Go your own way

By Allison Evans, Assistant Managing Editor, September 1, 2025

Whether you’re embarking on your career path, or you’re simply ready for a reset, there are a multitude of practice models to investigate. Each path offers a unique experience when it comes to factors like level of autonomy, compensation structure, staff interaction, patient care, and more.

Dermatologists in varying practice models share their experiences and the lessons they have learned along the way.

Group practice

With the current complexities involved in running a practice, dermatology groups have become the norm. They are the most common type of dermatology practice with about 70% (including academic and multispecialty groups) of AAD members reporting being in group practice — a 28% increase over the past 17 years, according to the Academy’s 2022 Practice Profile Survey. There are many reasons for the shift from solo practice to employed or group practice, including staffing challenges and increased compliance and regulatory burdens, making it increasingly difficult for solo practices to remain viable.

Small group

James J. Contestable, MD, FAAD, assistant professor of clinical dermatology at the Uniformed Services University School of Medicine who also works in a small dermatology group practice in Virginia Beach, sought out a private practice option that was not backed by private equity. “I wanted to ensure I could work with the staff that I would like, make decisions about where the practice is going and what types of materials/supplies I use, and not be told what kind of medical care I’d have to provide or when I must provide it.”

“I interviewed with a few groups, and I liked the people and the culture at the private practice where I now treat patients. While I considered solo practice, it would have reduced my ability to perform Mohs surgery, in which I am fellowship-trained,” he noted.

In a small single-specialty practice, Dr. Contestable appreciates the high level of autonomy. “I get to dictate what I do and I’m given support in doing it. I asked for surgical kick buckets — I got them in a few days. I requested more surgical staff and they hired more staff, and I was involved in the decision of who to hire. I have an idea about what medications and treatments I do not want to perform or offer — and I don’t have to.”

“I can become a partner in one or two years and will be better compensated as well as having more say in how the business is run.” While becoming a partner may not be a good fit for everyone, Dr. Contestable noted, you can negotiate being an associate or part-time — whatever fits your lifestyle. “There is nothing better than having control over your work life, which as we all know, is the bulk of our waking hours.”

Having a say over the staff you work with is particularly important. “When a staff member is an all-star, I can advise the partners and they will increase that person’s pay. That way we can retain the best and brightest and experience less turnover,” Dr. Contestable added.

“It’s much harder to be in solo practice now with increasing regulations like OSHA, CLIA, Medicare, and cybersecurity. Even if you’re in a small practice, you’re regulated to the same level as the hospital systems.”

Mid-sized group

About 30 years ago, Beth Goldstein, MD, FAAD, founding partner of Central Dermatology Center in North Carolina and member of the Academy’s Practice Management Committee, opened a solo practice. “It’s much harder to be in solo practice now with increasing regulations like OSHA, CLIA, Medicare, and cybersecurity. Even if you’re in a small practice, you’re regulated to the same level as the hospital systems.”

Dr. Goldstein has 28 physicians and non-physician providers on staff. “It has become much easier the larger we get because you can have really robust support inside of your practice,” she said. “It’s nice to be able to play to your strengths if you have a personal or professional interest to pursue. We have people who specialize in contact dermatitis or who really love hair loss, and we have in-house dermpath.”

Dr. Goldstein emphasized the importance of having skilled practice managers as a practice grows. A manager with a staff of five people needs a different skill set than one who manages a staff of 20, she said. “I like having the support staff where I’m not caught in the minutia of staffing details.”

There are some questions to keep in mind when evaluating a mid-sized practice. “You need flexibility and you need to do your due diligence to make sure you have the autonomy in terms of how you treat your patients,” Dr. Goldstein noted. If you want specific supplies or devices, she added, you need to find out how the decisions are being made and whether you can be part of those decisions. “Understand how your voice will be heard — or not heard.”

With more staff comes less control over how you like to schedule patients. “When you have three or four clinicians, you can decide to have 15 minutes for one type of appointment and 10 minutes for another type of appointment. But when you have 10 clinicians, your schedulers will be challenged if there are too many individualized schedules.”

Being in a single-specialty clinic is exciting, Dr. Goldstein said. “You’re always able to bounce ideas off one another and learn from each other.”

Large group

“With more than 40 offices, our practice operates as a collaborative group dermatology model supported by centralized management,” said Samuel Goos, MD, FAAD, who works at APDerm in Concord, Massachusetts.

“We aim to deliver the efficiencies and shared resources of a large organization while respecting the unique practice styles of our clinicians and the distinct cultures of each local community,” he said.

“Our practice model is designed to support both professional autonomy and personal well-being,” Dr. Goos said. “We respect each physician’s clinical decision-making, including their preferred approach to patient volume and care. We offer guaranteed initial compensation that transitions to a productivity-based model.”

“I’ve always valued the collegiality and intellectual stimulation of group practice,” remarked Dr. Goos. “I envisioned a model that allowed for collaboration among physicians while embracing varied clinical expertise and practice styles, all with a shared commitment to patient care.”

“Because our dermatologists are not burdened by administrative responsibilities, such as HR, compliance, and routine staff training, they can focus on cultivating an effective and well-supported clinical team,” he said.

Dr. Goos maintains that work-life balance is a priority. “Our size allows for reliable cross-coverage, enabling time off to truly be time off.”

One of the inherent challenges of being part of a large group practice is preserving strong connections across a wide network of colleagues. “We foster a sense of community and collaboration through monthly virtual medical education meetings, local gatherings with managers and regional medical leaders, colleague-supported community events such as lectures and skin cancer screenings, and periodic social events at the local, regional, and organizational levels. We also encourage clinical dialogue by sharing interesting cases through our electronic medical record system. These efforts help bridge distances and maintain a collegial and connected culture.”

Because there is such wide variance among group practices, Dr. Goos recommends taking the time to visit the practice you’re interested in and speak with a range of physicians — both newer employees and those who have been there for several years. “Their perspectives can offer valuable insight into the culture and support systems in place. Be open and honest about your own professional and personal goals so you can better assess whether the practice model aligns with what you’re looking for and how it can support your long-term growth.”

“What I appreciate most about our practice model is that we remain a physician-led organization supported by a highly skilled professional management team. Our physicians bring forward great ideas, and our professional staff has the expertise to turn those ideas into effective, operational plans,” Dr. Goos said.

Multispecialty group

Klint Peebles, MD, FAAD, is a dermatologist at Kaiser Permanente, Mid-Atlantic Permanente Medical Group in Washington, D.C., and Maryland. “Kaiser Permanente is a vertically integrated managed care organization, made up of three major parts: the Kaiser Foundation Health Plan (the insurance arm), Kaiser Foundation Hospitals (hospitals and medical office buildings), and the physician groups (e.g., Permanente Medical Groups, which are large, multi-specialty physician groups that exclusively serve Kaiser members). Physicians are not employed by the health plan or the hospitals, but by the medical group, which aligns clinical care closely with system goals. However, while the vertical integration model is consistent, the exact structure and function of the Kaiser Permanente systems differ across their eight primary geographic regions in the United States. Key differences include their size and market penetration, physician group structure, scope of owned facilities, and impact of state regulation and payment models, among others.”

“Our reimbursement model is not fee-for-service,” Dr. Peebles said. “The health plan is a capitated payment model, so the system receives a fixed amount per member, encouraging prevention-focused, cost-effective care.”

While the emphasis on preventative care is obviously excellent, it can have nuanced impacts on other specialties, Dr. Peebles noted. “For physicians newer to the system, it’s always good to figure out how specialty care fits into the broader mission of the organization and how that intersects with the way primary care and preventative services are delivered.”

Some dermatologists want the freedom to adjust their compensation by seeing more or fewer patients, depending on where they are in their lives and in their careers, he said. Other people prefer to practice in a situation where they have a fixed salary. “This can be a great model for those who simply want to provide quality, patient-centered care without worrying about many of the business aspects or expectations of seeing increasingly large patient volumes.”

As a complex medical dermatologist, Dr. Peebles began his career in academics and as an inpatient dermatology hospitalist. “Now my patient mix is quite different relative to what one might expect in an academic setting, though I am still able to do my subspecialty niche work, which is incredibly important to me.”

In some ways, there is a little less autonomy, as the Kaiser model is a top-down approach, Dr. Peebles said. “If you want to have a lot of flexibility in your schedule, these types of models may not be as good as they might be in solo or private practice.”

“Staffing is also very much independent of the physician arm, so we don’t have as much say over how staffing works and what their roles are. This can be challenging if you’re looking for those very tight and cohesive relationships,” Dr. Peebles added.

While many large, integrated systems can have siloed specialties and departments, Dr. Peebles’ experience is unique. “Kaiser is very integrated in the sense that interdisciplinary and inter-specialty collaboration is very much prioritized and emphasized. This type of communication is directly embedded into the electronic medical records software, where physicians can easily get in touch with one another and review charts or provide recommendations, encouraging a collegial working relationship across specialties.”

Dr. Peebles emphasized that similar practice models or various locations of the same organization can be very different depending on where you are located. For example, the Kaiser Permanente models in California have some important differences relative to the Mid-Atlantic system. “If you’re getting a lot of your information based on discussions in one geographic area, you might be missing important features of the model where you would actually be practicing.”

Academic, hospitalist

Daniela Kroshinsky, MD, MPH, FAAD, is an inpatient and outpatient full-time academic physician at Duke Health, and past president of the Society of Dermatology Hospitalists. She knew from the beginning of her residency in dermatology that this was the path she would follow.

“I was assigned to my first mentor, Dr. Joaquin Brieva at Northwestern, who would start off the day seeing patients in clinic, run over to the hospital at lunch to see patients, sometimes come back and do more clinic, and then go back to the hospital again at the end of the day. I was able to see how much of an impact he had on patient care in this very sick population but also what a resource he was to his colleagues from other specialties.”

“I really like working with the residents and I like to teach,” she added. “In academics, you get to see a broad patient population, a lot of difficult cases and rare diseases, and teach residents at the same time.”

As an academic and hospitalist, Dr. Kroshinsky gets to move between two worlds, moving at a fast pace while treating complex and diverse patients. “If I’m in clinic and a resident calls with an urgent inpatient consult, I take a pause from clinic workflow and review the situation with the resident in real time so we can triage.”

Dr. Kroshinsky often tells her patients in the hospital, “‘The best thing I can do is to make it so that you don’t ever need to see me again.’ In the outpatient setting, however, you really do cultivate an integration into your patients’ lives.”

A major advantage of academics is that you don’t have any of the business stressors of private practice, so you are able to focus on medicine. “On the flip side, you do have to follow the institution’s protocols and processes,” Dr. Kroshinsky explained. “You aren’t your own boss, so you can’t take off on a last-minute vacation or choose which EHR you use.”

“While there is a diversity of diagnoses, and excitement around being able to see interesting things and be impactful with your care, you offset that with the unpredictability in your work-life balance,” she said.

In academic practice, it’s important to collaborate and engage with colleagues, Dr. Kroshinsky remarked. “Some of the challenges can be figuring out how to work together as a team for a common goal. The way that dermatology approaches the management of conditions may not be how other services approach them.”

“The trade-off,” she added, “is that I don’t have to deal with hiring and firing, the regulatory issues, and I can hand off paperwork after I sign it and it magically gets done. It’s a huge privilege to be able to care for people at the most vulnerable times in their life.”

Concierge, direct pay

Some dermatologists have transitioned to concierge or direct pay practice models. Particularly for small practices and solo practitioners, a concierge or direct pay model may feel like one way to stay afloat.

There is considerable variation among concierge practices, but the concierge model is most commonly one in which doctors are paid a membership fee for “non-covered” services directly by the patient, instead of the physician relying entirely on health insurance to generate revenue for their practices. Typically, this means patients pay a quarterly, semi-annual, or yearly membership fee and if the physician remains “in network” with Medicare or commercial health insurance, the physician’s office files a claim for medically related care.

Concierge services often include services such as lengthened office visits, increased availability to physicians, lab tests, house calls, and same-day appointments. Some accept insurance but also charge a membership fee. Others may opt for a direct-pay-only model in which they accept payment for the visits and services directly from the patient but encourage patients to seek reimbursement on their own through their insurance.

Shawna Flanagan, MD, FAAD, is in solo practice in Florida and operates a concierge practice. “I do a lot of skin cancer and Mohs surgery as well as cosmetic dermatology. In 2017, I was at a turning point of whether to drop Medicare and become nonparticipating or try a concierge approach. I charged a yearly membership fee of $750 per year which could be used toward products and cosmetic procedures,” Dr. Flanagan added. “This way I could keep my Medicare patients, who had skin cancer and needed Mohs, who were also my cosmetic patients.”

“I have a lot of older skin cancer patients that need to see me at least twice yearly, so I went with the concierge approach, and it has been working well for the past decade,” she added.

“Initially I lost some Medicare patients who didn’t want to pay the yearly fee,” Dr. Flanagan said, “But I actually made more money, saw fewer patients, and was able to provide quality care to my patients without having to rush through their exams.”

The biggest challenge for concierge practices is that not everyone wants to pay a fee to be part of the practice, Dr. Flanagan said. “This is not necessarily a bad thing as it keeps the practice size smaller and more boutique-like.”

“I feel honored that my patients put enough trust in me to pay this extra fee just to be part of my practice. I think it has helped me avoid burnout these past few years,” she said.

“As with anything new, there are things I have changed along the way. It’s still a work in progress. The beauty of owning your own business is that you can control these variables and change them if they aren’t working.”

Additional DermWorld Resources