Dermatologists how do you defend your turf?

[fakin' the funk]

Practically every dermatologist around here takes months to see a new patient, unless it's something urgent.

Ah yes, the very essence of the altruistic spirit of medicine.

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[MrHide]

Back to the real world ....
I have not lost a single second of sleep worrying about non-derms taking patients/procedures from my future practice. If OB/Gyn's want to open up Medispas, and Family Med docs want to do fillers, and Psychiatrists want to work the gamma knife - more power to 'em. But the patient suffers in the end.
As someone had alluded to, the problem is in fact too few derm residents graduating into the workforce. With so few numbers, and many then opting to do worthless cosmetic procedures, that leaves a few derms seeing all the medical derm cases. All this equates to 3 month waits to see a derm and patients having to settle for sub-optimal care with their PCPs.

 

[ajce9]

Back to the real world ....
I have not lost a single second of sleep worrying about non-derms taking patients/procedures from my future practice. If OB/Gyn's want to open up Medispas, and Family Med docs want to do fillers, and Psychiatrists want to work the gamma knife - more power to 'em. But the patient suffers in the end.
As someone had alluded to, the problem is in fact too few derm residents graduating into the workforce. With so few numbers, and many then opting to do worthless cosmetic procedures, that leaves a few derms seeing all the medical derm cases. All this equates to 3 month waits to see a derm and patients having to settle for sub-optimal care with their PCPs.

Hardly sub-optimal. It is well known fact that 60 to 70% of all derm cases can be managed by PCPs. Almost every bread and butter case you treat as a derm. can be done in the PCP office.

Since most derms hire PAs to see basically the same patients as they do so that they can have a chance to see the more complicated cases, it would make perfect sense that the FP that has more knowledge of medicine and Derm than any PA can see most of those cases and deliver excellent care.

 

[MrHide]

Thanks for reminding me why I don't waste my time in this forum -- is anyone in here actually in dermatology?! If all you FP residents/2nd year med students/junior-college psych majors want to do Botox, hair transplants, TURPs, and hysterectomies .... get your license and you can have a field day. Just don't EVER delude yourself into believing that the care you give is better than someone who is residency/fellowship-trained in these areas. If your argument is that an FP doc is better than a PA - well, that's still sub-optimal care isn't it? You may be able to convince a few patients, but not a jury.

Excuse me as I now go into the Family Medicine forum to tell everyone that I can do everything they can do, only better. Hey! I've been practicing my diabetes-meds juggling!

 

[NSight8]

I also find it interesting that so many family practitioners or their lobbiers are telling dermatologists that their field is not important and can be done by family docs.

Why do family docs want to practice and pretend to be a dermatologist? Why are they not satisfied in their own broad reaching specialty?

It is just sad that the specialty of family practice is not one that is chosen by the people that go into it but is something chosen for them by their poor performance in medical school.

Saying a family practitioner can do the same thing as a dermatologist or that dermatology does nothing that requires special training is like the medical student that had to redo a year telling an AOA student how medicine works.

Please spare all of us your inferiority complex.

 

[deleted87716]

Please spare all of us your inferiority complex.

You do realize that you're replying to a banned user, don't you?

Never argue with a fool. People may not be able to tell you apart.

 

[howie]

As a practicing dermatologist, I have not lost a single patient to a non-dermatologist, or a cosmetics patient to a non-core cosmetic practitioner (ie, optho, plastics, derm).

I strongly believe that PMDs must practice dermatology, as it is an integral part of their field. There are far too few dermatologists to handle the volume of patients w/ skin problems. As someone in academics, I wish other departments would take the initiative to further integrate skin disease into their training programs so that upon graduation, any FP can handle any case of acne, warts, eczema etc. In fact, I have many motivated primary care colleagues who are quite adept at handling even the most severe cases of acne or hand dermatitis.

The more serious problem arises when non-dermatologists attempt to manage problems that are well outside of their domain. I get 3 or 4 referrals per week of grossly mismanaged patients. Several months ago, a young woman was referred to me after being evaluated by their PMD. The pt had non-resolving bumps on her trunk. The FP doc did not know what it was, so they naturally took a shave Bx and sent it for path. The report read "epidermotropism w/ atypical lymphocytes, can not r/o MF". The patient was referred to an oncologist who gave this poor woman 2 doses of chemotherapy. When the lesions did not resolve, the woman was referred to me. This patient had a dozen pink papules w/ necrotic crusted centers on her trunk. Clinically, this could be lymphomatoid papulosis, PLEVA, insect bites, etc. If this clinical information had been provided to the pathologist, he/she would have likely come to the diagnosis of lymphomatoid papulosis or PLEVA based on what was in the biopsy. The specimen was sent to a dermatopathologist who agreed w/ LyP. A reasonable clinical diagnosis needs to be included w/ path specimen, or the pathologist may arrive at 3 or 4 different diagnoses. It is not like when a surgeon biopsies a tumor, and the pathologist can incontrovertibaly give it a Dx. A good clinical diagnosis must accompany path requisitions or the pathologist will be mislead to an incorrect diagnosis. This woman fortunately suffered no side effects from the chemotherapy. Non-dermatologists need to understand that practicing effective dermatology takes years of training and dedicated study, and that by playing dermatologist, you are short-changing your patient.

If a PMD wants to learn to inject Botox into a patient's forehead, I am all for it. Everyone has a right to earn a good living, and if their empty wallets motivate them to pursue cosmetics, then by all means do so. We are all physicians, and are capable of learning new medical procedures, even if they are outside of the domain of our field (although I assure you, I won't be perfecting my arthrocentesis technique any time soon). In my area, medispas may take some of the cosmetics volume from my office, but in effect, they just take all the bargain-shopping patients off of my hands. As a result, I get more of the patients who are willing to spend the money, get fully treated and get a complete result.

Do NOT advertise yourself as a board certified dermatologist, plastic surgeon, or use iffy wording so your board certification (if any) is unclear. Do NOT use these materials/treatments unless you are sure they are indicated. DO educate yourself so you know what you are doing. Don't push a syringe of Restylane unless it's indicated (I could go on all day w/ stories about where PMDs put fillers. Your IPL is not a "hair removal laser", it's a light device that has a lot of different settings. You are not just hitting hair w/ it, trust me. Do NOT deceive people for economic gain. They are not just cash-paying customers, they are our patients.

 

[PeepshowJohnny]

Hopefully these market forces are enough to create the opening of more dermatology residency positions. I think everyone agree you could increase the numbers comfortably now and patients would STILL be waiting months to get into the dermatologist.

The saddest thing about dermatology is that I've seen people who are actually interested in the field because they CARE about skin pathology discouraged from going into it, and seen it pushed on those with AOA and 250+ board scores because of its hours and reimbursements.

Is dermatology a field that requires intelligence? Absolutely. But I don't think there's any field in medicine that is so difficult that someone with a 220 Step 1 can't learn with experience.

 

[dilated]

The saddest thing about dermatology is that I've seen people who are actually interested in the field because they CARE about skin pathology discouraged from going into it, and seen it pushed on those with AOA and 250+ board scores because of its hours and reimbursements.

Why is this sad? It's sad that busting your ass for 4 years to be at the top of your class in the most competitive profession outweighs "I love skin"?

 

[PeepshowJohnny]

Why is this sad? It's sad that busting your ass for 4 years to be at the top of your class in the most competitive profession outweighs "I love skin"?

People should be allowed to follow their passion. Like I said, Derm takes some smarts, but I imagine even the average student would be able to learn eventually if they're passionate. It's obvious there's plenty of room for more dermatologists without disturbing those already in practice and if you've got people passionate about the field who are being elbowed out because of insane competition, I consider that a sad situation.

Now sure, a lot of derm hopefuls realize it's impossible and bust their hump to get their scores up, but not everyone can get AOA, a 250 on Step 1, and derm head honcho LORs. And if you look at the outcomes in the match there's still very strong candidates rejected.

I've personally known people who have only become interested in Derm AFTER they get their killer board score and think "Hey, that's a field where I can make a lot of money and not take crazy call". Personally, I think it's unfortunate when they take slots away from people who would have more passion for the field.

 

[hardy]

I've personally known people who have only become interested in Derm AFTER they get their killer board score and think "Hey, that's a field where I can make a lot of money and not take crazy call". Personally, I think it's unfortunate when they take slots away from people who would have more passion for the field.

Okay, sorry for bringing back this old thread but I am really trying to understand this. Are there really people who think "skin is awesome, I can't imagine anything but looking at skin all day"? This is just such a foreign concept to me that I would really appreciate if somebody could explain this passion to me. What makes somebody love skin so much?

 

[Long Dong]

Okay, sorry for bringing back this old thread but I am really trying to understand this. Are there really people who think "skin is awesome, I can't imagine anything but looking at skin all day"? This is just such a foreign concept to me that I would really appreciate if somebody could explain this passion to me. What makes somebody love skin so much?

What's so foreign about it? Don't you get excited when you look at adult movies? It's a natural reaction to get excited when looking at skin.

 

[OHMAN0125]

Okay, sorry for bringing back this old thread but I am really trying to understand this. Are there really people who think "skin is awesome, I can't imagine anything but looking at skin all day"? This is just such a foreign concept to me that I would really appreciate if somebody could explain this passion to me. What makes somebody love skin so much?

The same reason why Orthopods love bones, Rads love their computers, Cardio loves hearts, GI loves scopes, hmmm...you catch my drift? Maybe ppl are just different! That's an idea.

 

[dermdocmd]

Im not totally convinced dermies have any lock on their market share (say unlike path, rads or other specialist-types). The most profitable dermatology practice in my area is actually run by a DO, and a DO that never did a dermatology residency or any residency for that matter.

Dont you think marketing plays a much greater role than say your hard earned credentials in this arena? Aside from getting more referrals from primary care types (who are doing more of their own derm these days anyway), Im not seeing a huge advantage in even doing the derm residency and fellowship when someone can simply blitz market you under the table, Harvard residency and all.

Aside from educated consumers who *might* recognize board certification and the name of a top residency, I see the average American consumer going more for bling bling.

I have plenty of FPs and Internists armed with a false sense of dermatologic knowledge and their tubes of lotrisone to "defend my turf."

Simply put, in my first year I will bring home around 400-475K pre-tax. I will do this in a small community. I will do this without working past 6 p.m. I will do this without working a single weekend. Most importantly I will provide essential care to my patients; something I love to do.

My practice breaks down as such:

5% or less cosmetic.

25-35% patients who have seen non-dermatologists for their presenting dermatologic concerns.

The remainder are patients who make a logical decision to see a board certified dermatologist who is part of a very reputable group practice.

My group has done quite well despite a lack of focus on cosmetic procedures. The profit margin on Botox, Restylane, etc. is so slim now that hair dressers are doing it, that I'll stick to general medical dermatology.

If things ever slow down I guess I could consider stepping into the complicated world of hypertension, hyperlipidemia, low back pain, et al. I think I still remember the starting dose of lipitor, HCTZ, lisinopril, and metoprolol!

The take home message is do what you are trained to do and take good care of patients; they deserve it.

 

[andromeda2072]

Why do family docs want to practice and pretend to be a dermatologist? Why are they not satisfied in their own broad reaching specialty?

Simple! Money and Passion!
Patients are waiting 2 months to get to a Board Certified Dermatologist. Do they care if you boarded or not? If you can help them with psoriasis, then not. If you missed their Dx for some "nobodyheard" syndrome with no treatment - maybe. This field is not so easy sometimes but for the time patients wait their appointments, you can see them twice and realize that you need a second opinion. 1/100 or 1/1000? This is the time when BCD comes up.

It could be easy if Dermatology had more position in the residency.

This field is hard as any medicine and need practicing and knowledge. The easy lifestyle makes it elite, if you have a certain stay of mind and enjoy seeing skin lesions and see it as a challenge of your intelligence and do not scratch yourself after seeing scabies. No calls, no dieing patients (if they die, they die in ER), limited treatment choice with minimal consequences for a misdiagnosis and mistreatment. Your poor patients are nicest patients ever possible - they are happy to show you their problem as others ignore people with skin lesions as a normal instinct to stay away from sickness (plague?)

BCD is pushing patients away with their waiting line and Board is pushing IM/FP to do their job (practicing Medicine).

US population is growing but number of positions in the residency the same for years.

 

[discontinuebed]

Simple! Money and Passion!
Patients are waiting 2 months to get to a Board Certified Dermatologist. Do they care if you boarded or not? If you can help them with psoriasis, then not. If you missed their Dx for some “nobodyheard” syndrome with no treatment - maybe. This field is not so easy sometimes but for the time patients wait their appointments, you can see them twice and realize that you need a second opinion. 1/100 or 1/1000? This is the time when BCD comes up.

It could be easy if Dermatology had more position in the residency.

This field is hard as any medicine and need practicing and knowledge. The easy lifestyle makes it elite, if you have a certain stay of mind and enjoy seeing skin lesions and see it as a challenge of your intelligence and do not scratch yourself after seeing scabies. No calls, no dieing patients (if they die, they die in ER), limited treatment choice with minimal consequences for a misdiagnosis and mistreatment. Your poor patients are nicest patients ever possible - they are happy to show you their problem as others ignore people with skin lesions as a normal instinct to stay away from sickness (plague?)

BCD is pushing patients away with their waiting line and Board is pushing IM/FP to do their job (practicing Medicine).

US population is growing but number of positions in the residency the same for years.

I can't tell what's worse. The content or the English.

 

[andromeda2072]

I can't tell what's worse. The content or the English.

I would say that:

The average waiting time for new patient appointments varied from a low of 31.1 days in solo practices to a high of 55.9 days in academic practices.

Journal of the American Academy of Dermatology
Volume 54, Issue 2, February 2006, Pages 211-216

Although most of the responders (93.5%) accepted the simulated new patient, they did so with a mean physician wait time of 38.2 days. These mean wait times:

varied widely from one geographic region to another (19.7 days in Little Rock, Arkansas, vs 73.4 days in Boston, Massachusetts);

Tsang MW, Resneck J Jr
J Am Acad Dermatol. 2006;55:54-58



And I am learning also Spanish as Third Language

 

[abefromann]

Why, besides scheduling issues, would anyone see a primary care doc instead of a specialist for a specific issue? Some of derm is easy, granted, but many cases certainly are better evaluated and treated in the hands of a dermatologist. I mean, I can see Pick bodies on a slide but I'd rather the neuropath guy read it.