Commentary

In May 1987, U2 released “I Still Haven’t Found What I’m Looking For” as a single from their legendary fifth album, The Joshua Tree. The song became their second consecutive #1 hit in the United States to chart on the Billboard Hot 100.1 Here I am, almost 4 decades later, composing an editorial focused on where we are now in dermatology with rosacea. The first thought that came to mind is that U2 was right—and still is—because with rosacea, we still haven’t found what we’re looking for.

In this editorial, I am discussing cutaneous rosacea, not including ocular disease and phymatous changes. The first challenge with cutaneous rosacea is to get the dermatology community on the same page with what the clinical disease state includes, as the individual “dots” that comprise the pathophysiology of rosacea are not similarly connected in each affected patient. This confounds our ability to effectively treat the disease state in many cases, as the clinical manifestations of rosacea are highly variable, reflecting relative contributions from different components of the pathophysiology.^2-5

On top of this challenge, the vast majority of US Food and Drug Administration (FDA)–approved therapies for rosacea have been directed at reducing papules and pustules, which are not present in all patients, and their associated perilesional erythema.^6,7 We have only had topical alpha agonists as FDA-approved therapies for persistent facial erythema, the superficial vascular component of rosacea that is distinct from the papulopustular component and can intensify during flares with flushing episodes. A major limitation of the alpha-agonist topical approach is the short duration of their effects, which last only hours, and the need for consistent application over time, which can be frustrating for patients. Physical modalities such as lights and lasers offer marked assistance, especially for the superficial vascular component, but may be limited by availability, cost, and differences in expertise. Is the above challenging enough? Keep in mind that I still have not addressed the skin barrier aspects of the disease, symptomatology, and patient education challenges.

I don’t want to sound as if dermatology has been defeated, as we have actually been able to provide marked improvement for many patients with rosacea.^6-9 This is especially true in those who present with papules and pustules and also are compliant and patient enough to allow for the integration of the topical and/or physical therapies needed to treat the vascular components including telangiectasias. What has lagged has been the ability to develop a more comprehensive selection of pharmaceutical options, as most have targeted the papulopustular manifestation of the disease. There are many highly effective options in this “papules and pustules of rosacea” space, including topical ivermectin, azelaic acid, and metronidazole, along with the addition of a foam formulation of minocycline, a microencapsulated formulation of benzoyl peroxide, and low-dose oral minocycline. What mostly limits experience with newer FDA-approved therapies is access for patients due to insurance coverage issues and generic substitutions. Overall, the development of newer FDA-approved pharmacologic therapies has become relatively stagnant and remains so at the present time.^6-9

So where are we now? Much of the emphasis on rosacea management has transitioned to alternative areas of consideration, including skin care and barrier dysfunction, the role of vitamins and other nutrients, and use of natural compounds.

An algorithm created by a consensus panel of dermatologists has provided foundational measures recommended for use in all patients with rosacea and rosacea-prone skin, including education, behavioral modifications, recognition and avoidance of triggers, avoidance of skin irritants, preventive skin care, and sun photoprotection measures.¹⁰ The algorithm emphasizes that assessment of an individual’s facial skin condition and grading of cutaneous rosacea are very important at the first visit and continually thereafter during treatment while the preventive measures continue. Individual dermatology panels have published on skin care nuances suggested for specific patient subgroups such as skin of color and Asian and Latino populations.^11-13 While the importance of skin care and skin barrier function in rosacea are well known to the dermatology community, it is essential for clinicians to consistently emphasize this importance to their patients and their staff.

A relatively recent publication has thoroughly addressed the potential roles of vitamins and nutrients in rosacea, discussing both systemic supplementation and topical approaches. A variety of ingredients were evaluated—including vitamin B3, a vitamin A derivative, vitamin C, vitamin D, zinc formulations, and omega-3 fatty acids—demonstrating a range of outcomes.¹⁴ There are data that support the potential of vitamins and nutrients as an adjunctive approach; however, at present, this area holds potential for future advancement without any definitive products or well-established recommendations available. More well-designed studies that are targeted for specific rosacea populations are needed.

A large array of natural compounds, primarily botanicals and phytochemicals, have been discussed in the literature for both short- and long-term management of rosacea.¹⁵ Many cosmeceutical products are gaining public notoriety, as the concept of “natural” is appealing to the lay population due to the assumption that natural implies greater safety, which is not necessarily true. Semenescu et al¹⁵ provided a very comprehensive review of the applicable characteristics of several plant-based agents and potential mechanisms that may be beneficial as adjunctive agents in rosacea. Similar to vitamins and nutrients, there is some scientific basis for the routine integration of natural phytochemicals, but research is needed with well-designed studies used in targeted specific rosacea populations.

Unfortunately, I cannot finish this editorial with ground-breaking news about a new gamechanger approach or product; however, I can tell you that dermatology never gives up. Advances in developing adjunctive therapies and future disease targets such as mast cell activation, microvesicle particles, NLRP3 inflammasome pathway, and Janus kinase inhibition are always in motion, and we continue to try to find what we’re looking for.¹⁶

In May 1987, U2 released “I Still Haven’t Found What I’m Looking For” as a single from their legendary fifth album, The Joshua Tree. The song became their second consecutive #1 hit in the United States to chart on the Billboard Hot 100.1 Here I am, almost 4 decades later, composing an editorial focused on where we are now in dermatology with rosacea. The first thought that came to mind is that U2 was right—and still is—because with rosacea, we still haven’t found what we’re looking for.

In this editorial, I am discussing cutaneous rosacea, not including ocular disease and phymatous changes. The first challenge with cutaneous rosacea is to get the dermatology community on the same page with what the clinical disease state includes, as the individual “dots” that comprise the pathophysiology of rosacea are not similarly connected in each affected patient. This confounds our ability to effectively treat the disease state in many cases, as the clinical manifestations of rosacea are highly variable, reflecting relative contributions from different components of the pathophysiology.^2-5

On top of this challenge, the vast majority of US Food and Drug Administration (FDA)–approved therapies for rosacea have been directed at reducing papules and pustules, which are not present in all patients, and their associated perilesional erythema.^6,7 We have only had topical alpha agonists as FDA-approved therapies for persistent facial erythema, the superficial vascular component of rosacea that is distinct from the papulopustular component and can intensify during flares with flushing episodes. A major limitation of the alpha-agonist topical approach is the short duration of their effects, which last only hours, and the need for consistent application over time, which can be frustrating for patients. Physical modalities such as lights and lasers offer marked assistance, especially for the superficial vascular component, but may be limited by availability, cost, and differences in expertise. Is the above challenging enough? Keep in mind that I still have not addressed the skin barrier aspects of the disease, symptomatology, and patient education challenges.

I don’t want to sound as if dermatology has been defeated, as we have actually been able to provide marked improvement for many patients with rosacea.^6-9 This is especially true in those who present with papules and pustules and also are compliant and patient enough to allow for the integration of the topical and/or physical therapies needed to treat the vascular components including telangiectasias. What has lagged has been the ability to develop a more comprehensive selection of pharmaceutical options, as most have targeted the papulopustular manifestation of the disease. There are many highly effective options in this “papules and pustules of rosacea” space, including topical ivermectin, azelaic acid, and metronidazole, along with the addition of a foam formulation of minocycline, a microencapsulated formulation of benzoyl peroxide, and low-dose oral minocycline. What mostly limits experience with newer FDA-approved therapies is access for patients due to insurance coverage issues and generic substitutions. Overall, the development of newer FDA-approved pharmacologic therapies has become relatively stagnant and remains so at the present time.^6-9

So where are we now? Much of the emphasis on rosacea management has transitioned to alternative areas of consideration, including skin care and barrier dysfunction, the role of vitamins and other nutrients, and use of natural compounds.

An algorithm created by a consensus panel of dermatologists has provided foundational measures recommended for use in all patients with rosacea and rosacea-prone skin, including education, behavioral modifications, recognition and avoidance of triggers, avoidance of skin irritants, preventive skin care, and sun photoprotection measures.¹⁰ The algorithm emphasizes that assessment of an individual’s facial skin condition and grading of cutaneous rosacea are very important at the first visit and continually thereafter during treatment while the preventive measures continue. Individual dermatology panels have published on skin care nuances suggested for specific patient subgroups such as skin of color and Asian and Latino populations.^11-13 While the importance of skin care and skin barrier function in rosacea are well known to the dermatology community, it is essential for clinicians to consistently emphasize this importance to their patients and their staff.

A relatively recent publication has thoroughly addressed the potential roles of vitamins and nutrients in rosacea, discussing both systemic supplementation and topical approaches. A variety of ingredients were evaluated—including vitamin B3, a vitamin A derivative, vitamin C, vitamin D, zinc formulations, and omega-3 fatty acids—demonstrating a range of outcomes.¹⁴ There are data that support the potential of vitamins and nutrients as an adjunctive approach; however, at present, this area holds potential for future advancement without any definitive products or well-established recommendations available. More well-designed studies that are targeted for specific rosacea populations are needed.

A large array of natural compounds, primarily botanicals and phytochemicals, have been discussed in the literature for both short- and long-term management of rosacea.¹⁵ Many cosmeceutical products are gaining public notoriety, as the concept of “natural” is appealing to the lay population due to the assumption that natural implies greater safety, which is not necessarily true. Semenescu et al¹⁵ provided a very comprehensive review of the applicable characteristics of several plant-based agents and potential mechanisms that may be beneficial as adjunctive agents in rosacea. Similar to vitamins and nutrients, there is some scientific basis for the routine integration of natural phytochemicals, but research is needed with well-designed studies used in targeted specific rosacea populations.

Unfortunately, I cannot finish this editorial with ground-breaking news about a new gamechanger approach or product; however, I can tell you that dermatology never gives up. Advances in developing adjunctive therapies and future disease targets such as mast cell activation, microvesicle particles, NLRP3 inflammasome pathway, and Janus kinase inhibition are always in motion, and we continue to try to find what we’re looking for.¹⁶

In May 1987, U2 released “I Still Haven’t Found What I’m Looking For” as a single from their legendary fifth album, The Joshua Tree. The song became their second consecutive #1 hit in the United States to chart on the Billboard Hot 100.1 Here I am, almost 4 decades later, composing an editorial focused on where we are now in dermatology with rosacea. The first thought that came to mind is that U2 was right—and still is—because with rosacea, we still haven’t found what we’re looking for.

In this editorial, I am discussing cutaneous rosacea, not including ocular disease and phymatous changes. The first challenge with cutaneous rosacea is to get the dermatology community on the same page with what the clinical disease state includes, as the individual “dots” that comprise the pathophysiology of rosacea are not similarly connected in each affected patient. This confounds our ability to effectively treat the disease state in many cases, as the clinical manifestations of rosacea are highly variable, reflecting relative contributions from different components of the pathophysiology.^2-5

On top of this challenge, the vast majority of US Food and Drug Administration (FDA)–approved therapies for rosacea have been directed at reducing papules and pustules, which are not present in all patients, and their associated perilesional erythema.^6,7 We have only had topical alpha agonists as FDA-approved therapies for persistent facial erythema, the superficial vascular component of rosacea that is distinct from the papulopustular component and can intensify during flares with flushing episodes. A major limitation of the alpha-agonist topical approach is the short duration of their effects, which last only hours, and the need for consistent application over time, which can be frustrating for patients. Physical modalities such as lights and lasers offer marked assistance, especially for the superficial vascular component, but may be limited by availability, cost, and differences in expertise. Is the above challenging enough? Keep in mind that I still have not addressed the skin barrier aspects of the disease, symptomatology, and patient education challenges.

I don’t want to sound as if dermatology has been defeated, as we have actually been able to provide marked improvement for many patients with rosacea.^6-9 This is especially true in those who present with papules and pustules and also are compliant and patient enough to allow for the integration of the topical and/or physical therapies needed to treat the vascular components including telangiectasias. What has lagged has been the ability to develop a more comprehensive selection of pharmaceutical options, as most have targeted the papulopustular manifestation of the disease. There are many highly effective options in this “papules and pustules of rosacea” space, including topical ivermectin, azelaic acid, and metronidazole, along with the addition of a foam formulation of minocycline, a microencapsulated formulation of benzoyl peroxide, and low-dose oral minocycline. What mostly limits experience with newer FDA-approved therapies is access for patients due to insurance coverage issues and generic substitutions. Overall, the development of newer FDA-approved pharmacologic therapies has become relatively stagnant and remains so at the present time.^6-9

So where are we now? Much of the emphasis on rosacea management has transitioned to alternative areas of consideration, including skin care and barrier dysfunction, the role of vitamins and other nutrients, and use of natural compounds.

An algorithm created by a consensus panel of dermatologists has provided foundational measures recommended for use in all patients with rosacea and rosacea-prone skin, including education, behavioral modifications, recognition and avoidance of triggers, avoidance of skin irritants, preventive skin care, and sun photoprotection measures.¹⁰ The algorithm emphasizes that assessment of an individual’s facial skin condition and grading of cutaneous rosacea are very important at the first visit and continually thereafter during treatment while the preventive measures continue. Individual dermatology panels have published on skin care nuances suggested for specific patient subgroups such as skin of color and Asian and Latino populations.^11-13 While the importance of skin care and skin barrier function in rosacea are well known to the dermatology community, it is essential for clinicians to consistently emphasize this importance to their patients and their staff.

A relatively recent publication has thoroughly addressed the potential roles of vitamins and nutrients in rosacea, discussing both systemic supplementation and topical approaches. A variety of ingredients were evaluated—including vitamin B3, a vitamin A derivative, vitamin C, vitamin D, zinc formulations, and omega-3 fatty acids—demonstrating a range of outcomes.¹⁴ There are data that support the potential of vitamins and nutrients as an adjunctive approach; however, at present, this area holds potential for future advancement without any definitive products or well-established recommendations available. More well-designed studies that are targeted for specific rosacea populations are needed.

A large array of natural compounds, primarily botanicals and phytochemicals, have been discussed in the literature for both short- and long-term management of rosacea.¹⁵ Many cosmeceutical products are gaining public notoriety, as the concept of “natural” is appealing to the lay population due to the assumption that natural implies greater safety, which is not necessarily true. Semenescu et al¹⁵ provided a very comprehensive review of the applicable characteristics of several plant-based agents and potential mechanisms that may be beneficial as adjunctive agents in rosacea. Similar to vitamins and nutrients, there is some scientific basis for the routine integration of natural phytochemicals, but research is needed with well-designed studies used in targeted specific rosacea populations.

Unfortunately, I cannot finish this editorial with ground-breaking news about a new gamechanger approach or product; however, I can tell you that dermatology never gives up. Advances in developing adjunctive therapies and future disease targets such as mast cell activation, microvesicle particles, NLRP3 inflammasome pathway, and Janus kinase inhibition are always in motion, and we continue to try to find what we’re looking for.¹⁶

Effective staffing is central to delivering high-quality, efficient dermatologic care. In the current landscape of American medicine, dermatologists manage complex medical conditions, perform surgical procedures, and in some cases expand into elective aesthetic services. The ability to offer advanced clinical services is dependent on the performance of those who operate equipment and sustain daily operations.

The “perfect” hire is therefore not a luxury but a necessity for practice survival: with shrinking reimbursements and rising administrative burden, staff capability influences clinic efficiency, medicolegal risk, and patient experience and outcomes. A dysfunctional team can contribute to physician burnout, whereas a high‑functioning one enables dermatologists to practice at the top of their license by focusing on diagnosis and complex interventions while the office functions efficiently. In this article, we examine the anatomy of modern dermatology hiring and highlight the benefits of shifting from reactive staffing to proactive talent acquisition.

PHASE 1: THE PHILOSOPHY OF THE DERMATOLOGY-SPECIFIC PROFILE

Before drafting a job description, it is important to have an idea of what the ideal candidate embodies. A medical assistant in a high-volume Mohs surgery suite requires a vastly different temperament and skill set than an aesthetic coordinator in a boutique cosmetic practice. Here are some factors to consider when approaching your ideal hire.

The Hybridity of the Specialty

Dermatology is unique in that the same patient can be treated for a life-threatening melanoma and a bothersome wrinkle within the same afternoon. This requires staff who can pivot emotionally and technically. When looking for a new employee, prioritize the 4 pillars of the ideal dermatology assistant: clinical competency, a hospitality mindset, digital agility, and a “get it done” mindset.

Clinical Competency—A basic understanding of skin anatomy and common pathologies is vital, even for nonclinical roles. A front-desk employee who understands the urgency of a changing mole in a patient with melanoma vs a new acne cyst is a vital triage asset.

Hospitality Mindset—When operating a dermatology clinic with offerings in the elective space (ie, aesthetics), be aware that patients increasingly are viewing themselves as consumers in these spaces. Dermatologists should look for candidates who have experience in high-end service industries such as retail, hospitality, or concierge services. These individuals understand that the patient experience begins in the parking lot and ends with the follow-up call.

Digital Agility—We are in the midst of a technological revolution. Between AI-driven diagnostic assistance, teledermatology platforms, and integrated electronic medical record/billing systems, the modern employee has to be more than just computer literate—they must be digitally native (eg, able to troubleshoot a tablet-based consent form or explain a patient portal with ease).

“Get It Done” Mindset—In a fast-paced dermatology clinic, it is important to find someone who looks for work instead of waiting for orders; otherwise, you might find yourself spending more time directing your employees than getting your actual work done.

The Culture Fit vs Culture Add

Traditionally, practices have prioritized hiring for “culture fit”—that is, looking for individuals who think and behave like existing staff. Contemporary management theory, however, favors hiring for “culture add,” recruiting candidates who contribute perspectives and skills absent from the current team. For practices expanding into aesthetics or focusing on a specific aspect of dermatology, the practice needs employees who bring perspectives it lacks. Perhaps the candidate has a background in hospitality, or they are involved in community health initiatives. These “adds” broaden the practice’s reach and depth.

PHASE 2: THE STRATEGIC RECRUITMENT PROCESS

The days of putting up “Help Wanted” signs are over. To find elite talent, dermatologists must treat recruitment like a diagnostic workup: thorough, methodical, and evidence based. Follow these steps for a thoughtful progression in finding the right candidate for your practice.

Step 1: Crafting a Magnetic Job Description

Most job postings read like a dry list of tasks: Take vitals, room patients, call in prescriptions. These descriptions attract clock-punchers. To attract careerists, the vision must be sold. An effective job description should include 2 main components: the vision statement and the growth path.

The Vision Statement—Start by stating your practice’s mission. If you’re focused on building a practice that values concierge-style care with long visit times, say so: “Join a team dedicated to patient care, slowing down, and personalized services.”

The Growth Path—High-quality candidates want to focus on their career trajectory. During the interview, mention opportunities for laser certification, scribe training, or management tracks. For those on a path toward higher education, describe the breadth of clinical training and experience.

Step 2: The Tiered Interview Protocol

We recommend a 3-tiered approach to the interview process to ensure multiple data points are collected before an offer is made: a behavior screen, a “shadow day,” and a “no doctor” zone.

Tier 1: The Behavioral Screen (Remote)—Conduct a 20-minute video call focused purely on soft skills using questions from the STAR method (Situation, Task, Action, Result). For example, ask something like, “Tell me about a time you may have faced an unsatisfied client. How did you de-escalate the situation?” Pay attention to whether the candidate takes responsibility or places blame.

Tier 2: The Shadow Day (Working Interview)—This can be an important part of the hiring process. We recommend inviting top candidates for a paid half- or full-day trial to assess how they perform in a real-world clinical setting. For medical assistant candidates, evaluate their ability to remain task focused and efficient and observe how they handle situations such as the sight of blood or interactions with needle-phobic patients. For front-desk candidates, pay attention to how they prioritize competing responsibilities and their openness to learning and feedback. For all positions, observing interactions with both patients and team members can provide valuable insight into professionalism, communication skills, and overall fit within the practice.

Tier 3: The “No-Doctor” Zone (Optional)—Leave the candidate alone with the current staff, if only for a few minutes. This allows the employer to gauge not only the candidate’s behavior with a senior member of staff but also with other members of the team, allowing for demonstration of character. Ask the team to assess if this is someone they would want to spend a workday with. If the staff says no, that may affect your choice of hire as well.  

PHASE 3: THE OFFER AND THE LEGAL GUARDRAILS

After finding the unicorn candidate, the closing process must be professional and legally sound. Here are the steps we have found most helpful to take once a decision for a hire is made.

The Offer Letter as a Blueprint

An offer letter is more than a salary statement; it is a document of expectations. It should include the following components:

• Clear Compensation Structure: Base pay plus any performance-based incentives (eg, bonuses for retail skin care sales or conversion rates on cosmetic consultations).
• Specific Benefit Clauses: Paid time off, benefits such as health insurance and 401(k) matching if you are offering, and professional perks such as discounted treatments or skin care stipends.
• At-Will Statement: Ensure your legal counsel has reviewed your at-will employment clauses to protect the practice. This allows the employer to terminate an employee without legal liability and conversely gives the employee flexibility to leave the position if it does not fit their needs.
• Employee Manual: Once formally hired, make sure you have an employee handbook with your expectations and regulations—ranging from dress code and safety regulations to paid time off—clearly written. Be more specific than you think is necessary, which will prevent potential discrepancies down the road.  

Onboarding: The First 90 Days

The first 90 days of employment are the most volatile. Statistics show that the majority of staff turnover happens in this window.¹ To mitigate this, use the following 90-day success map:

• The Immersion Period (Days 1-30): The new hire should not be expected to produce. They are there to learn the culture of the clinic: the protocols for rooming, the vernacular for explaining procedures, and the standards for documentation.
• The Guided Execution Period (Days 31-60): They begin performing tasks under the direct supervision of a senior lead.
• The Independent Integration Period (Days 61-90): They take on a full load, with weekly check-ins to address friction points.

PHASE 4: RETENTION THROUGH ­PROFESSIONAL DEVELOPMENT

In dermatology practices, staff members frequently are approached by competitors, medical spas, and industry representatives to work for them. Retention is not just about the paycheck; it’s about the “professional home.” Staff members want to feel valued and have a responsible role in the workplace.

As dermatologists, we often are seen as the captain of the ship; however, the most successful practices operate as high-reliability organizations. In this type of practice, everyone from the janitorial staff to the senior associate is encouraged to speak up if there is a safety issue or an efficiency gap. Here are some techniques to foster this culture.

The Weekly Huddle—For practices that are just starting to expand, this is a great way to make sure that friction points and difficulties are addressed before becoming a larger issue. Gathering the staff for just 15 minutes in the morning before clinic begins can be a great way to address housekeeping issues, encourage staff to speak up about problems they may have identified, and provide a chance for everyone to feel heard.

The Educational Bend—Encourage staff to grow their wealth of knowledge, whether from industry-sponsored educational product events to formal certifications. A front desk assistant who then moves on to get their advanced degree may return to the practice as a nurse and become a valuable partner and asset. 

PHASE 5: LOOKING TOWARD THE FUTURE

As we look toward 2027 and beyond, the employee of the future may not be entirely human. We already are seeing the integration of AI scribes and automated billing auditors. Practices should look for candidates who aren’t afraid of AI but are excited by it. A medical assistant who can oversee an AI scribe while still maintaining eye contact and holding a patient’s hand during a painful injection is the gold standard.

Final Thoughts

Our medical school training prepares us for the “what” of dermatology, but it rarely prepares us for the “who.” As practice managers, we are thrust into the role of CEO, human resources director, and culture architect without a formal syllabus. By applying the same clinical rigor to the hiring process that we do to a complex diagnostic case, we can build teams that don’t just work for us but build with us. The goal is a practice where the physician can focus on the art and science of the skin, confident that every other aspect of the patient journey is being handled by a team that is as dedicated, ethical, and clinical as they are. Hiring is one of the most difficult procedures you will likely perform in your practice; it also is the one with the highest long-term success rate if performed with thoughtfulness, precision, and above all, kindness.

Effective staffing is central to delivering high-quality, efficient dermatologic care. In the current landscape of American medicine, dermatologists manage complex medical conditions, perform surgical procedures, and in some cases expand into elective aesthetic services. The ability to offer advanced clinical services is dependent on the performance of those who operate equipment and sustain daily operations.

The “perfect” hire is therefore not a luxury but a necessity for practice survival: with shrinking reimbursements and rising administrative burden, staff capability influences clinic efficiency, medicolegal risk, and patient experience and outcomes. A dysfunctional team can contribute to physician burnout, whereas a high‑functioning one enables dermatologists to practice at the top of their license by focusing on diagnosis and complex interventions while the office functions efficiently. In this article, we examine the anatomy of modern dermatology hiring and highlight the benefits of shifting from reactive staffing to proactive talent acquisition.

PHASE 1: THE PHILOSOPHY OF THE DERMATOLOGY-SPECIFIC PROFILE

Before drafting a job description, it is important to have an idea of what the ideal candidate embodies. A medical assistant in a high-volume Mohs surgery suite requires a vastly different temperament and skill set than an aesthetic coordinator in a boutique cosmetic practice. Here are some factors to consider when approaching your ideal hire.

The Hybridity of the Specialty

Dermatology is unique in that the same patient can be treated for a life-threatening melanoma and a bothersome wrinkle within the same afternoon. This requires staff who can pivot emotionally and technically. When looking for a new employee, prioritize the 4 pillars of the ideal dermatology assistant: clinical competency, a hospitality mindset, digital agility, and a “get it done” mindset.

Clinical Competency—A basic understanding of skin anatomy and common pathologies is vital, even for nonclinical roles. A front-desk employee who understands the urgency of a changing mole in a patient with melanoma vs a new acne cyst is a vital triage asset.

Hospitality Mindset—When operating a dermatology clinic with offerings in the elective space (ie, aesthetics), be aware that patients increasingly are viewing themselves as consumers in these spaces. Dermatologists should look for candidates who have experience in high-end service industries such as retail, hospitality, or concierge services. These individuals understand that the patient experience begins in the parking lot and ends with the follow-up call.

Digital Agility—We are in the midst of a technological revolution. Between AI-driven diagnostic assistance, teledermatology platforms, and integrated electronic medical record/billing systems, the modern employee has to be more than just computer literate—they must be digitally native (eg, able to troubleshoot a tablet-based consent form or explain a patient portal with ease).

“Get It Done” Mindset—In a fast-paced dermatology clinic, it is important to find someone who looks for work instead of waiting for orders; otherwise, you might find yourself spending more time directing your employees than getting your actual work done.

The Culture Fit vs Culture Add

Traditionally, practices have prioritized hiring for “culture fit”—that is, looking for individuals who think and behave like existing staff. Contemporary management theory, however, favors hiring for “culture add,” recruiting candidates who contribute perspectives and skills absent from the current team. For practices expanding into aesthetics or focusing on a specific aspect of dermatology, the practice needs employees who bring perspectives it lacks. Perhaps the candidate has a background in hospitality, or they are involved in community health initiatives. These “adds” broaden the practice’s reach and depth.

PHASE 2: THE STRATEGIC RECRUITMENT PROCESS

The days of putting up “Help Wanted” signs are over. To find elite talent, dermatologists must treat recruitment like a diagnostic workup: thorough, methodical, and evidence based. Follow these steps for a thoughtful progression in finding the right candidate for your practice.

Step 1: Crafting a Magnetic Job Description

Most job postings read like a dry list of tasks: Take vitals, room patients, call in prescriptions. These descriptions attract clock-punchers. To attract careerists, the vision must be sold. An effective job description should include 2 main components: the vision statement and the growth path.

The Vision Statement—Start by stating your practice’s mission. If you’re focused on building a practice that values concierge-style care with long visit times, say so: “Join a team dedicated to patient care, slowing down, and personalized services.”

The Growth Path—High-quality candidates want to focus on their career trajectory. During the interview, mention opportunities for laser certification, scribe training, or management tracks. For those on a path toward higher education, describe the breadth of clinical training and experience.

Step 2: The Tiered Interview Protocol

We recommend a 3-tiered approach to the interview process to ensure multiple data points are collected before an offer is made: a behavior screen, a “shadow day,” and a “no doctor” zone.

Tier 1: The Behavioral Screen (Remote)—Conduct a 20-minute video call focused purely on soft skills using questions from the STAR method (Situation, Task, Action, Result). For example, ask something like, “Tell me about a time you may have faced an unsatisfied client. How did you de-escalate the situation?” Pay attention to whether the candidate takes responsibility or places blame.

Tier 2: The Shadow Day (Working Interview)—This can be an important part of the hiring process. We recommend inviting top candidates for a paid half- or full-day trial to assess how they perform in a real-world clinical setting. For medical assistant candidates, evaluate their ability to remain task focused and efficient and observe how they handle situations such as the sight of blood or interactions with needle-phobic patients. For front-desk candidates, pay attention to how they prioritize competing responsibilities and their openness to learning and feedback. For all positions, observing interactions with both patients and team members can provide valuable insight into professionalism, communication skills, and overall fit within the practice.

Tier 3: The “No-Doctor” Zone (Optional)—Leave the candidate alone with the current staff, if only for a few minutes. This allows the employer to gauge not only the candidate’s behavior with a senior member of staff but also with other members of the team, allowing for demonstration of character. Ask the team to assess if this is someone they would want to spend a workday with. If the staff says no, that may affect your choice of hire as well.  

PHASE 3: THE OFFER AND THE LEGAL GUARDRAILS

After finding the unicorn candidate, the closing process must be professional and legally sound. Here are the steps we have found most helpful to take once a decision for a hire is made.

The Offer Letter as a Blueprint

An offer letter is more than a salary statement; it is a document of expectations. It should include the following components:

• Clear Compensation Structure: Base pay plus any performance-based incentives (eg, bonuses for retail skin care sales or conversion rates on cosmetic consultations).
• Specific Benefit Clauses: Paid time off, benefits such as health insurance and 401(k) matching if you are offering, and professional perks such as discounted treatments or skin care stipends.
• At-Will Statement: Ensure your legal counsel has reviewed your at-will employment clauses to protect the practice. This allows the employer to terminate an employee without legal liability and conversely gives the employee flexibility to leave the position if it does not fit their needs.
• Employee Manual: Once formally hired, make sure you have an employee handbook with your expectations and regulations—ranging from dress code and safety regulations to paid time off—clearly written. Be more specific than you think is necessary, which will prevent potential discrepancies down the road.  

Onboarding: The First 90 Days

The first 90 days of employment are the most volatile. Statistics show that the majority of staff turnover happens in this window.¹ To mitigate this, use the following 90-day success map:

• The Immersion Period (Days 1-30): The new hire should not be expected to produce. They are there to learn the culture of the clinic: the protocols for rooming, the vernacular for explaining procedures, and the standards for documentation.
• The Guided Execution Period (Days 31-60): They begin performing tasks under the direct supervision of a senior lead.
• The Independent Integration Period (Days 61-90): They take on a full load, with weekly check-ins to address friction points.

PHASE 4: RETENTION THROUGH ­PROFESSIONAL DEVELOPMENT

In dermatology practices, staff members frequently are approached by competitors, medical spas, and industry representatives to work for them. Retention is not just about the paycheck; it’s about the “professional home.” Staff members want to feel valued and have a responsible role in the workplace.

As dermatologists, we often are seen as the captain of the ship; however, the most successful practices operate as high-reliability organizations. In this type of practice, everyone from the janitorial staff to the senior associate is encouraged to speak up if there is a safety issue or an efficiency gap. Here are some techniques to foster this culture.

The Weekly Huddle—For practices that are just starting to expand, this is a great way to make sure that friction points and difficulties are addressed before becoming a larger issue. Gathering the staff for just 15 minutes in the morning before clinic begins can be a great way to address housekeeping issues, encourage staff to speak up about problems they may have identified, and provide a chance for everyone to feel heard.

The Educational Bend—Encourage staff to grow their wealth of knowledge, whether from industry-sponsored educational product events to formal certifications. A front desk assistant who then moves on to get their advanced degree may return to the practice as a nurse and become a valuable partner and asset. 

PHASE 5: LOOKING TOWARD THE FUTURE

As we look toward 2027 and beyond, the employee of the future may not be entirely human. We already are seeing the integration of AI scribes and automated billing auditors. Practices should look for candidates who aren’t afraid of AI but are excited by it. A medical assistant who can oversee an AI scribe while still maintaining eye contact and holding a patient’s hand during a painful injection is the gold standard.

Final Thoughts

Our medical school training prepares us for the “what” of dermatology, but it rarely prepares us for the “who.” As practice managers, we are thrust into the role of CEO, human resources director, and culture architect without a formal syllabus. By applying the same clinical rigor to the hiring process that we do to a complex diagnostic case, we can build teams that don’t just work for us but build with us. The goal is a practice where the physician can focus on the art and science of the skin, confident that every other aspect of the patient journey is being handled by a team that is as dedicated, ethical, and clinical as they are. Hiring is one of the most difficult procedures you will likely perform in your practice; it also is the one with the highest long-term success rate if performed with thoughtfulness, precision, and above all, kindness.

Effective staffing is central to delivering high-quality, efficient dermatologic care. In the current landscape of American medicine, dermatologists manage complex medical conditions, perform surgical procedures, and in some cases expand into elective aesthetic services. The ability to offer advanced clinical services is dependent on the performance of those who operate equipment and sustain daily operations.

The “perfect” hire is therefore not a luxury but a necessity for practice survival: with shrinking reimbursements and rising administrative burden, staff capability influences clinic efficiency, medicolegal risk, and patient experience and outcomes. A dysfunctional team can contribute to physician burnout, whereas a high‑functioning one enables dermatologists to practice at the top of their license by focusing on diagnosis and complex interventions while the office functions efficiently. In this article, we examine the anatomy of modern dermatology hiring and highlight the benefits of shifting from reactive staffing to proactive talent acquisition.

PHASE 1: THE PHILOSOPHY OF THE DERMATOLOGY-SPECIFIC PROFILE

Before drafting a job description, it is important to have an idea of what the ideal candidate embodies. A medical assistant in a high-volume Mohs surgery suite requires a vastly different temperament and skill set than an aesthetic coordinator in a boutique cosmetic practice. Here are some factors to consider when approaching your ideal hire.

The Hybridity of the Specialty

Dermatology is unique in that the same patient can be treated for a life-threatening melanoma and a bothersome wrinkle within the same afternoon. This requires staff who can pivot emotionally and technically. When looking for a new employee, prioritize the 4 pillars of the ideal dermatology assistant: clinical competency, a hospitality mindset, digital agility, and a “get it done” mindset.

Clinical Competency—A basic understanding of skin anatomy and common pathologies is vital, even for nonclinical roles. A front-desk employee who understands the urgency of a changing mole in a patient with melanoma vs a new acne cyst is a vital triage asset.

Hospitality Mindset—When operating a dermatology clinic with offerings in the elective space (ie, aesthetics), be aware that patients increasingly are viewing themselves as consumers in these spaces. Dermatologists should look for candidates who have experience in high-end service industries such as retail, hospitality, or concierge services. These individuals understand that the patient experience begins in the parking lot and ends with the follow-up call.

Digital Agility—We are in the midst of a technological revolution. Between AI-driven diagnostic assistance, teledermatology platforms, and integrated electronic medical record/billing systems, the modern employee has to be more than just computer literate—they must be digitally native (eg, able to troubleshoot a tablet-based consent form or explain a patient portal with ease).

“Get It Done” Mindset—In a fast-paced dermatology clinic, it is important to find someone who looks for work instead of waiting for orders; otherwise, you might find yourself spending more time directing your employees than getting your actual work done.

The Culture Fit vs Culture Add

Traditionally, practices have prioritized hiring for “culture fit”—that is, looking for individuals who think and behave like existing staff. Contemporary management theory, however, favors hiring for “culture add,” recruiting candidates who contribute perspectives and skills absent from the current team. For practices expanding into aesthetics or focusing on a specific aspect of dermatology, the practice needs employees who bring perspectives it lacks. Perhaps the candidate has a background in hospitality, or they are involved in community health initiatives. These “adds” broaden the practice’s reach and depth.

PHASE 2: THE STRATEGIC RECRUITMENT PROCESS

The days of putting up “Help Wanted” signs are over. To find elite talent, dermatologists must treat recruitment like a diagnostic workup: thorough, methodical, and evidence based. Follow these steps for a thoughtful progression in finding the right candidate for your practice.

Step 1: Crafting a Magnetic Job Description

Most job postings read like a dry list of tasks: Take vitals, room patients, call in prescriptions. These descriptions attract clock-punchers. To attract careerists, the vision must be sold. An effective job description should include 2 main components: the vision statement and the growth path.

The Vision Statement—Start by stating your practice’s mission. If you’re focused on building a practice that values concierge-style care with long visit times, say so: “Join a team dedicated to patient care, slowing down, and personalized services.”

The Growth Path—High-quality candidates want to focus on their career trajectory. During the interview, mention opportunities for laser certification, scribe training, or management tracks. For those on a path toward higher education, describe the breadth of clinical training and experience.

Step 2: The Tiered Interview Protocol

We recommend a 3-tiered approach to the interview process to ensure multiple data points are collected before an offer is made: a behavior screen, a “shadow day,” and a “no doctor” zone.

Tier 1: The Behavioral Screen (Remote)—Conduct a 20-minute video call focused purely on soft skills using questions from the STAR method (Situation, Task, Action, Result). For example, ask something like, “Tell me about a time you may have faced an unsatisfied client. How did you de-escalate the situation?” Pay attention to whether the candidate takes responsibility or places blame.

Tier 2: The Shadow Day (Working Interview)—This can be an important part of the hiring process. We recommend inviting top candidates for a paid half- or full-day trial to assess how they perform in a real-world clinical setting. For medical assistant candidates, evaluate their ability to remain task focused and efficient and observe how they handle situations such as the sight of blood or interactions with needle-phobic patients. For front-desk candidates, pay attention to how they prioritize competing responsibilities and their openness to learning and feedback. For all positions, observing interactions with both patients and team members can provide valuable insight into professionalism, communication skills, and overall fit within the practice.

Tier 3: The “No-Doctor” Zone (Optional)—Leave the candidate alone with the current staff, if only for a few minutes. This allows the employer to gauge not only the candidate’s behavior with a senior member of staff but also with other members of the team, allowing for demonstration of character. Ask the team to assess if this is someone they would want to spend a workday with. If the staff says no, that may affect your choice of hire as well.  

PHASE 3: THE OFFER AND THE LEGAL GUARDRAILS

After finding the unicorn candidate, the closing process must be professional and legally sound. Here are the steps we have found most helpful to take once a decision for a hire is made.

The Offer Letter as a Blueprint

An offer letter is more than a salary statement; it is a document of expectations. It should include the following components:

• Clear Compensation Structure: Base pay plus any performance-based incentives (eg, bonuses for retail skin care sales or conversion rates on cosmetic consultations).
• Specific Benefit Clauses: Paid time off, benefits such as health insurance and 401(k) matching if you are offering, and professional perks such as discounted treatments or skin care stipends.
• At-Will Statement: Ensure your legal counsel has reviewed your at-will employment clauses to protect the practice. This allows the employer to terminate an employee without legal liability and conversely gives the employee flexibility to leave the position if it does not fit their needs.
• Employee Manual: Once formally hired, make sure you have an employee handbook with your expectations and regulations—ranging from dress code and safety regulations to paid time off—clearly written. Be more specific than you think is necessary, which will prevent potential discrepancies down the road.  

Onboarding: The First 90 Days

The first 90 days of employment are the most volatile. Statistics show that the majority of staff turnover happens in this window.¹ To mitigate this, use the following 90-day success map:

• The Immersion Period (Days 1-30): The new hire should not be expected to produce. They are there to learn the culture of the clinic: the protocols for rooming, the vernacular for explaining procedures, and the standards for documentation.
• The Guided Execution Period (Days 31-60): They begin performing tasks under the direct supervision of a senior lead.
• The Independent Integration Period (Days 61-90): They take on a full load, with weekly check-ins to address friction points.

PHASE 4: RETENTION THROUGH ­PROFESSIONAL DEVELOPMENT

In dermatology practices, staff members frequently are approached by competitors, medical spas, and industry representatives to work for them. Retention is not just about the paycheck; it’s about the “professional home.” Staff members want to feel valued and have a responsible role in the workplace.

As dermatologists, we often are seen as the captain of the ship; however, the most successful practices operate as high-reliability organizations. In this type of practice, everyone from the janitorial staff to the senior associate is encouraged to speak up if there is a safety issue or an efficiency gap. Here are some techniques to foster this culture.

The Weekly Huddle—For practices that are just starting to expand, this is a great way to make sure that friction points and difficulties are addressed before becoming a larger issue. Gathering the staff for just 15 minutes in the morning before clinic begins can be a great way to address housekeeping issues, encourage staff to speak up about problems they may have identified, and provide a chance for everyone to feel heard.

The Educational Bend—Encourage staff to grow their wealth of knowledge, whether from industry-sponsored educational product events to formal certifications. A front desk assistant who then moves on to get their advanced degree may return to the practice as a nurse and become a valuable partner and asset. 

PHASE 5: LOOKING TOWARD THE FUTURE

As we look toward 2027 and beyond, the employee of the future may not be entirely human. We already are seeing the integration of AI scribes and automated billing auditors. Practices should look for candidates who aren’t afraid of AI but are excited by it. A medical assistant who can oversee an AI scribe while still maintaining eye contact and holding a patient’s hand during a painful injection is the gold standard.

Final Thoughts

Our medical school training prepares us for the “what” of dermatology, but it rarely prepares us for the “who.” As practice managers, we are thrust into the role of CEO, human resources director, and culture architect without a formal syllabus. By applying the same clinical rigor to the hiring process that we do to a complex diagnostic case, we can build teams that don’t just work for us but build with us. The goal is a practice where the physician can focus on the art and science of the skin, confident that every other aspect of the patient journey is being handled by a team that is as dedicated, ethical, and clinical as they are. Hiring is one of the most difficult procedures you will likely perform in your practice; it also is the one with the highest long-term success rate if performed with thoughtfulness, precision, and above all, kindness.

Recent data suggest that approximately 20% to 40% of patients treated with isotretinoin have recurrence of acne. How should dermatologists interpret these findings?

DR. BARBIERI: While isotretinoin is highly effective and capable of delivering long-term remission, we should be careful to avoid describing it as a “cure” when counseling patients. Importantly, when acne does recur, it is often milder, and about half of those who have acne recurrence can be managed with topicals alone. For those who do require a subsequent course of isotretinoin, we should view this as an outcome that can be expected to happen in about 1 in 10 treated with isotretinoin rather than a treatment failure.

How important is cumulative dose in preventing relapse, and should we be rethinking traditional dosing targets?

DR. BARBIERI: Cumulative dose is one of the most important factors in preventing recurrence. Multiple studies support that higher cumulative dose is a strong predictor of long-term clearance. In contrast, daily dose does not seem to be as important a factor. However, higher cumulative dose also means longer courses and more potential for adverse effects, including long-term skin and eye dryness. For this reason, I prefer to treat to clinical endpoints of clear skin for 2 to 3 months and at least 120 to 150 mg/kg cumulative dose to balance achieving high cumulative doses with potential adverse effects and risks. For those with fewer adverse effects or who prioritize long-term clearance, we might go a little longer and for those with more adverse effects, we might use a shorter course and accept a higher risk for recurrence. By taking this approach, we can individualize our dosing approach to each patient.

What factors most strongly predict relapse after a completed isotretinoin course?

DR. BARBIERI: Some demographic factors that have been associated with higher rates of recurrence include greater baseline severity and younger age at treatment. Women with a strong hormonal component to their acne, such as those with polyendocrine metabolic ovarian syndrome (formerly polycystic ovary syndrome), also may be more likely to have recurrence. With respect to clinical factors, increasing cumulative dose has been associated with reduced risk for recurrence in multiple studies, and treating until a clinical endpoint of clear skin for 2 to 3 months also may be predictive of long-term clearance.

When a patient relapses, how do you decide between topical therapy, hormonal treatment, or a second isotretinoin course?

DR. BARBIERI: It depends on relapse severity and patient goals. Mild recurrence often responds well to topical therapies such as retinoids, benzoyl peroxide, antibiotics, and clascoterone. About half of those with recurrence will be able to manage it with topical therapies alone. For those with more severe acne requiring systemic therapy, about half will decide on a repeat course of isotretinoin, which I often find works faster and better than the first course. For second courses, I will typically try to use micronized isotretinoin due to the more consistent pharmacokinetics. For women—especially those with signs of hyperandrogenism such as hirsutism, irregular periods, or flaring with menstrual cycle—hormonal therapy such as combined oral contraceptives or spironolactone can be a great option. Oral antibiotics also can be a consideration for those with recurrence, though we need to be thoughtful about antimicrobial stewardship and risks of long-term antibiotic use.

Are low-dose or shorter-course regimens contributing to higher relapse rates?

DR. BARBIERI: While there is some evidence that higher daily doses may be associated with lower risk for recurrence, when you control for cumulative dose, it doesn’t seem like daily dose has much influence. In contrast, cumulative dose has a large effect on frequency of long-term clearance. While I don’t think low-dose regimens are inherently problematic, if they result in shorter cumulative dose courses, that could increase the risk for recurrence.

How does hormonal acne influence long-term outcomes after isotretinoin?

DR. BARBIERI: While all acne is “hormonal,” those with a stronger hormonal pathogenesis, such as women with polyendocrine metabolic ovarian syndrome or other signs of hyperandrogenism, may have a higher likelihood of recurrence after treatment. In these patients, I often find hormonal therapy such as combined oral contraceptives or spironolactone to be highly effective, even if they haven't worked before.

Should maintenance therapy be routine after isotretinoin, and if so, what strategies are most effective?

DR. BARBIERI: Since many patients have a goal of long-term clearance after isotretinoin, I do not routinely recommend maintenance therapy, as this seems antithetical to this goal. However, for those who are very concerned about recurrence or who would like to be on a topical retinoid for other reasons, I will sometimes start a topical retinoid after treatment with isotretinoin.

How should dermatologists counsel patients about expectations with respect to relapse before starting isotretinoin?

DR. BARBIERI: We should be careful to set appropriate expectations with isotretinoin. I counsel patients that isotretinoin is an incredibly effective therapy for severe acne, with a high likelihood of long-term remission, but not a guaranteed permanent cure. Setting this expectation upfront reduces disappointment if acne does recur and improves shared decision-making.

Recent data suggest that approximately 20% to 40% of patients treated with isotretinoin have recurrence of acne. How should dermatologists interpret these findings?

DR. BARBIERI: While isotretinoin is highly effective and capable of delivering long-term remission, we should be careful to avoid describing it as a “cure” when counseling patients. Importantly, when acne does recur, it is often milder, and about half of those who have acne recurrence can be managed with topicals alone. For those who do require a subsequent course of isotretinoin, we should view this as an outcome that can be expected to happen in about 1 in 10 treated with isotretinoin rather than a treatment failure.

How important is cumulative dose in preventing relapse, and should we be rethinking traditional dosing targets?

DR. BARBIERI: Cumulative dose is one of the most important factors in preventing recurrence. Multiple studies support that higher cumulative dose is a strong predictor of long-term clearance. In contrast, daily dose does not seem to be as important a factor. However, higher cumulative dose also means longer courses and more potential for adverse effects, including long-term skin and eye dryness. For this reason, I prefer to treat to clinical endpoints of clear skin for 2 to 3 months and at least 120 to 150 mg/kg cumulative dose to balance achieving high cumulative doses with potential adverse effects and risks. For those with fewer adverse effects or who prioritize long-term clearance, we might go a little longer and for those with more adverse effects, we might use a shorter course and accept a higher risk for recurrence. By taking this approach, we can individualize our dosing approach to each patient.

What factors most strongly predict relapse after a completed isotretinoin course?

DR. BARBIERI: Some demographic factors that have been associated with higher rates of recurrence include greater baseline severity and younger age at treatment. Women with a strong hormonal component to their acne, such as those with polyendocrine metabolic ovarian syndrome (formerly polycystic ovary syndrome), also may be more likely to have recurrence. With respect to clinical factors, increasing cumulative dose has been associated with reduced risk for recurrence in multiple studies, and treating until a clinical endpoint of clear skin for 2 to 3 months also may be predictive of long-term clearance.

When a patient relapses, how do you decide between topical therapy, hormonal treatment, or a second isotretinoin course?

DR. BARBIERI: It depends on relapse severity and patient goals. Mild recurrence often responds well to topical therapies such as retinoids, benzoyl peroxide, antibiotics, and clascoterone. About half of those with recurrence will be able to manage it with topical therapies alone. For those with more severe acne requiring systemic therapy, about half will decide on a repeat course of isotretinoin, which I often find works faster and better than the first course. For second courses, I will typically try to use micronized isotretinoin due to the more consistent pharmacokinetics. For women—especially those with signs of hyperandrogenism such as hirsutism, irregular periods, or flaring with menstrual cycle—hormonal therapy such as combined oral contraceptives or spironolactone can be a great option. Oral antibiotics also can be a consideration for those with recurrence, though we need to be thoughtful about antimicrobial stewardship and risks of long-term antibiotic use.

Are low-dose or shorter-course regimens contributing to higher relapse rates?

DR. BARBIERI: While there is some evidence that higher daily doses may be associated with lower risk for recurrence, when you control for cumulative dose, it doesn’t seem like daily dose has much influence. In contrast, cumulative dose has a large effect on frequency of long-term clearance. While I don’t think low-dose regimens are inherently problematic, if they result in shorter cumulative dose courses, that could increase the risk for recurrence.

How does hormonal acne influence long-term outcomes after isotretinoin?

DR. BARBIERI: While all acne is “hormonal,” those with a stronger hormonal pathogenesis, such as women with polyendocrine metabolic ovarian syndrome or other signs of hyperandrogenism, may have a higher likelihood of recurrence after treatment. In these patients, I often find hormonal therapy such as combined oral contraceptives or spironolactone to be highly effective, even if they haven't worked before.

Should maintenance therapy be routine after isotretinoin, and if so, what strategies are most effective?

DR. BARBIERI: Since many patients have a goal of long-term clearance after isotretinoin, I do not routinely recommend maintenance therapy, as this seems antithetical to this goal. However, for those who are very concerned about recurrence or who would like to be on a topical retinoid for other reasons, I will sometimes start a topical retinoid after treatment with isotretinoin.

How should dermatologists counsel patients about expectations with respect to relapse before starting isotretinoin?

DR. BARBIERI: We should be careful to set appropriate expectations with isotretinoin. I counsel patients that isotretinoin is an incredibly effective therapy for severe acne, with a high likelihood of long-term remission, but not a guaranteed permanent cure. Setting this expectation upfront reduces disappointment if acne does recur and improves shared decision-making.

Recent data suggest that approximately 20% to 40% of patients treated with isotretinoin have recurrence of acne. How should dermatologists interpret these findings?

DR. BARBIERI: While isotretinoin is highly effective and capable of delivering long-term remission, we should be careful to avoid describing it as a “cure” when counseling patients. Importantly, when acne does recur, it is often milder, and about half of those who have acne recurrence can be managed with topicals alone. For those who do require a subsequent course of isotretinoin, we should view this as an outcome that can be expected to happen in about 1 in 10 treated with isotretinoin rather than a treatment failure.

How important is cumulative dose in preventing relapse, and should we be rethinking traditional dosing targets?

DR. BARBIERI: Cumulative dose is one of the most important factors in preventing recurrence. Multiple studies support that higher cumulative dose is a strong predictor of long-term clearance. In contrast, daily dose does not seem to be as important a factor. However, higher cumulative dose also means longer courses and more potential for adverse effects, including long-term skin and eye dryness. For this reason, I prefer to treat to clinical endpoints of clear skin for 2 to 3 months and at least 120 to 150 mg/kg cumulative dose to balance achieving high cumulative doses with potential adverse effects and risks. For those with fewer adverse effects or who prioritize long-term clearance, we might go a little longer and for those with more adverse effects, we might use a shorter course and accept a higher risk for recurrence. By taking this approach, we can individualize our dosing approach to each patient.

What factors most strongly predict relapse after a completed isotretinoin course?

DR. BARBIERI: Some demographic factors that have been associated with higher rates of recurrence include greater baseline severity and younger age at treatment. Women with a strong hormonal component to their acne, such as those with polyendocrine metabolic ovarian syndrome (formerly polycystic ovary syndrome), also may be more likely to have recurrence. With respect to clinical factors, increasing cumulative dose has been associated with reduced risk for recurrence in multiple studies, and treating until a clinical endpoint of clear skin for 2 to 3 months also may be predictive of long-term clearance.

When a patient relapses, how do you decide between topical therapy, hormonal treatment, or a second isotretinoin course?

DR. BARBIERI: It depends on relapse severity and patient goals. Mild recurrence often responds well to topical therapies such as retinoids, benzoyl peroxide, antibiotics, and clascoterone. About half of those with recurrence will be able to manage it with topical therapies alone. For those with more severe acne requiring systemic therapy, about half will decide on a repeat course of isotretinoin, which I often find works faster and better than the first course. For second courses, I will typically try to use micronized isotretinoin due to the more consistent pharmacokinetics. For women—especially those with signs of hyperandrogenism such as hirsutism, irregular periods, or flaring with menstrual cycle—hormonal therapy such as combined oral contraceptives or spironolactone can be a great option. Oral antibiotics also can be a consideration for those with recurrence, though we need to be thoughtful about antimicrobial stewardship and risks of long-term antibiotic use.

Are low-dose or shorter-course regimens contributing to higher relapse rates?

DR. BARBIERI: While there is some evidence that higher daily doses may be associated with lower risk for recurrence, when you control for cumulative dose, it doesn’t seem like daily dose has much influence. In contrast, cumulative dose has a large effect on frequency of long-term clearance. While I don’t think low-dose regimens are inherently problematic, if they result in shorter cumulative dose courses, that could increase the risk for recurrence.

How does hormonal acne influence long-term outcomes after isotretinoin?

DR. BARBIERI: While all acne is “hormonal,” those with a stronger hormonal pathogenesis, such as women with polyendocrine metabolic ovarian syndrome or other signs of hyperandrogenism, may have a higher likelihood of recurrence after treatment. In these patients, I often find hormonal therapy such as combined oral contraceptives or spironolactone to be highly effective, even if they haven't worked before.

Should maintenance therapy be routine after isotretinoin, and if so, what strategies are most effective?

DR. BARBIERI: Since many patients have a goal of long-term clearance after isotretinoin, I do not routinely recommend maintenance therapy, as this seems antithetical to this goal. However, for those who are very concerned about recurrence or who would like to be on a topical retinoid for other reasons, I will sometimes start a topical retinoid after treatment with isotretinoin.

How should dermatologists counsel patients about expectations with respect to relapse before starting isotretinoin?

DR. BARBIERI: We should be careful to set appropriate expectations with isotretinoin. I counsel patients that isotretinoin is an incredibly effective therapy for severe acne, with a high likelihood of long-term remission, but not a guaranteed permanent cure. Setting this expectation upfront reduces disappointment if acne does recur and improves shared decision-making.

When contemplating the state of ethical dialogue in our modern world, the philosopher Alasdair MacIntyre had this to say: “I can only answer the question, ‘What am I to do?’ If I can answer the prior question ‘Of what story or stories do I find myself a part?’”¹ That is, our ethics must proceed from our understanding of ourselves, others, and the world. David Hume might scoff, but we do need an “is” to appreciate and grasp our “ought.” This is just as true for medical ethics as it is for the rest of life. Questions about what we should do in medicine should draw us to deeper questions about identity and purpose.

In this issue, Ruskin et al present a tragic case of a man who spent his later years walking the line between life and a self-chosen death.² After enduring the chronic decline of Parkinson disease, he faced a final diagnosis of glioblastoma. The patient enrolled in hospice while considering how he might move elsewhere to avail himself of assisted suicide. Before he had a chance to do that, he was admitted to an inpatient hospice unit where he weakened further. In the throes of what may have been delirium or a last effort to enact his wish of a hastened death, he attempted suicide on the hospice unit. He survived only to die days later from the cancer.

The authors reflect on the complexities of this case, including the distress of a clinician who may want to satisfy a veteran’s wish but cannot due to legal constraints, and the challenges of identifying pathologic suicidal ideation from an earnest and rational desire for a hastened death. How should they handle these conversations? They conclude by suggesting ways clinicians may assess and respond to requests for a hastened death, recognizing that assisted suicide remains illegal within the Veterans Health Administration (VHA).

Clinicians can return to the foundation of our profession to better consider these questions. The case report authors acknowledge this but avoid learning from what the conflict might teach us: “The inability to help veterans achieve their care preferences [to receive a hastened death] conflicts with the core mission of palliative care to reduce suffering and respect end-of-life wishes.” Before feeling like they have failed the veteran, a clinician must ask if it is really within their scope of practice to end someone’s life. While it is true that “the mission of VHA’s [Palliative and Hospice Care] program is to honor veterans’ preferences for care,” this mission exists within a greater context of appreciating that not all preferences can or should be honored.³ An obvious example is when a veteran requests an intervention that is not clinically indicated (eg, antibiotics for a viral infection). Clinicians are not bound to honor this preference; not because there is a law directing the clinicians’ decision making (there is not) but because there is a standard of care that accounts for but can supersede the veteran’s preference.

Is assisted suicide ever clinically indicated? While the answer shifts depending on the jurisdiction, the case report authors acknowledge why the preference for assisted suicide cannot be honored in a VHA facility: it is against the law.⁴ However, as they explain, this is insufficient to assuage the moral distress that might arise for some clinicians who want to fulfill a veteran’s request. They recommend several different strategies for clinicians to consider when receiving a request for assisted suicide. Distress in the form of cognitive dissonance may also arise from the tension that exists between stopping some forms of suicide while assisting in others.

While it is important to assess whether the request for a hastened death is driven by an untreated symptom or mental illness, this will only get a clinician so far when the request is made in earnest with no remediable drivers. While I cannot argue the point here, I accept that there are forms of suicide which are rational. However, that alone is insufficient to justify the act or assist someone with it; we must assess the good that the rational choice seeks to realize.⁵ If suicide can be rational, clinicians should ask whether it is within the goals of medicine to assist in suicide. The authors seem to take it for granted that the distressed clinician in the case hopes to hasten this veteran’s death or at least refer him to someone who could. Perhaps his suicide attempt on the hospice unit was, in part, a consequence of being incapable of offering such assistance. These presuppositions should be considered explicitly to better align one’s practice both with the mission of VHA and with the goals of medicine.

One way to do this is to consider whether we can cast assisted suicide as a medical therapy. Sulmasy proposes the provisional “canons of therapy” which might guide clinicians in assessing medical therapies.⁶ This article distinguishes 3 types of clinically and ethically distinct practices. I have split his first canon (proportionality) into 2 for the sake of clarity.

Priority: Do the benefits outweigh the burdens of the intervention?

The challenge of assessing priority when considering assisted suicide is that we cannot explain any benefits or burdens that might accrue after death; it is beyond our knowledge and informed consent is impossible. While there is always some uncertainty in discerning the benefits and burdens of an intervention, death presents an insurmountable procedural problem for informed consent to assisted suicide.

Fit: Are the means appropriate for the outcome of interest?

The outcomes of interest when considering assisted suicide are many—many—they range from symptom relief or avoidance to reclaiming dignity. In the case described by Ruskin et al, the interdisciplinary team offered the veteran a number of interventions to assuage his symptoms. Dignity therapy may have been employed as a meaningful, useful way of bringing closure to a life.^7,8 Ultimately, however, some distress, particularly existential distress, may be intractable and clinicians must commit, as they did in this case, to doing what they can to remedy other symptoms and not abandon the veteran. Suicide is a tempting option because it may eliminate some of these concerns, but one must first grapple with the ethical question of whether suicide is ever an appropriate way to pursue any of these outcomes. Addressing that question is beyond the scope of this commentary, but both clinicians and patients should consider whether and why suicide should be considered appropriate and whether it is appropriate for the medical profession to assist with it.

Parsimony: Is this the least invasive, least burdensome intervention available?

In US jurisdictions where it is legal, assisted suicide is considered an intervention of last resort. Assisted suicide seems to be neither invasive (it involves taking medications) nor burdensome: the medications usually work quickly and without adverse effects, although there are risks (eg, vomiting). Broadening our view beyond the individual reveals something different.

In a cultural sense, assisted suicide is invasive. It changes how clinicians and patients consider health and medical care. We no longer have the profession of medicine with another intervention in the toolbox; we have a totally different profession which now intends death instead of health for its patients. It changes medicine and society at large profoundly. This makes it culturally invasive.

Furthermore, although the veteran in the case recurrently grappled with the choice of suicide, most people do not. They live by default. Offering assisted suicide, even in broad, general terms, may still leave them deciding to live, but the offer has also taken from them the possibility of living by default. They must justify their choice if only to themselves, considering the reasons they continue to pursue life-prolonging treatment and incur financial, emotional, and physical costs for their family. This is a dangerous cultural burden ironically imposed by the offer of more choices.⁹ Clinicians, by offering assisted suicide even if a patient declines it, also affirm the reasonableness of ending one’s life given the circumstances. That affirmation may be burdensome (eg, “They see my life as not worth living”) rather than validating.¹⁰

Restoration: Will this intervention help to restore the patient overall (even if not immediately)?

It would seem restoration is impossible for someone who is dying. Dying is terrible and so one possibility would be to hasten the process with assisted suicide. If health is in view, though, clinicians could recognize that restoration is always possible as long as someone is alive.

For someone dying, restoration may look like symptom relief (restoring bodily distress) which in turn may restore one’s capacity to sleep or to converse with loved ones. Assisted suicide does not fit in this paradigm. Is it intended to help patients sustain and restore their health, whatever amount they have (this is what the hospice and psychiatric services attempted to do in the case). Or is it intended to help patients pursue whatever goals seem good to the patient even those goals which conflict with health? Happily, most patients want their health sustained or restored so there is usually no conflict. As medical technology advances, though, conflicts arise: Should a clinician prescribe stimulants to enhance a healthy student’s wakefulness during final exams? Should a clinician engineer embryos to provide parents with a particular kind of child? Should a clinician end a patient’s life? Assisted suicide is obviously not aimed at restoration. It is a concession to the intractability of one’s disease and disability and one’s impending death. Without clarity and agreement on the goal of medicine, the default provision of care centers instead on satisfying patient preferences whatever they are.

Holism: Does the intervention prioritize the whole patient (vs prioritizing a part for the sake of the whole)?

Clinicians offering assisted suicide suggest that providing a death on a patient’s own terms restores autonomy and brings coherence to a life narrative that, at its end, is fraught with tragedy. This is what it looks like to honor “the whole patient.” A clinician must scrutinize that judgment to determine whether the patient meets statutory criteria for assisted suicide. The impulse underlying the moral distress described by Ruskin et al and many other clinicians is that a patient’s judgment, once determined to be sound, should trump a clinician’s judgment about what is best for the patient’s health and whether there are limits on what the clinician can do to satisfy a patient’s preferences. Ironically, assisted suicide prioritizes a patient’s judgment about how their life should end above other considerations, namely, that medicine has traditionally sought the patient’s good by sustaining and restoring their health, not by intending and causing their death. Notably, there was no lack of holism in the care provided the veteran in the case both before and after his suicide attempt.

Discretion: What are the limits of the intervention itself? What is the scope of medicine in general? What is the limit of one’s own individual knowledge and skill?

Assisted suicide has a substantial limit: it does not offer relief from suffering because there will be no one left alive to experience relief. Assisted suicide cannot achieve anything for the patient because they are dead by the time they fully receive what has been given. This profound limit makes assisted suicide unlike anything else offered in medicine and should give clinicians pause before adopting it, prompting them to grapple with whether causing a patient’s death is within the scope of medicine. If so, how did this come to be after thousands of years to the contrary across cultures and traditions, and what justifies this change? Finally, clinicians must contend with the limits of informed consent.

This brief reflection on how clinicians should consider medical therapies brings us back to MacIntyre’s exhortation: We cannot decide what to do until we have discerned the story to which we belong. One way of telling the story of medicine is to tell it with the techniques front and center: we prescribe, we operate, we irradiate, make the numbers go in the right direction, cure infections, and shrink masses. We can also tell that story by rejoicing that technology is giving us increasing control over our bodies and we can put that power to whatever use we desire. Often that will align with health, but it may not and that is for many patients increasingly acceptable. There is another, better story to tell: the profession of medicine exists to help people sustain and restore health, whatever bit of it they have and even as they lay dying. All those things just listed may help clinicians in that pursuit or they may not, given the specific context.

Ruskin et al tell a story of clinicians living in the tension of wanting to satisfy the desires their patients bring to them but must settle for the best that medicine can provide. Medical intervention as preference satisfaction is a story we have been living and practicing for 50 years since Beauchamp and Childress described the 4-principle framework for biomedical ethics: respect for autonomy, justice, nonmaleficence, beneficence.

Medicine-as-preference-satisfaction conflicts with the VHA mission to “honor America’s veterans by providing exceptional health care that improves their health and well-being.” VHA does not owe veterans whatever they request. VHA owes them exceptional health care. When a patient comes to a clinician, a clinician owes them a bounded set of things in service to their health. The dissonance a clinician might experience in trying to discern whether a patient’s death can serve that patient’s own health should signal a need to step back and reflect on how they understand the foundations of medical practice.

I do not disagree with the authors in their general approach to how clinicians might discuss this with patients who request a hastened death. I also seek to assuage symptoms, validate emotions, and remain steadfast through someone’s dying. I also affirm my commitment as a physician to care for a person’s health which, while someone is dying, usually entails managing symptoms. It never entails ending someone’s life. The clinicians in the case did an excellent job caring for this veteran and could not have done better by helping him end his life.

When contemplating the state of ethical dialogue in our modern world, the philosopher Alasdair MacIntyre had this to say: “I can only answer the question, ‘What am I to do?’ If I can answer the prior question ‘Of what story or stories do I find myself a part?’”¹ That is, our ethics must proceed from our understanding of ourselves, others, and the world. David Hume might scoff, but we do need an “is” to appreciate and grasp our “ought.” This is just as true for medical ethics as it is for the rest of life. Questions about what we should do in medicine should draw us to deeper questions about identity and purpose.

In this issue, Ruskin et al present a tragic case of a man who spent his later years walking the line between life and a self-chosen death.² After enduring the chronic decline of Parkinson disease, he faced a final diagnosis of glioblastoma. The patient enrolled in hospice while considering how he might move elsewhere to avail himself of assisted suicide. Before he had a chance to do that, he was admitted to an inpatient hospice unit where he weakened further. In the throes of what may have been delirium or a last effort to enact his wish of a hastened death, he attempted suicide on the hospice unit. He survived only to die days later from the cancer.

The authors reflect on the complexities of this case, including the distress of a clinician who may want to satisfy a veteran’s wish but cannot due to legal constraints, and the challenges of identifying pathologic suicidal ideation from an earnest and rational desire for a hastened death. How should they handle these conversations? They conclude by suggesting ways clinicians may assess and respond to requests for a hastened death, recognizing that assisted suicide remains illegal within the Veterans Health Administration (VHA).

Clinicians can return to the foundation of our profession to better consider these questions. The case report authors acknowledge this but avoid learning from what the conflict might teach us: “The inability to help veterans achieve their care preferences [to receive a hastened death] conflicts with the core mission of palliative care to reduce suffering and respect end-of-life wishes.” Before feeling like they have failed the veteran, a clinician must ask if it is really within their scope of practice to end someone’s life. While it is true that “the mission of VHA’s [Palliative and Hospice Care] program is to honor veterans’ preferences for care,” this mission exists within a greater context of appreciating that not all preferences can or should be honored.³ An obvious example is when a veteran requests an intervention that is not clinically indicated (eg, antibiotics for a viral infection). Clinicians are not bound to honor this preference; not because there is a law directing the clinicians’ decision making (there is not) but because there is a standard of care that accounts for but can supersede the veteran’s preference.

Is assisted suicide ever clinically indicated? While the answer shifts depending on the jurisdiction, the case report authors acknowledge why the preference for assisted suicide cannot be honored in a VHA facility: it is against the law.⁴ However, as they explain, this is insufficient to assuage the moral distress that might arise for some clinicians who want to fulfill a veteran’s request. They recommend several different strategies for clinicians to consider when receiving a request for assisted suicide. Distress in the form of cognitive dissonance may also arise from the tension that exists between stopping some forms of suicide while assisting in others.

While it is important to assess whether the request for a hastened death is driven by an untreated symptom or mental illness, this will only get a clinician so far when the request is made in earnest with no remediable drivers. While I cannot argue the point here, I accept that there are forms of suicide which are rational. However, that alone is insufficient to justify the act or assist someone with it; we must assess the good that the rational choice seeks to realize.⁵ If suicide can be rational, clinicians should ask whether it is within the goals of medicine to assist in suicide. The authors seem to take it for granted that the distressed clinician in the case hopes to hasten this veteran’s death or at least refer him to someone who could. Perhaps his suicide attempt on the hospice unit was, in part, a consequence of being incapable of offering such assistance. These presuppositions should be considered explicitly to better align one’s practice both with the mission of VHA and with the goals of medicine.

One way to do this is to consider whether we can cast assisted suicide as a medical therapy. Sulmasy proposes the provisional “canons of therapy” which might guide clinicians in assessing medical therapies.⁶ This article distinguishes 3 types of clinically and ethically distinct practices. I have split his first canon (proportionality) into 2 for the sake of clarity.

Priority: Do the benefits outweigh the burdens of the intervention?

The challenge of assessing priority when considering assisted suicide is that we cannot explain any benefits or burdens that might accrue after death; it is beyond our knowledge and informed consent is impossible. While there is always some uncertainty in discerning the benefits and burdens of an intervention, death presents an insurmountable procedural problem for informed consent to assisted suicide.

Fit: Are the means appropriate for the outcome of interest?

The outcomes of interest when considering assisted suicide are many—many—they range from symptom relief or avoidance to reclaiming dignity. In the case described by Ruskin et al, the interdisciplinary team offered the veteran a number of interventions to assuage his symptoms. Dignity therapy may have been employed as a meaningful, useful way of bringing closure to a life.^7,8 Ultimately, however, some distress, particularly existential distress, may be intractable and clinicians must commit, as they did in this case, to doing what they can to remedy other symptoms and not abandon the veteran. Suicide is a tempting option because it may eliminate some of these concerns, but one must first grapple with the ethical question of whether suicide is ever an appropriate way to pursue any of these outcomes. Addressing that question is beyond the scope of this commentary, but both clinicians and patients should consider whether and why suicide should be considered appropriate and whether it is appropriate for the medical profession to assist with it.

Parsimony: Is this the least invasive, least burdensome intervention available?

In US jurisdictions where it is legal, assisted suicide is considered an intervention of last resort. Assisted suicide seems to be neither invasive (it involves taking medications) nor burdensome: the medications usually work quickly and without adverse effects, although there are risks (eg, vomiting). Broadening our view beyond the individual reveals something different.

In a cultural sense, assisted suicide is invasive. It changes how clinicians and patients consider health and medical care. We no longer have the profession of medicine with another intervention in the toolbox; we have a totally different profession which now intends death instead of health for its patients. It changes medicine and society at large profoundly. This makes it culturally invasive.

Furthermore, although the veteran in the case recurrently grappled with the choice of suicide, most people do not. They live by default. Offering assisted suicide, even in broad, general terms, may still leave them deciding to live, but the offer has also taken from them the possibility of living by default. They must justify their choice if only to themselves, considering the reasons they continue to pursue life-prolonging treatment and incur financial, emotional, and physical costs for their family. This is a dangerous cultural burden ironically imposed by the offer of more choices.⁹ Clinicians, by offering assisted suicide even if a patient declines it, also affirm the reasonableness of ending one’s life given the circumstances. That affirmation may be burdensome (eg, “They see my life as not worth living”) rather than validating.¹⁰

Restoration: Will this intervention help to restore the patient overall (even if not immediately)?

It would seem restoration is impossible for someone who is dying. Dying is terrible and so one possibility would be to hasten the process with assisted suicide. If health is in view, though, clinicians could recognize that restoration is always possible as long as someone is alive.

For someone dying, restoration may look like symptom relief (restoring bodily distress) which in turn may restore one’s capacity to sleep or to converse with loved ones. Assisted suicide does not fit in this paradigm. Is it intended to help patients sustain and restore their health, whatever amount they have (this is what the hospice and psychiatric services attempted to do in the case). Or is it intended to help patients pursue whatever goals seem good to the patient even those goals which conflict with health? Happily, most patients want their health sustained or restored so there is usually no conflict. As medical technology advances, though, conflicts arise: Should a clinician prescribe stimulants to enhance a healthy student’s wakefulness during final exams? Should a clinician engineer embryos to provide parents with a particular kind of child? Should a clinician end a patient’s life? Assisted suicide is obviously not aimed at restoration. It is a concession to the intractability of one’s disease and disability and one’s impending death. Without clarity and agreement on the goal of medicine, the default provision of care centers instead on satisfying patient preferences whatever they are.

Holism: Does the intervention prioritize the whole patient (vs prioritizing a part for the sake of the whole)?

Clinicians offering assisted suicide suggest that providing a death on a patient’s own terms restores autonomy and brings coherence to a life narrative that, at its end, is fraught with tragedy. This is what it looks like to honor “the whole patient.” A clinician must scrutinize that judgment to determine whether the patient meets statutory criteria for assisted suicide. The impulse underlying the moral distress described by Ruskin et al and many other clinicians is that a patient’s judgment, once determined to be sound, should trump a clinician’s judgment about what is best for the patient’s health and whether there are limits on what the clinician can do to satisfy a patient’s preferences. Ironically, assisted suicide prioritizes a patient’s judgment about how their life should end above other considerations, namely, that medicine has traditionally sought the patient’s good by sustaining and restoring their health, not by intending and causing their death. Notably, there was no lack of holism in the care provided the veteran in the case both before and after his suicide attempt.

Discretion: What are the limits of the intervention itself? What is the scope of medicine in general? What is the limit of one’s own individual knowledge and skill?

Assisted suicide has a substantial limit: it does not offer relief from suffering because there will be no one left alive to experience relief. Assisted suicide cannot achieve anything for the patient because they are dead by the time they fully receive what has been given. This profound limit makes assisted suicide unlike anything else offered in medicine and should give clinicians pause before adopting it, prompting them to grapple with whether causing a patient’s death is within the scope of medicine. If so, how did this come to be after thousands of years to the contrary across cultures and traditions, and what justifies this change? Finally, clinicians must contend with the limits of informed consent.

This brief reflection on how clinicians should consider medical therapies brings us back to MacIntyre’s exhortation: We cannot decide what to do until we have discerned the story to which we belong. One way of telling the story of medicine is to tell it with the techniques front and center: we prescribe, we operate, we irradiate, make the numbers go in the right direction, cure infections, and shrink masses. We can also tell that story by rejoicing that technology is giving us increasing control over our bodies and we can put that power to whatever use we desire. Often that will align with health, but it may not and that is for many patients increasingly acceptable. There is another, better story to tell: the profession of medicine exists to help people sustain and restore health, whatever bit of it they have and even as they lay dying. All those things just listed may help clinicians in that pursuit or they may not, given the specific context.

Ruskin et al tell a story of clinicians living in the tension of wanting to satisfy the desires their patients bring to them but must settle for the best that medicine can provide. Medical intervention as preference satisfaction is a story we have been living and practicing for 50 years since Beauchamp and Childress described the 4-principle framework for biomedical ethics: respect for autonomy, justice, nonmaleficence, beneficence.

Medicine-as-preference-satisfaction conflicts with the VHA mission to “honor America’s veterans by providing exceptional health care that improves their health and well-being.” VHA does not owe veterans whatever they request. VHA owes them exceptional health care. When a patient comes to a clinician, a clinician owes them a bounded set of things in service to their health. The dissonance a clinician might experience in trying to discern whether a patient’s death can serve that patient’s own health should signal a need to step back and reflect on how they understand the foundations of medical practice.

I do not disagree with the authors in their general approach to how clinicians might discuss this with patients who request a hastened death. I also seek to assuage symptoms, validate emotions, and remain steadfast through someone’s dying. I also affirm my commitment as a physician to care for a person’s health which, while someone is dying, usually entails managing symptoms. It never entails ending someone’s life. The clinicians in the case did an excellent job caring for this veteran and could not have done better by helping him end his life.

When contemplating the state of ethical dialogue in our modern world, the philosopher Alasdair MacIntyre had this to say: “I can only answer the question, ‘What am I to do?’ If I can answer the prior question ‘Of what story or stories do I find myself a part?’”¹ That is, our ethics must proceed from our understanding of ourselves, others, and the world. David Hume might scoff, but we do need an “is” to appreciate and grasp our “ought.” This is just as true for medical ethics as it is for the rest of life. Questions about what we should do in medicine should draw us to deeper questions about identity and purpose.

In this issue, Ruskin et al present a tragic case of a man who spent his later years walking the line between life and a self-chosen death.² After enduring the chronic decline of Parkinson disease, he faced a final diagnosis of glioblastoma. The patient enrolled in hospice while considering how he might move elsewhere to avail himself of assisted suicide. Before he had a chance to do that, he was admitted to an inpatient hospice unit where he weakened further. In the throes of what may have been delirium or a last effort to enact his wish of a hastened death, he attempted suicide on the hospice unit. He survived only to die days later from the cancer.

The authors reflect on the complexities of this case, including the distress of a clinician who may want to satisfy a veteran’s wish but cannot due to legal constraints, and the challenges of identifying pathologic suicidal ideation from an earnest and rational desire for a hastened death. How should they handle these conversations? They conclude by suggesting ways clinicians may assess and respond to requests for a hastened death, recognizing that assisted suicide remains illegal within the Veterans Health Administration (VHA).

Clinicians can return to the foundation of our profession to better consider these questions. The case report authors acknowledge this but avoid learning from what the conflict might teach us: “The inability to help veterans achieve their care preferences [to receive a hastened death] conflicts with the core mission of palliative care to reduce suffering and respect end-of-life wishes.” Before feeling like they have failed the veteran, a clinician must ask if it is really within their scope of practice to end someone’s life. While it is true that “the mission of VHA’s [Palliative and Hospice Care] program is to honor veterans’ preferences for care,” this mission exists within a greater context of appreciating that not all preferences can or should be honored.³ An obvious example is when a veteran requests an intervention that is not clinically indicated (eg, antibiotics for a viral infection). Clinicians are not bound to honor this preference; not because there is a law directing the clinicians’ decision making (there is not) but because there is a standard of care that accounts for but can supersede the veteran’s preference.

Is assisted suicide ever clinically indicated? While the answer shifts depending on the jurisdiction, the case report authors acknowledge why the preference for assisted suicide cannot be honored in a VHA facility: it is against the law.⁴ However, as they explain, this is insufficient to assuage the moral distress that might arise for some clinicians who want to fulfill a veteran’s request. They recommend several different strategies for clinicians to consider when receiving a request for assisted suicide. Distress in the form of cognitive dissonance may also arise from the tension that exists between stopping some forms of suicide while assisting in others.

While it is important to assess whether the request for a hastened death is driven by an untreated symptom or mental illness, this will only get a clinician so far when the request is made in earnest with no remediable drivers. While I cannot argue the point here, I accept that there are forms of suicide which are rational. However, that alone is insufficient to justify the act or assist someone with it; we must assess the good that the rational choice seeks to realize.⁵ If suicide can be rational, clinicians should ask whether it is within the goals of medicine to assist in suicide. The authors seem to take it for granted that the distressed clinician in the case hopes to hasten this veteran’s death or at least refer him to someone who could. Perhaps his suicide attempt on the hospice unit was, in part, a consequence of being incapable of offering such assistance. These presuppositions should be considered explicitly to better align one’s practice both with the mission of VHA and with the goals of medicine.

One way to do this is to consider whether we can cast assisted suicide as a medical therapy. Sulmasy proposes the provisional “canons of therapy” which might guide clinicians in assessing medical therapies.⁶ This article distinguishes 3 types of clinically and ethically distinct practices. I have split his first canon (proportionality) into 2 for the sake of clarity.

Priority: Do the benefits outweigh the burdens of the intervention?

The challenge of assessing priority when considering assisted suicide is that we cannot explain any benefits or burdens that might accrue after death; it is beyond our knowledge and informed consent is impossible. While there is always some uncertainty in discerning the benefits and burdens of an intervention, death presents an insurmountable procedural problem for informed consent to assisted suicide.

Fit: Are the means appropriate for the outcome of interest?

The outcomes of interest when considering assisted suicide are many—many—they range from symptom relief or avoidance to reclaiming dignity. In the case described by Ruskin et al, the interdisciplinary team offered the veteran a number of interventions to assuage his symptoms. Dignity therapy may have been employed as a meaningful, useful way of bringing closure to a life.^7,8 Ultimately, however, some distress, particularly existential distress, may be intractable and clinicians must commit, as they did in this case, to doing what they can to remedy other symptoms and not abandon the veteran. Suicide is a tempting option because it may eliminate some of these concerns, but one must first grapple with the ethical question of whether suicide is ever an appropriate way to pursue any of these outcomes. Addressing that question is beyond the scope of this commentary, but both clinicians and patients should consider whether and why suicide should be considered appropriate and whether it is appropriate for the medical profession to assist with it.

Parsimony: Is this the least invasive, least burdensome intervention available?

In US jurisdictions where it is legal, assisted suicide is considered an intervention of last resort. Assisted suicide seems to be neither invasive (it involves taking medications) nor burdensome: the medications usually work quickly and without adverse effects, although there are risks (eg, vomiting). Broadening our view beyond the individual reveals something different.

In a cultural sense, assisted suicide is invasive. It changes how clinicians and patients consider health and medical care. We no longer have the profession of medicine with another intervention in the toolbox; we have a totally different profession which now intends death instead of health for its patients. It changes medicine and society at large profoundly. This makes it culturally invasive.

Furthermore, although the veteran in the case recurrently grappled with the choice of suicide, most people do not. They live by default. Offering assisted suicide, even in broad, general terms, may still leave them deciding to live, but the offer has also taken from them the possibility of living by default. They must justify their choice if only to themselves, considering the reasons they continue to pursue life-prolonging treatment and incur financial, emotional, and physical costs for their family. This is a dangerous cultural burden ironically imposed by the offer of more choices.⁹ Clinicians, by offering assisted suicide even if a patient declines it, also affirm the reasonableness of ending one’s life given the circumstances. That affirmation may be burdensome (eg, “They see my life as not worth living”) rather than validating.¹⁰

Restoration: Will this intervention help to restore the patient overall (even if not immediately)?

It would seem restoration is impossible for someone who is dying. Dying is terrible and so one possibility would be to hasten the process with assisted suicide. If health is in view, though, clinicians could recognize that restoration is always possible as long as someone is alive.

For someone dying, restoration may look like symptom relief (restoring bodily distress) which in turn may restore one’s capacity to sleep or to converse with loved ones. Assisted suicide does not fit in this paradigm. Is it intended to help patients sustain and restore their health, whatever amount they have (this is what the hospice and psychiatric services attempted to do in the case). Or is it intended to help patients pursue whatever goals seem good to the patient even those goals which conflict with health? Happily, most patients want their health sustained or restored so there is usually no conflict. As medical technology advances, though, conflicts arise: Should a clinician prescribe stimulants to enhance a healthy student’s wakefulness during final exams? Should a clinician engineer embryos to provide parents with a particular kind of child? Should a clinician end a patient’s life? Assisted suicide is obviously not aimed at restoration. It is a concession to the intractability of one’s disease and disability and one’s impending death. Without clarity and agreement on the goal of medicine, the default provision of care centers instead on satisfying patient preferences whatever they are.

Holism: Does the intervention prioritize the whole patient (vs prioritizing a part for the sake of the whole)?

Clinicians offering assisted suicide suggest that providing a death on a patient’s own terms restores autonomy and brings coherence to a life narrative that, at its end, is fraught with tragedy. This is what it looks like to honor “the whole patient.” A clinician must scrutinize that judgment to determine whether the patient meets statutory criteria for assisted suicide. The impulse underlying the moral distress described by Ruskin et al and many other clinicians is that a patient’s judgment, once determined to be sound, should trump a clinician’s judgment about what is best for the patient’s health and whether there are limits on what the clinician can do to satisfy a patient’s preferences. Ironically, assisted suicide prioritizes a patient’s judgment about how their life should end above other considerations, namely, that medicine has traditionally sought the patient’s good by sustaining and restoring their health, not by intending and causing their death. Notably, there was no lack of holism in the care provided the veteran in the case both before and after his suicide attempt.

Discretion: What are the limits of the intervention itself? What is the scope of medicine in general? What is the limit of one’s own individual knowledge and skill?

Assisted suicide has a substantial limit: it does not offer relief from suffering because there will be no one left alive to experience relief. Assisted suicide cannot achieve anything for the patient because they are dead by the time they fully receive what has been given. This profound limit makes assisted suicide unlike anything else offered in medicine and should give clinicians pause before adopting it, prompting them to grapple with whether causing a patient’s death is within the scope of medicine. If so, how did this come to be after thousands of years to the contrary across cultures and traditions, and what justifies this change? Finally, clinicians must contend with the limits of informed consent.

This brief reflection on how clinicians should consider medical therapies brings us back to MacIntyre’s exhortation: We cannot decide what to do until we have discerned the story to which we belong. One way of telling the story of medicine is to tell it with the techniques front and center: we prescribe, we operate, we irradiate, make the numbers go in the right direction, cure infections, and shrink masses. We can also tell that story by rejoicing that technology is giving us increasing control over our bodies and we can put that power to whatever use we desire. Often that will align with health, but it may not and that is for many patients increasingly acceptable. There is another, better story to tell: the profession of medicine exists to help people sustain and restore health, whatever bit of it they have and even as they lay dying. All those things just listed may help clinicians in that pursuit or they may not, given the specific context.

Ruskin et al tell a story of clinicians living in the tension of wanting to satisfy the desires their patients bring to them but must settle for the best that medicine can provide. Medical intervention as preference satisfaction is a story we have been living and practicing for 50 years since Beauchamp and Childress described the 4-principle framework for biomedical ethics: respect for autonomy, justice, nonmaleficence, beneficence.

Medicine-as-preference-satisfaction conflicts with the VHA mission to “honor America’s veterans by providing exceptional health care that improves their health and well-being.” VHA does not owe veterans whatever they request. VHA owes them exceptional health care. When a patient comes to a clinician, a clinician owes them a bounded set of things in service to their health. The dissonance a clinician might experience in trying to discern whether a patient’s death can serve that patient’s own health should signal a need to step back and reflect on how they understand the foundations of medical practice.

I do not disagree with the authors in their general approach to how clinicians might discuss this with patients who request a hastened death. I also seek to assuage symptoms, validate emotions, and remain steadfast through someone’s dying. I also affirm my commitment as a physician to care for a person’s health which, while someone is dying, usually entails managing symptoms. It never entails ending someone’s life. The clinicians in the case did an excellent job caring for this veteran and could not have done better by helping him end his life.

Compared to later-onset procedures, early diagnosis of melanoma using affordable skin biopsies can result in better patient outcomes, lower health care expenditures, and enhanced psychological well-being.¹ Numerous research and economic evaluations that highlight the possible advantages of early intervention in melanoma care lend support to this strategy. In health care systems, the cost of early identification and screening for skin cancer is a critical factor.¹ There has been debate in the literature regarding performing more frequent biopsies earlier for skin cancers, which may greatly improve patient outcomes at the expense of increased financial cost, compared with performing fewer biopsies, which reduces costs at the potential expense of managing later-onset melanoma.^1,2 We sought to summarize the current literature and address some considerations that may help bring more clarity to this topic.

According to a study of a large health care system, the average cost of a skin cancer screening visit was $150, of which $105 (70%) went toward the costs of the office visit and $45 (30%) went toward the costs of the biopsy.¹ In the changing health care landscape, it is crucial to take into account the possible compounded savings from early diagnosis and treatment. While biopsies do involve some expenses, consideration of immunotherapy costs for advanced melanoma also should be considered, as they provide an alternative viewpoint on the financial effects of melanoma treatment.² The use of new systemic treatments such as immunotherapy has led to a notable rise in Medicare users’ first-year melanoma treatment expenses. The average expense of treating stage IV melanoma rose from $47,739 in 2007 through 2012 to $117,450 in 2018 through 2019. This sharp rise highlights how much more expensive treating advanced melanoma is than performing biopsies for early detection and treatment. Hundreds of biopsies might be carried out for the cost of a single advanced melanoma therapy, possibly identifying several cases at an earlier, more manageable stage.²

Patient quality of life and survival rates also can be considerably improved by early melanoma detection through screening.³ Compared to patients with later-stage diagnoses, those with early-stage melanoma reported a higher overall quality of life. Better physical functioning and reduced levels of anxiety and sadness were linked to early identification using skin biopsies. Patients with more advanced melanoma who had later-onset procedures, on the other hand, experience worsening psychological symptoms and physical health.³

A cost-effectiveness analysis using a Markov cohort model compared the long-term economic impact of early detection and primary prevention of melanoma. It found that daily use of sunscreen could prevent a substantial number of new skin tumors and melanoma deaths and reduce health care costs when compared to early detection strategies such as performing extra biopsies.⁴ There already are programs across the United States that aim to educate the public on the importance of wearing sunscreen; this has, in turn, reduced the prevalence of skin cancer in certain communities. Primary prevention resulted in just 1364 new melanomas and more than $430 million in expenditures per 100,000 individuals, whereas early diagnosis produced 2446 new melanomas and more than $660 million in economic expenses per 100,000 individuals.⁴ It is imperative to acknowledge that skin biopsies remain a vital tool for the early identification of melanoma, particularly in high-risk groups.

By using technologies such as teledermoscopy, the cost-effectiveness of skin cancer referral and consultation can be further enhanced; for example, teledermoscopy for skin cancer referral and triage would result in faster clinical resolution at an average cost of $54.64 per case. This method may reduce the need for redundant in-person consultations and increase the effectiveness of melanoma identification.⁵

Large-scale public health initiatives in skin cancer prevention and early detection have the potential to be very effective, as evidenced by the War on Melanoma project at Oregon Health & Science University (Portland, Oregon). This all-encompassing strategy, which uses cutting-edge technologies, public education, and health care professional training, has improved melanoma outcomes and decreased health care expenditures with encouraging results.⁶

A few tactics can be used to best balance the costs of later-onset procedures and early skin biopsies. These include using advanced technologies such as teledermoscopy and dermoscopy, provider training to increase diagnostic accuracy, public health campaigns to raise awareness and promote prevention, and a comprehensive strategy combining targeted early detection strategies with primary prevention.^5,6 Health care systems can optimize the financial efficiency and clinical results of melanoma treatment by putting these principles into practice.

Compared to later-onset melanoma procedures, early skin biopsies typically are more cost-effective, produce better patient outcomes, and offer psychological advantages, even if they may have a higher initial cost. Health care systems can optimize the trade-off between early detection and cost effectiveness in melanoma management by putting sophisticated technology to use, enhancing provider training, and implementing focused screening programs.^5,6 To support evidence-based policies and guidelines, future research should assess the long-term economic impact of different melanoma prevention and detection measures.

Compared to later-onset procedures, early diagnosis of melanoma using affordable skin biopsies can result in better patient outcomes, lower health care expenditures, and enhanced psychological well-being.¹ Numerous research and economic evaluations that highlight the possible advantages of early intervention in melanoma care lend support to this strategy. In health care systems, the cost of early identification and screening for skin cancer is a critical factor.¹ There has been debate in the literature regarding performing more frequent biopsies earlier for skin cancers, which may greatly improve patient outcomes at the expense of increased financial cost, compared with performing fewer biopsies, which reduces costs at the potential expense of managing later-onset melanoma.^1,2 We sought to summarize the current literature and address some considerations that may help bring more clarity to this topic.

According to a study of a large health care system, the average cost of a skin cancer screening visit was $150, of which $105 (70%) went toward the costs of the office visit and $45 (30%) went toward the costs of the biopsy.¹ In the changing health care landscape, it is crucial to take into account the possible compounded savings from early diagnosis and treatment. While biopsies do involve some expenses, consideration of immunotherapy costs for advanced melanoma also should be considered, as they provide an alternative viewpoint on the financial effects of melanoma treatment.² The use of new systemic treatments such as immunotherapy has led to a notable rise in Medicare users’ first-year melanoma treatment expenses. The average expense of treating stage IV melanoma rose from $47,739 in 2007 through 2012 to $117,450 in 2018 through 2019. This sharp rise highlights how much more expensive treating advanced melanoma is than performing biopsies for early detection and treatment. Hundreds of biopsies might be carried out for the cost of a single advanced melanoma therapy, possibly identifying several cases at an earlier, more manageable stage.²

Patient quality of life and survival rates also can be considerably improved by early melanoma detection through screening.³ Compared to patients with later-stage diagnoses, those with early-stage melanoma reported a higher overall quality of life. Better physical functioning and reduced levels of anxiety and sadness were linked to early identification using skin biopsies. Patients with more advanced melanoma who had later-onset procedures, on the other hand, experience worsening psychological symptoms and physical health.³

A cost-effectiveness analysis using a Markov cohort model compared the long-term economic impact of early detection and primary prevention of melanoma. It found that daily use of sunscreen could prevent a substantial number of new skin tumors and melanoma deaths and reduce health care costs when compared to early detection strategies such as performing extra biopsies.⁴ There already are programs across the United States that aim to educate the public on the importance of wearing sunscreen; this has, in turn, reduced the prevalence of skin cancer in certain communities. Primary prevention resulted in just 1364 new melanomas and more than $430 million in expenditures per 100,000 individuals, whereas early diagnosis produced 2446 new melanomas and more than $660 million in economic expenses per 100,000 individuals.⁴ It is imperative to acknowledge that skin biopsies remain a vital tool for the early identification of melanoma, particularly in high-risk groups.

By using technologies such as teledermoscopy, the cost-effectiveness of skin cancer referral and consultation can be further enhanced; for example, teledermoscopy for skin cancer referral and triage would result in faster clinical resolution at an average cost of $54.64 per case. This method may reduce the need for redundant in-person consultations and increase the effectiveness of melanoma identification.⁵

Large-scale public health initiatives in skin cancer prevention and early detection have the potential to be very effective, as evidenced by the War on Melanoma project at Oregon Health & Science University (Portland, Oregon). This all-encompassing strategy, which uses cutting-edge technologies, public education, and health care professional training, has improved melanoma outcomes and decreased health care expenditures with encouraging results.⁶

A few tactics can be used to best balance the costs of later-onset procedures and early skin biopsies. These include using advanced technologies such as teledermoscopy and dermoscopy, provider training to increase diagnostic accuracy, public health campaigns to raise awareness and promote prevention, and a comprehensive strategy combining targeted early detection strategies with primary prevention.^5,6 Health care systems can optimize the financial efficiency and clinical results of melanoma treatment by putting these principles into practice.

Compared to later-onset melanoma procedures, early skin biopsies typically are more cost-effective, produce better patient outcomes, and offer psychological advantages, even if they may have a higher initial cost. Health care systems can optimize the trade-off between early detection and cost effectiveness in melanoma management by putting sophisticated technology to use, enhancing provider training, and implementing focused screening programs.^5,6 To support evidence-based policies and guidelines, future research should assess the long-term economic impact of different melanoma prevention and detection measures.

Compared to later-onset procedures, early diagnosis of melanoma using affordable skin biopsies can result in better patient outcomes, lower health care expenditures, and enhanced psychological well-being.¹ Numerous research and economic evaluations that highlight the possible advantages of early intervention in melanoma care lend support to this strategy. In health care systems, the cost of early identification and screening for skin cancer is a critical factor.¹ There has been debate in the literature regarding performing more frequent biopsies earlier for skin cancers, which may greatly improve patient outcomes at the expense of increased financial cost, compared with performing fewer biopsies, which reduces costs at the potential expense of managing later-onset melanoma.^1,2 We sought to summarize the current literature and address some considerations that may help bring more clarity to this topic.

According to a study of a large health care system, the average cost of a skin cancer screening visit was $150, of which $105 (70%) went toward the costs of the office visit and $45 (30%) went toward the costs of the biopsy.¹ In the changing health care landscape, it is crucial to take into account the possible compounded savings from early diagnosis and treatment. While biopsies do involve some expenses, consideration of immunotherapy costs for advanced melanoma also should be considered, as they provide an alternative viewpoint on the financial effects of melanoma treatment.² The use of new systemic treatments such as immunotherapy has led to a notable rise in Medicare users’ first-year melanoma treatment expenses. The average expense of treating stage IV melanoma rose from $47,739 in 2007 through 2012 to $117,450 in 2018 through 2019. This sharp rise highlights how much more expensive treating advanced melanoma is than performing biopsies for early detection and treatment. Hundreds of biopsies might be carried out for the cost of a single advanced melanoma therapy, possibly identifying several cases at an earlier, more manageable stage.²

Patient quality of life and survival rates also can be considerably improved by early melanoma detection through screening.³ Compared to patients with later-stage diagnoses, those with early-stage melanoma reported a higher overall quality of life. Better physical functioning and reduced levels of anxiety and sadness were linked to early identification using skin biopsies. Patients with more advanced melanoma who had later-onset procedures, on the other hand, experience worsening psychological symptoms and physical health.³

A cost-effectiveness analysis using a Markov cohort model compared the long-term economic impact of early detection and primary prevention of melanoma. It found that daily use of sunscreen could prevent a substantial number of new skin tumors and melanoma deaths and reduce health care costs when compared to early detection strategies such as performing extra biopsies.⁴ There already are programs across the United States that aim to educate the public on the importance of wearing sunscreen; this has, in turn, reduced the prevalence of skin cancer in certain communities. Primary prevention resulted in just 1364 new melanomas and more than $430 million in expenditures per 100,000 individuals, whereas early diagnosis produced 2446 new melanomas and more than $660 million in economic expenses per 100,000 individuals.⁴ It is imperative to acknowledge that skin biopsies remain a vital tool for the early identification of melanoma, particularly in high-risk groups.

By using technologies such as teledermoscopy, the cost-effectiveness of skin cancer referral and consultation can be further enhanced; for example, teledermoscopy for skin cancer referral and triage would result in faster clinical resolution at an average cost of $54.64 per case. This method may reduce the need for redundant in-person consultations and increase the effectiveness of melanoma identification.⁵

Large-scale public health initiatives in skin cancer prevention and early detection have the potential to be very effective, as evidenced by the War on Melanoma project at Oregon Health & Science University (Portland, Oregon). This all-encompassing strategy, which uses cutting-edge technologies, public education, and health care professional training, has improved melanoma outcomes and decreased health care expenditures with encouraging results.⁶

A few tactics can be used to best balance the costs of later-onset procedures and early skin biopsies. These include using advanced technologies such as teledermoscopy and dermoscopy, provider training to increase diagnostic accuracy, public health campaigns to raise awareness and promote prevention, and a comprehensive strategy combining targeted early detection strategies with primary prevention.^5,6 Health care systems can optimize the financial efficiency and clinical results of melanoma treatment by putting these principles into practice.

Compared to later-onset melanoma procedures, early skin biopsies typically are more cost-effective, produce better patient outcomes, and offer psychological advantages, even if they may have a higher initial cost. Health care systems can optimize the trade-off between early detection and cost effectiveness in melanoma management by putting sophisticated technology to use, enhancing provider training, and implementing focused screening programs.^5,6 To support evidence-based policies and guidelines, future research should assess the long-term economic impact of different melanoma prevention and detection measures.