The changing face of dermatology

Edition: June 2007 - Vol 15 Number 06
Article#: 2698
Author: Repertoire

Everybody’s talking about Botox, chemical peels and anti-aging treatments. Indeed, this would seem to be a very good time to be a dermatologist. And in many senses, it is. Demand has never been greater, and the supply of these specialists is limited. The hours are pretty good, and much of the business — the cosmetic portion, at any rate — is cash up front.

But the fact is, dermatologists have their own set of worries to which Repertoire readers should be attuned. For one thing, others are moving into their space. It’s true that the number of training slots for dermatologists remains at about 300 per year, meaning that the supply of dermatologists is relatively stable, driving up demand. At the same time, physicians from other specialties — OB/GYNs, family practitioners and others — are beginning to offer laser hair removal and other cosmetic procedures to their patients. Then, there are the medical spas. “You go inside; Yanni is playing; there’s a nice attendant up front; the fountain is going in the background,” says PSS Vice President of Marketing Mark Steele, describing the spas. “And they’re not just doing massages, facials and hair and nails. They’re also now doing microdermabrasion, Botox injections, chemical peels.”

What’s a dermatologist to do? Dermatologists would be well-advised to hold on tight to what brought them to the specialty in the first place — their expertise in treating medical problems such as eczema, psoriasis and melanoma. At the same time, though, they can’t afford to cede the marketing war to medical and non-medical competitors. And that may bring them — and their distributor sales reps — into new treatment venues.

A highly motivated patient base

“It’s a good time to be a dermatologist for a lot of reasons,” says Jack Resneck, Jr., M.D., assistant professor of dermatology and health policy at the University California San Francisco School of Medicine. While the number of training slots may remain static, demand continues to increase. And that’s true for a number of reasons. Unlike patients with the so-called “silent diseases,” such as diabetes or high blood pressure, most people are highly motivated to take care of skin-related problems or age-related issues, he says.

“The population has grown, the scope of what dermatologists do has grown, and the population has aged, so you see large amounts of surgery for skin cancer,” he says. In addition, dermatologists have done a good job educating the public about skin cancer and the ability of dermatologists to address cancer and other problems of the skin. “All of this is good and bad,” says Resneck. “It’s nice to be wanted. But on the other hand, nobody wants to wait six or nine months to see a doctor.”

Being in demand, dermatologists have many choices before them. Some (about 40 percent) continue to work in solo practices, while others — particularly younger dermatologists — are joining group practices. Some work in industry, while others work in academic settings. (Resneck himself has spent time in the east African nation of Uganda, working with the population there on skin diseases, many precipitated by the AIDS virus. Stateside, he runs the residency training program at the University of California in San Francisco.) “It’s the type of field where … you can do whatever you want,” he says.

Despite the headlines, however, most dermatologists have stuck to their roots treating skin-related medical conditions. “As the shortage [of dermatologists] has become more publicized, the question is, ‘Is it because of the number of doctors doing cosmetic work instead of treating medical problems?’ This turned out to be a smaller factor than we thought.”

In fact, Resneck participated in a study that found that the average dermatology practice spends only about 8 percent of the doctors’ time on cosmetic work. While that’s up from past years, it’s not the 20 or 30 percent that recent headlines might have caused one to expect. Nor does Resneck expect the number to climb rapidly any time soon. “Some dermatologists love to do cosmetics, and that’s great. But I think your average dermatologist enjoys having a varied practice, and likes taking care of some patients with medical problems, some surgical patients, and a little bit of cosmetics.” What’s more, says Resneck, while cosmetic work can be lucrative, traditional dermatology pays the bills as well.

There are other reasons the profession continues to attract more applicants than it can absorb. For one, the hours are pretty good. “We’re seeing what a lot of specialties are seeing — a generational shift in the way people view their work,” says Resneck. “People are actually working a little less than they used to. The average number of days per week are going down; people are making slightly different decisions about their work lives.” Dermatology was one of the early fields to attract women, who traditionally have made different work decisions than men. “But even men are choosing to work a little less than the prior generation,” he says. All that said, modern technology and new ways of gaining efficiencies in the office have allowed dermatologists to pick up some of the slack.

Resneck says he thinks that the variety the specialty offers is another drawing card for medical students. It certainly is for him. “We see adults, kids, old people. We see people with skin cancers, who we hope to operate on; and people with psoriasis, who we get to sit down with and talk to. The patients vary a lot, and that’s what makes this field exciting. It’s what makes you want to get up and go to work every day.”

Medicare still accounts for 30 to 40 percent of the average dermatologist’s revenues, says Resneck. “The reality is, a lot [of skin disease] is due to sun damage and skin cancer, and that tends to be among older patients.” As a result, dermatologists — like other specialties — sweat out the Medicare agency’s annual threats to cut back on reimbursement. But private pay remains a big part of the dermatologist’s revenues. And that could be good or bad. “Because many cosmetic procedures are paid for out of pocket, you have to wonder, if the economy were to really turn south, would dermatology be affected?” asks Resneck. “We really don’t know. You’d be amazed at what people will give up. I have patients who wouldn’t blink at paying $200 for a fancy skin cream at Nordstrom’s, but who would be outraged if their co-pay went from $20 to $25. So it’s hard to predict.”

Impact of laser

If there is a new face to dermatology today, it probably looks a lot like that of David Goldberg, M.D. In practice since 1985, Goldberg is affiliated with the Mount Sinai School of Medicine and the New Jersey Medical School. He is the author of more than 125 academic papers and co-author of two books for the public entitled “Light Years Younger” and “Secrets of Great Skin.” He was named “One of the Top 10 Laser Surgeons in the United States by Self magazine.

Goldberg directs a practice with four locations – two in New Jersey, one in New York and one in Florida (which he operates with a plastic surgeon). The practice — Skin Laser & Surgery Specialists of New York and New Jersey — has been the site of FDA research on laser hair removal, skin rejuvenation, new botulinum toxins (Botox) and wrinkle fillers. Not surprisingly, the practice offers many cosmetic laser procedures, including hair removal, skin resurfacing, skin rejuvenation, vein treatment, acne treatment, skin tightening, stretch mark treatment, cellulite treatment and tattoo removal. The practice also uses laser to treat melasma, vitiligo and chronic psoriasis.

“Unequivocally,” says Goldberg when asked whether today is a good time to be a dermatologist. Medical and surgical dermatology are well-established, while cosmetic dermatology is growing in “exponential leaps and bounds,” he says. And unlike other specialties, dermatologists can turn to private-pay, cosmetic work when the feds tighten the screws on Medicare.

There’s no doubt that technology has changed the face of the profession, he says. Skin Laser & Surgery Specialists of New York and New Jersey has more than 30 lasers. “Fifteen years ago, if you wanted to improve your cosmetic appearance, you had no choice but to seek surgery,” he says. “There still are strengths in surgery, but there are many options for those who don’t want it. And a lot of people, as well as the press, are beginning to see dermatologists as experts in non-invasive treatment of skin conditions.”

That said, forward-thinking dermatologists and plastic surgeons are forming close working relationships, as Goldberg has done in his Florida office. “I focus on non-invasive anti-aging treatment of the skin, while the surgeon focuses on surgery. It’s a good synergy.”

Although dermatology lends itself to solo practices (because the hours are fairly regular), multispecialty practices — encompassing medical, surgical, cosmetic and potentially, pediatric dermatology — are growing. Goldberg says he believes that practices such as his — with multiple locations in multiple states — will become more common in the future. “It’s doable in dermatology because the lifestyle is reasonable; you can manage multiple practices,” he says. Electronic medical records link all the locations together. “We don’t drag charts from one location to another. We can see our patients [at any location] with the same efficiency. And large practices such as ours have some economy of scale; we can buy things in bulk.”

When one talks to Goldberg, the conversation inevitably turns to laser. “Laser has changed my practice and, frankly, my life and the lives of many dermatologists,” he says. “It has allowed us to find an area of expertise unique to dermatology. Nobody understands skin better than dermatologists, even though in the real world, all kinds of physicians are doing [laser] procedures. Because we truly understand the physics interaction of laser and skin, dermatologists are best equipped to do laser procedures.” He expects the next big advancement in lasers to be their application in the treatment of cellulite.

Sales rep’s role

Repertoire readers who approach dermatologists the same way they approach other specialists risk losing business — and they’re not doing their customers any favors either.

“Most of our sales of higher-end products with other specialties are related to treatment of disease states,” says PSS’s Steele. “Don’t get me wrong – there’s still the clinical aspect of dermatology. But with internists or family practitioners, [our conversations] are medical-based and reimbursement-based. You’re talking about CPT codes, ICD-9, and how this is good medicine for the patient.” Dermatologists are just as concerned about good medicine, but their practice environment is different, because so much of the cosmetic work they do is private pay or even pay-in-advance, he says. As a result, sales reps must rethink how they approach dermatologists, because their business model differs from that of the reps’ other customers.

Sales reps need to know that their dermatologists face a tough competitive market, says Steele. Just look at the number of billboards on the highway advertising hair removal and varicose-vein treatment, he says. Although some doctors may be uncomfortable marketing their services, they have little choice but to do so. Reps must let their customers know that they can help, and let it be known that they can be the doctor’s source for equipment and supplies should the doctor decide to open up a medical spa.

“A lot of times, the doctor is thinking, ‘Separate location, separate people’ for their solution,” says Steele. They may be thinking that for equipment, they need to work directly with manufacturers. But it doesn’t have to work out that way.

“The rep needs to talk to the doctor about what his or her vision of the practice is,” says Steele. “They need to ask, ‘Where do you see yourself three to five years from now? Do you recognize the opportunities in front of you? Do you want to do anything about it? If yes, I can help.’

“The last thing you want to happen is, you come to the office and notice that next door is a medispa, and you had nothing to do with setting it up — because you never had that conversation.”