The Price of Beauty
Already
saddled with about $330,000 in education loans, they borrowed $20,000 more so
they could fly around the country this winter for about two dozen residency
interviews each. All told, each applied to 90 such training programs.
Ms.
Singh, pregnant during interview season, gave birth to their second daughter in
early January. Three days later, she flew to Miami for an interview.
The
search has been difficult not because they are mediocre students; indeed, each
has a brand-name education, academic honors and published research on disease.
No, it has been hard because they aspire to be dermatologists.
As
thousands of medical students await word this week on residency programs, two
specialties concerned with physical appearance — dermatology and plastic surgery
— are among the most competitive.
Only 61
percent of seniors at American medical schools
whose first choice was dermatology received a residency in that field last
year, compared with 98 percent for those whose first choice was internal
medicine and 99 percent for those seeking family medicine, according to a
report by the Association of American Medical Colleges and the National
Resident Matching Program, which pairs candidates and programs. Although there
are far fewer positions in dermatology (320 residencies in 2007) than in
internal medicine (5,517) and family medicine (2,603), the field is attracting
some of the best and brightest future doctors.
Seniors
accepted in 2007 as residents in dermatology and two other appearance-related
fields — plastic surgery and otolaryngology (ear, nose and throat
doctors, some of whom perform facial cosmetic surgery) — had the highest
median medical-board scores and the highest percentage of members in the
medical honor society among 18 specialties, the report said.
The vogue
for such specialties is part of a migration of a top tier of American medical
students from branches of health care that manage major diseases toward
specialties that improve the life of patients — and the lives of
physicians, with better pay, more autonomy and more-controllable hours.
“It
is an unfortunate circumstance that you can spend an hour with a patient
treating them for diabetes and hypertension
and make $100, or you can do Botox and make $2,000
in the same time,” said Dr. Eric C. Parlette, 35, a dermatologist in
Chestnut Hill, Mass., who chose his field because he wanted to perform
procedures, like skin-cancer surgery
and cosmetic treatments, while keeping regular hours and earning a rewarding salary.
Medical
school professors and administrators say such discrepancies are dissuading some
top students at American medical schools from entering fields, like family
medicine, that manage the most prevalent serious illnesses. They are being
replaced in part by graduates of foreign medical schools, some of whom return
to their home countries to practice.
“We
have a shortage in America of primary-care or family-type doctors,” said
Dr. Joel M. Felner, a cardiology professor who is the associate dean for clinical
education at Emory University School of
Medicine in Atlanta. Last year, the school enlarged its incoming class, hoping
more students would specialize in the major diseases and preventative care, he
said. “We do need dermatologists, but I am more worried about the really
sick people and dermatologists aren’t taking care of them,” Dr. Felner
said.
Until
recently, saving skin did not have the cachet of saving lives. Doctors in other
fields jokingly dismissed dermatology as a province of red-spot diseases that
could not really be cured, but weren’t going to kill patients.
Twenty-five years ago, the fiercest competition among medical students was for
internal medicine and general surgery.
But
dermatology’s status is rising, not just for the pay, hours and
independence, but also because of the growing variety of treatments and devices
in this fast-developing field that can help people in a looks-obsessed world.
At a time of increased discussion of enhancing beauty, as well as narrowing
standards for skin perfection, the public has a newfound esteem for doctors who
treat appearance.
“People
greatly value the skin because it is what is on the outside that is the face
you present to the world,” Mr. Hocker said one evening last month after
coming off a hospital shift in which he dealt with afflictions like heart failure
and kidney
failure. “Most dermatological diseases won’t kill you, but they
can greatly affect your quality of life.”
Some
dermatology professors said the growing allure of their field among medical
students has raised the bar for applicants over the last decade.
“Dermatology has always attracted bright students,” said Dr. Harley
A. Haynes, a dermatology professor at the Harvard Medical School who has been
mentoring medical students there since 1970. “But now we are getting more
of the brightest and the best.”
Dr.
Haynes likes to joke that even faculty members might not be accepted for a
residency if they applied today.
A Psychological Lifeline
For an
idea of the competition facing dermatology aspirants, consider the application
numbers. Last fall, 383 people applied for 6 places — an average of about
64 applicants per spot — in Harvard’s dermatology
program. By comparison, Harvard College received an average of 11 applications
per offer of admission in the class of 2010.
Mr.
Hocker and Ms. Singh were well prepared for the Darwinian process of landing a
dermatology residency when they met as classmates at the Harvard Medical School
in 2003. Mr. Hocker, 27, holds a graduate degree from Cambridge University and
an undergraduate degree in chemistry from Yale, where he was a champion
hurdler. Ms. Singh, 26, was in several honor societies as a biomedical
engineering student at the University of
Southern California.
During
her senior year, she competed on an MTV reality show called
“Sorority Life,” but was ejected midseason for being too studious.
“In
one scene, you see her all happy getting the acceptance letter from Harvard and
in the next scene, you see her crying up a storm because she has been
de-pledged from the sorority,” Mr. Hocker recalled fondly.
Neither
student had planned to become a skin specialist.
Growing
up in Kansas City, Kan., Ms. Singh loved visiting the hospital with her mother,
an internist with long relationships with a diverse group of patients. Ms.
Singh said she initially planned to emulate her mother, a physician who focuses
on treating major adult diseases.
A lecture
on skin-pigment conditions like vitiligo
changed her mind.
“Nobody
can see if you have hypertension or asthma, but
everybody knows if you have a pigmentary disorder and these changes are a lot
more obvious and devastating to patients with skin of color,” Ms. Singh
said. “Having something on your skin is not life or death for people, but
it can be equally important for them emotionally as a life-threatening disease.”
Indeed, dermatology
can be a psychological lifeline for people with severe skin problems. At pools
or the beach, some people shun those with psoriasis who
have scaly skin, fearing the condition is contagious, doctors said. People with
deep acne scars say it
affects their personal and professional lives.
Then
there is the growing popularity among otherwise healthy people of tweaking
one’s appearance with cosmetic treatments, from Botox injections to lip
plumping and laser hair removal. Plastic surgeons, dermatologists and facial
surgeons in the United States performed about 9.6 million such nonsurgical
treatments in 2007, almost nine times the number a decade earlier, according to
the American Society for Aesthetic Plastic Surgery.
‘Your Input Is Valued’
Mr.
Hocker was finally sold on dermatology last year, while on a clinical rotation
during which neurosurgeons called him and a dermatology resident to an
intensive-care ward for a consultation. A patient, in a coma
after surgery, was covered with mysterious red half-moon-shaped blisters. They
could not determine the cause. Then Dr. Haynes of Harvard arrived.
“Dr.
Haynes comes in and he is like a walking CAT scan, who
eyeballs her from head to toe and has the diagnosis in 15 seconds,” Mr.
Hocker said. The verdict: a rare blistering disorder caused by an allergy to an
antibiotic.
Mr.
Hocker said he liked the idea of drawing independent conclusions without tests
or consultations with other doctors.
“The
No. 1 thing that is going to save your life is the humdrum preventative stuff
like blood
pressure and cholesterol,”
Mr. Hocker said. “But there is not a lot of respect for doctors who do
that because anyone can get into it. But if you are an expert where no one else
is, like the eye or the skin, your input is valued.”
Dermatology
also attracts students like Mr. Hocker because of the potential for basic
research on skin diseases that can lead to new treatments. Mr. Hocker said he
plans to focus his career on researching the role of genetics in
problems like skin cancer
and abnormal scarring; he took a year off during medical school to conduct melanoma
research.
While
students like Mr. Hocker choose dermatology planning on research careers,
others end up focusing on cosmetic treatments like skin tightening and
resurfacing. Half of the dermatology residents graduating over the last five
years from the program at the Boston Medical Center have chosen postgraduate
fellowships that teach a combination of skin-cancer operations and cosmetic
procedures, according to Dr. Barbara A. Gilchrest, the chairwoman of
dermatology at Boston University School of
Medicine.
Work Less, Earn More
Dermatologists
say they enjoy the variety of a specialty that encompasses serious illnesses
like skin cancer and psoriasis as well as conditions like uncombable hair
syndrome.
But
students interested in such work also often factor in personal benefits.
Internists, for example, worked an average of 50 hours a week in 2006 while
dermatologists worked about 40 hours, according to an annual survey by Medical
Economics magazine. Dermatology also offers more independence from the
bureaucracy of managed care, because patients pay up front for cosmetic
procedures not covered by health
insurance.
And while
an internist earns an average of $191,525, a dermatologist earns an average of
$390,274, according to an annual survey conducted by the Medical Group
Management Association, whose membership includes more than 21,000 managers of
medical practices. Dermatologists who specialize in cosmetic treatments or in
skin-cancer operations can earn much more.
For
thousands of medical students nationwide, especially those trying to enter the
most competitive fields, this week — when residency acceptances are
announced — has been fraught with tension. The National Resident Matching
Program uses an algorithm to pair applicants with the one program they have
ranked highest that also preferred them, a system that leaves some applicants
disappointed.
Mr.
Hocker and Ms. Singh face even longer odds because they entered the match
process as a couple, seeking positions at the same program, or at least in the
same region.
On
Monday, when applicants learned whether they had been paired with a program at
all, Mr. Hocker and Ms. Singh found out they will each obtain a residency.
Thursday, they find out where.
“My
friends going into general medicine and general surgery pretty much have an
idea that they are going to be at their No. 1 or No. 2 school,” Ms. Singh
said. “But we really could be anywhere in the country, together or not
together.”
She added:
“We would have a better chance of winning ‘American Idol.’ ”