Greg Goodman: Cosmetic credo

A DISCIPLINE as large and diverse as dermatology is designed not as a full stop at the end of training but as the beginning of a lifelong exercise in learning.

Everyone who embarks on a specialty requires a firm grounding in all its aspects, but realistically cannot maintain subspecialty expertise in all areas of that specialty.

Public hospitals have been the traditional training ground for dermatologists. Although continuing to provide trainees with exposure to general dermatology, hospital-based dermatology clinics have started to specialise, with clinics treating advanced and complicated medical dermatology and cutaneous oncology.

These clinics have never been resourced or equipped to provide the necessary training in cosmetic dermatology.

The training of dermatologists in this country is of extremely high standard, governed by the Australasian College of Dermatologists as the ultimate credentialing body. By necessity, teaching of cosmetic dermatology has required new training environments, including private practices and organisations such as Skin and Cancer Foundations (SCFs), which have evolved from a group of hybrid dermatology organisations that take on many aspects of public and private practice.

These SCFs run as non-profit training and research centres to foster further expertise within dermatology. They have also become a beacon for optimisation of subspecialty expertise. A vast array of clinics have been developed in these organisations offering specialised skin cancer services, hair and nail clinics, skin allergy clinics, and specialised treatment services. Some concentrate on cosmetic procedures such as laser and aesthetic dermatology.

The role of the College is to supply the tools, the foundation in skills and the knowledge to provide graduates with broad prowess in all areas of dermatology. SCFs, although private, are devoted to teaching SCF-funded registrars and registrars rotated from other hospitals, and are designed to foster advanced specialised learning based on those foundations.

College conferences also include sections for cosmetic dermatology techniques and concepts, so the groundwork and infrastructure for training of registrars in cosmetic surgery is in place and fairly rigorous.

A recent research article and editorial in JAMA Dermatology discussed the adequacy of cosmetic training in the US, highlighting the traditional strength of dermatologists in the field of cosmesis. The researchers, quoting from an article on the history of dermatological surgery, said: “Dermatologists have contributed significantly to the evolution of cosmetic surgery, including advancements in laser surgery, rhytidectomy, dermabrasion, blepharoplasty, botulinum toxin, chemical peeling, hair transplantation, tumescent liposuction, reconstructive surgery, and soft-tissue augmentation”.

While these facts reflect the historical place of dermatologists in cosmetic procedure development, they may have less to do with formal teaching of trainees than work and training taken on after graduation. The question is whether it is appropriate to aim for subspecialty competence within the structure of fellowship training or whether we should be grounding our trainees in the principles of all areas of their profession.

Those interested in both education and cosmetic dermatology would probably vote to see something in the middle, with a high standard in the theory underpinning lasers, filling materials, neurotoxins and surgical techniques.

To this end a new society has been formed to promote further education and training in cosmetic procedures for trainees and in the early postgraduate years. The Australasian Society of Cosmetic Dermatologists (ASCD) is designed to maximise the training in the College’s curriculum and is also closely aligned to SCFs. We will be using many of the strategies outlined in JAMA Dermatology editorial including didactic, observational and hands-on training at SCFs, in private rooms and at annual College meetings.

We also share many of the challenges elaborated in the JAMA Dermatology article, as not all hospital training centres and program directors have expertise, knowledge or interest in cosmetic dermatology techniques.

It is also harder to teach because of the need for expensive infrastructure compared with other components of dermatology training. This is awkward because it relies directly or indirectly on the generosity of industry, which creates an awkward tension with the unbiased ideal of training.

Other medical disciplines involving training in techniques requiring disposable or high-cost items share this problem. There is no easy answer for this but distancing the link between trainer/trainee and company is important.

A non-directed grant to bodies like SCFs or ASCD by companies that in turn fund treatment may be at least a partial answer to the question of how to teach cosmetic dermatology without sacrificing the proper emphasis on medical dermatology.
 

Associate Professor Greg Goodman is the chief of surgery at the Skin and Cancer Foundation in Victoria and an adjunct associate professor at Monash University, and specialises in cosmetic dermatology.