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LS, a Derm that's pissed at Medspa FP's and OB's.

The war to control cosmetic medicine that's been raging between plastic surgeons and dermatologists has a new additon, aesthetic physicians. And here's one derm that doesn't like it.

dermatology_current.jpgLS posted this comment on: Botox certification for family Practitioners

"When I graduated from med school, only me and another guy got into a derm residency - and he had a PhD in Immunology before getting into med school. The OB's and FP's were at the bottom of the class. Now they want to get into cosmetic dermatology for the money - but they are NOT TRAINED to do anything with skin. Derm is a 3 year residency - these people know so little they don't have a clue how little they know. Studies have shown that when primary care physicians get minimal (like 4-6 weeks) of Derm training, they begin to see that it's an incredibly complex field of which they know not, and the number of referrals to derms INCREASES - the more training they receive, the more they refer.

The Cosmetic companies and laser companies are all in it for the money so they don't care WHO they sell to. This is all going to change - the policy makers are already working on it so these FP's etc who are going into it better have their own practice of sore throats and earaches to fall back on since the balloon is about to bust."

LS has a point. Dermatology is a specialty.

It's also the study of 'diseases of the skin', not Botox and laser hair removal. Although some medical schools are geting into this, Dermatologists generally get training in cosmetic procedures the same as other doctors... see one, do one, teach one.

Dermatologists are physicians (medical doctors) specializing in the diagnosis and treatment of diseases and tumors of the skin and its appendages...

Pediatric dermatologists specialize in the diagnoses and treatment of skin disease in children. Immunodermatologists specialize in the diagnosis and management of skin diseases driven by an altered immune system including blistering (bullous) diseases like pemphigus. In addition, there are a wide range of congenital syndromes managed by dermatologists.

 LS is right that Florida has passed legislation, but it's going to be harder to enforce than keeping Paris Hilton at home.

There's also something of a conflict in that dermatologists are trained to treat medical problems like skin cancer. With skin cancer the fastest growing cancer in the US, there's a train or thought that says dermatologists should focus on where they can do the most good, not where they can make the most money. Of course that's not the real world either.


Reader Comments (122)

I don't think I've ever met a derm resident/fellow that didn't go into derm almost exclusively for the a) hours and b) money. I've never ever suspected they truly find skin disease fascinating. Why are there so many applying to derm? Is skin *that* fascinating to med students? Stop trying to kid yourself, LS. You aren't fooling anyone.

One other thing: Most derms practicing today probably were never trained on laser or botox during their residency. How'd they learn this technology? You guessed it..through a COURSE, the same as every other doc.

As far as legislation, I don't foresee any govt. legislation saying which specialty can perform what service. Sure, an FP/OB couldn't go into a hospital and perform a CABG. But for a small, in-office procedure that insurance companies have *no* part of? Hardly. Don't get your hopes up, LS. Feel free to prescribe a Zpak for that sore throat though in your derm office..FP's won't miss that $35 office visit. And no, I'm not an FP.
02.26 | Unregistered CommenterMichMD
The fact that nobody's yet addressed yet is that more often than not, at least in my neck of the woods (Orange County SoCal) it isn't even a PHYSICIAN doing these treatments. It's a nurse practitioner at best, and at worst? Well, I've heard more than I care to about ESTHETICIANS owning and operating laser hair removal devices, IPL, and doing aggressive peels etc.

The bottom line to me is, can the practitioner, ie. the person doing the procedure and caring for that patient all the way through, care for not only a routine procedure but the COMPLICATIONS of said procedure?

I do know how Lisa feels; I was in Dx Rads and we watched as Ortho proclaimed they could read chest & abdominal xrays, and the ER decided they could learn ultrasound in 2 weeks. I am being facetious of course, we all have these little turf wars.

Interesting how hot the skirmishes grow in direct relationship to reimbursement of the procedure? We never saw OB fight FP for uncomplicated childbirth,yet this is a HIGHLY experiencially driven procedure; But now a group of physicians has driven legislation to TRY and prevent another group of doctors from doing laser hair removal?! I smell "hippocrisy".

But seriously LS, Derm residency was NOT competitive because it was HARDER to endure or because you had to be SMARTER to understand it. It was competitive for quite the opposite: No real call to speak of, no laundry list of complaints; it is primarily an academic pursuit with a lot of reading and research (& not so many cures); all done keeping humane hours with very good remuneration,(since most everyone cares how they look).

Radiology is similar in many respects, except we do happen to lose sleep and we're expected to know everyone ELSE'S lingo and focus. Yes, it was competitive to gain a top spot, but I can't imagine belittling another profession because I happened to value my sleep and/or weekends more...

Oh, and BY THE WAY, Family Practice residencies might be easier to come by because they are needed, hence funded and more numerous, but IM and FP is certainly two of the most challenging fields to be accomplished and proficient in. Your comment about the bottom of the class might be amusing if it weren't so ignorant. Let's see, there's a roomful of people who made all As and Bs at respectable to reknown colleges, stayed well rounded enough to be accepted to medical school, completed said course in good standing competing with others of equal or greater talent. Hmmmm? Wow, the middle to second third ranking must really be some losers, right? No, I don't think the losers in that class went into Family practice.
02.26 | Unregistered CommenterDrB3
Totally correct MichMD!

I've had loads of patients come to me because their dermatologist only gives them one of about 3 meds depending on what drug rep came in that week with lunch. A good dermatologist is a great resource, but too many times I have seen simple things like ringworm treated like the plague with weekly follow-up visits, chronic antibiotics/antifungals, bizarre cleansing regimens and activity restrictions. After months without any progress, I happen to see the patient because they came by while their mother was getting Botox. A 2 minute history and exam and an inexpensive topical and the problem is gone in a week. It boggles my mind how some dermatologists try to treat acne; no wonder these kids get scarring. I know I would want a dermatologist to biopsy or diagnose some of the more complex issues, but requiring a dermatologist or plastic surgeon to do the laser procedures we do is like sending a patient to a neurosurgeon for a hangnail.

And I won't even dignify the 'bottom of the class' comment. In my class, the people who wanted to be dermatologists were the ones who couldn't handle simple internal medicine and didn't have good enough anatomy knowledge to be a radiologist.
02.26 | Unregistered CommenterDermaDoc
Right on DermaDoc, MichMD and DrB3,
I was quite embarrassed for LS after reading her post. I have been doing botox for 13 years and no I am not a derm. I learned the other cosmetic procedures the way all docs do (even derms!) as previously said. I have a nice cosmetic practice that I started on my own and am doing well. I work with a Derm in town (actually my own doctor!) that I refer to for skin checks and biopsy procedures etc. I am more than happy to not have to deal with that aspect for more than a few reasons. I have been teaching him about what I do but it is not his passion.
LS should stick with what she was trained to do-treat disease of the skin. Cosmetic procedures require skill, an artistic eye, and a more sunny disposition...
02.26 | Unregistered CommenterLA MD
I guess Ob's should comment, at least when I aplied for residency you had to be AOA or not apply.The last time I saw a Derm after hours he made a incurrect dx and had his Jaguar hit by wast management. I have been using laser for over 20 years and taught many surgeon how to turn the units on. None of these treatment are rocket science and Dermatologist are not exactly the best surgeon I have ever met. It is rare that anything seen a Bx does not give a Dx for so thank you for the good pathologist who help us all out. It is too bad AMA has sold us all out so none of us can afford to make our practice make ends meet, we are the only profession that make less now than 15 years ago and overhead and malpractice has gone out of sight. We must be making all the insurance companies happy by fighting each other other than uniting and asking for fair reimbursement for the many years we all sacrificed to do this honorable profesion.
Embarrassed for LS? That almost seems like an understatement. I'm downright appalled that I'm in the same field. To imply that a medical school graduate "at the bottom" goes into various fields because they aren't bright enough to get into dermatology is simply outrageous. And by they way, do you know what they call the person who graduates medical school at the bottom of their class...."Doctor"...just like every other person in that graduating class. Incidentally, the top person in my class actually did go into family medicine because she wanted to live in a rural part of the country and wasn't interested in "money or fame." And I always marveled at how difficult it must be to keep up with 3 different specialties! Fortunately, she was brighter than me and has never had any problem.

My own dermatologist does absolutely no cosmetics. I have a strong family history for melanoma and so I want a dermatologist who isn't trying to rush through my skin check so she can see the patients paying the "big bucks" for the cosmetic procedures. One time, in residency, I did see the fancy, cosmetic dermatologist for my mole check. She had me in a dimly lit room (perfect for a massage or facial) and barely looked underneath my clothes to see all my skin. I figured I could have done that check myself.

And, in turn, since my practice is now all cosmetics, I don't treat any skin disease beyond acne. I refer all my suspicious moles, etc to a dermatologist nearby. We have an excellent working relationship and respect for one another.

I really hope LS never gets into trouble with one of her patients and needs to rely on the expertise of a physician in another field since she has pretty much isolated herself as the end all be all in medicine. One of my attendings in medical school taught me that "the sign of a good doctor is one that knows when to ask for help." And that lesson has held true in so many cases. Clearly LS doesn't think she needs any help from anyone. And this specialty rivalry is like a bad movie about grade school children.
LS posted "only me and another guy".

Im assuming LS is male, not female. Just a note to all who've referred to LS as 'her'.
03.1 | Unregistered CommenterGenderMD
Sorry GenderMD,
Somebody referred to LS as Lisa so I assumed she was a girl. Either way she/he looks bad.
03.1 | Unregistered CommenterLA MD
LS, are you the same LS that posted on the board topic regarding how to entice a dr to become a med spa director? In that post, you mentioned that you were a PA in derm. Not a Dr. Is that correct?
03.2 | Unregistered CommenterSherry
lol...the plot thickens...
03.2 | Unregistered CommenterMidwest
I am a Family Medicine Specialist. I did not graduate at the bottom of my class. I was in the top third. I could have gone into any specialty. I chose Family Medicine because in med school I was not "drawn" to any one particular field of medicine. I also wanted to have the ability and knowledge to treat all organ systems, not just the eyes for example. I gravitated into cosmetics for a number of reasons.
Dermatologists, for whom I have respect, however treat skin disease. They do not have a monopoly on medical cosmesis. They have taken procedures devolped by many specialties and called it their own. Tumescent liposuction was first developed by a general surgeon for example.
But, more importantly, when a physician holds an unrestricted license to practice medicine, it is just that, unrestricted. It is therefore legal and ethical for any licensed physician to practice aesthetic medicine. It is up to the patient to decide who they want to have treat them. It is totally unethical however, to attempt to legally restrict a physician from practicing aesthetic medicine. It is a sign of fear and cowardice. Fear that they will loose their patient base and cowardice in the face of competition.
Any restriction that is attempted by cosmetic dermatologists to limit who can perform medical cosmesis is simply motivated by greed and fear and not by a concern for patient safety. For history has shown that a non-dermatologist/non-plastic surgeon can perform non-invasive and minimally invasive priocedures as well as, and in some cases better than, a dermatologis or plastic surgeon given adequate training.
03.2 | Unregistered Commenterbotoxdoc
I agree with ls. I am derm residency trained in all cosmetics, lasers, mohs, surgery, dermpath, after completing internal med at stanford. I did not learn at a weekend course.
I disagree with non skin md trying to create skin clinics that are cash only cosmetic.

It is a portion of my practice, that I don't market except for my patients that need it, and they get they get the best care. I break even and I am fine with that.

I think "selling" to patients is breaking down our image as doctors.

Non-derms do not know skin. If they wanted to go into derm they should have. OB should deliver babies not have skin clinics. Same for dentists, FP, etc.

Derm residency is very difficult, not only to get into but to learn what is needed.

I love my job. It is not often that someone is a surgeon, pathologist, and medical doctor.

03.3 | Unregistered Commenterct
Let's put it this way, ct. You, as a dermatologist, should be kissing up to FP's who send you referrals. How often do you send your local FP a referral? One per year? Keep it. Thanks anyway. As a derm, it's all take take take but no giving back, eh? Time to even the score there. Are FP/OB trying to earn extra money? You bet. Same as derms. Same as the plumber. Same as the electrician. Same as ANYBODY. Stop decrying the desire to better one's life through a simple procedure like botox (nurses, dentists, PA's, and podiatrists are giving it). Why am I actually calling it a procedure? It's a SHOT. Forgive me for complicating it with that term. Patients want it. It's easy. Literally anyone can give it. Feel free to get upset at your local OB/FP who is giving it and not refer to them anymore. LOL. Seriously. Every man for themselves.

And for the record, you, as a derm resident, wouldn't last 2 months in an OB or FP residency with every 3rd/4th night in house call. You went into derm for 2 reasons, stop lying to yourself for goodness sakes: Hours and Money. Period. You can say otherwise but every MD/DO in medicine KNOWS otherwise. You good get hours and money but the next guy shouldn't? Sorry buddy. Grumble, get mad, pout, cry but there isn't anything that's gonna stop them. Nothing.
03.3 | Unregistered CommenterMichMD
I understand that derm is a rigerous residency, perhaps, and difficult to get into. But, its competitive for only one Think about practicing medicine with no on-call...what a delight. Secondly, when I did my derm rotations, we weren't doing laser hair removal. We rounded on patients in the hospital with skin disease. Rashes, penphigus, etc. That is what dermatology cosists of. The anexation of medical cosmesis into the dermatology curriculum is a new phenomina. Why should dermatology have any more right to these procedures than FP? Because you specialize in skin? 10% of FP visits are dermatologic in nature. Obviously, if a patient has a dematologic condition that I can't treat, then I'll refer that patient to a dermatologist. But wrinkles, spider veins, rosacea, I CAN treat. And treat just as well as you can.
In terms of selling. I agree "selling" does cheapen the practice of medicine, but, providing a service or a procedure for a fee is the foundation of medical practice in this country whether that service is treating hemorrhoids or spider veins or whether its paid for by an insurance company or out of someone's pocket. Its the same thing.
03.3 | Unregistered Commenterbotoxdoc
as a reply,
I think a well trained derm (I trained on 10 lasers, liposuction, mohs, med depth peels, slero, botox), but also general derm, peds derm, and dermpath. I am a skin expert.

However, I do not limit my practice to cosmetics. I think that a physician that has not had any residency (formal) training in dermatology should not open a skin only business.
I have no problem with OB,FP, etc treating patients with what they like...However it should not be the focus of the practice. They will never know skin as well as a derm. All of these procedures were originally studied, and perfected by dermatologist.

I am a dermatologist because I like it...yes it is true that the lifestyle is nice. I am also trained in internal med...and and spent pleny of nights in the ccu, icu, etc.

I just wish people would do the job they were trained for.

03.3 | Unregistered Commenterct
I am practicing medicine. That is what I've been trained for. I spent 4 years in undergrad. 4 years in medical school and another 4 years in residency. And I understand skin because I have studied it. I can't diagnose an obscure skin rash or treat skin cancer. But, I'm not doing that. Thats what dermatologsts do. I'm fixing wrinkles, spider veins, and removing hair. I have been trained to do that. Not in a two day course, but in months of self-study and seminars. Whether that training was through a residency program or self-taught is inconsequential, beceause the reality is that I am held by state and federal law to the same standards as you. In addition, no one is forcing any of my patients to visit my clinic. Its their choice and they will receive the same level of care irrespective of whether I'm board certified in dermatology, Ob or FP. Because the bottom line is. I'm not practicing Dermatology!!! The study of skin DISEASE. I'm practicing cosmetic medicine. And there's nothing you can do about it!!! So get used to the idea.
This isn't brain surgery and you DO NOT need 3 years of residency to turn on a laser. In fact in many states you don't even need to be an MD to operate a laser. PA's do it. And if a PA with only two years of postgraduate education can safely and effectively do laser treatments, then I am certainly qualified to do the same. Yes, you can argue that PA's are under the direction of an MD. But, how many doctors do you know sit there and watch everything their PA's do.
Dermatologists practice dermatology-the study of skin disease and treatment. Cosmetic medicine is not dermatology. Ouside of the US there is a distinct specialty of aesthetic medicine. It is only in the US and a few other countries that dermatologists have falsely claimed that cosmetic medicine falls within the domain of their specialty.
Let me ask you something CT. How much time exactly out of your three year residency in dermatology was devoted exclusively to cosmetics? I suspect that number is less than a few months. As you said you've studied derm path, ped derm, mohs, and gen derm. I'm sure that took up most of your training.
I don't do any of that. I'm not a dermatologist. I do cosmetic medicine. And I'm damn good at it because thats all I do. Enough said.
03.4 | Unregistered Commenterbotoxdoc
Open a text book of dermatology (Bolognia for example). Read the chapters on cosmetics. Open your text books from school. Dermatology is not just the study of diseases of the skin, it is the study of skin, from epidermis to SQ fat. On my board exams there are questions on all areas of cosmetics...and I am board certified. Did you have questions on your boards about cosmetics?

Cosmetics comprised about 15% of my training.(1248 hours of patient time, excluding my self study)

Turning on laser is easy, but knowing the skin, anatomy, and caring for those who become injured by treatments is not easy.

If you really wanted to be a "full time "cosmetic doctor you should have gone through the proper training.

Why you stopped what you were trained for, and began your new job only you can answer.

good luck,
03.4 | Unregistered Commenterct

Technologies change. Cell phones were $1k and weighed 3 lbs way back when. Now, 12 year olds have them and they cost $20.

Way back when, only surgeons performed colonoscopies. Now, FP performs sigs and GI performs the whole shebang. Used to be only surgeons did liver biopsies. GI's now do transjugular biopsies and some do abdominal endoscopy.
Radiologists used to only read non-invasive imaging studies. Now, they are completely invasive. Everyone taps a knee now, not just orthos.

The point is, technologies change. Lasers were probably very crude and dangerous way back when. Now, they are almost running themselves. And no one on earth can try and complicate botox. You can't. It's impossible to do it. 90-year old grannies can learn how to do it. '

Learn and adapt your practice. Advertise. Learn the latest/greatest, etc. Medicine is changing. Procedures change. I'm sure surgeons were disgusted at GI's doing colonoscopies. Guess what? They all do them now.
03.4 | Unregistered CommenterMichMD

Let me take you way back to medical school. Do you remember your anatomy and histology classes. In anatomy we had to memorize every muscle in the body. Including all the facial muscles and bones. And in histology, skin structure down to the microscopic level. Therefore, every physician who holds an MD has studied skin at one time in their career.
In dermatology residency, you study skin disease. If I look at a dermatology textbook thats 20 years old, I don't see any chapters that have anything to do with cosmetics. Restalyn, Botox, etc. had not even been invented. The foundations, the basis of dermatology is not cosmetics. Ask a dermatologist that finished his/her residency 20 years ago if they ever studied cosmetic medicine.
Cosmetics is new to dermatology not the basis of dermatology.
One could argue that many of the lasers and techniques have been developed by dermatologists, but one could equally argue that lasers were developed by laser physicists. Dermatologists don't know anything more about laser physics than I do.
Likewise,airplanes are deveolped by aeronautical engineers. Does that mean I have have to be an aeronautical engineer to fly one? I don't think so.
OK. lets go back to training. You said you spent 15% of your time on cosmetics. In a three year residency thats equivelent to 5 months of training. Well, guess what CT. I've spent the last eight months learning these techniques. I guess that makes me as much of an expert as you. And if you want me to answer a few questions on an exam, I'de be happy to do that.
A piece of paper on my office wall from the AAD is not going to give me the manual dexterity nor the artistic acumen to inject botox, deliver sculptra, restalyn or do non-ablative laser treatments. The only thing a piece of paper can do is give me a paper cut.
The bottom line is this CT, The letters on my wall plaque (as long as there's an MD there) doesn't mean squat. What matters is the results I get from my procedures and if my patients get what they are paying for. Period.
03.4 | Unregistered Commenterbotoxdoc
Well said botoxdoc. It seems that what looked like a secure field is being overrun with uppity MD's. The real truth is that people, doctors included, get good at what they constantly do. I'd put my 6 years in this field up against anyone else's last 6 years for experience in what I've been doing.

What appeared to be an easy road into cosmetics is being challenged. People get upset when that happens.

I just wish that the Derms would stay in their fungal infections where they belong.

I quote "Dermatology is not just the study of diseases of the skin, it is the study of skin, from epidermis to SQ fat." You must stay away from botox and blephs by your reasoning since your expertise is not muscle. Of coarse this is nonsense since I see the nurse giving botox, filler, and all different kind of procedures in derms offices. I guess this give you more time for the important things to treat skin diseases, Just think in three years you are a pathologist, surgeon and a dermatologist, you must be more adept than any other physician by far by your criteria. Just do not practice on my family with that attiude.
03.4 | Unregistered CommenterSW MD
Well said SW and Curious. But there is no reason why a derm can't practice cosmetic medicine as there is no reason why a FP, Ob, IM, or GS can't either. I think what we need is our own specialty with our own set of rules and regulations. The specialty of ER for example was built out of need. I recall 20 years ago the specialty of ER didn't exist. Likewise, cosmetic medicine is being built out of need. There is demand for our services. Far beyond what can be supplied by plastic surgoens and Derms.
From where I sit, its entirely a business issue. Its the basic tenants of supply and demand. If demand is great and supply short, then a derm or plastics can charge a whole hell of a lot of money for a very simple procedure. To charge a patient $800 for a few injections of botox is criminal as far as I'm concerned. But this activity will persist until supply increases. (Thats us...non-derms, non-PS.) The argument that a derm is more capable of injecting botox is a whole lot of hot-air. But, it prevents, because of market forces, the person of average means from getting these services. It also ensures that derms and PS get a hefty paycheck for very little effort.
Consider this...a GS friend of mine told me that for a 4 hour lap chole he recieved $235. If a physician charges $550 for a botox injection, (50 units..three areas) which takes about 15 min.He/she will net the same as a 4 hour surgical operation.
I have a feeling that Derms are not going to be too willing to give up their pot of gold. But, lets be honest, there's nothing they can do.
03.4 | Unregistered Commenterbotoxdoc
Sure there is..they'll going back to treating what they love: Acne, rosacea and old ladies with itchy skin. Fascinating stuff that.
03.5 | Unregistered CommenterMichMD
Let's be honest. It's about the money and control!

You're absolutely correct. Its always been about money and it always will. Medicine in the US has always been a business and it always will. And right now we MD/DO's are getting the shaft. We've lost control of our own profession. Well earned money that used to go into the pockets of doctors is now going into the pockets of health management companies and insurance companies. How much did the CEO of Aetna make last year? And why is it that we need to get approval from the insurance companies to do a procedure or see a patient? Who is running the show anyway? Used to be doctors...not anymore.
Who is better at making medical decisions, some mid-level manager sitting in a office somewhere in a different part of the country and who probably never went to one medical lecture, or the doctor who has a patient sitting in front of him/her in the office? We physicians end up having to see more and more patients just to keep up with expenses. At the same time we have all the liability if something goes wrong. Here's an example: I saw a patient in the ER a few months ago. A critical patient with an MI. I spent two hours working the gentleman up and dispensing the appropriate meds. Fortunately, the retavase worked and his EKG normalized. And therefore, one could argue that I saved his life. His bill for my services was $3200. Of that, I received $75. I get paid $75 to save a life...that is a trajedy!!! I didn't go into medicine to get rich...but, I sure as hell didn't go into medicine to be exploited either. And anyway you look at it, $75 for two hours work at my level is exploitation.
The bubble is going to burst sooner or later, but until it does, we'll be seeing a mass exudus into fee for service practices like pain management and cosmetics.
Don't get me wrong, I love practicing medicine, and I love the art of medicine, but I am still human and I have my limits, as we all do.
Anyway, I'm probably jusy preaching to the choir here, sorry for the ranting and raving, but in the words of George C. Scott..."I'm not going to take it anymore".
03.5 | Unregistered Commenterbotoxdoc
The other angle to consider is that why should medicine be different than any other type of business? Head CEO's often start in fields other than their chosen degree and end up in a completely different field. Therefore why should a family MD be restricted to just family medicine? I have 20 years of experience as a PA and I can honestly say that in those 20 years I have really never met a physician that was incompetent. Most MD's are "obsessive" and go to every extreme to be great at what they do. Also I would like to point out that in most of these dermatology practices the PA/RN/other personnel are the ones performing the procedures. Sure the MD is "sometimes" on site but not always. Does that make it any safer? Once the injury has occurred even the derm cannot change that and most of us know how to take care of a mild burn, don't we?
My final comment is specific to my profession as a PA. There are facilities all around this country that staff a PA as the primary provider because MD's won't work in these rural areas for the money. In some of these cases, the PA's triage critically ill patients and perform life saving procedures. Just because these are indigent patients does that make their safety/life less important than a wealthy upper class lady that wants IPL/Botox/etc?
Furthermore, could this country's health care system afford to take those mid level providers out of these facilities? What would happen to the health care system in those areas?
Again it comes down to the control and money!
Botox Doc,

You have hit the nail on the head, We are all fighting a corrupt insurance monopoly that has prostiutionalize all of medicine. Our re-imbursement is not fair, our children will not even consider medicine as a profession and no one will be left to take care off the holy than thou art lawyers that will steal the family bible for payment. We all had honorable intentions when we entered medicine but not to work for low pay, no incentive and lack of respect from just about everyone, maybe even the Derms now.

lets all unite and demand fair and equal compensation for the many years we have devoted to taking care of the non- funded, medicaid fraud and general insulting re-imbursement from HMO and PPO. AMA your have screwed all of us because we all forgot what we learned in Medical School, we all have to work together to get thru this.
03.6 | Unregistered CommenterSW MD
Lovely. Impressive. Medicine at its highest level. There are enough patients for all of us with out this silly name calling and fighting. Look at Florida where the governor(!) (BTW,aren't we at war somewhere? Anyone left to treat the wounded?) got into the act saying who could be a medical director of a medspa! And we know how much work medical directors do on patients. So, the derms and plastic surgeons get a percentage of every medspa's take if it obeys the laws-- and the Family docs and NPs are still doing the work. And well too, I might add. When did making women and men feel better about their appearance and face or butt, etc. get to be the property of a dermatologist? Who else but NPs and family practice MDs are used to TALKING with pts anyway and hearing what THEY want?
If it isnt about money, how come the derms and plastics aren't beating on the estheticians and their facials and peels saying only they can do them? Can dermatologists do breast augmentations since its skin? And plastic surgeons are better at performing laser hair removal because they trained in esthetics?
Anyway, LS must have forgotten opthalmologists and neurologists were using botox probably before she ever heard of it....
03.9 | Unregistered Commenterarnp
I would like to see a response from LS at this point. I find it very passive/aggressive to write a post like the one above and to not follow up with rebuttles to some of the posts in response.

LS...where are you?
03.10 | Unregistered CommenterMidwest
[This comment has been edited by the site owner since it contained some unacceptable content.]


So what if you know lasers. What kind ? What device ? They are all different. What about fractional CO2? Active FX , etc.. how many have you treated ? you haven't because they have only come out in last few months.

HAVE you performed LASER SMART LIPO ? (cynosure) 1064nm cannula into the fat tissue ? probably not because residency programs have ONLY CHEAP equiptment. (MAYBE ONLY PLASTICS SURGEONS SHOULD TREAT THAT BECAUSE THEY KNOW MORE ABOUT SURGERY THAN YOU!)

Give me a break . Cosmetic procedures is for any physician who can learn and train. I will send the cancer medicare and medical patients to you.

I teach lasers to every MD/DO including local derms, FP, and medicine. Its not difficult.

PS - if you want to learn some procedures from me I will be happy to teach you, tuition of course !
03.11 | Unregistered CommenterFPMD
Physicians are life long learners and we should update as needed. However, that should be built on a strong foundation. I see doctors trained in other fields, doing cosmetics to make money, to sell, and to no longer do what they were trained to do.

Cosmetics is a small portion of my practice. I do not market. I treat the skin and that is part of my training, including the cosmetic treatment. I find this a strange continuing argument...The facts are there are specialists in each field. To select cash pay only portions of a specialty seems odd to me. If a OB wants to treat acne patients with a laser, he or she should treat acne with all fda approved methods. To sell to a patient as a physicain, after marketing to them really undermines the field. To answer questions: There are very few new lasers, they are all variations of old lasers. Prior to using any new device one should be trained on that device.

Just don't IPL any melanoma in situ, fill lupus profundus depressions with perlane, etc.
03.12 | Unregistered Commenterct
Just to interject, while I am not an MD, I have the utmost respect for all MD's regardless of specialty. As long as the physician has been trained appropriately and seriously does have genuine concern for positive outcomes for the patient, I have no problem with non-derms and non-plastics practicing aesthetic medicine... furthermore the so-called exclusivity of the dermatology programs seems far distorted by the fact that the board limits the number of residency programs and spots.
03.13 | Unregistered CommenterRichard

I was wondering what happened to you. Haven't heard from you in a while.
Based on your argument about lasers you beleive I should have been trained on an antiquated laser before I bought my Cutera. Does that mean if I want to drive a 2007 Ford explorer I should first learn how to drive a model T, or if I drive an automatic, I have to learn manual first. I think you present a very weak argument.
As far as cosmetics go: sure its now part of you're training in Derm. but, it never used to be. I don't think you have a valid argument when it comes to cosmetics.

Cosmetics isn't brain surgery. Obviously, I wouldn't want a gastroenterologist to do a craniotomy, or a neurosurgeon to do a colonoscopy on me. But, injecting Restalyne....a nurse can do it. And i know many nurses who get damn good results too.
You have to agree with Richard. What patients want are results. PERIOD. They want to look good and they don't care who does it.
Go into a plastic surgeon's office that sells Restalyne. Who is providing the treatments? Its not the MD. 9 times out of 10 its a nurse or NP.
The state of Florida says you need to be a plastic surgeon to oversee the NP,(PA) but, an FP isn't qualified for oversight. However, in the case of the NP I was speaking about above, the plastic surgeon who runs that particular office doesn't do fillers, has no interest in learning, and doesn't know a hyaluronic acid from calcium hydroxyapetite. So how come he is more qualified than me to oversee a PA doing fillers? Because the State of Florida says so? Or a Dermatologist says so? Its a bunch of H.O.G.W.A.S.H. The real reason is POLITICS and has no medical merit whatsoever.
I'll take this one step further, you mentioned doing an IPL on a Melanoma. Get real CT. Any FP can diagnose a melanoma. And if they can't, thats your job and what referals are all about. You were trained as a dermatologist. Thats what dermatologists do. They diagnose and treat skin DISEASE. And when I looked it up in Steadman's I didn't see nasolabial folds being cosidered a disease.
Get off of your high horse CT. You're no more of an "expert" in cosmetic medicine than I am.
03.14 | Unregistered Commenterbotoxdoc
By the way CT, I'm assuming you recently finished residency from you're writing. My advice to you CT is wait 20 years and see if you're still interested in lupus rashes. There is no reason why a physician can't change interests in mid-career. It happens all the time in "the real world". The problem with a physician changing specialities however is the way medicine is structured in this country. Nurses go from the ER to the ICU, to peds to whatever all the time. If an IM has an interest in aneastheology in his/her 40's for example, how is he/she going to get trained in that specialty without going back and doing a residency? Fortunately, cosmetic medicine is different. All it takes is a few months of training and a doc can be injecting restylane like a pro. Like it or not CT thats the way it is. Better get used to it. Cosmetic medicine is NOT dermatology and dermatologists do NOT OWN these procedures. I've got a license, I can do it. Better move over and make some room.
03.14 | Unregistered Commenterbotoxdoc
thanks couldn't have put it better. i will be getting my xeo this month. the patients we have already treated with the titan are very satisfied. i forsee most patients will be coming to their PCP to get these easy treatments ie - hair removal etc. i no longer send cosemetic procedures to the derm down the street when i now can do them myself. anything that looks like cancer/squamous/basel/lupus/ ill be happy to send to ct. ha.ha....
03.14 | Unregistered Commenterinternist
Looking at this site and reading your words is sort of addictive. I am newly trained out several years. Cosmetics is a small portion of my practice and I do all the procedures myself...because I am better that anyone else in my practice.
I want the best for my patients. I actually make more money doing dermatology than cosmetics. sure, I could open a spa and have 4 np, doing procedures for everyone and do much better...but that is not what I think would be best for patients or the practice. I am not trying to keep only derms doing cosmetic procedures, I just do not want all other doctors(IM, FP, OB, Pathologist, etc) quitting what they were trained to do to do what they were not.

Being trained recently I am trained in plastic closures, and yes I have had alot of training in cosmetics....And I use it as a portion of a well balanced practice.

Being able to evaluate Laser tissue interaction just like knowing how to orient a closure takes study. I see alot of problems in my community from non-skin specialists trying to concentrate on skin only practices.

A IM, FP opening a skin treatment only clinic and not treating his or her patients any more for usual problems should not happen.
03.15 | Unregistered Commenterct

You seem to be a reasonable and caring physician and I applaud you for that and I'm sure your patients appreciate it too.
03.15 | Unregistered CommenterMichMD

You sound like a dedicated and caring physician. I too applaude you for that. I also believe that a doc shouldn't necessarily abandon his/her pts. and go into a cosmetics only practice. That doesn't seem to be the case. But a physician has the right to do that if he/she desires. Many FP's, IM's, Ob's are adding cosmetics to their practices, however. its a matter of who is "qualified" to practice cosmetic medicine. As of now there doesn't appear to be a governing board apart from the sub-speciality of procedural dermatology. However, procedural dermatology is not limited to cosmetics. My belief is that we need to develope an independant speciality of "cosmetic medicine" as opposed to cosmetic or plastic "surgery". It should be open to physicians of all specialties who practice cosmetic medicine, derms., FP's IM's, Ob's etc. not just dermatologists.
As an aside, CT. Before I did my FP residency I did three years of Gen Surg. with 5 months on the plastics service. I too can do a darn nice plastics closure.
03.16 | Unregistered Commenterbotoxdoc
I just want to point out one piece of the puzzle left out by LS and CT. The vast majority of skin problems are NOT taken care of by dermatologists. I have seen studies that show up to 85% of all skin rashes and skin issues are taken care of by the patients PCP. So if you look at the numbers we are the skincare specialists. Derms would not be able to handle all of the skincare issues out there and they would be overwhelmed as well as bored.

Yes, I love having my friends that are dermatologists around for those rare skin diseases and I refer when neccessary. The reason I refer is because it is the best thing for the patient as I may only see one case of mycosis fungoides every 10 years. It is not worth my time to try to research treatment options and try to treat these patients.

As you will see in my other post under LS's original post I do more of this stuff than the derms in my area and I have had to correct some of their results. This is a turf battle so call it what it is. Currently, there are not enough derms out there to do all of the cosmetic procedures that patients want. The patients have up to a 8 week wait to see the derm for botox most patients do not want to wait that long.

I also think this is beneficial to the patients as well. The competition in my area has helped bring down the prices of these procedures so more can afford it.

I agree with botoxdoc that we need to join forces and develope the specialty of "cosmetic medicine". The American Academy of Cosmetic Surgery says they are doing this but in reality they are not. They only allow "core trained" physicians to become fellows. I find this difficult to understand. I beleive they are doing it for political reasons as they have managed to be accepted as a board in California. I do more cosmetic medicine than most of the core trained physicians in my area and I can not become a fellow.

I appreciate the last post by CT I beleive he/she holds themself to a higher standard as I do. I do all of the procedures except hair removal and IPL. These are all done under my supervision. I do wonder why some derms get into this when they make a lot more for mohs than botox or lip augmentation?

I think many physicians are getting into this to fill the need in their areas. Many are tired of spending 30 minutes seeing a medicaid patient for type II diabetes, hypertension and CAD and getting paid $30.00 for it and then having to pay overhead etc out of it. I chose to get into cosmetic medicine because I enjoy it and I am very procedure oriented. I also want to work for myself and not some system owned by a hospital/health system. I actually have taken a pay cut to do this.

CT mentions something about being able to evaluate laser tissue interaction and orientation of closures. I can guarantee he did not understand it until he saw it. I have done a few thousand laser procedures with various lasers and light sources. I think I understand laser tissue reaction.

It sounds as though CT has had more than the normal cosmetic training than most derm docs. I know a derm doc that had done all of 5 liposuctions and than went into practice doing liposuction. Do you think she saw all of the possible complications by doing 5 procedures. We all have a learning curve. Some physicians are better at procedures than others and are going to be much more compitent. By the way on her first post residency submental lipo she dinked a patients nerve.

We all need to do our best to take care of the patients. I hope that CT's concerns are heard and that he/she steps up to the plate to make sure that all of the physicians doing cosmetic medicine are well trained. I think CT should be one of the founding members of the "cosmetic medicine" group open to all physicians practicing cosmetic medicine. Then and only then will we able to hold ourselves to higher standards without the politics of specialties being involved.
03.18 | Unregistered CommenterLH

Your sentiments are heard and appreciated. I did some investigation in terms of the developement of a AMA house of delegates recognized speciality. It can be done if there is enough interest. It will also take 5 years or so to become recognized. But, I think the time to organize is soon approaching. As it stands we (those of us who practice cosmetic medicine) are divided and therefore have very little political clout. Turf wars will undoubtably continue, but, I believe it is much easier to hold one's ground with numbers. Besides for every derm or plastic surgeon practicing cosmetic "medicine" there are probably 5 or 6 non-derms/non-plastics. Why did HB699 get passed in the first place? Its becouse we have no political voice. Obviously, Derms and PS will resist because they won't be able to continue to charge unheard of prices for their services if a pt. can go down the steeet and get the same procedure for less money and not have to wait 2 weeks. However, there is power in numbers. United we stand.
03.18 | Unregistered Commenterbotoxdoc
By the way CT. Derms make injecting Restalyne or Botox out to be some highly advanced procedure that takes years of training. Lets face it. We're not exactly doing a three vessel bypass here. Obviously, it take some manual dexterity and practice. But if you don't do it well, all you've done is created a lump that will go away in a few months, or at worse an ulcer. This is not a life threatening complication. (although a few women will disagree with this). Obviously, if you don't do it well, you probably won't be getting any return patients, but you're hardly going to kill anyone. And what about Botox? Obviously, you can get complications with that too if not done correctly. But, a drooping eyebrow has never been known to be life threatening either. Like I said this isn't brain surgery.
Training you ask? do a Google search. I bet you'll find plenty of opportunity to get trained.
CT you're equating injecting Botox with performing a laparotomy. Thats like comparing apples to oranges. What about patient safety? There is absolutely no indication that a non-derm/non-PS has more complications than a derm/PS. There is anecdotal information only which is worth about as much as the paper its written on. (oh wait, I forgot, it wasn't written on paper) We've all heard about the PS that had to fix the Botox treatment by an FP. But, we've also heard about Big-Foot. Unless you can show me a randomized prospective double blinded case-controlled study that shows having a cosmetics procedure performed by a non-derm/non-PS results in more complications than a derm/PS, than you have no argument. I'll even take a retrospective study. But, guess what, CT? that study was never done. Why? my guess is that the results would show no difference. And that would blow yours and the AAD's argument that you need university affiliated residency training right out the window.
03.18 | Unregistered Commenterbotoxdoc
I wanted to add one last comment to the site. If a patient is consulting you for a problem about one topic, do not pick out what you would consider a target for a cosmetic procedure and ask, "Does that large nose bother you"?
I think that is the worst thing that could be done. I have patients that come in asking about certain "problems" that other physicians have pointed out to them. It becomes a psychological problem for the patients, and knowing that they are a variation of normal is very pleasing to them.

To answer a few know if you get good results, and if you do why argue?

I still stand, that non ABMS trained physicians should not open skin only practices. Keep it part of you practice, fine. Patients do not understand...they think if it is called skin clinic that you are a trained dermatologist.

03.24 | Unregistered Commenterct

Thank you for the advice. Please understand that my argument is not with you, but the commonly held belief that any one speciality has a "right" to do a procedure and others don't. The history of medicine is otherwise. 50 years ago all physicians were generalists. Specialization came to pass as medicine became more complex and physicians began practicing in those areas that most interested them. To be a specialist, one focused his/her practice in a particular area. Medical societies then sprang up which became exclusive. However, these medical societies to which we all adhere to are a relatively new aspect of medicine. Medicine has been practiced for thousands of years. The American College of Surgeons for example is 40 maybe 50 years old. And the sub-speciality of procedural dermatology is less than 5 years old. I'm not saying that medical society's are hogwash,they certainly have a place, but, we need to keep everything in perspective. By the way, I am boaed certified in an ABMS specialty. And if a patient asks, I tell them I'm boarded in FM. I also display my diplomas in my office. I don't claim to be a dermatologist. That would be fraud. Everything I do is 100% legal and ethical.
03.24 | Unregistered CommenterBotoxdoc

No one here would challenge a word you said if you were talking about skin cancer. But you're not. Skin, aesthetics, laser... whatever the name of the clinic, the rules of medicine and ethics still apply.

Physicians get good at what they're constantly doing. Just because derms or plastics think they own the aesthetic medical world 'don't make it so', as we say around here.

Anything that a derm will have a PA doing so that they can make more money is hard to defend from a MD.
03.24 | Unregistered CommenterDocHoward
Forgot one thing. Not need to have a 'last post' on this site. Best conversation I've had with a derm in a long time.
03.24 | Unregistered CommenterDocHoward
I agree with DocHoward. I want everyone that works in the aesthetic procedures market to feel like thay can discuss anything including the topics in this string.

With that said, I still think I would want someone to do a procedure if they do it a lot. I do more minimally or non-invasive aesthetic procedures than the derms in my area. They dabble in it and it is "part" of their clinic. As with me, it is all of my clinic. I think I do a better job at it because I do more of it.
03.24 | Unregistered CommenterLH
Well said LH and that do particular procedures more frequently do them better. This is not only true outside of "core" specialties but within them as well. For example, research showed that those hospitals that had the best results with CABG were the hospitals that did the most CABG procedures. As they say, practice makes perfect.
It is generally beleived by physicians and lay persons alike that a physician needs to be "board certified" in order to perform certain procedures. For example, you need to be boarded in GS to do an appendectomy. This is not true. Family practitioners in rural areas have been doing appys. C-sections, etc. for years. The law that exists today and has existed for hundreds of years in this country states that a physician who holds an unrestricted license to practice medicine is legally entitled to perform any procedure that he/she is comfortable with and has adequate training in. Adequate training does not by definition necesarily mean a university affiliated residency. Standard of care dictates that the physician is capable of the procedure as well as responsible for any complications that may manifest from doing the procedure. Responsibility does not imply capability. An invasive cardiologist for example does not have to know how to repair a ruptured aneurysm from a Cardiac cath. but, there needs to be in a means by which an untoward outcome can be handled. That usually means having a thoracic surgeon on-call whenever a card. cath. is done. Likewise, a physician doing a laser treatment has the responsibility for any possible complication of the procedure which is a burn or hypo/hyperpigmentation. That is all. Standard of care does not dictate that a "dermatologist" must perform the procedure.
Private hospitals and insurance companies, and medicare however, are the entities that determine who gets hospital privilages and reimbursement for procedures. If a PRIVATE insurance company's policy states that the hospital will not be reimbursed unless a "board certified" physician is doing the procedure, than a family practitioner who does an appy will not get paid for his services. However, it is perfectly legal for him/her to do so.
There is great confusion with what is "legal" and what is "reimbursable".
In the world of cosmetic medicine, however, it is all paid for out of pocket by the patient and, therefore, the restrictions that are placed by medicare, and private insurance companies no longer exist. And therefore, being "board certified" does not hold the same weight and is not a requirement for reimbursement since it comes from the patient him/herself.
As a disclaimer: this is only my opinion and should not be taken as legal advice. Please confer with you're own legal counsel.
03.24 | Unregistered CommenterBotoxdoc

Guess this thread has died in the past two months- but I would like to chime in:

In my opinion (as a plastic surgeon), we as physicians would all like to assume that we are uniquely gifted and qualified to perform the procedures and/or treatments that we do. Are there FPs, derms, ect that can do fillers, lasers, ect. better than me? Most likely.
But the real issue in regard to training and ability is not the difficulty of the procedure- I think someone above alluded to the fact that these treatments are for the most part pretty basic- but are you able, willing, and have the training (and hospital privileges) necessary to handle the complications that can arise from these treatments. If you really feel like you do, great. If not, I think you need to rethink about the disservice you may be providing to your patients.

There is a dermatologist here where I live who does breast augmentations in his office. He advertises heavily and has a pretty busy practice, but when he runs into trouble with his cases (which is not infrequent), he calls the ambulance, tells the driver to take them to the ER of the nearest hospital (of which I am on staff), and tells the patient "good luck!!". The ER doc calls the plastic surgeon on call And now it is our problem to deal with. Now my afternoon is shot because he does not have the ability to deal with the complications. Not fair to me, and certainly not fair to the patients.

just my two cents

07.18 | Unregistered CommenterRLS

WOW, you can smell the testosterone burning around here...but then, maybe only a Endocrinologist can smell it!!!!!

As a second year resident having survived internship and still possessing a genuine interest in patients suffering from disease, this whole thread saddens me. No wonder the prestige of the physician has fallen, what a bunch of money-hungry whores. You can have all the lasers and cosmetics and make your money...better yet just trade in your MD for a cosmetology degree and think of all the lives you can make better and impact you will have on the world. Non-plastics/derms who do cosmetics have no professional integrity. All of the above posts are just sad justifications for selling out. I want an FP who will provide appropriate preventive care to my family (if you don't like how GME are reimbursed, spend the time/resources you put into cosmetics courses into a lobby for change). I guess since there's finally some awareness that Obs are cashing in on unnecessary C-sections (hysterectomies etc), need more ways to make cash money My 2c, flame on brothers and sisters.

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