To answer some of your questions in your PM about being a derm NP... Yes, in an independent state, you could open up your own derm practice. I have no idea how well that would work. You'd likely have to collaborate with MD's, or at least be able to refer out for skin issues that require an MDs scope of practice, (which would be quite a bit wider than your own.... Significantly wider).
I also don't know how many patients will want to show up to an NP solo practice with that limited scope. I see derm MDs being very territorial because it's an extremely lucrative and competetive area of medicine. It seems like if it was something that was easy for an NP to do, I would see more of them out doing it in their own clinics, but that's not common at all where I am. Admittedly, I'm not dialed in to a ton of NPs that are out running their own clinics, and the ones that I know about are mostly in primary care or psyche. In theory, though, an NP could go out and hang a shingle, but theory and reality frequently collide.
Theres a lot that people don't consider about what it takes to run your own practice in healthcare. It seems like it should be possible to have your spouse run the front desk and answer phones, and hire a medical assistant to bring people back and get vitals, but there is so much more. That's why you witness physicians banding together into larger and larger practices to pool resources. You need to have proper workspace, equipment, business arrangements for billing, insurance authorizations (if you can even get insurance companies to authorize you and your interventions), supplies, lab services, electronic medical records documentation software, etc. If one expects to be injecting Botox and prescribing acutane all day and making a lot of money, the real outcome might be disappointing. Successful practices are built up and have reputations behind their name, and you can't establish that if you aren't set up to solve a broad range of issues beyond just the stuff that you think everyone is going to come in for treatment of. Additionally, a lot of derm services are able to be addressed by family practice providers, so patients go to them for the easy stuff, and get referred to derm MDs for the hard stuff, leaving the "derm NP" in the middle doing the Botox injections that derm MDs give out already at a discount to get patients in the door of their clinic to offer other services to those patients and their family members. But in any event, I have a friend that is a dermatologist, and is in huge practice for a reason, and it's because working small isn't the way things are headed.
You asked about PAs in derm. A PA could not go out solo very easily, especially because I don't imagine many are able to find a supervising physician in derm willing to allow their supervisee to go and compete with their own lucrative practice... after all, a dermatologist will always be fine with the possibility of making even more money. I also don't see a PA in that situation being able to make a big enough payment to a dermatologist to sway him or her to go into that kind of arrangement. It's too much hassle for a physician that could just go out and open up a branch office across the street from said PA and be booked out 8 months in advance whole hiring their own PA. In the situation with a PA trying to run solo, the PA relies upon the MD for everything, whereas the MD relies on the PA not at all.
I know a few PAs in derm and they are very well taken care of by the places that they work.... I believe they are probably the best paid PAs I've run into. They likely make as much as the average Psyche NPs I've met. I think their doctors pay them well because there is always the chance that another MD will try to poach them to leave and go to their practice. But there's really nothing to keep the docs from deciding to pay them $90k per year, except maybe that chance of putting effort and money into a PA and having them go work for another doctor if they don't pay out to keep them around.
