. There is some useful pertaining to this topic on the American Academy of Dermatology website, which I helped develop. This should help you decide whether you want to go solo, small group, large group, VA, or academic practice. These options all have certain advantages and drawbacks.
Your first decision should be where you want to practice geographically, which will determine many of the details of any practice situation. For instance, if you go where there is a shortage of dermatologists, you will be more welcome and more sought after. I will never forget sitting in a hospital break room in New York City after giving grand rounds with a large group of residents, who asked me about practice opportunities. I asked them where they wanted to practice. Every resident – first, second, and third year – indicated they wanted to stay in New York City. I had to laugh to myself. If there are any cities with a surplus of dermatologists, it’s the hip ones: New York, San Francisco, Los Angeles, Miami, and so on. If you can find a job there, it will be a “this is what everyone signs” contract situation, and a large part of your pay is the privilege of living in an urban “paradise.”
If you are willing to look further afield, I suggest you start with an old classic, the “” (Washington: Places Rated Books, 2007). This is a resource (that needs a new edition) that provides all kinds of details on different areas of the country that you may not have considered, including median income, schools, climate, and livability.
When you know the general area where you would like to settle – and after considering the parents, the in-laws, and the outlaws – remember that the best jobs are not advertised. You should contact all the dermatology, multispeciality, and hospital groups in the area (yes, write them a nice snail mail letter) indicating you are interested, and ask them if they are hiring. Practices are usually interested in a general dermatologist, or perhaps a Mohs surgeon or dermatopathologist, willing to practice general dermatology half time. For example, I know a very nice general dermatology practice in the Midwest that has been looking for the right derm-path/general derm for years. The days of strolling in and setting up an all-Mohs or all-dermpath practice are over, unless you buy out, or become employed by one of the older established specialist groups.
Ask the staff (and former physician employees if you can find them) lots of questions. See if their style of medicine suits you. See if their electronic health record system is fast or a major hindrance. Find out how many extenders you will be responsible for supervising.
And find out if they are considering selling out (selling you) to private equity. Private equity groups are a major new influence on the specialty, run a lot of ads, and hire a lot of graduating dermatologists. They offer more benefits and higher initial salaries. There is no free lunch, however, and these perks must be paid back with future earnings. The private equity groups take 20%-30% of profits “off the top” and your earnings will hit a ceiling at a level that is significantly lower than it would be in a solo practice or dermatology group. They also have long, detailed, ferocious contracts with penalty clauses and noncompetes from all outlets. More numerous advertisements are a negative tip off, but will give you an idea of which markets they think are promising with regard to need and payer mix. See what the private equity group’s private health insurance rates are. If they are significantly greater than Medicare rates, they deserve a second look, though few are. Remember that the senior physician who pitches for them in the lounge doesn’t work for free, but receives a significant bonus for getting you to sign.
If you find a great location, it is time for contract review. The first rule is that no contract is better than who you sign it with. If they are determined to mistreat you, they will – no matter the contract. I advise always having a graceful exit written into the contract specifying severance terms (if any), even if you never need this.
If you are ready to work hard and make more income, you should forgo the perks and go on a percentage of collections basis. If you are considering a place where they very much need dermatologists (sorry, not New York City), you may have some negotiating room and it is worth spending a few thousand dollars to ask a medical contract attorney to go over the contract for you, or even negotiate for you. Don’t overestimate your value, however, because you might negotiate your way right out of a job. The expanding scope of nurse practitioners and physician assistants have taken away much of your indispensability. While there is a shortage of dermatologists in most of the United States, there generally is no shortage of dermatology appointments.
When you start a new job you are not certain about, resist the urge to buy a big house and put down roots right away. You may need to move on if it doesn’t work out. You may want to work a few years, pay down school loans, save a little, and set up your own practice somewhere.
All things considered, these are exciting times and being a board-certified dermatologist is a wonderful place to be in the medical world. I am not at all sure if any of the proposed end-of-the-world health care plans will come true. And let me know if you are one of those New York City residents who struck out for the western frontier. Us fly-over-country folk have got to stick together!
Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at.