Physician Activism: Why It is Time to Step Up

By Heidi A. Waldorf, MD

Heidi A. Waldorf, MD, FAAD is Director of Laser and Cosmetic Dermatology at The Mount Sinai Medical Center; Private practice, Waldorf Dermatology & Laser Associates

In the last two decades, the healthcare landscape has undergone significant changes. Physicians have become “healthcare providers” and the patients “consumers.” Managed care, capitation, pre-authorization, nurse practitioners running clinics in drug stores, electronic medical records have all become standard parts of medical practice.

The aesthetic specialties have been insulated from many of the increasing regulations impacting reimbursable medicine. Who among us hasn't stood with a group of doctors at a cocktail party hearing the internists and surgeons (both general and specialized) complain about longer hours, increasing overhead, preauthorization requirements, electronic medical records and the pressure to see more patients for less money? Invariably, one of them will turn to the aesthetic physician in the crowd and say, “of course you don't have to worry about that.” However, regulations that previously only affected physicians participating in insurance and government programs have begun to threaten all of us. If all physicians, including those of us in core cosmetic specialties, do not actively start saying “no,” the practice of medicine, including aesthetic surgery, will not be recognizable: It is time for physician activism.

What is Physician Activism?

As physicians, we are used to taking action during emergencies. I can still see one of my chief residents during internship calmly but firmly directing interns, residents, and nurses during a code, like the captain of a ship. Whether dealing with excessive bleeding during surgery, or an impending vascular occlusion while injecting filler, aesthetic physicians are the captains of their ships. We are trained to fight for our patients in our procedure rooms and operating suites. However, as a group, physicians are passive about the external powers that affect our patients and our practices.

So how do we change that paradigm? Physicians must own that it was our complacency that allowed the current situation to evolve over decades. It isn't that we were stupid or lazy, but because we are consumed by our careers. Despite our apparent power to change what nature created, we have been trained to follow institutional and governmental guidelines or face the consequences (losing your license being the worst). At this point, we certainly can't revert back to the “golden age” of laissez faire medicine—that ship has sailed. However, with action, improvements are possible. There are three main avenues through which we can focus our activist efforts: protecting our patients, protecting our specialties, and protecting medicine.

One of the most natural ways to become active is to protect patients through public education. Core cosmetic specialty societies have been active in educating patients about safety in aesthetic procedures. Providing information about best practices and the importance of being treated by an appropriately trained core cosmetic physician gives the public the tools to make the right choices. Better choices mean better outcomes, which improves public safety. And reducing bad outcomes reduces the bad press.

There are other forms of patient focused activism that provide more immediate results. Cosmetic surgeons can use their expertise to help underserved populations. For example, medical missions to repair congenital anomalies like cleft palates or traumatic injuries of war protect these patients by allowing them to lead normal lives. As a dermatologist, I can't provide that type of aid, but as a member of the US Afghan Womens' Council, I was happy to use my limited sphere of influence to arrange donations of renewing body wash from Unilever and moisturizing lotions from Proctor & Gamble for refuge women and children in Afghanistan.

The second area physicians can have a huge impact is in the protection of our specialties. Core cosmetic physicians face increasing competition from those without specialty training or even medical training. A side effect of decreased reimbursements in healthcare has been the flocking of non-core trained physicians into cosmetic medicine. They think it is “easy money” and patients generally don't ask physicians the boards through which they have been certified. Frankly, they don't often ask if it is even a physician, which is increasingly the case. State regulations allowing non-physician providers to practice independently originally meant to provide medical care to underserved areas are expanding because they are seen as “cheaper” equivalents. The offshoot will be the expansion of non-physician owned and operated cosmetic centers with only non-physician providers.

The final front of activism is the protection of Medicine as a career. Satisfaction among US physicians is on the decline: doctors in all specialties feel overwhelmed, underappreciated, and under attack. Experienced practitioners are retiring early. It is also rare to hear a physician recommend a young person go into clinical medicine. If the state of medical practice doesn't improve, who will take care of us when we are old? Through action—against government intervention, public doctor bashing, and even negativity among young physicians—we can improve the state of medicine and help reinvigorate a sense of passion for what we do as physicians.

A Case Study in Activism

Passion for a cause or mission is also the key to successful activism. Life is busy and just getting busier is a refrain commonly expressed these days. So find one issue or project to which you can commit. Recently, I have concentrated my activist spirit on the battle to stop the onerous Maintenance of Certification (MOC) requirements. In the dermatology space, the conflict over MOC has reached high levels of member awareness, thanks to the efforts of those who have spoken out against it.

I achieved board certification in dermatology in 1994. I recertified by open book take home exam in 2002 for 2004 and then by closed book exam in 2013 for 2014. The former wasn't pleasant, but the latter was horrible. It was expensive, stressful, time consuming, and I learned nothing because the most efficient way to pass was to read the sample questions and answers given at the review courses. In addition, I felt insulted and demeaned as the testing center personnel checked my forearms and inner pockets for cheat notes. But I was done until 2024—or so I thought. Then in February 2015, Dr. Jeanine Downie asked for support of a resolution for the American Academy of Dermatology to support stopping the MOC. I had been completely unaware of the myriad of other requirements from patient safety modules to peer review surveys that were required. That was my “just say no” moment. I joined Jeanine and a core group of “dermactivists” to plan what was referred to by others as “The Rebellion.”

My “comrades” and I read everything we could about what had been done in other fields as well as our own. The internists have been battling the American Board of Internal Medicine (ABIM) for years and finally sued them and created an alternative board. A plethora of data from peer reviewed journal articles, physician discussion sites and the news media supported our assertion that MOC did not improve patient care and was creating significant dissatisfaction among physicians. And we found out that a similar resolution had been proposed to the AAD a year prior and failed without fanfare. We created an online petition, spread the word via social media and word of mouth, handed out campaign buttons at the AAD meeting, spoke with every board member who would listen and attended every open committee meeting. After the meeting we rallied supporters to send their own emails to ABD members directly.

The feedback to this grassroots campaign was extraordinary and the discussion expanded. Dr. Downie and I were featured in separate videos discussing our efforts and asking for others to join (available at DermTube and Modern Aesthetics TV). We were gratified when AAD president, Mark Lebwohl, MD, sent a public email from the AAD board to the American Board of Dermatology stating that stating that the current MOC requirements are not acceptable, the boldest political action an AAD president has taken against the ABD. The AAD followed with a survey to members, which confirmed the results from other studies: Members did not find value in any MOC recertification activities other than CME.

As a result of a discussion between two “Derm Divas,” there is now greater awareness for the issue and a growing coalition against it. The movement has also spread to other specialties, with pediatrics having recently begun their own petition to fight their MOC requirements.

I do not know what the future holds for this movement; as a realist, I do not expect 100 percent success, but I feel proud of my association with its growth these past several months. We've opened eyes and created wider awareness for this cause, which can only be a good thing for our specialty. Now we can take that momentum and continue moving forward so that more can be done to not only improve our specialty but also protect our patients and the soundness of medicine itself.

Finding Our Voice

None of us individually can fix everything, but the more we raise awareness for the issues that matter to us, the more likely we are to stimulate change. We do not all need to agree on what requires action, nor will we likely always unite all in one voice over every issue. But one thing is clear: If we do not help ourselves, others will define our future. Physician activism means claiming our voices. For those of us that know and love medicine and are respectful of the process, we must ask ourselves: How are we going to secure medicine for the next generation?

When I was distributing pins and speaking with colleagues about the importance of fighting MOC at the President's Dinner at the recent AAD meeting, some folks asked me why I was going to all this trouble, implying that nothing would ultimately change. But if you consider various movements throughout history and you see only the flaws and problems that remain, you may fail to see the real progress that occurs. With more voices speaking up, change happens. I believe in optimistic fatalism: I am optimistic about the things over which I have control and fatalistic about things over which I do not. We all need to move our careers and practices back into the first category.

It's time that we all find our voices.