Lure of cosmetic procedures compounds a shortage of dermatologists

As tanning beds and sun worshipers drive skin cancer rates ever higher, the number of specialists available to treat them is not keeping pace.

Minnesota currently has 233 practicing dermatologists, or 4.3 for every 100,000 residents, and the University of Minnesota Medical School typically graduates only five new ones each year. Many devote a considerable part of their practice to cosmetic procedures, which tend to pay much better than treating malignant moles or other medical conditions.

The situation is resulting in delays in diagnosis and treatment of skin cancer and other issues, some doctors say. "Cosmetic dermatology takes time away from more important medical issues," said Dr. Spencer Holmes, a dermatologist at Park Nicollet and adjunct professor at the University of Minnesota Medical School. "It is ethically wrong, in my opinion."

The cosmetic work has contributed to a noticeable increase in dermatologists' incomes. From 1995 to 2012, incomes for dermatologists rose nearly 50 percent, while primary care physicians' income rose about 10 percent. Dermatologists now earn about $471,555 on average, the fourth-highest earners in American medicine, according to the Medical Group Management Association in Colorado.

But some wonder whether skin cancer and malignant moles are taking a back seat to a youth and beauty-obsessed culture wanting Botox, chemical peels and lip augmentation. Cosmetic dermatology now fills 20 to 40 percent of some doctors' schedules in the Twin Cities.

Meanwhile, the threat of skin cancer is going to get worse. By 2015, it is estimated, one in 50 Americans will develop melanoma in their lifetime, said Dr. Jack Resneck, vice chairman of dermatology at the University of California San Francisco School of Medicine. In fact, the incidence of non-melanoma skin cancer in the U.S. more than doubled from 1994 to 2006 to 3.5 million tumors, according to a 2010 study, Resneck said.

The cosmetic side of the medical specialty came under intense scrutiny in 2007 after a survey by the Journal of the American Academy of Dermatology showed wait times for a Botox appointment at eight days while wait times for a person with a changing mole were 26 days.

But he disputes the notion that his office focuses on aesthetic dermatology. "Eighty percent of my practice is medical," he said. "I leave four appointments open each day for emergency appointments when a primary physician contacts me to check someone," he said. "If four are filled, I stay late."

Holmes said that the reason for the expansion into cosmetic dermatology is simple — to make more money. "If a dermatologist spends 20 percent of the time on cosmetic issues, that 20 percent will be much more well-compensated than the 80 percent for medicine," he said.

Typically, a health insurer might reimburse a doctor less than $100 for a full body skin cancer check taking 10 minutes. But the same doctor could receive up to $500 for a 10 minute Botox injection, paid in cash or credit card by the patient on the day of service.

Dr. Brian Zelickson, a dermatologist at Zel Skin and Laser Specialists in Edina and Minneapolis, said he spends three days at his medical office downtown and two days at his Edina clinic, which is primarily cosmetic. He is also launching a new line of 12 skin care products with Target available in stores next month called MD Complete by Dr. Brian Zelickson.

But the idea that the cosmetic side of his business is more lucrative is not true, he said. "I could do just as well with the medical side of the practice," he said. With the medical side, he said, there are no advertising fees to pay.

When he started his solo practice 12 years ago, he was worried about paying off student loans so he took a marketing course. "I learned if you're going to go in, go big," he said.

Some have described cosmetic dermatology as entrepreneurial medicine, a label that Crutchfield likes. His office employs 40 people, which he describes as contributing to the health and welfare of the state by paying corporate and other taxes.

Blaming longer wait times on cosmetic dermatology is wrong, according to Crutchfield. Nationwide, dermatologists spend only 8 percent of patient care hours on cosmetic services, according to a nationwide survey.

"There are no published studies indicating that the rise of beauty procedures has caused harm to dermatology patients," Resneck said.

Many dermatologists say the real culprit is the perennial shortage of skin doctors that goes back more than 30 years. They point to Medicare cutbacks that leave less money to fund residency programs that produce more doctors. But Resneck believes that adding another 50 residencies per year still wouldn't abate the shortage in many communities.

John Ewoldt • 612-673-7633