In Reply Comments and Opinions Declining Interest in Medical Dermatology Lynch's editorial 1 is laudable in its attempts to maintain an optimistic perspective as it relates to medical dermatology. Lynch's contributions to dermatology are significant and we have long admired his insights and leadership. However, after reading his essay, we believe a key issue has not been fully addressed.
Medical dermatology is seriously ill and in danger of dying.
The declining interest in medical dermatology is reflected in the attendance at medical dermatology course offerings at American Academy of Dermatology meetings for the past decade, and although improvements in medical information science are desirable and may improve the delivery of care to patients, these improvements will likely not be sufficient to rescue this dying patient. Medical dermatology is dying because it has become financially unsupportable. Furthermore, unless the system that assigns value to the management of complex medical problems is changed, the expertise associated with medical dermatology will cease to exist. Reimbursements for medical dermatology are insufficient to cover the costs of delivering services, particularly in high-overhead environments characteristic of academic practices where medical dermatology expertise is often found. In typical contracts, a practitioner is routinely paid significantly more to snip skin tags or perform acne surgery than to treat a patient with pemphigus who is receiving risky immunosuppressive drugs.