[Current situation and future direction of dermatology].

If this were not the case, only university hospitals could operate dermatology departments, with the excuse at least of ensuring comprehensive university training, given that specialized training relies on the national health system. In a period when universities failed in their responsibility to train specialists, this role was assumed solely and exclusively by the public health system. In the specific case of dermatology—and unlike most specialties—there has been and continues to be a close link between university hospitals and the Spanish medical resident training system. Nonetheless, the current trend towards converting the best public hospitals into university hospitals merely confirms what has previously been asserted. Dermatologists outside the public health system survive fundamentally thanks to insurance companies, which, in turn, depend on MUFACE—an insurance body for Spanish civil servants—and on individual private medical insurance policies. This system is referred to as “prepaid medicine” in the USA and in other countries. These dermatologists are poorly paid (on the basis of standard scales), and this makes it difficult for them to freely exercise their profession; furthermore, their possibilities for equipping a surgery with state-of-the-art technology are limited. Impossible dreams for many dermatologists are laser, pulsed light, radiofrequency, ultrasound, and photodynamic therapy, as the cost is prohibitive. Such investments, in fact, could only be supported by a medical practice relying almost exclusively on a private clientele. One only has to ask banks about financing methods for these procedures to determine the real difficulties facing young dermatologists. The consequences of this situation are self-evident. Data published on cosmetic interventions reveals Spain to be one of the countries where most procedures are performed. Yet few dermatologists offer botulinum toxin or laser treatments for wrinkles, peeling procedures, laser or pulsed light depilation, or therapies for telangiectasis and solar lentigines. As for critically ill patients with lymphomas, melanomas, erythroderma, and toxicoderma (as just some examples), we can only concur with Ackerman: who do these patients belong to, and what is to become of dermatology patients if dermatologists fail to treat them? Returning from the 6th Dermatology Symposium of the Hospital Juan Canalejo in La Coruña, Spain, where I could observe how, in 3 days, over 300 dermatologists barely moved from their seats, I could only feel reassured that the future of dermatology is Where is dermatology heading? This question is one that could be posed in regard to Spanish medical practice in general and the Spanish national health system in particular. Long gone is the time when public hospital dermatology departments were typically—although not exclusively—located in teaching hospitals or at least hospitals attached to universities. In addition to the traditional allergy and oncology units, these departments were equipped with dermatopathology and mycology units. Recent developments and the current complexity of dermatopathology have led to the almost wholesale disappearance (with some honorable exceptions) of dermatopathology units, and mycology has now been absorbed—for better or for worse—into microbiology departments. Furthermore, not all dermatology departments have skin allergy units, which should be managed by suitably trained staff with expertise in occupational skin diseases, contact dermatitis, atopic dermatitis, and urticaria. Dermatological oncology is another area that is not well served in all hospitals or by all dermatologists. We dermatologists need to be aware that our continued presence in the hospitals of the future will depend, above all, on our surgical activities, given that nearly all other procedures can be performed outside a hospital setting in specialty centers or even in primary care centers. Depending on the size of a hospital, just one or two staff will be required to deal with dermatology consultation requirements. Dermatologists should, evidently, perform dermatological surgery procedures that are markedly more advanced than the so-called minor ambulatory surgery carried out by primary care physicians and nurses, many of whom do not have specific training in this area. Clinical and surgical oncology criteria are both required in order to be able to attend to the dermatology patient, using, for example, dermatoscopy for pigmentation lesions and competently performing flap and grafting techniques, including direct suture. In other words, the head of a unit with these characteristics would need to have excellent clinical and surgical training. Current Situation and Future Direction of Dermatology