Has derm always been a comfy/well paid specialty? Will it always be?

imtheman25

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50 years ago was derm still number 1?....where attendings got paid $$$$ and had a relatively nice work/life balance? I am just curious beacause i want to know if things will change in the future for derm and other specialties like ortho etc.
 
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Dantes

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I've read that ortho was once one of the least competitive specialties, which has obviously changed since so who knows. Depends on what kind of healthcare we'll have in the future and the model of compensation.
 

Pagan FutureDoc

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Derm will likely remain a lifestyle speciality for some time, however compensation is always subject to change.
 

allantois

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Yea, they are in incredibly low supply (300 graduates a year?). The appointments are 5 min long and they do lots of small procedures.
 
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altblue

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It isn't just about the work/life/money balance, you should also enjoy what you do.
 
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50 years ago was derm still number 1?....where attendings got paid $$$$ and had a relatively nice work/life balance? I am just curious beacause i want to know if things will change in the future for derm and other specialties like ortho etc.
50 years ago, in 1967, the marketplace for physicians was vastly different than it was today with fee for service by most physicians, the vast majority were independent practitioners that had much more general practices than anything today. For example my GP as a child, had delivered babies, done surgeries, and treated kids during his career. Medicare had just come into existence a few years before and models for pricing were still being developed . The number of Dermatologists doubled from 1965-1989 (3500-7300) and now currently is about 8,000-8,500 so relatively stable or slow growth over past 20 years. That would imply a stable market in the future.
 
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Coltuna

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Was just talking to an attending about this the other day. He showed me some video that portrayed orthopods as these oofs who always say "must fix fracture." He was surprised when I told him it's one of the more competitive specialties these days.
 
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Dermatology is one of the most misunderstood specialties, given that physicians learn almost zero derm in their training. There is no free lunch. If you honestly think you can make good $ while being lazy/unproductive, you are misled.

Also, the concept of "number 1" you pose here is silly; there's no such thing. Attendings in many fields have a similar lifestyles to Derm, even in some fields you would not think possible (e.g. surgical fields). Decide if you like the field first, but only do so after spending ample time on service. Without that, you won't truly understand what being a resident/attending in a field is like and you will end up spewing the same old tired generalizations around that each field has.

If interested in really understanding Derm, i'd recommend a full months rotation at an academic institution and research together. Try to get enough clinical experiences in all subspecialty areas if possible (i.e. get enough dermpath, mohs surgery/reconstruction/procedural, medical derm (blistering, CTCL, rheum, autoimmune, infectious, etc), inpatient, and pediatric if possible). Make sure you also attend resident education and try to read through a few chapters of a derm text (like Fitzpatrick) to get a sense of the detail and if you like it. this will allow to you decide if you are interested, after seeing all the pieces at hand.
 
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SunsFun

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Dermatology is one of the most misunderstood specialties, given that physicians learn almost zero derm in their training. There is no free lunch. If you honestly think you can make good $ while being lazy/unproductive, you are misled.

Also, the concept of "number 1" you pose here is silly; there's no such thing. Attendings in many fields have a similar lifestyles to Derm, even in some fields you would not think possible (e.g. surgical fields). Decide if you like the field first, but only do so after spending ample time on service. Without that, you won't truly understand what being a resident/attending in a field is like and you will end up spewing the same old tired generalizations around that each field has.

If interested in really understanding Derm, i'd recommend a full months rotation at an academic institution and research together. Try to get enough clinical experiences in all subspecialty areas if possible (i.e. get enough dermpath, mohs surgery/reconstruction/procedural, medical derm (blistering, CTCL, rheum, autoimmune, infectious, etc), inpatient, and pediatric if possible). Make sure you also attend resident education and try to read through a few chapters of a derm text (like Fitzpatrick) to get a sense of the detail and if you like it. this will allow to you decide if you are interested, after seeing all the pieces at hand.
Why not just spend some time at a community program/small clinic to get a better feel for what the actual majority of practicing dermatologists does? He/she may end up doing things with their hands even if invited to shadow only instead of just standing around waiting for resident to finish yet another note.

This comment is not limited to derm. Sometimes bread-and-butter community hospitals are way more useful and fun than super-specialized academic centers with countless residents, fellows, research fellows, other students, observers and enormous amount of scut. This may not be the case for every program I've seen but seems to be a pattern that others have noticed as well.
 
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Dermpire

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50 years ago was derm still number 1?....where attendings got paid $$$$ and had a relatively nice work/life balance? I am just curious beacause i want to know if things will change in the future for derm and other specialties like ortho etc.
Anyone who thinks derm will remain this magical field with high salaries and decent work/life balance over the course of the next 15-30 years is going to be sorely disappointed. There are some very real threats to dermatology (and other "comfy" specialties) that may or may not happen in the near future. The lifestyle will likely remain the same, but I wouldn't be surprised to see hefty cuts to certain reimbursements or the rise of NP/PA "providers" which would deflate salaries significantly. Sure right now derm is a good field compensation wise, but whether it will make the same money in 20 years or will drop lower to around family medicine pay, is impossible to predict.

Moral of the story, don't do derm unless you like it, and do a rotation and see what it's actually like as someone posted previously.
 

ActinicKeratosis

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Anyone who thinks derm will remain this magical field with high salaries and decent work/life balance over the course of the next 15-30 years is going to be sorely disappointed. There are some very real threats to dermatology (and other "comfy" specialties) that may or may not happen in the near future. The lifestyle will likely remain the same, but I wouldn't be surprised to see hefty cuts to certain reimbursements or the rise of NP/PA "providers" which would deflate salaries significantly. Sure right now derm is a good field compensation wise, but whether it will make the same money in 20 years or will drop lower to around family medicine pay, is impossible to predict.

Moral of the story, don't do derm unless you like it, and do a rotation and see what it's actually like as someone posted previously.
I'm currently applying into derm. I've spent a good amount of time in derm clinics throughout medical school so this is what I've concluded:

-Derm is essentially all outpatient with few emergencies therefore lifestyle will likely remain the same.
-Who knows what the future will hold in terms of salary but this is true of all medical specialties. However, derm is still more immune to insurance changes due to cash only/cosmetics.
-NP/PA will never encroach into dermpath or Mohs because they have no pathology training. Also, there is no way a patient will allow an NP to do a complex Mohs reconstruction on them (some even request a plastic surgeon imagine how they would feel if they had an NP!)
-NP/PA will never encroach on complex medical dermatology...the difficult cases that come in where patients are frustrated with no change in their condition after going to 5 different dermatologists.
-NP/PA may do more general dermatology...but who cares? Taking care of basic acne/eczema is not rocket science and there are more than enough patients to go around.
 
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ActinicKeratosis

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The prestige of dermatologists. Are they "last among equals"? - PubMed - NCBI

In the 80s, derm was a lowly paid, poorly respected specialty.
Not true actually. Low prestige yes. Low income no.

"Although the actual reported income data place dermatology somewhere in the mid-range of the specialty income hierarchy, the findings suggest that a major reason for the relatively low prestige ranking of dermatology is that the public believes that dermatologists earn less money than other specialists."
 

Dermpire

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I'm currently applying into derm. I've spent a good amount of time in derm clinics throughout medical school so this is what I've concluded:

-Derm is essentially all outpatient with few emergencies therefore lifestyle will likely remain the same.
-Who knows what the future will hold in terms of salary but this is true of all medical specialties. However, derm is still more immune to insurance changes due to cash only/cosmetics.
-NP/PA will never encroach into dermpath or Mohs because they have no pathology training. Also, there is no way a patient will allow an NP to do a complex Mohs reconstruction on them (some even request a plastic surgeon imagine how they would feel if they had an NP!)
-NP/PA will never encroach on complex medical dermatology...the difficult cases that come in where patients are frustrated with no change in their condition after going to 5 different dermatologists.
-NP/PA may do more general dermatology...but who cares? Taking care of basic acne/eczema is not rocket science and there are more than enough patients to go around.
Great post and I agree with you for the most part. However, your average dermatologist doesn't go into Mohs or dermpath, (both of which are relatively saturated anyways) and true complex medical derm is far more rare than the bread and butter cases that make up the majority of derm visits.

That said, I'll also be applying to derm in a few years, and while I wouldn't be happy with a massive reduction in income, it wouldn't make me regret the decision to do what I love.
 
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Jabbed

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-NP/PA may do more general dermatology...but who cares? Taking care of basic acne/eczema is not rocket science and there are more than enough patients to go around.
How much of what you saw in clinic would you consider to be complex medical derm? I've never had any derm exposure, but I still can't shake the idea that most of the day is spent shilling self-branded lotions and taking biopsies.
 

SunsFun

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I'm currently applying into derm. I've spent a good amount of time in derm clinics throughout medical school so this is what I've concluded:

-Derm is essentially all outpatient with few emergencies therefore lifestyle will likely remain the same.
-Who knows what the future will hold in terms of salary but this is true of all medical specialties. However, derm is still more immune to insurance changes due to cash only/cosmetics.
-NP/PA will never encroach into dermpath or Mohs because they have no pathology training. Also, there is no way a patient will allow an NP to do a complex Mohs reconstruction on them (some even request a plastic surgeon imagine how they would feel if they had an NP!)
-NP/PA will never encroach on complex medical dermatology...the difficult cases that come in where patients are frustrated with no change in their condition after going to 5 different dermatologists.
-NP/PA may do more general dermatology...but who cares? Taking care of basic acne/eczema is not rocket science and there are more than enough patients to go around.
FYI, http://www.the-dermatologist.com/content/life-surgical-physician-assistant

And this is what the guy is willing to admit in the article for dermatologists. Who knows how much more he is doing. And he is by far not the only one.

I am no visionary, but if I had to bet money on where the field is going, my money would be on a model where one physician is overseeing a dozen of midlevels who in turn are pushing through dozens of patients each. It makes more sense to maximize billing and such practice can quickly soak up all quick visits leaving the complex stuff for those who actually love treating those patients. That will likely result in "lifestyle" and "compensation" more in line with similar fields.
 
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Attendings in many fields have a similar lifestyles to Derm, even in some fields you would not think possible (e.g. surgical fields).

I take a lot of issue with this statement, especially given that I have had a lot of derm exposure (+mohs) as well as surgery exposure and my experiences at n=6 institutions for derm could not have been more polar opposite to my surgery rotations. I found every single field (including geriatrics) to be much busier than dermatology. I respect Derm just like every other field of medicine for the role they play in human health but come on, saying a general or neurosurgeon has the same lifestyle as a dermatologist? Grasping.
 
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I take a lot of issue with this statement, especially given that I have had a lot of derm exposure (+mohs) as well as surgery exposure and my experiences at n=6 institutions for derm could not have been more polar opposite to my surgery rotations. I found every single field (including geriatrics) to be much busier than dermatology. I respect Derm just like every other field of medicine for the role they play in human health but come on, saying a general or neurosurgeon has the same lifestyle as a dermatologist? Grasping.
even though this wasn't directed to me, I feel like you're hand-selecting a small portion of surgeons (neurosurgery) to represent the entire population.
ent, urology, plastics in many private settings, ortho hand, ophtho, colorectal surg, surg onc, breast. Lots of these have regular hours. Operate 7-5, or have clinic 830-5. that's the reality as an attending. Residency is a different beast, but attendings can work regular hours more or less. Even sometimes in "heavier" fields, attendings can elect a pay cut and work less. FYI, i am applying medicine
 
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even though this wasn't directed to me, I feel like you're hand-selecting a small portion of surgeons (neurosurgery) to represent the entire population.
ent, urology, plastics in many private settings, ortho hand, ophtho, colorectal surg, surg onc, breast. Lots of these have regular hours. Operate 7-5, or have clinic 830-5. that's the reality as an attending. Residency is a different beast, but attendings can work regular hours more or less. Even sometimes in "heavier" fields, attendings can elect a pay cut and work less. FYI, i am applying medicine
I have minimal exposure to ENT, urology, and ophtho. But have rotated in the rest and at the places I was at, their schedules were pretty rough. Also though, I am mostly speaking from a academic point of view. I've seen neurosurg and ophtho in private practice-neurosurg was still very demanding work and hours wise and ophtho was pretty chill comparatively. I would agree with your last statement, although I'm not sure how feasible that is in academia, probably more a thing in private/group practice.
 

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It can easily change. In the 90s anesthesiology was one of the best specialties and was one of the highest paid, lots of jobs... fast forward 20 years, reimbursements have plummeted , and dealing with many issues (lack of jobs, nurses)
The same can easily happen to derm in the future. While the top cash cow derms may be heavily shielded since they do minimal insurance, the rest not so much.
 
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ActinicKeratosis

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How much of what you saw in clinic would you consider to be complex medical derm? I've never had any derm exposure, but I still can't shake the idea that most of the day is spent shilling self-branded lotions and taking biopsies.
Respectfully, if you have never had any derm exposure then I don't think you can answer this question fairly. If you want to be an academic dermatologist and see the difficult/cool cases then you can. Many academic institutions have clinics 100% devoted to this kind of stuff. You can make the same argument about virtually every specialty. Each medical field has its bread and butter that seems "basic and mundane" from a medical student's standpoint. Primary Care: cough/colds/htn/diabetes, Rheumatology: arthritis, Peds: well child checks/otitis media, Gen Surg: hernias, IM: CHF, COPD...the list goes on. How about we just abolish medical school, and have a 3-5 year apprenticeship where people just learn only the skills for the job and nothing more? Most of medicine is not rocket science, and there are no physicians who are actively using everything that they have learned. I'm just kidding but you get my point.

FYI, http://www.the-dermatologist.com/content/life-surgical-physician-assistant

And this is what the guy is willing to admit in the article for dermatologists. Who knows how much more he is doing. And he is by far not the only one.

I am no visionary, but if I had to bet money on where the field is going, my money would be on a model where one physician is overseeing a dozen of midlevels who in turn are pushing through dozens of patients each. It makes more sense to maximize billing and such practice can quickly soak up all quick visits leaving the complex stuff for those who actually love treating those patients. That will likely result in "lifestyle" and "compensation" more in line with similar fields.
I've spent lots of time in Mohs clinic and people like this PA are few and far between. Also, he is supervised and will always be if he is truly doing Mohs closures. What if what he does results in an infection? What if he cuts the facial nerve? Also, this guy is not reading the path...too much liability. I'm confident that there will never be independent practice by PA/NP in this area of derm. Again if midlevels want to freeze warts/do simple excisions than great!...as already stated there are plenty of patients to go around.

I want to address the difficult cases and help patients. I want to use knowledge that no one has to be able to help people control their skin disease. If NP/PA wants to take a weekend course and open botox clinic then awesome...less of those patients that I have to deal with.
 
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Jabbed

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Respectfully, if you have never had any derm exposure then I don't think you can answer this question fairly. If you want to be an academic dermatologist and see the difficult/cool cases then you can. Many academic institutions have clinics 100% devoted to this kind of stuff. You can make the same argument about virtually every specialty. Each medical field has its bread and butter that seems "basic and mundane" from a medical student's standpoint. Primary Care: cough/colds/htn/diabetes, Rheumatology: arthritis, Peds: well child checks/otitis media, Gen Surg: hernias, IM: CHF, COPD...the list goes on. How about we just abolish medical school, and have a 3-5 year apprenticeship where people just learn only the skills for the job and nothing more? Most of medicine is not rocket science, and there are no physicians who are actively using everything that they have learned. I'm just kidding but you get my point.
I think you misunderstood me. To rephrase: I've never rotated in derm, how much of what you saw in clinic would constitute complex medical derm?
 

ActinicKeratosis

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I think you misunderstood me. To rephrase: I've never rotated in derm, how much of what you saw in clinic would constitute complex medical derm?
To answer your question honestly a small percentage of general dermatology is true complex medical derm. Therefore in order to see these unique cases on a regular basis it makes sense to be an academic.
 
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SunsFun

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I've spent lots of time in Mohs clinic and people like this PA are few and far between. Also, he is supervised and will always be if he is truly doing Mohs closures. What if what he does results in an infection? What if he cuts the facial nerve? Also, this guy is not reading the path...too much liability. I'm confident that there will never be independent practice by PA/NP in this area of derm. Again if midlevels want to freeze warts/do simple excisions than great!...as already stated there are plenty of patients to go around.

I want to address the difficult cases and help patients. I want to use knowledge that no one has to be able to help people control their skin disease. If NP/PA wants to take a weekend course and open botox clinic then awesome...less of those patients that I have to deal with.
You're arguing against the point I didn't make. Mohs trained physician is needed for path reads but the rest of the work can be easily outsourced. My, maybe more limited, experience with Mohs was much different from yours with midlevels or residents doing closures/reconstructions and some more simple excisions. The number of midlevels going for derm training has also been increasing according to some. Now, there will still most likely be a need for some degree of supervision, but the demand for services provided by a newly minted dermatologist seeing patients on his own may be impacted significantly. Nobody knows what is going to happen but the risk is there and should be acknowledged.

No disagreement with you regarding complex medical derm. Those services will most likely be in demand. However, I doubt that for people who go into derm for lifestyle/money or to be "plastic/onc/cosmetic surgery light" this specialty is still a safe option.
 
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