Are the 500K+ days in derm over...

[Gunneria]

Pardon my grave and innate illness of gunneria, but in all seriousness, as you resident studs continue to evaluate your future after residency and/or converse with your fellow peer practicioners, how is the income outlook in derm? I suppose in light of the new health care reform, we will start to see new trends (i.e.- closing down of the solo practicioner era in favor of a multi-specialist approach) that I was just curious as to whether or not that goldmine 500k earning potential was still there and for what reasons. I did hear that derm did receive a 10% increase in compensation (ranked 2nd amongst specialties) from last year which is noteworthy.

Thanks for answering this trite and age old question. I'll guess that the lack of responses to this thread are either people really don't know (most likely reason) or perhappppppppps its in the protective nature of residents of keeping derm salaries a secret

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[Long Dong]

It appears that 400k/year is still doable. Well let you know next year if this is true or just salary guarantee to entice new grads in to buy out old guys practice.

 

[MOHS_01]

Pardon my grave and innate illness of gunneria, but in all seriousness, as you resident studs continue to evaluate your future after residency and/or converse with your fellow peer practicioners, how is the income outlook in derm? I suppose in light of the new health care reform, we will start to see new trends (i.e.- closing down of the solo practicioner era in favor of a multi-specialist approach) that I was just curious as to whether or not that goldmine 500k earning potential was still there and for what reasons. I did hear that derm did receive a 10% increase in compensation (ranked 2nd amongst specialties) from last year which is noteworthy.

Thanks for answering this trite and age old question. I'll guess that the lack of responses to this thread are either people really don't know (most likely reason) or perhappppppppps its in the protective nature of residents of keeping derm salaries a secret

Use the little search function and Google a little better, gunner. Recruiting sites don't lie. The vast majority of us are not salaried. The easy money days dried up years ago (in the 70's and 80's they were paid $100 for each SK frozen, no questions asked). Incomes across the board went up as skin cancer and other age related small procedure driven practice mixes changed in accordance with demographics. In short, there is no way to answer your question other because no one can predict what the asshats in Washington are going to shove down our throats or up our *****, but derm will remain fairly well compensated relative to other specialties as long as we maintain some form of production based fee for service environment.

 

[Gunneria]

Well in that mindest, I have a few questions:

1.What about the lucrativeness of subspecialites- Mohs and dermpath? Not worth it anymore?
2.What multispecialist practice model seems to be financially ideal (group of dermatologists?, plastic surgeon + dermatologist + anesthesiologist?)...I see a variety of practice models and I definitely understand the benefits of each one in terms of the efficacy and type/# of cases that one can encounter
3. Can side positions (i.e. university institutional positions + consulting positions for skincare companies) highly profitable as well? I notice some derms who are involved in more than just clinical practice (i.e.-lecturing, research) and I was wondering the benefit$ of these as well.


Sorry I sound like a clown asking these questions and I have used the search function indeed but I guess with this direct approach, I thought it'd be quicker and more up to date with times.

 

[dermRus]

Use the little search function and Google a little better, gunner.

Was that comment really necessary...

 

[Long Dong]

Here is an example of an email I get daily from recruiters that I'll cut n paste below:

Dear Doctor,



I received word today regarding your recent inquiring about the Dermatology positions with my clients in various states (see attachments). I would appreciate receiving your updated CV with daytime contact phone # in order to better understand your background and to best represent you to my clients who are in need of a qualified Dermatology specialist such as yourself. When are you available to interview, accept a permanent practice offer, and commence a full time Dermatology practice? Take a look at the following Dermatology jobs and let me know if any of them interest you. I look forward to assisting you with your future practice search.



#20401…. Wichita Falls, TX….join MSG as 1st gen DERM, $350-400K base salary, MOHS welcomed but not required, signing bonus, loan assistance, full benefits, shareholder status

#20783....Temple, TX………join MSG replacing solo gen DERM, $300K base salary, $25K signing bonus, production bonuses, full benefits, 5 weeks vacation/CME, 1 year to shareholder status

#20437…. Longview, TX………join MSG as 1st gen DERM, $350-450K base salary, MOHS welcomed but not required, signing bonus, full benefits, shareholder status

#21145…….Houston, TX……..solo practice for sale in highly desirable area of city, over 15,000 patient files

#20817…. Sacramento, CA…..2nd gen DERM needed to join 1 in MSG, NO MOHS, NO cosmetics, must see PEDS, salary, signing bonus, production bonuses, full benefits, 2 year to shareholder, NO visa issues

#21215…. Oakland, CA……join 5 DERMS in SSG, 3 clinical locations in Bay area, 100% production based income, NO visa issues

#20808…. Bryan, OH…..2nd gen DERM needed to join 1 in MSG, salary, signing bonus, production bonuses, full benefits, 2 years to partnership, NO visa issues

#20702…. Mankato, MN…..Mayo clinic branch in need of gen DERM, hospital employed, salary, full benefits, production bonuses, J1 & H1B visa accepted

#20695…. Greenville, NC….Academic Faculty Dermatologist needed, practice will involve hospital consults, clinical patients, teaching residents, salary, production bonuses, full benefits

#20519…. Bowling Green, KY…join MSG as 2nd gen DERM, attractive base salary, signing bonus, botox/cosmetic surgery welcomed, full benefits

#21465…. Springfield, MO….join 5 DERMS in MSG, 1:6 call, $330-350K base salary, $20K signing bonus, full benefits, production bonus, NO MOHS or cosmetics, no visa issues

#20288…. Hannibal, MO……..join MSG as 1st gen. DERM, $325K base salary, $20K sign on bonus, production bonuses, full benefits

#20292…. Modesto,CA………..join MSG as 2ndgen. DERM, call 1:2, 4 ½ days work week, EMR, income guarantee, full benefits, stockholder options, no MOHS surgery

#20293…. Stockton, CA……… join MSG as 2nd DERM w/MOHS, call 1:2, 4 ½ days work week, EMR, income guar, full benefits, stockholder options

#19470…. Eau Claire, WI……..join 6 gen DERMS in MSG, cosmetics/botox welcomed, $325K base salary, $45K signing bonus, full benefits, H1-B visa accepted

#21377…. Plattsburgh, NY…… take over hospital employed private Derm practice, signing bonus, salary, prod bonus, full benefits, 53 total PTO

#16364…. Malone, NY…………..hosp spons solo, employee, $300K base, $25K signing bonus, up to $150K bonuses, 5 wks vac/CME, full benefits, H1-B visa accepted

#18176…. Middletown, NY…..join 2 DERMS in MSG, salary, production bonuses, full benefits, 4 weeks vac/CME, 2 years to shareholder status

#21064… Watertown, NY….. join 1 female general Derm in hospital employed practice, $300-350K base salary, $20K sign bonus, Loan assistance, production bonuses, full benefits

#20534…. Melbourne, FL……..1st Derm needed in MSG, salary, production bonuses, full benefits

#20623…. Kinston, NC…………General Derm needed to join private practice of 1 DERM, 1 PA, guarantee, buy out practice, signing bonus, can do cosmetics or MOHS, must have experience

#20622….Kinston, NC…………General Derm to join MSG, salary, signing bonus, production bonus, full benefits, can do cosmetics or MOHS

#17365…. Laconia, NH…………2 Derms needed to join MSG, $300K base, bonuses, loan assistance, 6 wks vac/CME, full benefits, J1 & H1-B visa accepted

#20927…. Berlin, NH……….first full time gen Derm needed as hospital employed solo, salary, bonuses, full benefits

#17408…. Gallipolis, OH………2 Derms needed to join 1 derm in MSG, salary, full benefits, 7 wks vac/CME, partnership track

#17804…. Astoria, OR………hospital employee, salary, full benefits

#17866… Birmingham, AL…hospital sponsored solo with gross guarantee or can be employee with salary, full benefits

#21362… Wausau, WI…..first Derm needed in MSG, salary, $20K signing bonus, full benefits, 9 weeks PTO, no visa issues

#18018… Portage, WI…..join part time DERM in MSG, salary, full benefits, loan repaymt assistance, full benefits, 8 wks vac/CME, J1 & H1B visa accepted

#20996… Stevens Point, WI…..join MSG, 1 year salary $325-350K, signing bonus, loan assistance, full benefits, EMR

#18149… Ogden, UT……..join MSG, salary, production bonuses, full benefits, 1 year to shareholder CONTRACT PENDING

#18536… Philadelphia, PA…..2 DERMS needed for Philly area as independent contractors, $300K guarantee, malpractice ins, must be BE/BC

#18484… Fort Dodge, IA…..1 Derm needed for 2010 start date, join 2 Derms in MSG, No call, 2 year guarantee, loan repayment asstnce, J1 & H1-B visa qualifier

#18736… State College, PA…..join 1 gen Derm in MSG for 2010 start date, botox/cosmetics welcomed, $300-325K base salary, bonuses, full benefits, 5 weeks vacation/CME, 18 months to partnership, H1B visa accepted

#18958… Albuquerque, NM…. Join 1 Derm in MSG, must have MOHS training/experience, $325K base, $10K signing bonus, production bonuses, full benefits, 2 years to partnership, will build new Dermatology suites to specifications

#19143…Rome, GA….join female Derm in MSG, 2 year guarantee, bonuses, full benefits, 2 year partnership track

#19202…Richmond, IN…hospital employed full time Derm, $325K, $30K signing bonus, bonuses, full benefits, $10K relocation

#19261…Biloxi, MS…….hospital sponsored solo, NO CALL, clinical based practice, $350K base salary, full benefits, 600K patient draw area

#19819… Charlotte, NC…. Join MSG with 6 Derms, no MOHS training needed, salary, possible signing bonus, production bonuses, full benefits

#19979…Findlay, OH…..2nd gen Derm needed in MSG, cosmetics and/or MOHS experience welcomed, 2 year guarantee, partnership, H1-B visa accepted

#19980…Peoria, IL… 1st DERM needed to join MSG, $325-350K salary, signing bonus, prod. Bonuses, full benefits

#20014…Caribou, ME…. employed solo general Derm needed to join MSG, salary, production bonuses, full benefits, J1 & H1-B visa accepted

#20015…Waterville, ME…employed solo Derm w/MOHS needed, will include teaching, $300-350K base, production bonuses, full benefits

#20017…Freeport, IL…. First general Derm needed to join MSG, $350K base, production bonuses, full benefits, NO visa issues

#20021…Clive, IA…….general w/cosmetics Derm needed to join 2 plastic surgeons, suburb of Des Moines clinic, work 4 days/wk, 12K patient base, salary, production bonuses, full benefits

#21004… Dothan, AL…..MOHS needed, hospital employed, salary, full benefits, referrals from Derms and NS on staff

#21084… Maitland, FL….general Derm for SSG in Jacksonville clinic, salary, signing bonus, full benefits, 5 weeks vac/CME, No call, NO visa issues

#21289… Fort Walton Beach, FL….. replace retiring DERM in MSG, no call, salary, production bonuses, full benefits, 5 wks vac/CME, NO visa issues

#21456… Naples, FL……join 7 DERMS in SSG, no call, salary, full benefits

#21203… Grosse Pointe, MI……join 2 female DERMS, general w/cosmetics, can do 1 day wk MOHS, salary, full benefits, NO visa issues



Thanks and look forward to hearing back from you soon!

 

[doc84]

The job opportunities look great. I need to pay off those pesky loans.

 

[MOHS_01]

Was that comment really necessary...

The OP's chosen handle incorporates gunner. In short, yes -- if you intend to run and compete with the big boys, intellectual laziness is not a great way to start.

Well in that mindest, I have a few questions:

1.What about the lucrativeness of subspecialites- Mohs and dermpath? Not worth it anymore?
2.What multispecialist practice model seems to be financially ideal (group of dermatologists?, plastic surgeon + dermatologist + anesthesiologist?)...I see a variety of practice models and I definitely understand the benefits of each one in terms of the efficacy and type/# of cases that one can encounter
3. Can side positions (i.e. university institutional positions + consulting positions for skincare companies) highly profitable as well? I notice some derms who are involved in more than just clinical practice (i.e.-lecturing, research) and I was wondering the benefit$ of these as well.


Sorry I sound like a clown asking these questions and I have used the search function indeed but I guess with this direct approach, I thought it'd be quicker and more up to date with times.

There is no simple or global answer to your question. IF you could secure a Mohs job or straight dermpath gig where you would be busy, solo is the way to go. The problem is those rarely, if ever, exist in the wild. Single specialty is probably the next best bet if you are going to be a subspecialist, with MSG being the least attractive. It takes a sound general derm base to support a subspecialist, and that is not generally found in MSG settings. You trade profit and margin for security and volume in either of the above settings.

No one can give you an answer to how things will pay in the future. That is the single greatest logical error that I see students, residents, and attendings make -- the assumption that past results is predictive of future performance. Mohs got slammed in 2008 with the loss of the multiple procedure reduction exemption. Path's day is coming... as will anything that generates high incomes and offers. Central planners at CMS do monitor these sorts of things and turn them against the specialty that is doing well using the faulty logic of "obviously, those codes are overvalued".

As money is sucked out of what I will call "traditional medicine", your side gigs -- and cosmetics -- will likely become both less available and less lucrative in response to the increase in the supply of folks looking for said work.

There really is no golden goose... and there is nowhere to hide. Bust your ass is the best advice that can be given to anyone who desires an income above the median... which is a moving target itself.

 

[reno911]

Agree with most everything Mohs01 said.

To answer the original question, 500K or more is still very achievable today. This is true whether you're doing general derm, Mohs, or dermpath. How much longer that will be true is anyone's guess.

My guess is that it will still be achievable for a while (at least 10 yrs), but the things that one would need to do to achieve it are going to become increasingly undesirable (see more patients, work in less desirable geographic regions, hire extenders, etc.). However, this is just my guess.

 

[Transformers]

that sucks...do you think a lot is due to todays economy and declining reimbursements (I am assuming once cuts are made, they never go back to normal)? Would you still recommend choosing dermatology over say...going into business (finance) or law in todays environment and especially in even 10-15 years?

 

[reno911]

that sucks...do you think a lot is due to todays economy and declining reimbursements (I am assuming once cuts are made, they never go back to normal)? Would you still recommend choosing dermatology over say...going into business (finance) or law in todays environment and especially in even 10-15 years?

Obviously, I think you should just pick the one you like best (med vs business vs law). However, if you are looking at it from a financial perspective, then here's how it breaks down:

The most successful businessmen and lawyers (top 5%) will absolutely crush the most successful doctors (including dermatologists) in income. So if you want to be extremely wealthy, medicine is not the answer (and never was)

However, average and below average doctors, will be still be at least financially secure. On the other hand, if one is an average or below average lawyer or businesman, there is a significant chance that you may be poor and unemployed.

In my opinion, declining reimbursements in medicine will not change this for some time.

This is a broad generalization, and doesn't address many scenarios (e.g. above average attorney vs average MD), but this is basically the way it works.

 

[gonogo]

Most of the jobs listed above are in undesireable areas. I would guess salaries are way much lower in places like nyc, sf, chicago, boston, etc...

 

[N-Surge]

That Houston gig could be hot!

 

[Gunneria]

Good point about not being fooled by high starting offers as you probably will just stagnate...I don't understand a couple of things:

1- Do your salaries stagnate at the starting offer in a private practice setting? If not, what increments can you see (corresponding with years out) at a healthy practice?
2-What are the pros/cons of buying in vs. not buying into a practice?
3-Can volume alone compensate whatever earnings you desire...that is can't you literally (and this is messed up) run your practice seeing a patient every 5 mins, work even 9-5 6 days a week to reach that 500k mark? OR are reimbursement cuts simply that bad?
4-I see a lot of derms who have an adjacent medspa practice run by an aesthetician...how does that factor in?
5- What about all these random side ventures I see derms in- speaking at conferences, being in proactiv commericals (there were like derm commercials constantly playing during the jersey shore marathon today), talking on nbc, or consulting for Galderma for example...

 

[comedone]

5- I plan to trend lightly. To me, world-wide conferences & health policy discussions on NBC are minor; however, commercials and Galderma consulting would not align with my values in medicine.

http://www.boston.com/news/health/articles/2010/10/19/mass_doctors_earn_drug_firms_dollars/?page=2

http://www2.timesdispatch.com/lifestyles/virginia-news/2011/jan/02/tdmain01-payments-to-doctors-from-drug-companies-s-ar-747608/

5- What about all these random side ventures I see derms in- speaking at conferences, being in proactiv commericals (there were like derm commercials constantly playing during the jersey shore marathon today), talking on nbc, or consulting for Galderma for example...

But... I'm not in it to win it. The 500k plan is not for everyone.

I hope to be an unbiased, academic dermatologist with a research integrity that is transparent. However, some of my dermo friends enjoy the 'perks' of these types of random side ventures as their private practice, more patient-focused work isn't at risk of being hindered.

 

[comedone]

http://www.npr.org/templates/story/story.php?storyId=130644774

 

[Gunneria]

my other questions...

1- Do your salaries stagnate at the starting offer in a private practice setting? If not, what increments can you see (corresponding with years out) at a healthy practice?
2-What are the pros/cons of buying in vs. not buying into a practice?
3-Can volume alone compensate whatever earnings you desire...that is can't you literally (and this is messed up) run your practice seeing a patient every 5 mins, work even 9-5 6 days a week to reach that 500k mark? OR are reimbursement cuts simply that bad?
4-I see a lot of derms who have an adjacent medspa practice run by an aesthetician...how does that factor in?

 

[Gunneria]

my other questions...

1- Do your salaries stagnate at the starting offer in a private practice setting? If not, what increments can you see (corresponding with years out) at a healthy practice?
2-What are the pros/cons of buying in vs. not buying into a practice?
3-Can volume alone compensate whatever earnings you desire...that is can't you literally (and this is messed up) run your practice seeing a patient every 5 mins, work even 9-5 6 days a week to reach that 500k mark? OR are reimbursement cuts simply that bad?
4-I see a lot of derms who have an adjacent medspa practice run by an aesthetician...how does that factor in?

 

[reno911]

The answer to all of your questions is that it varies widely based on the specifics of your particular scenario.

Here's the best I can do:

1. Normally, in private practice, your long term salary will be much higher than your starting salary if you want to work what most would consider a full schedule. However, in academia you will often (but not always) find that your salary is more likely to stagnate (i.e., not go much above what you start at) no matter how hard you work.

2. Impossible to answer in general. It totally depends on what (i.e. the practice) you're buying.

3. Depends on the earnings you desire, but if you desire 500K then a decent volume (probably less than you think) will allow you to achieve it, even with recent cuts. However, you not only have to have the willingness to have a high volume, you actually have to have sufficient referrals/patient population. Working 7 days a week is not good, if you are only able to book 10 patients a day.

4. Also impossible to answer in general. Totally depends on the details.

 

[LifeDeath]

Obviously, I think you should just pick the one you like best (med vs business vs law). However, if you are looking at it from a financial perspective, then here's how it breaks down:

The most successful businessmen and lawyers (top 5%) will absolutely crush the most successful doctors (including dermatologists) in income. So if you want to be extremely wealthy, medicine is not the answer (and never was)

However, average and below average doctors, will be still be at least financially secure. On the other hand, if one is an average or below average lawyer or businesman, there is a significant chance that you may be poor and unemployed.

In my opinion, declining reimbursements in medicine will not change this for some time.

This is a broad generalization, and doesn't address many scenarios (e.g. above average attorney vs average MD), but this is basically the way it works.

I totally agree with you in your comments above. I have a cousin, who went to medical school to become rich. He did not do ANY volunteering, shadowing, nor did research (none in extra-curricular activities), but he got MCAT 35, applied to 30 schools, only got into two schools, which are not even ranked in U.S. news.

He is originally from CA, but now somewhere in mid-west. In recent conversation with him, I notice that he is working very hard to get a high score at the step1 since he firmly believes that he can get into one of top CA surgery residences (possibly ortho) if he can the high step 1 score. Of course I gave a lot of advice as you guys did here: get research experience, get excellent LOR, get AOA, do networking, etc, etc. I doubt he would listen to my advice as he did ignore my advice when he applied to med schools.

He still believes that he would become a rich doctor...

My point is that he went to the medical school to chase money not to pursue medicine...How sad...

 

[Long Dong]

What about those who chase skirts?

 

[pupster]

What about those who chase skirts?

Works for me. lolz. Doesn't Derm have the hottest residents (male and female)?

 

[sore eye asses]

Works for me. lolz. Doesn't Derm have the hottest residents (male and female)?

and trannies too.

i got all cryin game up in that mother on a couple interview stops.

you know who you are. you kiss so hard, then you come in soft.

 

[pupster]

and trannies too.

I got all cryin game up in that mother on a couple interview stops.

You know who you are. You kiss so hard, then you come in soft.

lolz.

 

[Gunneria]

yo for you average male derms whove made it to the promised land, do u tend to go for the hot derms or are they impossible...im guessing u cant get both brains and hots so you choose the trophy hottiez at the clubs and bars...ok im an idiot for asking that

 

[pupster]

yo for you average male derms whove made it to the promised land, do u tend to go for the hot derms or are they impossible...im guessing u cant get both brains and hots so you choose the trophy hottiez at the clubs and bars...ok im an idiot for asking that

Well...I used to teach other guys how to meet women. Google "PUA" and "pickup" and "game theory." I basically go for them all and let Allah sort it out....

 

[Long Dong]

Works for me. lolz. Doesn't Derm have the hottest residents (male and female)?

I would say yes. Just go to the AAD meeting and you'll see the most attractive group compared to other physician specialty meetings.

yo for you average male derms whove made it to the promised land, do u tend to go for the hot derms or are they impossible...im guessing u cant get both brains and hots so you choose the trophy hottiez at the clubs and bars...ok im an idiot for asking that

Yes it can be done don't settle for just looks, cuz looks fade stupidity doesn't.

Well...I used to teach other guys how to meet women. Google "PUA" and "pickup" and "game theory." I basically go for them all and let Allah sort it out....

Hey I was on those PUA forums too, do what you gotta do to be alpha.

 

[pupster]

I would say yes. Just go to the AAD meeting and you'll see the most attractive group compared to other physician specialty meetings.



Yes it can be done don't settle for just looks, cuz looks fade stupidity doesn't.




Hey I was on those PUA forums too, do what you gotta do to be alpha.

Lol...I was there in NO . Good times, lad!

 

[asmallchild]

I would say yes. Just go to the AAD meeting and you'll see the most attractive group compared to other physician specialty meetings.

Incredibly enough, one of our male attendings actually complained about this in New Orleans

 

[MedicalSport]

Looking for an update in 2018. How are things now?

 

[bronx43]

Just an outside observer dropping by, but one thing I've noticed is that the number of dermatologists out there has increased drastically in the past 5-10 years. Is this what you guys are all noticing or is it just my area? Back in the day (maybe 5-6 years ago), my patients would have to wait months to see a dermatologist. Now, most of my patients get in the same week if they wanted to.

 

[asmallchild]

Looking for an update in 2018. How are things now?

I thought this was a great post from @MOHS_01 when posted 8 years ago. Much of it, if not all of it, still rings true.

No one can give you an answer to how things will pay in the future. That is the single greatest logical error that I see students, residents, and attendings make -- the assumption that past results is predictive of future performance. Mohs got slammed in 2008 with the loss of the multiple procedure reduction exemption. Path's day is coming (ASMALLCHILD EDIT: and did) ... as will anything that generates high incomes and offers. Central planners at CMS do monitor these sorts of things and turn them against the specialty that is doing well using the faulty logic of "obviously, those codes are overvalued".

As money is sucked out of what I will call "traditional medicine", your side gigs -- and cosmetics -- will likely become both less available and less lucrative in response to the increase in the supply of folks looking for said work. (ASMALLCHILD EDIT: and did)

There really is no golden goose... and there is nowhere to hide. Bust your ass is the best advice that can be given to anyone who desires an income above the median... which is a moving target itself.

 

[asmallchild]

Just an outside observer dropping by, but one thing I've noticed is that the number of dermatologists out there has increased drastically in the past 5-10 years. Is this what you guys are all noticing or is it just my area? Back in the day (maybe 5-6 years ago), my patients would have to wait months to see a dermatologist. Now, most of my patients get in the same week if they wanted to.

I think this is still regionally dependent but in general, there is a concern that we are overtraining now and there is significant encroachment from midlevels.

I'm practicing in a desirable but quiet part of the country and it is still difficult to recruit dermatologists and even mid levels.

I think your level of competition in a big attractive city will continue to grow if we continue to train like we do (and will likely only be exacerbated by the MD / DO merger)

 

[Skindoc83]

I think your level of competition in a big attractive city will continue to grow if we continue to train like we do (and will likely only be exacerbated by the MD / DO merger)

Derm is definitely now overtraining. Residency class sizes are expanding and I’ve received emails recruiting to start up a new residency somewhere in Pennsylvania. But I think the MD DO merger will help temporarily because it will shut down the crap DO residencies, particularly in Florida. There are “residencies” where an IM or FM trained DO physician works in some guys private practice for free or sometimes pays them. They don’t do hospital consults, read path, see Peds, or do the many other things required by an ACGME accredited residency. You just freeze AKs for 3 years and then you’re considered fully trained. But derm is a volume based field and with the surge in mid levels and increase in graduating residents, our days are numbered

 

[dermie1985]

I think that changes to reimbursement models threaten derm more than increased number of training spots. Just look at that whole recent fiasco over 25 modifier codes - we avoided this, but more threats like this are coming. Every market is different, but I personally feel that, outside of a few urban areas, there really is a lack of board-certified dermatologists and the training quota increases were (and continue to be) entirely justified.

Not sure about mid-levels - if anything most dermatologists just "make" money off of derm NPs/PAs, especially in less urban areas where it can be harder to attract a board-certified dermatologist. At our practice, they essentially see wart follow-ups and easy skin checks to help offset the burden volume on our other providers to reduce our wait times (which are essentially at 3-4 months for a new patient).

 

[MedicalSport]

if anything most dermatologists just "make" money off of derm NPs/PAs

How exactly (what kind of model) are dermatologists making money off of NPs/PAs?

 

[username456789]

I think that changes to reimbursement models threaten derm more than increased number of training spots. Just look at that whole recent fiasco over 25 modifier codes - we avoided this, but more threats like this are coming. Every market is different, but I personally feel that, outside of a few urban areas, there really is a lack of board-certified dermatologists and the training quota increases were (and continue to be) entirely justified.

Not sure about mid-levels - if anything most dermatologists just "make" money off of derm NPs/PAs, especially in less urban areas where it can be harder to attract a board-certified dermatologist. At our practice, they essentially see wart follow-ups and easy skin checks to help offset the burden volume on our other providers to reduce our wait times (which are essentially at 3-4 months for a new patient).

They only make you money if you own part of the practice.

 

[cableguy555]

Lemme give you a simple example. Sculpsure, laser fat loss treatment, costs the dermatologist $75,000 for the machine. Get 5 patients a day for $1000, (market price is $1200 to $1500). So in an year that’s $1.3Million, assuming 260 working days. Machine company takes 20% of cut so you are left with $1.04 million. Consider electricity costs and nurse salary, you are left with probably $700k.

Want to get even more conservative? Assume 2.5 patients on the machine per day. Then your still left with $350k. Keep in mind that you don’t actually do the treatment, it’s the nurses who do it. You just “supervise”: meet the patient for 5 minutes, do some small talk, and then then move on to your regular consults.


The days of 500k are FAR from gone if you do cosmetics. There are lasers for nearly everything these days and most of them only require physician supervision, the nurses or PA’s can do the procedures. In addition there is no hassle with insurance and payment for cosmetics is usually taken upfront.

My dermatologist at coral gables made $3.2M last year. I used to shadow him and he loves to brag about how much he makes.

 

[MedicalSport]

It's easier said than done to build your cosmetic patient base. It's all about being able to market yourself and being business savvy.

I'm not sure how easily a new grad or even one with a couple years of experience can build their patient base to average 2.5 patients on Sculpsure per day. Furthermore, your 260 working days presumes no vacation.

A Dermatologist at Coral Gables making $3.2M is heavily impressive! However, I imagine he's been there for very long and has a wicked/awesome reputation. In other words, a successful business.

 

[cableguy555]

It's easier said than done to build your cosmetic patient base. It's all about being able to market yourself and being business savvy.

I'm not sure how easily a new grad or even one with a couple years of experience can build their patient base to average 2.5 patients on Sculpsure per day. Furthermore, your 260 working days presumes no vacation.

A Dermatologist at Coral Gables making $3.2M is heavily impressive! However, I imagine he's been there for very long and has a wicked/awesome reputation. In other words, a successful business.

Yup there are a lot of other factors involved. Coral gables has a ideal target base for dermatologists. A lot of wealthy retirees in need of mohs and other skin cancer procedures. In addition, there are over 30,000 potential young adults from colleges such as UMiami, FIU, and Miami Dade who usually come in for lip fillers, acne laser treatments, etc... And then you have your regular 30-50 year olds who usually opt for the SculpSure, fillers, and other cosmetics.

In addition, he does some sketchy, borderline unethical stuff. For example, if someone calls in for an appointment for a rash, he makes his assistant tell them that the next appointment is 2 months away. By doing this, he prioritizes cosmetic patients because most of the procedures have multiple steps requiring multiple visits. I personally was made to write over 70 fake reviews on yelp, google, zocdoc etc... And then there is a cash discount of 10%, which I'm convinced he doesn't pay taxes on.

 

[Skindoc83]

Yes, there is potential to make a lot of money in cosmetics but there a lot of docs competing for the same pool of patients. You have other derms, plastic surgeons, ENT, dentists, and sometimes IM, gyn, etc. cosmetics also has high overhead-neuromodulators, fillers are expensive and they expire. There are also high rates of office staff stealing products. Lasers often cost over 100,000 dollars and that doesn’t include a service contract or the cost of consumables like laser tips. And in the age of medispas and Groupon there is a race to the bottom with regards to cost. Furthermore your overhead becomes expensive because patients who are going to spend hundreds to thousands of dollars expect a fancy and expensive office with plush couches, soft lighting, immaculate furniture, etc. these patients also expect to be seen right away and, here’s the big one, SPEND AS MUCH TIME WITH YOU AS THEY DESIRE. That means you often spend 40 mins with a patient and you better hope that they choose to actually purchase services from you. And remember that these patients don’t ever want to wait, so you can’t overbook patients. Furthermore, these patients are often very fickle and have higher rates of mental disorders than the average medical patient, making you always scared that they will leave you a bad review or bad mouth you to their friends. Have you ever watched any of the real housewives shows? Those are the kinds of patients you catering to. And if takes a special person who can tolerate being around that kind of patient 8 hours a day 4 days a week.

 

[asmallchild]

Yup there are a lot of other factors involved. Coral gables has a ideal target base for dermatologists. A lot of wealthy retirees in need of mohs and other skin cancer procedures. In addition, there are over 30,000 potential young adults from colleges such as UMiami, FIU, and Miami Dade who usually come in for lip fillers, acne laser treatments, etc... And then you have your regular 30-50 year olds who usually opt for the SculpSure, fillers, and other cosmetics.

In addition, he does some sketchy, borderline unethical stuff. For example, if someone calls in for an appointment for a rash, he makes his assistant tell them that the next appointment is 2 months away. By doing this, he prioritizes cosmetic patients because most of the procedures have multiple steps requiring multiple visits. I personally was made to write over 70 fake reviews on yelp, google, zocdoc etc... And then there is a cash discount of 10%, which I'm convinced he doesn't pay taxes on.

I would be careful. Much of what you're saying probably is true. But derm is a small community. Even smaller in a place like South Florida...

 

[cableguy555]

I would be careful. Much of what you're saying probably is true. But derm is a small community. Even smaller in a place like South Florida...

An overwhelming amount of dermatologists are honest, hard working physicians. But for some of them, greed kicks in. All of y’all will love this: read on!!!

When dermatologists code insurance and Medicare for reimbursement , they got to code based on time spent. 99201 is less than 5 min while 99205 is about 45 minutes to 1 hour spent with the patient. Everything else is in between. And reimbursement is given proportionally.

So this dude makes sure that his consults are spread out over the week proportionally by insurance carrier. For example, if 5 Medicare patients wanted to come in on a Monday, he’d instead schedule each patient on Medicare for a each day of the week. He would do the same for patients with the same insurance company. So every day he’d have the same proportion of patients with Medicare, blue cross, Aetna, United etc...

Why does he do this? He ends up billing the highest code to each of the insurers. If he were to take all Medicare patients on one day, Medicare would flag him for fraud because you can’t bill 99205, 12 times in one day if your working hours are only 8 hours!!! Since insurers can’t share health data , he gets away with nearly twice the reimbursement money despite seeing the same amount of patients.

I could care less if I upset people. But this is what I witnessed first hand. Will I ever report this dude? Never

 

[asmallchild]

An overwhelming amount of dermatologists are honest, hard working physicians. But for some of them, greed kicks in. All of y’all will love this: read on!!!

When dermatologists code insurance and Medicare for reimbursement , they got to code based on time spent. 99201 is less than 5 min while 99205 is about 45 minutes to 1 hour spent with the patient. Everything else is in between. And reimbursement is given proportionally.

So this dude makes sure that his consults are spread out over the week proportionally by insurance carrier. For example, if 5 Medicare patients wanted to come in on a Monday, he’d instead schedule each patient on Medicare for a each day of the week. He would do the same for patients with the same insurance company. So every day he’d have the same proportion of patients with Medicare, blue cross, Aetna, United etc...

Why does he do this? He ends up billing the highest code to each of the insurers. If he were to take all Medicare patients on one day, Medicare would flag him for fraud because you can’t bill 99205, 12 times in one day if your working hours are only 8 hours!!! Since insurers can’t share health data , he gets away with nearly twice the reimbursement money despite seeing the same amount of patients.

I could care less if I upset people. But this is what I witnessed first hand. Will I ever report this dude? Never

1. If you are applying for derm and want to stay in the area, this is not wise. Even if you are applying to derm and NOT staying in the area, this is not wise. But some people have to learn the hard way. Again, I would proceed with caution. You would be surprised who lurks here and it is not hard to identify posters.

2. Again, much of what you are writing may be true. But it's also important to point out the exaggerations. E/M billing codes are not solely based on time. Most dermatologists do NOT utilize time spent with patient as the rationale for their E/M coding (there are much quicker ways to bill a higher level E/M code). And if a dermatologist is consistently billing 99205's regardless of insurance carrier, he/she will be earning an audit regardless of how they're splitting their schedule.

 

[cableguy555]

1. If you are applying for derm and want to stay in the area, this is not wise. Even if you are applying to derm and NOT staying in the area, this is not wise. But some people have to learn the hard way. Again, I would proceed with caution. You would be surprised who lurks here and it is not hard to identify posters.

2. Again, much of what you are writing may be true. But it's also important to point out the exaggerations. E/M billing codes are not solely based on time. Most dermatologists do NOT utilize time spent with patient as the rationale for their E/M coding (there are much quicker ways to bill a higher level E/M code). And if a dermatologist is consistently billing 99205's regardless of insurance carrier, he/she will be earning an audit regardless of how they're splitting their schedule.

That’s true, I don’t know all the coding nuances yet but it’s nevertheless shady. To be honest, I’m not worried about people finding out who I am.

 

[doctalaughs]

That’s true, I don’t know all the coding nuances yet but it’s nevertheless shady. To be honest, I’m not worried about people finding out who I am.

What is the point of your posts? As you said, it doesnt apply to 99.9% of dermatologists so truly you arent really talking about derm.

You can commit medical fraud in any specialty- derm isn’t unique. You can also go into cosmetics from many specialties. Those that make 3 million plus off medical cosmetics arent making money off being a doctor- it’s no different than selling obscenely expensive “designer” watches, or furniture etc. If you can convince enough rich people that your “brand” is worth it, you make bank. Your “brand” is likely no better from any rational standpoint than the guy down the street but your sales/marketing/ business acumen allows you to capture more of a limited market. Good for them, but it has nothing to do with derm or really medicine at all.

 

[ERDOC555]

Lemme give you a simple example. Sculpsure, laser fat loss treatment, costs the dermatologist $75,000 for the machine. Get 5 patients a day for $1000, (market price is $1200 to $1500). So in an year that’s $1.3Million, assuming 260 working days. Machine company takes 20% of cut so you are left with $1.04 million. Consider electricity costs and nurse salary, you are left with probably $700k.

Want to get even more conservative? Assume 2.5 patients on the machine per day. Then your still left with $350k. Keep in mind that you don’t actually do the treatment, it’s the nurses who do it. You just “supervise”: meet the patient for 5 minutes, do some small talk, and then then move on to your regular consults.


The days of 500k are FAR from gone if you do cosmetics. There are lasers for nearly everything these days and most of them only require physician supervision, the nurses or PA’s can do the procedures. In addition there is no hassle with insurance and payment for cosmetics is usually taken upfront.

My dermatologist at coral gables made $3.2M last year. I used to shadow him and he loves to brag about how much he makes.

What most people fail to remember is that very few people are doing large volume cosmetics. The overhead on some of these lasers is absurd for how little they actually get used in a regular practices.

Cosmetics is a rat race and literally every doctor that can is going to try to get a piece of the pie. Unlike rashes and skin checks, there are only a limited number of cosmetic patients to go around. This means that most doctors are doing such a small volume 0-10% that it barely makes a bump in their income.

I've also seen NP/PA, Dentist, Optho, FM, and IM all doing Botox. I've seen some of my faculty correct some pretty funny cases as well. The point is that everyone is fighting over these cash pay cosmetic patients and it's near impossible to corner the market

Sure, 1 in 300 are premiere Beverly Hills or NYC Derms pulling in 2 mil per year, but the vast majority aren't using their lasers and gadgets even close to every hour of every day.

I guess the point I'm trying to make is that being the loaded cosmetic only doctor in any field is incredibly rare, takes years to build, and involves a massive amount of luck.

 

[PatsyStone]

Here are some random thoughts:

If you don't increase the number of physicians practicing derm, mid-levels will fill the void. However, the derm labor force is unique compared to other specialties. The vast majority of dermatologists work 4 days a week or fewer; this is not true of most physicians. Additionally, with a heavy skewing of women who want to work 2 or 3 days a week to raise their kids, the true active labor force numbers are different, than, say, urology or general surgery.

I've been surprised that even in what one would assume to be "saturated" markets, the jobs exist and wait times are still long. I'm finishing residency in one of the largest metro areas, and the demand is insatiable. I know several large groups that have hired year-after-year, and despite this, their wait times have not budged. Could this change in the future? Absolutely

The issue of the DO merger is not necessarily a bad thing because it does not add to the current number being trained. If anything, it may decrease the number because not all DO programs are seeking or will meet ACGME standards

I agree with the above that a cosmetic-only practice is hard work and expensive. While we may not have a shortage of procedural dermatologists, there will probably always be a shortage of medical dermatologists

It's funny, as a med student, I thought cash-only practices were all about making more money. Turns out that cash-only practices or "we do not do prior auths" or "we will not bill your insurance directly" are about decreasing bureaucratic headaches (while also decreasing your overhead costs)

Finally, call me prejudiced, but whenever someone references how a doctor in Florida is doing something, my initial reaction is that it probably fraudulent

 

[Dr. Bruce Banner]

derm seems to be getting a lot of competition? PAs and NPs now can do a lot of things they do? I was just in family medicine and one of our attendings and her friend do almost everything a dermatologist does including excisions EXCEPT Moh's surgery. what do people think abbout that?

 

[asmallchild]

derm seems to be getting a lot of competition? PAs and NPs now can do a lot of things they do? I was just in family medicine and one of our attendings and her friend do almost everything a dermatologist does including excisions EXCEPT Moh's surgery. what do people think abbout that?

Who is making that judgement call? The family medicine attending? Her friend? I'd bet if you asked a dermatologist that wouldn't be the case.

That's like saying what can a neurologist offer that a NP working for an Neurologist cannot do... and the answer is a LOT. Neurologists are experts in the CNS, physiatrist are experts in the PNS, MSK, rehab management, and pain management.

You seem to have a pretty good handle of the situation when it comes to neurology and PM&R. It works similarly for dermatology too.

Midlevels are great at handling some of the simpler tasks in dermatology.

Primary care physicians are often also great at handling many of the simpler aspects of dermatology. (Simple, of course, can vary depending on how often you see a certain condition)

Dermatologists are experts in all aspects of the skin. My recommendation for those who are truly interested in dermatology? Become a dermatologist so you can do everything a dermatologist does and not almost everything a dermatologist does.