PracticalDermatology

My son, Daniel, who recently started his second year as a dermatology resident at Washington University of St. Louis, was married this past month. Nancy and I are delighted with the newest member of our family, Stephanie, who met Daniel shortly before the pandemic when he did his internship at Mass General Hospital. They became nearly inseparable during the pandemic, despite great risk to her health by being close to a front-line worker. We couldn’t have planned in 2019 for this joyful union any more than we could have planned for what happened in 2020. Sometimes, life just gives you what you get, and it can be remarkable or the opposite.

With regards to planning, I have always looked at multiple scenarios when confronted with a tough choice. Daniel noted this in a recent Father’s Day Facebook post about the apparent contradiction of me being seemingly spontaneous, yet also being the ultimate planner. Detailed planning is a personal characteristic that can help some of you in your career optimization, whether you are just starting out or are considering a change in your practice. I have always found it important to plan carefully when there are several options available.

One of the first major decisions any dermatologist-in-training makes is which style of practice they will work in at the start of their career. While my choice was private practice, this may not be the best choice for everyone. Clearly, there are many excellent practices with happy, fulfilled dermatologists who have no desire to take this path in their lives and I applaud them for this choice and realize that I have experienced mainly my own form of practice and can’t “walk in their shoes.” On the other hand, it saddens me to see fewer and fewer dermatologists starting their own practice or practicing with other dermatologists in a non-corporate environment.

The prevailing wisdom is that owning a practice or working in a private practice with others is too much work, while working for a corporation is much easier. I would argue that for every savings in time and effort, there is an equal and opposite increase in stress-level and frustration, although there is huge variability in corporate practices, and many provide an excellent option for a career in dermatology. Whatever the case, there is no panacea.

The joys of being in practice with those you choose to be around on a daily basis can’t be understated. Truly, if you are spending 40-60 hours weekly for 30+ years with people other than your family, having the ability to choose your fellow workers, rather than having others choose them for you, is critical. It can make or break your practice and your happiness. Not everyone in private practice has the good fortune to work with great staff and, conversely, phenomenal staff and relationships definitely abound in forms of practice other than traditional private practice, but having the ability to choose who you work with is one of the single greatest benefits I can imagine. Additionally, it is no small consideration to have the ability to determine your own hours, electronic medical records systems (EMR), equipment/lasers, marketing dollars spent, approach to marketing, amount of vacation, and the appearance of your office. Repeated analyses have shown that private practice dermatologists actually earn more than corporate dermatologists, which can lead to more satisfaction and happiness.

The decision to start my own practice was eventually a no-brainer for me, though it was much more difficult to consider when I first started in 1993, without easy access to other dermatologists for advice. Luckily, with the advent of Dermchat and Rx-Derm (a list group that was started by Art Huntley, MD and furthered by the late Haines Ely, MD), I found my “tribe” and have benefited greatly over the years from their friendship and collegiality. I would highly encourage any dermatologist to consider joining this great group (write me privately at skindoc@LovelySkin.com for instructions).

Owning or operating a practice involves quite a few decisions. My planning method for how I have conducted my practice includes envisioning any major option I have to a significant degree. It is possible that this style of decision-making could be helpful to many of you who are contemplating other choices in life.

As an example, early in my practice, I was considering building an office rather than renting. First, I tried to envision what my future life would be like in the building I was renting. I recalled the answer a longtime dermatologist in St. Louis had given me a year earlier when I asked him to summarize his career: “I walked between these four rooms.” Would I enjoy my practice if I walked these same hallways in my rented space for 20+ years? Furthermore, what options might I have for expansion? How would my employees age and prosper in the space? What if I wanted to expand and the landlord didn’t have space for me? Where would I find space to expand? I put myself into that potential “life” for 20 or more years and tried to imagine my future in an almost meditative manner, “seeing” or “living” my future. Four years later, when the decision to expand had to be made, it was frightening to think of building an expensive office building. But that alternative future, including my own space, where I could have a sunny, well-lit and modern office with happier employees and a happier me outweighed the major concerns I had with taking on a huge loan at the time. Again, I envisioned that scenario of what it would be like to be in that new “life.” This proposed building was perhaps the most important determinant of the success of my practice in the long run as it created an identity for me in my area that offered an accurate glimpse of what my esthetic was and offered a great environment in which to practice.

Careful, detailed planning can be done in many situations. For example, on any airplane trip I take, I also plan for (and expect) delays, canceled flights, and other interruptions by investigating what alternative flights are available and by always making sure that I don’t leave myself without back-up options for my travel. I have those options memorized in case things change and then check not only my flight, but the incoming flight that will eventually be my flight. There may be surprises, but I consider how many times airlines didn’t show an obvious flight delay even though it was quite visible when I realized that the incoming flight that would be my plane was significantly delayed. I imagine this compulsion goes back to my days as a medical student when I was expected by my attendings to have the morning labs for each patient ready (and memorized), even while they were still “cooking” in the lab. To me, this example is the difference between effective and ineffective planning.

The point is that oftentimes, decisions can be made whimsically, or as the result of careful, dedicated, and positive preparation. In our profession, the preparation for the style of practice you wish to work in will affect the town you live in, the friends you make, the schools to which you send your kids, the places you worship, and the hours you work. It also affects the employees you are surrounded by, as employee hiring and firing decisions are often not available other than in private practice. With careful planning, you can surround yourself with a cadre of like-minded, goals-oriented, and honest people, but it takes a great deal of effort, and it also includes a visionary effort when interviewing individuals.

Planning, however, can’t be endless. Decisions must be made with a cutoff time in mind. Otherwise, planning is just a euphemism for procrastination. Additionally, this level of planning must be reserved for the bigger decisions, not mundane tasks.

Lastly, planning of this sort involves creating a world where you, and your family and employees, are the happiest that they can be. When my wife, Nancy, and my parents, June and Bernie (we were fortunate to have their sage advice), involved themselves in the process of creating my private practice, I never imagined the rich, nuanced, and fulfilling relationships that would develop between ourselves and the hundreds of employees and hundreds of thousands of patients I treated. That was a serendipitous but natural by-product of careful planning, hard work by everyone involved, and a desire to create a good place for employees and patients. I hope the same can happen for you and your practice, whichever style of practice you choose.