037PubMedGoogle ScholarCrossref
6.
Kimball  AB.  Dermatology: a unique case of specialty workforce economics.  J Am Acad Dermatol. 2003;48(2):265-270. doi:10.1067/mjd.2003.108PubMedGoogle ScholarCrossref
7.
Shaw  TE, Currie  GP, Koudelka  CW, Simpson  EL.  Eczema prevalence in the United States: data from the 2003 National Survey of Children’s Health.  J Invest Dermatol. 2011;131(1):67-73. doi:10.1038/jid.2010.251PubMedGoogle ScholarCrossref
8.
Suneja  T, Smith  ED, Chen  GJ, Zipperstein  KJ, Fleischer  AB  Jr, Feldman  SR.  Waiting times to see a dermatologist are perceived as too long by dermatologists: implications for the dermatology workforce.  Arch Dermatol. 2001;137(10):1303-1307. doi:10.1001/archderm.137.10.1303PubMedGoogle ScholarCrossref
9.
Resneck  J  Jr.  Too few or too many dermatologists? difficulties in assessing optimal workforce size.  Arch Dermatol. 2001;137(10):1295-1301. doi:10.1001/archderm.137.10.1295PubMedGoogle ScholarCrossref
10.
Resneck  J  Jr, Kimball  AB.  The dermatology workforce shortage.  J Am Acad Dermatol. 2004;50(1):50-54. doi:10.1016/j.jaad.2003.07.001PubMedGoogle ScholarCrossref
11.
Horev  T, Pesis-Katz  I, Mukamel  DB.  Trends in geographic disparities in allocation of health care resources in the US.  Health Policy. 2004;68(2):223-232. doi:10.1016/j.healthpol.2003.09.011PubMedGoogle ScholarCrossref
12.
Rosenthal  MB, Zaslavsky  A, Newhouse  JP.  The geographic distribution of physicians revisited.  Health Serv Res. 2005;40(6 Pt 1):1931-1952. doi:10.1111/j.1475-6773.2005.00440.xPubMedGoogle ScholarCrossref
13.
Glazer  AM, Farberg  AS, Winkelmann  RR, Rigel  DS.  Analysis of trends in geographic distribution and density of US dermatologists.  JAMA Dermatol. 2017;153(4):322-325. doi:10.1001/jamadermatol.2016.5411PubMedGoogle ScholarCrossref
14.
Yoo  JY, Rigel  DS.  Trends in dermatology: geographic density of US dermatologists.  Arch Dermatol. 2010;146(7):779. doi:10.1001/archdermatol.2010.127PubMedGoogle ScholarCrossref
15.
Aneja  S, Aneja  S, Bordeaux  JS.  Association of increased dermatologist density with lower melanoma mortality.  Arch Dermatol. 2012;148(2):174-178. doi:10.1001/archdermatol.2011.345PubMedGoogle ScholarCrossref
16.
Stitzenberg  KB, Thomas  NE, Dalton  K,  et al.  Distance to diagnosing provider as a measure of access for patients with melanoma.  Arch Dermatol. 2007;143(8):991-998. doi:10.1001/archderm.143.8.991PubMedGoogle ScholarCrossref
17.
Criscito  MC, Martires  KJ, Stein  JA.  A population-based cohort study on the association of dermatologist density and Merkel cell carcinoma survival.  J Am Acad Dermatol. 2017;76(3):570-572. doi:10.1016/j.jaad.2016.10.043PubMedGoogle ScholarCrossref
18.
Cheng  CE, Kimball  AB.  The canary seems fine: the effects of the economy on job-seeking experiences of recent dermatology training program graduates.  J Am Acad Dermatol. 2010;63(2):e23-e28. doi:10.1016/j.jaad.2010.02.043PubMedGoogle ScholarCrossref
19.
Tierney  EP, Kalia  S, Kimball  AB.  Assessment of incentives for student loan debt repayment among recent dermatology residency graduates.  Arch Dermatol. 2009;145(2):208-209. doi:10.1001/archdermatol.2008.563PubMedGoogle ScholarCrossref
20.
Ley  TJ, Rosenberg  LE.  Removing career obstacles for young physician-scientists: loan-repayment programs.  N Engl J Med. 2002;346(5):368-372. doi:10.1056/NEJM200201313460515PubMedGoogle ScholarCrossref
21.
Jacobson  CC, Nguyen  JC, Kimball  AB.  Gender and parenting significantly affect work hours of recent dermatology program graduates.  Arch Dermatol. 2004;140(2):191-196. doi:10.1001/archderm.140.2.191PubMedGoogle ScholarCrossref
22.
Staiger  DO, Marshall  SM, Goodman  DC, Auerbach  DI, Buerhaus  PI.  Association between having a highly educated spouse and physician practice in rural underserved areas.  JAMA. 2016;315(9):939-941. doi:10.1001/jama.2015.16972PubMedGoogle ScholarCrossref
23.
US Department of Health and Human Services, Health Resources and Services Administration. Area Health Resources Files (AHRF). https://datawarehouse.hrsa.gov/topics/ahrf.aspx. Accessed March 10, 2016.
24.
US Department of Agriculture Economic Research Service. Rural-Urban Continuum Codes. https://www.ers.usda.gov/data-products/rural-urban-continuum-codes/. Accessed February 26, 2016.
25.
Jayakumar  KL, Samimi  SS.  Trends in US dermatology residency and fellowship programs and positions, 2006 to 2016.  J Am Acad Dermatol. 2018;78(4):813-815. doi:10.1016/j.jaad.2017.09.072PubMedGoogle ScholarCrossref
27.
Pruthi  RS, Neuwahl  S, Nielsen  ME, Fraher  E.  Recent trends in the urology workforce in the United States.  Urology. 2013;82(5):987-993. doi:10.1016/j.urology.2013.04.080PubMedGoogle ScholarCrossref
28.
Odisho  AY, Fradet  V, Cooperberg  MR, Ahmad  AE, Carroll  PR.  Geographic distribution of urologists throughout the United States using a county level approach.  J Urol. 2009;181(2):760-765. doi:10.1016/j.juro.2008.10.034PubMedGoogle ScholarCrossref
29.
Williams  AP, Schwartz  WB, Newhouse  JP, Bennett  BW.  How many miles to the doctor?  N Engl J Med. 1983;309(16):958-963. doi:10.1056/NEJM198310203091606PubMedGoogle ScholarCrossref
30.
Lango  MN, Handorf  E, Arjmand  E.  The geographic distribution of the otolaryngology workforce in the United States.  Laryngoscope. 2017;127(1):95-101. doi:10.1002/lary.26188PubMedGoogle ScholarCrossref
31.
Vickery  TW, Weterings  R, Cabrera-Muffly  C.  Geographic distribution of otolaryngologists in the United States.  Ear Nose Throat J. 2016;95(6):218-223.PubMedGoogle Scholar
32.
Bauder  AR, Sarik  JR, Butler  PD,  et al.  Geographic variation in access to plastic surgeons.  Ann Plast Surg. 2016;76(2):238-243. doi:10.1097/SAP.0000000000000651PubMedGoogle ScholarCrossref
33.
Ehrlich  A, Kostecki  J, Olkaba  H.  Trends in dermatology practices and the implications for the workforce.  J Am Acad Dermatol. 2017;77(4):746-752. doi:10.1016/j.jaad.2017.06.030PubMedGoogle ScholarCrossref
34.
Jacobson  CC, Resneck  JS  Jr, Kimball  AB.  Generational differences in practice patterns of dermatologists in the United States: implications for workforce planning.  Arch Dermatol. 2004;140(12):1477-1482. doi:10.1001/archderm.140.12.1477PubMedGoogle ScholarCrossref
35.
Dorsey  ER, Jarjoura  D, Rutecki  GW.  Influence of controllable lifestyle on recent trends in specialty choice by US medical students.  JAMA. 2003;290(9):1173-1178. doi:10.1001/jama.290.9.1173PubMedGoogle ScholarCrossref
36.
Resneck  JS  Jr, Kimball  AB.  Who else is providing care in dermatology practices? trends in the use of nonphysician clinicians.  J Am Acad Dermatol. 2008;58(2):211-216. doi:10.1016/j.jaad.2007.09.032PubMedGoogle ScholarCrossref
37.
Chen  AJ, Schwartz  J, Kimball  AB.  There’s no place like home: an analysis of migration patterns of dermatology residents prior to, during, and after their training.  Dermatol Online J. 2016;22(6):13030/qt3sf6z3pn.PubMedGoogle Scholar
38.
Resneck  JS  Jr, Kostecki  J.  An analysis of dermatologist migration patterns after residency training.  Arch Dermatol. 2011;147(9):1065-1070. doi:10.1001/archdermatol.2011.228PubMedGoogle ScholarCrossref
39.
Ellsbury  KE, Doescher  MP, Hart  LG.  US medical schools and the rural family physician gender gap.  Fam Med. 2000;32(5):331-337.PubMedGoogle Scholar
40.
Rabinowitz  HK, Diamond  JJ, Markham  FW, Paynter  NP.  Critical factors for designing programs to increase the supply and retention of rural primary care physicians.  JAMA. 2001;286(9):1041-1048. doi:10.1001/jama.286.9.1041PubMedGoogle ScholarCrossref
41.
Jolly  S, Griffith  KA, DeCastro  R, Stewart  A, Ubel  P, Jagsi  R.  Gender differences in time spent on parenting and domestic responsibilities by high-achieving young physician-researchers.  Ann Intern Med. 2014;160(5):344-353. doi:10.7326/M13-0974PubMedGoogle ScholarCrossref
42.
Guille  C, Frank  E, Zhao  Z,  et al.  Work-family conflict and the sex difference in depression among training physicians.  JAMA Intern Med. 2017;177(12):1766-1772. doi:10.1001/jamainternmed.2017.5138PubMedGoogle ScholarCrossref
43.
Bae  G, Qiu  M, Reese  E, Nambudiri  V, Huang  S.  Changes in sex and ethnic diversity in dermatology residents over multiple decades.  JAMA Dermatol. 2016;152(1):92-94. doi:10.1001/jamadermatol.2015.4441PubMedGoogle ScholarCrossref
44.
Armstrong  AW, Wu  J, Kovarik  CL,  et al.  State of teledermatology programs in the United States.  J Am Acad Dermatol. 2012;67(5):939-944. doi:10.1016/j.jaad.2012.02.019PubMedGoogle ScholarCrossref
45.
Adamson  AS, Suarez  EA, McDaniel  P, Leiphart  PA, Zeitany  A, Kirby  JS.  Geographic distribution of nonphysician clinicians who independently billed medicare for common dermatologic services in 2014.  JAMA Dermatol. 2018;154(1):30-36. doi:10.1001/jamadermatol.2017.5039PubMedGoogle ScholarCrossref
46.
Uhlenhake  E, Brodell  R, Mostow  E.  The dermatology work force: a focus on urban versus rural wait times.  J Am Acad Dermatol. 2009;61(1):17-22. doi:10.1016/j.jaad.2008.09.008PubMedGoogle ScholarCrossref
47.
Jolly  P, Erikson  C, Garrison  G.  U.S. graduate medical education and physician specialty choice.  Acad Med. 2013;88(4):468-474. doi:10.1097/ACM.0b013e318285199dPubMedGoogle ScholarCrossref
48.
Iglehart  JK.  The residency mismatch.  N Engl J Med. 2013;369(4):297-299. doi:10.1056/NEJMp1306445PubMedGoogle ScholarCrossref
49.
Hustedde  C, Wendling  A.  Highly educated spouses and physician practice in rural areas.  JAMA. 2016;316(6):664. doi:10.1001/jama.2016.6721PubMedGoogle ScholarCrossref
50.
MacDowell  M, Glasser  M, Fitts  M, Nielsen  K, Hunsaker  M.  A national view of rural health workforce issues in the USA.  Rural Remote Health. 2010;10(3):1531.PubMedGoogle Scholar
51.
Pandya  AG, Alexis  AF, Berger  TG, Wintroub  BU.  Increasing racial and ethnic diversity in dermatology: a call to action.  J Am Acad Dermatol. 2016;74(3):584-587. doi:10.1016/j.jaad.2015.10.044PubMedGoogle ScholarCrossref
52.
Marrast  LM, Zallman  L, Woolhandler  S, Bor  DH, McCormick  D.  Minority physicians’ role in the care of underserved patients: diversifying the physician workforce may be key in addressing health disparities.  JAMA Intern Med. 2014;174(2):289-291. doi:10.1001/jamainternmed.2013.12756PubMedGoogle ScholarCrossref
53.
Saha  S.  Taking diversity seriously: the merits of increasing minority representation in medicine.  JAMA Intern Med. 2014;174(2):291-292. doi:10.1001/jamainternmed.2013.12736PubMedGoogle ScholarCrossref
54.
Linos  E, Wintroub  B, Shinkai  K.  Diversity in the dermatology workforce: 2017 status update.  Cutis. 2017;100(6):352-353.PubMedGoogle Scholar
55.
Van Voorhees  AS, Enos  CW.  Diversity in dermatology residency programs.  J Investig Dermatol Symp Proc. 2017;18(2):S46-S49. doi:10.1016/j.jisp.2017.07.001PubMedGoogle ScholarCrossref
56.
Phillips  RLJ, Dodoo  MS, Petterson  S,  et al. Specialty and Geographic Distribution of the Physician Workforce: What Influences Medical Student and Resident Choices? http://www.graham-center.org/dam/rgc/documents/publications-reports/monographs-books/Specialty-geography-compressed.pdf. Accessed March 16, 2017.
57.
Dermatology residency partnership addresses rural specialty needs. https://www.umc.edu/news/News_Articles/2017/August/dermatology-residency-partnership-addresses-rural-specialty-needs.html. Accessed June 10, 2018.
58.
Gruen  RL, Weeramanthri  TS, Knight  SE, Bailie  RS.  Specialist outreach clinics in primary care and rural hospital settings.  Cochrane Database Syst Rev. 2004;(1):CD003798.PubMedGoogle Scholar
59.
Winters  R, Pou  A, Friedlander  P.  A “medical mission” at home: the needs of rural America in terms of otolaryngology care.  J Rural Health. 2011;27(3):297-301. doi:10.1111/j.1748-0361.2010.00343.xPubMedGoogle ScholarCrossref
60.
Uhlman  MA, Gruca  TS, Tracy  R, Bing  MT, Erickson  BA.  Improving access to urologic care for rural populations through outreach clinics.  Urology. 2013;82(6):1272-1276. doi:10.1016/j.urology.2013.08.053PubMedGoogle ScholarCrossref
61.
Coates  SJ, Kvedar  J, Granstein  RD.  Teledermatology: from historical perspective to emerging techniques of the modern era, part I: history, rationale, and current practice.  J Am Acad Dermatol. 2015;72(4):563-574; quiz 575-566.Google ScholarCrossref
62.
Coates  SJ, Kvedar  J, Granstein  RD.  Teledermatology: from historical perspective to emerging techniques of the modern era, part II: emerging technologies in teledermatology, limitations and future directions.  J Am Acad Dermatol. 2015;72(4):577-586; quiz 587-578.Google ScholarCrossref
63.
Landow  SM, Oh  DH, Weinstock  MA.  Teledermatology within the Veterans Health Administration, 2002-2014.  Telemed J E Health. 2015;21(10):769-773. doi:10.1089/tmj.2014.0225PubMedGoogle ScholarCrossref
64.
Kahn  E, Sossong  S, Goh  A, Carpenter  D, Goldstein  S.  Evaluation of skin cancer in Northern California Kaiser Permanente’s store-and-forward teledermatology referral program.  Telemed J E Health. 2013;19(10):780-785. doi:10.1089/tmj.2012.0260PubMedGoogle ScholarCrossref
65.
Uscher-Pines  L, Malsberger  R, Burgette  L, Mulcahy  A, Mehrotra  A.  Effect of teledermatology on access to dermatology care among Medicaid enrollees.  JAMA Dermatol. 2016;152(8):905-912. doi:10.1001/jamadermatol.2016.0938PubMedGoogle ScholarCrossref
66.
McFarland  LV, Raugi  GJ, Reiber  GE.  Primary care provider and imaging technician satisfaction with a teledermatology project in rural Veterans Health Administration clinics.  Telemed J E Health. 2013;19(11):815-825. doi:10.1089/tmj.2012.0327PubMedGoogle ScholarCrossref
67.
Hsueh  MT, Eastman  K, McFarland  LV, Raugi  GJ, Reiber  GE.  Teledermatology patient satisfaction in the Pacific Northwest.  Telemed J E Health. 2012;18(5):377-381. doi:10.1089/tmj.2011.0181PubMedGoogle ScholarCrossref
68.
Raugi  GJ, Nelson  W, Miethke  M,  et al.  Teledermatology implementation in a VHA secondary treatment facility improves access to face-to-face care.  Telemed J E Health. 2016;22(1):12-17. doi:10.1089/tmj.2015.0036PubMedGoogle ScholarCrossref
69.
Leavitt  ER, Kessler  S, Pun  S,  et al.  Teledermatology as a tool to improve access to care for medically underserved populations: a retrospective descriptive study.  J Am Acad Dermatol. 2016;75(6):1259-1261. doi:10.1016/j.jaad.2016.07.043PubMedGoogle ScholarCrossref
70.
Carter  ZA, Goldman  S, Anderson  K,  et al.  Creation of an internal teledermatology store-and-forward system in an existing electronic health record: a pilot study in a safety-net public health and hospital system.  JAMA Dermatol. 2017;153(7):644-650. doi:10.1001/jamadermatol.2017.0204PubMedGoogle ScholarCrossref
71.
Lewis  H, Becevic  M, Myers  D,  et al.  Dermatology ECHO - an innovative solution to address limited access to dermatology expertise.  Rural Remote Health. 2018;18(1):4415. doi:10.22605/RRH4415PubMedGoogle ScholarCrossref
72.
Katzman  JG, Galloway  K, Olivas  C,  et al.  Expanding health care access through education: dissemination and implementation of the ECHO model.  Mil Med. 2016;181(3):227-235. doi:10.7205/MILMED-D-15-00044PubMedGoogle ScholarCrossref
73.
Sayre  GG, Haverhals  LM, Ball  S,  et al.  Adopting SCAN-ECHO: the providers’ experiences.  Healthc (Amst). 2017;5(1-2):29-33. doi:10.1016/j.hjdsi.2016.04.006PubMedGoogle ScholarCrossref
74.
Chow  EY, Searles  GE.  The amazing vanishing Canadian dermatologist: results from the 2006 Canadian Dermatology Association member survey.  J Cutan Med Surg. 2010;14(2):71-79. doi:10.2310/7750.2010.09025PubMedGoogle ScholarCrossref
75.
Schmitt  JV, Miot  HA.  Distribution of Brazilian dermatologists according to geographic location, population and HDI of municipalities: an ecological study.  An Bras Dermatol. 2014;89(6):1013-1015. doi:10.1590/abd1806-4841.20143276PubMedGoogle ScholarCrossref
76.
Lester  J, Wintroub  B, Linos  E.  Disparities in academic dermatology.  JAMA Dermatol. 2016;152(8):878-879. doi:10.1001/jamadermatol.2016.1533PubMedGoogle ScholarCrossref
77.
Glazer  AM, Holyoak  K, Cheever  E, Rigel  DS.  Analysis of US dermatology physician assistant density.  J Am Acad Dermatol. 2017;76(6):1200-1202. doi:10.1016/j.jaad.2017.02.018PubMedGoogle ScholarCrossref
78.
Slade  K, Lazenby  M, Grant-Kels  JM.  Ethics of utilizing nurse practitioners and physician’s assistants in the dermatology setting.  Clin Dermatol. 2012;30(5):516-521. doi:10.1016/j.clindermatol.2011.06.022PubMedGoogle ScholarCrossref
Original Investigation
November 2018

Comparison of Dermatologist Density Between Urban and Rural Counties in the United States

Author Affiliations
  • 1The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York
  • 2Yale University School of Medicine, New Haven, Connecticut
JAMA Dermatol. 2018;154(11):1265-1271. doi:10.1001/jamadermatol.2018.3022
Key Points

Questions  What are the longitudinal dermatologist density trends, and are there urban and rural disparities?

Findings  In this study county-level data from the Area Health Resources File, from 1995 to 2013, dermatologist density increased the most in rural followed by nonmetropolitan and metropolitan counties; however, the gap between metropolitan and other areas also widened. Dermatologists were heterogeneously distributed and consistently located in well-resourced communities.

Meaning  The findings suggest that substantial disparities in the geographic distribution of dermatologists exist and have been increasing with time; correcting workforce disparities is important for patient care.

Abstract

Importance  As the US population continues to increase and age, there is an unmet need for dermatologic care; therefore, it is important to identify and understand the characteristics and patterns of the dermatologist workforce.

Objective  To analyze the longitudinal dermatologist density and urban-rural disparities using a standardized classification scheme.

Design, Setting, and Participants  This study analyzed county-level data for 1995 to 2013 from the Area Health Resources File to evaluate the longitudinal trends and demographic and environmental factors associated with the geographic distribution of dermatologists.

Main Outcomes and Measures  Active US dermatologist and physician density.

Results  In this study of nationwide data on dermatologists, dermatologist density increased by 21% from 3.02 per 100 000 people to 3.65 per 100 000 people from 1995 to 2013; the gap between the density of dermatologists in urban and other areas increased from 2.63 to 3.06 in nonmetropolitan areas and from 3.41 to 4.03 in rural areas. The ratio of dermatologists older than 55 years to younger than 55 years increased 75% in nonmetropolitan and rural areas (from 0.32 to 0.56) and 170% in metropolitan areas (from 0.34 to 0.93). Dermatologists tended to be located in well-resourced, urban communities.

Conclusions and Relevance  Our findings suggest that substantial disparities in the geographic distribution of dermatologists exist and have been increasing with time. Correcting the workforce disparity is important for patient care.

Introduction

An adequate and appropriately trained physician workforce is necessary to meet the nation’s current and future health care demands. As the US population continues to increase and age, there is an unmet need for dermatologic care.1 The increasing incidence of skin cancer, high prevalence of complex inflammatory skin disorders, advanced therapeutics, and widening market for surgical and noninvasive procedures have also contributed to an increased demand for dermatologists that is expected to continue to increase.1-7

The undersupply of dermatologists has been described during the past 2 decades,5,8-10 and previous work has identified the maldistribution of physicians and dermatologists.11-14 Rural areas face significant physician workforce shortages, with rural residents experiencing long wait times and traveling long distances to receive care.5 This pattern is especially important given previous studies15-17 that found that dermatologist density is associated with patient outcomes for diseases, such as melanoma and Merkel cell carcinoma.

To develop strategies and effective policies to offset a shortage, we must better understand the characteristics and patterns observed in the dermatologist workforce. We hypothesize that despite an expanding dermatologist workforce, there is a widening gap between dermatologists in urban and rural settings given the greater professional opportunities in urban areas, desire for proximity to family and support, and insufficient financial incentives to practice in resource-poor areas.13,18-22 The goal of this study was to build on existing work by evaluating the up-to-date longitudinal trends and demographic and environmental factors associated with the geographic distribution of dermatologists, using a classification scheme that measures the degree of urbanization in each US county.

Methods

Demographic and physician data from 1995 to 2013 were obtained from the Area Health Resources File (AHRF).23 The New York University School of Medicine's Institutional Review Board waived the need for review and informed consent. All data were deidentified.

Primary outcome measures included the densities of dermatologists, general practitioners, physicians of other specialties, and total physicians in each US county, which are derived from the number of these physicians in each county per 100 000 people. We specifically used data on active physicians who reported involvement with patient care. The AHRF assigns each county a 9-point Rural-Urban Continuum Code (RUCC), a formal classification scheme that distinguishes counties by size, degree of urbanization, and proximity to metropolitan areas.24 Counties with RUCCs of 1 to 3 were classified as metropolitan, 4 to 7 as nonmetropolitan, and 8 to 9 as rural using the most recent 2013 RUCCs (eAppendix in the Supplement). For comparison, we conducted a longitudinal analysis of the density and distribution of physicians in otolaryngology, urology, and plastic surgery, which are medical specialties similar to dermatology in size and practice pattern of being referral-based subspecialties that provide a combination of medical and surgical clinical care.

We also conducted a longitudinal analysis of the age distribution of dermatologists using the ratio of number of dermatologists older than 55 years to the number of dermatologists younger than 55 years. Because a number of rural counties had no dermatologists younger than 55 years, we combined dermatologists into metropolitan (RUCCs 1-3) and nonmetropolitan or rural (RUCCs 4-9) categories.

To better delineate the demographic and environmental differences between counties with no dermatologists and those with at least 1, we performed a logistic regression analysis. Dermatologist density was dichotomized (0 and >0). Univariate associations between indicators and dermatologist density were tested, and correlations between indicator variables were analyzed to identify potential associations. A 2-sided P < .05 was considered to be significant. Because so many counties had no dermatologists, a multivariate linear regression was used for counties that had 1 dermatologist or more. The same covariates were used but excluded number of hospitals and referral centers because their presence, but not necessarily their magnitude, is informative for modeling.

Data management and analysis were performed with Microsoft Excel for Mac 2011, version 14.2.3 (Microsoft Corp) and R Statistical Software, version 2.14.0 (R Foundation for Statistical Computing).

Results

The longitudinal analysis of the density and distribution of dermatologists and general practitioners revealed a geographic heterogeneity in the distribution and density among both physician types across the United States (eFigures 1 and 2 in the Supplement).

Dermatology

The density of dermatologists nationally and by urbanization is given in Table 1. Although the percentage changes in dermatologist density in nonmetropolitan counties (25.1%) and rural counties (30.3%) were higher than in metropolitan counties (18.4%), the differences in the dermatologist density in metropolitan vs nonmetropolitan and rural areas increased from 1995 to 2013. The difference in dermatologist density between metropolitan and nonmetropolitan counties increased from 2.63 per 100 000 people (3.47 vs 0.84 per 100 000 people) in 1995 to 3.06 per 100 000 people (4.11 vs 1.05 per 100 000 people) in 2013 (P = .048). In addition, the difference in dermatologist density between metropolitan and rural counties increased from 3.41 per 100 000 people (3.47 vs 0.065 per 100 000 people) in 1995 to 4.03 per 100 000 people (4.11 vs 0.085 per 100 000 people) in 2013 (P = .053).

The number of dermatologists younger than 55 years increased by 21.3% from 1995 to 2013 in metropolitan areas and by 6.5% in nonmetropolitan and rural areas. The number of dermatologists older than 55 years increased by 112.4% in metropolitan counties and by 153.0% in nonmetropolitan and rural areas. The ratio of all dermatologists in the United States who were older than 55 years to younger than 55 years increased by 78.1% from 0.32 in 1995 to 0.57 in 2013. In metropolitan counties, the age ratio in 1995 was 0.32 and increased to 0.56 by 2013 (increase of 75.0%). From 2010 to 2013, the ratio decreased from 0.57 to 0.56. In nonmetropolitan and rural areas, the ratio was 0.34 in 1995 and increased to 0.93 by 2013 (increase of 170.5%).

Total Physicians and General Practitioners

The density of total physicians and general practitioners nationally and by urbanization is given in Table 1. From 1995 to 2013, the national mean density increased by 15.6% for total physicians and 9.58% for general practitioners. The difference between total physician density in metropolitan and nonmetropolitan counties increased from 164 per 100 000 people in 1995 to 188 per 100 000 people in 2013 (P = .04). The difference between total physician density in metropolitan and rural counties increased from 220 per 100 000 people in 1995 to 257 per 100 000 people in 2013 (P = .049).

Otolaryngology, Urology, and Plastic Surgery

The density of otolaryngology, urology, and plastic surgery physicians nationally and by urbanization is given in Table 1. The differences in otolaryngologist density decreased from 2.25 per 100 000 people to 2.16 per 100 000 people between metropolitan and nonmetropolitan counties and decreased from 3.57 per 100 000 people to 3.41 per 100 000 people between metropolitan and rural counties from 1995 to 2013. The differences in urologist density increased from 1.85 per 100 000 people to 1.86 per 100 000 between metropolitan and nonmetropolitan counties and decreased from 3.54 per 100 000 people to 3.35 per 100 000 people between metropolitan and rural counties from 1995 to 2013. The differences in plastic surgeon density increased from 2.13 per 100 000 people to 2.35 per 100 000 people between metropolitan and nonmetropolitan counties and increased from 2.35 per 100 000 people to 2.77 per 100 000 people between metropolitan and rural counties from 1995 to 2013.

Dermatologist Regression Analyses

From 1995 to 2013, the number of counties with no dermatologists decreased from 2285 of 3200 (71.4%) to 2196 of 3200 (68.6%). For our logistic univariate regression, counties with a higher advanced practice registered nurse (APRN) density, primary care physician density, median household income, percentage of urban population, population per square mile, and number of hospitals were more likely to have at least 1 dermatologist (Table 2). Counties with a higher percentage of population without insurance, percentage of population older than 65 years, percentage of white people, and number of rural referral centers were less likely to have at least 1 dermatologist.

For our multivariate linear regression in counties with at least 1 dermatologist, variables that had a significantly positive association with dermatologist density were APRN density, primary care physician density, median household income, percentage without insurance, percentage older than 65 years, and population per square mile (Table 3). Variables significantly inversely associated with dermatologist density were percentage of unemployed people and percentage of white people.

Discussion

This study evaluated the geographic distribution of active dermatologists over time using a formal rural-urban county classification scheme. Our analysis revealed there was a 21% increase in dermatologist workforce during the study period, which was higher than otolaryngology, urology, plastic surgery, general practitioners, and total physicians. This finding may be partially associated with the quantity of residency positions for dermatology having increased faster than other specialties and the overall number of graduate medical education positions.25,26 In addition, the 30% increase in dermatologist density in rural areas exceeded that of most other compared physician groups, some of which experienced a decrease in rural physician density.

However, our analysis revealed that although the density of dermatologists has been increasing, there have been substantial disparities in the geographic distribution and density of dermatologists across the United States and these disparities have been increasing with time. Although from 1995 to 2013, the percentage of increase of dermatologist density was higher in rural and nonmetropolitan areas than in urban areas, the difference in density between metropolitan and nonmetropolitan, as well as metropolitan and rural regions, widened. This increase in disparity for the dermatology workforce parallels that of total physicians, but there were variations among specialties, with a decrease in the otolaryngology workforce density gap between metropolitan and other areas during the study period. Although the exact reasons for the differences between specialties are unclear, concerns regarding the increasing geographic maldistribution of physicians span across specialties, and innovative approaches in health care delivery and proactive advocacy will be needed to reduce the widening gap.27-32

Trends in dermatologist age groups likely play a role in the observed urban-rural workforce disparities. In 2013, dermatologists in nonmetropolitan areas were older than their counterparts in metropolitan locations. We found that the ratio of dermatologists older than 55 years to younger than 55 years increased more substantially between 1995 and 2013 in nonmetropolitan and rural areas compared with metropolitan areas. Thus, older dermatologists retiring in the next 1 to 2 decades will likely affect nonurban areas more heavily. In addition, our data indicate that the number of young dermatologists is increasing in metropolitan counties but decreasing in nonmetropolitan and rural counties. This finding may be because recent graduates are more likely to practice in a dermatology group or multispecialty group or be academics, which are more common in urban communities. Solo practices are much more common in rural areas.33 Physicians tend to settle in urban areas because of the combination of professional and personal considerations.12,30,32 Given increasing interest in surgical and cosmetic dermatology among younger dermatologists, market forces in urban areas with higher procedural and elective cosmetic demands, proper patient demographics, and economic prosperity may be driving dermatologists to metropolitan communities.25,32 More than half of married physicians have highly educated spouses, which makes greater job opportunities in metropolitan areas an important consideration.22 A desirable location with lifestyle flexibility has consistently ranked as one of the highest priorities for recent graduates.18,28,34-36 In addition, dermatology graduates have a geographic preference to settle close to their hometown37 or training site and are also less likely to move to rural areas after residency.19,38-40 Support from and proximity to family may be instrumental because female physicians bear more childrearing and household responsibilities and experience greater depressive symptoms from work-family conflict.21,41,42 The increasing proportion of women in dermatology may be an additional explanation for the observed geographic maldistribution and differences observed compared with other specialties.43

Univariate and multivariate regression models supported the clustering trends seen in our density mapping. Areas with higher densities of dermatologists were positively correlated with areas of higher population density. Of interest, numbers of hospitals and APRNs were among the covariates significantly associated with dermatologist presence. This finding demonstrates that few dermatologists are practicing in areas without systems support. Despite the use of nonphysician practitioners, such as nurse practitioners and physician assistants, to compensate for physician shortages,5,36,44 our study suggests that physicians and APRNs, who can practice independently in many states, seem to be similarly clustered in metropolitan, well-resourced communities. This finding is consistent with results from a recent study45 analyzing Medicare data showing that most dermatologists and nonphysician practitioners favor practicing in urban environments and are located in similar geographic areas.

Rural and Urban Disparity Trends

Accounting for demographic and medical coverage changes, the projected increase in dermatology visits between 2013 and 2025 is among the highest of all specialties at 16%.1 In 2014, dermatologists reported a mean appointment wait time of 18 days for established patients and 29 days for new patients, which is largely stable from 2005.33 Although not observed consistently,46 wait times for new and established dermatologic patients in rural areas were longer than those for their more urban counterparts on a national level.5 In addition, rural residents travel longer distances to receive care, especially from specialists, including dermatologists.5,12,14

Failure to train sufficient dermatologists may exacerbate already long wait times, reduce access, and impede clinical outcomes and quality of life, especially for patients in rural areas. The supply of dermatologists is unlikely to increase substantially in the immediate future given lack of sufficient federal funding. The number of dermatology residency training slots has not kept up with the pace of demand and has increased only at an annual rate of 0.9% from 2001 to 2010.47,48

Many of the small and rural states have limited residency training capacity, which has contributed to the discrepancy because the location of graduate medical education training is often associated with the location where physicians ultimately practice.38,48 In addition, developing strategies to attract dermatologists to rural and underserved areas will be needed, and such strategies may include financial incentives, such as loan repayment and higher reimbursement, funding rural graduate medical education training spots, increasing physician spouse job opportunities, and recruiting students of rural origin and diverse backgrounds to enter medical school and the specialty.19,22,49-55 In fact, rural origin is the strongest indicator of physicians’ eventual rural practice, but students from rural backgrounds are consistently underrepresented in medical schools.49,56 Partnerships between existing residency programs and rural regional medical centers that have difficulty recruiting dermatologists may offer a viable alternative model to expand residency positions while simultaneously addressing rural health care needs.57 Increasing rural exposure during medical school and residency may influence eventual rural practice while providing trainees with increased medical and surgical dermatology opportunities. Rural outreach and visiting consultants, approaches that have been successful for expanding specialist care in underserved nonurban areas, can be considered for dermatology.58-60 Data from Kaiser Permanente, Veterans Health Administration, Medicaid managed care plan, and safety-net health system teledermatology programs have demonstrated that telemedicine is a feasible and effective method to deliver dermatologic care in rural and underserved areas.33,44,61-70 Provision of remote telementoring and dermatology-specific case-based education to primary care physicians in underserved regions serves as an additional avenue to improve access.71-73

The maldistribution of dermatologists has also been observed in other countries.74,75 Our findings are in concordance with a Brazilian study75 that reported that higher socioeconomic factors, as well as urban areas with better infrastructure and higher income levels, favor the settlement of dermatologists and physicians in general. In a 2006 Canadian survey,74 95% of dermatologists had an urban practice component (population >70 000), 16% had a rural component (population between 10 000 and 69 999) to their practice, and 7% had a remote practice component (population <10 000). There was a shift from rural to urban practice locations over time.

Strengths and Limitations

Compared with previous studies on this subject,13,14 this study has several differences and advantages. The primary data for this study are inclusive of all dermatologists across the country regardless of American Academy of Dermatology membership and include only those who are actively practicing clinical medicine, an important distinction that may not be captured through the membership directory. The geographic analysis based on county is more representative of the type of dermatologist accessibility that patients face. The period studied includes data from as recent as 2013 and spans more than 19 years, the longest, to our knowledge, of any existing study on this topic in dermatology. The long study period allows for more accurate examination of trends and patterns. We were also able to compare and contrast trends for dermatologists with those for other medical specialties, so we can better understand and evaluate unique aspects for our specialty. The use of a formal, standardized classification scheme in the RUCC to distinguish metropolitan, nonmetropolitan, and rural areas, by considering factors such as population sizes and degree of urbanization, is unique to this study. In addition, to our knowledge, no study has used a logistical regression analysis to analyze associations between demographic, socioeconomic, and environmental factors and dermatologist density.

There are limitations to this study, including inability to differentiate among a medical dermatologist, dermatologic surgeon, and cosmetic dermatologist. We were not able to differentiate between full-time and part-time dermatologists, including those who have family obligations, such as childbearing and raising young children, especially in a changing demographic situation.5,6,21,76 We were unable to account for locum tenens work or care provided at satellite offices. We did not account for dermatology-focused nurse practitioners and physician assistants because these data were not available, but they constitute a significant proportion of the dermatology workforce, and many practice in similar geographic areas as dermatologists.45,77 Nonphysician dermatology practitioners are becoming increasingly prevalent and used by dermatology practices, with an estimate of more than 2500 dermatology physician assistants in 2016 and more than 600 dermatology nurse practitioners in 2011.33,36,77,78 Although we can find associations with density of dermatologists, we cannot establish causality. Through this study, we were not able to determine the association of the data with clinical outcomes.

Conclusions

From 1995 to 2013, dermatologist density overall and in rural communities substantially increased at a rate higher than that seen among total physicians and general practitioners. However, the disparity between the urban vs nonurban distribution of dermatologists in the United States continued to worsen, with many counties lacking a dermatologist. Dermatologists, especially young dermatologists, tend to practice in well-resourced, urban communities. The percentage of older dermatologists was 2-fold greater in nonurban than urban communities, and the number of dermatologists younger than 55 years who practice in rural communities was decreasing. Correcting this workforce disparity, which is likely to worsen, is important to minimize disruptions in patient care. Careful workforce planning will be needed to consider alternative health care delivery models, dermatologist recruitment strategies, and the role of nonphysician practitioners and telemedicine, especially in nonmetropolitan or rural areas.

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Article Information

Accepted for Publication: July 13, 2018.

Corresponding Author: Jennifer A. Stein, MD, PhD, The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, 240 E 38th St, 11th Floor, New York, NY 10016 (jennifer.stein@nyumc.org).

Published Online: September 5, 2018. doi:10.1001/jamadermatol.2018.3022

Author Contributions: Drs H. Feng and Berk-Krauss had full access to all the data and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: H. Feng, Berk-Krauss.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: H. Feng, Berk-Krauss.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: H. Feng, Berk-Krauss, P. Feng.

Supervision: Stein.

Conflict of Interest Disclosures: None reported.

References
1.
Dall  TM, Gallo  PD, Chakrabarti  R, West  T, Semilla  AP, Storm  MV.  An aging population and growing disease burden will require a large and specialized health care workforce by 2025.  Health Aff (Millwood). 2013;32(11):2013-2020. doi:10.1377/hlthaff.2013.0714PubMedGoogle ScholarCrossref
2.
Kosmadaki  MG, Gilchrest  BA.  The demographics of aging in the United States: implications for dermatology.  Arch Dermatol. 2002;138(11):1427-1428. doi:10.1001/archderm.138.11.1427-aPubMedGoogle ScholarCrossref
3.
Donaldson  MR, Coldiron  BM.  No end in sight: the skin cancer epidemic continues.  Semin Cutan Med Surg. 2011;30(1):3-5. doi:10.1016/j.sder.2011.01.002PubMedGoogle ScholarCrossref
4.
Resneck  JS  Jr.  Dermatology workforce policy then and now: reflections on Dr Peyton Weary’s 1979 manuscript.  J Am Acad Dermatol. 2013;68(2):338-339. doi:10.1016/j.jaad.2012.09.035PubMedGoogle ScholarCrossref
5.
Kimball  AB, Resneck  JS  Jr.  The US dermatology workforce: a specialty remains in shortage.  J Am Acad Dermatol. 2008;59(5):741-745. doi:10.1016/j.jaad.2008.06.037PubMedGoogle ScholarCrossref
6.
Kimball  AB.  Dermatology: a unique case of specialty workforce economics.  J Am Acad Dermatol. 2003;48(2):265-270. doi:10.1067/mjd.2003.108PubMedGoogle ScholarCrossref
7.
Shaw  TE, Currie  GP, Koudelka  CW, Simpson  EL.  Eczema prevalence in the United States: data from the 2003 National Survey of Children’s Health.  J Invest Dermatol. 2011;131(1):67-73. doi:10.1038/jid.2010.251PubMedGoogle ScholarCrossref
8.
Suneja  T, Smith  ED, Chen  GJ, Zipperstein  KJ, Fleischer  AB  Jr, Feldman  SR.  Waiting times to see a dermatologist are perceived as too long by dermatologists: implications for the dermatology workforce.  Arch Dermatol. 2001;137(10):1303-1307. doi:10.1001/archderm.137.10.1303PubMedGoogle ScholarCrossref
9.
Resneck  J  Jr.  Too few or too many dermatologists? difficulties in assessing optimal workforce size.  Arch Dermatol. 2001;137(10):1295-1301. doi:10.1001/archderm.137.10.1295PubMedGoogle ScholarCrossref
10.
Resneck  J  Jr, Kimball  AB.  The dermatology workforce shortage.  J Am Acad Dermatol. 2004;50(1):50-54. doi:10.1016/j.jaad.2003.07.001PubMedGoogle ScholarCrossref
11.
Horev  T, Pesis-Katz  I, Mukamel  DB.  Trends in geographic disparities in allocation of health care resources in the US.  Health Policy. 2004;68(2):223-232. doi:10.1016/j.healthpol.2003.09.011PubMedGoogle ScholarCrossref
12.
Rosenthal  MB, Zaslavsky  A, Newhouse  JP.  The geographic distribution of physicians revisited.  Health Serv Res. 2005;40(6 Pt 1):1931-1952. doi:10.1111/j.1475-6773.2005.00440.xPubMedGoogle ScholarCrossref
13.
Glazer  AM, Farberg  AS, Winkelmann  RR, Rigel  DS.  Analysis of trends in geographic distribution and density of US dermatologists.  JAMA Dermatol. 2017;153(4):322-325. doi:10.1001/jamadermatol.2016.5411PubMedGoogle ScholarCrossref
14.
Yoo  JY, Rigel  DS.  Trends in dermatology: geographic density of US dermatologists.  Arch Dermatol. 2010;146(7):779. doi:10.1001/archdermatol.2010.127PubMedGoogle ScholarCrossref
15.
Aneja  S, Aneja  S, Bordeaux  JS.  Association of increased dermatologist density with lower melanoma mortality.  Arch Dermatol. 2012;148(2):174-178. doi:10.1001/archdermatol.2011.345PubMedGoogle ScholarCrossref
16.
Stitzenberg  KB, Thomas  NE, Dalton  K,  et al.  Distance to diagnosing provider as a measure of access for patients with melanoma.  Arch Dermatol. 2007;143(8):991-998. doi:10.1001/archderm.143.8.991PubMedGoogle ScholarCrossref
17.
Criscito  MC, Martires  KJ, Stein  JA.  A population-based cohort study on the association of dermatologist density and Merkel cell carcinoma survival.  J Am Acad Dermatol. 2017;76(3):570-572. doi:10.1016/j.jaad.2016.10.043PubMedGoogle ScholarCrossref
18.
Cheng  CE, Kimball  AB.  The canary seems fine: the effects of the economy on job-seeking experiences of recent dermatology training program graduates.  J Am Acad Dermatol. 2010;63(2):e23-e28. doi:10.1016/j.jaad.2010.02.043PubMedGoogle ScholarCrossref
19.
Tierney  EP, Kalia  S, Kimball  AB.  Assessment of incentives for student loan debt repayment among recent dermatology residency graduates.  Arch Dermatol. 2009;145(2):208-209. doi:10.1001/archdermatol.2008.563PubMedGoogle ScholarCrossref
20.
Ley  TJ, Rosenberg  LE.  Removing career obstacles for young physician-scientists: loan-repayment programs.  N Engl J Med. 2002;346(5):368-372. doi:10.1056/NEJM200201313460515PubMedGoogle ScholarCrossref
21.
Jacobson  CC, Nguyen  JC, Kimball  AB.  Gender and parenting significantly affect work hours of recent dermatology program graduates.  Arch Dermatol. 2004;140(2):191-196. doi:10.1001/archderm.140.2.191PubMedGoogle ScholarCrossref
22.
Staiger  DO, Marshall  SM, Goodman  DC, Auerbach  DI, Buerhaus  PI.  Association between having a highly educated spouse and physician practice in rural underserved areas.  JAMA. 2016;315(9):939-941. doi:10.1001/jama.2015.16972PubMedGoogle ScholarCrossref
23.
US Department of Health and Human Services, Health Resources and Services Administration. Area Health Resources Files (AHRF). https://datawarehouse.hrsa.gov/topics/ahrf.aspx. Accessed March 10, 2016.
24.
US Department of Agriculture Economic Research Service. Rural-Urban Continuum Codes. https://www.ers.usda.gov/data-products/rural-urban-continuum-codes/. Accessed February 26, 2016.
25.
Jayakumar  KL, Samimi  SS.  Trends in US dermatology residency and fellowship programs and positions, 2006 to 2016.  J Am Acad Dermatol. 2018;78(4):813-815. doi:10.1016/j.jaad.2017.09.072PubMedGoogle ScholarCrossref
27.
Pruthi  RS, Neuwahl  S, Nielsen  ME, Fraher  E.  Recent trends in the urology workforce in the United States.  Urology. 2013;82(5):987-993. doi:10.1016/j.urology.2013.04.080PubMedGoogle ScholarCrossref
28.
Odisho  AY, Fradet  V, Cooperberg  MR, Ahmad  AE, Carroll  PR.  Geographic distribution of urologists throughout the United States using a county level approach.  J Urol. 2009;181(2):760-765. doi:10.1016/j.juro.2008.10.034PubMedGoogle ScholarCrossref
29.
Williams  AP, Schwartz  WB, Newhouse  JP, Bennett  BW.  How many miles to the doctor?  N Engl J Med. 1983;309(16):958-963. doi:10.1056/NEJM198310203091606PubMedGoogle ScholarCrossref
30.
Lango  MN, Handorf  E, Arjmand  E.  The geographic distribution of the otolaryngology workforce in the United States.  Laryngoscope. 2017;127(1):95-101. doi:10.1002/lary.26188PubMedGoogle ScholarCrossref
31.
Vickery  TW, Weterings  R, Cabrera-Muffly  C.  Geographic distribution of otolaryngologists in the United States.  Ear Nose Throat J. 2016;95(6):218-223.PubMedGoogle Scholar
32.
Bauder  AR, Sarik  JR, Butler  PD,  et al.  Geographic variation in access to plastic surgeons.  Ann Plast Surg. 2016;76(2):238-243. doi:10.1097/SAP.0000000000000651PubMedGoogle ScholarCrossref
33.
Ehrlich  A, Kostecki  J, Olkaba  H.  Trends in dermatology practices and the implications for the workforce.  J Am Acad Dermatol. 2017;77(4):746-752. doi:10.1016/j.jaad.2017.06.030PubMedGoogle ScholarCrossref
34.
Jacobson  CC, Resneck  JS  Jr, Kimball  AB.  Generational differences in practice patterns of dermatologists in the United States: implications for workforce planning.  Arch Dermatol. 2004;140(12):1477-1482. doi:10.1001/archderm.140.12.1477PubMedGoogle ScholarCrossref
35.
Dorsey  ER, Jarjoura  D, Rutecki  GW.  Influence of controllable lifestyle on recent trends in specialty choice by US medical students.  JAMA. 2003;290(9):1173-1178. doi:10.1001/jama.290.9.1173PubMedGoogle ScholarCrossref
36.
Resneck  JS  Jr, Kimball  AB.  Who else is providing care in dermatology practices? trends in the use of nonphysician clinicians.  J Am Acad Dermatol. 2008;58(2):211-216. doi:10.1016/j.jaad.2007.09.032PubMedGoogle ScholarCrossref
37.
Chen  AJ, Schwartz  J, Kimball  AB.  There’s no place like home: an analysis of migration patterns of dermatology residents prior to, during, and after their training.  Dermatol Online J. 2016;22(6):13030/qt3sf6z3pn.PubMedGoogle Scholar
38.
Resneck  JS  Jr, Kostecki  J.  An analysis of dermatologist migration patterns after residency training.  Arch Dermatol. 2011;147(9):1065-1070. doi:10.1001/archdermatol.2011.228PubMedGoogle ScholarCrossref
39.
Ellsbury  KE, Doescher  MP, Hart  LG.  US medical schools and the rural family physician gender gap.  Fam Med. 2000;32(5):331-337.PubMedGoogle Scholar
40.
Rabinowitz  HK, Diamond  JJ, Markham  FW, Paynter  NP.  Critical factors for designing programs to increase the supply and retention of rural primary care physicians.  JAMA. 2001;286(9):1041-1048. doi:10.1001/jama.286.9.1041PubMedGoogle ScholarCrossref
41.
Jolly  S, Griffith  KA, DeCastro  R, Stewart  A, Ubel  P, Jagsi  R.  Gender differences in time spent on parenting and domestic responsibilities by high-achieving young physician-researchers.  Ann Intern Med. 2014;160(5):344-353. doi:10.7326/M13-0974PubMedGoogle ScholarCrossref
42.
Guille  C, Frank  E, Zhao  Z,  et al.  Work-family conflict and the sex difference in depression among training physicians.  JAMA Intern Med. 2017;177(12):1766-1772. doi:10.1001/jamainternmed.2017.5138PubMedGoogle ScholarCrossref
43.
Bae  G, Qiu  M, Reese  E, Nambudiri  V, Huang  S.  Changes in sex and ethnic diversity in dermatology residents over multiple decades.  JAMA Dermatol. 2016;152(1):92-94. doi:10.1001/jamadermatol.2015.4441PubMedGoogle ScholarCrossref
44.
Armstrong  AW, Wu  J, Kovarik  CL,  et al.  State of teledermatology programs in the United States.  J Am Acad Dermatol. 2012;67(5):939-944. doi:10.1016/j.jaad.2012.02.019PubMedGoogle ScholarCrossref
45.
Adamson  AS, Suarez  EA, McDaniel  P, Leiphart  PA, Zeitany  A, Kirby  JS.  Geographic distribution of nonphysician clinicians who independently billed medicare for common dermatologic services in 2014.  JAMA Dermatol. 2018;154(1):30-36. doi:10.1001/jamadermatol.2017.5039PubMedGoogle ScholarCrossref
46.
Uhlenhake  E, Brodell  R, Mostow  E.  The dermatology work force: a focus on urban versus rural wait times.  J Am Acad Dermatol. 2009;61(1):17-22. doi:10.1016/j.jaad.2008.09.008PubMedGoogle ScholarCrossref
47.
Jolly  P, Erikson  C, Garrison  G.  U.S. graduate medical education and physician specialty choice.  Acad Med. 2013;88(4):468-474. doi:10.1097/ACM.0b013e318285199dPubMedGoogle ScholarCrossref
48.
Iglehart  JK.  The residency mismatch.  N Engl J Med. 2013;369(4):297-299. doi:10.1056/NEJMp1306445PubMedGoogle ScholarCrossref
49.
Hustedde  C, Wendling  A.  Highly educated spouses and physician practice in rural areas.  JAMA. 2016;316(6):664. doi:10.1001/jama.2016.6721PubMedGoogle ScholarCrossref
50.
MacDowell  M, Glasser  M, Fitts  M, Nielsen  K, Hunsaker  M.  A national view of rural health workforce issues in the USA.  Rural Remote Health. 2010;10(3):1531.PubMedGoogle Scholar
51.
Pandya  AG, Alexis  AF, Berger  TG, Wintroub  BU.  Increasing racial and ethnic diversity in dermatology: a call to action.  J Am Acad Dermatol. 2016;74(3):584-587. doi:10.1016/j.jaad.2015.10.044PubMedGoogle ScholarCrossref
52.
Marrast  LM, Zallman  L, Woolhandler  S, Bor  DH, McCormick  D.  Minority physicians’ role in the care of underserved patients: diversifying the physician workforce may be key in addressing health disparities.  JAMA Intern Med. 2014;174(2):289-291. doi:10.1001/jamainternmed.2013.12756PubMedGoogle ScholarCrossref
53.
Saha  S.  Taking diversity seriously: the merits of increasing minority representation in medicine.  JAMA Intern Med. 2014;174(2):291-292. doi:10.1001/jamainternmed.2013.12736PubMedGoogle ScholarCrossref
54.
Linos  E, Wintroub  B, Shinkai  K.  Diversity in the dermatology workforce: 2017 status update.  Cutis. 2017;100(6):352-353.PubMedGoogle Scholar
55.
Van Voorhees  AS, Enos  CW.  Diversity in dermatology residency programs.  J Investig Dermatol Symp Proc. 2017;18(2):S46-S49. doi:10.1016/j.jisp.2017.07.001PubMedGoogle ScholarCrossref
56.
Phillips  RLJ, Dodoo  MS, Petterson  S,  et al. Specialty and Geographic Distribution of the Physician Workforce: What Influences Medical Student and Resident Choices? http://www.graham-center.org/dam/rgc/documents/publications-reports/monographs-books/Specialty-geography-compressed.pdf. Accessed March 16, 2017.
57.
Dermatology residency partnership addresses rural specialty needs. https://www.umc.edu/news/News_Articles/2017/August/dermatology-residency-partnership-addresses-rural-specialty-needs.html. Accessed June 10, 2018.
58.
Gruen  RL, Weeramanthri  TS, Knight  SE, Bailie  RS.  Specialist outreach clinics in primary care and rural hospital settings.  Cochrane Database Syst Rev. 2004;(1):CD003798.PubMedGoogle Scholar
59.
Winters  R, Pou  A, Friedlander  P.  A “medical mission” at home: the needs of rural America in terms of otolaryngology care.  J Rural Health. 2011;27(3):297-301. doi:10.1111/j.1748-0361.2010.00343.xPubMedGoogle ScholarCrossref
60.
Uhlman  MA, Gruca  TS, Tracy  R, Bing  MT, Erickson  BA.  Improving access to urologic care for rural populations through outreach clinics.  Urology. 2013;82(6):1272-1276. doi:10.1016/j.urology.2013.08.053PubMedGoogle ScholarCrossref
61.
Coates  SJ, Kvedar  J, Granstein  RD.  Teledermatology: from historical perspective to emerging techniques of the modern era, part I: history, rationale, and current practice.  J Am Acad Dermatol. 2015;72(4):563-574; quiz 575-566.Google ScholarCrossref
62.
Coates  SJ, Kvedar  J, Granstein  RD.  Teledermatology: from historical perspective to emerging techniques of the modern era, part II: emerging technologies in teledermatology, limitations and future directions.  J Am Acad Dermatol. 2015;72(4):577-586; quiz 587-578.Google ScholarCrossref
63.
Landow  SM, Oh  DH, Weinstock  MA.  Teledermatology within the Veterans Health Administration, 2002-2014.  Telemed J E Health. 2015;21(10):769-773. doi:10.1089/tmj.2014.0225PubMedGoogle ScholarCrossref
64.
Kahn  E, Sossong  S, Goh  A, Carpenter  D, Goldstein  S.  Evaluation of skin cancer in Northern California Kaiser Permanente’s store-and-forward teledermatology referral program.  Telemed J E Health. 2013;19(10):780-785. doi:10.1089/tmj.2012.0260PubMedGoogle ScholarCrossref
65.
Uscher-Pines  L, Malsberger  R, Burgette  L, Mulcahy  A, Mehrotra  A.  Effect of teledermatology on access to dermatology care among Medicaid enrollees.  JAMA Dermatol. 2016;152(8):905-912. doi:10.1001/jamadermatol.2016.0938PubMedGoogle ScholarCrossref
66.
McFarland  LV, Raugi  GJ, Reiber  GE.  Primary care provider and imaging technician satisfaction with a teledermatology project in rural Veterans Health Administration clinics.  Telemed J E Health. 2013;19(11):815-825. doi:10.1089/tmj.2012.0327PubMedGoogle ScholarCrossref
67.
Hsueh  MT, Eastman  K, McFarland  LV, Raugi  GJ, Reiber  GE.  Teledermatology patient satisfaction in the Pacific Northwest.  Telemed J E Health. 2012;18(5):377-381. doi:10.1089/tmj.2011.0181PubMedGoogle ScholarCrossref
68.
Raugi  GJ, Nelson  W, Miethke  M,  et al.  Teledermatology implementation in a VHA secondary treatment facility improves access to face-to-face care.  Telemed J E Health. 2016;22(1):12-17. doi:10.1089/tmj.2015.0036PubMedGoogle ScholarCrossref
69.
Leavitt  ER, Kessler  S, Pun  S,  et al.  Teledermatology as a tool to improve access to care for medically underserved populations: a retrospective descriptive study.  J Am Acad Dermatol. 2016;75(6):1259-1261. doi:10.1016/j.jaad.2016.07.043PubMedGoogle ScholarCrossref
70.
Carter  ZA, Goldman  S, Anderson  K,  et al.  Creation of an internal teledermatology store-and-forward system in an existing electronic health record: a pilot study in a safety-net public health and hospital system.  JAMA Dermatol. 2017;153(7):644-650. doi:10.1001/jamadermatol.2017.0204PubMedGoogle ScholarCrossref
71.
Lewis  H, Becevic  M, Myers  D,  et al.  Dermatology ECHO - an innovative solution to address limited access to dermatology expertise.  Rural Remote Health. 2018;18(1):4415. doi:10.22605/RRH4415PubMedGoogle ScholarCrossref
72.
Katzman  JG, Galloway  K, Olivas  C,  et al.  Expanding health care access through education: dissemination and implementation of the ECHO model.  Mil Med. 2016;181(3):227-235. doi:10.7205/MILMED-D-15-00044PubMedGoogle ScholarCrossref
73.
Sayre  GG, Haverhals  LM, Ball  S,  et al.  Adopting SCAN-ECHO: the providers’ experiences.  Healthc (Amst). 2017;5(1-2):29-33. doi:10.1016/j.hjdsi.2016.04.006PubMedGoogle ScholarCrossref
74.
Chow  EY, Searles  GE.  The amazing vanishing Canadian dermatologist: results from the 2006 Canadian Dermatology Association member survey.  J Cutan Med Surg. 2010;14(2):71-79. doi:10.2310/7750.2010.09025PubMedGoogle ScholarCrossref
75.
Schmitt  JV, Miot  HA.  Distribution of Brazilian dermatologists according to geographic location, population and HDI of municipalities: an ecological study.  An Bras Dermatol. 2014;89(6):1013-1015. doi:10.1590/abd1806-4841.20143276PubMedGoogle ScholarCrossref
76.
Lester  J, Wintroub  B, Linos  E.  Disparities in academic dermatology.  JAMA Dermatol. 2016;152(8):878-879. doi:10.1001/jamadermatol.2016.1533PubMedGoogle ScholarCrossref
77.
Glazer  AM, Holyoak  K, Cheever  E, Rigel  DS.  Analysis of US dermatology physician assistant density.  J Am Acad Dermatol. 2017;76(6):1200-1202. doi:10.1016/j.jaad.2017.02.018PubMedGoogle ScholarCrossref
78.
Slade  K, Lazenby  M, Grant-Kels  JM.  Ethics of utilizing nurse practitioners and physician’s assistants in the dermatology setting.  Clin Dermatol. 2012;30(5):516-521. doi:10.1016/j.clindermatol.2011.06.022PubMedGoogle ScholarCrossref
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