Entry 4

I saw 45 patients today. While that seems like a lot, many dermatologists see 60 patients a day, five minutes per patient, running into the room to say hello, taking a quick look at the problem, declaring a diagnosis, and then rushing out of the room. It wasn’t always this way, but as managed care has decreased payments, the number of patients the doctor has to see in order to meet his overhead costs, including increasing rents, paying the staff, maintaining equipment, and malpractice insurance, has gone up and up.

So while patients complain that doctors seem rushed, doctors complain that on some patients we actually lose money. On an uncomplicated patient who will require no procedures, the amount paid by insurance actually does not meet my overhead. In many cases, it’s around $25. A car mechanic won’t even lift the hood of your car for $25. If I seem rushed, it isn’t that I don’t want to hear about making the cheerleading squad or how well the roses are growing this year. In fact, those are the kinds of things I love to hear about it. The opportunity to get to know so many different people is a large part of what makes medicine fun. The problem is that I have a staff to pay.

Dermatologists are actually lucky because we are in a procedure-based field. For some reason, insurance companies have decided they can’t figure out a way to put a price tag on thinking, but they can figure out how much they want to pay for the actual nuts and bolts things that we do, for biopsies and surgeries and burning off warts, and so they pay for doing things but not for the much more difficult task of figuring out what something is and how to treat it. I probably froze off 10 warts today with my can of liquid nitrogen and biopsied at least 20 moles or possible skin cancers. I will get paid more for these little procedures than for the half-hour I spent talking with my patient with advanced melanoma.

Dermatologists also are in a position to make a lot of money because we can do purely cosmetic medical procedures, for which the patients pay (handsomely) out-of-pocket. In my new practice, I will be doing botulinim toxin (Botox) injections. Most of the nurses had never seen this done, so at lunch time, we took a bottle of Botox that had just expired (one vial of Botox costs around $500) and injected some volunteers for free.

A friend of one of the nurses came in and pointed to her frown lines. “Get rid of these,” she said.

I injected about $250 worth of Botox into her forehead and crow’s feet. If she were a private patient, I would probably charge her at least double or triple that amount, and while I doubt this particular patient will be forking over $700 to smooth out her wrinkles, there are plenty of people who will.

I did not go to medical school to free the world of unsightly frown lines, but realistically, I know I must do these easy procedures so that I can spend the time I want on other patients, like Mrs. Walsh. I plan to bring her to present at Grand Rounds at Emory University in a few weeks. She’s a fascinating patient with a very difficult problem. She’s on dialysis having lost her kidneys to a genetic disease. Now her legs are scarring down, most likely from repeated tiny blood clots. The fat in her skin is turning to gristle, and she is in constant pain. It’s difficult to figure out what to do with her. Since she was referred to me last Monday, I’ve talked to her every day. Nothing I’ve tried makes her feel better, and so I asked her if she’d be willing to go to Emory to have her case presented.

It’s a measure of her misery that she said yes, since I practice in the far suburbs of Atlanta, and it will take her at least an hour and a half, navigating Atlanta rush-hour traffic, to get to Emory at 7:30 in the morning for the conference. My father says I’m going to tire myself out doing things like this, but I remind him that I would probably have died if my doctors at Massachusetts General Hospital, way back in college, had not taken this kind of special interest in the difficult case of a young woman with swollen lymph nodes and chronic infections. And so I owe it to the Mrs. Walshes of the world to pay back what has been given to me. Besides, these difficult cases are what I love about medicine, and if I lose interest in them, then it’s just a job.