The Road More Frequently Traveled

At one time many medical school graduates pursued careers as generalists, opting for residencies in internal medicine or family practice. Historically, careers in these areas guaranteed long work weeks—daily office hours coupled with frequent overnight calls and emergencies—in exchange for median level salaries, with little time left for family life and leisure.

Nowadays, more and more graduates are opting to travel a different road, pursuing careers in Radiology, Ophthalmology, Anesthesiology, or Dermatology—the ROAD to reasonable hours, few emergencies and financial success.

Today’s New York Times carries an article about two recent graduates from Harvard Medical School, a husband and wife with two small children, both of whom have elected to pursue careers in dermatology. Both of these individuals have been stellar students throughout their academic careers; both are backed by degrees from prestigious universities. And together they are heavily in debt—over $330,000—not including the $20,000 they borrowed to finance their recent cross country treks to interview for those few select spots in dermatology residencies.

If their selections match, they will be set for life in jobs that will guarantee relative autonomy, reasonable working hours, and excellent salaries ($200,000 – $500,000/year).

Those of us slugging it out in the trenches of primary care medicine work long hours, servicing many more patients every day than we are comfortable seeing, for considerably less income. Most times our remuneration is determined exclusively by third-party payers. Perhaps we need to have our heads examined. But be forewarned—chances are you’ll have to wait at least three months to get an appointment with a psychiatrist: most of them work eight hour days and have their weekends free.

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“Dermanities”—Spring, 2007

The spring 2007 issue of Dermanities is now online.

For those readers not famililar with this publication, Dermanities is an open-access web-based journal dedicated to melding the medical humanities and the practice of dermatology.

Articles are written by and for the benefit of patients and practitioners alike.

You can read my article “Beauty’s Only Skin Deep” or browse the table of contents here.

The Long and the Short of It

Recently I saw an adolescent boy for a routine physical exam. As he was disrobing in the exam room, our medical assistant handed me a sealed envelope along with his chart. The envelope contained a one-page letter from his mother, asking that I address several concerns: his frequent visits to the nurse at school, recurring headaches, a question of substance abuse, self body piercing, and the discovery of a cache of gay pornographic magazines in his bedroom. I had been allotted 15 minutes in my busy afternoon schedule for this visit.

It’s a small wonder that a decade after adolescent medicine became a board certified subspecialty, it is largely shunned by doctors seeking to advance their careers—only 466 certificates in adolescent medicine were issued by the American Board of Medical Specialties from 1996 to 2005. In the same period, 2,839 were issued in geriatric medicine.

Yet despite these numbers, geriatric medicine is in no better shape, as Dr. Atul Gawande attests in his recent New Yorker article, “The Way We Age Now.” “Despite a rapidly growing elderly population,” Gawande writes, “the number of certified geriatricians fell by a third between 1998 and 2004. Applications to training programs in adult primary-care medicine are plummeting, while fields like plastic surgery and radiology receive applications in record numbers.”

Why these trends? According to Dr. Gawande, “Partly, this has to do with money—incomes in geriatrics and adult primary care are among the lowest in medicine. And partly, whether we admit it or not, most doctors don’t like taking care of the elderly.”

I would argue that the same logic follows for adolescent medicine as well. Regardless of whether you consider adolescents as pediatric, family or internal medicine patients, they all require extended office time to address their issues and concerns. This is a luxury that most high-volume private primary-care practices can not afford. And then again, as is the case with the elderly, most doctors don’t like taking care of adolescents.

What can be done to remedy the situation?

“Nothing,” according to Chad Boult, a geriatrics professor at Johns Hopkins. “It’s too late.” Gawande reports that “creating geriatricians takes years, and we already have far too few. This year, just three hundred doctors will complete geriatrics training, not nearly enough to replace the geriatricians going into retirement, let alone meet the needs of the next decade.”

“Boult believes that we still have time for another strategy: he would direct geriatricians toward training all primary-care doctors in caring for the very old, instead of providing the care themselves. Even this is a tall order—ninety-seven per cent of medical students take no course in geriatrics, and the strategy requires that the nation pay geriatricians to teach rather than to provide patient care.”

In my estimation, the same strategy may hold up for adolescents, most of whom are cared for by pediatricians. But the pediatric clinician must be willing to devote the time to care for the adolescent patient.

So, what did I do with my adolescent patient? As it turned out, he knew nothing about his mother’s note. I addressed her concerns with him, point by point. After I examined him, I discussed the results. We talked about his issues. With his permission, I spent some time conferring with his mother afterwards. She was grateful, and so was he. “I never had a physical exam like this before,” he remarked as he left.

I felt immensely satisfied for a moment, until I stepped in to see my next patients—a pair of seven-year-old twin boys with severe behavioral problems and ADHD. As I glanced at my watch before entering the exam room, I noted that I was already half an hour behind.

Beauty’s Only Skin Deep

Ronald Regan was our first chief executive with Hollywood roots. I thought of this bit of trivia when I overheard someone comment that Washington, D.C., is just like Hollywood without the glamorous good-looking actors and actresses. But now I read in a recent New York Times article that Dr. Tina S. Alster is working tirelessly to change all that.

Dr. Alster has built a career in cosmetic dermatology by catering to the desires of the political elite. Upper crust clientele such as members of Congress and the White House, heads of state and royalty, ambassadors, and TV journalists underwrite her multimillion dollar medical enterprise. She is even treating two presidential candidates.

With the magic of the laser, Dr. Alster can treat wrinkles, facial telangiectasias, scars, warts on the nose, and a whole host of other blemishes to create the appearance of flawless skin. Many of her clients in Congress consult her regularly the week before scheduled appearances on “This Week” or “Meet the Press.”

Described as “an immaculate blond,” Dr. Alster maintains a professional demeanor herself, choosing to wear conservative but form-fitting Prada and Lanvin dresses. She is “a sought-after guest at cocktail parties, fund-raising events, dinner parties and embassy functions,” and appears regularly in local glossy magazines.

Although she used to treat patients with surgical scars and children with birthmarks, Dr. Alster no longer accepts such referrals; her practice now consists entirely of offering cosmetic treatments—“aesthetic services”—to the well-to-do.

I doubt that these services come cheap. (Dr. Alster recently spent several millions of dollars relocating her practice to an office condominium on K Street, not far from the Capitol.) But we can rest assured that our national leaders have top-of-the-line health insurance coverage—at the expense of the American taxpayer. (Of course, they could always choose to pay out of pocket. I’m certain that the IRS would allow them a business deduction, given their line of work as career spin doctors.)

In his book, Better Than Well, Carl Elliott addresses the role of “enhancement technologies” in what has become the business of modern American medical practice. Those that can afford to pay purchase whatever they choose, from performance-enhancing drugs to breast implants, sex-change surgery to nose jobs, growth hormone injections to Viagra—all in the pursuit of self-fulfillment. Dr. Alster’s cosmetic practice merely serves as one example of this trend.

The old cliché, “beauty’s only skin deep,” says it all. In our superficial society, we’re hell-bent on the pursuit of shallow happiness—and power.

This is what modern American medicine has devolved into: a catering service to Hollywood.