Question about changing specialties

[joedoctor]

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I was wondering what the regulations are for doctors who want to practice in a specialty outside of their residency training. For example, I know of a local physician who was residency trained in ENT but now he just does plastic surgery, including breast implants and tummy tucks, etc, that are in no way related to ENT. Is he able to do this because ENTs train in surgery? Could an internist have done this?

The reason I am asking is because I was wondering if it would be possible to go through a primary care residency and then go in to private practice as a dermatologist. Would this be against any regulations assuming I only took patients with the less complicated cases that I could easily treat?

 

[cdql]

Just like anything else, you could do it but if you're caught, boy are you in trouble.

It's the same as driving without insurance.

Your local physician is able to do what he did because one can apply for a plastics fellowship after ENT. While his training may have been in the head area, once you have made it into plastics, you can choose to focus in the area of your choice. Breast implants and tummy tucks are quite profitable and that is why your local doc has probably chosen to do that.

That being said, you could probably go through a primary care residency and then masquerade as dermatologist. The first time someone files a lawsuit against you though, they'll check your qualifications. And if you aren't what your diploma says you are, I am fairly sure they'll take every dime and nickel you've got.

I think the smarter choice is this: if you want derm, study hard, get into derm, avoid the problems with the backdoor method 🙂

 

[PhillyGuy]

I think as a licensed physician, you can pretty much do anything. However, residency training is what get you certified in a particular field. The certification is required for liability insurance and reimburment purposes. So you would not be able to get coverage for certain procedures and open yourself to legal liability.

 

[cchoukal]

Most board certifications require a residency in that field. I know a pediatrician who tends to attract dermatalogic outpatients and is kind of known for that, but he could not be a board-certified dermatologist without the derm residency. It is tempting for primary care physicians to try to get special training in a particular procedure and then market themselves along those lines. Some do vasectomies, others sigmoidoscopies, and I'm sure there are others, but they could never advertise themselves as urologists or gastroenterologists, for example.

 

[NinerNiner999]

CDQL is correct, but if you disclose to your patients that you are not a board trained/certified dermatologist you should be fine. In fact, you only need to complete an internship to obtain a medical license, so in theory, if you wanted to be a "dermatologist" you could complete one year, take and pass step III, become a licensed general practitioner, pay to attend CME/training for derm procedures (dermabrasion, collagen, etc), and practice. Then again, I'm not sure how good you will be, if you will be respected by your "colleagues," or if you will ever be able to defend yourself monetarily if you get sued for a bad outcome.

In regards to the OP - any licenensed practitioner can perform any medical procedure they are comfortable with...

 

[skypilot]

Would this be against any regulations assuming I only took patients with the less complicated cases that I could easily treat?

This would be absolutely fine. As long as you don't get in over your head and refer when necessary you would be well within your scope of practice as a FP. I think there is too much referring going on for simple problems anyway. FPs can do a heck of a lot ... many do minor procedures with no problems at all. If you are interested in this then you can do more elective months in dermatology during residency.

 

[joedoctor]

My biggest fear would be if while I was doing really simple derm procedures, I didn't recognize a patient's subtle signs of skin cancer or something else unrelated to the procedure. If a patient turned out to have skin cancer in the future would I be liable for treating them and not catching it?

This article was passed around quite a bit a while back - http://depts.washington.edu/gim/calendar/hmcjc_abstracts/JCJul04Article1.pdf - and it talks about a resident and hospital getting sued because the resident asked the patient if he wanted to be screened for colon cancer and he said no, then he turned out to develop colon cancer a few years later.

 

[cdql]

Hmm...that's touchy

I think if you didn't disclose the fact that you aren't a dermatologist, then you would probably get into trouble. If you tell the patient right away that you aren't a dermatologist, that you can only perform the simple procedure, but that you could provide them with a referral to an actual dermatologist, then you might be able to get away with it.

The problem with that plan, of course, is the patient has no real incentive to come back to you when he/she can go to an actual dermatologist.

Very tricky! 🙂

 

[deleted87716]

This article...talks about a resident and hospital getting sued because the resident asked the patient if he wanted to be screened for colon cancer and he said no, then he turned out to develop colon cancer a few years later.

The article actually concerns prostate CA, not colon CA. The issue on trial was evidence-based medicine. The patient made an informed decision, but the jury held the doctor liable. If anything, the doctor was guilty of "over-informing" the patient. This is a very sad case where evidence-based medicine backfired.

Getting sued isn't the same as getting sued successfully. Document, document, document. When I talk to patients about CA screening, I always document our discussion in the chart, including my specific recommendation and their refusal, including the reason (if given). I also don't let the issue drop. When they come in for subsequent visits, I will again ask them if we could schedule their colonoscopy or whatever, and again document the conversation, my recommendation, and their refusal. If somebody turns out to have colon CA after I've repeatedly badgered them about having a colonoscopy for the past five years, good luck making much of a case for negligence on my part.

As to your question regarding liability, yes, you could be held liable for missing a malignancy.

 

[joedoctor]

Hmm...that's touchy
The problem with that plan, of course, is the patient has no real incentive to come back to you when he/she can go to an actual dermatologist.
Very tricky! 🙂

Of course they would. I would be doing mostly cosmetic procedures that are not covered by insurance. It would be cash only and I could charge less than certified dermatologists. When people realize they have to pay out of their own pocket, price differences between doctors becomes a huge factor in their decision.

 

[sophiejane]

Getting sued isn't the same as getting sued successfully. Document, document, document. When I talk to patients about CA screening, I always document our discussion in the chart, including my specific recommendation and their refusal, including the reason (if given). I also don't let the issue drop. When they come in for subsequent visits, I will again ask them if we could schedule their colonoscopy or whatever, and again document the conversation, my recommendation, and their refusal. If somebody turns out to have colon CA after I've repeatedly badgered them about having a colonoscopy for the past five years, good luck making much of a case for negligence on my part.

This is excellent advice that is worth its weight in gold. I can't believe the poor quality of documentation out there. It's really scary what docs regularly do not document.

I'm just keeping a running list in my head of do's and don'ts for the future...

As for doing derm as an FP, I think there are plenty of FPs who end up doing a lot of derm. Especially if you do a good job at treating acne, psoriasis, removing moles, etc., people will tell others and will keep coming back to you. Chemical skin peels and laser hair removal are good ways to bring in cash, too. Your work will speak for itself.

 

[cchoukal]

The problem with that plan, of course, is the patient has no real incentive to come back to you when he/she can go to an actual dermatologist.

Very tricky! 🙂

One incentive to come back to the "fake" dermatologist is that you could probably get same- or next-day appts, as opposed to the typical 3-6 month wait for the "real" dermatologist...

 

[skypilot]

My biggest fear would be if while I was doing really simple derm procedures, I didn't recognize a patient's subtle signs of skin cancer or something else unrelated to the procedure. If a patient turned out to have skin cancer in the future would I be liable for treating them and not catching it? .

Removing questionable moles and sending them to the Pathologist is well within the FPs scope of practice. It had better be! The FP is the first line of defense against skin cancer. If people waited the 6 months it takes to see the dermatologist they might really be in trouble.

I see this one as a non issue. Of course if there is something really funky you had better refer it out.

 

[cdql]

Of course they would. I would be doing mostly cosmetic procedures that are not covered by insurance. It would be cash only and I could charge less than certified dermatologists. When people realize they have to pay out of their own pocket, price differences between doctors becomes a huge factor in their decision.

I think it depends on the type of cosmetic work you do. For something is simple, then yes, price would be the greatest factor.

I personally don't know of any complicated cosmetic derm procedures seeing as I'm just a student, but if there were, my personal inclination would be to go to someone who is truly licensed in that area. Just my opinion though!