In the 15 years of its existence, dermatology at the KSA has already experienced eventful times. It took 15 years to go from a one-man operation to a training company with eight doctors – good ideas take time!
At the Kantonsspital Aarau (KSA), dermatological problems that could not be solved by hospital physicians themselves were, until the 1980s, either dealt with by a dermatologist in private practice or patients had to be referred to a university hospital center in Zurich, Basel or Bern. For the head of internal medicine at the time, Prof. Dieter Conen, this was an unsatisfactory situation for one of the largest hospitals in Switzerland. Calculations had shown that a potential saving of CHF 700,000 was possible with a separate hospital dermatology department: the canton paid CHF 1.2 million per year for the treatment of patients with dermatological problems outside the canton.
After initial plans for a dermatology department at the KSA were presented to the cantonal government in 1987, it took almost ten years before a positive decision was made by the canton to establish a hospital dermatology department in 1996.
For the establishment of the new department, Prof. Conen enlisted the help of Prof. Theo Rufli, then chief physician of the Dermatological University Clinic Basel. It was hoped that close cooperation with Basel would provide a future-proof basis for meeting the high demands on quality and performance. Administratively, the department was integrated into the Department of Internal Medicine. However, it should function independently, which has been left that way until today.
The tasks of the department have remained essentially the same to this day: In addition to consultations requested by hospital wards, an outpatient clinic evaluates patients referred to the KSA by family physicians and dermatologists in the region. Patients in need of hospitalization with severe skin diseases are admitted to the Internal Medicine ward: An internal medicine resident admits patients and is the first point of contact on the ward. The dermatologist makes daily rounds and monitors dermatologic therapy. Additional internal medicine issues that arise are covered by the internal medicine senior physician.
The Peter Itin era
Dermatology at the KSA opened in December 1997 in House 6, one of the oldest buildings at the KSA. PD Dr. Peter Itin from the University Hospital Basel was appointed chief physician, working 50% in the KSA and 50% in the University Hospital Basel. He was assisted by an assistant physician whose position had already been converted into a senior physician position in 1999. A nurse practitioner and a secretary completed the first dermatology team.
The demand for dermatological evaluation of patients referred by general practitioners proved to be huge: 1640 patients were evaluated in the first year, and by the second year this number had increased to 2350. Due to waiting times of more than three months, two additional senior physician positions were created in 2000 and 2002.
However, the large patient turnover also led to considerable space problems: Because there was no more room available for consultations, even the chief physician’s office was temporarily converted into an outpatient clinic room with four bunks.
The integration of dermatology into a medical clinic was the special attraction of the department: The threshold for a dermatological consultative co-assessment of inpatients was always very low for colleagues from other specialties, and the dermatological opinion was accordingly in demand. Throughout the hospital, the acceptance of the department was very high from the beginning.
Since most patients were referred directly by primary care physicians, many patients presented “unfiltered” with dermatologic problems. Therefore, in the dermatology department of the KSA, one always sees exceptional cases, as they occur in an average population of half a million inhabitants.
Dermatology at the KSA under Markus Streit
After Prof. Peter Itin was elected full professor and clinic director of dermatology at the University Hospital Basel in 2006, Dr. Markus Streit was appointed as his successor, a long-time senior physician in dermatology at the Inselspital Bern with a broad internal medicine curriculum. Markus Streit’s declared goal was to continue building up the department in the spirit of his predecessor.
Sales figures also increased with a new team, with over 10,000 consultations in 2007. After an additional senior physician position had been approved, three dermatological specialists in senior physician positions now ran consultation hours in addition to the chief physician. The “group practice at the hospital” was perfect.
In addition to the normal consultation hours, every specialist also offers his or her own – preferably interdisciplinary – special consultation hours to this day. Such specialty consultations exist for pruritus, hyperhidrosis, complex ulcers, vulvar dermatoses, dermatopediatric problems, and hair and nail disorders. In the offer of allergology, the mastocytosis consultation should be emphasized.
Interdisciplinary collaboration with other specialties is especially important: Monthly case discussions are held with rheumatologists and infectiologists. For the large number of patients with skin tumors, a tumor board has been established in which dermatologists, plastic surgeons, radiation oncologists and oncologists jointly evaluate patients who present. Around 300 patients are assessed annually in this process.
The dermatohistopathological slice preparations – which are prepared by the KSA pathology department – are evaluated in a weekly colloquium together with colleagues from the Basel histopathology department. The clinical-pathological correlation is significant: clinical images are shown for almost all histological preparations.
The further expansion of the department eventually also led to structural measures. After a major renovation, the dermatology department moved into almost all the rooms on the first floor in building 6.
The establishment of dermato-allergology as a separate subdivision
Already under Peter Itin, the increasing number of allergology referrals had led to the creation of a senior physician position, half of which was to be devoted to allergology issues. A wide range of allergological clarifications has been established for patients with suspected drug reactions, possible allergies to inhalant allergens or food. Above all, the large number of patients from Aargau in whom a relevant bee-wasp sting allergy was found led to the introduction of ultra-rush desensitization, which was initially still performed in the intensive care unit of the KSA.
After the number of referrals for an allergology workup continued to increase and even a 50% position was no longer sufficient to handle the task, the hiring of an allergist in a 100% position was considered. In the person of Prof. Jürgen Grabbe – most recently deputy director of the dermatological University Hospital Lübeck – a dermatological allergist was found in 2009 who was a guarantor for the further expansion of allergology at a high level. The range of allergological services was further expanded: Test procedures were standardized and provocations were firmly integrated into the program. Ultra-rush treatment is now carried out in the department under appropriate monitoring. All of these developments were possible because special nurse practitioners were also fully engaged in allergology. The achievements of allergology were recognized and appreciated by the hospital management: in 2012 Jürgen Grabe was promoted to head physician for allergology and allergology definitely became an independent sub-department.
The Dermatology Department at the “KSA am Bahnhof
In 2009, the KSA acquired an entire floor in the new Aarau train station for new use. The renovation of the dermatology department in building 6 had just been completed when the decision of the hospital management became known that the dermatology department was to be located alongside other outpatient clinics in the new branch at the Aarau railroad station. Bad news for dermatology! With the renovation of building 6, space had just been found in the center of the hospital that was adapted to operations, which was so important for interdisciplinary networking and integration into the hospital as a whole.
However, the hospital’s dictum also opened up new perspectives: More jobs and even more space were talked about for the operation at the station, and a technical upgrade with laser equipment was also promised. The fact that the additional three physician positions were planned for assistants turned out to be an advantage: finding graduated specialists for a senior physician position in the hospital has become increasingly difficult in the dried-up job market. In addition, the professional society would like to see training positions for residents created at hospital dermatology departments.
One has gone one step further in Aarau: At the request of the hospital, a position was kept open for medical assistants from the KSA. And after the canton of Aargau planned a family physician curriculum for better training of family physicians, a six-month rotation position in dermatology was created for this purpose. However, in order to have more experienced assistants on the team, a rotation position has been kept open for training assistants from Basel Dermatology since the beginning of 2013. With the new assistant positions, dermatology has evolved from a “group practice at the hospital” to a “training department.”
The planning work for the new building at the station proved to be energy-sapping. The start in the station succeeded thanks to the great effort of the entire department. After more than a year of KSA at the station, the balance sheet is positive: The demand from referring physicians is high. Revenue figures from consultations, new referrals and generated tax points continued to increase strongly. This is despite the fact that the development into a training department has its price: The use of assistants who start from scratch in dermatology requires 1:1 supervision at the beginning. Appropriate time must be allowed for reassignments. For an outpatient clinic that should (also) work on turnover, this is actually an impossibility. The question naturally arises as to whether a patient can be expected to undergo a three-quarter hour nevus check, which must then also be charged according to the time factor. So far, no problems have been encountered with it. Apparently, many patients feel better perceived when they are given more time. This is remarkable in times when people often only pay attention to bare sales figures.
Markus Streit, MD
