Is the demand for dermatologists keeping up with the insane residency growth rate?

[Student189045]

I was looking through some match data and noticed that Dermatology is right up with EM as the most rapidly growing residency. The number of positions offered has increased from 297 to 538 in the past 12 years, an 81% percent increase. For reference, EM, which I see everyone on these forums complain about oversaturation, has increased 90%. Is there a threat of oversaturation in dermatology? Especially considering the pending bill to add 15000 more Medicare funded residency positions, some of which would surely go to derm.

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[PhillyMed777]

Yikes, I knew it was growing, but not that much.

As of now, job market is decent for general derm. Most saturated areas remain the usual offenders.

Prognosticating here...if we keep dermpath and mohs spots the same, and continue expanding the gen derm market, it may help those sub-specialties job wise in the future.

 

[Dr. Doctor MD]

I was looking through some match data and noticed that Dermatology is right up with EM as the most rapidly growing residency. The number of positions offered has increased from 297 to 538 in the past 12 years, an 81% percent increase. For reference, EM, which I see everyone on these forums complain about oversaturation, has increased 90%. Is there a threat of oversaturation in dermatology? Especially considering the pending bill to add 15000 more Medicare funded residency positions, some of which would surely go to derm.

Dermatology expansion has also mirrored Rad-Onc as well, and we all know how that ended up. Jobs in Dermatology are tight in the most desirable cities right now, but fortunately they are wide open in most other places (rural, suburban, midwest/south, etc). But it's really scary how fast these saturation issues pop-up (ie. Rad-Onc, ER), and even more terrifying is the glut of midlevels being pumped out each year who seem to gravitate towards derm :/ I've seen many of these large PE groups go from 75-80% MD/20-25% Midlevel to closer to 50/50 and even lower. This very clearly does not bode well for the future.

I think things are okay for right now, but I am honestly concerned about 10 years from now, especially seeing how ER was 5 and 10 years ago and how it has declined even prior to the pandemic.

 

[carolp]

This is clearly the biggest issue facing our field over the next 20 years. No one seems to care since just like Rad Onc - the academic attendings that are in charge of the meetings and publications are making bank off of cheap resident labor. Back prior to hospital consolidation, there simply were not that many academic derm departments since it was so much better to work in private practice. Status post ACA with hospital based billing, every mid sized hospital opened up or expanded their derm department. Once a department opens its very difficult to shut it down. The only ones that have shut down as far as I am aware are from mismanagement. When I have brought up this issue with residents, they just laugh and think I'm joking. We need to contract if we want to maintain the job market but I do not see how that happens since even in Rad Onc they aren't contracting their spots (other than by not filling even with IMGs).

We need to police ourselves as a specialty but I do not see how to convince people to shut down or limit the number of spots since it is in every academic department's self interest to expand. I encourage everyone in derm to bring this up. We don't want to be the next Rad Onc. Derm is a small subspecialty, we should not be training 1/3 as many residents as family medicine, it should be 1:10 max derm to family medicine for the nations benefit as well as dermatologists.

 

[doctalaughs]

It’s definitely a major problem for the future. Good jobs are already harder to find.

Unlike radonc we rely less on referral streams and partially generate our own demand with patients we “own”

That being said I’m glad that I am mid to late career and able to retire basically anytime after 5 more years (though likely to just cut down and do 10 more easy years after that). Would not want to be matching now, because who knows what things will be like in 5-10 more years for the job market (although that’s true of all medicine, which seems to be in a downward trajectory).

 

[Slack3r]

Nobody cares except the early career folks and current or future residents. The academics don’t care, as you pointed out, and the busy private practices are happy to bring on cheap new grads for 40% collections, non-partnership track positions. When I interviewed for gen derm positions, exactly 0 had any sort of partnership structure. With a glut of new grads, there’s even less incentive to offer any sort of equity.

 

[PhillyMed777]

he academic attendings that are in charge of the meetings and publications are making bank off of cheap resident labor

I wish my attendings would see their own BS.
Even the most "famous" ones are so incompetent at getting through clinics w/o residents, I am embarrassed for them . They literally CANNOT do the job on their own. You can see from their actions at work their singular goal is to do exactly nothing. Ideally, they would not do a single order, note, call back, follow up, etc. anything really.

OH, and they also love masquerading "interesting" cases for you to see...by interesting i mean that this patient will be on multiple high risk meds, and will require lots of work outside of clinic ( workup, lab work, PAs and med approval, call backs, follow ups), and I certainly don't want to do that. As if I don't see what they are doing.

 

[PatsyStone]

A major jump was due to the accreditation of DO programs. Disproportionately, there were a lot of DO programs (I think there were actually more DO derm programs than DO Peds or neurology programs).

There are a lot mid-levels in derm because there is unmet demand. An increase in derm spots will help to alleviate it. I think it is prudent to study the growth and act sooner rather than later, but I also wouldn't compare it to rad-onc

 

[Skindoc83]

A major jump was due to the accreditation of DO programs. Disproportionately, there were a lot of DO programs (I think there were actually more DO derm programs than DO Peds or neurology programs).

There are a lot mid-levels in derm because there is unmet demand. An increase in derm spots will help to alleviate it. I think it is prudent to study the growth and act sooner rather than later, but I also wouldn't compare it to rad-onc

How many DO programs were accredited. Anecdotally I knew of some really trashy ones where you just worked in some guys private practice for three years, unpaid. I’m hoping those all shut down.

 

[PatsyStone]

How many DO programs were accredited. Anecdotally I knew of some really trashy ones where you just worked in some guys private practice for three years, unpaid. I’m hoping those all shut down.

I think it was close to 40 programs, but some did not take residents every year, and many only took 1-2 per year.

The training at many of the former DO derm programs is terrible, but it is still more training than mid-levels receive

 

[MOHS_01]

I was looking through some match data and noticed that Dermatology is right up with EM as the most rapidly growing residency. The number of positions offered has increased from 297 to 538 in the past 12 years, an 81% percent increase. For reference, EM, which I see everyone on these forums complain about oversaturation, has increased 90%. Is there a threat of oversaturation in dermatology? Especially considering the pending bill to add 15000 more Medicare funded residency positions, some of which would surely go to derm.

You are exactly 17 years behind me in making this argument; I was instructed to sit down and shut up (as a resident) at that time.

To answer your question, no, the job market is absolutely not what it was then. Not by a long shot.

 

[MOHS_01]

A major jump was due to the accreditation of DO programs. Disproportionately, there were a lot of DO programs (I think there were actually more DO derm programs than DO Peds or neurology programs).

There are a lot mid-levels in derm because there is unmet demand. An increase in derm spots will help to alleviate it. I think it is prudent to study the growth and act sooner rather than later, but I also wouldn't compare it to rad-onc

I would not compare general dermatology to rad onc for the demand for general dermatology is more elastic than is the demand for radiation oncology. The problem is not necessarily with the number of general dermatologists that we are turning out -- although that, too, is becoming a problem -- rather, it's with the Mohs and path folks. That is very comparable to rad onc.

 

[doctalaughs]

I would not compare general dermatology to rad onc for the demand for general dermatology is more elastic than is the demand for radiation oncology. The problem is not necessarily with the number of general dermatologists that we are turning out -- although that, too, is becoming a problem -- rather, it's with the Mohs and path folks. That is very comparable to rad onc.

I suppose although Mohs and dermpath folk can always fall back on their genderm skills (and frequently go hybrid or just don’t use the fellowship altogether).

Radoncs cannot do that.

I do agree the job market is far worse than 15 years ago, and will continue to worsen if the trend with churning out trainees (and over-utilizing midlevels) continue.

Glad I’m mid-career.

 

[dermie1985]

I'm more recently out of residency, so don't have anything to compare to... but would say the job market for derm is probably (at least relatively) more competitive than it has been in the past due to the increased number of graduates, especially if you're looking to practice in urban metro areas (West/East coast). That's not to say its difficult to find a job, just more difficult than in the past. This is for general dermatology. Mohs/dermpath are a whole other issue and I do feel as though we have too many fellowship positions for those career paths given the poor job market for each. Also, for gen derm, private equity/etc. is a whole other issue as well...but another discussion.

I will say that there is a unmeet need for general dermatology services, so the increase in the number of graduates isn't necessarily a bad thing. I would, however, say these unmet needs are in rural areas, poorer, underserved urban areas, and the Midwest/South - and I don't believe our recruitment efforts have concentrated on medical students who are interested in pursuing these career goals. Thus, while we're increasing the pure # of dermatologists, we haven't been targeting increasing the # interested in practicing in those underserved areas - which is why the urban-suburban job market on the East/West coast has become more competitive. I do feel as though derm is at a turning point where we need to think more about the future of our specialty and how we can (actually) address unmet needs through the training pipeline. Just my thoughts.

 

[MOHS_01]

I'm more recently out of residency, so don't have anything to compare to... but would say the job market for derm is probably (at least relatively) more competitive than it has been in the past due to the increased number of graduates, especially if you're looking to practice in urban metro areas (West/East coast). That's not to say its difficult to find a job, just more difficult than in the past. This is for general dermatology. Mohs/dermpath are a whole other issue and I do feel as though we have too many fellowship positions for those career paths given the poor job market for each. Also, for gen derm, private equity/etc. is a whole other issue as well...but another discussion.

I will say that there is a unmeet need for general dermatology services, so the increase in the number of graduates isn't necessarily a bad thing. I would, however, say these unmet needs are in rural areas, poorer, underserved urban areas, and the Midwest/South - and I don't believe our recruitment efforts have concentrated on medical students who are interested in pursuing these career goals. Thus, while we're increasing the pure # of dermatologists, we haven't been targeting increasing the # interested in practicing in those underserved areas - which is why the urban-suburban job market on the East/West coast has become more competitive. I do feel as though derm is at a turning point where we need to think more about the future of our specialty and how we can (actually) address unmet needs through the training pipeline. Just my thoughts.

This problem is decades old; you cannot address a distribution problem merely by increasing the supply. If you want people to be attracted to practicing in the target areas, you have to address the reasons why these areas are underserved currently. Oftentimes you will find that there is a very clear financial disincentive to practice in underserved areas; while the notion of altruism is quaint, underserved regions remain underserved.... so pay the provider properly to reside and / or practice there.

You have a toxic conglomeration of factors that make this true: first, population density. Rural areas have lower populations and lower densities, making it difficult for a specialist to exist. Second, socioeconomic: rural areas tend to be poorer and older -- translation: more Medicare and Medicaid as a percentage of the population mix, and a greater number of folks who struggle with their deductibles. Fewer union tradesmen, too, so gold plated insurance plans are not the norm. Lastly, educational: it is very difficult to recruit and retain a stable working class in an area that structurally suffers from brain drain (health and teaching are the only two semi-available and semi-stable fields in rural America).

There is nothing that the .gov can do about population density, little it can do about the social/educational headwinds -- but they can address the payment issue. They won't, however, because there is no sound politics in it. Why? See problem number one.

Lastly -- every election cycle needs political footballs, be it the minorities who are only given lip service every four years or rural health. I kept hoping that one day there would be a great awakening, 20 years on and people prefer to believe the lies rather than learn any truths.

 

[deleted941485]

I'm more recently out of residency, so don't have anything to compare to... but would say the job market for derm is probably (at least relatively) more competitive than it has been in the past due to the increased number of graduates, especially if you're looking to practice in urban metro areas (West/East coast). That's not to say its difficult to find a job, just more difficult than in the past. This is for general dermatology. Mohs/dermpath are a whole other issue and I do feel as though we have too many fellowship positions for those career paths given the poor job market for each. Also, for gen derm, private equity/etc. is a whole other issue as well...but another discussion.

I will say that there is a unmeet need for general dermatology services, so the increase in the number of graduates isn't necessarily a bad thing. I would, however, say these unmet needs are in rural areas, poorer, underserved urban areas, and the Midwest/South - and I don't believe our recruitment efforts have concentrated on medical students who are interested in pursuing these career goals. Thus, while we're increasing the pure # of dermatologists, we haven't been targeting increasing the # interested in practicing in those underserved areas - which is why the urban-suburban job market on the East/West coast has become more competitive. I do feel as though derm is at a turning point where we need to think more about the future of our specialty and how we can (actually) address unmet needs through the training pipeline. Just my thoughts.

As Someone whose not in the field, these conversations could be pasted in the job market forum in RO and it wouldn’t seem out of place as we have been having these conversations for the last 5 years.

The bottom line is programs will continue to open up in places that don’t need more residents. Heck PE May even get in on the action as well (See ER Med) Naming and shaming won’t work and the specialty societies are powerless. The economics are just too tempting. You can argue and rightly so about the distribution of residents and yet it won’t matter either. Many of the residents don’t come from these areas that need serving anyway and they like cities and suburbs like everyone else.

One academic Derm attending was complaining about how her grads were not able to find jobs in the city and had to head for the suburbs. I almost laughed. They tell people in my field to draw a 2 hour radius around and city and then maybe get a job in the circle!

Since the sheer magnitude of demand for derm is higher than RO, these problems will develop at a slower pace but by the time they reach the higher ups in your field it will be too late for anyone to do anything meaningful. Med Students are slow to catch on to the governing dynamics but eventually they do and competitiveness will fall reflected in the step scores and quality of the applicants. Comp will likely fall as well and employers and practice owners will have the upper hand.

For better or worse they’re is no central planning body. Everyone just follows their own self interest. The only consolation is that it could be much much worse Like path, nucs, and RO. Also many derms end up in industry evaluating skin products or pharmaceuticals so I mean at least you have some kind of source of extra income.

 

[qwerty89]

As Someone whose not in the field, these conversations could be pasted in the job market forum in RO and it wouldn’t seem out of place as we have been having these conversations for the last 5 years.

The bottom line is programs will continue to open up in places that don’t need more residents. Heck PE May even get in on the action as well (See ER Med) Naming and shaming won’t work and the specialty societies are powerless. The economics are just too tempting. You can argue and rightly so about the distribution of residents and yet it won’t matter either. Many of the residents don’t come from these areas that need serving anyway and they like cities and suburbs like everyone else.

One academic Derm attending was complaining about how her grads were not able to find jobs in the city and had to head for the suburbs. I almost laughed. They tell people in my field to draw a 2 hour radius around and city and then maybe get a job in the circle!

Since the sheer magnitude of demand for derm is higher than RO, these problems will develop at a slower pace but by the time they reach the higher ups in your field it will be too late for anyone to do anything meaningful. Med Students are slow to catch on to the governing dynamics but eventually they do and competitiveness will fall reflected in the step scores and quality of the applicants. Comp will likely fall as well and employers and practice owners will have the upper hand.

For better or worse they’re is no central planning body. Everyone just follows their own self interest. The only consolation is that it could be much much worse Like path, nucs, and RO. Also many derms end up in industry evaluating skin products or pharmaceuticals so I mean at least you have some kind of source of extra income.

While this is controversial to say the nature of the labor force for derm is very different from rad onc. Derm has a higher proportion of women who are more likely to want to work part-time. That makes it easier to absorb a surplus of graduates into the workforce. 1 old time male dermatologist who retires may need 2 0.5 FTE female dermatologists to replace his productivity. Rad onc is male dominated by individuals who want to work full time.

 

[deleted941485]

While this is controversial to say the nature of the labor force for derm is very different from rad onc. Derm has a higher proportion of women who are more likely to want to work part-time. That makes it easier to absorb a surplus of graduates into the workforce. 1 old time male dermatologist who retires may need 2 0.5 FTE female dermatologists to replace his productivity. Rad onc is male dominated by individuals who want to work full time.

Again just buys you time. Eventually PT becomes saturated too. And if productivity for a female is really 0.5FT then expect practices to just use more MLPs to pick up the slack.

 

[dermie1985]

This problem is decades old; you cannot address a distribution problem merely by increasing the supply. If you want people to be attracted to practicing in the target areas, you have to address the reasons why these areas are underserved currently. Oftentimes you will find that there is a very clear financial disincentive to practice in underserved areas; while the notion of altruism is quaint, underserved regions remain underserved.... so pay the provider properly to reside and / or practice there.

You have a toxic conglomeration of factors that make this true: first, population density. Rural areas have lower populations and lower densities, making it difficult for a specialist to exist. Second, socioeconomic: rural areas tend to be poorer and older -- translation: more Medicare and Medicaid as a percentage of the population mix, and a greater number of folks who struggle with their deductibles. Fewer union tradesmen, too, so gold plated insurance plans are not the norm. Lastly, educational: it is very difficult to recruit and retain a stable working class in an area that structurally suffers from brain drain (health and teaching are the only two semi-available and semi-stable fields in rural America).

There is nothing that the .gov can do about population density, little it can do about the social/educational headwinds -- but they can address the payment issue. They won't, however, because there is no sound politics in it. Why? See problem number one.

Lastly -- every election cycle needs political footballs, be it the minorities who are only given lip service every four years or rural health. I kept hoping that one day there would be a great awakening, 20 years on and people prefer to believe the lies rather than learn any truths.

I would say that derm (and probably other specialties) do not appropriately value rural practice in the training pipeline. I'm in academic derm and review residency applications every year. Every year we get applicants who are originally from rural areas and explicitly want to go back rural areas (they write about this in their personal statement). Usually these applicants don't have as great of board scores, they don't have a lot of research, they may have attended a lower tier medical school without a derm department, or be a bit lower ranked in their medical school class. Many of them don't get interviewed. I've argued we should probably create a rural dermatology residency position slot to encourage these applicants, but it hasn't happened yet. I think a lot of academic dermatologists are still infatuated with brand-name schools / pedigree, board scores, research output, and these qualities do not particularly correlate with interest in rural practice (or urban underserved). I think changing this will take a commitment to value this more in our residency training pipeline. Having said that, there are definitely other forces (e.g. tele-dermatology) that are increasing access to specialty services in remote areas, so there are other answers to this issue (e.g. technology) other than increasing providers physically in those locations. But, we clearly have a problem and there hasn't been a focus in our field on really addressing this.

I would say there are still incentives to practice in rural or underserved areas. These include loan forgiveness programs through the government (which typically have more funding than the number of people who take advantage of them). Also, my colleagues who have all gone into rural gen derm practice make more than me (>500k) and many of them signed contracts while in residency which included a monthly stipend during training. I think the incentives are out there, there just aren't enough people wanting to pursue them.

 

[MOHS_01]

I would say that derm (and probably other specialties) do not appropriately value rural practice in the training pipeline. I'm in academic derm and review residency applications every year. Every year we get applicants who are originally from rural areas and explicitly want to go back rural areas (they write about this in their personal statement). Usually these applicants don't have as great of board scores, they don't have a lot of research, they may have attended a lower tier medical school without a derm department, or be a bit lower ranked in their medical school class. Many of them don't get interviewed. I've argued we should probably create a rural dermatology residency position slot to encourage these applicants, but it hasn't happened yet. I think a lot of academic dermatologists are still infatuated with brand-name schools / pedigree, board scores, research output, and these qualities do not particularly correlate with interest in rural practice (or urban underserved). I think changing this will take a commitment to value this more in our residency training pipeline. Having said that, there are definitely other forces (e.g. tele-dermatology) that are increasing access to specialty services in remote areas, so there are other answers to this issue (e.g. technology) other than increasing providers physically in those locations. But, we clearly have a problem and there hasn't been a focus in our field on really addressing this.

I would say there are still incentives to practice in rural or underserved areas. These include loan forgiveness programs through the government (which typically have more funding than the number of people who take advantage of them). Also, my colleagues who have all gone into rural gen derm practice make more than me (>500k) and many of them signed contracts while in residency which included a monthly stipend during training. I think the incentives are out there, there just aren't enough people wanting to pursue them.

BTW, this reads similarly to what my personal statement and exit interview did; It gained zero traction and several eyerolls from the academics. Keep fighting the good fight!

as for the incentives — too little, too short term. Loan forgiveness is taxable. It is very difficult to address the structural economic maladies of rural America — I live it — but how many derms do you know who would be willing to travel hundreds of miles to staff clinics weekly AND willing to accept 60-110% of Medicare rates and average 80% collection rates to do it? These problems will only be intensified with proposed QA metrics... it’s truly vexing given the political aspect — it’s not that they don’t know what needs to be done, it’s that it’s toxic to support in today’s environment

 

[reno911]

I think in conversations like these, it also helps to define exactly what 'rural' is. I have friends that live in NYC that would insist that practicing in Des Moines, IA would be rural. And they would not be joking. This is what they actually think. In their mind, it's all corn fields.

It's not only factually incorrect, but a place like that avoids many of the problems endemic to the truly rural areas. I've never actually been to Des Moines, but if my perception is accurate, not only is it not rural, but it's exactly the type of place one might consider for a successful derm practice.

 

[MOHS_01]

I think in conversations like these, it also helps to define exactly what 'rural' is. I have friends that live in NYC that would insist that practicing in Des Moines, IA would be rural. And they would not be joking. This is what they actually think. In their mind, it's all corn fields.

It's not only factually incorrect, but a place like that avoids many of the problems endemic to the truly rural areas. I've never actually been to Des Moines, but if my perception is accurate, not only is it not rural, but it's exactly the type of place one might consider for a successful derm practice.

Yes; I have two practice locations, one is a county of 300k, the other has 80k — neither are terribly rural - but they pull from truly rural areas. Back when I had my old PM software, I had a report that showed payer mix and bad debt by home zip code. It was quite telling, the SES breakdown by zip code, with rural areas having higher gov payer percentage and higher bad debt levels....

 

[doctalaughs]

Yes; I have two practice locations, one is a county of 300k, the other has 80k — neither are terribly rural - but they pull from truly rural areas. Back when I had my old PM software, I had a report that showed payer mix and bad debt by home zip code. It was quite telling, the SES breakdown by zip code, with rural areas having higher gov payer percentage and higher bad debt levels....

The only thing that is going to solve the rural distribution problem is sky taxis (which I bet will be around in 10 years or less).

They aren’t going to solve it by offering 2x pay or 5x pay (which they wouldn’t do anyway).

But imagine if you could get to your satellite practice site 300 miles away in 45 minutes door to door for minimal cost (while reading a few journals and drinking coffee). Suddenly makes sense.

 

[MOHS_01]

The only thing that is going to solve the rural distribution problem is sky taxis (which I bet will be around in 10 years or less).

They aren’t going to solve it by offering 2x pay or 5x pay (which they wouldn’t do anyway).

But imagine if you could get to your satellite practice site 300 miles away in 45 minutes door to door for minimal cost (while reading a few journals and drinking coffee). Suddenly makes sense.

Makes sense... IF the payer mix and collection ratios are favorable; as is, even then it will not make financial sense.

 

[DoctwoB]

The only thing that is going to solve the rural distribution problem is sky taxis (which I bet will be around in 10 years or less).

They aren’t going to solve it by offering 2x pay or 5x pay (which they wouldn’t do anyway).

But imagine if you could get to your satellite practice site 300 miles away in 45 minutes door to door for minimal cost (while reading a few journals and drinking coffee). Suddenly makes sense.

Wait we're going to have sky taxis now?

Color me skeptical. As far as I can tell small airplanes remain expensive, require a skilled pilot and maintainence/hanger space (expensive), and require runways, meaning more travel time. And haven't appreciably evolved in a long time. Maybe AI can replace the pilot, but even then the other factors are still an issue. The sky car you can park in the lot has been a fantasy for 80 years, and unless you've developed a new energy source that can counteract gravity will likely remain so.

 

[Sushirolls]

Psych here...

Derm has the flexibility to throw up a shingle and do solo practice and hire like one front desk assistant just like Psych, with limited, low equipment investment. Why aren't more people talking about private practice and simplifying overhead? I think this model will emerge as more people get tired of the high volume, and large medical group practices. Also by not seeing the high volume of patients, you don't need the support staff. And by needing less volume of patients you can select for the better paying insurance and drop those that don't meet the desired rate. This isn't boutique or spa or cash only, but simply low volume, low overhead, selective insurance. What am I missing that this isn't doable?

 

[reno911]

Psych here...

Derm has the flexibility to throw up a shingle and do solo practice and hire like one front desk assistant just like Psych, with limited, low equipment investment. Why aren't more people talking about private practice and simplifying overhead? I think this model will emerge as more people get tired of the high volume, and large medical group practices. Also by not seeing the high volume of patients, you don't need the support staff. And by needing less volume of patients you can select for the better paying insurance and drop those that don't meet the desired rate. This isn't boutique or spa or cash only, but simply low volume, low overhead, selective insurance. What am I missing that this isn't doable?

I can think of a couple of people who do this. They do well and they're quite happy. It's not a bad way to go. It is harder now than it used to be, but the same can be said for a lot of things.

 

[doctalaughs]

Psych here...

Derm has the flexibility to throw up a shingle and do solo practice and hire like one front desk assistant just like Psych, with limited, low equipment investment. Why aren't more people talking about private practice and simplifying overhead? I think this model will emerge as more people get tired of the high volume, and large medical group practices. Also by not seeing the high volume of patients, you don't need the support staff. And by needing less volume of patients you can select for the better paying insurance and drop those that don't meet the desired rate. This isn't boutique or spa or cash only, but simply low volume, low overhead, selective insurance. What am I missing that this isn't doable?

Sure, it’s much more possible than some other specialties, but it’s not quite as low overhead as you think.

Derm does have more equipment overhead and needs more space than I imagine psych does (think several exam rooms, an excision room with lighting/venting etc, several exam tables etc). Also you can start with one front desk person to do phones/rooming etc but you’ll probably be doing all the billing+ practice management which isn’t the best use of physician time as volume ramps up. It’s actually quite hard to see more than 15 -20 patients with zero help (need 2 staff to see an average volume of 35-40 probably). So then you are looking at practice manager, medical assistant etc.

Again- doable but less profitable as insurance and regulation continues to pile up.

 

[wamcp]

It’s definitely a major problem for the future. Good jobs are already harder to find.

Unlike radonc we rely less on referral streams and partially generate our own demand with patients we “own”

That being said I’m glad that I am mid to late career and able to retire basically anytime after 5 more years (though likely to just cut down and do 10 more easy years after that). Would not want to be matching now, because who knows what things will be like in 5-10 more years for the job market (although that’s true of all medicine, which seems to be in a downward trajectory).

What’s your take, fearmongering or legit concerns over next five years?

WCD 2019: The Perils of Private-Equity Dermatology Practices Are Many and Far-Reaching

www.practiceupdate.com

“Currently, about 10% of dermatology practices in the United States are controlled by private equity. In 2009 there were 229 dermatology practices bought by private equity. In 2019, there were 747. “They are bragging that in 5 years they are going to own 80% of dermatology in the United States,” said Dr. Grant-Kels.

Private equity firms may let go of more seasoned physicians in the practice, replacing them with younger physicians, who will work for less, as well as physician extenders such as nurse practitioners and physicians’ assistants. A single physician may oversee as many as 5 to 10 physician extenders, who often see new patients or perform complex diagnoses and procedures that are beyond their scope of training. The private equity firm may also mandate more expensive treatment options, even if it goes against the patient’s best interests. “Any primary skin cancer on the face has to be sent for Mohs, even if you think you can excise it,” said Dr. Grant-Kels.


“They offer a young dermatologist a pretty good salary to start, and then they ‘normalize’ those salaries and lower them,” she continued. “They make them sign a noncompete [agreement]. … You owe your soul to them because the noncompetes can be very wide and very unreasonable. And although you could fight them if you go to court, that's very expensive to do it. Most young people don't have the funding to do that.”

There are wider consequences. Private equity firms are starting their own residencies and then hiring their own residents. “Residents are paid an unlivable wage and are [therefore] required to borrow from the private equity practice. When they graduate, they immediately have to pay it back or work for the private equity firm,” said Dr. Grant-Kels. “It’s a form of indentured servitude.” Specialists are hired away from academic medical centers, making it more difficult to train new dermatologists in academic settings.

 

[deleted314957]

I’m just about 70 and have seen lots. It all goes in cycles. I remember when path was an easy 1M/yr (today’s dollars) and no one wanted to be a dermatologist. Shrinks made nothing.

 

[MOHS_01]

What’s your take, fearmongering or legit concerns over next five years?

WCD 2019: The Perils of Private-Equity Dermatology Practices Are Many and Far-Reaching

www.practiceupdate.com

“Currently, about 10% of dermatology practices in the United States are controlled by private equity. In 2009 there were 229 dermatology practices bought by private equity. In 2019, there were 747. “They are bragging that in 5 years they are going to own 80% of dermatology in the United States,” said Dr. Grant-Kels.

Private equity firms may let go of more seasoned physicians in the practice, replacing them with younger physicians, who will work for less, as well as physician extenders such as nurse practitioners and physicians’ assistants. A single physician may oversee as many as 5 to 10 physician extenders, who often see new patients or perform complex diagnoses and procedures that are beyond their scope of training. The private equity firm may also mandate more expensive treatment options, even if it goes against the patient’s best interests. “Any primary skin cancer on the face has to be sent for Mohs, even if you think you can excise it,” said Dr. Grant-Kels.


“They offer a young dermatologist a pretty good salary to start, and then they ‘normalize’ those salaries and lower them,” she continued. “They make them sign a noncompete [agreement]. … You owe your soul to them because the noncompetes can be very wide and very unreasonable. And although you could fight them if you go to court, that's very expensive to do it. Most young people don't have the funding to do that.”

There are wider consequences. Private equity firms are starting their own residencies and then hiring their own residents. “Residents are paid an unlivable wage and are [therefore] required to borrow from the private equity practice. When they graduate, they immediately have to pay it back or work for the private equity firm,” said Dr. Grant-Kels. “It’s a form of indentured servitude.” Specialists are hired away from academic medical centers, making it more difficult to train new dermatologists in academic settings.

Price transparency, if allowed to exist, will serve as a natural limit and price them out of the market; there simply is not 15% of bloat to be realized by centralization or bulk purchase discounts.

 

[doctalaughs]

Price transparency, if allowed to exist, will serve as a natural limit and price them out of the market; there simply is not 15% of bloat to be realized by centralization or bulk purchase discounts.

I agree price transparency (across all of Medicine) would be great.

Every time you have a procedure, medication, visit there should be a requirement to list in huge/bold font the TOTAL price to our system (not what the patient pays after insurance/ coupons/discounts etc) along with 5 similar quotes in your area. And any facility fees etc should be in there.

It’s ridiculous the variance in cost for the same thing across our medical system (not to mention how interested parties deliberately hide costs for the patients who then pay higher premiums each year).

I would go so far as to say patients should be required to always pay 5% of every medical bill across the board - skin in the game makes people think about actual value.