By Allison Evans, assistant managing editor

“Back in my day in order to find your way anywhere, you purchased an atlas and then plotted your journey like a 17th Century explorer.” Who hasn’t been on the receiving end of a story like this? Often these stories are met by those who did not share the experience with a roll of the eyes, a blank stare, or a deferential nod of the head. In reality, however, there is much to be gained from listening to those whose experiences have been different.

What did being a solo practitioner look like 30 to 40 years ago? Are there generational differences in how dermatologists practice? This month, Dermatology World talks to seasoned dermatologists to explore how the practice of dermatology has changed over time. 

Regulations and insurance

Illinois dermatologist Michael Greenberg, MD, who has been practicing for 40 years, has seen a dramatic shift in how dermatology practices operate. “We didn’t worry so much about the regulations. It was a much simpler time.”

Back in the day, malpractice insurance was relatively cheap. “When I was a resident, the biggest crisis began with malpractice insurance. Malpractice insurance used to be really inexpensive,” said Dr. Greenberg, who watched as his insurance skyrocketed from $200 per year to nearly $4,000.

Back in the day, physicians practiced medicine without a computer. “When I first started practicing, we had a peg board where patients would walk away with a peg board receipt with their diagnosis on it, pay for their visit in cash, and then they would send the receipt to their insurance company to get reimbursed.”

Back in the day, when you prescribed a medication, a patient would be able to fill it. “Doctors never had to worry about insurance companies turning down claims. Medications were so inexpensive we used to distribute them in the office as a convenience,” Dr. Greenberg said. “Insurance companies were not turning down medications — you could prescribe the medication that you felt was best for the patient.”

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Insurance hurdles have become burdensome and frustrating for physicians. “Physicians have lost control of medicine. Nonphysicians who have no pre-existing relationship with the patient are making decisions on how medicine is practiced and are attempting to tell us what we should do and what we shouldn’t do,” said Bruce Thiers, MD, president-elect of the Academy, and distinguished professor in the department of dermatology and dermatologic surgery at the Medical University of South Carolina.

“Insurance companies want to make a lot of money, pharmacies want to make a lot of money, doctors want to make a lot of money, and patients want their health care for free. Somehow we have to come to the middle and say what’s enough here,” Dr. Greenberg said.

So long, solo

Back in the day, physicians aspired to running their own practice. Owning and operating a private practice has become increasingly difficult over the years. It used to be that a lot of people went into private practice, Dr. Greenberg said. “The economics are different now; we didn’t come out of training with huge loans. It was easy to open a practice by yourself. People weren’t looking for group practices.”

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“There was a different mindset of work back then. It was about building a practice. You worked as hard as you had to. You didn’t worry about life — you worried about old-fashioned building a practice,” he said.

Dr. Greenberg, along with his colleagues, formed the Illinois Dermatology Institute because he could see the increasing expenses coming down the road. “Groups are getting bigger and bigger because the cost of running a practice to get a decent income requires that we join together,” he explained.

Technology: Friend and foe

EHRs can be a sticky subject for some physicians, especially those who began practicing before the technology existed. With conflicting studies and opinions about whether EHRs are more efficient or whether they improve patient care, Dr. Greenberg sees both sides of the coin. He doesn’t believe EHRs improve patient care. “We are paying to collect data for insurance companies.” However, “The positive side is that everything is accessible electronically and easily organized. Going back to my paper records to find things can be horribly inefficient.”

It was only a little more than a year ago that Dr. Greenberg agreed to transition to an EHR because the younger physicians in the practice taught him how to use the system in a way that would not detract from time with his patients. “I use macros, which make certain updates automatically in the few minutes between patients,” said Dr. Greenberg.

Initially Dr. Greenberg was hesitant to use an EHR because he prides himself on spending quality time with each patient. “As there are more and more distractions, there is less careful listening to patients,” he said. In fact, a few years ago, Dr. Greenberg started doing improv classes as a way to strengthen his listening skills. “We used to spend our time talking with patients because the records could be minimal. And now we’re so worried about getting the record right — putting in the right code so we get paid, and then asking all the right questions so that Medicare will give us a bonus, that we’re not listening to the patient as much.”

Some physicians hire medical scribes to help allay the time and attention burdens, however, Dr. Greenberg believes the exam room is sacred space. “Patients talk to me about a lot of other problems besides their skin. They trust me. I don’t want a scribe there while a patient is talking to me about their feelings about their parents dying or their child’s problem with addiction.”

“Our job isn’t just to hand out pills or do procedures. Our job is to hold patients’ hands and give them peace of mind whether the diagnosis is good or bad. A lot of the additional technology and regulations have gotten in the way of that,” he said.

Dr. Greenberg also laments the rising importance of internet rating sites. “Any patient with an axe to grind can go online and write terrible things about you. Since we’re bound by HIPAA requirements, we can’t respond.” As more patients come into the office with unrealistic expectations about insurance and drug costs, negative reviews continue to grow. (The issue is such a concern for physicians that Dermatology World has run two recent Legally Speaking columns on it; see staging.aad.org/dw/monthly/2017/july/avoiding-the-pitfalls-of-social-media and staging.aad.org/dw/monthly/2017/october/responding-to-online-defamation.)

While technology has certainly brought with it many challenges, the benefits may outweigh the disadvantages. “Whoever thought that we would be able to sit down at a computer and Google a list of symptoms and come up with a differential diagnosis for a patient sitting right there in our office?” said Phoebe Rich, MD, owner of a dermatology practice in Portland, Oregon. “When I was a resident we had to go to the library and sift through stacks of journals to do that. I would take an entire weekend to get the information that we can get now in three minutes. Technology has been a trade-off,” she said.