How dermatology became the 'it' job in medicine
wsj.com
wsj.com
As a layperson, it seems like we (patients / society) would benefit from having more doctors, i.e. opening up more residency slots and admitting more people to med school, but there's probably a lot I don't understand about the issue. Not sure if it's a lack of political willpower to do this, or if there are other reasons why the number of doctors we train is so restricted.
[1] https://pubmed.ncbi.nlm.nih.gov/29710082/ ("PAs performed more skin biopsies per case of skin cancer diagnosed and diagnosed fewer melanomas in situ, suggesting that the diagnostic accuracy of PAs may be lower than that of dermatologists")
Like so many of America’s issues, it’s due to lobbying based on entrenched greed.
> In 1997, the AMA lobbied Congress to restrict the number of doctors that could be trained in the United States, claiming that, "The United States is on the verge of a serious oversupply of physicians."
Here in Sweden have almost 2x as many physicians you do, and we pay them about half of what you do, so we end up paying approximately the same in salaries (the average Swedish physician is paid 131k) and I think it works out completely.
We start our training of physicians right after high school, so we push them to get an MSc in Medicine, rather than treating physicians as some kind of pseudo-PhDs, with however requiring head physicians to have an actual PhD; and this system is fine. I think it's the same way in Denmark, and given the stuff they've come up with I imagine one can't complain much about their system.
In Scandinavia, student loans are taken to cover living expenses, not the cost of tuition. Private schools exist, but are not nearly as common as in the U.S.
Biopsy stats might differ because PA's are used in large (cough private equity) practices to do a lot of checks esp. in old-folks homes, and medicare pays. Patients per week can average 120+; no doctor does that. Plus, the PA is supposed to err on the side of caution, meaning more biopsies. DR's are more willing to ignore possible risks.
That said, most anyone (Dr. or PA) who is recently trained at a good school is often better than people with 15+ years of experience.
Also, derm exam skills are not enhanced by the depth of medical education or even much by experience (by contrast to the cardio exam). It's mostly a function of pattern recognition and patient skills.
In some places, it is possible to go from high school to ARNP within 6 years.
And while supervision requirements for PAs might vary in terms of actual oversight, ARNPs are ostensibly fully fledged independent providers.
And I'll also say that you see the same pre-hospital too. In the PNW, while there are valid criticisms that can be leveled against two of the pre-eminent paramedic programs (Harborview, and Tacoma Community), there are far, far, too many "strip mall schools" in other states that will take you from "zero to hero" in 4 or 5 months (of 6 days a week, 8 hours a day, of just class time), and dump you out on the world with just enough retained knowledge to pass your NREMT and the barest amount of ride time to meet DOT mandated minimums. It's scary, to be blunt. These people go out with no clinical experience and are now expected not just to work as a team on a 911 call, but to lead it.
When I actually got my appointment within 30 days, due to calling and advocating for myself politely, I started wondering how much ground medical dermatology has ceded to elective and cosmetic dermatology. I am concerned that dermatology is becoming centered around the personal appearance of affluent people rather than medical need.
Try requesting appointments during December or January. A little birdie told me that appointment cancellations go through the roof at some practices during those months.
In USA, with PPO insurance, you can see specialists without a referral. Direct specialist appointments without seeing your primary doctor for a referral.
It's a matter of "current patients have filled the schedule indefinitely."
If high-skill jobs are compensated (relatively) less, workers are less incentivized to pursue those jobs, or they move to other markets.
B. Capitalist countries like the U.S. are not completely immune to his phenomenon either.
I hadn't needed to go to a primary care doctor in my adult life, but it was mind blowing that this was the case. Many friends of mine have had the same experience.
When I was younger on crap insurance, I was able to quickly find one by having no standards other than "be a medical physician". And the doctor I went to was definitely lower rung.
Full disclosure: I am a retired board-certified anesthesiologist.
I asked around town (Charlottesville, Virginia) and got two names from doctors I trust.
The first was not taking new patients; the second was, so I made an appointment: first available appointment was January 2025 (i.e., in 18 months). I happily took it.
I figured maybe this was a way of triaging old people like myself: if we're forced to wait long enough before being seen, maybe we'll die in the meantime so slots will open up.
If you're going to do it, I would recommend having a bunch of labs done so you can at least know how you're doing. For example might as well test A1C, Vitamin D, Iron, Thyroid, Testosterone and many other hormones and vitamin levels to get a good picture of your nutrition. If you're low/high in many of these things a simple supplementation can radically improve your life, but not if you don't know about it. A friend of mine recently found his Testosterone levels were really low, and after starting TRT he feels way, way better. It improved depression levels and many other things, with a bonus that now when he goes to the gym it's actually possible to get some results.
Worth pointing out is that you can have (most) of these labs done without a doctor. There are websites you can buy kits, and you can sometimes just go in-person to Labcorp offices and they'll run stuff for you.
Anyway, just something to consider.
It reminds me of what some Canadian friends described their healthcare system being like 20 years ago. If we’re paying more and getting the same service, I’m not sure there’s much reason not to socialize healthcare now (health care, not insurance).
While getting less service, as a marketplace insurance purchaser my premiums are doubling next year. It’s still “cheap”, but that would be a significant shock for most families.
https://www.salaryexpert.com/salary/job/dermatologist/belgiu...
> The average dermatologist gross salary in Belgium is 215.909 € or an equivalent hourly rate of 104 €. In addition, they earn an average bonus of 13.041 €. Salary estimates based on salary survey data collected directly from employers and anonymous employees in Belgium. An entry level dermatologist (1-3 years of experience) earns an average salary of 143.218 €. On the other end, a senior level dermatologist (8+ years of experience) earns an average salary of 286.875 €.
that is... out of the box, a very very nice salary to start your career with. OMG. Top IT jobs in Belgium are at 130k or so (none management)
https://lcme.org/directory/accredited-u-s-programs/
At one point the AMA did lobby Congress to restrict the number of residency slots but they long since reversed that position and now lobby for an expansion.
You would think that Hospitals would be able and willing to pay for residents.
Something doesnt add up.
Why would you think that? Pay... out of their profit margins... to reduce their profit margins? Or do you mean in la-la-land where American CEOs make investments that are likely to show returns only 10+ years out in the future?
Anyways, a huge number of hospitals are non profit and still have the residency issue. There is something systemically fucked going on if a hospital can't turn a profit on a MD with "only” 8 years of postsecondary education, and needs 4-6 years more
As a hospital, they also have no incentive to treat people earlier in disease progression with less expensive care or anything. Just let the ailments fester until they have to be rescued with the most expensive interventions on the planet.
No one said anything about "not turning a profit." If you think a profit-seeking organization exists only to turn a profit, you misunderstand the enterprise.
You are not engaging with the question posed, merely listing a number of cynicisms tangential at best, or factually incorrect at worst.
Independent practices generally cant operate licensed residency programs. Similarly, your model of hospital behavior ironically requires them to forgo money could make today to cash in on expensive interventions decades in the future - exactly what you claim they are incapable of doing.
Last, you claim doctors are a dime a dozen, yet hospitals pay 4, 5, or 600k to employ them, and frequently close due to an inability to secure them at reasonable costs.
They're one of the largest lobbying groups in America with disastrous consequences. They have a consistent history of empty promises, including their rhetoric on expansion which hasn't been successful despite the years they've had and the political leverage during the national health emergency. https://www.zippia.com/advice/largest-lobbyist-groups/
Here's a differing opinion from yours where "The American Medical Association (AMA) bears substantial responsibility for the policies that led to physician shortages". https://blog.petrieflom.law.harvard.edu/2022/03/15/ama-scope...
I hear about how wealthy and powerful the medical community is yet they shift the blame at every opportunity. I hope medical schools require students have a spine too.
It's always disappointing to see this kind of lazy, low-effort comment on HN. This is all public information that you could easily find if you bother to look.
For at least two months, no appointments were available with any derm in my network, so I immediately set up a telehealth appointment with one in another state, explained the condition, and got an RX on the same day.
Perhaps if supply of dermatologists was not so strongly limited, prices and wait times would improve.
Every time it comes up in the US, nationalized healthcare is demonized in some media. But it just feels like a facade perpetrated by the hospitals and insurance companies (and now private equity) who stand to lose the most. If it's good enough for veterans and retirees, why can't it be good enough for the rest of us? Maybe it's because when the government pays the bill, they don't just roll over and accept $EXORBITANT_FEE after $EXORBITANT_FEE - they negotiate and get some reasonable value.
Make it a law that all doctor offices need one or two residency slots. That should alleviate the problem in time due to compounding growth.
Maybe force every doctor office by law to be a teaching hospital of some sort. They get paid 500K, seems to be a good form of taxation on an undeserved salary.
That hospital will then have enough support staff to maintain a large load of interns as the compounding growth continues. Of course the growth has to level off at some point. But yeah.
And as for conscripting physicians and forcing them to train residents, that's a completely bizarre and unrealistic suggestion. Forcing someone to teach and mentor who doesn't want to do it will guarantee bad results. And many practicing physicians don't live anywhere near a teaching hospital.
Who are you to decide how much salary someone deserves? I think you deserve $4 an hour. That seems fair to me. In the real world fairness to subjective. What actually matters is negotiating power. The most straightforward way to reduce physician negotiating power is for Congress to increase graduate medical education funding through Medicare. Income in the $500K range is already in the 35% tax bracket (plus any state income tax) so doctors are paying quite a bit; Congress just chooses to spend that money on other priorities.
I think it’s fucking disgusting the amount doctors get paid. It’s revolting and evil the way health is held hostage for money.
I don’t care if it’s a 35 percent tax bracket I have very little respect or appreciation for doctors who want to coast and get paid 500k while I have to pay 1000 just to get some uvb shined on my fucking skin. Like seriously some of these treatments are outta this world expensive and doctors charge an arm and leg just to have a goddamn intern shine a light on my skin.
Who am I to decide how much someone deserves? How about when all your patients are disgusted by you and your fucking money making tendencies then come talk to me about being entitled. The only reason why I’m not shining that light on myself is because the law forms a cartel and allows you to literally steal money from me. The AMA lobbies congress to limit the amount of residency spots. It’s a cartel. Don’t blame the government. Blame the business interests that limit the government.
People used to respect doctors. Now the majority of people I know fucking hate them. Your comment really pissed me off. I don’t think you’re aware at how much people in the US hate doctors. It’s like their life is in your hands so they don’t tell you first hand what they hate about you.
How about you cut your pay to 100k and increase the supply of doctors 10x so you have an easier time and can be more affective? Do you actually think what you do is so professional that only you can do it? The whole md degree is a gate keeping tool.
The other developed countries doing this don't pay dermatologists 500k though.
My cousin graduated med-school last year and is still unemployed because no hospital had a place for her. Private practices don't fix that issue since they're not designed to be part of the medical teaching cycle. So a lot of young doctors have to emigrate to other EU countries where they can find spots to practice.
Would this not also be a problem in single payer systems? The article does not do a great job of it but it would be interesting to see the billings split between cosmetic and medical. The article is already on how the field is booming because of cosmetics, one of the interviewed doctors does not even accept insurance. This has nothing to do with capitalism vs socialized healthcare and all to do with cosmetic procedures which would mostly not be covered under a single payer style system anyway.
From what I gather, Congress set the current low limit due to lobbying from the AMA something like 30 years ago. The AMA has since changed its tune and wants more slots to alleviate shortages in some regions and specialties, but the funding has not materialized.
What would they do if the government didn't fund any slots, just shrug and decide they didn't need doctors?
Note that I'm not opposed to the government funding lots more slots, I am objecting to the presumption that government funding is the only possible way to make a doctor.
There are a small number of residency slots funded by non-profit foundations but those are a drop in the bucket. None of the other major players in the national healthcare system have an incentive to pay for this stuff.
Unpopular opinion: if the student will be able to pay that loan off in 10-20 years and maintain a good standard of living while doing so, then it is probably fine.
> None of the other major players in the national healthcare system have an incentive to pay for this stuff.
I'm pretty sure the entire system's revenue model breaks without physicians, so there are plenty of businesses (hospitals, labs, practices, etc...) with an incentive to have more billing capacity.
There are some hospitals you will go to (big names!) where you will never actually see an attending physician most of the time. Your entire care team are residents.
How a hospital can’t turn a profit off $60k/yr “junior doctors” doing all the actual work is beyond me. I’m sure there are costs I am not considering, but my immediate gut reaction is that it’s nearly all creative accounting to pretend residents cost more than they bring in - to keep that sweet government subsidy coming in as well as limiting the number of slots.
Some programs of course this makes sense, but on the whole it doesn’t seem to pass a smell test to me.
For the math to work, the fully qualified attending would have to be ~10x more efficient than the residents ($600k salary vs $60k salary - very rough, obv).
The current state seems to be "a single attending is more efficient practicing solo than the same attending overseeing five residents"
The value of residents varies a lot by experience and specialty. Like a 1st-year neurosurgery resident might be worse than useless and a huge burden to everyone around them. Whereas a 3rd-year family medicine resident can do a lot with minimal supervision.
https://en.wikipedia.org/wiki/Residency_(medicine)#:~:text=B...
Our demographic makeup means we have more elderly in need of care and fewer to care for them, which means we will need to revert our requirements. The UK is already discussing/planning-for this in their healthcare system: https://www.independent.co.uk/news/health/nurses-doctors-deg...
I understand that it's scary that care quality may be lower, but that argument is similar to demanding that every road worker and civil engineer have a PhD. Our bridges and roads would likely be better if all participants were so educated and qualified, at least for the horrifically expensive and few roads/bridges we would be able to build.
I already mostly see NPs for my checkups. If they aren't sure, then I can jump through the hoops to get a Physician.
It works well and I get plenty of time to discuss things during my appointments.
EDIT: I still think my original point may stand for specialists however, we'll have to see how it shakes out and what healthcare systems under more stress than ours decide to do in the near future.
I think there are parallels to nursing as well, with increasing credentialism and then creation of new classes. 30 years ago nurses entered the workforce with a 2 year associates from a junior college. Heck, my highschool had a nursing occupational program.
Maybe the graduate medical education programs would have to compete on price as well as quality and reputation?
But, the fact that hospitals don't fund their own seems to prove the underlying assumption - that offering a residency is a net loss to the hospital. If that weren't true, they'd fund the slots on their own.
It's bizarre that these discussions seem to start from the assumption that we got here intentionally by only making good decisions.
Regulation, left unchecked, favors constant indirect damage from shortage to more visible direct harms.
This is why it takes 3000 hours of training to cut someone's hair.
The lack of doctors allows hospitals to charge more money for access to the ones they have. And right now the government foots the bill for training new doctors.
If they funded new residency slots they'd simultaneously increase their expenses, and reduce long-term revenues. Even if the resident's work is profitable by itself - in the sense of generating more in billings than the costs in salary, benefits, and teaching time - it could be bad for the hospital in a decade or two.
If the government simply ended the practice of funding residencies then hospitals and the rest of the medical establishment would be forced to come up with a new approach. Until then they're content to ride the gravy train.
But imagine how available and inexpensive dermatologists would be.
(Okay, let's not say 600, but let's say 2x or 4x the current #)
How many people who get into surgery would still do it with all the same education, testing, training, and licensure requirements if it paid $100k/yr? My guess is not many. If you're in a highly litigious state in a high-risk specialty your malpractice insurance alone could be more than that.
It's not surprising to see smart people leave risky positions with pretty objectively bad work-life balance for more money, less stress, and better WLB.
However a concrete example is the "pulling up the ladder behind you" effect of regulatory capture.
There are more people who want to become doctors than our country allows to become doctors.
Our current state of affairs regarding compulsory medical residency programs is a result of years of increasing the barriers to entry (for good or bad reasons, doesn't really matter). Now it's up to Congress to pass Medicare reform laws to update their funding for the residency programs, but that has just not happened (one of the major I-told-you-sos when dealing with government intervention).
It's probably not the case that we want to completely deregulate, however a major consequence of almost any regulatory intervention that operates on the basis of increasing credentialism is that we will end up with some % less than ideal supply.
One of those ten interviewers was a dermatologist: arrived late; bitchy attitude; chip-on-her-shoulder; challenged an easily-verifiable fact about my candidacy (she even rolled her eyes when I tried to change the subject!)... tl;dr: her undeserved apathy turned me off from her program, entirely.
The first few years after leaving medical school I felt bad about having "wasted a spot." After years of reflection (and an alternate career), I am now able to better-empathize with physicians — mainly for all the sacrifices they have made just for (most) patients to ignore their professional advice.
You cannot pay a US physician enough money to counteract all they've given up (life/balance/youth).