NYtimes on Derm residency

pseudoknot said:

Oh also something that most people in this thread are missing is that dermatology doesn't pay extraordinarily well on an absolute basis. What makes it so unique is the lifestyle (I'd argue that psychiatrists can enjoy a similar lifestyle, but their pay is lower and there is the stigma of mental illness).

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Sure. Strictly speaking it's the (reimbursement) / (actual work performed) ratio that is higher than most specialties.

pseudoknot, I have nothing against you so why these attacks against me? This a forum post not a final essay, so congratulations if you found some spelling or other mistakes but that wasn't really my biggest concern. If you disagree with my opinions, fine, I respect that, but why stoop to name calling? (econ 101 etc.). Following are my responses to your points.

Derm oversupply: There might be a wait for melanoma treatment, but there is not a wait for cosmetics. Derms and others are opening up plenty of clinics to improve skin care. If derms make most of their income from these cosmetic procedures, then their incomes will fall once these cosmetics market are saturated.

For the issue of non-specialists doing derm. This is the same arguments that PCPs used against mid levels like Nurse Practicioners and gas passer used against CNRA's. Sooner or later, some insurance company is going to figure out that Fam Med injecting botox is not inherently more dangerous than derm and they are going to cover it. Besides, you can always get people to sign consent forms and take risks if the price is low enough. And I'm not saying that derm's will get replaced, I am saying that they will have to lower their high fees because other people are offering their services for less.

What I am saying in 3 is that its a poor investment to go into derm and plastics simply for the money because the field is so difficult to get into while their economic future is uncertain. You could use the same amount of effort to get into a better program in another speciality.

Your probably right that cosmetic procedures will always pay more, but I'm saying the difference will narrow. The current state of affairs where derms make 400K and FM make 150K is not sustainable given the projected lack of PCPs.

Residency and reimbursements have much to do with supply and demand. In the short term, you can create artificial barriers that make it easier for yourself to have a monopoly and have reimbursements that produce supply that falls below demand, but these trends are unsustainable in the long run. I'm not saying that things will suddenly change, but I do like to point out that major changes have taken place in the past 25 years in our health care system that people probably thought would never happen. In the same vein, other countries of the world do not have such huge descrepencies between different specialities so it shows that our system is not the only system that can ever exist.

HQAMIGO said:

pseudoknot, I have nothing against you so why these attacks against me? This a forum post not a final essay, so congratulations if you found some spelling or other mistakes but that wasn't really my biggest concern. If you disagree with my opinions, fine, I respect that, but why stoop to name calling? (econ 101 etc.). Following are my responses to your points.

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No attacks against you my friend, only your arguments. And yes, one spelling correction, but I'm passionate about BMWs so I couldn't let that go 🙂

HQAMIGO said:

Derm oversupply: There might be a wait for melanoma treatment, but there is not a wait for cosmetics. Derms and others are opening up plenty of clinics to improve skin care. If derms make most of their income from these cosmetic procedures, then their incomes will fall once these cosmetics market are saturated.

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There is a wait to see dermatologists, period. A very long one. And I don't know where dermatologists make most of their money. I'd guess it's less than half cosmetic but have no idea really.

HQAMIGO said:

What I am saying in 3 is that its a poor investment to go into derm and plastics simply for the money because the field is so difficult to get into while their economic future is uncertain.

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I agree it's a bad idea to go into any field solely because of money since these things can change unpredictably.

HQAMIGO said:

Residency and reimbursements have much to do with supply and demand.

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I don't agree.

HQAMIGO said:

In the short term, you can create artificial barriers that make it easier for yourself to have a monopoly and have reimbursements that produce supply that falls below demand, but these trends are unsustainable in the long run.

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In our system of healthcare and medical education, these things are controlled by Congress and small boards accountable to no one. Supply and demand has no say here.

HQAMIGO said:

I'm not saying that things will suddenly change, but I do like to point out that major changes have taken place in the past 25 years in our health care system that people probably thought would never happen. In the same vein, other countries of the world do not have such huge descrepencies between different specialities so it shows that our system is not the only system that can ever exist.

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Yes, there are other systems, many of which I think are better than ours. Yes, there have been many changes and will be many more, but as you say these are hard to predict. Including by you!

I'm not saying that derm or plastics will always be extremely competitive or relatively well paid. I have no idea. But you can't say for sure that any of that will change. Also, the lifestyle advantages are unlikely to disappear unless people start having a lot more skin emergencies soon (global warming??)

Again, the situations with derm and plastics are pretty different. Derm is a moderately well paying field (not $400k) with perhaps the best lifestyle in medicine (rivaled only by psych and PM&R, I think). Plastics is a surgical subspecialty, meaning you will still work very hard, but it also has some incredibly cool cases and relatively controllable hours in the end. I have no doubt that most people going into plastics do so because they love the field.

HQAMIGO said:

Your probably right that cosmetic procedures will always pay more, but I'm saying the difference will narrow. The current state of affairs where derms make 400K and FM make 150K is not sustainable given the projected lack of PCPs.

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Yes, it is. It's called reimbursing NPs 80k. The delusion that some med students have that primary care is in for a major salary upswing when mid-level practice rights are constantly expanding is absurd. If anything the insurance companies could cut reimbursements further.

Choosing the one city in the US with the worst oversaturation of doctors isn't very convincing. There may be an oversaturation of plastic surgeons in NYC, but it's no worse than the oversaturation of ENTs, urologists or cardiologists.

sure I agree with that, but following your logic, what would prevent a similar replacement of dermatologists by IM or FPs? I would argue that the difference b/w a NP and FP is less than the difference b/w a FP and Derm. So if the insurance companies are ready to back FP's doing primary care, what would prevent them from supporting FP's injecting botox?

I think there is definitely a movement towards consumer driven health care in this country where the old established order of things are going to cave in to consumer demand. People might prefer a derm treating their acne or a FP doing their annual physical, but the reality is that if they can get slightly less service much cheaper then they are going to go for it. We are seeing now that medicine, despite all the bull**** they feed you in med school is and will be another service that has to fight for its place among all other goods and services in this world. The walmart-ization of medicine is inevitable.

DoctaJay said:

There is no other professional profession in the world where you may bill for $100, and the consumer can decide to only pay $30.

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If I may modify your comments a little: "There is no other profession in the world where you may bill for $100, an intermediary can decide to pay only $30, while the consumer (i.e. patient) thinks it shoulda been free."

agranulocytosis said:

“It is an unfortunate circumstance that you can spend an hour with a patient treating them for diabetes and hypertension and make $100, or you can do Botox and make $2,000 in the same time,” said Dr. Eric C. Parlette, 35, a dermatologist in Chestnut Hill, Mass., who chose his field because he wanted to perform procedures, like skin-cancer surgery and cosmetic treatments, while keeping regular hours and earning a rewarding salary.

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I wouldn't mind it if my tuition was 5k a year. But hey! don't make me graduate with 250k n debt and later blame me for not going into family medicine.

riverie said:

yeah some of those salaries look higher than what i'm used to seeing.

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Those numbers are BS. They are self-reported salary surveys which is skewed towards above-median numbers due to reporter bias. Furthermore, most of those surveys are based on only a couple hundred respondents.

If you want real numbers, look at the US Labor Department. They get their figures from tax records from hundreds of thousands of doctors, so there is no reporter bias. According to them, the average physician across all specialties makes 165k per year (before taxes).

So in the future whenever you see a salary report that shows the average pediatrician making 190k, you can correctly call BS on it.

dilated said:

Yes, it is. It's called reimbursing NPs 80k. The delusion that some med students have that primary care is in for a major salary upswing when mid-level practice rights are constantly expanding is absurd. If anything the insurance companies could cut reimbursements further.

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This is true, but it applies equally if not more so to specialists rather than primary care.

Do you really think NPs and PAs are content for the primary care jobs that pay about 50% less than the specialty jobs? Trust me they'll come right after your cush derm practice soon enough. Hell they're already doing it.

In fact, I'd argue that midlevels are more likely to cause a greater reduction in specialty salaries rather than primary care. Both will fall, but in terms of percent decrease the subspecialists (non-surgical) will take a greater hit than the primary care docs. Consider that PAs has basically abandoned primary care and running to the subspecialties. NPs are following that trend. They may be conniving bastards, but they arent stupid and they know where the money's at.

The only specialty group thats somewhat immune for the time being is surgery. As it stands right now, there is a bright line between who can do surgery and who cant. Every surgery that takes place in the United States is required by law or other regs to have an MD/DO surgeon for at least part of the case. That mandate exists nowhere else in medicine and the midlevels are taking advantage of it.

well i would say that mid levels would not enter surgery not because they can't do it but because they don't want to. i've scrubbed in on neuro operations where the techs are drilling bore holes, cutting away skin. Of course, when it comes to the tricky stuff of taking out a tumor, the surgeon's in charge, but much of surgery is so routine that you don't need to spend 4 years of med school learning about the krebs cycle to do it. Now I'm not saying surgeons are ever going to be replaced, but if your a cheap hospital admin, you can probably shave off 1 outta 5 surgeons and let some tech do the boring stuff while the surgeon still "supervises" the case.

Of course, considering that general surgeons make like 250K but work 80 hours a week and get sued up their *** all the time, why any NP want to do surgery is another matter. If I were an NP, i go for the easiest, cushiest specialties first like anesthesia where you basically sit around and just watch the monitors. Most operations are routine, you leave the high risk ones to the MDs and if **** hits the fan, have someone on call.

On a separate note, you going to see a lot more focus on preventive care in the future as a way to cut costs. You can pay a cardiothoracic surgeon to do a bypass for 500K and live for 5 more years, or you can go talk to a nurse who gets you to quite smoking, stop eating at Mickey D's and get off your Lazy Boy for 100 bucks which lets you live 20 more years. Which one is more cost effective and better for the patient? If we fired all the neurosurgeons and replaced them with public health programs, we probably get a lot more bang for the buck. Of course, you're not going to see passing pamphlets in a high school cafeteria on the Discovery channel anytime soon.

by the way, there are comments to the story posted:

http://www.nytimes.com/2008/03/24/opinion/l24derm.html

HQAMIGO said:

On a separate note, you going to see a lot more focus on preventive care in the future as a way to cut costs. You can pay a cardiothoracic surgeon to do a bypass for 500K and live for 5 more years, or you can go talk to a nurse who gets you to quite smoking, stop eating at Mickey D's and get off your Lazy Boy for 100 bucks which lets you live 20 more years. Which one is more cost effective and better for the patient? If we fired all the neurosurgeons and replaced them with public health programs, we probably get a lot more bang for the buck. Of course, you're not going to see passing pamphlets in a high school cafeteria on the Discovery channel anytime soon.

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Yea... right. This is not happening anytime soon in America.

From the response page:

To the Editor:
The article about how top medical students are going into the field of dermatology is probably the best argument I have heard so far that the free marketplace does not work when it comes to the field of medicine. It is absurd to see the best and the brightest going into the field of dermatology.
This is further proof that the American medical system is gravely ill and needs major lifesaving surgery. If that does not happen, I hope we can at least take solace in the fact that the rich will look good when they die.

The writer is a medical doctor.

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I can't believe that an actual doctor could blame this situation on the Free Market and not the external forces that have been setting reimbursement rates for decades. Does he think that if we switched over to a Single Payor system without fixing the asymmetry of reimbursement for time worked that afflicts primary care medicine and general surgery that students would suddenly flock into those fields?

I guess he could be blaming the free market in that it's the fault of the free market in Derm/Plastics that students flock there instead of to the other specialties that lack the ability to set their own prices.

All of the responses to the article were pretty wide of the mark, IMO. Just goes to show you that doctors don't necessarily understand politics.

1) BS, they're doing Derm for the lifestyle and money. That's OK, but
I love how they have the gall to sugar-coat it. None of this "walking CT scan" stuff is believable to me.

2) I don't feel bad for them. Couples matching in Derm is incredibly
dumb and is damned near impossible, and I'm sure they were warned
against it by everyone they asked.

3) I don't feel bad about the loans issue either. They're choosing to
have kids during med school and while interviewing? ridiculous. Now
they were couples-matching and they had to convince a program that they were as diligent and hardworking as single residents while taking care of TWO
infants?

does anyone know what happened with these two?

They are both heading to the Mayo Clinic for residency

HQAMIGO said:

On a separate note, you going to see a lot more focus on preventive care in the future as a way to cut costs. You can pay a cardiothoracic surgeon to do a bypass for 500K and live for 5 more years, or you can go talk to a nurse who gets you to quite smoking, stop eating at Mickey D's and get off your Lazy Boy for 100 bucks which lets you live 20 more years. Which one is more cost effective and better for the patient? If we fired all the neurosurgeons and replaced them with public health programs, we probably get a lot more bang for the buck. Of course, you're not going to see passing pamphlets in a high school cafeteria on the Discovery channel anytime soon.

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I love the fact that liberals think that a conversation with a nurse is going to get 80-IQ people living in the most prosperous nation on earth where large fries can be had for $1 and the "poor" all have satellite TV to start eating healthily and exercising.

Trismegistus4 said:

I love the fact that liberals think that a conversation with a nurse is going to get 80-IQ people living in the most prosperous nation on earth where large fries can be had for $1 and the "poor" all have satellite TV to start eating healthily and exercising.

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I'm a liberal and I don't think a conversation with a nurse is going to change human nature. Obviously what you quoted was absurd, but I don't think it's a partisan issue.

preventive care doesn't mean fluffy bunny ears kid talk hoping that the patient will change their habits, its a real program with real enforcement measures like jacking up insurance rates if they don't comply. I mean, alcoholics anonymous, drug rehab, smoking cessation programs all work to a certain degree so you can't argue they are useless. If we concentrated on those more by supplying more money they probably work better. Even if we could decrease some bad habits by 5%, thats potentially billions in savings.

OP29 said:

They are both heading to the Mayo Clinic for residency

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wow, how awesome! good for them