The Derm Response

I recently did a review of a ridiculous study and you can see it here.  After mocking it I said this:

I guess when you make so much money you have to find a way to distract people from being too critical?  How? First up, throw the evil sun at them.  If that fails then you create a new prejudice. All we need now is a law to stop any movie from depicting someone who is “integumentary challenged”.  (I made that term up.  Do you like it?)

Before anyone thinks I am too insensitive let me summarize my thoughts on this:

  1. Humans are not perfect and we all have our blemishes.

  2. We all don’t need a personal dermatologist to see us to fix every blemish.

  3. ALL sun is not evil.

  4. This study is ridiculous.

  5. Dermatologists make too much money.

Was I too harsh?  Maybe.  Is it true? You decide. (You will notice that I never mentioned their value, their intelligence, or their work ethic).

Well, the dermatologists struck back and treated me as if I committed a hate crime.   Please read the above again and then see if the following comments were warranted. All are real and from dermatologists who felt they needed to say this:

  1. “Don’t be bitter because of your poor performance in medical school. Had you worked harder you could have been a happy dermatologist, not a miserably envious PCP.”
  2. “Trial lawyers get paid over 1.5 million on average too…And your field makes 300-350,000 with a full time schedule of 14 days a month so what’s your point you guys get way more time off than anyone and are grossly over paid for running a bunch of test in the ER that insurance companies have to dish out lots more money for driving everyone else’s health care cost to the moon. All my primary doctors call me up and I get their patients in the day of we make room for our schedule in my office for emergencies. The reason why you can’t get your patients in is bc of you, you sound like the biggest jerk who blames everyone else for their unhappiness while looking at other specialty journals you wish you got into but didn’t have the grades or the good standing in medical school.”
  3. “Doug your full of shit, punch biopsies free etc. yea they are free because your charging patients a monthly recurring fee regardless of if they need your services that month. You are charging each patient 900 a year. When they see a dermatologist they get charged for appropriate care. I bet you don’t even know what to do with your biopsy results and then you send to Derm. Hahah next time around get a better step 1 score and do what you really wanted to do in life and stop hating! Your ego really shows AKA “the king of medicine” And stop doing biopsies when you don’t even know what your looking for!”
  4. “Wow. Who are you? An offensive ass. I am a dermatologist and dermatopathologist in private practice. I do not practice cosmetology- that is a joke. Do you say the same of plastic surgeons who choose to practice cosmetic surgery only? I doubt it. Yes, I help patients with treating their disfiguring acne scars and birthmarks. Primarily though, I see complex medical dermatology patients, manage autoimmune blistering skin conditions and other severe dermatoses and prescribe many immunosuppressants. I diagnose and treat skin cancers much earlier than any other specialty. Last year, I diagnosed a systemic aggressive lymphoma in a pregnant woman that everyone else missed for six months and she nearly died. Two weeks ago I saw a patient with unrecognized gangene of the penis due to warfarin-induced necrosis that had been treated for 2 months by his PMD for an “infection” and had to undergo penectomy. These are just many examples of what I and many dermatologists do each day. Many of my referring MDs have my cell phone and I will work in patients for them. I am so sick and tired of dermatologists getting no respect from other specialties. Wait until you or a family member gets a crazy skin condition, develops melanoma or another skin cancer and needs our help to get them better. I am damn good at what I do. I see a lot of patients in day due to demand and that is why I might make more money than some, but not all, primary care docs. Demonizing another specialty is pathetic. You’re just a troll. If I was a patient looking for a PMD I would stay far away from you. There’s something called karma- watch out, Doug.”
  5. “Wow Doug you sound really super bitter. That first line, “who cares what you resent?” just reeks of resentment. Also, you’re kind of an ass. Maybe not kind of, really an ass. You took the time to write this piece and mock one of the most competitive specialties in medicine. More importantly, you’re quite out of touch with reality. I can’t tell if you’ve just had interactions with bad physicians or if you’re delusional, but something’s off. If you’d like your patients to have sub-par care then great, get rid of dermatologists altogether. Take care of all their skin problems yourself. See how happy your patients are when you can’t figure out their rashes, can’t clear their acne (yes, acne is important, anyone who’s ever been a teenager will tell you), can’t stop them from losing their hair, can’t catch their skin cancer at an early stage so they can live, can’t put together a complicated pathology report with an unusual rash to come up with a life changing diagnosis, can’t tell the difference between neonatal lupus and seborrheic dermatitis (yes, that happened), can’t tell the difference between a wart on the foot and fungating melanoma (yes, that happened), etc etc. You’ve clearly never seen a dermatology textbook (try opening one! I recommend you start with Bolognia) and since you clearly have no idea what the majority of dermatologists do all day, you have no space to talk, let alone insult and ridicule. Do we also freeze warts and inject pimples and Botox and yada yada? Yeah, we do, that’s our job, comes with the territory. We are all physicians and we all have our corner of medicine. You couldn’t do my job. Quit complaining about it, because you sound pathetic.”
  6. “Oh Doug! You are such a saint! If only the rest of the world were so righteous and selfless the world would be perfect. You have masterfully proven the point that you are superior to other doctors because you do things for free. Capitalism is so bad!! Gosh golly. If everyone would just do stuff for free then they too would be justified in whining about how everyone else makes too much money. Then everything would be as peachy as it is Venezuela.(To the rest of the primary care guys reading this, I think you should get paid more than you do. I respect your work and I think it goes under compensated. Farrago though, I think he should make less so he can be more justified in his complaining here. His sense of moral superiority…. THAT is what he gets to have instead of payment)”
  7. “Many of us don’t do cosmetology that’s an aesthetician. I personally practice general dermatology taking melanomas out, putting my psoriasis patients on biological and Mohs surgery on skin cancer patient most of which are VA patients that have served our country. If you guys feel we are useless and don’t see “real cases” than why don’t you guys start seeing dermatology patients instead of texting us pictures and calling us since most doctors have never had even one month of dermatology since it’s not required. Or better yet let Dr Google be your new dermatologist. I resent this physician shaming that is in this article. This should never be done to another physician or a speciality group in public or on paper. We already have enough people against us physician trying to pay off our loans, trying to get insurances to cooperate so patients can get the medications they need, people stealing from our offices and frustrated patients. This energy should be better spent on tackling getting better care to our patients.”
  8. “He’s an idiot masquerading as an writer. Can’t believe I wasted my time reading his envious, uneducated post.”

I am not going to even reply to these comments and sent them right to the trash section.  After a few days I changed my mind and felt they need to be seen.  I welcome your response to this.  But before you do please take a look at this article entitled “Elephant in the room of dermatology” by Dr. Brett Coldiron where he states the following:

“The honest ones in private practice, however, say, “Man, I make $200,000 a year off my PA while I am off.” The honest academics say, “Listen, I work in a gulag, and I would never be able to travel if my nurses didn’t see my patients.” Time is money, and the academic who gets an extra 10 hours a week out of clinic is benefiting as much as the guy who makes $200,000 a year.”

Dr. Coldiron, by the way, was past-president of the American Academy of Dermatology.

Making $200K off your PA while you’re off?  Family docs don’t make this themselves in a year.  Does anyone else see something wrong with this?  I understand that not all derms do this but the fact remains that the average dermatologist makes double what a primary care doctor makes. 

I think it is fair game to question a procedure based payment system that results in a disparity between  dermatology and family medicine by a ratio of 2 to 1.   If that makes me bitter, offensive, self-righteous or an idiot then so be it.

Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  7 comments for “The Derm Response

  1. Bill Ameen MD
    May 29, 2017 at 10:24 am

    Out of the handful of docs who showed up at our last reunion the only two who were still working were the dermatologists. Why not? They don’t have to sell their practices to survive. The fact that so many responded and were irrationally cranky shows how defensive docs are for making money in their specialties. When I was working I saw about 10-12 derm cases a day in family medicine because it took weeks to get in to see the local derms. I very rarely had to refer anyway. In terms of melanoma, I diagnosed only one in my career and, sadly, it was the husband of one of my employees. Your point about the Axis of Evil (presumably tilting insurance payments to proceduralists) is as always well-taken but not about to change anytime soon, unfortunately.

  2. Richard
    May 24, 2017 at 5:06 pm

    It is good to see such united consensus, equanimity, dispassionate analysis, and objectivity among our Dermatology friends. I wonder how representative they are.

  3. May 23, 2017 at 8:51 am

    Lot’s of anger here. Oh well, it’s good for people to get things off their chest. I didn’t think it was that offensive Doug, but we are living in the Age of Offense. Also, most successful ‘public figures’ are amongst the most hated: Rush, Hannity, and those on the left too, Barack Obama, Bill Clinton. Keep up the good work. It’s better to be edgy and funny than boring and boring.

  4. David Dierks Fitzpatrick
    May 23, 2017 at 7:29 am

    Touch a nerve much? I notice none of them try to deny the “Sun Fear” that they have created.

  5. DrBonz
    May 23, 2017 at 7:19 am

    Love ya Doug, but I have to agree with our Dermatology colleagues. You often come across as resentful over what other specialties earn and frequently cry the blues over what you earn. You’ve done it to my specialty in the past and I called you out on it back when you did. Look, I don’t have to tell you this but we are all in this together. All physicians. All specialties. You have to know that, you’re a pretty smart guy.

    My brother is a Family Practice guy like you. He is one of the last ones in this area to hold out on being employed by a hospital system. He works hard. But he never cries over the disparity between my salary as an orthopedic surgeon and his because he knows that my training was significantly longer and harder than his was and that my hours and my call are significantly longer and harder than his. He knows full well that family practice residencies are a dime a dozen and an orthopedic surgical residency spot is extremely hard to get. Am I overpaid? I don’t know. You would probably say so.

    The article you wrote could have been funny if your attack was on the article itself. But you made it personal by attacking an entire specialty. You made fun of what they do and what they earn. No longer funny.

    I would think that you would be far less resentful now that you have found your ‘calling” in direct primary care. You always state how much happier you are now. If that’s true, then please ACT happier OK? Keep on calling out the Axis of Evil and scam artists and rip offs that we ALL (in ALL specialties) have to deal with day after day in this field. But please, don’t resent your colleagues, your brothers and sisters, for what we earn or what we do.

    • Doug Farrago
      May 23, 2017 at 9:23 am

      I know you and I have gone back and forth on this. To be clear, there are some specialties that are freaking grueling in both training and in their career. I never have said that family docs should make the same as them. I get that. I have said that over and over. A neurosurgeon who has been on call every other night for seven years of training and then continues that in her career probably deserves that huge paycheck. You do ortho and I never said that family medicine should make the same as ortho. If I did then please find that if you can. That being said, a one year transitional internship and then three years in a derm residency with no call then or in their career just seems a little different. You have to admit that. And, yes, they can still make more than family docs but a 2:1 ratio is an example of a broken system. That helps nobody. Calling that out should not be heresy. Lastly, I am very happy in my career and 99% of my time I still attack the Axis of Evil.

      • Kurt
        May 24, 2017 at 3:19 pm

        Yeah, and all the “R.O.A.D’s” scholars too! 🙂 ;-O

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