From a rad onc resident: Derm specialty's experience with over-training?

[Krukenberg]

Rad onc resident here. In the rad onc world, academic leaders have expanded the # of residency slots to the point that the number of graduating rad onc residents each year doubled over a decade for no good reason other than probably to provide their faculty with resident coverage so they can write papers. Our SDN board has done a great job of raising the alarm that at this rate the job market is going to fall out from under us and rad onc residents will be faced with having to do "Fellowships" until a job opens up, similar to path or radiology. Sadly, our professional society has taken the stance that reducing the number of residency spots would violate anti-trust law, and has therefore thrown their hands up and done nothing.

I was wondering if dermatology has any experience with over-training? I've heard that may be the case in Mohs. If so, what led to the over-training? Has it resulted in a tougher job market? Is anything being done to reduce the # of training spots to loosen up the job market?

Derm is often held up on our SDN board as having done a good job of not increasing the # of residency spots. What has prevented academic leaders from expanding the # of dermatology residency training spots? Is there a conscious effort among Chairs and Program Directors to keep the number of spots tight to keep a healthy job market?

If you read our SDN board, it sounds like the sky is falling so I was curious to ask around in other SDN boards about similar experiences.

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[doctalaughs]

Hi,

My 2 cents- The Derm academics/chairs are no more vigilant than radonc and don’t care much about the future of the job market. If they are able to expand their department for their own benefit, they will do so selfishly and in fact, have done so to some extent - job market is tighter than 20 years ago directly as a result.

The difference is that the demand for Derm services is more elastic and has grown significantly. We are not dependent on expensive equipment, hospitals, and to some extent can still “hang a shingle.” This blunts the effect of residency expansion to some degree (not completely though). Make no mistake that this is some sort of “visionary” effort of the chairs/ powers that be in Derm. though.

 

[dermie1985]

Hi,

My 2 cents- The Derm academics/chairs are no more vigilant than radonc and don’t care much about the future of the job market. If they are able to expand their department for their own benefit, they will do so selfishly and in fact, have done so to some extent - job market is tighter than 20 years ago directly as a result.

The difference is that the demand for Derm services is more elastic and has grown significantly. We are not dependent on expensive equipment, hospitals, and to some extent can still “hang a shingle.” This blunts the effect of residency expansion to some degree (not completely though). Make no mistake that this is some sort of “visionary” effort of the chairs/ powers that be in Derm. though.

The derm job market is definitely still excellent - basically any resident trained at any program can reasonably find *some* job in any geographic location (it may not be the *best* job, but you can get one practically anywhere). They have expanded residency slots in the last 5 years, but this was generally needed given derm services are in high demand and there really weren't enough residents being trained annually to keep up with this demand. There are certain job markets where things can be tighter (San Francisco, NYC come to mind)...but that has more to do with physician geographic preferences and local market conditions rather than the # of trainees (at least IMO). Also, I saw this in the context of a general medical dermatologist +/- cosmetics, which is what most people do and where there is the most demand for providers.

In terms of Mohs - in some way, yes, we overtrain Mohs surgeons. In metro areas, it's becoming increasingly difficult to find a post-fellowship position where you're solely performing Mohs surgery (e.g. many will have to have a number of general dermatology clinics - this may be less desirable for some who don't like general dermatology / these clinics may reduce overall salary given a 1/2 day of Mohs has the potential to pay much higher than a 1/2 day of general dermatology). This has to do mostly with market saturation in metro areas. I know of (personally) many Mohs programs (including those at prestigious institutions) that specifically aim to train fellows that don't want to eventually practice in that metro area so they won't be future "competition" for patients. Having said that, many derms are looking for hybrid models including Mohs / cosmetics / gen derm, and I think, in general, Mohs still continues to be one of the more "high-yield" derm fellowships given the value of surgical dermatology and the salary potential. I think it's around a 50% match rate, though this is partially due to the high interest in Mohs fellowship by derm resident (something like 20-30% apply for it, though less match).

I think the major threat to dermatology is probably more on the side of venture capital taking over and, of course, from the constant threats to change billing for procedures.

 

[doctalaughs]

The derm job market is definitely still excellent - basically any resident trained at any program can reasonably find *some* job in any geographic location (it may not be the *best* job, but you can get one practically anywhere). They have expanded residency slots in the last 5 years, but this was generally needed given derm services are in high demand and there really weren't enough residents being trained annually to keep up with this demand. There are certain job markets where things can be tighter (San Francisco, NYC come to mind)...but that has more to do with physician geographic preferences and local market conditions rather than the # of trainees (at least IMO). Also, I saw this in the context of a general medical dermatologist +/- cosmetics, which is what most people do and where there is the most demand for providers.

In terms of Mohs - in some way, yes, we overtrain Mohs surgeons. In metro areas, it's becoming increasingly difficult to find a post-fellowship position where you're solely performing Mohs surgery (e.g. many will have to have a number of general dermatology clinics - this may be less desirable for some who don't like general dermatology / these clinics may reduce overall salary given a 1/2 day of Mohs has the potential to pay much higher than a 1/2 day of general dermatology). This has to do mostly with market saturation in metro areas. I know of (personally) many Mohs programs (including those at prestigious institutions) that specifically aim to train fellows that don't want to eventually practice in that metro area so they won't be future "competition" for patients. Having said that, many derms are looking for hybrid models including Mohs / cosmetics / gen derm, and I think, in general, Mohs still continues to be one of the more "high-yield" derm fellowships given the value of surgical dermatology and the salary potential. I think it's around a 50% match rate, though this is partially due to the high interest in Mohs fellowship by derm resident (something like 20-30% apply for it, though less match).

I think the major threat to dermatology is probably more on the side of venture capital taking over and, of course, from the constant threats to change billing for procedures.

I would agree that we have nothing to complain about compared to the job markets in other specialties.

That being said, being a little older and having seen the prior job market in Derm I would not rate our market now as “excellent.” Sure you can get a job in any city but it can be really bad job. 20 years ago it was generally difficult for senior partners to take huge advantage of the new meat, and the larger systems would have to beg to get dermatologists. Now with PE and partial saturation in large cities often the kaisers and huge PE groups are the “best” deal out there. And you won’t be calling the shots there with a very “hard” cap on your salary. For mohs and dermpath it’s a Bimodal situation - if you can get a good position you can establish and make 700k-1mill: but good luck trying to “break-in” to the market any large city. It’s likely a coin flip even with the best of skills.

 

[TMP-SMX]

Funding is a serious issue for dermatology residency spots. We are largely independent of hospitals that give out CMS money for spots. Hospitals don't depend on our services generating revenue (no ORs, expensive inpatient procedures). We do utilize labs/pathology and help keep costs down but requires educating inpatient teams about inflammatory skin disease over infection. The fee for service model encourages higher utilization though medicare is starting to penalize hospitals for readmissions for nonexistent cellulitis due to dermatologic disease. We don't worry about other board certified dermatologists given demand is high. We don't just treat cancer or adults we have a very general and useful training that is versatile. A bigger problem is midlevel encroachment (often perpetuated by practices with minimal supervision wanting to make more money and compete to keep doors open). The other issue is private equity.

 

[Krukenberg]

Funding is a serious issue for dermatology residency spots. We are largely independent of hospitals that give out CMS money for spots. Hospitals don't depend on our services generating revenue (no ORs, expensive inpatient procedures). We do utilize labs/pathology and help keep costs down but requires educating inpatient teams about inflammatory skin disease over infection. The fee for service model encourages higher utilization though medicare is starting to penalize hospitals for readmissions for nonexistent cellulitis due to dermatologic disease. We don't worry about other board certified dermatologists given demand is high. We don't just treat cancer or adults we have a very general and useful training that is versatile. A bigger problem is midlevel encroachment (often perpetuated by practices with minimal supervision wanting to make more money and compete to keep doors open). The other issue is private equity.

Yes in rad onc we make a lot of money for the hospital so all these new residency spots are outside of CMS money. Thankfully our specialty is well protected from midlevel encroachment due to regulations on prescribing ionizing radiation, and PE’s foray into rad onc is failing pretty badly (proton therapy business model of churning through prostate patients). So we have that going for us. But it’s basic math that if you double the number of graduating residents you’re going to limit employment opportunities. Unfortunately we need contraction of the residency spots but our leaders are holding up this “anti-trust” reason to not do so. Also, no individual program wants to be the one to lose residents.

 

[jupiterianvibe]

Private equity is your enemy.

Pathology sucks because private equity got involved. They control CAP which is supposed to be our professional society but now lobbies for residency expansions for a 'looming shortage'. In reality, more pathology spots = more cheap labor for private equity.

Dermatology should be very careful.

 

[dermie1985]

Yes in rad onc we make a lot of money for the hospital so all these new residency spots are outside of CMS money. Thankfully our specialty is well protected from midlevel encroachment due to regulations on prescribing ionizing radiation, and PE’s foray into rad onc is failing pretty badly (proton therapy business model of churning through prostate patients). So we have that going for us. But it’s basic math that if you double the number of graduating residents you’re going to limit employment opportunities. Unfortunately we need contraction of the residency spots but our leaders are holding up this “anti-trust” reason to not do so. Also, no individual program wants to be the one to lose residents.

I've also heard similar things about rad-onc from med school friends who are current residents - mostly that the job market is incredibly tight (e.g. 0-2 open positions annually in some large, desirable metros) and extremely competitive, especially as most residents are pretty much universally great candidates. As you stated...it has to do with the residency slot expansion despite the fact that the patient demand didn't really justify it. They all expressed similar outrage that the system will need to change in rad-onc or there will be increasing issues with graduates not being able to obtain jobs.

I would also echo other's statements...I think there's similar pressure from department chairs to increase the number of dermatology residency slots. This can sometimes be from a selfish standpoint -- i.e. more residents to cover call, staff clinics, etc. At my own institution, this is bottle-necked by funding issues - derm just isn't prioritized for residency slot expansion, so until that money comes, nothing will change. So, I think the same motivations are there, but often unfulfilled.

I do know personally of a few departments (some quite prestigious) who have expanded training slots. At the same time, I think academic dermatology has become more competitive in the last few years, as more residents are attracted by the stability of a salaried position with good benefits, especially in large metro markets where venture capital is eroding the private practice market. Accordingly, I personally know of a few great residents from great (Top 10) training programs, who simply couldn't get a job in academics at their home program and went into private practice in order to avoid a move to a less desirable city.

 

[Krukenberg]

I've also heard similar things about rad-onc from med school friends who are current residents - mostly that the job market is incredibly tight (e.g. 0-2 open positions annually in some large, desirable metros) and extremely competitive, especially as most residents are pretty much universally great candidates. As you stated...it has to do with the residency slot expansion despite the fact that the patient demand didn't really justify it. They all expressed similar outrage that the system will need to change in rad-onc or there will be increasing issues with graduates not being able to obtain jobs.

I would also echo other's statements...I think there's similar pressure from department chairs to increase the number of dermatology residency slots. This can sometimes be from a selfish standpoint -- i.e. more residents to cover call, staff clinics, etc. At my own institution, this is bottle-necked by funding issues - derm just isn't prioritized for residency slot expansion, so until that money comes, nothing will change. So, I think the same motivations are there, but often unfulfilled.

I do know personally of a few departments (some quite prestigious) who have expanded training slots. At the same time, I think academic dermatology has become more competitive in the last few years, as more residents are attracted by the stability of a salaried position with good benefits, especially in large metro markets where venture capital is eroding the private practice market. Accordingly, I personally know of a few great residents from great (Top 10) training programs, who simply couldn't get a job in academics at their home program and went into private practice in order to avoid a move to a less desirable city.

Exactly. One of our academic leaders in the field actually suggested the only solution is to wait until the job market gets so bad that med students stop applying. Our argument is those spots will just get filled by IMGs, and of course the field would be worse off because we wouldn’t have the brightest minds innovating and pushing the field forward, as we’re fortunate to have now.

 

[Splenda88]

Exactly. One of our academic leaders in the field actually suggested the only solution is to wait until the job market gets so bad that med students stop applying. Our argument is those spots will just get filled by IMGs, and of course the field would be worse off because we wouldn’t have the brightest minds innovating and pushing the field forward, as we’re fortunate to have now.

That is a remarkable statement...

 

[deleted950463]

That is a remarkable statement...

Very interesting that one of the biggest mover and shaker in the field of Radonc is a DO.

 

[jupiterianvibe]

That is a remarkable statement...

He's not wrong. Fmgs are in perpetual survival mode

 

[radsisrad]

That is a remarkable statement...

Remarkable in its simple truth.

 

[asmallchild]

This thread has run its course. A reminder to all to keep it professional...