The business of dermatology

April 1, 2018

It goes without saying that medical students and residents receive invaluable training that prepares them to provide high-quality care to their patients. For the vast majority of physicians the quality of medical education training they receive is not accompanied by a similar level of business training.

It goes without saying that medical students and residents receive invaluable training that prepares them to provide high-quality care to their patients. At the same time, this medical training also allows physicians to achieve a great deal of financial success, but amazingly for the vast majority of physicians the quality of medical education training they receive is not accompanied by a similar level of business training, which would facilitate physicians developing successful, efficient, cost-effective and high-quality personalized medical practices.

As a former university department chair, I believe this failure to educate future physicians in even the most basic business principles is most likely due to two things.

The first being that medical business education is of lesser importance than the traditional medical curriculum and as such, it can easily be avoided.

The second is that, from my perspective, medical schools and academic hospitals probably deliver the most inefficient healthcare around and simply don’t have the talent or expertise to run their own medical system properly much less attempt to train medical students and residents on the many important business aspects of running a medical practice.

This issue of Dermatology Times focuses on the business of medicine. I would like this editorial to address some business issues in which dermatologists could benefit from receiving additional training.

In the past, a lot of medical business training occurred in an ad hoc fashion by informally following and watching a willing successful practitioner: “Learn by observing.” However, this didn’t necessarily guarantee a high level of quality or even appropriateness to deal with current administrative or business issues. Just because one practitioner has achieved success with the way he/she runs their office doesn’t mean that another practitioner will obtain that success by trying to duplicate those same techniques of the established practice in their own new practice. That technique simply doesn’t work very well anymore and today it is obvious that additional specific business training is necessary.

Perhaps one of the first business training requirements that proved the old system of medical business training didn’t work well was the introduction of the governmental mandated electronic health record (EHR). This appeared so suddenly that no one had any real previous experience or practical expertise in transitioning from a paper medical record to an electronic one.

The introduction of the EHR was touted as a way to provide more cost effective healthcare, improve payments to physicians, reduce duplication of lab or radiologic tests and permit sharing of medical information. The required change to an EHR brought massive adjustments to the way in which healthcare was documented and delivered. Not only did this require the purchase of new software and computer systems, it also required extensive training of the physician and their staff on its proper use. While many new IT companies suddenly appeared to help provide training in this regard, the whole process was viewed as being so onerous by many physicians that some dermatologists I personally know retired rather than have to implement this new system.

Training in the EHR was initially done by the software providers, but there was no effective way to evaluate the quality of training provided. I know two large multispecialty groups who had to dump their expensive EHR’s because they didn’t work properly, were cumbersome and were responsible for many errors.

I have also heard from many dermatologists that they feel they have lost some of the personal contact they once had with patients due to the need to document all of the patient’s problems and the treatments that were provided in the EHR. Of course, there are solutions to that part of the problem. One of which is to simply use a well-trained scribe or medical assistant to do the documentation while the physician can still maintain eye contact and develop rapport with the patient. While scribes may help to eliminate one problem, they create a new one by increasing personnel cost.

The electronic medical record has taken on added importance with the increasing governmental intrusions on the practice of medicine (EHR, HIPAA, MACRA, MIPS, Meaningful Use, PQRS and other “Pay-for-Performance” programs), the old “learn-by-doing” technique for practicing dermatology used in the past may not even qualify as being acceptable in satisfying the new regulatory requirements of these various programs. In these cases, failure to effectively document patient care activities can lead to both penalties as well as reduced reimbursements. There are many dermatologists who no longer accept Medicare patients or have converted their practices to a “concierge or retainer practice” in order to avoid the hassles of having to document a certain level of performance to fulfill the requirements of these Medicare governmental programs. I have also noticed over the past 10-15 years a growing number of dermatologists who have gone back to school to get their MBA’s, probably as a manifestation of the increased difficulty in effectively managing a successful practice under all these governmental pressures. I truly believe that most physicians became doctors to care for patients, not to be bookkeepers, accountants or business people.

With that in mind, I also believe that many young dermatologists are opting to avoid solo private practice and join single specialty groups or larger multispecialty groups to obtain a better “work life balance” and to avoid having to deal with the headaches brought about by implementation of these new administrative issues. Since they didn’t receive the necessary training in medical school or residency in the important fundamental business skills necessary to run a successful medical practice by themselves, they may choose to allow the administrators of their larger group practices to deal with the issues of staying current and in compliance with the new and increasingly important administrative regulations that now govern the practice of dermatology.

In my opinion, education in the business aspects of medicine is so vital that it should become an established part of the curriculum at all medical schools. With earlier training in the important business issues in medicine, I believe physicians can become more efficient practitioners, reduce healthcare costs and provide quality care to more patients. This training can also improve work-life-balance and lead to greater physician satisfaction. Business training in dermatology should also receive greater attention by our specialty societies so that we can more easily and effectively deal with any new governmental and insurance company regulations that are sure to arise in the future.

Dr. Wheeland is in private practice in Tucson, Ariz. He is a past president of the American Academy of Dermatology, the American Society for Dermatologic Surgery and the American Society for Laser Medicine and Surgery. He is a member of the Dermatology Times editorial board and a co-medical editor.