SUMC Medical Staff Update

Dermatology

Q: What are some major issues facing your department?

lane.jpeg (5096 bytes) LANE: Clinicians in private practice fare better financially, and this affects faculty recruitment. We have intentionally kept some billets open rather than alter our standards. We are grateful to many of our 84 VCF for their support during this period. Many of these physicians are former faculty who realize what an exciting residency program we have and find value in coming here to participate.

Q: Why are recruitment and retention difficult?

LANE: It's a vicious circle of higher costs that raise our overhead and affect our operating margins. Our outpatient services operate under hospital rules that place expensive requirements on us, even though we are reimbursed by payers as if we were in private practice. For instance, we must have a higher ratio of licensed nurses than is required in a private practice, or what we realistically believe is even necessary. So we must have licensed nurses respond to routine questions and do routine skin care that could easily be done by an office assistant. I understand primary care faces the same issue.

sawitke.jpeg (4743 bytes) SAWITKE: Meeting hospital joint commission requirements helps us participate in Medicare and other contracts but, overall, having to meet these standards can be difficult and costly.

Q: What plans do you have for the future?

LANE: We hope to expand our clinic by adding four or five faculty physicians by July 1999. We then expect to expand our general clinic hours, possibly from 7 in the morning to 7 at night, while helping to make our overhead more manageable. We will be able to give improved service and better meet our contractual commitments to see non-urgent referral patients within two weeks.

Q: How and why do you plan such a rapid expansion of the department?

LANE: We think we have an industry partner who will support the academic effort, but we are also making some structural changes that should help us recruit and retain faculty members. First, we are addressing the financial incentives. People join the faculty for a year or two and then go into private practice. While they're here, we have the opportunity to ask, "Besides seeing patients, what else can you do?" We're hoping new faculty members will develop an academic interest during non-clinical time. One way to support that is to develop industry partnerships in clinical trials, particularly drug trials, that would generate income not only for the institution but for the individual as well. It's a win-win situation, since faculty will be reimbursed for their time doing blinded studies. We're already doing trials in areas as varied as mycosis fungoides and new diaper products. There is a particular need for pediatric trials, since many drugs used in children have never been tested for pediatric use. Our second approach involves our clinical trials center started in January 1998 under the direction of faculty member Youn Kim. Many research faculty members have expressed interest in seeing patients in clinical trials but have hesitated because of what can become an inordinate amount of paperwork. The center has facilitated the logistics.

On another front, we have one of the best residency programs in the United States. We see that as not only a recruiting vehicle but also as an incentive for faculty to remain in an academic setting. By the way, it used to be that all of our patients were seen with residents. Now our volume has increased so that we conduct about 20 percent of our clinic without residents. As we increase our faculty, we'll have more and more patients seen without residents, because our residents are already working full time now, and we don't have funds for increasing their numbers.

Q: Is UCSF Stanford Health Care helping you deal with financial issues?

LANE: Yes, I really do think the organization is starting to recognize the issues that we face. The hospital seems to be closely looking at how it will structure a new emphasis on ambulatory services - primary care, dermatology, neurology, a big portion of the medicine service, and others. The administration seems to be willing to look at UCSF's traditionally larger support of ambulatory services as a possible role model for action here. The bottom line is that if the university and UCSF Stanford come through with support for the ambulatory services, we can soar.

Q: What about inpatient hospital services?

LANE: We do about 300 inpatient consults yearly, but we gave up our inpatient service about two years ago. We had to rely on surgery and medicine residents to handle the significant comorbidities almost all of these patients faced, especially since we had no inpatient residents of our own. And many conditions are now being treated exclusively through outpatient therapy. Ten years ago, if you had bad psoriasis that made you extremely uncomfortable, you might be hospitalized for six weeks. Now we have much better medications that work well in the outpatient setting.

Q: Whom do you care for in an inpatient setting?

LANE: Infectious disease patients, immunosuppressed transplant patients, as well as people with dermatologic drug reactions or complications, or wound infections. Most of our inpatients have dermatology issues that are secondary to their primary reasons for hospitalization. An EB patient, for example, might be admitted for a blocked esophagus.

Q: How does your patient mix of general dermatology vs. specialty services compare?

SAWITKE: Our general derm clinic is the busiest single service we offer. The most common conditions we treat are those caused by dermatitis and sun damage. For many common conditions, including acne, we regularly conduct clinical trials that may benefit patients. When we expand our cosmetic laser service, we'll have a state-of-the-art treatment that can benefit patients with scarring caused by acne.

LANE: The specialty volume is probably 30 to 40 percent of our care right now. The number of specialty patients hasn't changed much in the last five years, but the number of general dermatology patients is increasing because of managed care contracts that send patients here. But as we mentioned, the total volume isn't rising as fast as the need because of the shortage of physicians.

Q: What are you doing as an interim measure?

LANE: We're shifting staff from subspecialty areas into general dermatology, which is sometimes frustrating. Because of the long waits before appointments are scheduled, our potential subspecialty referrals, especially patients who need to travel to get here, are sometimes going to other centers.

SAWITKE: In addition, we are also trying to educate primary care physicians how to handle common dermatologic problems.

Q: What sorts of things could primary care doctors do when triaging patients to make sure the right patients are sent here?

LANE: As a practical matter, I don't think that's an issue. First, most of our subspecialty clinic patients and 10 percent of pediatric referrals are sent here by other dermatologists, not by primary care doctors. Second, and perhaps more important, I think the referral and community dermatologists are doing an excellent job. They're making good decisions on whom to send. However, one obstacle, I will say, is the managed care referral system. We often see capitated patients too late because the system often doesn't allow for rapid referral.

Q: Can you think of cases for which a specialty referral to Stanford would have made a positive difference - for the patient and payer alike?

LANE: Complicated melanoma workups are often ordered for children with a benign condition that can look like cancer to someone who doesn't see it regularly. We've had kids who have had complicated melanoma workups when a simple biopsy would have ruled out cancer, sparing the child and family fear and turmoil. And often HMOs channel kids to a pediatric oncologist, because they do not have a melanoma specialist in their networks. By the way, biopsies can help with even such common conditions as red, itchy skin. Often, it's more efficient and ultimately less costly to biopsy the patient to gain a confirmed diagnosis than it is to waste time with a trial-and-error treatment approach. On the other hand, we need to be able to ensure access so patients can, in fact, be treated here.

Q: Has the merger been beneficial for dermatology?

LANE: Yes, UCSF has excellent pediatric dermatologists, including Mary Williams and Ilona Frieden. I think that between the two programs we have one of the strongest pediatric dermatology referral bases in the country. We're constantly trying to find better ways to integrate and to work together. Next July, UCSF will have a pediatric dermatology fellow. Eventually we hope to have a combined program. By the way, currently all of our 17 fellows are researchers, not clinicians. The UCSF Stanford capital budget has helped support our laser program as well as the laser program at UCSF. Between the two programs, we will have the most up-to-date and effective laser therapy programs of any centers in the United States. Soon, we will have one of the dermatological surgeons from UCSF working parttime at Stanford as part of her faculty appointment. We are beginning to discuss collaborations for clinical trials and specialty care. Because of close interpersonal relationships between the Stanford and UCSF dermatology faculties, we hope to increase the integration of our residency programs and our clinical care to make our programs the absolute best in the nation.

Q: What are you doing to make the clinic more user friendly, Kim?

SAWITKE: Through our patient satisfaction survey responses, we've learned that patients want increased telephone access. So we have shifted resources into the telephone response area. Now patients have easier access and can speak with an actual staff member instead of reaching a recording or voice mail.

Q: What's new on the research front?

LANE: We've got a lot going on in a variety of areas. For skin cancer treatment, we welcomed Dr. Jon C. Starr as our dermatologic surgeon in September 1997. This is the first time the department has had a full-time surgeon. Dr. Starr specializes in difficult to treat skin cancers, which are removed by a technique called Mohs' micrographic surgery, named after its developer. In this technique, frozen sections are removed to identify the exact area of involvement of the skin cancer so that minimal normal tissue is removed in the surgical process. We are looking at opportunities to develop and expand our psoriasis research. Dr. Eugene Farber, who was the first chair of the department and now emeritus, focused his lifetime effort on psoriasis. We are looking at possibilities of collaborating with Dr. Farber in the future to develop a world center for psoriasis treatment. We are also exploring wound healing, atopic dermatitis, eczema and on another note, hair development. Dr. Youn Kim has begun a research program on cutaneous lymphoma. She is currently doing clinical trials and is beginning basic research in collaboration with the Department of Pathology. But perhaps the most exciting work is occurring in epidermolysis bullosa. When Gene Bauer came here to head the Department of Dermatology - before he became dean - he wanted to make this the Western Regional Center for EB. Now we are that center. We have a program project grant of $4.9 million over five years to develop gene therapy for EB, which is a severe blistering disease in which the skin can be rubbed off with only minor trauma, such as changing a diaper. EB research is a natural for Stanford because of the gene therapy orientation here. We hope to have our therapy approved as an investigational new drug by the FDA during 1999 and to begin therapy by the year 2000.

Q: Where are you with the gene therapy grant and related clinical activities?

LANE: Currently, we see patients from all over the world in our regional evaluation center. As we approach gene therapy, we expect that the number of EB patients referred to Stanford will greatly increase because we will be able to provide special treatment. We are hopeful in the future to move our EB therapy to Lucile Salter Packard Children's Hospital, because it will be children we treat. When we do begin gene therapy, we hope that LPCH will offer resources to help support these patients.

Q: Where else can EB patients receive treatment?

LANE: The University of North Carolina at Chapel Hill is the only other treatment center in the United States. We see patients from all over the world. However, there are lots of pediatric dermatologists around the world who take care of EB patients. We make a strong effort to make sure that the latest treatment improvements are disseminated widely and quickly.

Q: Can you describe the gene therapy approach?

LANE: After identifying the defective protein, we would send the biopsy to a central lab where cells would be grown in large numbers, then corrected with the appropriate retroviral vector. Those cells would then be sent back to us, and we would transplant them on the patient. Once the techniques are developed and successful, we hope that those cells could be sent back to the patient's home clinic and transplanted there. We already have data showing that those cells, once corrected, will be able to attach to the skin, spread and correct the wounds - replacing the defective cells that in normal activity are constantly falling off. We hope that this technology will be adaptable at many local sites throughout the country.

Q: Could this mean control of symptoms for EB patients?

LANE: It will help the skin, but EB patients often have multiple involvement - in the lungs, gastrointestinal tract and elsewhere. These issues won't go away with gene therapy. But the important thing we'll do is we'll decrease the pain and the number of wounds that never heal.

SAWITKE: This will help reduce, or possibly eliminate, the three-hour baths and other daily topical treatments these kids go through every day. For kids with severe EB - most patients die in early adulthood - they can't ride a bike, run or participate in sports or other normal childhood activities because of chronic sores. We hope gene therapy will take out a huge chunk of the suffering for these patients.

Q: What's the time frame for EB gene therapy?

LANE: We are optimistic that within the next two years we will begin full-blown clinical trials. We have an important sequence of experiments that we are doing now, and by April 1999, we will be able to give a more accurate estimate of the timing.

Q: Who will get the first crack at treatment?

LANE: We will start with the most severe early lethal types. The more common chronic EB will be a little tougher to tackle with gene therapy, but we're working on that, too.

Q: What percentage of your practice is cosmetic?

SAWITKE: Really less than 1 percent. But we are hoping to increase it, at least in part through a growing collaboration with UCSF They're very well developed in cosmetic surgery.

LANE: We expect that several dermatology surgeons at UCSF and Stanford will be part time at both institutions. Cosmetic surgery is an excellent place for us to integrate our departments.

Q: You've recently started an Oral Medicine Clinic. Can you talk about that a bit?

LANE: That has been a good model of collaboration between Stanford and UCSF. UCSF has a large dental school, and we, of course, have the area's EB center. To help our EB patients who have severe mouth blistering, Dr. Francina Nur from the UCSF School of Dentistry has been on our voluntary clinical faculty for many years and has been especially helpful with EB patients. She is no longer able to hold clinic here but we have two local oral medicine specialists on our VCF, Dr. Cristian Miranda and Sarah de Sanz. We will be supporting their activities as well, since our subspecialty clinics will be available to their complicated patients. The opportunity for synergy is great. Starting this month, the Oral Medicine Clinic will be held twice a month, but we hope over the next few months to increase frequency to every week, always overlapping with either the EB or the blistering diseases clinics. This will facilitate cross-fertilization.

Q: What sort of volume are you predicting?

LANE: Modest, initially - about six patients per morning.

Q: The psoriasis day care center has closed. Why?

LANE: This was an expensive unit to operate, and the need has fallen off over the years as oral medications supersede the need to bring patients into the Medical Center for all-day treatment and monitoring. The one or two patients who still require this service are being referred to UCSF, which still has a day care facility.

Q: Anything else you want to add?

LANE: Despite the occasional frustrations, this is a very exciting time for dermatology. Skin problems are exposed and cannot be hidden. I can't think of any other area of medicine with the scope and variety - from basic science to the most practical - of resources to help desperately ill patients decrease their pain and suffering. Now, with new techniques for improving appearance, dermatology is also offering easier and more effective ways to assist people so they feel better about themselves and their appearance.

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