The opportunities in dermatology are endless, and choosing a single option to pursue may seem both exciting and limiting. The ultimate destiny of your career is going to be based on interests that are in harmony with the practice setting you choose, combined with additional training after residency. However, nearly every dermatologist goes through some form of “mid-life crisis” in their career, usually leading to some element of new training, whether this be incorporating dermatopathology, adding a laser or some cosmetic procedure to the practice, or increased involvement with clinical research, educational speaking, or the industry. The template for the decisions made by dermatologists in their careers starts and ends with good decision-making about where to start.
Getting Started: Choosing a Path
Choosing what to do after training will depend on the early influences and exposures of your residency years, but also on your motivation, energy levels, and even some position of financial security if starting a private practice is an option. In addition, the opportunities for success are highly dependent on making prudent business decisions. However, no matter which practice setting you choose up front, there will be some form of “paying dues” early on in your career.
Choosing an Option
Options are always a wonderful commodity, but they come with a price. Usually that price is an opportunity lost, so you need to choose your option wisely for maximum benefit. The practice options that a graduating resident might have are influenced by many factors, including marital status, children, academic ambitions, and specialty training.
However, the motivations that bias your options may be even more influential, such as the wish for a desirable geographic location, higher salary, or proximity to family. In addition, despite the changing marketplace for dermatologists due to hospital consolidation, accountable care organizations, and over-saturation in the larger population centers, there is still a high demand for a dermatologist’s services.
The proximity to a teaching institution may bring with it the opportunity to serve as a volunteer or even full-time faculty depending on your interest and practice flexibility. There are significant personal rewards to routine part-time teaching in the school clinics, coordinating didactic sessions, or even participating in grand rounds. Even if continuing medical education (CME) credits are not offered, the potential to serve as a volunteer clinical instructor or as a clinical professor can enrich your career.
Location vs Opportunity
One of the most basic economic tenets is the balance between supply and demand, where market saturation may lead to diminished needs and therefore less competitive reimbursements for services provided. This could not be truer than in medicine, and especially in dermatology, where operations are primarily on an outpatient basis and often considered elective.
Unfortunately, this is not just the case for cosmetic surgery, but is also relevant to this era of high deductibles, high copayments, and a drive to concierge medicine where patients pay cash rather than use health insurance. As a result, the graduating resident who wants to practice only cosmetic dermatology in a market such as New York City, Miami, or Southern California is going to face a different challenge than someone who wants to practice general dermatology in North Dakota or Kansas. In addition, the concept of camaraderie among physicians that permeates a small non-competitive market, for example, is in sharp contrast to some other more competitive and litigious markets that you might face.
Aside from these examples of influential factors, there will be other intangibles that make certain practice locations more attractive than others. State income tax rates, malpractice premiums, and saturation of government assistance patients in the system have strong fiscal influences on job satisfaction as well as on income. The presence of a strong local and state dermatology society, proximity to a teaching institution, or other factors might impact on accountable care organizations (ACOs), Independent Practice Associations (IPAs), and of course managed care saturation.
Finally, the personal drive for happiness and the needs of family will always play a significant role in the location you choose. This might be especially true if you have been away from home for training and wish to return to be closer to family and friends, or conversely wish to stay closer to your training ground to cultivate referral connections that you have made. A spouse or significant other will also have a strong input into the location, especially if his or her job is based elsewhere or the personal fit in the new community is not seamless. For example, the non-dermatologist spouse may desire the amenities of the big city, the ocean, the mountains, or some other perceived “positive” to the relocation.
As previously mentioned, the well-trained dermatologist will have many options for expanding and growing their practice acumen, but there are inevitable limits on the scope of practice based on specialty training, interest level, and even compensation in the chosen market. There may be eventual declines in reimbursements for dermatopathology and Mohs surgery, and even for general dermatology codes such as destructions and patch testing. This may have a strong influence on overhead and eventually create a fine-tuning within your practice. In addition, a bad economy may significantly impair the vanity market, especially in smaller cities, resulting in the need to scale back the marketing of such services to avoid the price of competition.
However, the opportunities to expand skills in the chosen marketplace should be handled slowly and efficiently to avoid not only financial overextension but also dilution of skills. Adding cosmetic surgery to a practice that is either just starting out or that has been primarily medical has the potential to backfire if not handled well. Rather than diving in headfirst with a high overhead of lasers, marketing of high-priced cosmetic procedures, and the promise of services that do not fit the image of the existing practice or market, a more prudent and fiscally responsible approach might be based on a survey of the needs of patients who either inquire for the service by phone or in person, or else by the value of those procedures and their reimbursements in the region. From there your approach should be based on the “Aim to Please” philosophy of adding services that are actually in demand rather than creating a supply that may not be desirable. Not all practices need the same services—knowing the market, the potential adaptability of the office, and the cost/benefit ratio will eventually impact potential revenue stream from the change in practice philosophy. In short, that same practice may benefit from the steady incorporation of peels and microdermabrasion, then from assessing the need and costs for lasers, and eventually from integrating higher level procedures such as fillers, toxins, and resurfacing treatments if the market has indicated the return on investment. The same practice needs to be diligent about tracking success as well as overhead and expenditures to avoid chasing an empty promise of revenues that will not materialize.
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