There’s no denying the problem. Patient wait times for medical dermatology appointments are getting longer and longer, while patients undergoing treatment with Botox or dermal fillers are whisked into the office within a day or two. Clearly the “job security” that dermatologists joke about is no laughing matter to patients who have changing moles or worsening psoriasis.
This reality was documented in a recent New York Times article,1 which cited a Journal of the American Academy of Dermatology workforce study,2 to create the title: “Shorter Waits for Botox Than Examinations of Moles.”
We interviewed four dermatologists about this issue that many have long regarded as a crisis in supply and demand in the specialty. They discussed their ideas on the problem — its causes, solutions, and whether it exists at all — and how they can structure their own practices to meet the needs of their patients when new opportunities, as well as social and economic forces, are affecting the supply of and demand for dermatology services more than ever.
A Medical Dermatologist’s Perspective
Michael J. Franzblau, M.D.,F.A.A.D., a San Francisco-based dermatologist, has seen the evolution of his specialty from the perspective of 41 years in practice in Marin County, which has the country’s highest per capital income and nearly three times its share of the five dermatologists deemed adequate for its 250,0000 population.
He observes parallel trends that put unprecedented pressure on demand. “There’s been a phenomenal increase in the number of requests for cosmetic procedures but also an increasing awareness of the excellence of dermatologists in caring for complex medical issues.” This, he says, prompts primary physicians to more quickly refer non-responsive patients with such conditions as severe psoriasis, lupus erythematosus, exfoliative erythrodermas, cutaneous lymphomas, suspected melanomas, other pigmented lesions and suspicious lesions, which increases the burden on medically oriented dermatologists.
Dr. Franzblau says he has always attempted to minimize office wait times to 15 minutes for patients who have already waited 2 to 3 weeks for an appointment, “But if patients called to say they had moles that didn’t look right, they were seen that day — even if it meant working late or skipping lunch.”
Dr. Franzblau feels strongly about the patient-physician relationship, which he believes is negatively impacted by insurance considerations. It is for that reason that he accepts only Medicare or Medicaid (called MediCal in California) as well as self-pay.
“It’s my feeling, based on my personal philosophy, that the most ethical care is rendered when the patient and doctor face each other with no extraneous forces. It’s considered autonomy under the four tenets of the ethical practice of medicine: non maleficence; beneficence; autonomy; and distributive justice.”
Dr. Franzblau says further, “It’s my view that we have a contract with every patient we see that the patient in front of us is the only concern, period, that the third-party payor can be breathing down my neck, but I have to just focus on the patient.”
He considers himself fortunate to have established his practice largely before “the explosion of managed care,” and adds, “I am the exception, not the rule.”
It’s All About Scheduling
Yet it is at least partly the desire for autonomy as well as economic gain that drives many of his colleagues to focus on cosmetic patients.
For economic and ethical reasons, Michael Gold, M.D., balances his practice to serve the needs of his demanding cosmetics patients as well as medical patients. But he is unapologetic about wait times for non-emergent medical patients.
“In today’s world, when you combine medical and cosmetic dermatology, where one is a cash-paying business and one is a wait-to-be-reimbursed business, many of us who do this have time slots available for our cosmetics patients that make it quicker to get into the clinic than new medical patients who have had a rash for 6 months and 14 doctors who have seen them before.”
He describes his triage system for medical patients:
“If you call my office and say ‘I have been diagnosed with a malignant melanoma,’ you’re in my office tomorrow, no matter what — as long as it can be verified with a pathology report. But if you call with a 10-year-old mole that ‘may be changing,’ we’ll get you in as soon as we can. And if you call with a skin tag that’s bothering you, you’ll wait until we have an opening.”
Dr. Gold structures his practice to maximize efficiency in keeping with the realities of his own practice, which includes a staff of 55. “I have a payroll to meet, 55 families to feed, so the economics of my life are important for my staff as well.”
The cosmetic dermatologist, he explains, has an “inherent advantage” in understanding how to efficiently schedule patients. “Botox patients, as the Journal of the American Academy of Dermatology article highlighted, don’t wait long at all — maybe a day or two. Longer than that, and the business is lost.” Laser patients, he explains, must be scheduled for visits including a physician consult and treatment plan, the procedure itself, and a follow-up appointment. “They are handled quickly, but not as quickly as the Botox or filler patients,” he says, adding, “There’s an incentive to get these patients in because they will go elsewhere. You have to have availability for them or you will lose them. It’s not right or wrong, it’s the reality of where we are today.”
Dr. Gold says it’s this understanding of scheduling, in combination with the volume of patients seen daily, that enables him to accommodate an urgent medical issue. “Remember, in private practice dermatology, there are very few medical emergencies. If I have 80 people on my books, I’m going to have five no-shows anyhow. It’s the reality of life that something will always go wrong. It’s factored in, so I can always fit in another patient or two. And doctors who can’t do this in a busy practice haven’t learned time management.”
Supply-Demand Inequity Not Due to Cosmetic Work
Alexa B. Kimball, M.D., M.P.H., an associate professor of dermatology at the Harvard Medical School is a researcher who studies wait times. Noting the “tremendous demand for services and limit in supply of dermatologists available,” she nonetheless calls the conclusion that it is directly related to cosmetic procedures “a strong misconception.”
“I think it’s important not to over-blow the findings from the study you’re referencing. We have known for quite some time that the wait times for patients in general dermatology tend to be among the longest for specialties across medicine.
However, I interpret the data from the study to show that there just aren’t that many patients out there who are requesting cosmetic services and that there are lots of people — many in other specialties — competing for them. So, even if you converted those patients appointments into medical derm appointments — something I’m not sure you could do — you would make almost no dent at all in wait times for medical dermatology.”
She says the misconception she refers to is partly due to attention garnered by cosmetic procedures and those who offer them. “Cosmetic practices are designed like cosmetic products. Because they are heavily advertised, they create a perception that they are ubiquitous, but that is not at all the case. That is not what most dermatologists do.”
Her own research reveals that the average dermatology practice devotes no more than approximately 10% of its time to cosmetics, and 50% of practices don’t offer Botox at all.
She says, however, many dermatologists may want to improve their wait times — as many already do — by examining their differentials in wait time for different types of patients and taking measures to improve them through more efficient office structure and scheduling.
“Every practice I know of has some mechanism for triaging patients. Patients should be aware that they can ask to talk to the person who assists with that process, whether it be a nurse, physician, or medical assistant. He or she can in turn help determine which patients are most urgent and how to get them in the door appropriately.”
It’s Clearly a Capacity Issue
But Wm. Philip Werschler, M.D., believes the numbers are different and the problem is real and likely to get worse for economic reasons, lifestyle choices, and increased demand.
“It’s a capacity issue. Dermatology has never been especially oversupplied. There are about 10,000 dermatologists in United States, a number that hasn’t changed in 20 years and about 30% are now cosmetic — principally or exclusively — and two-thirds are general medical, surgical, or involved in research or teaching.”
Just do the math, he says, to get a worrisome portrait of where things are headed.
“Take a specialty that has a relatively tight supply/demand ratio and in a short period of time, add new access issues.”
To this equation, he factors in trends that do not bode well for med derm wait times.
“Residents coming out — more than half of whom are now women — are greatly skewed toward cosmetics and they work fewer hours, while older derms, who are predominantly male and have traditionally worked longer hours, are now providing most of the med derm appointments.”
This, he concludes, has already led to “a balance within current supply that is uneven and awkward.” And, furthermore, he says, it is becoming more so.
“Those older dermatologists who are now retiring at perhaps a rate of 300 per year are being replaced by these younger derms, who provide fewer med derm appointments both because they tend to work fewer hours and because they are less experienced and therefore initially less efficient with their time.”
He attributes the decreased number of hours to another documented trend among young doctors, “to seek more balance in their lives” than their elders in medicine. This, he adds, is true of both sexes, but it is especially the case with women as they choose to take off time and work shorter hours to raise families.
The upshot of these changes supports his point. “This is not just a net decrease in capacity, but also a shift in capacity. Sixty appointments replaced by 30 — half of which are cosmetic — adds up to a 75% decrease in capacity.”
Dr. Werschler describes the changing dermatology practice “model” as much of industry does, in terms of cosmetic office practice (COP) levels.
Level 1, he says, is the traditional practice, which is approximately 95% medical and/or surgical, and Level 2 is the transitional practice, which has dedicated days or people assigned to different types of procedures as they enter the practice.
Level 3, a blended model like his own, he says, “integrates medical, surgical, and cosmetic dermatology seamlessly.” This integration, he says, can be by providers, for example, a small group of derms in which one does cosmetic work. It can also be divided by day or procedure specialty, with perhaps a separate site for laser procedures. “Level 3,” he claims, “is like diversifying your portfolio. It is the model most dermatologists aspire to.”
As for Level 4, he says, “That is the investment model, which is totally cosmetic and all fee-for-service.”
But expressing a viewpoint shared by fellow “Level 3” practitioner Dr. Gold, Dr. Werschler says he would never completely abandon medical patients’ needs for needs of his own as a physician. “It’s an interest issue. I think people are not moving to Level 4 partly because variety is the spice of life. Pumping injectables is good revenue, but it gets boring after a while. It’s exciting to go to a derm clinic and utilize your diagnostic and surgical skills.”
There’s no denying the problem. Patient wait times for medical dermatology appointments are getting longer and longer, while patients undergoing treatment with Botox or dermal fillers are whisked into the office within a day or two. Clearly the “job security” that dermatologists joke about is no laughing matter to patients who have changing moles or worsening psoriasis.
This reality was documented in a recent New York Times article,1 which cited a Journal of the American Academy of Dermatology workforce study,2 to create the title: “Shorter Waits for Botox Than Examinations of Moles.”
We interviewed four dermatologists about this issue that many have long regarded as a crisis in supply and demand in the specialty. They discussed their ideas on the problem — its causes, solutions, and whether it exists at all — and how they can structure their own practices to meet the needs of their patients when new opportunities, as well as social and economic forces, are affecting the supply of and demand for dermatology services more than ever.
A Medical Dermatologist’s Perspective
Michael J. Franzblau, M.D.,F.A.A.D., a San Francisco-based dermatologist, has seen the evolution of his specialty from the perspective of 41 years in practice in Marin County, which has the country’s highest per capital income and nearly three times its share of the five dermatologists deemed adequate for its 250,0000 population.
He observes parallel trends that put unprecedented pressure on demand. “There’s been a phenomenal increase in the number of requests for cosmetic procedures but also an increasing awareness of the excellence of dermatologists in caring for complex medical issues.” This, he says, prompts primary physicians to more quickly refer non-responsive patients with such conditions as severe psoriasis, lupus erythematosus, exfoliative erythrodermas, cutaneous lymphomas, suspected melanomas, other pigmented lesions and suspicious lesions, which increases the burden on medically oriented dermatologists.
Dr. Franzblau says he has always attempted to minimize office wait times to 15 minutes for patients who have already waited 2 to 3 weeks for an appointment, “But if patients called to say they had moles that didn’t look right, they were seen that day — even if it meant working late or skipping lunch.”
Dr. Franzblau feels strongly about the patient-physician relationship, which he believes is negatively impacted by insurance considerations. It is for that reason that he accepts only Medicare or Medicaid (called MediCal in California) as well as self-pay.
“It’s my feeling, based on my personal philosophy, that the most ethical care is rendered when the patient and doctor face each other with no extraneous forces. It’s considered autonomy under the four tenets of the ethical practice of medicine: non maleficence; beneficence; autonomy; and distributive justice.”
Dr. Franzblau says further, “It’s my view that we have a contract with every patient we see that the patient in front of us is the only concern, period, that the third-party payor can be breathing down my neck, but I have to just focus on the patient.”
He considers himself fortunate to have established his practice largely before “the explosion of managed care,” and adds, “I am the exception, not the rule.”
It’s All About Scheduling
Yet it is at least partly the desire for autonomy as well as economic gain that drives many of his colleagues to focus on cosmetic patients.
For economic and ethical reasons, Michael Gold, M.D., balances his practice to serve the needs of his demanding cosmetics patients as well as medical patients. But he is unapologetic about wait times for non-emergent medical patients.
“In today’s world, when you combine medical and cosmetic dermatology, where one is a cash-paying business and one is a wait-to-be-reimbursed business, many of us who do this have time slots available for our cosmetics patients that make it quicker to get into the clinic than new medical patients who have had a rash for 6 months and 14 doctors who have seen them before.”
He describes his triage system for medical patients:
“If you call my office and say ‘I have been diagnosed with a malignant melanoma,’ you’re in my office tomorrow, no matter what — as long as it can be verified with a pathology report. But if you call with a 10-year-old mole that ‘may be changing,’ we’ll get you in as soon as we can. And if you call with a skin tag that’s bothering you, you’ll wait until we have an opening.”
Dr. Gold structures his practice to maximize efficiency in keeping with the realities of his own practice, which includes a staff of 55. “I have a payroll to meet, 55 families to feed, so the economics of my life are important for my staff as well.”
The cosmetic dermatologist, he explains, has an “inherent advantage” in understanding how to efficiently schedule patients. “Botox patients, as the Journal of the American Academy of Dermatology article highlighted, don’t wait long at all — maybe a day or two. Longer than that, and the business is lost.” Laser patients, he explains, must be scheduled for visits including a physician consult and treatment plan, the procedure itself, and a follow-up appointment. “They are handled quickly, but not as quickly as the Botox or filler patients,” he says, adding, “There’s an incentive to get these patients in because they will go elsewhere. You have to have availability for them or you will lose them. It’s not right or wrong, it’s the reality of where we are today.”
Dr. Gold says it’s this understanding of scheduling, in combination with the volume of patients seen daily, that enables him to accommodate an urgent medical issue. “Remember, in private practice dermatology, there are very few medical emergencies. If I have 80 people on my books, I’m going to have five no-shows anyhow. It’s the reality of life that something will always go wrong. It’s factored in, so I can always fit in another patient or two. And doctors who can’t do this in a busy practice haven’t learned time management.”
Supply-Demand Inequity Not Due to Cosmetic Work
Alexa B. Kimball, M.D., M.P.H., an associate professor of dermatology at the Harvard Medical School is a researcher who studies wait times. Noting the “tremendous demand for services and limit in supply of dermatologists available,” she nonetheless calls the conclusion that it is directly related to cosmetic procedures “a strong misconception.”
“I think it’s important not to over-blow the findings from the study you’re referencing. We have known for quite some time that the wait times for patients in general dermatology tend to be among the longest for specialties across medicine.
However, I interpret the data from the study to show that there just aren’t that many patients out there who are requesting cosmetic services and that there are lots of people — many in other specialties — competing for them. So, even if you converted those patients appointments into medical derm appointments — something I’m not sure you could do — you would make almost no dent at all in wait times for medical dermatology.”
She says the misconception she refers to is partly due to attention garnered by cosmetic procedures and those who offer them. “Cosmetic practices are designed like cosmetic products. Because they are heavily advertised, they create a perception that they are ubiquitous, but that is not at all the case. That is not what most dermatologists do.”
Her own research reveals that the average dermatology practice devotes no more than approximately 10% of its time to cosmetics, and 50% of practices don’t offer Botox at all.
She says, however, many dermatologists may want to improve their wait times — as many already do — by examining their differentials in wait time for different types of patients and taking measures to improve them through more efficient office structure and scheduling.
“Every practice I know of has some mechanism for triaging patients. Patients should be aware that they can ask to talk to the person who assists with that process, whether it be a nurse, physician, or medical assistant. He or she can in turn help determine which patients are most urgent and how to get them in the door appropriately.”
It’s Clearly a Capacity Issue
But Wm. Philip Werschler, M.D., believes the numbers are different and the problem is real and likely to get worse for economic reasons, lifestyle choices, and increased demand.
“It’s a capacity issue. Dermatology has never been especially oversupplied. There are about 10,000 dermatologists in United States, a number that hasn’t changed in 20 years and about 30% are now cosmetic — principally or exclusively — and two-thirds are general medical, surgical, or involved in research or teaching.”
Just do the math, he says, to get a worrisome portrait of where things are headed.
“Take a specialty that has a relatively tight supply/demand ratio and in a short period of time, add new access issues.”
To this equation, he factors in trends that do not bode well for med derm wait times.
“Residents coming out — more than half of whom are now women — are greatly skewed toward cosmetics and they work fewer hours, while older derms, who are predominantly male and have traditionally worked longer hours, are now providing most of the med derm appointments.”
This, he concludes, has already led to “a balance within current supply that is uneven and awkward.” And, furthermore, he says, it is becoming more so.
“Those older dermatologists who are now retiring at perhaps a rate of 300 per year are being replaced by these younger derms, who provide fewer med derm appointments both because they tend to work fewer hours and because they are less experienced and therefore initially less efficient with their time.”
He attributes the decreased number of hours to another documented trend among young doctors, “to seek more balance in their lives” than their elders in medicine. This, he adds, is true of both sexes, but it is especially the case with women as they choose to take off time and work shorter hours to raise families.
The upshot of these changes supports his point. “This is not just a net decrease in capacity, but also a shift in capacity. Sixty appointments replaced by 30 — half of which are cosmetic — adds up to a 75% decrease in capacity.”
Dr. Werschler describes the changing dermatology practice “model” as much of industry does, in terms of cosmetic office practice (COP) levels.
Level 1, he says, is the traditional practice, which is approximately 95% medical and/or surgical, and Level 2 is the transitional practice, which has dedicated days or people assigned to different types of procedures as they enter the practice.
Level 3, a blended model like his own, he says, “integrates medical, surgical, and cosmetic dermatology seamlessly.” This integration, he says, can be by providers, for example, a small group of derms in which one does cosmetic work. It can also be divided by day or procedure specialty, with perhaps a separate site for laser procedures. “Level 3,” he claims, “is like diversifying your portfolio. It is the model most dermatologists aspire to.”
As for Level 4, he says, “That is the investment model, which is totally cosmetic and all fee-for-service.”
But expressing a viewpoint shared by fellow “Level 3” practitioner Dr. Gold, Dr. Werschler says he would never completely abandon medical patients’ needs for needs of his own as a physician. “It’s an interest issue. I think people are not moving to Level 4 partly because variety is the spice of life. Pumping injectables is good revenue, but it gets boring after a while. It’s exciting to go to a derm clinic and utilize your diagnostic and surgical skills.”
There’s no denying the problem. Patient wait times for medical dermatology appointments are getting longer and longer, while patients undergoing treatment with Botox or dermal fillers are whisked into the office within a day or two. Clearly the “job security” that dermatologists joke about is no laughing matter to patients who have changing moles or worsening psoriasis.
This reality was documented in a recent New York Times article,1 which cited a Journal of the American Academy of Dermatology workforce study,2 to create the title: “Shorter Waits for Botox Than Examinations of Moles.”
We interviewed four dermatologists about this issue that many have long regarded as a crisis in supply and demand in the specialty. They discussed their ideas on the problem — its causes, solutions, and whether it exists at all — and how they can structure their own practices to meet the needs of their patients when new opportunities, as well as social and economic forces, are affecting the supply of and demand for dermatology services more than ever.
A Medical Dermatologist’s Perspective
Michael J. Franzblau, M.D.,F.A.A.D., a San Francisco-based dermatologist, has seen the evolution of his specialty from the perspective of 41 years in practice in Marin County, which has the country’s highest per capital income and nearly three times its share of the five dermatologists deemed adequate for its 250,0000 population.
He observes parallel trends that put unprecedented pressure on demand. “There’s been a phenomenal increase in the number of requests for cosmetic procedures but also an increasing awareness of the excellence of dermatologists in caring for complex medical issues.” This, he says, prompts primary physicians to more quickly refer non-responsive patients with such conditions as severe psoriasis, lupus erythematosus, exfoliative erythrodermas, cutaneous lymphomas, suspected melanomas, other pigmented lesions and suspicious lesions, which increases the burden on medically oriented dermatologists.
Dr. Franzblau says he has always attempted to minimize office wait times to 15 minutes for patients who have already waited 2 to 3 weeks for an appointment, “But if patients called to say they had moles that didn’t look right, they were seen that day — even if it meant working late or skipping lunch.”
Dr. Franzblau feels strongly about the patient-physician relationship, which he believes is negatively impacted by insurance considerations. It is for that reason that he accepts only Medicare or Medicaid (called MediCal in California) as well as self-pay.
“It’s my feeling, based on my personal philosophy, that the most ethical care is rendered when the patient and doctor face each other with no extraneous forces. It’s considered autonomy under the four tenets of the ethical practice of medicine: non maleficence; beneficence; autonomy; and distributive justice.”
Dr. Franzblau says further, “It’s my view that we have a contract with every patient we see that the patient in front of us is the only concern, period, that the third-party payor can be breathing down my neck, but I have to just focus on the patient.”
He considers himself fortunate to have established his practice largely before “the explosion of managed care,” and adds, “I am the exception, not the rule.”
It’s All About Scheduling
Yet it is at least partly the desire for autonomy as well as economic gain that drives many of his colleagues to focus on cosmetic patients.
For economic and ethical reasons, Michael Gold, M.D., balances his practice to serve the needs of his demanding cosmetics patients as well as medical patients. But he is unapologetic about wait times for non-emergent medical patients.
“In today’s world, when you combine medical and cosmetic dermatology, where one is a cash-paying business and one is a wait-to-be-reimbursed business, many of us who do this have time slots available for our cosmetics patients that make it quicker to get into the clinic than new medical patients who have had a rash for 6 months and 14 doctors who have seen them before.”
He describes his triage system for medical patients:
“If you call my office and say ‘I have been diagnosed with a malignant melanoma,’ you’re in my office tomorrow, no matter what — as long as it can be verified with a pathology report. But if you call with a 10-year-old mole that ‘may be changing,’ we’ll get you in as soon as we can. And if you call with a skin tag that’s bothering you, you’ll wait until we have an opening.”
Dr. Gold structures his practice to maximize efficiency in keeping with the realities of his own practice, which includes a staff of 55. “I have a payroll to meet, 55 families to feed, so the economics of my life are important for my staff as well.”
The cosmetic dermatologist, he explains, has an “inherent advantage” in understanding how to efficiently schedule patients. “Botox patients, as the Journal of the American Academy of Dermatology article highlighted, don’t wait long at all — maybe a day or two. Longer than that, and the business is lost.” Laser patients, he explains, must be scheduled for visits including a physician consult and treatment plan, the procedure itself, and a follow-up appointment. “They are handled quickly, but not as quickly as the Botox or filler patients,” he says, adding, “There’s an incentive to get these patients in because they will go elsewhere. You have to have availability for them or you will lose them. It’s not right or wrong, it’s the reality of where we are today.”
Dr. Gold says it’s this understanding of scheduling, in combination with the volume of patients seen daily, that enables him to accommodate an urgent medical issue. “Remember, in private practice dermatology, there are very few medical emergencies. If I have 80 people on my books, I’m going to have five no-shows anyhow. It’s the reality of life that something will always go wrong. It’s factored in, so I can always fit in another patient or two. And doctors who can’t do this in a busy practice haven’t learned time management.”
Supply-Demand Inequity Not Due to Cosmetic Work
Alexa B. Kimball, M.D., M.P.H., an associate professor of dermatology at the Harvard Medical School is a researcher who studies wait times. Noting the “tremendous demand for services and limit in supply of dermatologists available,” she nonetheless calls the conclusion that it is directly related to cosmetic procedures “a strong misconception.”
“I think it’s important not to over-blow the findings from the study you’re referencing. We have known for quite some time that the wait times for patients in general dermatology tend to be among the longest for specialties across medicine.
However, I interpret the data from the study to show that there just aren’t that many patients out there who are requesting cosmetic services and that there are lots of people — many in other specialties — competing for them. So, even if you converted those patients appointments into medical derm appointments — something I’m not sure you could do — you would make almost no dent at all in wait times for medical dermatology.”
She says the misconception she refers to is partly due to attention garnered by cosmetic procedures and those who offer them. “Cosmetic practices are designed like cosmetic products. Because they are heavily advertised, they create a perception that they are ubiquitous, but that is not at all the case. That is not what most dermatologists do.”
Her own research reveals that the average dermatology practice devotes no more than approximately 10% of its time to cosmetics, and 50% of practices don’t offer Botox at all.
She says, however, many dermatologists may want to improve their wait times — as many already do — by examining their differentials in wait time for different types of patients and taking measures to improve them through more efficient office structure and scheduling.
“Every practice I know of has some mechanism for triaging patients. Patients should be aware that they can ask to talk to the person who assists with that process, whether it be a nurse, physician, or medical assistant. He or she can in turn help determine which patients are most urgent and how to get them in the door appropriately.”
It’s Clearly a Capacity Issue
But Wm. Philip Werschler, M.D., believes the numbers are different and the problem is real and likely to get worse for economic reasons, lifestyle choices, and increased demand.
“It’s a capacity issue. Dermatology has never been especially oversupplied. There are about 10,000 dermatologists in United States, a number that hasn’t changed in 20 years and about 30% are now cosmetic — principally or exclusively — and two-thirds are general medical, surgical, or involved in research or teaching.”
Just do the math, he says, to get a worrisome portrait of where things are headed.
“Take a specialty that has a relatively tight supply/demand ratio and in a short period of time, add new access issues.”
To this equation, he factors in trends that do not bode well for med derm wait times.
“Residents coming out — more than half of whom are now women — are greatly skewed toward cosmetics and they work fewer hours, while older derms, who are predominantly male and have traditionally worked longer hours, are now providing most of the med derm appointments.”
This, he concludes, has already led to “a balance within current supply that is uneven and awkward.” And, furthermore, he says, it is becoming more so.
“Those older dermatologists who are now retiring at perhaps a rate of 300 per year are being replaced by these younger derms, who provide fewer med derm appointments both because they tend to work fewer hours and because they are less experienced and therefore initially less efficient with their time.”
He attributes the decreased number of hours to another documented trend among young doctors, “to seek more balance in their lives” than their elders in medicine. This, he adds, is true of both sexes, but it is especially the case with women as they choose to take off time and work shorter hours to raise families.
The upshot of these changes supports his point. “This is not just a net decrease in capacity, but also a shift in capacity. Sixty appointments replaced by 30 — half of which are cosmetic — adds up to a 75% decrease in capacity.”
Dr. Werschler describes the changing dermatology practice “model” as much of industry does, in terms of cosmetic office practice (COP) levels.
Level 1, he says, is the traditional practice, which is approximately 95% medical and/or surgical, and Level 2 is the transitional practice, which has dedicated days or people assigned to different types of procedures as they enter the practice.
Level 3, a blended model like his own, he says, “integrates medical, surgical, and cosmetic dermatology seamlessly.” This integration, he says, can be by providers, for example, a small group of derms in which one does cosmetic work. It can also be divided by day or procedure specialty, with perhaps a separate site for laser procedures. “Level 3,” he claims, “is like diversifying your portfolio. It is the model most dermatologists aspire to.”
As for Level 4, he says, “That is the investment model, which is totally cosmetic and all fee-for-service.”
But expressing a viewpoint shared by fellow “Level 3” practitioner Dr. Gold, Dr. Werschler says he would never completely abandon medical patients’ needs for needs of his own as a physician. “It’s an interest issue. I think people are not moving to Level 4 partly because variety is the spice of life. Pumping injectables is good revenue, but it gets boring after a while. It’s exciting to go to a derm clinic and utilize your diagnostic and surgical skills.”
