Cosmetic vs. Medical Dermatology: A Widening Gap?


I s dermatology today being drawn into two distinct camps? If so, the battle lines might be drawn this way: On one side sits a growing army of cosmetic/surgical dermatologists armed with lasers, Botox injections, and a cadre of patients happy to pay for their procedures. On the other, medical dermatologists provide traditional therapies to patients and wait for reimbursement from managed care plans. In this article, we’ll take a closer look at whether dermatology is splitting into two distinct parts. Armed with this information, you can decide what — if any — changes to make in your practice. Growing Popularity Only those buried under a pile of rocks for the past few years could have missed the vast popularity of cosmetic dermatology. The overall number of cosmetic procedures has increased a whopping 228% since 1997, says the American Society for Aesthetic Plastic Surgery. Nearly 6.9 million cosmetic surgical and nonsurgical procedures were performed in the United States last year. As you’re already aware, cosmetic procedures tempt dermatologists on various levels. Because they’re provided largely on a self-pay basis, cosmetic dermatologists avoid the maddening frustrations involved with obtaining reimbursements from managed care companies. You don’t wait to collect your money, you have a better cash flow, and your collections are virtually 100%, according to Phillip Williford, M.D., associate professor of dermatology and director of dermatologic surgery at Wake Forest University School of Medicine, Winston-Salem, NC. Treatments for rheumatic diseases, for instance, the professor notes, might involve agents that carry potential toxicities. Comparing that with the low-risk practice of injecting Botox, he can see why some might not want to have a practice that’s overwhelmed by the medical aspects of dermatology. "Siren Call" of Cosmetics But does this attraction come with a price to pay? In part because of the "siren call of cosmetic dermatology," patients may find it harder to access medical dermatologists, according to Dr. Williford. There is a perception, he says, that the cosmetic part of dermatology is leading to a shortage of medical dermatologists. In the Winston-Salem, NC, area, estimates Dr. Williford, the waiting time for a new medical dermatology visit ranges from 8 to 10 weeks. But if you want Botox, he suspects that the wait time is far shorter. From his perch as president of the American Academy of Dermatology, Raymond L. Cornelison Jr., M.D., agrees with Dr. Williford’s assessment. It’s more difficult to see a dermatologist, he says, because not as many medical appointment slots are available. Even the dermatologists who practice pure surgery “will tell you that we can’t forget to take care of the medical problems within dermatology,” he notes. Dermatologists don’t want to give up their expertise in medical diseases of the skin: “We must maintain our focus and interest in that area,” he stresses. Medical Still the Focus While no doubt those statements hold truth, it’s important not to exaggerate the case. In no way is the profession experiencing a wholesale flight of medical dermatologists to cosmetic/surgical dermatology. “In contrast to some of the conventional wisdom out there, it’s not as if the majority of dermatologists are spending 50% of their time or greater doing cosmetic dermatology. They’re clearly doing cosmetic dermatology, but it’s not the bulk of most people’s practices,”says Alexa Boer Kimball, M.D., M.P.H., assistant professor, dermatology at Stanford University Medical Center and chairperson of the Workforce Task Force for the American Academy of Dermatology. “Medical dermatology is still the focus of most dermatology practices,” she says. “Surgical dermatology is the second most prevalent activity.” AAD statistics reveal that the average dermatologist spends about 5 hours per week doing cosmetic dermatology, says Dr. Kimball, out of a mean of 32 hours per week seeing patients. (Physicians typically report 5 to 10 more hours per week spent in practice-related activities.) Recent graduates, she notes, report spending about 3 to 4 hours a week. Dermatology resembles other specialties, such as otolaryngology, says Dwight Scarborough, M.D., of Affiliated Dermatology Cosmetic Surgery Center Inc., Dublin, OH, and adjunct assistant professor at the College of Physicians and Surgeons, Columbia University. Otolaryngology used to be primarily a medical specialty, but then that specialty’s surgical side developed great expertise in performing cancer surgery, including radical neck dissections, and then branched out into facial plastic surgery. Likewise, radiology now boasts interventional radiologists, as opposed to clinicians who just read X-rays. Dermatologists, he posits, are similar. Once you start moving large pieces of tissue around to cover areas, you obtain better aesthetic results and address other facial concerns, he says. There is, he says, “greater diversity in our group.” Hard to Separate Although very medically oriented, he finds that he also performs cosmetic procedures, says Steven R. Feldman, M.D., Ph.D., professor of dermatology, pathology and public health science, Wake Forest University School of Medicine, Winston-Salem, NC. It’s difficult, he notes, to separate medical dermatology completely from cosmetic dermatology. A patient, for instance, might have a bothersome skin tag. Although most dermatologists wouldn’t consider it a medical procedure, it’s something most medical dermatologists can help the patient with, he says. Instead of thinking of the profession as separating into medical and cosmetic/surgical dermatology, he proposes a view based more on “the intensity of what people are willing to do.” That is, dermatologists decide how surgical they want to be in the procedures they do, in how aggressive the treatments they’ll provide. “The breadth of what dermatologists are able to do is increasing, the quality of what we offer is increasing, and some dermatologists are doing these more intensive procedures more than others,” says Dr. Feldman. What’s more, those who decry cosmetic dermatology, saying there aren’t enough medical dermatologists to meet the need, “may be underestimating how important the cosmetic services are to patients,” he says. Patients may be willing to spend a lot more money to treat wrinkles as opposed to psoriasis, he suggests. In the patient’s mind, addressing the wrinkles means the doctor provides a greater medical service. Best of Both Worlds For the great majority of dermatologists, the challenge may be to find the right balance of cosmetic/surgical and medical dermatology and discern what makes sense to meet their own interests, their patients’ needs, and the future of their practice. Dr. Cornelison, for instance, has seen his practice mix shift from 20% surgical and cosmetic procedures to 50%. That shift has accelerated during the past 5 years, he says, driven economically and by developments in cosmetic/surgical dermatology, such as the use of Botox, liposuction, vein sclerosis, and photorejuvenation. The profession isn’t experiencing so much a polarization as a continuum, says Victoria P. Werth, M.D., associate professor of dermatology and medicine at the University of Pennsylvania. Many dermatologists offer the whole range of what patients request, she notes. While some practice cosmetic dermatology exclusively, and some practice medical dermatology exclusively, a broad range of dermatologists occupy the middle, says James Del Rosso, D.O., of the Las Vegas Skin and Cancer Clinics. These clinicians provide lighter cosmetic procedures, such as microdermabrasion, Botox and fillers. These require skills, but are technically less challenging than, for instance, laser resurfacing. The trend to cosmetic dermatology, he notes, is based on trying to stay competitive and counteract the difficulties related to managed care and reimbursement in medical dermatology. Clinicians, he says, are interested in expanding services and obtaining better cash flow. “It’s the rare dermatologist” who does pure cosmetic dermatology and surgery, agrees Howard Steinman, M.D., The Dermatology Institute, Chula Vista, CA. He is part of a practice that’s undergone a major transformation from a medical to a cosmetic/surgical practice (see Making the Transition: One Practice’s Story, on page 33). Most dermatologists spend more than 50% of their time doing medical dermatology, he says. Dr. Steinman also points to dermatologists’ ability to provide a range of services. If you treat an acne patient traditionally, but then also treat the patient for pigmentation, at some point you’ve gone from medical to cosmetic dermatology, he suggests. “Where do you draw the line?” he asks. On a practical level, dermatologists don’t magically transform from medical dermatologists one day to cosmetic gurus the next. Cosmetic dermatology represents “a different patient and a different demand” from the medical dermatology practice, says Dr. Del Rosso. The dermatologist and staff must prepare to do more handholding than they would with a medical patient. Long-time practitioners may decide not to make the shift, even if it may seem financially attractive. In fact, doing cosmetic dermatology can harm a practice, if not done correctly. “A well-run medical dermatology practice can be harmed financially if it becomes a poorly run cosmetic dermatology practice,” Dr. Del Rosso says. Into the Future Dermatology training reflects this new mix between cosmetic and medical dermatology. Among residents, Dr. Werth at the University of Pennsylvania sees more of an interest in the surgical aspect of dermatology. Residents view cosmetic procedures, she says, as a way to supplement their dermatology practice. Similarly, at the University of Oklahoma, Dr. Cornelison feels most of his residents will have a mixed practice. To address their interests and to fulfill residency training requirements, the faculty teaches more surgical and cosmetic dermatology than before, he notes. If he had to guess, the large percent of younger dermatologists coming out of training and many dermatologists under age 40 to 50 are driven toward surgical dermatology, says Emil Bisaccia, M.D., professor of clinical dermatology, College of Physicians and Surgeons, Columbia University. He also notes that quality is of the utmost importance because the field is extremely competitive, with competition from such professions as oculoplastic surgeons. He and Dr. Scarborough co-direct two fellowships from offices in Dublin, OH, and Morristown, NJ. Stronger than Ever Younger dermatologists, agrees Dr. Feldman, will incorporate cosmetics into their practice mix. What’s more, he notes that residents obtain far greater surgical experience than what typical dermatologists were trained previously to do. “Over the last 15 years,” he says, “the surgical armamentarium for treating skin disorders has vastly improved.” As the underlying scientific concepts have been delineated, for instance, for liposuction and collagen, all of those procedures have been dramatically enhanced. Perhaps Dr. Scarborough’s and Dr. Bissacia’s fellowship training program serves as an object lesson in the training of dermatologists today. Each year, they teach four fellows, who are fully trained as medical dermatologists. During the fellowship, they learn advanced surgical techniques. Despite the enthusiasm, at least one cosmetic dermatologist sounds a cautionary note. While the majority of residents want training in cosmetic dermatology, the pendulum may swing back when there’s great competition in the field, says longtime cosmetic dermatologist Bruce Katz, M.D., director of the Juva Skin & Laser Center and Juva MediSpa in New York City. But advances of course are occurring outside cosmetic dermatology as well. New biologic therapies to treat psoriasis have “reawakened an interest in medical dermatology,” says Dr. Cornelison. With the exception of methotrexate, biologic therapies are the most significant development in the treatment of psoriasis since he’s been a dermatologist, he says. Two-Tier Training On a contrasting note, Dr. Steinman expresses concern over a “two-tiered level of training” for dermatologists with respect to advanced dermatology and cosmetic surgery. One group will have had 3 years of residency but no surgical fellowship. While they can take courses to learn advanced procedures, doing so may not be easy. But another group takes advantage of a small number of advanced surgical fellowships. They learn Mohs surgery, then advanced skin flaps and grafts, and then naturally progress to such procedures as blepharoplasty and liposuction. After a year of such training, these dermatologists are comfortable doing advanced cosmetic procedures, depending on what they achieved from their fellowship. That special fourth year of fellowship, Dr. Steinman says, has been approved as “accreditation without certification.” The natural solution, says Dr. Steinman, would be to develop a 4-year residency program. In essence, dermatology would become more like ophthalmology. All ophthalmologists, he notes, learn both eye surgery and medical treatment as an inherent part of their residency. Dermatologists should have a comparable training in dermatology, he suggests. Dealing with Competition However the pulls between medical and surgical/cosmetic dermatology continue, all dermatologists need to deal with growing competition from outside the profession. With other specialties starting to provide skin care, dermatology faces a threat from clinicians such as OB/GYNs. One patient, says. Dr. Steinman, came to have her acne treated. Her gynecologist had sold her a cosmeceutical product line, and she was already undergoing a series of prepaid glycolic acid peels given by an RN in the gynecologist’s office. Many dermatologists could likely tell similar tales. Choosing Your Practice As opposed to taking away from medical dermatology, cosmetic/surgical dermatology can enhance it, suggests Dr. Katz. With impressive advances in cosmetic/surgical dermatology, dermatologists could treat traditional dermatology problems using these newer advances, he maintains. Cosmetic dermatologists could lead the way in this regard. No matter what form dermatology takes, ultimately dermatologists’ skills will be in even greater demand. Technical advances, along with an aging population and other forces, bode well for dermatologists. Right now, says Dr. Feldman, the demand for dermatologists is so great that dermatologists are in the “extremely enviable position of being able to choose whatever kind of practice makes them happy.”