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Feasibility of a dermatology practice....

Derminterest

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    For those who have knowledge about the benefits and challenges of having a derm practice, please respond to my dilemma.

    I am in my mid-30's and would like to do derm. I feel confident that a residency is within my reach. My concern is that by the time I finish, I'll be 40+ and am wondering how feasible a derm practice would be for me. If I was to do dermatology, I'd like to have a practice near a metropolitan area. I would like to do derm and perhaps some cosmetics. If I was to hire a physicians assistant, what is the potential take home salary that I could realize after a year or two in practice? By doing a Mohs fellowship and join a dermatology group, what potential income could I realize? Also, I enjoy international travel once or twice each year, how is this doable being a business owner? Are the benefits of having a business worth the headaches? I do not want to practice medicine day to day, just getting by financially. I have seen some family practice docs do this and felt sorry for them. They work so hard, just to be a little above the break even point.

    Hospital base medicine seems financially attractive. A friend who is an anesthesiologist just signed a contract for $300k/year. No overhead and guaranteed income. Sometimes, I consider my age and loans and think this may be appropriate for me, even though my interest is in skin.

    I realize that financial info is a sensitive issue. I also realize my age and the loans I have to repay. I live simply and do not expect to get rich from my pursuit. Please share your knowledge, experiences or advice. Thanks for helping. :)
     

    Mariah246

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      I feel confident that a residency is within my reach

      If you haven't started med school yet and could only see yourself happy as a dermatologist, I would recommend not doing it.

      No one is 100% confident that a derm residency is within their reach.

      I hate to rain on the party but that would prove to be the bigger hurdle at this point. Not setting up a business in a competitive urban area.
       

      Derminterest

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        If you haven't started med school yet and could only see yourself happy as a dermatologist, I would recommend not doing it.

        No one is 100% confident that a derm residency is within their reach.

        I hate to rain on the party but that would prove to be the bigger hurdle at this point. Not setting up a business in a competitive urban area.


        Your response is entertaining and quite presumptuous. For your edification, I am currently in a MD/PhD program in the Northeast part of the U.S. and AOA status. Initially, academic research was my pursuit, however, some life experiences have changed this. About a year ago, I became a single parent after I adopted the child of a relative who passed away. Also, through my med school rotations I realized that I enjoy the clinic and working with people. Research has been consuming and with a little one that I am now responsible for, I want more control over my schedule. Dermatology was of most interest to me. Only until I researched about it did I find it to be quite competitive. Fortunately, through my program and research I have made several notable contacts, one who happens to be a derm. residency director. I spoke to this person about my situation and interests and they suggested that I apply to their program. So, you are correct, I am not 100% that I can get derm. However, as initially stated, I feel a derm residency is within reach.

        And you may ask, why do I not propose my initial concerns to the residency director? This person is primarily academic and at the point of retirement. I thought, perhaps, this forum is where the derm residents or practicing derms could help.
         
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        orbitsurgMD

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          For those who have knowledge about the benefits and challenges of having a derm practice, please respond to my dilemma.

          I am in my mid-30's and would like to do derm. I feel confident that a residency is within my reach. My concern is that by the time I finish, I'll be 40+ and am wondering how feasible a derm practice would be for me. If I was to do dermatology, I'd like to have a practice near a metropolitan area. I would like to do derm and perhaps some cosmetics. If I was to hire a physicians assistant, what is the potential take home salary that I could realize after a year or two in practice? By doing a Mohs fellowship and join a dermatology group, what potential income could I realize? Also, I enjoy international travel once or twice each year, how is this doable being a business owner? Are the benefits of having a business worth the headaches? I do not want to practice medicine day to day, just getting by financially. I have seen some family practice docs do this and felt sorry for them. They work so hard, just to be a little above the break even point.

          Hospital base medicine seems financially attractive. A friend who is an anesthesiologist just signed a contract for $300k/year. No overhead and guaranteed income. Sometimes, I consider my age and loans and think this may be appropriate for me, even though my interest is in skin.

          I realize that financial info is a sensitive issue. I also realize my age and the loans I have to repay. I live simply and do not expect to get rich from my pursuit. Please share your knowledge, experiences or advice. Thanks for helping. :)

          As a non-dermatology specialist (ophthalmic plastic surgery) who has only observed what dermatologist colleagues have been able to do in private practice, I think the most difficult hurdle you will have is getting a residency slot. Once board-eligible, I think you will have no difficulty establishing a viable practice. Just about every dermatologist I have ever worked with has had the problem of having too many patients. This is true even in the most "overserved" markets. Most have had to either limit their practices or close off to new patients. The Mohs surgeon I work with most frequently routinely has his front office staff reject physician referrals.

          It is only because I can advance the diagnostic process by performing biopsies and sending referrals with a pathological diagnosis that I can jump the line, so to speak and get a Mohs excision done when I think that is the best approach.

          I would guess you would have a full practice in a year.
           

          MOHS_01

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            "Full" practice in one year is more unlikely than one would believe, depending upon your definition of full, but you will be busy. Income is very, very variable depending upon practice location, disease & patient mix, volume, etc.


            Mohs vs general derm -- really depends on what you like to do and how you want to practice. Every Mohs surgeon that I know did the fellowship because they like the reconstructions, not the tumor extirpation. With the changes in reimbursement this year one can no longer make a strong economic case for doing the fellowship, so its value is questionable at this time. Strictly speaking, a fellowship is not required to perform micrographic surgery (you can always be a "weekend warrior" and go the Mohs society route, and be chastised and ridiculed by duly trained surgeons).

            Starting a practice is a very slow and painful way to start out -- I did it two years ago. I would strongly suggest looking into alternative practice models (for a multitude of reasons).

            Another thing to consider is that dermatology is on everyone's, including the payors, hit list. To put it bluntly -- if every naive and inexperienced med student knows that dermatology is a good gig (which it is, but not nearly as good as everyone outside of it believes), the payors do too. They already target the integumentary series of codes (UHC started that trend) in comparison to other systems, and this will continue (at least it would if I owned an insurance company). If you don't believe this is true or possible -- ask any ophtho how well cataracts pay today compared to years gone by. Everyone gets their day on the chopping block....
             

            leagueelbow

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              Isn't there an option to deny insurance companies though?

              The dermatologist in my home town has such a stacked waiting list that he actually stopped taking insurance.

              First consultation: $500

              Every other visit: $100

              My parents happen to be family friends with him so I squeak by with the "bargain basement" payment of $50 per visit.

              Needless to say, I'll be finding a new doctor on campus.

              But if that guy does it, isn't it possible for others to do so? (Considering the low supply, high demand, and insane waiting lists out there)
               

              MOHS_01

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                Well.... tell me where your hometown is and I guarantee that I can remedy this in short order.

                Everyone is on the "insane waiting time" kick -- I believe that this is another case of perception greater than reality. Merritt Hawkins did a study in 2004 comparing wait times for various specialties in several major metros. Dermatology was not significantly longer than most of the specialties represented -- and, arguably, it is acceptable and appropriate that dermatology wait times are longer.

                Several things factor into this as well -- the number of hours that dermatologists work (I have always contended that there is no shortage; rather, we are turning out far too many part time prima donnas wanting to do cosmetics, etc). Case in point -- wait times for a patient wanting Botox injections were shorter than wait times for a changing mole.
                 

                Doublecortin

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                  "Full" practice in one year is more unlikely than one would believe, depending upon your definition of full, but you will be busy. Income is very, very variable depending upon practice location, disease & patient mix, volume, etc.


                  Mohs vs general derm -- really depends on what you like to do and how you want to practice. Every Mohs surgeon that I know did the fellowship because they like the reconstructions, not the tumor extirpation. With the changes in reimbursement this year one can no longer make a strong economic case for doing the fellowship, so its value is questionable at this time. Strictly speaking, a fellowship is not required to perform micrographic surgery (you can always be a "weekend warrior" and go the Mohs society route, and be chastised and ridiculed by duly trained surgeons).

                  Starting a practice is a very slow and painful way to start out -- I did it two years ago. I would strongly suggest looking into alternative practice models (for a multitude of reasons).

                  Another thing to consider is that dermatology is on everyone's, including the payors, hit list. To put it bluntly -- if every naive and inexperienced med student knows that dermatology is a good gig (which it is, but not nearly as good as everyone outside of it believes), the payors do too. They already target the integumentary series of codes (UHC started that trend) in comparison to other systems, and this will continue (at least it would if I owned an insurance company). If you don't believe this is true or possible -- ask any ophtho how well cataracts pay today compared to years gone by. Everyone gets their day on the chopping block....
                  do you think the procedural derm fellowship is worth it?
                   

                  MOHS_01

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                    do you think the procedural derm fellowship is worth it?

                    Depends upon your definition of worth -- financially, there is no way to make the numbers work. Given the fact that it is not a ABMS recognized specialty, with no plans by the AAD to pursue subspecialty recognition, there is no financially justifiable incentive to endure the fellowship. Now if you want to be "the best person for the job", then that is another matter entirely.... but in the current medical system "being the best" does not pay any better than "being average" or "being the worst", and it arguably pays less (b/c it takes longer to do a job right than to half a** it).

                    That said, I did a fellowship... even knowing that the financial rewards did not justify it (for surgical dermatology)... but, I know when I enter the room that I am the most qualified, best trained individual within 100 mile radius to do the job, and do it right... which was (and is) important to me.
                     

                    Doublecortin

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                      Depends upon your definition of worth -- financially, there is no way to make the numbers work. Given the fact that it is not a ABMS recognized specialty, with no plans by the AAD to pursue subspecialty recognition, there is no financially justifiable incentive to endure the fellowship. Now if you want to be "the best person for the job", then that is another matter entirely.... but in the current medical system "being the best" does not pay any better than "being average" or "being the worst", and it arguably pays less (b/c it takes longer to do a job right than to half a** it).

                      That said, I did a fellowship... even knowing that the financial rewards did not justify it (for surgical dermatology)... but, I know when I enter the room that I am the most qualified, best trained individual within 100 mile radius to do the job, and do it right... which was (and is) important to me.
                      yes, I meant financially, even if you focus your practice on doing elective procedures, such as laser, lipo, etc. you don't think it's worth investing an extra year to get that extra training?
                       

                      MOHS_01

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                        yes, I meant financially, even if you focus your practice on doing elective procedures, such as laser, lipo, etc. you don't think it's worth investing an extra year to get that extra training?

                        Honestly? No, not financially, and I'll tell you why.

                        As a dermatologist, you will predominantly be limited to minimally invasive procedures (excluding lipo and possibly resurfacing, which has largely fallen by the wayside due to complication rates). These quick, easy, low $$ procedures are the very same ones that your Ob's, gen surg's, FP's, internists, your grandma, her aunt, cousin Susie's next door neighbor's kid who went to school for two years and is now a nurse, etc will be performing in low cost, high volume "spas". All of this will cap what you can effectively charge for the procedures, thereby limiting your potential revenue stream.

                        I cannot say this strongly enough -- cosmetic dermatology is not an easy path to riches. If you like aesthetic medicine, jump in the race for an integrated plastic surgery residency.....
                         

                        leagueelbow

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                          Honestly? No, not financially, and I'll tell you why.

                          As a dermatologist, you will predominantly be limited to minimally invasive procedures (excluding lipo and possibly resurfacing, which has largely fallen by the wayside due to complication rates). These quick, easy, low $$ procedures are the very same ones that your Ob's, gen surg's, FP's, internists, your grandma, her aunt, cousin Susie's next door neighbor's kid who went to school for two years and is now a nurse, etc will be performing in low cost, high volume "spas". All of this will cap what you can effectively charge for the procedures, thereby limiting your potential revenue stream.

                          I cannot say this strongly enough -- cosmetic dermatology is not an easy path to riches. If you like aesthetic medicine, jump in the race for an integrated plastic surgery residency.....

                          I'm conflicted here. On the one hand, I would think that people do ultimately opt for the cheapest price in shopping for a procedure.

                          On the other, there's probably a whole slew of people willing to pay more to receive the treatment, beautifying cream, ::insert aesthetic procedure of choice:: from a dermatologist and not a nurse/family practitioner/OBGYN
                           

                          Doublecortin

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                            I'm conflicted here. On the one hand, I would think that people do ultimately opt for the cheapest price in shopping for a procedure.

                            On the other, there's probably a whole slew of people willing to pay more to receive the treatment, beautifying cream, ::insert aesthetic procedure of choice:: from a dermatologist and not a nurse/family practitioner/OBGYN
                            i agree, yes there will be riffraff who would be looking for the cheapest price on a cosmetic procedure, even if it's done by someone with no proper credentials and no proper training, such as a nurse, beautician, a high school dropout etc. it's the same kind of people who take the medical tourism trips to have their boobs done on the cheap in india or thailand.

                            but i think there will be plenty of well-to-do, educated, intelligent people, who care about their health, who would look for a board certified derm of plastics guy and would be willing to spend a little extra to have the procedure done right by the professional
                             

                            leagueelbow

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                              That being said, the irony is that while they're paying the premium to get it done at a derm/plastic office, sometimes it's the medical assistant performing the minor procedures "under the supervision of the derm/plastic surgeon"
                               
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