5 Things I Wish I Knew Before I Went into Clinical Practice in Dermatology

This guest post for the dermatology section of The Specialist Series was contributed by Dr. Stephen W. Lewellis, MD, PhD, FAAD.  You can connect with him on Instagram (@LewellisMD). In the near future, he will be sharing information pertinent to both patients and fellow physicians at www.LewellisMD.com.

If you’d like to contribute an article to The Specialist Series, check out this page.  We’d love to hear your perspective on your specialty!

An interesting thing happens when an internship-weary recent medical graduate finally starts their residency training in dermatology.

They feel understandably excited about joining one of the coveted “lifestyle” specialties.  These new residents are no longer facing 36-hour surgery call or sleepless nights in the ICU.  As a result, they think they’ve “made it” before completing a single day of specialty training. 

It’s tempting to feel that the start of your PGY-2 year finally marks the beginning of the “good life.” You hope it’s everything you have worked so long to attain.

Dermatology: The Medical School Olympics

I remember bitterly referring to the dermatology interview trail as the Med School Olympics. Medical school was selective enough, but this was a whole new level. As a result, one might think that simply getting into a dermatology residency was the finish line.

This may result in a rude awakening for some.  It sure did for me as well as some of the junior residents I informally mentored at Stanford.

Sure, the call is relatively sparse, especially if you’re lucky enough to be at a big program.  Also, the direct patient care hours are reasonable, but the work rarely stops when the clinic door closes.

Most nights, I had to log back into my electronic health record (EHR).  I would finish notes, communicate results, field patient messages, or prep for an upcoming clinic from home after work. That doesn’t even take into account studying, which is a gargantuan task in our field.

Because of this, many dermatology residents gain a lot of humility during the first few months of residency. I wish I had known this prior to starting dermatology residency.   If I had, I could have approached my training with a better mindset and plan.

Now that I’m an early career attending physician, there are a few things I wish I would have known earlier.

Here are five things I wish I had known before I started dermatology residency.  I hope my reflections can help you be better prepared when starting your practice.

1. You’re in charge now, but you’re not a miracle worker. Be kind to yourself and your colleagues, communicate openly, and keep growing.

Rome wasn’t built in a day.  Likewise, untreated severe atopic dermatitis in an infant of first-time parents certainly didn’t get controlled in a day.

As the physician, you know the natural course and what to expect.  So, it’s your job to guide your patients, and sometimes your other team members, through that journey. 

My situation

I work as an employed dermatologist in a large community health system with a growing dermatology residency program. I see patients of all ages with diseases of any severity from a wide range of socioeconomic/cultural backgrounds.

Regardless of the complexity of the case, I typically have only 15 minutes (and that’s a lot for a dermatologist!).  That’s all the time we have to get the patient in a room (assuming they arrive on time), update the EHR, and develop a rapport.  We also have to elicit a story, review prior records, perform an examination, discuss our findings, and come to an agreement on an initial plan.

That doesn’t count time spent ordering prescriptions and tests or performing a procedure.  We also have to print an action plan and document the visit.

Do you want to nurture an efficient, productive, and satisfying practice that won’t burn you out?  If so, you need to set reasonable and well-defined expectations for yourself, your staff, and your patients.

The culture in your dermatology clinic

You should also encourage your team members to embrace and develop their strengths so they can improve the practice and be more engaged in their work. It’s your job as a leader to build a culture of mutual respect and autonomy that allows all team members to thrive and contribute regardless of their position or level of training.

Make bidirectional feedback, both positive and constructive, a routine part of your practice so that it doesn’t feel threatening or confrontational. Don’t be afraid to give your patients feedback on what they’re excelling at and what they could improve in terms of how they’re addressing their skin conditions. If you’re feeling really brave, invite patients to give you some feedback, too.

Finally, be honest about your limitations, and know when to seek help. Tell your patients you’ll go to bat for them and never give up if you don’t have the right answer immediately.

Many skin conditions are chronic, so fostering long-term, mutually fulfilling relationships with your patients is a critical and rewarding part of the job.

2. Hair loss doesn’t have to be a schedule busting nightmare. Develop and utilize a reliable system.

Dermatology is as much an art as it is a science.

That doesn’t mean there isn’t a place for systems, though. Having a systematic approach to challenging cases can make you and your patients feel more in control of the process. Control leads to confidence, and confidence is attractive to patients, just as it is to potential mates.

Alopecia, more commonly known as hair loss, is an excellent diagnosis for which to use a systematic approach.

While hair loss can be as simple as androgenetic alopecia (though we know even this is never simple), which rarely requires a biopsy and has only a couple of FDA-approved treatments, it can also be much more complex. It’s almost always emotionally charged as well, making the patient’s distress sometimes seem out of proportion to the condition’s objective severity.

Patients suffering from hair loss often need more time than the typical patient in a dermatology practice. They need you to hear their stories, understand the impact on their lives, and give them their best shot of either growing their hair back or halting the spread of scarring hair loss. 

There are many scheduling constraints we face in order to stay in business

Here’s a possible scheduling solution:

1. The first visit focuses on history, examination, and some preliminary lab work if warranted.
2. Then, the second visit focuses on a scalp biopsy if needed.
3. Finally, the third visit focuses on reviewing lab and pathology results and developing an initial treatment plan based on all of the available information and the patient’s values.

This system does require a more substantial buy-in from the patient in terms of time and money.  However, it shows your patients you’re willing to put in the time and effort necessary to address such a challenging and debilitating problem.

It’s also a great way to prevent cases like these from derailing your schedule.

3. Cost is often the elephant in the dermatology clinic room.

I practice primarily as a medical and surgical dermatologist.  So, most of the work I do is paid for by a third party.

Co-pays and deductibles, not to mention premiums, have ballooned over the years. Consequently, dermatologists must consider cost along with more conventional risks.  This increases the complexity of discussing risks, benefits, and alternatives of a procedure or treatment plan.

There’s no easy way to deal with this.  That’s especially true when you have patients on many different insurance plans.

Strategies for addressing the cost of dermatology procedures

I’m as transparent as possible about what procedures or medications are typically covered by insurance.  For example, a biopsy to evaluate for skin cancer is typically covered.  However, removal of skin tags or a using a modified Kligman’s formula for melasma is usually not covered.

In some cases, insurance coverage is in doubt or a patient has a high deductible.  For those times, I offer patients a menu of common procedures and how much our clinic charges for them.

Some purely cosmetic services won’t be billed to insurance.  For those, we have a separate menu that makes the conversation quick and transparent.

If the procedure isn’t urgent, I also offer to provide the patient with the ICD-10 and CPT codes that I would submit to their insurance company if I performed the procedure.  They can then inquire about what their responsibility would be and return later if they’d like to pursue it. Of course, this option often involves an additional co-pay when they return. 

There’s no easy way out.  As a rule, maximizing transparency in these matters to the best of your ability is the best way to go.

Strategies for dealing with exorbitant prescription drug costs in dermatology

I frequently prescribe 5-fluorouracil cream for treatment of extensive sun damage and actinic keratoses. It’s become increasingly common for these patients to contact our team shortly thereafter saying their share of the cost is too high.

This is frustrating because a patient with insurance should easily be able to afford their medications.  That’s especially true given how expensive premiums have become.

If the patient’s co-insurance is too high, I can only imagine what the insurance company’s portion of the bill is.  That doesn’t sit well with me.

Here’s an intriguing alternative available to a dermatologist who encounters this issue.  Use a service like Skin Medicinals that bypasses the insurance company.  (Disclosure: I have no financial or other interest in Skin Medicinals.)

Skin Medicinals partners with a compounding pharmacy to provide common topical dermatologic therapies at reasonable prices. They don’t take insurance.  Even so, their prices remain competitive given the absurd costs associated with many pharmacy benefit plans.

I just used this service earlier today to cut a patient’s cost in half for a topical prescription.  Even though the medication was technically “covered” by their insurance plan, bypassing the insurance company saved the patient money.

4. Caring about your compensation doesn’t make you a less noble physician.

Insurance premiums, co-pays, and deductibles seem to increase regularly, often outpacing inflation.  However, the same isn’t necessarily true about physician compensation.

Physicians generally receive high compensation, but this doesn’t come without sacrifice.

First, there’s the monetary and opportunity cost of medical school and the time required to reach peak earning years.  Additionally, there is the simple fact that many physicians generate income only when trading their time for money. 

This is particularly true for employed physicians who don’t own or control the means of production.

On top of that, employed physicians like me usually earn W-2 income.  There are financial disincentives to this model compared to other forms of income under our current tax code.

As an employed physician, it’s important to understand how you’re compensated and how that changes over time.

Dermatology compensation packages

If it’s your first job out of residency, as was the case for me, you might not investigate compensation packages thoroughly.  That’s a mistake.

Consider the salary guarantee, wRVU conversion factor (or percentage of collections), and benefits package before accepting your position.  I urge you to exercise more due diligence when negotiating your employment benefits. 

There’s one thing I wish I had explored while still negotiating with my employer.  That is how the organization ensures that physician compensation at least keeps pace with inflation.

What if your compensation ties directly to wRVU levels?  Ask your employer when the last time the wRVU conversion factor was adjusted and if this happens at regular intervals.

Inquire about historical figures and have them show you some numbers. If they’re hesitant to do this, that’s a red flag. What you find may surprise you.

Additional considerations for negotations

It’s also important to ask about any earning opportunities that don’t involve a direct trade of time for money. If those don’t exist within your organization, make sure you understand your employer’s position on outside work.  This could include consulting, moonlighting, running a small business, and other opportunities to earn supplemental income.

It’s important to think about ways to diversify your income streams. That’s particularly relevant given the high rate of burnout among physicians who are limited to swapping their time for money.

Beware of non-compete agreements, a type of restrictive covenants in many employment contracts.

Last, there’s no excuse not to capture the full value of your time and work. As a resident, I dreaded the concept of billing because it was such a black box to me.  However, the process has proved far less burdensome than I anticipated.  You still need to pay attention, though.

It’s important to know how to capture all the work you do so that you’re properly compensated.

For instance, why would you code cryosurgery for genital warts on the penis with CPT code 17110?  Instead, you can more accurately and appropriately bill 54056.  That’s a more valuable code that reflects the higher risk and complexity of treating this sensitive area.

Similarly, avoid the tendency to underbill for evaluation and management. Know your worth, and always capture the value inherent in your education, training, and efforts. You can do this while still practicing ethically and with integrity.

5. Take advantage of every opportunity to hone your procedural skills during dermatology residency.

Residency can be a challenging and thankless time. If you’re still in it, you’re likely looking forward to the other side.

It is, indeed, so much better on the other side, but this is a double-edged sword. When you’re in practice, you no longer have someone looking over your shoulder.  There’s no one to back you up if something goes wrong or you encounter a particularly difficult case. 

The more you take advantage of procedural opportunities during residency, the more confidence you’ll have in your skills. The more confidence you have in your skills, the more options you’ll be able to offer your patients.  That way, you’re less likely to have to refer them to another colleague or outside practice. 

Take the pulsed dye laser for instance. This is a workhorse in the world of energy-based devices in dermatology.  However, if you’re not confident in using it safely and effectively, you may be hesitant to offer it to your patients. If you are, however, you’ll be able to add it to your arsenal for treating conditions such as recalcitrant warts, rosacea, and keloids. 

This can also augment your ability to generate revenue.  You can use many procedural skills for medically necessary treatments and bill them to insurance companies.  You can also use these skills for cosmetic treatments for which patients are willing to pay cash. It’s also a fun way to add variety to your day. 

This general advice pertains to surgical skills as well. Being confident with a #15 blade in your hand allows you to mix in excisions of benign and cancerous growths.  This will complement your medical dermatology practice in a meaningful way.

Bonus – One thing I’m grateful I did know…

Keep your financial house in order, even when there’s hardly any furniture in it. 

For as long as I can remember, I’ve thought a lot about making and saving money.

As a young child, I sold amateur drawings to my family. I bought candy and gum in bulk and sold it to my elementary school classmates. I sold baseball cards on eBay in the early days of the Internet.

Eventually, I asked my parents to serve as my “bank” with a generous interest rate.  That way, I could experience the power of compounding. I couldn’t wait to get my first checkbook, debit card, credit card, and then brokerage account. Heck, I even got excited about certificates of deposit.

I’m not sure what exactly laid this foundation. Perhaps it was my 4^th grade teacher who first suggested the “Bank of Dad/Mom” learning model.  Maybe it was simply seeing my mom diligently work through receipts and balance the checkbook at the end of each month. Regardless, I’m grateful that being intentional about money has always felt more like a hobby than a chore to me. 

I encourage you to get motivated to get your financial house in order from the beginning when things are relatively simple.  Trust me, it makes all of the next steps easier.

Start early!!

Take time to setup automated savings and investing strategies even when you have only a small amount to save or invest.  This helps you build a reliable system and capture a bigger chunk of the long-time investing horizon.  That is so critical to making your money work for you!

This isn’t to say I always had it all figured out and don’t still need teachers and mentors.

It wasn’t until my second year of residency that I even learned about the importance of an individual own-occupation disability insurance policy.  That’s arguably one of the most important aspects of a young physician’s financial house. I only learned about it because someone with just a bit more knowledge and experience than me took the time to share what he had learned.

While I continue to learn and build my own house, I’m also focusing on paying it forward.

A note of encouragement for early career dermatologists

Maybe you’re still in training or have just started your career.  If so, you’ve likely heard about or experienced the dramatic changes occurring in the field of dermatology.  This includes the increasing burnout rate, the evolving role of advanced practitioners, private equity ownership, sagging reimbursements, and onerous administrative tasks. 

You’ll definitely hear all this doom and gloom talk.  However, it’s important to step back and realize how wonderful this job can still be.

All it takes is to realize this is one patient looking you in the eyes and saying they finally feel like someone has truly heard them and cared, even if you don’t have a quick fix for their problem.

If you won’t take my word for it, just wait until a patient comes to see you covered from head to toe in traumatic ulcers who is absolutely convinced that they have tiny worms under their skin. Don’t judge them and assume you won’t be of much help. Instead, be patient, listen actively and with empathy, and form a partnership. You may be surprised at what unfolds.

Final thoughts

I’ve discussed just a few of the things I wish I had known (and one I’m glad I did know) prior to practicing independently.  However, there is plenty that my fellow dermatologists could add to this discussion.  There’s more to learn, especially from those in other settings such as managed care, academia, and solo private practice.

The community of Board-Certified Dermatologists is small, tight-knit, remarkably accomplished, and generous. If you want to learn more or have any questions, feel free to reach out to me or someone in a practice setting that more closely matches your interests.

Finally, remember, the heart of dermatology has little to do with Boards fodder and “once in a blue moon” case reports.

It’s important to be able to recognize rare and even life-threatening conditions.  However, the keys to high quality patient care are humility, open communication, empathy, persistence, and competence.

Believe me, these don’t require a 96^th percentile on the in-training exam. Good luck out there!

About Dr. Lewellis

 

Dr. Lewellis is a board-certified dermatologist who practices medical and surgical dermatology at Park Nicollet Clinic & Specialty Center in Maple Grove, MN. Opinions shared on this site are his own and do not necessarily reflect those of his employer. 

Originally from eastern Pennsylvania, he completed his medical training at the New York University School of Medicine and dermatology residency at Stanford University. He lives with his wife and their son and Sato in Minneapolis, MN.

You can connect with him on Instagram (@LewellisMD). In the near future, he will be sharing information pertinent to both patients and fellow physicians at www.LewellisMD.com.

If you’d like to contribute an article to The Specialist Series, check out this page.  We’d love to hear your perspective on your specialty!

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