can you be a good dermatologist while seeing high volumes

[doctalaughs]

I've been out in practice just over 10 years.

Just wanted to pose a question mostly to practicing dermatologists here (no offense to trainees, but they don't have much perspective on this).

Do you think you can be a high-volume dermatologist (ie seeing 45+ patients/day) and still be a careful, thorough and good dermatologist?

I struggle with this. I consider myself fairly efficient and see on average 32-35/day, but when I try to get up into 40, 45 etc I find either a) running unacceptably behind b) making patients mad c) not delivering the type of quality care I think needs to be done.

It's easy to see skin checks, spot checks, acne, simple psoriasis, botox, fillers, interlesionals, slam-dunk rashes etc in 7-10 min per patient including all the documentation and a bathroom break. I could do that all day and not break a sweat.

The problem is with the smattering of complex or high-maintenance patients, which I inevitably have 2 on a good day, 5 on a bad day and WILL (for me) throw the schedule way off (even if you handle each in 20 minutes, 2 in a row and you're day is a wreck). So here are a 5 interesting hypothetical but fairly common scenarios which I'd love to hear how other derms deal with with efficiently:

1) 80 yo unhealthy male with a ton of meds/ pmhx comes in with large purpuric macules/papules on the legs, chest back x 1 week. No prior workup.

2) 40 yo obese female with severe plaque psoriasis over 40% BSA, miserable, who failed topicals, light, MTX, soriatane and needs a biologic. She also has hepatitis C and a hx of breast cancer 5 years ago currently in complete remission.

3) 65 yo farmer lives 3 hours from the city and drives in to your clinic for a bleeding lesion on his face but you notice there are literally 25 other lesions that are likely NMSC on his skin exam.

4) 55 year old anxious college professor who came to see you "because of your good rating on yelp" with a 2 page written list of inconsequential things she wishes to ask. Your staff has already told her we can address 2 problems but she is entitled, frustrated and she's a talker so keeping her happy appears it will take some type of time-investment.

5) 70 year old woman with a 12-month history of extensive dermatitis NOS. She is miserable with itch and brings 30 pages of paper records which after 3-4 min of quick review show an extensive workup from 2 prior dermatologists with multiple biopsies showing spong derm, DIF etc, tried already multiple topicals, phototherapy and patch testing with no improvement who presents to your practice as a new patient to "establish care and get to the bottom of this."

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[asmallchild]

I've been out in practice just over 10 years.

Just wanted to pose a question mostly to practicing dermatologists here (no offense to trainees, but they don't have much perspective on this).

Do you think you can be a high-volume dermatologist (ie seeing 45+ patients/day) and still be a careful, thorough and good dermatologist?

I struggle with this. I consider myself fairly efficient and see on average 32-35/day, but when I try to get up into 40, 45 etc I find either a) running unacceptably behind b) making patients mad c) not delivering the type of quality care I think needs to be done.

It's easy to see skin checks, spot checks, acne, simple psoriasis, botox, fillers, interlesionals, slam-dunk rashes etc in 7-10 min per patient including all the documentation and a bathroom break. I could do that all day and not break a sweat.

The problem is with the smattering of complex or high-maintenance patients, which I inevitably have 2 on a good day, 5 on a bad day and WILL (for me) throw the schedule way off (even if you handle each in 20 minutes, 2 in a row and you're day is a wreck). So here are a 5 interesting hypothetical but fairly common scenarios which I'd love to hear how other derms deal with with efficiently:

1) 80 yo unhealthy male with a ton of meds/ pmhx comes in with large purpuric macules/papules on the legs, chest back x 1 week. No prior workup.

2) 40 yo obese female with severe plaque psoriasis over 40% BSA, miserable, who failed topicals, light, MTX, soriatane and needs a biologic. She also has hepatitis C and a hx of breast cancer 5 years ago currently in complete remission.

3) 65 yo farmer lives 3 hours from the city and drives in to your clinic for a bleeding lesion on his face but you notice there are literally 25 other lesions that are likely NMSC on his skin exam.

4) 55 year old anxious college professor who came to see you "because of your good rating on yelp" with a 2 page written list of inconsequential things she wishes to ask. Your staff has already told her we can address 2 problems but she is entitled, frustrated and she's a talker so keeping her happy appears it will take some type of time-investment.

5) 70 year old woman with a 12-month history of extensive dermatitis NOS. She is miserable with itch and brings 30 pages of paper records which after 3-4 min of quick review show an extensive workup from 2 prior dermatologists with multiple biopsies showing spong derm, DIF etc, tried already multiple topicals, phototherapy and patch testing with no improvement who presents to your practice as a new patient to "establish care and get to the bottom of this."

Very interesting topic, would love to hear the answers

I'm afraid I can't chime in too much on the hypotheticals as I don't do much gen derm anymore

From the surgical perspective, I think the same problem is encountered.

I've spent the last few years furiously trying to build a patient base and trying to get busier and busier. This is the first year where I've feel I'm reaching my limit in terms of cases performed per day while still delivering what I consider to be acceptable results. As the case load grows, I also struggle with staying on time (especially for established patients who have been with me for a while and have come to expect that their surgical day ends at a certain time) and not angering patients.

I don't know what I am going to do. I see 2 choices.

Choice #1 is to cap my schedule at a number I feel comfortable with, thereby allowing me to continue seeing all kinds of cases from the slam-dunk ones to the complex reconstructions. I practice in a large multi-specialty group so I'm sure there are plenty of other doctors that would be happy to catch my overflow. I can understand the difficulty of doing so in a solo practice as I would now be making patients wait longer for care.

Choice #2 is to continue growing my practice but outsourcing the "time drains". While this would be the more lucrative option, I'm afraid it's a slippery slope and would result in continually increasing referral of cases and ultimately skill atrophy (e.g. hire a PA for simple closures, coordinate with plastics for closures I don't want to do)

 

[Dral]

I don't think so. However, it of course depends on specifics of how a practice is set up (scribes, quality of scribes, support staff, etc).

I feel that part of providing good care is setting up a good social connection with the patient, or at least attempting. It's impossible to do with such short visit times. Also, "I have to pay $50? I was only with the doctor for 5 minutes????!?"

Of note, I would take almost any scenario over your scenario #4 (other than maybe a delusions of parasitosis patient)

 

[doctalaughs]

I don't think so. However, it of course depends on specifics of how a practice is set up (scribes, quality of scribes, support staff, etc).

I feel that part of providing good care is setting up a good social connection with the patient, or at least attempting. It's impossible to do with such short visit times. Also, "I have to pay $50? I was only with the doctor for 5 minutes????!?"

Of note, I would take almost any scenario over your scenario #4 (other than maybe a delusions of parasitosis patient)

I've come to the same conclusion- just wanted to see if anyone had a contrary opinion or super-efficient but appropriate way to deal with these type of situations. In my mind, no matter how good your support staff and scribes are, in order to see those super-high volumes you need do one of 3 things.

1. Refuse to take certain cases (ie "I don't see any rashes" or "I don't treat complex psoriasis or use systemic meds")
2. Send everything complex or time-consuming away (ie to the local university, or to your poor non-partner junior associate)
3. Do a perfunctory/poor job for complex or high-maintenance patients, thereby ensuring they will not return to you.

All 3 situations are unethical in my mind, so I guess my volume is capped.

 

[reno911]

I've come to the same conclusion- just wanted to see if anyone had a contrary opinion or super-efficient but appropriate way to deal with these type of situations. In my mind, no matter how good your support staff and scribes are, in order to see those super-high volumes you need do one of 3 things.

1. Refuse to take certain cases (ie "I don't see any rashes" or "I don't treat complex psoriasis or use systemic meds")
2. Send everything complex or time-consuming away (ie to the local university, or to your poor non-partner junior associate)
3. Do a perfunctory/poor job for complex or high-maintenance patients, thereby ensuring they will not return to you.

All 3 situations are unethical in my mind, so I guess my volume is capped.

I think you're more or less right. I think you could see very large volumes if you worked insane hours. That's extremely rare though.

I would disagree with the "unethical" part and I more or less have the same mindset as you. I only do Mohs, but I treat all tumors and do virtually all of my own reconstructions. Nevertheless I don't see docs who choose not to do certain complicated things as unethical. I don't think there is anything ethically wrong about limiting one's practice for most reasons. The reasons involved here are definitely not admirable. I just view people who do this sort of thing as just as not very good. I just don't want to be like that, so I don't do it myself, even if I could make more money that way.

People who do this kind of thing are probably greedy and are probably not very good dermatologists, but I'm not sure I can quite get to unethical in most cases. It really depends on what exactly they are doing.

 

[doctalaughs]

I think you're more or less right. I think you could see very large volumes if you worked insane hours. That's extremely rare though.

I would disagree with the "unethical" part and I more or less have the same mindset as you. I only do Mohs, but I treat all tumors and do virtually all of my own reconstructions. Nevertheless I don't see docs who choose not to do certain complicated things as unethical. I don't think there is anything ethically wrong about limiting one's practice for most reasons. The reasons involved here are definitely not admirable. I just view people who do this sort of thing as just as not very good. I just don't want to be like that, so I don't do it myself, even if I could make more money that way.

People who do this kind of thing are probably greedy and are probably not very good dermatologists, but I'm not sure I can quite get to unethical in most cases. It really depends on what exactly they are doing.

I suppose unethical for some cases (providing poor care on purpose in order to move the meat along and get the "easy cases") and just greedy/bad doctor for others (offloading the complex stuff to others on purpose).

It's one thing to be a cosmetic-only dermatologist and deal that population because you've built up enough of those clients through years of hard work. Or a mohs surgeon who only does surgery (of course).

It's another thing to be a general dermatologist who purposely decides not to see rashes, or even the most basic of systemic drugs (imagine a rheumatologist who refused to prescribe DMARDs). Unethical or not, I think that's the point where you really become not a doctor and more of a glorified midlevel.

 

[reno911]

I suppose unethical for some cases (providing poor care on purpose in order to move the meat along and get the "easy cases") and just greedy/bad doctor for others (offloading the complex stuff to others on purpose).

It's one thing to be a cosmetic-only dermatologist and deal that population because you've built up enough of those clients through years of hard work. Or a mohs surgeon who only does surgery (of course).

It's another thing to be a general dermatologist who purposely decides not to see rashes, or even the most basic of systemic drugs (imagine a rheumatologist who refused to prescribe DMARDs). Unethical or not, I think that's the point where you really become not a doctor and more of a glorified midlevel.

I think we're mostly on the same page. I just don't think it's quite unethical.

For example, a long time ago, I knew a high-volume general derm who did pretty much this. Saw about 100 pts per day. If something complicated came in he just told the patient that they would be better served by going to the university and seeing someone who deals with complex medical derm more frequently. He also didn't charge the patient for the visit. The person he referred to was also someone I knew and was without question absolutely better at those things than he was (and virtually anyone else I've ever met).

I'm not sure I'm ready to call that behavior unethical, but it's certainly not something to be proud of.

 

[doctalaughs]

I think we're mostly on the same page. I just don't think it's quite unethical.

For example, a long time ago, I knew a high-volume general derm who did pretty much this. Saw about 100 pts per day. If something complicated came in he just told the patient that they would be better served by going to the university and seeing someone who deals with complex medical derm more frequently. He also didn't charge the patient for the visit. The person he referred to was also someone I knew and was without question absolutely better at those things than he was (and virtually anyone else I've ever met).

I'm not sure I'm ready to call that behavior unethical, but it's certainly not something to be proud of.

Interesting... I know dermatologists that see 60 a day and think they are providing sh*itty care. 100 a day is extreme though.... Out of curiosity what would he do for situation #1, #3 and #4 I put above (I assume he would send #2 and #5 to the university)?

In an regular clinic day that would be an average of 4 minutes 45 sec per patient. Can you even physically do a cursory skin exam and a biopsy or two in this situation? I suppose physically it seems possible if you make sure there is zero communication between physician and patient (like examining a piece of meat). Obviously all the documentation, coding, counseling and med-ordering would have to be done by scribes or staff.

 

[reno911]

Interesting... I know dermatologists that see 60 a day and think they are providing sh*itty care. 100 a day is extreme though.... Out of curiosity what would he do for situation #1, #3 and #4 I put above (I assume he would send #2 and #5 to the university)?

In an regular clinic day that would be an average of 4 minutes 45 sec per patient. Can you even physically do a cursory skin exam and a biopsy or two in this situation? I suppose physically it seems possible if you make sure there is zero communication between physician and patient (like examining a piece of meat). Obviously all the documentation, coding, counseling and med-ordering would have to be done by scribes or staff.

Well, I'm just guessing, but 1 goes to university. On 4, I have no idea. 3 he would probably take care of. Just biopsy the worst ones and then have him come back for more later.

Of course, he wouldn't biopsy himself. He had staff to do all the biopsies, cryo, and destructions. If I remember correctly, there was not a lot of competition where he practiced, so his patients didn't have a lot of choice. About 1 hr from university, so making someone go there wasn't that horrible. Also his days were long (10-12hrs I think), but I don't think he did it 5 days a week.

 

[asmallchild]

I've been out in practice just over 10 years.

Just wanted to pose a question mostly to practicing dermatologists here (no offense to trainees, but they don't have much perspective on this).

Do you think you can be a high-volume dermatologist (ie seeing 45+ patients/day) and still be a careful, thorough and good dermatologist?

I struggle with this. I consider myself fairly efficient and see on average 32-35/day, but when I try to get up into 40, 45 etc I find either a) running unacceptably behind b) making patients mad c) not delivering the type of quality care I think needs to be done.

It's easy to see skin checks, spot checks, acne, simple psoriasis, botox, fillers, interlesionals, slam-dunk rashes etc in 7-10 min per patient including all the documentation and a bathroom break. I could do that all day and not break a sweat.

The problem is with the smattering of complex or high-maintenance patients, which I inevitably have 2 on a good day, 5 on a bad day and WILL (for me) throw the schedule way off (even if you handle each in 20 minutes, 2 in a row and you're day is a wreck). So here are a 5 interesting hypothetical but fairly common scenarios which I'd love to hear how other derms deal with with efficiently:

1) 80 yo unhealthy male with a ton of meds/ pmhx comes in with large purpuric macules/papules on the legs, chest back x 1 week. No prior workup.

2) 40 yo obese female with severe plaque psoriasis over 40% BSA, miserable, who failed topicals, light, MTX, soriatane and needs a biologic. She also has hepatitis C and a hx of breast cancer 5 years ago currently in complete remission.

3) 65 yo farmer lives 3 hours from the city and drives in to your clinic for a bleeding lesion on his face but you notice there are literally 25 other lesions that are likely NMSC on his skin exam.

4) 55 year old anxious college professor who came to see you "because of your good rating on yelp" with a 2 page written list of inconsequential things she wishes to ask. Your staff has already told her we can address 2 problems but she is entitled, frustrated and she's a talker so keeping her happy appears it will take some type of time-investment.

5) 70 year old woman with a 12-month history of extensive dermatitis NOS. She is miserable with itch and brings 30 pages of paper records which after 3-4 min of quick review show an extensive workup from 2 prior dermatologists with multiple biopsies showing spong derm, DIF etc, tried already multiple topicals, phototherapy and patch testing with no improvement who presents to your practice as a new patient to "establish care and get to the bottom of this."

The first patient I ever saw as a med student on a derm rotation was patient #4.

The resident I was shadowing told me that the best way to deal with these patients is to obtain the list from them ASAP. He called it "controlling the list" because many of the items on the list can be consolidated into the same group thereby saving time. It also helps to address the patient with direct eye contact rather than have them constantly look down and scan the list.

He said the sooner you can grab the list, the sooner you can control how the visit will go.

In practice, even with controlling the list, I struggled terribly with these patients and found it sunk my morning or afternoon session. While I don't have a "2 problem limit" to my appointments, the best solution I found was to explain to them that I cannot address all their issues in one visit, that I would address the 2 most pressing issues today, and that I would give them the last appointment of the day on another day so I can dedicate as much time as they need to run through the list. I've also found the more you try to talk, the more they feel the need to interrupt which tends to frustrate me. So at that lengthy 2nd appointment, I tell them I want them to go through the list and I won't interrupt until they are done. I let them talk themselves to exhaustion. Then when I do go through my spiel, I ask that they don't interrupt until the end. It's still a rather painful exercise and the thing I miss least about gen derm. I do bill them for both office visits.

 

[doctalaughs]

Well, I'm just guessing, but 1 goes to university. On 4, I have no idea. 3 he would probably take care of. Just biopsy the worst ones and then have him come back for more later.

Of course, he wouldn't biopsy himself. He had staff to do all the biopsies, cryo, and destructions. If I remember correctly, there was not a lot of competition where he practiced, so his patients didn't have a lot of choice. About 1 hr from university, so making someone go there wasn't that horrible. Also his days were long (10-12hrs I think), but I don't think he did it 5 days a week.

Makes sense.... I hope for #1 he at least did a cursory ROS and bloodwork to make sure the guy didn't damage his kidney or bowel etc by the time he made it to university a week later.... same for all the (luckily rare) conditions that need some sort of immediate workup.

 

[TMP-SMX]

I'm in gen derm academics so my opinion is somewhat skewed, but in private practice it depends on how you are documenting and how versatile your MAs are. With scribes one can be efficient in documentation and also have sit down time with your patients. Being in academics, I can focus on that type of interaction with patients as I've already whittled the problem and ddx before going in the room. I've seen some questionable stuff in some private practices, but as long as we have a fee for service reimbursement model rather than value based payment model I don't think that will change.

 

[reno911]

Makes sense.... I hope for #1 he at least did a cursory ROS and bloodwork to make sure the guy didn't damage his kidney or bowel etc by the time he made it to university a week later.... same for all the (luckily rare) conditions that need some sort of immediate workup.

Once again, I'm just guessing, but if it was truly urgent, he would probably either call and get them into clinic the same day or send them to the university ER. If you're on the other end of that phone call, you're going to be seeing it either way, so you'll probably just find a clinic spot to make it easier on everyone.

I got calls like that from community derms occasionally when I was a resident.

 

[smartparts]

#5 gets empiric dupilumab for 3 months

 

[MOHS_01]

I've been out in practice just over 10 years.

Just wanted to pose a question mostly to practicing dermatologists here (no offense to trainees, but they don't have much perspective on this).

Do you think you can be a high-volume dermatologist (ie seeing 45+ patients/day) and still be a careful, thorough and good dermatologist?

I struggle with this. I consider myself fairly efficient and see on average 32-35/day, but when I try to get up into 40, 45 etc I find either a) running unacceptably behind b) making patients mad c) not delivering the type of quality care I think needs to be done.

It's easy to see skin checks, spot checks, acne, simple psoriasis, botox, fillers, interlesionals, slam-dunk rashes etc in 7-10 min per patient including all the documentation and a bathroom break. I could do that all day and not break a sweat.

The problem is with the smattering of complex or high-maintenance patients, which I inevitably have 2 on a good day, 5 on a bad day and WILL (for me) throw the schedule way off (even if you handle each in 20 minutes, 2 in a row and you're day is a wreck). So here are a 5 interesting hypothetical but fairly common scenarios which I'd love to hear how other derms deal with with efficiently:

1) 80 yo unhealthy male with a ton of meds/ pmhx comes in with large purpuric macules/papules on the legs, chest back x 1 week. No prior workup.

2) 40 yo obese female with severe plaque psoriasis over 40% BSA, miserable, who failed topicals, light, MTX, soriatane and needs a biologic. She also has hepatitis C and a hx of breast cancer 5 years ago currently in complete remission.

3) 65 yo farmer lives 3 hours from the city and drives in to your clinic for a bleeding lesion on his face but you notice there are literally 25 other lesions that are likely NMSC on his skin exam.

4) 55 year old anxious college professor who came to see you "because of your good rating on yelp" with a 2 page written list of inconsequential things she wishes to ask. Your staff has already told her we can address 2 problems but she is entitled, frustrated and she's a talker so keeping her happy appears it will take some type of time-investment.

5) 70 year old woman with a 12-month history of extensive dermatitis NOS. She is miserable with itch and brings 30 pages of paper records which after 3-4 min of quick review show an extensive workup from 2 prior dermatologists with multiple biopsies showing spong derm, DIF etc, tried already multiple topicals, phototherapy and patch testing with no improvement who presents to your practice as a new patient to "establish care and get to the bottom of this."

Welcome to Established Practice Quandaries 101; it's the Kobayashi Maru of medicine with derm being more extreme in application than other specialties quite likely. You'll go hungry and broke running a 50 person per day operation and getting bogged down in complex inflammatory conditions, so my best solution is to recognize what requires the extra time and that person has to schedule for one of those complex derm spots. You limit the number of them that you have, limit the number and scope of emergency work-ins, and come to grips internally that the trade off for greater attention / intensity of service maybe a longer wait for that service. If you don't compromise or dilute the necessary quality of service, you should sleep well at night. Don't fret with a clock, the visit only takes as long as is necessary to do a good job... and it averages out in the end.

I can tell you that all volume is not equal, either. My caseload per day has actually declined since 2012-13, but the difficulty, acuity, and basic BS level has not. Gone are the days of the simple primary 1cm BCC in the middle of the cheek or forehead, oh no, those have to be ED&C plus aldara, superficial XRT, excised x 3, or some other similar story before referring on (only a small exaggeration, wish I was kidding). 10 years ago I was doing roughly the same number of cases, but they were mostly simple and relatively small cases, cleared in a single stage, and capable of being closed primarily. That has gone from 70-80% of my day to maybe 15-20%? It's been a crazy change.

 

[MOHS_01]

Very interesting topic, would love to hear the answers

I'm afraid I can't chime in too much on the hypotheticals as I don't do much gen derm anymore

From the surgical perspective, I think the same problem is encountered.

I've spent the last few years furiously trying to build a patient base and trying to get busier and busier. This is the first year where I've feel I'm reaching my limit in terms of cases performed per day while still delivering what I consider to be acceptable results. As the case load grows, I also struggle with staying on time (especially for established patients who have been with me for a while and have come to expect that their surgical day ends at a certain time) and not angering patients.

I don't know what I am going to do. I see 2 choices.

Choice #1 is to cap my schedule at a number I feel comfortable with, thereby allowing me to continue seeing all kinds of cases from the slam-dunk ones to the complex reconstructions. I practice in a large multi-specialty group so I'm sure there are plenty of other doctors that would be happy to catch my overflow. I can understand the difficulty of doing so in a solo practice as I would now be making patients wait longer for care.

Choice #2 is to continue growing my practice but outsourcing the "time drains". While this would be the more lucrative option, I'm afraid it's a slippery slope and would result in continually increasing referral of cases and ultimately skill atrophy (e.g. hire a PA for simple closures, coordinate with plastics for closures I don't want to do)

That's where I was 5 years ago. I went with choice #1 with a smattering of #2, coordinating with plastics for the "difficult" patients (not cases, personalities). I also attempt to restrict rashes... but they still manage to squeak by with the old "bleeding spot on the nose" complaint...