Procedural Skill – Dermatology

Procedural Skill and Technique Proficiency for Surgery and Other Energy-Based Therapies in Dermatology

Purpose

To enhance high quality patient care and to increase patient safety through a process that identifies and assesses physician proficiency in laser medicine and surgery.

Overview

Proficiency standards in laser medicine and surgery can have a significant impact on the quality of the care delivered by physicians practicing this technique. Proficiency standards can also provide consistency in education and training in this field. It can raise the standards related to quality patient care and patient safety.

Proficiency standards can:

1. Enhance communication between the specialty disciplines that train physicians in laser surgery and other energy based therapies.
2. Require additional expertise and unify the practice of laser treatment among specialties.
3. Enhance the quality of scientific research and presentations and the level of clinical data to further enhance quality patient care and safety.
4. Facilitate granting of hospital and laser clinic privileges, improve management of adverse effects, lower the incidence of complications, and increase patients safety and satisfaction.
5. Ensure that the use of this technology is in the hands of qualified physicians or others under their supervision.
6. Provide a consistent knowledge and skill level across the specialties and will assure those physicians completing formal education and training or completing specified continuing medical education requirements have a level of knowledge and expertise commensurate with the established standards in the field.
7. Increase the quality of patient care.
8. Increase public confidence in laser surgery and other energy based therapies and enhance international standards. The ASLMS working with multiple ABMS Certifying Boards in developing proficiency standards is essential for enhancing patient care and increasing patient safety.
9. Increase professional safety reducing eye injury, fire hazards and other potential risks to the device operators.
   1. Name of Proposed Field
      Technique Proficiency in Laser Medicine and Surgery
   2. Purpose
      To identify physicians who through education and experience have acquired a proficiency in laser surgery and other energy based therapies. Through this proficiency basic minimum standards will be established in this field, which will enhance high quality patient care and increase patient safety.
   3. Need
      The techniques of laser surgery and other energy based therapies have evolved in dermatology similar to the evolution of techniques in other disciplines i.e. procedural skills in colonoscopy as recognized in internal medicine. There exists a growing need to identify an all-inclusive definition of the parameters of the technique and the need to establish basic minimum standards to guide the profession in the delivery of high quality patient care. Establishment of standards will also maximize patient safety and facilitate documenting training and proficiency.
      
      There is a need to establish these standards in ambulatory patient care settings. The public must understand that creation of this proficiency process will promote confidence in the physicians practicing laser medicine and surgery. In addition, adoption of these standards and this template will provide a model for other specialties establishing high quality patient care and patient safety in the use of the laser.
      
      This procedure, while niche oriented, now constitutes a significant portion of treatment modalities in a growing number of specialty areas. These include, but are not limited to the following.
      • Dermatology
      • Plastic and Reconstructive Surgery
      • Urology
      • Obstetrics and Gynecology
      • Oral and Maxillofacial Surgery
      • Ophthalmology
      • Otolaryngology
      • Cardiology
      • Orthopaedic Surgery
      This multi specialty group is producing the majority of scientific papers and clinical data to support the need for standards. From these specialty areas also emerge the opinion leaders, education leaders and leaders in clinical expertise. Specialty technique oriented organizations like the American Society for Laser Medicine and Surgery (ASLMS) are documenting the need for education and experience in this special area. The ASLMS has developed a number of policy positions and statements to further document the needs in this special area and these contributions include the following:
      • Standards of Training for Physicians for the use of lasers in medicine and surgery
      • ASLMS guidelines for office-based laser procedures
      • Standards of perioperative clinical practice in laser medicine and surgery
      • Standards of care
      • Standards of professional performance
   4. Standards of Training
      Proficiency in the techniques of laser medicine and surgery requires that the physician have the prerequisite knowledge and skills needed to treat problems of patients requiring expertise in the modality.
      
      Dermatologists in this area of specialty patient care must show:
      • Knowledge and understanding of anatomy, physiology and pathology.
      • Proficiency in wound healing and repair.
      • Proficiency in understanding basic physics and safety issues relating to the use of lasers.
      • Familiarity with the various modalities of sedation and anesthesia for cutaneous laser therapy.
      • An understanding of and the ability to treat/manage possible complications such as infections, pain, pigmentary changes, poor wound healing, excess swelling and scarring.
      • An understanding of and the ability to identify appropriate clinical indications and contra-indications to laser surgery and other energy based therapies.
      • Proficient in the evaluation and management of treatment options related to laser medicine and surgery such as:
        1. Ablative resurfacing: photodamaged skin, scarring
        2. Non-ablative resurfacing: photodamaged skin, scarring
        3. Benign pigmented lesions
        4. Removal of traumatic, decorative and cosmetic tattoos
        5. Treatment of scars and striae
        6. Removal of excessive or unwanted hair
        7. Photodynamic therapy: actinic keratoses, and skin cancers
        8. Treatment of inflammatory skin diseases including acne and others
        9. Treatment of vascular abnormalities such as port wine stains, hemangiomas and other lesions
   5. Educational programs – Continuing Medical Education and Graduate Medical Education
      The American Society for Laser Medicine and Surgery is the most prominent national society dedicated to developing CME programs and standards in laser medicine and surgery. Accredited by the Accreditation Council for Continuing Medical Education (ACCME) the ASLMS has as a primary mission providing CME for physicians in laser medicine and surgery.
      
      To further the development of CME in lasers the ASLMS is in the process of developing a curriculum that outlines the declarative, procedural and conditional areas of knowledge for laser medicine and surgery. This curriculum covers the following areas:
      • Laser Safety
      • Laser techniques and modalities
      • Laser evaluation and management including indications and contra indications for treatment
      • General laser medicine and surgery topics
      • Research in laser medicine and surgery
      • Evidence-based overview in laser medicine and surgery and other energy based therapies
      Providing education in this variety of areas the ASLMS utilizes a number of education techniques. These include the following:
      • Review courses
      • Hands on workshops
      • Physicians mentoring and proctoring by experienced physicians trained in laser medicine and surgery
      • Self assessment examinations
      • Regional CME courses
      • An Annual Meeting – the world’s largest meeting for physicians in laser medicine and surgery
      • Interactive CME programs on the internet
      The ASLMS is committed to the development of continuing medical education for physicians in laser medicine and surgery. It is also interested in enhancing the experience of physicians internationally.
      
      In Graduate Medical Education the ASLMS is interested in working with the appropriate certifying boards and residency review committees in providing experience and knowledge in enhancing the educational experience of residents at ACGME approved residency programs.
      
      Providing clinical faculty to residency programs, funding the participation of residents at the ASLMS Annual Meeting, recommending training requirements to the residency program where feasible, and developing a mentoring program in cooperation with the residency programs would be included in the GME program.
      
      All of this would be in cooperation with and subject to the approval of the Chairs or Directors of the residency programs.
   6. Physician Qualification for Laser Technique Proficiency
      • Possession of an appropriate medical degree or its equivalent. Candidates must be a Doctor of Medicine (MD) or Doctor of Osteopathy (DO) and complete an ACGME accredited residency in their specialty areas.
      • Must possess primary specialty certification from the American Board of Dermatology.
      • For a specified period of time (five years) there will be a practice category for eligibility. Specific criteria for qualifying under this category will be determined and approved by an independent certifying body. Suggested requirements for this category may include the following:
        1. Completion of at least 150 hours of Category 1 CME including laser safety and physics. At least 20 hours of the 150 hours must entail hands on workshops proctored by an experienced physician in laser medicine and surgery and a minimum of 50 hours in programming approved by the American Society for Laser Medicine and Surgery (ASLMS), American Academy of Dermatology (AAD) or the American Society for Dermatological Surgery (ASDS).
        2. Submission of 100 cases with a minimum of 15 sets of before and after photos or videotapes representative of at least 4 of the 9 management areas.
        3. Mastery of Standards of Training must be demonstrated by obtaining a passing grade on an examination the content of which will be determined by an independent certifying body.
        4. Letters of recommendation attesting to character from at least three practicing physicians in the same specialty.
   7. Requirements for Proficiency
      The following specific requirements are recommended for consideration by an independent certifying body:
      • Must be a diplomat of the American Board of Dermatology and have been actively in the practice of laser medicine and surgery for at least three years post residency.
      • Must have a current, full and unrestricted license to practice medicine in the United States, a United States jurisdiction, or a Canadian province.

Summary Comments

Technique Proficiency in Surgery and Other Energy Based Therapies is an important aspect of high quality care of patients seeking laser medicine and surgery. Advancing the safety and efficacy of laser treatments is a central undertaking of the Specialty Boards and Specialty Societies coordinating the process.

This important process will enhance public confidence and understanding of the specialty and the proficiency standard. The “knowledge bar” must be raised at this time to rebuild the public confidence and provide critical information to the federal, state, and local governmental regulatory agencies overseeing the practice of laser medicine and surgery.