Dermatologists Will Be Targeted in Healthcare Reform

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Originally Posted by Silent Cool

Laxman,

Your post is awesome. I completely agree with the general sentiment of your post--a lot of people are attracted to Derm because of the cushy lifestyle and big bucks. I feel like it gets a lot of disengenous people because of the high pay and easy life. And I've hear the same thing before about community Derms not seeing more difficult cases--it interferes with them making more money faster (who cares about serving the community, right?) I feel like the sense of entitlement in medicine is at an all-time high, and the mentality of a lot of people going into derm right now seems to embody that pretty well: all I need to worry about is making money and I'm not going to work hard to do it.

The other thing is that Dermatology has become its own worst enemy: by keeping the numbers of graduating derms artifically low, there is enormous demand in the community for Derms. Wait times are, what, weeks bordering on months in many places? That's ridiculous. I'm not supprised that the NP/PA/DNP whatevers are coming in and getting a piece of the action. Granted, I don't support the midlevel business and the watering down of medical education, but I'm not the least bit suprised. Derms seem to be serving more of their own interests rather than serving the community, and at some point a group of people are going to step in and do something about it: witness the creation of DNP Derm residencies.

Bingo!

I like to look at medicine like most things in life using the 80/20 rule - meaning that 80% of cases are routine. That's true for pretty much for all medical fields. It's that 20% that you really need a physician with all the training that is involved. So, if you're an NP who wants to work autonomously, your job is to separate the routine from the complex cases.

This is where primary care and derm get into trouble with NP's. Like primary care, most derm cases are non-emergent. So even if you misdiagnose something initially, you can follow the patient on short-term follow-up - say within one or two weeks. After one or two follow-up visits and your treatment plan isn't working, what do you do? Simple. Refer the patient to a real physician, in this case a dermatologist. Again like primary case, what does an NP do if she suspects if the patient appears in serious imminent trouble? Send the patient to the ED, where a dermatologist can be consulted.

The reason why a field like surgery is less at risk from NP's is because the NP does not have the luxury of time or margin for error. If the NP accidentally snips a vessel, the patient is dead within minutes. If the NP cuts a nerve, the patient is paralyzed permanently. Then it gets into the media and the politicians will crack down on it.

But I suspect that most NP's want to do derm for the same reason why most med students want to do it. It's not for medical derm. It's for cosmetics. Like I said before, cosmetics is unregulated and practically anyone with the appropriate healthcare license and enough money can go into it.

If they can open up a medical spa now, why do NP's want to start derm residencies? I suspect that it's to be able to introduce themselves as "doctor" and to legitimatize themselves by claiming that they are "a derm specialist" because they are "board-certified" by some stupid nursing organization which will no doubt be created to accredit these residencies.

As someone pointed out before, these derm residencies are not under the control of the GME but under the nursing programs. They will spring up like weeds nationwide because nursing in general wants to push itself onto as much of medical turf as possible and because it will be a big money maker for the nursing programs because they will charge these wannabe nursing derms a lot of tuition money. If students are naive enough to hand over $50k per year in tuition for law or pharmacy schools where the job prospects are horrendous, then I bet that these derm residencies will have no trouble getting applicants.

So, bottom line, the factors that drove up interest in derm from medical students will be the same ones that will turn people off from it in the future.

http://www.bloomberg.com/video/88992941/

Here's Mary Mundinger, the creator of the DNP, talking recently to Bloomberg.

Start watching at 3:00.

"let's turn primary care over to nurses"

What she doesn't say on the record is that nurses also want to enter the specialties like derm and EM.

[QUOTE=Silent Cool;12395259]Laxman,

Your post is awesome. I completely agree with the general sentiment of your post--a lot of people are attracted to Derm because of the cushy lifestyle and big bucks. I feel like it gets a lot of disengenous people because of the high pay and easy life. And I've hear the same thing before about community Derms not seeing more difficult cases--it interferes with them making more money faster (who cares about serving the community, right?) I feel like the sense of entitlement in medicine is at an all-time high, and the mentality of a lot of people going into derm right now seems to embody that pretty well: all I need to worry about is making money and I'm not going to work hard to do it.

That's exactly what I said pretty much, in particular regarding the $$ and the deep desire for lots of $$ and easy lifestyle that derms have. I don't know why I got my head chopped off when this is not only true, but you and laxman have pretty much also said the same thing. If dermies don't wake up, it's not a rosy future. Ok, end of
post on this thread.

Originally Posted by Taurus

Bingo!

I like to look at medicine like most things in life using the 80/20 rule - meaning that 80% of cases are routine. That's true for pretty much for all medical fields. It's that 20% that you really need a physician with all the training that is involved. So, if you're an NP who wants to work autonomously, your job is to separate the routine from the complex cases.

This is where primary care and derm get into trouble with NP's. Like primary care, most derm cases are non-emergent. So even if you misdiagnose something initially, you can follow the patient on short-term follow-up - say within one or two weeks. After one or two follow-up visits and your treatment plan isn't working, what do you do? Simple. Refer the patient to a real physician, in this case a dermatologist. Again like primary case, what does an NP do if she suspects if the patient appears in serious imminent trouble? Send the patient to the ED, where a dermatologist can be consulted.

The reason why a field like surgery is less at risk from NP's is because the NP does not have the luxury of time or margin for error. If the NP accidentally snips a vessel, the patient is dead within minutes. If the NP cuts a nerve, the patient is paralyzed permanently. Then it gets into the media and the politicians will crack down on it.

But I suspect that most NP's want to do derm for the same reason why most med students want to do it. It's not for medical derm. It's for cosmetics. Like I said before, cosmetics is unregulated and practically anyone with the appropriate healthcare license and enough money can go into it.

If they can open up a medical spa now, why do NP's want to start derm residencies? I suspect that it's to be able to introduce themselves as "doctor" and to legitimatize themselves by claiming that they are "a derm specialist" because they are "board-certified" by some stupid nursing organization which will no doubt be created to accredit these residencies.

As someone pointed out before, these derm residencies are not under the control of the GME but under the nursing programs. They will spring up like weeds nationwide because nursing in general wants to push itself onto as much of medical turf as possible and because it will be a big money maker for the nursing programs because they will charge these wannabe nursing derms a lot of tuition money. If students are naive enough to hand over $50k per year in tuition for law or pharmacy schools where the job prospects are horrendous, then I bet that these derm residencies will have no trouble getting applicants.

So, bottom line, the factors that drove up interest in derm from medical students will be the same ones that will turn people off from it in the future.

Precisely. It is a well known fact that the vast majority of med students going into derm mostly want to do cosmetics for the big bucks, rather than medical derm. As I said before, it's derm's fault in this case. Having such an excessively low # of positions when there is such a tremendous need, and when the incidence of skin cancer has increased exponentially, it's inevitable that the gap will need to be filled somehow. And instead of being filled by derms, it will be filled by midlevels, who will be able to treat 80% of most cases, and will refer the small % that they can't treat.

I had to pick myself off the floor after reading this.

But all laughs aside, it's just a matter of time before nurses say they're equivalent to derms when it comes to recognizing melanoma.

Nurse-led care vs. usual care for patients with atrial fibrillation: results of a randomized trial of integrated chronic care vs. routine clinical care in ambulatory patients with atrial fibrillation

Aims: The management of patients with atrial fibrillation (AF) is often inadequate due to deficient adherence to the guidelines. A nurse-led AF clinic providing integrated chronic care to improve guideline adherence and activate patients in their role, may effectively reduce morbidity and mortality but such care has not been tested in a large randomized trial. Therefore, we performed a randomized clinical trial to compare the AF clinic with routine clinical care in patients with AF.

Methods and results: We randomly assigned 712 patients with AF to nurse-led care and usual care. Nurse-led care consisted of guidelines based, software supported integrated chronic care supervised by a cardiologist. The primary endpoint was a composite of cardiovascular hospitalization and cardiovascular death. Duration of follow-up was at least 12 months. Adherence to guideline recommendations was significantly better in the nurse-led care group. After a mean of 22 months, the primary endpoint occurred in 14.3% of 356 patients of the nurse-led care group compared with 20.8% of 356 patients receiving usual care [hazard ratio: 0.65; 95% confidence interval (CI) 0.45–0.93; P= 0.017]. Cardiovascular death occurred in 1.1% in the nurse-led care vs. 3.9% in the usual care group (hazard ratio: 0.28; 95% CI: 0.09–0.85; P= 0.025). Cardiovascular hospitalization amounted (13.5 vs. 19.1%, respectively, hazard ratio: 0.66; 95% CI: 0.46–0.96, P= 0.029).

Conclusion: Nurse-led care of patients with AF is superior to usual care provided by a cardiologist in terms of cardiovascular hospitalizations and cardiovascular mortality.

Originally Posted by laxman310

The solution IS midlevels, that we oversee and train, and that we bill for. Optimally the patient would always have access to the doctor, knowing that it would cost more to see them, Initial visits should always be staffed with the doc (IMHO) to establish rapport and provide a quick screening.

Once you've trained them, tested them, and had the AAD issue them a certificate of competence, what exactly is stopping them from demanding independent practice rights? Why should an "residency trained" PA settle for letting you bill for their services? The anesthesiologists got greedy too, training CRNAs so they could run (and bill for) 6 ORs at the same time - now look at the mess they've created for themselves.

I honestly can't understand why physicians as a group are so penny-wise and pound-foolish.

Originally Posted by Skinceutical

Once you've trained them, tested them, and had the AAD issue them a certificate of competence, what exactly is stopping them from demanding independent practice rights? Why should an "residency trained" PA settle for letting you bill for their services? The anesthesiologists got greedy too, training CRNAs so they could run (and bill for) 6 ORs at the same time - now look at the mess they've created for themselves.

I honestly can't understand why physicians as a group are so penny-wise and pound-foolish.

Greed. And if derm does not learn from the mistakes of anesthesia, they are in for a rude awakening.

Originally Posted by Dermpath

Precisely. It is a well known fact that the vast majority of med students going into derm mostly want to do cosmetics for the big bucks, rather than medical derm. ....

People say this all the time, but in my experience it is rarely true (at least in the way you seem to mean it). There is a difference between compensation and lifestyle being THE reason that one chooses a specialty versus just being one of many factors.

You do realize that it is possible to enjoy the practice of Dermatology and also enjoy a highly compensated, comfortable lifestyle?

For example, for me, when I was choosing what to do, there were three fields that I thought that I'd enjoy doing. Derm had much better compensation and lifestyle, so that had a lot to do with why I chose it. I don't think there's anything wrong with this (of course, if you were to say something like this on an interview, it would absolutely be taken in the worst possible way), and I know many dermatologists that had a similar thought process.

So, I suppose you could say that I chose derm for compensation/lifestyle reasons, but it's not like I wasn't very interested in the subject matter.

Besides, you can do just fine financially (for now anyway) compared to most other specialties just doing general medical derm. So only doing general medical dermatology and making "big bucks" are not really conflicting things at all.

The only people who should be practicing medicine are doctors.

Our ilk has been quite greedy and has allowed for the creation of lower-level representatives to do the grunt work while we reap the financial rewards. We have favored this, rather than an expansion of our own ranks.

How stupid we are.

The hired-guns have gotten arrogant and now demand that they become independent. They mistake a lack of knowledge for efficiency. They do not know what they do not know. The politikos, reeling from dire economic pressure and reluctant to rein in the unmitigated financial scourge of the Wall St. barons, will award these hired-guns with independence inasmuch as they are a cheaper alternative to us - nevermind patient safety.

Derm will meet this fate, as will primary care, EM, and every other low-stress, regular hours field without immediate patient risk or a basis of heavy book knowledge.

Derm needs to open more spots. Primary care needs better pay. Anaesthesia needs to stop using CRNAs and get back to the grind. The only fields that seem safe are the surgical fields (minus hernia repairs), rads and path, and rad onc. Every other field is a target if they let their guard down.

Physicians need to take responsibility for their patients again. Otherwise, someone else will, and they will be dangerous.

Originally Posted by Substance

The hired-guns have gotten arrogant and now demand that they become independent. They mistake a lack of knowledge for efficiency. They do not know what they do not know. The politikos, reeling from dire economic pressure and reluctant to rein in the unmitigated financial scourge of the Wall St. barons, will award these hired-guns with independence inasmuch as they are a cheaper alternative to us - nevermind patient safety.

Derm will meet this fate, as will primary care, EM, and every other low-stress, regular hours field without immediate patient risk or a basis of heavy book knowledge.

i like that

Originally Posted by Skinceutical

Once you've trained them, tested them, and had the AAD issue them a certificate of competence, what exactly is stopping them from demanding independent practice rights? Why should an "residency trained" PA settle for letting you bill for their services? The anesthesiologists got greedy too, training CRNAs so they could run (and bill for) 6 ORs at the same time - now look at the mess they've created for themselves.

I honestly can't understand why physicians as a group are so penny-wise and pound-foolish.

Would you rather a nursing board control certifcation?

Control the test, then you control the numbers and the expected competencies.

Do you think insurance companies will pay for whatever services an NP, without any attending oversight, bills for? Every benign excision of a nevus will be denies reimbursement. We set the standard.

Now in time, society will change, and NPs/PAs will gain acceptance, but when it comes to surgery, patients will prefer an MD. This all comes down to the power of regulatory bodies at the state level.

Originally Posted by laxman310

Would you rather a nursing board control certifcation?

I'd rather we didn't legitimize the such a ridiculous system, just so lazy private practitioners can sell our profession down the river in an effort to make a quick buck.

Originally Posted by laxman310

Do you think insurance companies will pay for whatever services an NP, without any attending oversight, bills for?

They already do. NPs can practice and bill independently, without any sort of physician oversight, in 16 states. CRNAs have won the right to independently bill Medicare, without physician oversight, in 16 states as well.

Set up PA "residencies" and I guarantee they'll be demanding the same in another couple years.

Dermatologists will be targeted for the very reasons Brett highlighted, not only in these most recent talks, but in talks spanning the past decade at least. Like everything in medicine, there is a heavy dose of politics mixed in with demographic and technological factors that determine the pace and direction of change. Politically, we're hosed -- we are a small numbers specialty who suffers from a horrible image problem. Envy runs deep (right along with ignorance). Soviet modeled resource allocation coupled with demographic (both provider and population based) trends have combined like fuel + forced air induction, accelerating and intensifying the resentment and pressures highlighted before. One does not have to go far to find the tell-tale signs of this ignorance and envy... just scroll through...

So yeah, we're hosed in the intermediate term. Here's the skinny, though -- the RUC will not cut the prevailing members throats just to stick derm. The highly specific derm codes will get raped (destructions, biopsies, Mohs) -- but shared codes will be protected as much as anything else. That includes reconstructions and E&M -- and those who have the skill set required to get ahead in life or medicine will continue to do so.

.

http://findarticles.com/p/articles/m.../ai_n57951637/

Originally Posted by molmol

yea... that's not going to work.

Already is for some... co-op and retainer practice models.

With regards to branching out into other fields, we have crossover with rheum as well as somewhat of a crossover with psych and neuro as well.

MOHS_01, +2

Substance, +2, word!

+1 all around, as I keep reading back over the comments. We do need MORE spots. That's for sure.

[QUOTE=laxman310;12392044]


The solution is to align incentives with what is best for society. I'm all for medicare not covering Mohs or fancy flaps. Thats ok, because anyone with $2K extra will pay me to do it, and I will take the time necessary to do the best job.


Why?

[QUOTE=Nellyakgo;12522978]

Originally Posted by laxman310

The solution is to align incentives with what is best for society. I'm all for medicare not covering Mohs or fancy flaps. Thats ok, because anyone with $2K extra will pay me to do it, and I will take the time necessary to do the best job.


Why?

Because he/she is not far enough along in the process to have a good understanding of the practical matters and the reality of the situation. The truth is the above sentiment is pie in the sky wishful thinking with little to no basis in reality outside of very limited confines (such as ultra high income, high deductible areas). It is in not feasible in the current or foreseeable world, is not scalable, and believing such is to open oneself to a world of disappointment.

[QUOTE=MOHS_01;12527406]

Originally Posted by Nellyakgo

Because he/she is not far enough along in the process to have a good understanding of the practical matters and the reality of the situation. The truth is the above sentiment is pie in the sky wishful thinking with little to no basis in reality outside of very limited confines (such as ultra high income, high deductible areas). It is in not feasible in the current or foreseeable world, is not scalable, and believing such is to open oneself to a world of disappointment.

OK.
But I still only partly understand the position here. If a patient would benefit from MOHS or a fancy flap, do you think medicare/medicaid should cover it?

[QUOTE=Nellyakgo;12527667]

Originally Posted by MOHS_01

OK.
But I still only partly understand the position here. If a patient would benefit from MOHS or a fancy flap, do you think medicare/medicaid should cover it?

As much as they should cover anything else. Personally I don't believe either program should exist and that there exists no great way to effectively ration within the political construct... but to answer your question, yes, I personally believe that micrographic surgery has been demonstrated time and again to be a cost effective treatment modality. This matter is more nuanced than is being discussed here, though, and is something that I have not the time to go into at this very moment. In short, micrographic surgery is the best treatment and is quite cost effective. It should be considered first line treatment for many tumors. Reconstruction is a highly variable process and does not lend itself well to this should be covered / should not be covered paradigm.

...and while we're on the subject, while laxman's post may give the dermwannabe's and dermgonnabe's the warm and fuzzies, there's a lot in there that simply does not measure up to any form of honest intellectual scrutiny. Take for instance the assertion that we are paid well because we are the cream of the crop -- complete and total BS. We, as dermatologists, are paid well because we have a system wherein the normal function and mechanism of pricing are completely out of whack -- the don't exist. We have a combination of highly reimbursed procedure mix and appropriate demographics to drive high volumes. The same can be said for ortho, retina, etc. We're not paid well because we're smart. We're not paid well because patients love us. We're paid based solely upon the volume and mix of services we provide minus the costs incurred in their provision. That's it. The prices are fixed in some Soviet style BS way, the volume of potential providers has traditionally been fairly low relative to the demand for these services (although that is changing and will continue to do so thanks to shortsighted and possibly self serving leadership on the part of the AAD and ABD).