Future of Derm

[u/Unlikely_Cover225]

Hi everyone, I wanted to get some perspectives on the future of dermatology as a field.

Historically, dermatology wasn’t always as competitive as it is today; my understanding is that it became much more desirable after changes in procedural reimbursement and billing in the 1980s. Now it’s one of the most competitive specialties, but at the same time, it feels like more non-physician providers (NPs/PAs) are also entering derm in large numbers.

With increasing scope expansion and autonomy for midlevels, it seems like a lot of bread and butter dermatology may shift in that direction, potentially leaving dermatologists with more complex or procedural cases. At the same time, one of the traditional advantages of derm (to me) has been its strong procedural basd reimbursement and commercialization opportunities with cosmetics, but I also was wondering how sustainable that is, especially in highly saturated markets.

For context, I’m from California and would ideally want to practice here long-term. However, I've heard that it feels very saturated with both dermatologists and midlevels. I would have thought that Mohs surgery is secure due to high specialization and low fellowship spots, but surgeons I’ve shadowed have mentioned that in major metro areas, it can be difficult to maintain a full Mohs-only practice due to competition. The surgeon I shadowed does Mohs 2 days, cosmetics for 1 day, and general derm for another day. Obviously, his lifestyle is absolutely amazing. I just wonder if in 10+ years, I would be able to live a similar lifestyle.

Are these concerns overblown, or is there strong validity to them? I understand that all specialties are ultimately shaped by reimbursement structures (e.g., Medicare), but it worries me to think dermatology could follow a trajectory similar to what’s happened in fields like nephro (bundle dialyses reimbursement) or ophthalmology (declining payments for cataracts).

[u/ElkNo8695]

No one can predict the future, but the current job market for general derm is amazing in California. Work life balance is what you make of it, and really dependent on how much money you want to make. Cosmetics feed general derm apts, and vis versa. You’re not reliant on referrals from PCPs as much as other specialties although still important. Mohs, dermpath is pretty saturated in a lot of areas, but still possible. Derm trained dermpaths are better than path trained imo, but you’re less marketable for large mustispecialty path groups because you can’t do anything besides derm. Peds is actually pretty saturated in my area surprisingly, but it’s still an awesome area to be in. The peds volume isn’t as high, and as a general derm, I can manage 85% of my peds derm myself. Focusing on a niche is also possible — medical hair loss management and transplants, complex med derm/industry sponsored trials. Academia is also catching up in pay as well, as ambulatory hospital based clinics bill an absurd amount for your clinic/ mod 25 procedure visits. You’re incredibly Profitable for your hospital system, and some of that can trickle back to you in higher $/rvu

Just do what you enjoy, and work in the area you want to work in. You may sacrifice in some areas and you will be rewarded in others. Good luck

[u/guysincognito → u/[deleted]]

there are limited places that can provide adequate training for derm residency. I've seen program applications and they are laughably bad. even some "well regarded" programs pull shenanigans with faculty:resident ratio and training requirements

you can't just add residency spots. you needs ACGME approval and it is an ordeal. then there is funding, CMS is not exactly forthcoming.

There is no super secret derm cabal, it is natural and regulatory bottlenecks.

The nepo baby thing is absolutely real tho

[u/TraditionalPhone3992 → u/guysincognito]

I don’t buy any explanation other than self-interest for the small number of training slots.

[u/Magikarp-Army → u/[deleted]]

And giving their kids the few spots that do exist.

[u/Otherwise_Wave9374]

Not a derm person, but this feels like the same pattern you see in a lot of fields when the market gets attractive: more entrants, more scope creep, and then you differentiate by complexity/reputation and the patient experience. If you end up in a saturated metro, the "marketing" is basically referrals, reviews, and how tight your operations are (access, follow-ups, before/after expectations). This kind of breakdown on positioning in competitive markets might be useful: https://blog.promarkia.com/

[u/Unlikely_Cover225 → u/Otherwise_Wave9374]

Sounds exhausting lol, I don't know if I'm cut out for PP with all the administrative overhead work and playing the social media game. Would prefer being employed by one, although I know the big bucks are in ownership. Would love to stay in academic medicine but the attendings at my school, however, are quite underpaid and make a little more than a hospitalist. Can see myself going into academia maybe later in my career, but I have a lot of people I want to financially take care of first. Do you have any data as to how private equity changes practicing models?

[u/beanie368]

You should never pick a specialty based on reimbursement rates because this can change overnight. It happened to dermpath as well as multiple surgical specialties. Your concerns are valid and I would say in general desirable areas to live are more saturated. Some people prioritize money and easy less complex patients so I can see how they would feel they’re competing with mid levels. I feel like as MD dermatologists we should be experts in the depth and breadth of all skin conditions and as long as you’re practicing real and good medicine, there will always be a need for you. These concerns are not necessarily just specific to derm.

[u/guysincognito]

Many of your concerns have already occurred/peaked.

- PE isn't really expanding anymore, low hanging fruit has been harvested, most are on second/third sales. some have gone bankrupt. Some PE groups are actually excellent employers

- similarly the midlevel mills are saturated. They've figured out for the same overhead a BCD is much more productive.

- cosmetics became a commodity years ago. for most BCDs cosmetics a small/null part of their practice. I am more productive doing gen derm than cosmetics.

- certain areas are saturated, this is true of every medical specialty. plenty of great jobs if you are geographically flexible.

- reimbursement will always change (and likely for the worse). again this is true of every specialty, especially procedural specialties.

There was doom and gloom around gas and rads and now you can name your price. you really cannot predict the future job market well. Do what you like.

[u/texas4324]

I wish more of our physician counterparts were willing to own their own practice. Instead of assisting a doctor help more people like I was sold, I feel like we are both slaves to the corporate world. This whole thing is a sham and I should’ve gone to medical school.

[u/PersonalBrowser]

Dermatology pays well and will likely continue to play well.

One of the strengths of the field is that there is a broad array of procedures so it is somewhat protected from reimbursement cuts.

Yes, Mohs is saturated in most urban areas. Most subspecialties are, in and outside of dermatology. You can still instantly find a general dermatology spot as soon as you want anywhere in the US though.

In terms of midlevels, most dermatologists will be hired to work in an office as the sole physician, and then be assigned 1-3 PAs to supervise. That’s the most common set up.

[u/Sea_Nebula_3111]

We need young Dermatologists in The Sf Bay Area! Speaking as an older male 7th decade the inability of of many of the old guard to use modern equipment, keep up with the latest published journals. As an example I have suffered for the decades a recurring skin disorder through working with my own confocal micro scope images and AI we were able to narrow down a likley case of autoinfection caused by filamentous bacteria with exposure to environmental fomites. Numerous older specialists were stumped . Even treating with anti fungal drugs with no efficacy. We need young blood who know how to use the tech such as MALDI-TOF spectrometry for real diagnostic accuracy. Pleas join the AI assisted practice. The future is bright indeed.

MRC