Skin in the Game

July 30th, 2008 by DrRich

The New York Times recently took dermatologists to task for creating a two-tiered system of dermatology - one for patients with skin disorders, and one for “cosmetic dermatology.”

As the Times describes it, patients who wish to see a dermatologist for, say, possible skin cancer are put on a waiting list, and when their appointed time finally arrives (generally months later) they are subjected to modern medical hell. To wit: Upon arriving in a lackluster office, the patient is shelved for a while in an unattractive, poorly lit waiting room equipped with a broken TV, old magazines, unruly children of other patients, and surly office personnel. Eventually her name is called by a not-necessarily-pleasant nurse practitioner who will “triage” her to the appropriate category (e.g., acne, fungus, cancer, warts- you know, dermatology stuff), have her strip in order to fully expose the large surface-area organ (the skin) for which she has sought assistance, give her a scratchy yellow paper gown to cover her nakedness, and have her wait for some time in a chilly exam room to see the actual doctor. At last the dermatologist arrives, mutters a greeting (or some other ritual uttering), glances at a clipboard, and announces, “Show me your [acne, fungus, cancer, warts];” whereupon, having regarded the cause of cutaneous concern and having made a professional determination, he either signs the prescription that has been pre-written for him by the nurse practitioner, or schedules a procedure. Then, shoving into the patient’s arms her bra and other structural and non-structural equipage, the doctor pushes her out into the hall, as the formal interview is over.

Presumably, one hopes, some dermatology practices not visited by the New York Times might not be quite so bad. Still, anyone who’s been seen by an American PCP lately will nod sympathetically at the dermatology patient’s ordeal.

Now observe what the Times observes when the patient, instead of having an actual skin problem, merely is sagging here and there and wishes to be shorn up. That is, the patient has a cosmetic issue. That is, the patient wants Botox.

The same dermatologist will often have an entirely different setup for these patients. This time the patient is seen immediately, possibly the same day, as dermatologists are sensitive to the needs of those who are about to appear in public, say, at an impending dinner party. If this patient is to wait at all, she will wait in a modern, tastefully decorated private room. She will then be seen not by a mere nurse practitioner but by an aesthetician, who will do a formal assessment of the sagging parts, and, aside from suggesting more injection sites than the patient might originally have had in mind, will offer a complete program for long-term cosmetic maintenance, which naturally will include quarterly Botoxification. At just the proper moment the dermatologist comes in, greets the patient warmly and reassuringly; then reviews the recommendations of the aesthetician and discusses those recommendations at length with both the aesthetician and the patient, studying the patient’s face in depth as he does so, pointing, nodding, agreeing, adjusting, all the while smiling confidently. Yes, he indicates, we will all be very happy indeed with the results. Finally the doctor begins to make the now-thoroughly-discussed-and-agreed-upon injections, doing so with the greatest solicitation and sensitivity. The patient is then given as much time as she needs to collect herself, and is invited to “recover” in a room set aside for this purpose with flattering lighting, soft music, a cappuccino machine, and perhaps a glass of wine. She leaves the office a new person. And, just as the dermatologist has promised, all are indeed very happy with the results.

Naturally, the New York Times is scandalized by the dichotomy which its discerning readers will note here. Why should a patient with a mere cosmetic issue be treated so well, when a patient with an actual medical problem, possibly even skin cancer, is treated so shabbily? How can dermatologists openly encourage such a two-tiered system?

DrRich has a word of advice for the commentators and reporters of the New York Times and any other concerned Americans worried that dermatologists, by setting up separate-but-not-equal practices for their two kinds of patients, are moving us one step closer to the dreaded two-tiered healthcare system we all abhor. That word is: Chill.

Allow DrRich to support this friendly recommendation with two observations.

1) We already have a multi-tiered healthcare system, and little or none of it is the fault of dermatologists. It is the fault of human nature. All countries have at least a two-tiered healthcare system, including countries (like Cuba and China) that have specifically embraced egalitarianism (rather than individual autonomy) as the fundamental operating principle. The second tier, like the poor, will always be with us.

2) When a dermatologist spends Tuesday afternoon in her run-down office, treating people who come to her for bona fide skin disorders like they’re widgets on an assembly line, then goes to her other, better office on Wednesday, treating the merely cosmetically-challenged like minor nobility, she is not really engaging in two-tiered healthcare. Not at all. Instead, she is practicing real, true, prescribed-by-society, by-the-book American healthcare on Tuesday, and doing Something Altogether Different on Wednesday.

Injecting Botox is officially and formally not part of American healthcare. How do we know this? Because it is not covered by Medicare or health insurance. If you want Botox you’ve got to pay for it your own self, just as you do if you want a TV or a car. So by all that is sacred, injecting Botox is NOT American healthcare.

Furthermore, when one looks objectively, injecting Botox is not even really practicing medicine, at least not in any true sense. In actual truth, it takes very little training or expertise to inject Botox. There’s no reason one must go to college, graduate from medical school, or do several additional years of training in dermatology (or any other specialty) to do this. Anyone with a needle and syringe, an alcohol wipe, and access to Botox could do as well. Just find the wrinkle and stick it. If they made the materials available over-the-counter, folks would do just fine with it.

Of course, doctors in general (and dermatologists in particular) have legally cornered the market on Botox injections. So it’s not like you could just set up a booth at the Mall and hire high school students to do this (as you can for, say, ear-piercing - which, in contrast to Botox injections, is an actual surgical procedure which results in a permanent structural change in a body part). If you set up a chain of Botox Booths, you would be practicing medicine without a license, which is a serious offense.

And consider this. Dermatologists could just as easily have taken up a somewhat different well-known cosmetic procedure, one that also involves injecting substances through the skin via needles, and that has much more to do with the skin itself than Botox injections (which actually do not affect the skin itself at all, only the muscles under the skin), but they chose not to. DrRich speaks, of course, of the tattoo. But unlike making Botox injections, tattooing requires real skill, knowledge, training, expertise and artistic talent. Most dermatologists simply could not manage a highly-technical skill like that.

The point, of course, is that injecting Botox does not involve intrinsic skill, knowledge, difficulty, risk, or any other objective characteristic that necessarily renders this a medical procedure while ear-piercing and tattooing are not. Viewed from this perspective, one must conclude that declaring the injection of Botox to be a medical procedure, which cannot be performed by anyone not having a medical license and years of specialty training, is an entirely arbitrary determination.

Fundamentally, then, while performing Botox injections may have a certain legal status, in any true sense it is not really practicing medicine. Rather, it is simply an activity some dermatologists may choose to do when they’re not doing real dermatology.

Doctors engage in this sort of thing all the time. That is, they partake in activities other than practicing medicine when they could, in fact, be seeing more patients. Some have taken up golf. Others have started side businesses such as restaurants or software companies. Some go to graduate school (usually for MBAs). Still others have opted to work part time in order to raise their families.

Society generally finds such activities acceptable, and - to this point - does not insist that all doctors forego all other human endeavors in order to see as many patients as humanly possible, during all their waking hours. While society seems to be moving closer to declaring that doctors owe this duty, it has not reached this point quite yet.

Until society sees fit to legislate otherwise (which, DrRich supposes, could happen as early as the next president’s administration), doctors will continue to spend some of their time engaging in hobbies and business or family activities outside of the formal healthcare system. Some may even leave the formal healthcare system altogether in favor of these other activities. DrRich himself has done this. And until society renders it officially illegal for doctors to do so, DrRich respectfully asks that doctors be left alone to celebrate their individual autonomy as granted to them under America’s founding documents, whether it’s by establishing authentic Indian restaurants, setting up Botox clinics, or even becoming retainer practitioners.

One last word of advice for dermatologists: Have fun with your Botox clinics, fellas, but please don’t become too invested in them. Injecting Botox is not exactly cardiac electrophysiology. This is definitely a shallow-moat business, and the only thing that gives you any protection at all is your aura as highly trained specialists, with special and secret knowledge about an organ (i.e., the skin) which visibly droops when the underlying muscles become lax with age and gravity. A single action by forces entirely out of your control - say, Congress or the FDA - could render your monopoly entirely moot overnight, and you will be instantly priced out of business by hordes of PCPs, nurse practitioners, Botox booths in Walmart, and even home Botox injection kits. So please remember to at least keep your hand in genuine dermatology, or get your MBA, or perfect your long iron shots - but do something that will provide you with a Plan C. Because Plan Botox is definitely a high risk endeavor over the long term.

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