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REGIONAL DERMATOLOGY
OF DURHAM

For more information about skin conditions and treatment, contact:

 

REGIONAL DERMATOLOGY
OF DURHAM

Elizabeth H. Hamilton, MD, PhD
Amy Stein, MD
Julie Dodge, PA-C

4321 Medical Park Dr., #102
Durham, NC 27704
Telephone: (919) 220-7546 (SKIN)
www.dermatologydurham.com

Training Is Ongoing in
Treating Skin Conditions

Ongoing training to develop sharp, sensitive listening and observational skills is critically important in doctor-patient relationships, notes Dr. Amy Stein of Regional Dermatology of Durham. “Becoming a successful practitioner requires experience, hands-on training, and especially the ability to listen to patients and their problems.

Dr. Stein engages with a patient
before an annual exam

“When you’re in medical school you’re so excited and in many ways naïve about what to expect when you finally graduate. Medical school teaches in black and white, but the longer you’re in practice you realize there are so many more gray tones in everything we do. Textbooks teach us about a particular disease and what the best treatment is, but it’s so different in real world clinical practice because many diseases present themselves in ways we don’t expect.

“During residency training, we may see patients once or twice and think we’ve ‘fixed’ them. Transitioning into private practice we have continuity of care, and quickly realize that not all treatments work for everyone. The same treatment may not work for the same problem, for different people, or at different stages in their condition. When I entered practice more than a decade ago, this awareness was eye opening: our specialty really isn’t black and white, but often shades of many colors. There’s a lot of art, as well as science, involved in diagnosing conditions of the skin.”

Another lesson learned, notes Dr. Stein, was a practical one. “As a resident student prescribing medications, I had no concept of cost. Now there’s more follow-up and, increasingly, we and patients have limited access to medications due to either insurance coverage or cost. So, this issue comes up multiple times a day and it is quite frustrating. We are constantly trying to find the best treatment while our hands may be tied, by insurance coverage limitations. On top of which, prescription costs have increased alarmingly in the last few years. Those are important lessons to learn when you leave academia and confront the challenges in the world of doctor and patients.”

Keeping Pace with Developing
Science and Treatment Options

“As a physician I’m constantly learning,” says Dr. Stein. “It may be at the annual conferences we attend, smaller clinically-oriented classes, or researching solutions on-line. And much of our education relates to understanding the value of new products. We learn from patients taking the drugs and from drug reps who show us studies and relevant information about outcomes and cost. Once we’re comfortable prescribing a medicine, we carefully monitor results. Clinical studies may claim exceptional outcomes, especially with acne or psoriasis medicines, but what I see in front of me means more than all the clinical trials. Safety is always an issue.”

Among the more important developments in recent years are biologic medications. “This is the area of greatest growth in dermatology,” Dr. Stein notes. “These are medications made from living organisms or their products, such as antibodies or other chemicals. Most of the very best outcomes we see are in the treatment of psoriasis. In the past, people unfortunately had to live with psoriasis and manage it to some degree. We have relatively recently become aware of the degree to which the internal inflammation is detrimental to cardiovascular health. Earlier, topical steroids were the predominant viable treatment option. As providers we were naively okay with using steroids if they ‘improved’ the condition, focusing on the skin’s response.

Excellent Education Is the Bedrock of Their Practice

The providers at Regional Dermatology of Durham offer their patients a rich combination of education and experience:

Elizabeth H. Hamilton, MD, PhD: Dr. Hamilton moved back to North Carolina in 1997 after practicing a number of years with Danville Dermatology Associates. She completed her medical education, PhD work, Medical Internship and Dermatology residency at the University of North Carolina.

Amy Stein, MD: Dr. Stein joined private practice in dermatology in Durham in 2004 after completing her medical education at the State University of New York Health and Science Center at Brooklyn, followed by her Internal Medicine internship, clinical fellowship and Dermatology residency at the UNC.

Julie Dodge, PA: Julie Dodge trained at both East Carolina University and the Physician Assistant program at Duke University. She has years of experience in dermatology and specializes in general dermatology in both adult and pediatric patients.

“Today the standard of care is such that we can markedly reduce psoriasis activity with medication, and hopefully, internal inflammation is reduced decreasing risk to cardiovascular health.

“Every so often a new medicine appears with different types of mechanisms of action. Now there are also new medications that are showing incredible results with atopic dermatitis. We have an obligation to keep up with these new options, but not necessarily be the first to prescribe them.”

She noted, too, the impact of rapidly evolving technology on the practice of medicine. “When I think of relying on technology, I think of electronic medical records—which can be both challenging and invaluable. They allow for easy follow-up and improved continuity of care. There are fewer medication errors because we do electronic prescribing.”

Training and Repetition

“People tend to go into professions where there is an interest and an inherent ability,” says Dr. Stein. “With training and repetition, you become adept at knowing what’s wrong. Quite often patients say, ‘Well, I don’t understand how you know that mole is okay?’ Or, “I have absolutely no concern over this spot, why do you want to biopsy it?’

“And the answer is the value of experience. Over the years, we see skin problems multiple times—you know when things look, feel, or “smell” different, and you learn to recognize them. It’s all about repetition and pattern and lesion recognition.

“Still, on occasion, a patient comes in with a rash or lesion that can’t be explained or definitively diagnosed. The key is knowing your limitations; when you don’t know an answer to a presenting problem, you absolutely do a biopsy. With every biopsy, I take a photo; then when I get a biopsy back, I check and compare with the photo and make sure it all makes sense.

“Over the years, we keep learning and improving, making this investigative aspect of medicine fun and interesting. It keeps us doing what we do. Unfortunately, in the last three weeks three patients came in with spots that they were not concerned about—and they were melanomas. Those ‘routine visits’ illustrate the importance of skin exams by professionals.”

The Role of “Dr. Google”

Notes Dr. Stein, “The ability to just Google anything related to the skin provides information about an array of skin conditions that is simply staggering. And, as a result, patients come in with pre-conceived diagnoses of skin conditions—and as far as I am concerned, if that’s what brings people in, that’s a good thing. Overall, the more education people have, the better. But,” she cautions, “it is very helpful to get health care information from reliable, reputable sources—because you can find a great variety of all sorts of crazy cures out there in the digital world.

“Today we are experiencing an explosion of new medications, many of them over-the-counter and advertised directly to consumers. The fact is, skin conditions can be made worse by self-treatment. I regularly have patients who have tried many different products—developing allergic contact dermatitis or skin irritation in the process. Often their lesion is so incredibly irritated that you have no idea what it was like to begin with, but you know it’s not normal now. Perhaps they thought it was a wart and they used over-the-counter wart remover. Often, we will biopsy the problem because it looks so beyond normal and find that it’s a squamous cell skin cancer.

“The bottom line to successful patient care is being able to learn from each other and always listening to the patient. Then it’s a matter of further investigation till you come up with the correct treatment.”