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Subspecialties in Dermatology: Dermatopathology

Subspecialties in Dermatology: Dermatopathology

In this ongoing series, we’ll discuss what steps you need to take and what you need to know to add a successful subspecialty service to your practice.

Dermatology is a visual discipline where observation to detail is key to making the correct diagnosis. In the clinical setting, a patient’s lesion may stand out as an obvious benign lesion — perhaps a seborrheic keratosis. Other times, though, a rash becomes dramatically more thought-provoking. Could the ulcerated lesion on a South American immigrant’s leg have an infectious etiology? Are the infiltrative plaques of the hospitalized woman indicative of a neutrophilic dermatosis? Maybe the dark macules represent more than a benign melanocytic process.

Clearly, in these situations, the wide differential diagnosis calls for a skin biopsy to ensure more accurate assessment and treatment of the skin condition. This then leads to the less publicly known, behind-the-scenes world of diagnosing dermatologic conditions on a cellular level. The lesion is transformed into cellular cross sections, beautifully stained as the dermatopathologists would like, and the cellular architecture is transformed into a staining pattern that eventually gels with a diagnosis. This is the visual playground of the dermatopathologist.

Dermatopathology at a Glance

Dermatopathology is a subspecialty that focuses on the study and diagnosis of diseases of the skin and associated mucous membranes, cutaneous appendages, hair, nails and subcutaneous tissues. Although “dermatopathology” was first coined by Henry Seguin Jackson in 1792, progression toward the integration of clinical findings with pathological findings seen on a microscopic level was slow. Dermatopathology was developed and progressed mainly through the efforts of dermatologists who reviewed the first set of dermatopathology textbooks; subsequent publications were then written by dermatologists. In the present day, the evaluation is done through microscopic study with histological, histochemical, immunological, ultrastructural, molecular and microbiological techniques. Clinical dermatologists are challenged by the presence of more than 1,500 existing skin conditions that they can encounter. Therefore, the assessment of the specimen performed by a dermatopathologist is an imperative step to the correct diagnosis of a skin disease1.

The purpose of this article is to highlight important details for those interested in pursuing dermatopathology subspecialty training. This article shares the optimal steps a dermatologist may take in preparation to becoming a dermatopathologist.

Training

In the earlier years, formal training in dermatopathology was not essential to sit for the certifying board examination — physicians were allowed take the exam based on their experience, self-attained knowledge and informal training. Currently, the Accreditation Council for Graduate Medical Education (ACGME) and the American Osteopathic Association (AOA) require qualified physicians to receive 12 months of formal training. There are a total of 54 ACGME-accredited fellowship programs and no AOA-accredited fellowship programs nationwide. Dermatologists or pathologists from AOA-accredited residency programs may receive permission from the AOA to apply and enroll at an ACGME-accredited fellowship program. Prior to initiation of dermatopathology training, fellows must have completed residency in dermatology (3 to 4 years) and anatomic pathology (3 years) or anatomic and clinical pathology (4 to 5 years). Although the application process may vary from program to program, the following items should be prepared in a timely manner: curriculum vitae, personal statement, minimum of three letters of recommendation, medical school transcripts, medical school dean’s letter and USMLE and/or COMLEX reports2,3.

All dermatopathology fellows must devote at least 4 months of their training exclusively to the study of dermatopathology. Due to the two separate paths available to enter dermatopathology (dermatology and pathology), the curriculum compensates for insufficient areas of expertise prior to the fellowship. Thus, fellows who are dermatologists are required to devote 50% of each training day for the remaining 8 months in the education of anatomic pathology or vice versa for fellows who are pathologists. Therefore, interested dermatologists should assess the quality of the pathology or dermatology component of a fellowship to ensure proper training.

Another area that should be considered includes the annual volume of specimens that are examined at the program site. Higher frequency of specimen evaluation and diagnosis will give fellows a higher probability of observing more challenging and complicated cases. Like many other areas of medicine, an increase in frequency of specimen evaluation will promote familiarity and enhance the diagnostic skills of the fellow. Fellows should also look to learn from numerous mentors in order to acquire alternate skills and techniques. This allows fellows to customize their practice style and will enhance the quality of diagnostic skills.

An additional option may be to consider an extended program, which is a slightly longer fellowship. Longer fellowships may offer more specimens to observe, additional research involvement and greater number of mentors for guidance. There are currently only six ACGME-accredited fellowship programs that offer 2 years of training2,3.

The best way to investigate these opportunities is by contacting or browsing the websites of the American Society of Dermatopathology (ASDP), American Academy of Dermatology (AAD), Accreditation Council for Graduate Medical Education (ACGME) and American Osteopathic Association (AOA). Additionally, discussing interests with one’s own dermatopathology or dermatology faculty from residency can be extremely valuable.

Staffing Issues

Dermatopathologists can practice in academic institutions as well as private practices. Regardless of where one practices, successful dermatopathologists often have a team of well-trained technicians and administrative staff.

A key component to the team is a qualified histology technician. Histology technicians have the crucial role of preparing slides of the specimen for evaluation by the dermatopathologist. Histology technicians can acquire training through a 2-semester certificate program or a 2-year associate degree program. Certification is received after passing an examination. It is paramount that the histology technician is capable of preparing high-quality slides, as this is a major factor in the ability of the dermatopathologist to read the slide and subsequently assign a diagnosis. Due to the pivotal role of histology technicians in a dermatopathology practice, it is suggested that clinicians take the time to interview and select the highest-qualified histology technicians. In addition, it is important to keep an archive of potential employees in case the present histology technician is unavailable or there is a change in volume of specimens received. Since there has been a progressive reduction in qualified histology technicians, some practices may train personnel in the conceptual and technical components to sit for the histology technician certification. This allows for compensation of any potential shortage and ensures that the practice has the necessary number of histology technicians to prepare slides.

The number of histology technicians needed is determined by the volume of specimens received. Generally, private practices only require one histology technician, but an additional histology technician should be considered if the volume is high (a rough estimate would be more than 5,000 specimen a year). There is the additional option of establishing relationships with larger labs. The established relationship may be based on the lab’s willingness to process additional slides and/or the inability of smaller labs to do so. Larger dermatopathology practices, such as those in university dermatology departments, may see upward of 80,000 specimens a year and will require several histology technicians.

As the capacity of the lab exceeds a particular volume (5,000 specimens/year), the practice should consider hiring a secretary to handle accessioning cases and answering phones. If the capacity is within a reasonable range, the histology technician or non-histology technicians may perform these duties. In addition, laws vary by state regarding the specific personnel that may accession and gross specimens. Therefore, it would be best to check the local Clinical Laboratory Improvement Amendments (CLIA) to ensure that the requirements are fulfilled and not violated.

Other personnel requirements are quite similar to other medical practices.  In both academic and private practice settings, administrative staff requires front-desk personnel, billing and coding specialists and an office manager.  For private practices, the physician may choose to hire personnel for solicitation of services.  If the lab processes specimen sfrom outside sources, the lab will need to hire a courier or arrange a courier service to transport specimens daily. The expense will vary according to various factors, such as distance and number of trips. Overall, the number of hired personnel will vary according to the size of the lab and the various demands that must be fulfilled.

Dermatopathology Laboratory: Considerations and Necessary Equipment

The process of opening a laboratory involves various steps. The minimum space necessary to operate a lab is approximately 300 to 400 square feet. The required size will depend on the volume of slides that will be processed per year and the number of employees necessary to fulfill that demand. The upfit costs will vary according to the geographic location and whether the existing practice has the office space to fulfill the space requirements. If the physician was to choose an off-site location, special considerations (management, lease agreements, insurance, phone systems, etc.) must be made. An estimated budget should be placed around $100 per square foot but may range from $50 to $200 per square foot.

There is variability in the utilized equipment; therefore, the budget will vary according to the needs to open a lab. The total equipment needs of a dermatopathology lab can run at least  $50,000 but may far exceed that cost depending on the size of the laboratory and the process techniques utilized. Equipment includes a tissue processor ($10,000 to $40,000), embedding center ($4,000 to $10,000), microtome ($2,000 to $8,000), water bath ($500 to $1,000), incubator ($200 to $1,000), slide staining system (manual $300 to $600; automated $7,000 to $25,0000), fume hood ($1,000 to $8,000) and flammable storage cabinet ($300 to $800).

In addition, a computer system and software package capable of accessioning specimens and generating pathology reports is often required. There are several companies that have software packages that are specifically designed for accessioning surgical pathology specimens; the cost of these systems can vary greatly, but one should expect to spend at least $10,000 and up to $75,000, depending on the system. In addition, the production of microscopic slides requires the use of various disposable items such as glass slides, chemicals, stains and other items. An estimated budget of at least $5.00 per slide produced as a regular variable cost for basic slide preparation should be expected, and much more if the production of immunohistochemical stained slides is being considered.

Once a decision has been made to start a lab, the next step might be to hire a consultant to help with the process. Consultants may provide invaluable expertise in the setup and design of a laboratory space but may charge a premium for their expertise. Many laboratory equipment suppliers may also provide this service at little or no cost, but be wary of suppliers who may entice you to purchase more equipment than is necessary for your practice — it’s always possible to expand or upgrade equipment if the need arises.

Practical Considerations for Academic Institutions and Private Practices

Depending on the interest of the physician, there should be careful consideration between entering the academic or private practice realm of dermatopathology. Regardless of the path that new dermatopathologists eventually decide on, the physicians may want to consider their initial employment at a larger institution to gain additional guidance from senior dermatopathologists who have more experience. Once adequate knowledge and expertise have been acquired, the physician may begin to consider pursuing a career at a larger academic institution or opening a private practice.

Physicians who decide to work at an academic institution are required to fulfill a certain amount of work for employment. The typical requirements include evaluation of specimens that are received by the laboratory, being active in research, publishing articles and books, giving lectures and training students, residents and fellows if there is a residency or fellowship program onsite.

Salary may be influenced by the quantity and/or quality of the teaching, number of publications or involvement in research that garners grants. The benefit to the requirements and significance in quality of work, by nature, keep the physician up-to-date and relevant in the field. By working at a teaching hospital or academic institution, the physician has the ability to influence knowledge of the field through publishing papers and books as well as giving lectures. This creates an impact on the future of dermatopathology and the physicians in the field.

Academic settings are also very intellectually stimulating. The presence of students and residents provides constant stimulation through continual challenging of concepts and techniques. The environment also provides other dermatopathologists and a cohort of dermatologists and pathologists. The team of physicians promotes an environment for collaborative learning and assessment of patient concerns.

Physicians who are interested in additional autonomy in practice (such as with administration) may want to consider opening a private practice. Private practices allow the physician to have greater control over the administrative policies and regulations. Also, there may be a financial gain. This is usually due to the much greater overhead expenses to maintain a large institution because of location and maintenance of facilities. Though the factors that affect the salary in academic settings will be less important in a private practice, there may be less stability in net income and will depend on the number of specimens received from other clinicians. As compared to practices at larger institutions that are generally guaranteed specimens from the associated hospital or clinics, private practices must solicit their services to other clinicians in order to receive specimens. The uncertainty of where the specimen will be attained from causes inherent risks with private practices.

However, the general trend is that there is greater financial gain per specimen in a private practice. Since private practices receive specimens from the other clinicians, it is crucial that the physicians establish and maintain relationships with those clinicians. In addition to completing work in a timely and professional manner, physicians should be aware of the preferences of individual clinicians, such as the style of the report. The ability of the physician to adapt to the specific needs of the referring clinicians allows greater assurance that there will be an influx of specimens to the practice.

The variety of specimens received at larger academic institutions may differ from the specimens encountered in private practices. Though there is variance due to regional differences, academic hospitals are often referral centers for difficult cases, and this may result in a greater spectrum of diagnoses with a higher frequency of more challenging and complicated cases compared to private practices within the same area. However, if the private practice is situated in an area where there are no large institutions associated with a dermatopathology practice, the variety of cases may be similar in complexity and challenges.

Reimbursement Issues

There are many factors that contribute to reimbursements for dermatopathology service. Before opening a laboratory, it is crucial that practitioners check with insurance carriers to ensure that they will be paid for services. There is a growing trend for some insurance companies to only have specimens processed at certain labs. Carriers may only allow dermatopathologists to perform the technical part (processing the slides) and not the professional part (interpretation of the slides). Most importantly, policies are continually changing, so it is necessary for the physician to be up-to-date on current policies.

Physicians will need to formulate a “proforma” that estimates the number of times a code will be billed and the compensation for each of the codes. The codes planning to be billed will need to be presented to the insurance carriers; the most common are 88305-TC or 88304-TC for technical work and 88305-26 or 88304-26 for professional work. There are other codes for special stains. This is primarily to develop a business model for the laboratory and will provide information to the physician in order to be aware of the start-up budget. If the physician is unaware of the process, it may be helpful to refer to a consultant for guidance.

Academic institutions will also form contracts with insurance companies. Like private practices, there will be variability in the policies. The insurance companies will reimburse the hospital directly.

Summary

Entering the world of dermatopathology brings new challenges and rewards to the physician on a number of levels. Intellectually speaking, the required knowledge of dermatologic pathophysiology, appropriate selection of pathologic tests for the patient and diagnosis based on the results and accurate communication to the consulting physician will provide career-long stimulation. Apart from the academic excitement, a physician should consider the logistics as well, including the educational investment and practical steps to enter or start a practice. Given the many avenues through which doctors may pursue dermatopathology, the decision to join the field is personal, and hopefully considering the items that were outlined here will assist in the task. For more information, see “Additional Readings and Resources” at left.

Ms. Huynh is with the Center for Dermatology Research, Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, NC.

Dr. Dabade is with the Center for Dermatology Research, Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, NC.

Dr. Feldman is with the Center for Dermatology Research and the Departments of Dermatology, Pathology and Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC.

Dr. Elenitsas is with the Department of Dermatology, Hospital of the University of Pennsylvania.

Dr. Kostuchenko is with the Westgate Dermatology and Laser Center, PA.

Disclosure: The Center for Dermatology Research is supported by an educational grant from Galderma Laboratories, L.P.  Dr. Feldman has received research, speaking and/or consulting support from Galderma, Abbott Labs, Warner Chilcott, Aventis Pharmaceuticals, 3M, Connetics, Roche, Amgen, Biogen, GSK/Steifel and Genentech. Dr. Elenista has received book loyalties from Lippincott Williams and Wilkins. Dr. Kostuchenko has received research and consulting support from CBR International and Fibrocell Science. Dr. Dabade and Ms. Huynh have no disclosures.

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