How dermatology became the 'it' job in medicine

When my primary care doc referred me to a dermatologist for a suspicious mole, I could not find an actual dermatologist who would see me in less than ~8 months. I ended up seeing a physician's assistant, which I'm still uneasy about since there's been a study that shows that PA's seem to have a lower success rate vs. doctors [1], and the educational requirements are very different for PAs.

As a layperson, it seems like we (patients / society) would benefit from having more doctors, i.e. opening up more residency slots and admitting more people to med school, but there's probably a lot I don't understand about the issue. Not sure if it's a lack of political willpower to do this, or if there are other reasons why the number of doctors we train is so restricted.

[1] https://pubmed.ncbi.nlm.nih.gov/29710082/ ("PAs performed more skin biopsies per case of skin cancer diagnosed and diagnosed fewer melanomas in situ, suggesting that the diagnostic accuracy of PAs may be lower than that of dermatologists")

> As a layperson, it seems like we (patients / society) would benefit from having more doctors, i.e. opening up more residency slots and admitting more people to med school, but there's probably a lot I don't understand about the issue. Not sure if it's a lack of political willpower to do this, or if there are other reasons why the number of doctors we train is so restricted.

Like so many of America’s issues, it’s due to lobbying based on entrenched greed.

> In 1997, the AMA lobbied Congress to restrict the number of doctors that could be trained in the United States, claiming that, "The United States is on the verge of a serious oversupply of physicians."

I don't think there's necessarily much not understood.

Here in Sweden have almost 2x as many physicians you do, and we pay them about half of what you do, so we end up paying approximately the same in salaries (the average Swedish physician is paid 131k) and I think it works out completely.

We start our training of physicians right after high school, so we push them to get an MSc in Medicine, rather than treating physicians as some kind of pseudo-PhDs, with however requiring head physicians to have an actual PhD; and this system is fine. I think it's the same way in Denmark, and given the stuff they've come up with I imagine one can't complain much about their system.

Yep. The requirements (and cost!) to become a physician are absolutely insane, and it's entirely intentional. As a society we seem to assume that people in certain trades are altruistic and moral, simply because of their job. For some reason, everyone assumes doctors wouldn't act self-interested. Teachers are often thought of the same way. I don't want to swing the pendulum to the other side and start thinking of them as selfish (though certainly some individuals are), but I do wish as a society we would remember that people are still people. Our systems need to be structured to overcome the natural and innate tendency of people to optimize for themselves or their groups. We don't let the cigarette companies do all the science and make all the laws/rules around tobacco sales, we probably shouldn't do that with medical stuff either. We don't need antagonistic people in charge, but they should be independent.

A big driver for the high salaries of medical doctors in the U.S. is the staggering educational debt their degrees leave them with. Is it the same in Sweden? Some degree of wage depression is practically inevitable if we had more doctors, but I wonder how much that could be offset with affordable education?

No. Universities in Sweden are free to citizens (including EU/EEA citizens). That includes highly regarded universities such as Karolinska Institute (considered one of the top medical schools in Europe), Lund University, the University of Gothenburg, and so on.

In Scandinavia, student loans are taken to cover living expenses, not the cost of tuition. Private schools exist, but are not nearly as common as in the U.S.

(Pretty familiar with PA's.)

Biopsy stats might differ because PA's are used in large (cough private equity) practices to do a lot of checks esp. in old-folks homes, and medicare pays. Patients per week can average 120+; no doctor does that. Plus, the PA is supposed to err on the side of caution, meaning more biopsies. DR's are more willing to ignore possible risks.

That said, most anyone (Dr. or PA) who is recently trained at a good school is often better than people with 15+ years of experience.

Also, derm exam skills are not enhanced by the depth of medical education or even much by experience (by contrast to the cardio exam). It's mostly a function of pattern recognition and patient skills.

And then you have the ARNP, and schools who are speedrunning people from the street into ARNPs. Oh, you need an RN? We'll have you in our "Accelerated RN" course, getting your RN in parallel with other studies.

In some places, it is possible to go from high school to ARNP within 6 years.

And while supervision requirements for PAs might vary in terms of actual oversight, ARNPs are ostensibly fully fledged independent providers.

And I'll also say that you see the same pre-hospital too. In the PNW, while there are valid criticisms that can be leveled against two of the pre-eminent paramedic programs (Harborview, and Tacoma Community), there are far, far, too many "strip mall schools" in other states that will take you from "zero to hero" in 4 or 5 months (of 6 days a week, 8 hours a day, of just class time), and dump you out on the world with just enough retained knowledge to pass your NREMT and the barest amount of ride time to meet DOT mandated minimums. It's scary, to be blunt. These people go out with no clinical experience and are now expected not just to work as a team on a 911 call, but to lead it.

It started with the flexner report (1910). I urge you to look into it if you are interested in this topic and let me know your thoughts

https://en.m.wikipedia.org/wiki/Flexner_Report

I recently had the exact same experience.

When I actually got my appointment within 30 days, due to calling and advocating for myself politely, I started wondering how much ground medical dermatology has ceded to elective and cosmetic dermatology. I am concerned that dermatology is becoming centered around the personal appearance of affluent people rather than medical need.

Try requesting appointments during December or January. A little birdie told me that appointment cancellations go through the roof at some practices during those months.