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SUMMER

2009

Newsletter of the American Osteopathic College of Dermatology

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AOCD ANNUAL MEETING 2009November 1-4, 2009New Orleans, LA

AOCD MIDYEAR MEETING 2010April 14-17, 2010Sedona, AZ

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American OsteopathicCollege of DermatologyP.O. Box 75251501 E. IllinoisKirksville, MO 63501Office: (660) 665-2184

(800) 449-2623Fax: (660) 627-2623Site: www.aocd.org

PRESIDENTDonald K. Tillman, D.O., FAOCD

PRESIDENT-ELECTMarc I. Epstein, D.O., FAOCD

FIRST VICE-PRESIDENTLeslie Kramer, D.O., FAOCD

SECOND VICE-PRESIDENTBradley P. Glick, D.O., FAOCD

THIRD VICE-PRESIDENTJames B. Towry, D.O., FAOCD

SECRETARY-TREASURERJere J. Mammino, D.O., FAOCD

IMMEDIATE PAST-PRESIDENTJay S. Gottlieb, D.O., FAOCD

TRUSTEESDavid L. Grice, D.O. Karen E. Neubauer, D.O.Mark A. Kuriata, D.O. Suzanne S. Rozenberg, D.O.Rick J. Lin, D.O. Brian Matthys, D.O.

EXECUTIVE DIRECTORRebecca Mansfield, MA

UPDATE CONTACT INFORMATION

Is your contact information current? If not,you may be missing need-to-know newsfrom the AOCD.Visit www.aocd.org/membership. Enteryour username and password then clickthe “Login Now” button. Should you have trouble accessing yourprofile, you can fax the new information tothe AOCD at 660-627-2623. Send the faxto the attention of Marsha Wise, residentcoordinator.

CONTRIBUTE TO DERMLINE

If you have a topic you would like to readabout or an article you would like to writefor the next issue of DermLine, contact RuthCarol, the editor, by phone at 847-251-5620, fax at 847-251-5625 or e-mail [email protected].

http://www.aocd.org

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May and June are beautiful months to visit western Kansas. Usually hotand arid, in May we had a lot of rain and the wheat looks great; thereare many beautiful wildflowers lining the roads and fields. But youbetter come fast, because it won’t last long!

Increasing communication has been one of the goals of my presidency.This month, I want to highlight the AOCD website. For those of youwho have not yet visited the site, please take some time to go towww.aocd.org. Dr. Jere Mammino has worked tirelessly in perfectingthis site.

Our website will pop up on many Google searches. For example, lastnight I was googling actinic keratosis and the first website on the list wasthe AOCD’s site.

We are currently averaging more than 3 million visitors per year, who view approximately 4.5 million pages.Ninety-five percent of the visitors are viewing the dermatologic disease database, which was a collaborationof many members of our College. This database has a tremendous amount of useful information that canbe shared with your patients to help explain diseases and treatments.

Our website is in the top 1% of all websites visited on the World Wide Web.

I encourage members to check out their profile under the “find a D.O. dermatologist” tab. Feel free to sendus updates, corrections, or information that you want to add to your profile. This is a very cost-effectivemeans of advertisement.

I, again, want to congratulate Jere, Roger Watson, and all those individuals who have helped organize andcontribute to the AOCD website.

I continually respond to e-mails from the membership. I encourage you to e-mail either me [email protected] or Becky at [email protected] regarding any questions or concerns about theCollege.

Sincerely,

Donald K. Tillman Jr., D.O., FAOCDAOCD President, 2008-2009

Message from the President

Will Kirby, D.O., FAOCD, is putting insome board time as of late.

He was recently appointed to serve asan expert reviewer for the OsteopathicMedical Board of California in the fieldof dermatology.

This appointment requires the recipientto possess medical knowledge, profes-sionalism, discretion, and ethical valueof the highest level. “I was honored toeven be considered for the position,”Dr. Kirby says. “It’s flattering that theyreached out to me and I’ll do my bestto ensure that the dermatological carein California is of the highest quality.”

He also was asked to serve on theeditorial advisory board of Skin & Agingmagazine. This widely circulated

monthly publication addresses practicaland clinical issues in dermatology. “Theopinions of osteopathic physicians areinfluencing the dermatology professionmore and more each day and it’simportant that we contribute toacademic journals so that the medicalcommunity as a whole can benefit fromour knowledge,” says Dr. Kirby.

In addition, Dr. Kirby signed a three-year contract with Neutrogena’sadvanced science division, NeutrogenaDematologics, to serve as the companyspokesperson. He currently presentsthe company’s newest product—RetinolNX Concentrated Retinol Serum—onhome shopping network QVC eachmonth.

Dr. Kirby to Serve on Boards

Get Well Soon

We wish aspeedy recovery toBecky who is recu-perating fromsurgery. Look forher column in thenext issue ofDermLine.

The AOCD’s Board of Trustees has unanimously approved awording change in the description of the student membershipcategory in the College’s constitution.

The purpose of this change is to allow medical students whoare not yet accepted into a dermatology residency programto remain AOCD student members until they can becomeresident members.

The new category would be as follows (with the change inbold):

“Any osteopathic medical student who is in goodstanding with the American Osteopathic Association andinterested in pursuing a career in the field of derma-tology shall be eligible to become a student member.This membership status may be maintained for amaximum of three years after a student graduates.Student members shall have all rights and obligations offellow members except they shall not be eligible to holdelective office or vote.”

This proposed amendment will be voted on at the College’sBusiness Meeting held during the AOCD 2009 AnnualMeeting scheduled Nov. 1-4 in New Orleans.

BOT Approves Change inStudent Membership Category

Support the Foundation of OsteopathicDermatology (FOD) by placing an adin the 2009 Ad Journal.

The ad journal, which will bepresented during the PresidentialBanquet at the AOCD Annual Meetingin November, honors the incoming andoutgoing president as well as theAOCD residents and members.

“Your support is vital,” notes ShirleyGottlieb, the AOCD’s Director of Devel-opment. “Contributing to this journaloffers you an opportunity to give backto the organization that made itpossible for each of you to becomepracticing dermatologists.”

Monies for FODFounded in 2004, the purpose of theFOD is to improve the standards of thepractice of osteopathic dermatology byraising awareness, providing publichealth information, conducting chari-table events, and supporting researchthrough grants and awards given tothose applicants under the jurisdictionof osteopathic dermatology physicians.

The FOD instituted a research grantsprogram to encourage and supportscientific investigations into the poten-tial causes of dermatological issues andother key aspects of various dermato-logical conditions. Research grants are

provided to encourage improvement intreatment and potential preventionand/or cure in the related dermatologyfield. The two types of research awardsavailable are the Resident Award andthe Attending Physician Award.

In addition, multiple grants are avail-able to an osteopathic dermatologistthrough the FOD. They include thefollowing:

The FOD Resident Research Grant isawarded annually to an osteopathicdermatology resident in an AOA-accredited institution. The purpose ofthis grant is to foster research in derma-tology medicine conducted bydermatologists at a graduate level.

The FOD Young Investigator Grant isawarded annually to an osteopathicdermatologist who is a graduate of anaccredited dermatology residency andpracticing dermatology in an accreditedinstitution for five years or less. Thepurpose of this grant is to fosterresearch among young dermatologistsand is awarded to promising physicianresearchers meeting specified criteria.

The FOD Investigator Grant isawarded annually to an establishedosteopathic physician who is certifiedin dermatology and conductingresearch in dermatology at an accred-

ited institution. The purpose of thisgrant is to sponsor or co-sponsorresearch in any area of dermatology.

The FOD Charitable Award isawarded annually to an osteopathicphysician who is certified in derma-tology and providing care in adeveloping country. The purpose ofthis award is to sponsor a dermatologisthelping to improve the dermatologicneeds of that specific country.

For more specific information about theFOD and the aforementioned awards,visit the AOCD website athttp://www.aocd.org/aboutus/founda-tion_osteopathic_dermatology.html orcontact Brad Glick, D.O., FAOCD, at954-242-1632.

To submit an ad for the 2009 journal,contact Shirley at [email protected] or 954-963-5862.

2009 Ad Journal to Support FOD

Bill V. Way, D.O., FAOCD, was recentlyhonored by his peers for 23 years ofservice in the House of Delegates ofthe Texas Osteopathic Medical Associa-tion (TOMA).

He was presented with an honorarycertificate in May during the 64thannual meeting of the TOMA House ofDelegates held in Austin.

During his 23 years of service in theHouse of Delegates, which is thelegislative body of TOMA, Dr. Wayactively participated in the discussionand debate of policy and administrativeresolutions considered by that body.

These resolutions determine the advo-cacy by the association for thebetterment of quality health care,access to medical care, and safety ofthe public seeking osteopathic medicalservices for citizens across Texas. Hisparticipation has helped determine thedirection of TOMA and its advocacy forthe health care of all Texans.

An active member since 1983, Dr. Wayis a TOMA past president. He also is apast president and active member ofhis divisional society, TOMA District 5.As a member of the AOA, Dr. Way wasrecently recognized for outstandingservice as a mentor in the Association’s

Mentor Hallof Fame.

The TOMAhas repre-sentedosteopathicphysicians inTexas sinceits foundingin 1900. Itcurrently represents nearly 2,300members, including 588 osteopathicmedical students at the University ofNorth Texas Health Science Center inFort Worth.

Dr. Way Honored for Years of Service

From the quality improvement initiatives introduced in the1990s to today’s pay-for-performance arena, physicians havebecome accustomed to being graded for their performance.But now the tables are being turned and payers are the oneswho are being graded.

How easy it is to do business with a health plan and howappropriate its reimbursement is are just some of the issuesthat payers are being graded on. Much of the data beingcollected, to date, are national in nature and applicable forphysician services in general. The American Medical Associa-tion’s National Health Insurer Report Card on claimsprocessing and athenahealth’s PayerView™ are two exam-ples that come to mind.

However, one ranking service, the Center for HealthcareReimbursement, a division of IQS Research, recently begancollecting reimbursement data specifically for dermatology.

Dermatology-Specific DataThe Center for Healthcare Reimbursement began collectingreimbursement data in 2007. To date, the Louisville,Kentucky-based company has such data for five specialtiesin 15 major markets throughout the Midwest. This year,dermatology was added based on interest from the derma-tology community, says Shawn Herbig, President.

The Center began collecting reimbursement data for 35dermatology-related CPT codes this spring using a propri-etary process that enables it to gather data directly from

physician practices while adhering to Federal Trade Commis-sion (FTC) regulations.

There are two types of data the company gleans. Dermatolo-gists can use the in market data to compare their currentreimbursement with other dermatologists in the same city.They can use the across market data to compare currentreimbursement with their peers in the major Midwestmarkets.

“We have found, in general, that individual doctors andsmall practices are more concerned with the in market datawhereas colleges, societies, and large industry trade groupstend to be more interested in the across market data,” hesays, adding, “We would expect to see the same with derma-tology.”

In 2010, there will be enough data collected to start showingsome historic trends. “We will be able to tell over time if thereimbursement is increasing or decreasing overall, orincreasing for certain codes and decreasing for other ones,”Herbig explains. “Every year, that data set will becomericher.”

Data-Driven ReportsThe Center provides an independent statement of the marketaverage, 25th, 75th, and 95th percentiles for each of the topprocedure codes. Then it distributes a practice summaryreport, which indicates whether the practice is above orbelow the market average with regard to the CPT codes and

Grading the Payers

Figure 1 illustrates a reimbursement disparity of $108,480, distributed by carrier, that a sample practice is expe-riencing. The bars show the amount of additional annual revenue from each carrier that the practice could earnif it were reimbursed at market average for all codes currently reimbursed below the average by that carrier.

Figure 2 illustrates the patient volume for each carrier (blue bars) compared to the reimbursement disparity foreach carrier (red bars).

reimbursement. “We look at utilization and reimbursementand then calculate a total dollar amount,” says Herbig. “Thereport is designed to simply say this is how much money thepractice is off and this is how many codes contribute to thatdollar amount. The first question every practice has is howdoes its reimbursement amount compare to the rest of themarket. This report will answer that question.” (See Figures1 and 2.)

After reviewing the practice summary report, if the dermatol-ogist decides to find out exactly which codes are off, byhow much, and what that is costing the practice on anannual basis, there is the practice profile. The latter reportbreaks down every single code and carrier and compares itto the Center’s benchmarks. “The dermatologist can look atit on a code-by-code basis or a carrier specific basis,” heexplains. “It gives all the details the practice manager needsto go in and conduct a negotiation.”

If the practice wants a third-party to negotiate on its behalf,the Center can conduct a reimbursement analysis and give itto a company that specializes in negotiations. The Center isprohibited by the FTC from conducting negotiations.

“We believe that there should be timeliness and transparencyin regard to what dermatologists expect to be reimbursed,but that’s not the reality,” says Herbig. “Without that, derma-tologists are operating in the dark. By putting thesebenchmarks out there, we level the playing field. Dermatolo-gists will have some information to help them makedecisions that are in the best interest of the practice andtheir patients, as well.”

Other Ranking ServicesAt approximately the same time that the Center forHealthcare Reimbursement began collecting reimburse-ment data in the Midwest, other ranking services begancollecting similar data on a national basis.

PayerView™ is a national ranking of payers introduced byathenahealth in 2006. It uses seven metrics to rankhealth plans on a national and regional basis. Themetrics are as follows: days in accounts receivable, firstpass resolve rate, percentage of patient liability, denialrate, denial transparency rate, percentage of claimsrequiring medical documentation, and percentage ofnon-compliance with the national Correct Coding Initia-tive. In 2008, performance data were gathered frommore than 12,000 medical providers and 30 millionmedical charge lines from 39 states.

Also in 2008, the American Medical Association launchedits National Health Insurer Report Card on claimsprocessing. The report card uses 14 metrics divided intofive categories as follows: payment timeliness, accuracy,transparency of contracted fees and payment policies onpayer web sites, compliance with generally acceptedpricing rules, and denials. It provides an in-depth look at

the claims processing performance of Medicare andseven national commercial health insurers: Aetna,Anthem Blue Cross Blue Shield, CIGNA, Coventry HealthCare, Health Net, Humana, and United Healthcare.

The data are based on a random sample pulled frommore than five million electronically billed services.

Want In?If you are interested in participating in the Center’s datacollection process, it is open to all dermatologists inLouisville, Nashville, Kansas City, St. Louis, Cincinnati,Dayton, Columbus, Cleveland, Toledo, Detroit, GrandRapids, Milwaukee, Minneapolis, Chicago, and Indi-anapolis.

Data collection is done electronically. Once the samplesize is reached, the Center will e-mail a complimentarypractice summary report to participating dermatologists.

To learn more about the data collection process, visit theCenter’s website at www.center.iqsresearch.com or callthe office at 502-244-6600.

Baby NewsCongratulations to Dr. LloydCleaver on the birth of hisnew grandson, BrightonHarris Cleaver, born on May5 to Jonathan and TabithaCleaver. Brighton weighed 7lbs 14 oz and was 19 incheslong. Jonathan Cleaver willbe a first-year residentbeginning July 1.

Dermatologic surgeons should with-hold empiric coverage ofmethicillin-resistant Staphylococcusaureus (MRSA) unless there is a veryhigh clinical suspicion or significantrisk factors, concludes Roger Sica,D.O., a third-year resident at theNSUCOM/Largo Medical Center Derma-tology Program, in his paper entitled“Prevalence of Methicillin-ResistantStaphylococcus aureus in the Setting ofDermatologic Surgery.”

In the paper, published in the March2009 issue of Dermatologic Surgery, Dr.Sica set out to examine the prevalenceof MRSA infections in the post-opera-tive setting of dermatologic surgery. Heperformed a retrospective chart reviewof 70 patients who had bacterialcultures taken from January throughDecember 2007. The mean age of theoverall study population was 57 years,with the mean age of post-surgicalMRSA-positive cases being 75.5 years.

Of the 70 total cultures, there were 21post-surgical ones. Of the 21 culturestaken, 16 grew pathogen and 2 of the16 pathogen-positive cultures grewMRSA. (See Table 1.) That means thatMRSA was isolated from only 13% ofthe positive post-surgical cultures.

Patients with such risk factors as historyof diabetes, residence in a long termcare facility, and recent hospitalization,were observed in 6 of the 16 positivecultures (38%). Neither case of MRSAoccurred in a patient with pre-existingrisk factors.

With approximately 1,000 surgeriesperformed over the course of the year,Dr. Sica found that the overall infectionrate for cutaneous surgery was 1.6% or16 out of 1,000. He noted that thisfigure is concurrent with recent data,which cite overall incidence of infec-tion in routine dermatologic surgery at1.47%.1

Common PathogensHistorically, the most commonpathogens isolated in cutaneoussurgical wound infections are gram-positive organisms, Staphylococcusaureus and Streptococcus pyogenes.Gram-negative organisms, such asPseudomonas aeruginosa, have beenless commonly isolated in high-risklocations such as the ear or perineum,particularly in patients with a history ofdiabetes mellitus.

Methicillin-resistant Staphylococcusaureus developed as a result of antibi-otic resistance through a variety ofgenetic and biologic mechanisms.2 Itwas first described in the UnitedKingdom in 19613 as a nosocomialpathogen.4 Since that time, MRSA hasalso become an increasingly prevalentpathogen in the community setting.5 Ithas been subdivided into healthcareassociated, which includes community-onset and hospital-onset subtypes, andcommunity associated.6

Of particular interest to dermatologists,it is well documented that MRSA skininfections are increasing at an alarmingrate in a variety of clinical settings.Examples include emergency depart-ments7 and inpatient dermatologyservices8 as well as in previouslyhealthy individuals, often presenting asspontaneous abscesses.5 Many authorshave suggested modifying empiricaltherapy to cover MRSA in such situa-tions if clinical index of suspicion ishigh.7,9-11

Different Patient PopulationsHowever, the patient population forwhich it is increasing is not representa-

tive of the population typically seen bydermatologic surgeons.

As an example, in a study of patientspresenting in emergency departmentswith acute skin and soft tissue infec-tions, the prevalence of MRSA was 59%overall, with a rapid increase in preva-lence seen in Los Angeles from 2001 to2004.7

Reported cases of MRSA at militarymedical facilities in San Diego from1990 to 2004 showed that 65% of thecases were community acquired.Patients were younger and less likely tohave concurrent medical conditions.Total MRSA isolates rose from 10 in1990 to 632 in 2004, with the greatestincrease occurring from 2002 to 2004.3

In a chart review of hospitalizeddermatology patients in 2001, MRSAincreased in leg ulcers from 26% in1992 to 75% in 2001. For superficialwounds, MRSA increased from 7% in1992 to 44% in 2001.8

In a chart review of patients whounderwent operative debridement ofskin and soft tissue infections at aVeterans Affairs hospital in Texas, anincrease in MRSA from 34% in 2000 to77% in 2006 was demonstrated.9

Patients Seen by DermatologicSurgeonsDermatologic surgeons encounter anentirely different situation on a routinepost-operative basis. Patients whoundergo cutaneous surgery are gener-ally otherwise healthy and not prone todeveloping MRSA infections.

Established common risk factors forcommunity-onset and hospital-onsetinfections include a history of hospital-ization within the past year, history ofrecent surgery, residence in a long termcare facility, and history of MRSA infec-tion or colonization.6 Other historicalrisk factors of skin infection in the post-

To Give or Not to Give: Empiric Coverage of MRSA inDermatologic Surgery Patients

Total Cultures Pathogen + MRSA MSSA Other Pathogen21 16 2 (13%) 6 (38%) 8 (50%)

Table 1: Post-Surgical Cultures

operative setting include patients with ahistory of diabetes or uncontrolledhypertension, and those who takechronic corticosteroids and are alco-holics, smokers, and malnourished orobese. All factors should be consideredwhen choosing empiric antibiotics,noted Dr. Sica.

Other factors that Dr. Sica analyzedinclude the site of cutaneous surgeryand type of repair. Because themajority of surgical cases undertakenduring the course of the year occurredon the head and neck as opposed tothe extremities, it suggests that theincreased number of infections on theextremities, compared with other sites,is significant. This supports previousstudies that demonstrated cutaneoussurgery below the knee to be a signifi-cant risk factor of infection.1

Given that the prevalence of MRSA inthe typical population following derma-tologic surgery is quite low, thequestion becomes what to prescribeempirically in the setting of a post-surgical patient with whom MRSAinfection is suspected.

Treatment OptionsProviding empirical treatment followingdermatologic surgery on a routine basiswith MRSA-sensitive antibiotics (ie,trimethoprim-sulfamethoxazole, clin-damycin or tetracycline derivatives)would be premature, Dr. Sica noted,and may only further increase the like-lihood of creating antibiotic resistance,potentially losing these valuable antibi-otic agents in the future.

Unless there is a very high clinicalsuspicion or the patient has multiplerisk factors, he recommended contin-uing to prescribe the traditionalantibiotics given for uncomplicated skininfections in the post-surgical setting.These include penicillins,cephalosporins, and aminoglycosides,among others. Dr. Sica also recom-mended obtaining a culture and

adjusting the antibiotic therapyaccording to sensitivity. The empiricaluse of MRSA-sensitive antibioticsshould be reserved for high-riskpatients or locations, he concluded.

Dr. Sica received the Young Investiga-tors Writing Competition Award fromthe American Society of DermatologicSurgery for this paper and alsopresented the topic at the society’sannual meeting held last November.

References1 Dixon A.J., Dixon M.P., Askew D.A., et al:

Prospective study of wound infections indermatologic surgery in the absence ofprophylactic antibiotics. Dermatol Surgery2006;32(6):819-26.

2 Del Rosso J.Q., Leyden, J.J.: Status reporton antibiotic resistance: implications forthe dermatologist. Dermatologic Clinics2007;25(2):127-32.

3 Crum N.F., Lee R.U., Thornton S.A., et al:Fifteen-year study of the changingepidemiology of methicillin-resistantStaphylococcus aureus. Am J Med 2006;119(11):943-51.

4 Cohen P.R., Kurzrock R.: Community-acquired methicillin-resistantStaphylococcus aureus skin infection: anemerging clinical problem. J Am AcadDermatol 2004;50:277-280.

5 Elston D.R.: Community-acquired methi-cillin-resistant Staphylococcus aureus. JAm Acad Dermatol 2007;56(1):1-16.

6 Klevens R.M., Morrison M.A., Nadle J., etal: Invasive methicillin-resistant Staphylo-coccus aureus infections in the UnitedStates. JAMA 2007; 298(15):1763-71.

7 Moran G.J., Krishnadasan A., Gorwitz R.J.,et al: Methicillin-resistant Staphylococcusaureus infections among patients in theemergency department. N Engl J Med2006;355:666-674.

8 Valencia I.C., Kirsner R.S., Kerdel F.A.:Microbiologic evaluation of skin wounds:alarming trend toward antibiotic resistancein an inpatient dermatology service duringa 10-year period. J Am Acad Dermatol2004;50:845-849.

9 Awad S.S., Elhabash S.I., Lee L., et al:Increasing incidence of methicillin-resistant Staphylococcus aureus skin andsoft-tissue infections: reconsideration ofempiric antimicrobial therapy. Am J Surg2007;194:606-10.

10Nicolle L.: Community-acquired MRSA: apractitioner’s guide. Canad Med Assoc J2006;175(2):145.

11Elston D.M.: Optimal antibacterial treat-ment of uncomplicated skin and skinstructure infections: applying a noveltreatment algorithm. J Drugs Dermatol2005; 4(6 Suppl):s15-9.

New Orleans—host of the 2009 AOCDAnnual Meeting—is an American citywith a European flare.

Similar to other early American settle-ments, New Orleans served as acultural gateway to North America.Unlike the others, it was here that thelives and customs of the AmericanIndians and Africans, both free andslaves, intermingled with those of Euro-pean settlers resulting in a cultureunique to the Crescent City.

Established in 1718, a century aftersome of the other American settle-ments, New Orleans remained anoutpost of the French and Spanishempires until Napoleon sold it to theUnited States as part of the LouisianaPurchase in 1803. Despite the fact thatFrench Louisiana was connected bywater to the rest of the country, itremained isolated and guarded in itsway of life. While it became the South’schief cotton and slave market, its influ-ence was still largely foreign as moreimmigrants than Americans came tolive in the city nearly until thebeginning of the 20th century. TheFrench, Spanish, and Cubanswere later joined by the Irishand Germans. From 1820 to1870, New Orleans was oneof the main immi-grant ports in thenation, secondonly to NewYork. TheCrescent Cityalso was thefirst Amer-ican city tohost asignifi-

cant settlement of Italians, Greeks,Croatians, and Filipinos.

Birthplace of JazzOne of the ways its many cultures wereblended is reflected in the city’s music.Known as the birthplace of jazz,African drums were combined withEuropean horns to create a new sound.Add to that, the music heard inchurches and in barrooms, and a wild,jubilant music was born. The likes ofBuddy Bolden, Jelly Roll Morton, andLouis Satchmo Armstrong carried thenotes outside the city giving it world-wide popularity.

The tradition continues to the presentday. Some of today’s world-renownedjazz musicians who call New Orleanshome are Wynston and BranfordMarsalis, as well as Harry Connick, Jr.

No matter what night of the week, youwill find a jazz club with live music.Preservation Hall in the French Quarterserves up

traditional jazz with neither a bar norclimate control. The music beginsnightly at 8 p.m. with a line usuallyforming outside one half-hour before.Also in the Vieux Carré is the FunkyPirate, long time Bourbon Street hangout of Big Al Carson & the BluesMasters, featuring raunchy blues fromlate afternoon to the wee, wee hours. Ifyou prefer going off-shore to hearmusic, the Steamboat Natchez featurestraditional jazz on its evening cruise,which includes dinner. (Reservationsrequired.)

This classic Mississippi riverboat is alsoknown for another kind of music, theSteam Calliope, which is a 32-notesteam pipe organ. While walkingthrough the French Quarter during theday, listen carefully at 11 a.m. and 2p.m. to hear the lively music of acalliope, which is an exact copy of theoriginal built 100 years ago. Follow thesound to the Toulouse Street Wharf andsee the music coming from the calliope

in the form of steam plumesshooting with each whistle

played. There is a synchro-nized colored light show thatoccurs just before one of theNatchez’s daily treks down

the river.

New Orleans Offers Cool Jazz, Hot Cuisine

When you’re taking that stroll,remember that November is technicallywinter in New Orleans. That means ahigh of 68 degrees and a low of 51degrees. Rain is not uncommon for thistime of year, so an umbrella mightcome in handy.

Cajun, Creole CookingThe Crescent City also set its mark inthe culinary world with its Cajun andCreole cooking.

A combination of French and Southerncuisines, Cajun food is robust, country-style food found along the bayous ofLouisiana. The French, who migratedhere from Nova Scotia 250 years ago,brought with them their heavy, one-potdishes, such as jambalaya or crawfishétouffée, served over steaming rice.

Unlike Cajun fare, Creole food wascreated by New Orleans’ residentsbased on their European and Africanroots. Some would say Creole food isCajun food's more refined city relative.While the French influence is verystrong, the essence of Creole is foundin rich sauces, local herbs, red ripetomatoes, and the prominent use ofseafood caught in local waters.Common Creole dishes are rich, roux-based gumbo, shrimp creole, grits andgrillades, and redfish courtbouillion.

Both types of cooking rely on theliberal use of chopped green peppers,onions, and celery. The most commonmisconception is that both are spicy,fiery hot. Both Creole and Cajuncuisines have a depth of flavor, borneof a blend of local herbs and (quiteoften) roux and may or may not bespicy.

Authentic Creole and Cajun delicaciescan be found at one of the city’s 3,000restaurants.

Other Food TraditionsNew Orleans also has many coffee-houses. Whether you need apick-me-up after a day touring the cityor a night jazzing it up, a cup of coffeeand sweet treat can be found aroundthe corner. Probably the most famous isCafé Du Monde in the French Quarter,which has been serving café au lait and

beignets since 1862. Beignets are, ofcourse, the pastries made from deep-fried dough and sprinkled withconfectioner’s sugar. These Frenchdoughnuts were brought to NewOrleans by the Acadians. Café DuMonde is a city landmark locateddirectly across from Jackson Square andthe Pontalba apartments. Many localcoffee shops also serve light meals,such as sandwiches and salads.

Instead of having a regular sandwich,try a po’ boy (or poor boy), the tradi-tional local submarine sandwichconsisting of meat or seafood, usuallyfried, served on baguette-like LouisianaFrench bread. The key is the breadwith a light and airy inside and crispyoutside. A dressed po’ boy includeslettuce, tomato, and mayonaise, withoptional pickles and onion. The sand-wich’s origin is said to result from a1929 strike against the streetcarcompany. A former streetcar conductorturned restauranteer served his formerpeers free sandwiches during the strike.

Another local favorite is the muffulettasandwich created by a Sicilian immi-grant, Salvatore Lupo, in 1906 at theCentral Grocery, which still operates inthe French Quarter. A muffuletta isactually a type of Sicilian bread, similarto focaccia. The muffuletta loaf is splithorizontally and covered with a mari-nated olive salad, layers of capiloca,salami, mortadella, emmentaler, andprovolone.

Another food tradition in New Orleansis Sunday brunch. Some of the morenoted places serving up these midday

meals are Brennan’s, Antoine’s,Arnaud’s Restaurant, and Court of TwoSisters Restaurant, all in the FrenchQuarter. Remember, jacket may berequired for brunch fare.

So take some time to enjoy the cooljazz and hot foods compliments of theblended cultures in New Orleans whileat the 2009 AOCD Annual Meeting.

In the next issue of DermLine, learnabout the neighborhoods, including sitesnot to be missed, that make up NewOrleans.

Warm and sunny convention sites havebeen chosen for the next two AOCDmidyear meetings.

Next year, the AOCD Midyear Meetingwill be held April 14-17 at the SedonaArizona Hilton. This hotel, which isnestled among the gorgeous Arizonared rock mountains, is fabulous. Itoffers swimming, tennis, and spa serv-ices, and is 90 minutes from thePhoenix airport. The updated Flagstaff

airport, which is a 15-minute shuttleride away, now accepts large jets, aswell. The town has great restaurants,

golf courses, and even an outletmall. A short drive to the moun-tains reveals a light skiing area(call the hotel or website for theconditions of the slopes beforearriving). There also are manyopportunities for hiking and trailriding.

In 2011, the midyear conventionwill be held at the MarcoIsland Florida Marriottsituated directly on theGulf of Mexico. The datehas not yet been deter-

mined. The Marriott isapproximately 100 minutes fromthe Miami airport or 30 minutesfrom the regional airport byshuttle. The hotel offers jetskiing, swimming activities,umbrellas on the beach at $20 aday, rental boats or cruises (with

or without food), separate kid andadult pools, off-campus golf by hotelshuttle, great restaurants, shopping, asite-seeing trolley, and a museum, allwithin walking distance. A short drivecould deliver one to outlet malls,Naples, and south Florida site-seeing.A Hertz car rental agency is located inthe hotel.

These are great convention sites, and Iam very excited to be able to return tothem. See y'all there.

Midyear Meeting Sites Setby Dr. Schwarze

A live injection workshop usingBotox™ and fillers will be conductedby Susan Weinkle, M.D., and MaryLupo, M.D., FAAD, at this year’s AOCDAnnual Meeting to be held Nov. 1-4,2009 in New Orleans.

The three-hour workshop is scheduledfor the morning session on Monday,says Program Chair Marc Epstein, D.O.,FAOCD. .In addition, Ken Gordon, M.D., and JeffCrowley, M.D., will present a two-hourpsoriasis symposium on Wednesdaymorning.

Incoming American Academy ofDermatology (AAD) President DavidPariser, M.D., has agreed to speakabout AAD and AOCD relations.

This year, resident lectures are slatedfor Tuesday and Wednesday after-noons.

Expect an unexpected venue befittingthe heritage of New Orleans for thePresident’s Banquet.

Annual Meeting: Live Injection Workshop, Psoriasis Symposium

The AOCD recently implemented thenew FileWorks Online system, whichstores files on secure servers andenables access to them through theInternet.

The AOA began using the system lastMarch to upload various documents,instead of mailing them, to all of thespecialty colleges.

For now, the AOCD’s Education Evalu-ating Committee (EEC) is using theFileWorks system to upload the resi-dents’ annual reports. This will enablecommittee members to review thereports at their leisure. Previously,copies of the reports were carried tothe EEC meeting in St. Louis wherethey were reviewed and then carriedback to Kirksville. Thus, the use of

Fileworks will eliminate the trans-porting of 100+-plus copies of thesereports.

“This is still a learning process for us alland bugs are still being worked out,”notes Marsha Wise, resident coordi-nator.

Future expansion on how FileWorkswill be used will be discussed at the2009 AOCD Annual Meeting.

AOCD Implements FileWorks Online

If you have five or more years ofAOBD certification and are interestedin becoming an inspector, the AOCDwould like to hear from you.

Inspectors are the eyes and ears of ourtraining programs for the EducationEvaluation Committee (EEC), says ChairJames Bernard, D.O., FAOCD. They areofficial representatives of the AOA andthe AOCD. “The inspectors’ review andrecommendations are extremely impor-tant in maintaining quality control andexcellence in our current and futureeducational programs,” he adds. Theinspectors’ reports are viewed by theAOCD’s EEC as well as the AOA’sProgram Training Review Committee.

Inspectors are responsible forreviewing the AOCD’s current resi-dency training programs as well as newprogram applicants.

Currently, the AOCD has five activeinspectors, who review 20 existingprograms every three to five years.After conducting an inspection, whichtakes one to two days on site, inspec-tors are required to write a summaryreport noting areas of strengths and

weaknesses (if any). Through theinspection, the inspector verifies thatthe training program is following theBasic Standards guidelines.

Inspectors are expected to attend thequarterly EEC meetings that areconducted either in person or by tele-conference. At these meetings,

members review the inspection reportsand other documents or training issuesthat arise, as well as the residents'annual reports. The EEC members thensubmit summary reports with recom-mendations to the AOA Council onPostdoctoral Training, which thenapproves or disapproves them.

Inspectors are reimbursed for expensesby the AOA per Association guidelines.

The EEC is chaired by Dr. Bernard.Lloyd Cleaver, D.O., FAOCD, is the vicechair. Members include Drs. Brad Glick,Susan Kelly, Steven Kessler, LeslieKramer, Jere Mammino, Richard Miller,Robert Schwarze, Michael Scott, StanleySkopit, Bill Way, and Schield Wikas.

If you are interesting in becoming aninspector, you may submit a letter ofintroduction/application along with acurrent CV to the EEC at the AOCDoffice addressed to AOCD/EEC, P.O.Box 7525, Kirksville, Mo. 63501. Theinformation also can be faxed to theAOCD at 660-627-2623.

Inspectors Wanted

Hello Everyone,

Winter is behind us(finally) and thespring and summermonths will be busyhere in the AOCDOffice.

Annual ReportsIt will soon be time for annual reports to be turned in! Allforms can be downloaded from the AOCD website athttp://www.aocd.org/qualify/annual_reports.html.

The Education Evaluation Committee (EEC) met this pastFebruary and reviewed the resident requirements for theannual reports and resident lectures.

The Resident’s Annual Report, Program Director’s AnnualReport, Resident’s Annual Paper with two referenced ques-tions, Documentation Submission Form for Publication, andAOA Core Competency Report are all due in the AOCDOffice 30 days after the end of each training year.

Residents should send one original copy with an attachedsignature page. The signature page should be signed by theresident, program director, and director of medical educationas it is a confirmation that the reports are complete andaccurate. Once the reports are received by the AOCD, wewill upload them to FileWorks, which is our new on-linestorage system. (See page13 for story on FileWorks)

The EEC members will then be able to view each report asthey are uploaded at their convenience. This will give themembers more time to review each report before the nextEEC meeting slated this fall. Incomplete reports will not beuploaded.

All reports submitted late are subject to a late fee penaltyand will not be reviewed by the EEC until the fee is paid.

The fee schedule is as follows:• $100 for all reports submitted 30 to 365 days after

submission deadline• $250 for all reports submitted 365 to 730 days after

submission deadline• $500 for all reports submitted 730 days after submission

deadline

Late documents will delay the approval of each year oftraining by the EEC and the AOA’s Postdoctoral TrainingReview Committee. Board eligibility is granted only uponapproval by both committees.

Lectures Intent-to-Lecture applications for the 2009 AOCD AnnualMeeting are now being accepted.

Because there is a limited number of spots, applicationshould be submitted as soon as possible. Resident lecturesare slated from 1 to 5 p.m. on Tuesday, November 3, andfrom 1 to 5 p.m. on Wednesday, November 4.

The faculty disclosure statements and Intent-to-Lecture formscan also be downloaded from the AOCD website athttp://www.aocd.org/qualify/annual_reports.html.

Upon recommendation of the Awards Committee, thefollowing rules apply to the resident lectures.

Each resident must present two lectures of at least 15minutes in length (as stated in the current Basic Standardsdocument).

Priority in scheduling will be given to second- or third-yearresidents to ensure that they have ample time to meet theirtraining requirements. First-year residents will not be sched-uled to speak at the annual meeting in the fall of their firstyear of training.

Also, the residency program director is responsible forreviewing all oral presentations and manuscripts for publica-tion prior to the resident submitting them. In addition, theresidency program director must submit a signed and datedstatement that the resident’s oral presentation has beenreviewed, thereby allowing the resident to be included inthe AOCD meeting program.

The administrative requirements for resident oral presenta-tions are as follows:

• Call For Lectures/Papers 7 months prior to the first dayof the meeting

• Intent-to-Lecture Form: AOCD office notified by residentof intent to lecture 6 months prior to the first day ofthe meeting or resident will not be placed on schedule

The signed documents required to be in the AOCD office 8weeks prior to the first day of the meeting are as follows:

• Disclosure Statement• Copyright/Consent• Program Director’s Statement• Copy of completed PowerPoint presentation

If the PowerPoint materials are not received by the specifieddeadline date, then the resident will not be eligible for eval-uation of the Koprince Award. If the materials are notreceived by the deadline, the resident will not be able topresent at the meeting.

Residents Updateby Marsha Wise, Resident Coordinator

Sending the aforementioned items two months prior to themeeting will allow ample time for evaluation, review, andapproval by CME accredited bodies.

The lecture schedule sign-up closes 12 weeks prior to thefirst day of the meeting. No last minute additions to thelecture schedule will be allowed.

This year, the lecture sign-up closes August 1, the documen-tation/presentations are due September 1, and the meetingstart date is November 1.

Lectures are accepted on a first come, first serve basis. Anytopics “to be announced” will be placed on the waiting list.Once slots are filled, anyone requesting to speak who hasnot been assigned a spot, will be placed on the list for themidyear meeting slated in March, 2010 and will be givenpriority scheduling.

Currently, a presentation on “How to Give a PowerpointPresentation” is being developed. This session will takeplace either at an annual meeting or a midyear meeting forresidents as well as any AOCD members who would like toattend.

In-Training ExamThe program directors continue to work on the in-trainingexamination (ITE) questions for this year’s exam, which willbe held on Sunday, November 1 in New Orleans. Residents’dues must be current to sit for this exam.

The intent of the ITE is to identify knowledge-basedstrengths and weaknesses in both the training programs andthe residents in a non-punitive manner. Participation in theITE program is mandatory. The exam format includes thetype of multiple-choice questions that appear on the certi-fying exam, such as one best answer, matching, andidentification of images. The ITE is not meant to be a mirrorof the actual board.

Residency Programs GrowThe AOCD residency programs continue to grow.

In July 2005, there were 80 residents. One year later, therewere 87. In July 2007, there were 90 residents. One yearlater, there were 97. This July, there will be 97 residents.

To date, the following residency programs have accepted 29new residents who will begin July 1. They are as follows:

Oakwood Southshore: Dr. GrekinPeter Sattia, D.O.Ari Goldsmith, D.O.

O’Bleness Memorial Hospital: Dr. DrewKate Chilek, D.O.Frank Morroco, D.O.

Genesys Regional Medical Center: Dr. SilvertonDavid Kasper, D.O.

St. Barnabas Hospital: Dr. HoffmanKate Kleydman, D.O.

Columbia Hospital: Dr. AllenbyRoxanna Menendez, D.O.Kurt Grelck, D.O.

Northeast Regional Medical Center #2: Dr. WayHelen Kaporis, D.O.

NSU-COM/BGMC: Dr. SkopitTheresa Cao, D.O.Roya Ghorsriz, D.O.Jerry Obed, D.O.

Wellington Regional Medical Center: Dr. GlickBetsey, Leveritt, D.O.Danielle Manolakos, D.O.

Richmond Medical Center/Case Medical Center: Dr.Tamburro

Allyn Hatter, D.O.Ligaya Park, D.O.

St. John’s Episcopal Hospital, South Shore: Dr. WatskyRobert Levine, D.O.Tara Whelan, D.O.

NSUCOM/Largo Medical Center: Dr. MillerAngela Bookout, D.O.Lana McKinley, D.O.Khonnie Wongkittiroch, D.O.

COMP/Phoenix Area Dermatology: Dr. KesslerAmanda Beehler, D.O.

TUCOM/Valley Hospital Medical Center: Dr. Del RossoBrent Michaels, D.O.

Northeast Regional Medical Center: Dr. CleaverJonathan Cleaver, D.O.

Pontiac/Botsford Osteopathic Hospital: Dr. MahonJonathan Richey, D.O.Michelle Legacy, D.O.

St. Joseph Mercy Health System: Dr. StewartAmy Basile, D.O.Ryan Jawitz, D.O.Christopher Messana, D.O.

All residents are asked to provide the following documents:• A copy of your medical school diploma (and exact date

of graduation)• A copy of your internship diploma (exact dates of atten-

dance and name and address of school)• A copy of your state license• 2 passport size photos• A current CV

Please remember to keep your address and e-mail addresscurrent. If you experience problems logging on tohttp://www.aocd.org, please let me know.

A recently published numerical scalecan help dermatologists assess howmany laser treatments it will take toremove a tattoo.

The Kirby-Desai Scale was developedby Will Kirby, D.O., FAOCD; AlpeshDesai, D.O., FAOCD; Tejas Desai, D.O.,FAOCD; and first-year resident Fran-cisca Kartono, D.O. In their studypublished in the March issue of theJournal of Clinical and Aesthetic Derma-tology, the scale was determined to be apractical tool to assess the number oflaser tattoo-removal sessions required.

More Tattoos, More RemovalsTattoos have become increasinglypopular in the Western world. Currentestimates suggest that more than 20million people—or between 3% and 5%of the population—have at least onetattoo.1,2 Also on the rise are tattoo-removal requests, as patients oftenregret getting this form of body art. Upto 50 percent of adults 40 years of ageand older seek to remove their tattoos.3

Lasers have been used to removetattoos since the late 1970s. In recentyears, they have become the treatmentof choice due to their high efficacy andlow incidence of deleterious sideeffects. However, due to the varyingtypes of tattoos, it has been difficult toquantify the number of laser treatmentsrequired with certainty.

Currently, patients receive a poorlydefined assessment of the number oftreatments. As a result, they oftenengage in the process without fullawareness of the potential success andcost.

The ScaleConsequently, the authors developedthe Kirby-Desai scale to be used duringpre-consultation. The scale was madewith the assumption that the dermatol-ogist is using a quality-switchedNd:YAG (neodymium-doped yttriumaluminum garnet) or Alexandrite laserincorporating selective photothermol-ysis with six to eight weeks betweentreatments.

To test the scale, the authorsperformed a retrospective chart reviewon 100 clinic patients who presentedfor laser tattoo removal between July2004 and August 2008. Using an algo-rithm, they assigned a numerical scoreto each tattoo across six different cate-gories (e.g., skin type, location, color,amount of ink, scarring, and layering).The cumulative score was proposed tocorrelate with the number of treatmentsessions required for satisfactory tattooremoval.

Several factors within the aforemen-tioned categories can affect thenumber of treatments required. Forexample, colors other than black canbe twice the size of the black pigment,thus requiring more treatments.Amateur tattoos are typically placedunevenly in the superficial dermis andtend to contain less ink than thosedone by professional artists. As aresult, amateur tattoos tend to respondquicker to laser treatment. Whenpatients layer an undesirable tattoowith another, the second one tends tobe larger and darker, thus requiringmore treatments to remove.

The average number of treatmentsrequired to satisfactorily remove atattoo was 10, with a range of three to20, the study revealed. The number oftreatments correlated well with theaverage Kirby-Desai scale of 9.87 witha standard deviation of ±2.45. (SeeFigures 1 and 2.)

Using the scale will enable dermatolo-gists to better estimate the number oflaser treatments required for tattooremoval, the study concluded, whiledecreasing the uncertainty of theprocess for patients.

References1 Armstrong M. Career-oriented women

with tattoos. Image J Nurs Sch.1991;23:215–220.

2 Anderson R. Tattooing should be regu-lated. N Engl J Med.1992;326:207.

3 Kilmer S, Fitzpatrick R, Goldman M.Tattoo lasers.http://www.emedicine.com/derm/topic563.htm. (Accessed March 2009.)

Scale Quantifies Laser Tattoo-Removal Sessions Required

Figure 1 is a histogram showing the distributionof the calculated Kirby Desai scores. Figure 2 isa histogram of actual laser treatments required

to achieve satisfactory tattoo removal.

Figure 2

Figure 1

As the program yearcomes to a close, all ofus need to startthinking about thefuture regardless ofwhether we are gradu-ating this July or wehave a couple of resi-dency years left.

To that end, I have asked one of our office managers at theGrekin Skin Institute, Amanda Lusk, what is typicallyrequired in order to be credentialed after residency. Sherecommended the following “to do” list:

Ongoing Paperwork, Requirements• If you do not already have one, apply for a National

Provider Identifier athttps://nppes.cms.hhs.gov/NPPES/Welcome.do.

• Call your accountant to obtain a tax identificationnumber and obtain information about how to start apractice.

• Call your hospital medical education department toobtain a “Malpractice Face Sheet” for every year youhave been a physician.

• Check the Centers for Medicare & Medicaid Serviceswebsite at http://www.cms.hhs.gov/default.asp fordetails about Medicare participation. Guidelines for allstates are available on this site.

• Create a credentialing packet that contains the followinginformation:- Copies of all licensures- Copies of your Social Security card- Copies of your photo identification- Copies of all your degrees (starting with your bach-

elor’s)- Copies of anything in relation to your CME credits- Copy of your ACLS/BLS certification- Current CV- List of all publications in which you have published- Copies of any special certificates (Mohs micrographic

surgery certification, military documents, etc.)

Countdown to GraduationOne year prior to graduation, you should

1. Begin contract talks with potential employers andestablish where you want to practice.

2. Start checking on the cost of malpractice insurance andstate liability requirements.

Six months prior to graduation, you should1. Finalize your contract if you have not already done so.2. Apply for a medical license within the state you plan

on working.3. Begin looking at insurance applications.4. Call local hospitals and apply for privileges. Remember

that insurance companies usually require that you have

visiting or courtesy privileges before you are approvedin a plan.

5. Call your local Medicare administrator and ask whenyou can begin the application process.

Three months prior to graduation, you should1. Have a complete credentialing packet with current

licenses, CV, and a tuberculosis test within the last year.2. If you have not already done so, start Medicare and

insurance applications.3. Obtain a minimum of four letters of recommendation.

Only one letter can be from a source such as a physi-cian assistant or nurse practitioner.

At graduation, you should1. Schedule boards and, if possible, obtain a letter from

your Director of Medical Education indicating boardeligibility.

2. Live a life less ordinary.

Greetings from the Resident Liaisonby Reagan Anderson, D.O., M.P.H., M.C.S.

VO

LUN

TE

ERSPOTLIGHT

The two garishly outrageously painted,uncomfortable, fume-belching chickenbuses precariously negotiated steepmountain passes as they carried avolunteer DOCARE Internationalmedical team to makeshift clinicsthroughout remote medically deprivedareas of Guatemala.

The team consisted of medical studentsand faculty from the University ofKansas Medical School and the KansasCity College of Osteopathic Medicine.Tagging along with them on their thirdmission trip were myself and residentsDrs. Tony Nakhla, Marian Shasafari,Joseph Del Priore, and Jack Griffith.

Base camp was the enchanting colonialmountain village of Antigua. Datingback to 1524, its seemingly endlesscobbled streets traversed through openplazas and narrow alleys. Its unique,colorful architecture still reflects its richMayan heritage. Looming above thishistorical area are several ominoussmoke spewing volcanoes that encirclethe village.

Challenging PatientsMore than 500 patients with multipleproblems were treated by the medicalteams each day. The dermatology resi-dents were well prepared and wereable to perform a variety of surgicalprocedures, including the amputationof accessory digits on an 8-month-oldbaby, the removal of multiple verruca

from the tongue of a 10-year-old boy,the excision of a painful perirectalabscess, and the avulsion of a finger-nail to eradicate an underlyingpyogenic granuloma. I was amazed atthe skills of the residents and by theiradaptation to the primitive workingconditions.

The dermatology residents wereintrigued and challenged by thenumber of patients who presented withmultiple presentations of photoder-matitis. The spectrum includedpolymorphous light eruption, lupus-likemalar rashes, actinic reticuloid, actinicgranuloma, and photo contactdermatitis, among others.

Luckily, an ample supply of systemicantibiotics were available to treat cases

of eczema, severe skin infections asso-ciated with uncontrolled atopicdermatitis, and cellulitis covering thescalp of an infant, as well as other diffi-cult-to-treat skin infections.

Embrace the UnexpectedWhat makes trips like these so adven-turous for me is to expect and embracethe unexpected when traveling to aThird World country. Examples of theseassertions are streets too narrow toaccommodate our bus trying to make awrong way turn on a one-way streetbacking up traffic in all directions formore than 30 minutes, or running outof gas on a steep mountain incline onour way back from a hot, gruelingclinic day. But, no problem; we can justsiphon gas from the other bus. Goodidea. So, that is what they did. So, let’s

Medical Mission Adventures: Guatemalaby David Horowitz, D.O., FAAD

Pictured from left to right: Drs. David Horowitz, Jack Griffith and Joseph Del Priore.

Dr. Tony Nakhla and a group of local children.

go. What? The engine won’t turn over.Now, the battery is dead. No problem.We will just borrow the battery fromthe other bus. Three-and-a-half hourslater, we arrived back safely at ourhome base and were rewarded withthe traditional cold shower.

Did I also mention that a good sense ofhumor and a cold beer with chips andsalsa makes everything, for themoment, seem all right?

Now off for some restful sleep, only tobe jolted awake every 15 minutes bythe menacing convent gong that merci-lessly clangs to mark the local time forthe villagers without access to clocksand watches. But exhaustion eventuallytakes its toll, and sometime in the weehours of the morning, you finally dozeoff until the 5 o’clock rooster in theoutside courtyard announces that anew day has arrived. So much forsleep.

Worth the TripYou might ask what makes a medicalmission trip like this worthwhile. Well,it depends on whom you ask.

For Dr. Nakhla, it is witnessing theliving conditions of people in ThirdWorld countries, which he finds aston-ishing and humbling. “It gives one atrue appreciation for life in the states,and a great perspective about our smallworries back home,” he said. Dr.Nakhla also was touched by the grati-tude of the patients whom heencountered. He encourages all physi-cians to participate in this type ofvolunteerism. “It is an experience thatrewards the physician as much as, ifnot more than, the patients who aretreated.”

For Dr. Griffith, it was the warmheartedpeople with the smiling faces whom heencountered as he traveled throughoutGuatemala that impressed him themost. “Despite their harsh social condi-tions and abject poverty, theGuatemalan people were some of themost friendly people I have ever met.”

Dr. Del Priore stated that this trip hasdefinitely sparked his interest in futuremedical missions. “Guatemala is a

country where most people do nothave the resources to go to the doctorwhen they are sick; however, peopleshow gratefulness in such ampleamounts compared to the U.S. where itseems that entitlement predominates,”he noted.

Dr. Shasafari concurred. “It made mefeel very fortunate for all that I have,and I will no longer take what I havefor granted. I have never seen so muchpoverty, pollution, and lack ofresources in one place coupled withsome of the happiest people I haveever encountered. The dichotomy ofwealth and poverty was almostcomical.” She also was impressed bythe extent to which commondermatoses can progress by the lack ofcare to make them almost unrecogniz-able. Dr. Shasafari found this trip to bea very humbling, but wonderful, expe-rience. “I hope that all of my fellowresidents get an opportunity for suchan experience,” she added.

In a country enveloped in culturalcontradictions, a rich historical heritage

and widespread poverty surrounded bybreathtaking natural environmentalbeauty intermixed with civil unrest andgovernment greed there are stillpeople, like you and me, who want thebest for their children and are contentwith their place on this earth. Whatlittle that I did to improve their plight,or to quell a chronic itch if just for amoment or two, was expressed throughsmiling faces and unspoken gestures.

Being able to share my limited medicalknowledge and knowing that I mighthave helped to relieve the suffering ofanother human being in a far off placeis enough for me to keep going backagain and again.

Dr. David C. Horowitz is Director of theDermatology Residency Program atWestern University/Pacific Hospital ofLong Beach. He and his residents went onthis medical mission to Antigua,Guatemala from February 13-28, 2009.

DOCARE InternationalFounded by an osteopathic physician in1961, DOCARE International is amedical outreach organizationdedicated to providing much-needed health care toindigent and isolatedpeople in remote areasaround the world. Its all-volunteer membershipincludes D.O. and M.D.physicians, nurses, dentists,veterinarians, pharmacists,optometrists, podiatrists, physicianassistants, and interested laypersonswho can contribute special skills.

Typically, missions occur during the spring or falland last between seven and 14 days, depending onthe availability of volunteers.

In 2009, DOCARE medical missions have gone toMalawi and various parts of Guatemala. The nextmission to Peru is scheduled for August 6-19.

To learn more about DOCARE International,visit its website at www.docareintl.org orcall (312) 202-8163.

RESI

DEN

CYSPOTLIGHT

The residents in the Palm Beach Centrefor Graduate Medical Education(PBCGME)/Columbia Hospital Derma-tology Residency Program in West PalmBeach, Fla., share a schedule packedwith consults and grand rounds atmultiple facilities not to mention seeingpatients at a handful of clinics and rota-tions at various dermatologists’ offices.

But that’s not the only thing that theyhave in common. All of the residentshave a medical background in some-thing other than dermatology. In fact,most of them are board certified inprimary care fields. “This allows eachindividual resident to contribute some-thing different to the program,” saysProgram Director Janet Allenby, D.O.,FAOCD.

To date, three residents have graduatedfrom the program, which was estab-lished in 2003. One is expected tograduate in June. As of July, there willbe a total of seven residents.

Rigorous ScheduleWith so much on the schedule, morn-ings start at 7:15 a.m. with a review ofchapters in Bolognia’s Dermatology.

The program has a strong foundation indermatopathology, notes Dr. Allenby.The residents attend weeklydermatopathology conferences atDermpath Diagnostics in PompanoBeach reading slides with well-knowndermatopathologists including Drs.Neal Penneys, Alexander Kowalczyk,Pascual Abenoza, Les Rosen, andCarlos Nousari.

But the dermatopathology lessons don’tstop there. The residents attend arigorous and comprehensive weeklyreview of assigned chapters in Lever'sHistopathology of the Skin conducted bya local dermatopathologist, Dr. MichaelNowak.

Every other week, residents participatein providing care to patients at Dr.Nousari’s Immunodermatology/BullousClinic at NOVA Southeastern Universityin Fort Lauderdale. Various diagnosesof the patients at the clinic includepemphigus vulgaris, pemphigus folia-ceous, epidermolysis bullosa acquisita,bullous pemphigoid, mucosalmembrane pemphigoid, sarcoidosis,lupus erythematosus, dermatomyositis,urticarial vasculitis, and dermatitisherpetiformis.

The residents participate in adult inpa-tient dermatology consults at ColumbiaHospital in West Palm Beach. Theyparticipate in pediatric inpatient derma-tology consults at Palms West Hospitalin Loxahatchee.

On Wednesdays, residents participatein providing care for patients at aVolunteer Dermatology Clinic, which ispart of the Caridad Clinic in BoyntonBeach. The clinic serves migrantworkers, who lack health insurance,and their families.

Residents have an opportunity to gainexperience in dermoscopy with Dr.Harold Rabinovitz as an elective rota-tion and lectures.

They gain surgical experience both atthe Veterans Administration MedicalCenter in West Palm Beach and atprivate offices with various Mohsmicrographic surgeons.

A rotation with Dr. Allenby offerscosmetic, surgical, and general derma-tology experience.

On Tuesdays, first-year residents seepatients with Associate Program

Columbia Hospital Residency Program Packs Schedule

Residents listed (left to right): Jacqueline (Jacqui) Thomas, Andleeb Usmani, Sadaf (Sabrina) Waqar, Danica Alexander, Amara Sayed and Laura DeStefano.

Director Dr. Brent Schillinger. All resi-dents participate in a monthly Saturdayclinic.

Senior residents attend weekly derma-tology grand rounds at the Universityof Miami. They also rotate with Dr.Francisco Kerdel, seeing both inpatientsand outpatients at the University ofMiami.

“We have a dynamic program that isconstantly changing and reinventingitself,” says Dr. Allenby. “This allows usto provide a broad range of dermato-logic experiences for our current andfuture residents.” To that end, theprogram is always recruiting facultywith a variety of dermatologic subspe-cialty expertise. As an example, theprogram will begin offering a weeklyon-line interactive dermatopathologyconference with Michael Morgan, M.D.,in Tampa. Dr. Allenby is in the processof establishing both a Mohs surgeryand pediatric dermatology rotations atthe University of Miami.

Clubs, Lectures, PapersThe PBCGME residents present weeklylectures on various dermatology topics,including mastocytosis and histiocy-toses, to internal medicine andpediatric residents as well as medicalstudents.

The residents host dermatology grandrounds with Dr. Nousari on a bi-annualor quarterly basis. Dermatologists fromthe community are invited to partici-pate in these discussions focused ondifficult cases.

On a monthly basis, they host derma-tology journal clubs for dermatologistsin the community. Each resident pres-ents a PowerPoint presentation ofarticles published in the Journal of theAmerican Academy of Dermatology orArchives of Dermatology. Dr. Schillingerserves as moderator.

Once or twice a year, residents have anopportunity to participate in a surgicalskills workshop at Nova SoutheasternUniversity to hone their cutaneoussurgery skills.

Residents routinely participate in aCrisis Intervention Stress Managementprogram at Columbia Hospital. Theyserve as peer counselors for residentsand interns (dermatology, internalmedicine, pediatrics) as well as medicalstudents who have been involved in acrisis, such as the death of a patient.

They attend various academic meetingsincluding those hosted by the AOCDand the AAD. Residents also attend theChicago Board Review, the DermpathDiagnostics Review Course, and theNational Psoriasis Foundation ChiefResident’s Meeting.

Residents have published papers in theJAOCD and given presentations atAOCD annual meetings. Currently, allof the residents are preparing posterson their respective research topics forpresentation at the 2009 FloridaMedical Association meeting scheduledin July.

Guiding the ProgramPrior to being named program directorthis past January, Dr. Allenby met withresidents weekly to biweekly andreviewed topics from Bolognia.Second- and third-year residents did amonthly rotation in her office, whichthey still do. As director, she actively

participates in research with residents,dermatology grand rounds, and lecturesas well as coordinating core and elec-tive rotations.

“Being program director has beenrewarding both academically andpersonally,” Dr. Allenby says. “I contin-ually learn from the residents and I amforced to stay up-to-date in the everchanging medical information arena. Asa program director, which is a non-funded position, I feel my time is asmall price to pay back to a specialty towhich I owe so much and am gratefulto be part of.”

Regarding what she would like the resi-dents to accomplish after graduation,Dr. Allenby says, “I would like my resi-dents to accomplish their own goals. Iknow some of these goals includeobtaining faculty positions in academicinstitutions, obtaining various fellow-ships, settling into private practice in arural location, and joining a largegroup. I know that I have helped theseresidents build the foundation for apromising career as the excellentdermatologists I know they will be.”

Third-year resident Dan Marshall, D.O.,at the Northeast Regional MedicalCenter Residency Program in Kirksville,Mo., recently went down under toobserve Anthony Dixon, M.B., B.S.,Ph.D., Assistant Professor (School ofMedicine) at Bond University in GoldCoast, Australia, and Fellow of theAustralasian College of Skin CancerMedicine.

Dr. Marshall won this opportunity bysubmitting the winning paper entitled“Work Horse Flaps and Nasal Recon-struction” in a writing contestsponsored by the College last year. Thetrip was supported by the silent auctionheld at the 2008 AOCD AnnualMeeting.

Most of his time was spent observingDr. Dixon as he treat patients in hisprivate office in Deelong, one hoursouth of Melbourne. “Dr. Dixon is actu-ally the busiest skin cancer surgeon inAustralia,” says Dr. Marshall. “He seestwo melanomas a week, on average, athis clinic.”

Dr. Marshall also attended a weekenddermoscopy conference in Brisbanegiven by Scott Menzies, M.B. B.S.,Ph.D., Director of the Sydney

Melanoma Diagnostic Centre and anAssociate Professor in the Discipline ofDermatology, University of Sydney,Australia. “I was able to listen to theworld-renown dermoscopist,” he says.

Two things struck Dr. Marshall aboutthe experience.

One is how differently dermatologiststreat skin cancer here and there, largelybased on the respective country’spayment system. “They don’t do Mohsthere because the government won’tpay for it,” he explains. “They don’t doas many biopsies as we do becausethey’re not well paid for them, either. Ifthey think it looks like skin cancer,they do dermoscopy. If it looks likebasal cells, they just excise it withmargins. They have to cut widermargins, which leads them to do moreflaps and graphs.”

The other is the prevalence of skincancer, citing the Australians’ geneticmake-up as a primary reason. “Inoticed a lot more redheads and fair-skinned people there than what we seein the states and in Missouri for sure,”notes Dr. Marshall. “They also haveaccess to warm, beautiful beaches year-round and participate in a lot of

outdoor activities. I was amazed at howmuch sun damage they had and evenin younger people.”

The three-week April trip wasn’t allwork. Dr. Marshall was able to take ina few sites, such as the Great OceanRoad, which offers spectacular sceneryof the coastline of southwest Victoria.An added bonus was having his wifeaccompany him on the trip. “Thehospitality that Dr. Dixon showed uswas amazing,” says Dr. Marshall. “Hetreated us like family.”

Overall, it was a great work opportu-nity, he says. The only negative partwas him having to watch Dr. Dixoninstead of assisting. “I was like a kid ina candy store. So many skin cancers, somuch work to do, and I could onlywatch.”

Dr. Marshall Learns Dermatology Down Under

Many people think financial planningmeans discussing their stock portfoliowith a stock broker or their insurancepolicies with an insurance broker, butthose are only two aspects of financialplanning, according to Steve Lopez, afinancial representative with CrystalCove Wealth Management, an invest-ment management firm in Irvine, Calif.

“Financial planning by definition is acomprehensive analysis of assets, liabil-ities, cash flow, and protection,” hesays. It encompasses all of one’swealth, which is different than income.Wealth is what a person has accruedover a lifetime. Income is his or herpaycheck.

Regarding liabilities, taxes are a majorone for physicians. Not only do theyhave to contend with a 33 percentfederal tax, there is state and local tax,not to mention property taxes, andtaxes on goods and services.

One’s debt-to-income ratio could be aliability if the physician owes moremoney than what he or she brings in.Property and the practice can also beliabilities. For example, if the physicianowns an office building that is notbeing rented out, it can be a liability.As a general rule, what determines ifsomething is an asset or a liability is theresulting cash flow, explains Lopez. Ifthe cash flow is positive, then it’s an

Conduct an AnalysisThe first step in financial planning is toconduct an analysis of one’s assets,liabilities, cash flow, and protection.

Physicians may have several differenttypes of assets. One is property, whichcan refer to a house, an office buildingthat houses the practice, or buildingspurchased for real estate investments.The practice itself, which includes theemployees, is an asset. Other assets area stock portfolio, life insurance, anddisability insurance. An art collection,jewelry, and collectibles are anothergrouping of assets that physicianscommonly own.

Defining Financial Planning

Drs. Dixon and Marshall.

asset. If the cash flow is negative, it’s aliability.

The next thing to be analyzed is cashflow. Physicians generate two kinds ofincome: non-passive and passive. Typi-cally most of their income isnon-passive, that is, they generateincome by treating patients. But theyalso can generate a significant amountof passive income from owning build-ings and renting themout. Both of thesetypes of income cancause a significantnumber of taxableevents in the form ofcapital gains and non-capital gains. “Cashflow can be verycomplicated for aphysician because ofthe multiple streams ofincome that they typi-cally have,” he says.

The last piece to beanalyzed is protection,which comes in manyforms. There ismedical malpracticeinsurance, businessliability insurance, anddisability insurance,the latter of which thegovernment sets limitson the amount. A part-nership agreementwith a buy/sell clauseessentially allows thepartnership to useresources to replace aphysician if he/shebecomes disabled orworse. Legal estate docu-ments, such as wills andtrusts, ensure in the eventof a disability or death it isthe family members, notthe government, that areprovided for.

RecommendationsOnce all of these items areanalyzed, a financialplanner can providerecommendations on howto build one’s wealth. Ifthe physician has trusted

advisors, such as a certified publicaccountant, an insurance broker, or anattorney, they should be included inthis process. If they do not, it wouldbehoove them to work with a financialplanner who has an ongoing relation-ship with these types of advisors, saysLopez.

Often times, physicians talk aboutgrowing their wealth by investing their

money to get abetter rate ofreturn. WhileLopez agreesthat that is anoption, it isnot the onlyone. “Some-times I cansave moremoney bycoming upwith a bettertax reductionstrategy than Ican by puttingmore moneyin the stockmarket, espe-cially today,”he says.

Financial planners look to turn liabili-ties into assets. For example, if aphysician owns five buildings outrightand owns the deeds on five others,raising the rent by five percent shouldcover what the physician is spending tokeep up the owned properties, heexplains. That, in turn, would result ina positive cash flow.

By studying the physician’s businessstructure and possibly changing it, thephysician could save a significantamount of money on taxes over aperiod of years, says Lopez. “Physicians can minimize their taxes bycountering them with the expensesthey have,” he says. In order to do that,they must have a top down view ofwhat they’re worth. “To understandtheir wealth, they have to subtract theirassets and liabilities to determine theirnet worth.”

Upon review, is it not uncommon thatthe liability insurance is determined tobe inadequate, says Lopez, because ithas not been updated over the years.The practice has literally grown out ofits liability insurance. Beefing up theliability insurance enhances one’sprotection.

Many practices do not havepartnership agreements witha buy/sell clause becausethey are complex and timeconsuming to execute, headds. Having this type ofagreement drawn up isanother way to enhanceone’s protection.

“The bottom line of financialplanning is to become awareof your financial position inorder to meet your financialgoals,” concludes Lopez.“There are many ways thatthis can be accomplished. Itcould involve reducing a taxliability, offering a betterportfolio allocation, ensuringthat the proper legal docu-ments are in place, ormaking sure that your protec-tion strategies are sound.”

Recommendations for gener-ating more wealth typicallyrevolve around six phases oflife. They are as follows:protection, education, retire-ment, distribution, long termcare, and legal estate.

“Everyone regardless ofwhether they’re an employeeat the local restaurant or theygenerate a half a milliondollars worth of revenue ayear, will hit these six phasesduring their lives,” saysLopez.

Because the government hastaxable events at each one ofthese, it is imperative to beaware of the phases and havea financial plan to addressthem.

Six Phases of Life

If you enjoyed a defined benefit plan in the past, I wouldventure a guess that your allowance of a maximum annualcontribution has been stifled by recent market variances.

Still, if you are approaching retire-ment and are pecuniary privileged,a defined benefit plan allows you tomake significantly higher contribu-tions as compared to other types ofretirement plans. As an example, themaximum annual target benefit thatcan be funded for the 2009 tax yearis $195,000 whereas the maximum2009 contribution to a solo 401(k)plan is closer to $49,000, dependingon earnings and age.

Defined benefit plans based on atarget account balance at retirementand a target retirement age, whichare carefully worded by law, areprefaced on current balance, conser-vative economic estimates, andyears until retirement.

This type of plan promises a speci-fied monthly benefit at retirement. Itdoes so, by paying out a “target”level of annual benefits from youraccount after you reach the retire-ment age specified in the plan.1

Typically, the benefit is calculatedusing a formula that considers suchfactors as salary and service. Some-times the plan may indicate the benefit as an exact dollaramount per month of retirement. Specifically, the benefitmay be based on a fixed percentage of your average salaryor self-employment income over your entire career withyour practice or over a certain number of years near the endof your working life; a flat monthly dollar amount, or; aformula based on years of service in your practice.1

Candidates for defined benefit plans are individuals who arehighly compensated and have few or no employees. For

example, physicians who cancontribute $80,000 or more annuallyfor at least five years and are in a solopractice employing three staffmembers. Because assets can be accu-mulated over a shorter period of time,individuals who have deferred savingfor retirement can make up for losttime. Of course, the older you are andthe closer to retirement, the larger theannual contribution.

On the down side, if your accountbalance at retirement surpasses yourstated goal, penalties apply and othersin the plan often take preference overyou. However, if you already have aplan, you can amend it (eg, if you sellyour practice, these monies could beapplied to the defined benefit planprovided you retire within sevenyears). In addition, there are otheramendments you can dictate asallowed by law. Of course, adviserscharge for making changes to definedbenefit plans.

Still, they are worth a considerationand you should talk to your advisorabout this venue. Personally, I ambiased as I don’t anticipate a marketrebound for a long time, and see this

as one investment option for those who wish to stay withstocks and bonds.

1 Bischoff B: The Perks of the Solo Defined-Benefit Plan. SmallBiz.August 11, 2005. http://www.smsmallbiz.com/benefits/The_Perks_of-the_Solo_Defined-Benefit_Plan.html (accessed April21, 2009).

Financial Tidbits: The Current Market andDefined Benefit Plansby Robert Schwarze, D.O., FAOCD

According to the Pension

Benefit Guaranty Corpora-

tion, which protects the

benefits in most traditional

defined benefit plans, there

are approximately 30,000

insured defined benefit

plans today, down from

112,000 in the mid 1980s.

One potential reason for this

drastic decline is that they

are administratively

complex and costly to

establish and maintain.

Dermatologist Wanted in Iowa.Can a girl from Brooklyn be happy in the Midwest? Youbetcha!! Come see why I've made Iowa my home.Whether you're just starting out or have years of experi-ence, Cedar Rapids Dermatology may be the place foryou. Cedar Rapids Dermatology provides medical,surgical, and cosmetic dermatology services to residentsliving in the eastern Iowa communities. No HMO quotasor hassles. Practice dermatology the way it should be,the way you want it to be.

The Cedar Rapids-Iowa City corridor has it all. Expansionmagazine gave the area its highest rating for the “quality oflife." Outlook magazine ranks Cedar Rapids #2 in the nationfor overall "quality of life," #1 "safest place to live," and #2for "favorable drive times." Iowa is ranked the nation’s most"livable state." Cedar Rapids has a diversified economy thathas been little affected by the recent economic downturn. Itis home to Quaker Oats, Rockwell Collins, and two majorhospitals. This vibrant city has many unique attractions.

Iowa City, just a 30-minute commute from Cedar Rapids, ishome to the University of Iowa, also known as "Home of theHawkeyes." Iowa City offers the cultural and entertainmentactivities of a much larger city. As a university town, it hasone of the highest educational levels in the country for itspopulation. The children in Iowa schools score, on average,at the 75th percentile nationally on standardized tests, andIowa City children average higher than that.

For more information, please contact Leslie Kramer, D.O., bye-mail at [email protected] or DawnLongwell, Office Administrator, [email protected] or 319 362-3434.

Seeking a general dermatologist to join group inLas Vegas.Desert Dermatology is a comprehensive dermatologypractice providing medical and cosmetic dermatology aswell as Mohs micrographic surgery. In addition, we havea busy, competent aesthetician onsite. We are lookingfor a full- or part-time dermatologist to join us. Mohsand cosmetic experience a plus. We offer a flexibleschedule, either working four ten-hour days with athree-day weekend or alternating two- and four-dayweekends, or five eight-hour days. There also is theoption of early or late hours in this 24-hour town.

Desert Dermatology recently expanded its offices, whichnow include 16 examination rooms with two dedicatedMohs rooms. All rooms are equipped with state-of-the-artequipment. The office is cheerful, comfortable, and visuallymore than pleasant.

Regarding location, the office is well positioned near upscaleSummerlin and Sun City on the west side of Las Vegas. Weare just off the 215.

For more information about this dermatology opportunity,please call Carmen at 702-233-4569 or e-mail her [email protected]. Check out our website at www.Desert-Dermatology.net.

Dermatologists Wanted

We are dedicated to helping patients

attain a healthy and youthful appearance

and self-image.

© 2007 Medicis Pharmaceutical Corporation MED 07-003 01/30/08

Your marketing plan and budgetdictates the actions you will take toachieve your business objectives over apredetermined period of time.

Marketing goals and business goals areoften closely connected. For the sakeof this article, our business goal is toadd an additional 50 patients andsolidify our practice’s brand reputationwithin the community. Our marketingplan will include many of the coremarketing principles discussed in thefirst article of this series entitled “Howto Market Your Practice: Begin with theBasics” published in the Spring 2009issue of DermLine. We will focus prima-rily on activities that will attract newpatients and establish our brand.Further, it is assumed that our practiceis focused on medical dermatologywith minimal cosmetic procedures.

You will find a sample marketingbudget, complete with notes andinsight on page 27. Use it as a refer-ance and starting point when creatingyour own budget.

Our budget will account for threepercent of gross revenue. Four percentis the average for most businesses, sowe are taking a more conservativeapproach. A new practice will investmuch more money in marketing thanan established one. Sometimes astartup business’s marketing budget canbe as much as 25 percent of grossrevenue. Once we know how much wehave to spend, we can go about thebusiness of developing the budgetitems.

An event-driven approach to devel-oping a marketing budget may includecommunity outreach, office presenta-tions, special events, and relatedpromotions. Practice expansion, hiringnew associates, and acquiring newequipment can be promoted as events,as well. The benefit to an event-drivenmodel is the ability to easily trackresults. Simply put, if the event is wellattended, the marketing efforts weresuccessful. If not, the marketing efforts

should be improved before the nextevent. General expenditures, such asyellow pages and magazine advertising,do not typically fit well into an event-driven marketing plan.

Another approach features expendi-tures along a timeline, which istypically one fiscal year. This model ispreferred when quarterly and/ormonthly budgets are essential. Trackingresults can be more difficult within thismodel, but can be done with carefuldata collection. A separate spreadsheetwill be needed to quantify events andspecial promotions for which marketingexpenditures spans multiple months.Marketing initiatives such as televisionand radio campaigns, yellow page list-ings, and billboard advertising are just afew initiatives that can span multiplemonths.

A hybrid budget is often the bestchoice for most small- to mid-sizedcompanies including medical practices.This approach categorizes expendituresbased on events and includes unrelatedand yearly expenditures under separateline items. Tracking event-relatedexpenditures is easy and seeing otherexpenditures is straightforward. Extrap-olating monthly or quarterly budgetswill require additional spreadsheets,additional layers of complication, andtime commitments.

Our fictitious dermatology practice willbe located in sunny central Florida andinclude the following elements in themarketing budget:

• Yellow pages advertising (yearlycontract)

• E-mail newsletter• “Importance of Early Melanoma

Detection” in-office seminars• Free melanoma screening at local

July 4th Festival in the Park• Free melanoma screening at Amer-

ican Cancer Society Relay for Life• Free melanoma screening at city-

sponsored 5k run• Free melanoma screening at city-

sponsored triathlon

• Free Melanoma Screening atNational Surf Contest

• Free melanoma screening at SpringTraining Opening Day

• Search Engine OptimizationConsulting for existing website

• Google Adwords

We will support each melanomascreening and seminar with print andradio advertising. Additionally, ourpractice will receive advertising from allof the event presenters as they promotethe screening as part of their respectiveevents. Our logo will be displayed onevent websites, print advertising, televi-sion ads, and t-shirts. Plus, we willhave display space at the event andeach participant will receive promo-tional literature from our practice. Thisstrategic branding keeps our practicefresh in the minds of participants andcertainly will influence them to chooseour dermatology practice should amelanoma be discovered during a freescreening.

Couple our in-person appearances andsponsorships with targeted yellow pageads, and a revamped website that isdesigned to capture natural searchtraffic and we will easily achieve ourgoal to attract 50 new patients. More-over, our practice will solidify itsbranding and improve name recogni-tion within the community, not tomention build significant good will.

In the next issue of DermLine, we willlook at website designs that driveresults.

Roger Watson is a marketing and e-commerce consultant and owner ofCreative Innovations. He has worked withthe AOCD for more than seven years,designing the website, logos, andDermLine. Roger has vast experience withbrand development, search engine opti-mization, and website design. Learn moreabout his capabilities atwww.2create.com.

Developing a Marketing Plan & Budgetby Roger Watson

Sample Marketing Budget2009 Fiscal Year Projected Gross Income: $685,000 Marketing Investment: $20,550 (3% of Gross Income)

Strategic Item/Line Item Amount Balance

Opening Balance $20,550

Yellow Pages Advertising (yearly) $2,750 $17,800

Search Engine Optimization $3,500 $14,300

E-mail Newsletter Jan-Mar $600 $13,700

Google Adwords Jan-Mar $900 $12,800

Custom Promotional Brochures $900 $11,900

5,000 Full-Color Business Cards $200 $11,700

Relay for Life Sponsorship & Screening $300 $11,400

Spring Training Opening Day $100 $11,300

Q1 Total: $9,250

E-mail Newsletter Apr-Jun $600 $10,700

“Youthful Skin” Radio Advertising $1,600 $9,100

“Youthful Skin” In Office Presentation $100 $9,000

Google Adwords Apr-Jun $600 $8,400

Surf Contest Melanoma Screening $100 $8,300

Q2 Total: $3,000

E-mail Newsletter Jly-Sep $600 $,7,700

“Youthful Skin” Radio Advertising $1,600 $6,100

“Youthful Skin” In Office Presentation $100 $6,000

Google Adwords Jly-Sep $300 $5,700

Citywide 5K Run Melanoma Screening $100 $5,600

Q3 Total: $2,700

E-mail Newsletter Oct-Dec $600 $5,000

Google Adwords Oct-Dec $300 $4,700

Citywide Triathlon Melanoma Screening $200 $4,500

Website Hosting (yearly) $600 $3,900

Misc. Website updates $1,900 $2,000

Misc. Marketing $2,000 $0

Q4 Total: $5,600

Contact your local phonebook publishers to get thedeadlines for payment andcopy.

Mass e-mail should never besent from an office computer.Always use reputable massemail companies. Last year wehired a professional designfirm to handle the design andlayout of the template.

Our office works with one ofour skin care vendors tocreate a presentation about askin care regimen. At thesesessions we educate patientsand the general public on thekey to maintaining youthfulskin. At the end of the pres-entation products areavailable for purchase butthis is not a salespresentation.

If your budget is very smallyou can substitute your timefor money. Offer free skinor melanoma screenings at asmany events and to as manygroups as you can. Staytuned-in to local radio asthat’s where most events areadvertised.

General Notes: We’ve front loaded expenses in the First Quarter because many of these items will be used throughout the year.Bulk printing business cards and brochures result in cost savings. We’ll be using these at appearances and screen-ings all year. Search engine optimization is extremely important and since it takes weeks or months to see goodresults, we have to do it as soon as possible.

Disclaimer: This sample budget can be used to help you get started. The numbers have a root in reality but should not be considered “real world.” Everybudget is different and your expenses may vary widely from those used here. Always consult an experienced marketing professional beforecommitting budget resources to projects or items for which you have little experience. Like most business endeavors, the devil can be in thedetails.

Journal of the American Osteopathic College ofDermatology-JAOCD.

We are now accepting manuscripts for the publicationin the upcoming issue of the JAOCD. ‘Information forAuthors’ is available on our website at www.aocd.org.Any questions may be addressed to the Editor [email protected]. Member and resident member contri-butions are welcome. Keep in mind, the key to havinga successful journal to represent our College is in thehands of each and every member and resident memberof our College. Let’s make it great!

- Jay Gottlieb, D.O., FAOCD

American Osteopathic College of Dermatology1501 E. IllinoisKirksville, MO 63501

PRSRT STD

U.S. POSTAGE PA I D

PERMIT # 1556

ORLANDO, FL

mailto:[email protected]

http://www.aocd.org

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