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Dermatology’s two-tier patient classification and its implications for effecting change in the medical profession   Leave a comment

A few years ago, the New York Times reported a strange scheduling phenomenon encountered by patients at dermatology clinics in southern California. The article cited a study in the Journal of the American Academy of Dermatology that examined scheduling wait times in a number of American cities. If a patient were looking for a chemical peel or Botox┬« injection, clinics could routinely schedule the patient for later the same week. In contrast, if a patient had a concerning mole or eczema that had not responded to routine treatment, it would often take a month to get an appointment. Interviews with industry experts at the time suggested that many dermatology practices were effectively running two separate practices split along patients needing medical versus cosmetic dermatological consultations. “Medical dermatology” is a category within the specialty that addresses dermatological disease (e.g., skin cancer, acne, eczema, psoriasis). “Cosmetic dermatology” refers to dermatologic needs to improve one’s appearance but are not the result of any derangement within the body. Common problems in cosmetic dermatology include wrinkle-reduction, altering skin pigmentation, and removing age spots.

An important aspect of this distinction between the two major categories of dermatologic needs is the grossly different financial impact of each. Cosmetic dermatology is almost never reimbursed by medical insurance while medical dermatology is usually required by law to be included in insurance coverage. This difference effectively creates two classes of patients in a typical dermatology practice. The medical dermatology patients pay a nominal co-pay and then a physician could spend weeks trying to capture a relatively small amount of additional revenue from the patient’s insurance company. In contrast, cosmetic dermatology patients are paying in full at the time of their visit at a price that can theoretically be as high as the local market will bear. The New York Times article noted that a dermatologist could double his or her annual income by focusing more of their practice on cosmetic procedures. The reported scheduling behavior suggests that many dermatology practices attempt to capture a greater share of cosmetic dermatology while potentially limiting the volume of medical dermatology because of these financial incentives.

While the reader’s knee-jerk reaction may be that government regulation be used to “force” dermatologists to more equitably accept both types of patients, I would suggest that the current situation highlights an opportune moment for professional activism of a kind rarely seen in medicine. The ultimate obstacle to scheduling a medical dermatology appointment is a limited supply of appointment slots in certain localities. Ironically, this long-time shortage of medical dermatology care notwithstanding, clinical training in dermatology is one of the most competitive specialties in medicine within which to receive a training position. In theory, if enough dermatologists were trained and sent to practice in an area this shortage would solve itself. However, increasing the number of dermatologists being trained would likely create a disproportionate amount of cosmetic dermatology practices. This disproportionate desire from graduates to practice cosmetic dermatology limits the profession’s desire to expand the number of trainees each year. One potential solution is for a formal distinction in training to be made from cosmetic and medical dermatology. Doing so would not be easy and would likely require a combined effort from accreditation bodies to require the trainees in dermatology only be trained in either subspecialty, and it would also require cooperative state medical boards to prohibit one group practicing the other’s trade. Given the different financial incentives of each subspecialty, a likely result of such a change would be that cosmetic dermatology would continue to be the highly-competitive, highly-compensated field that dermatology largely resembles today while medical dermatology would be a more academically-focused, less competitive, moderately-compensated field that it should be.

The real take away from this discussion is not determining whether the greater dermatology community ever makes such a radical step to fix a distorting externality of the profession. The ultimate point here is that the medical profession, its accrediting bodies, and training institutions ultimately have many of the tools to improve healthcare delivery and training in the U.S. today. Historically, our profession has been relatively passive which encourages external actors (e.g., governments, industry) to shape how we provide care to patients. While engaging outside influencers is important, medical providers are often best suited to recognize and adapt to problems that arise in the practice of medicine. It is up to medical providers then to embrace their role as change-makers.