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Medical and cosmetic dermatologists may bring different views to the discussion of skin care, but they do agree on one thing – health should always come before beauty.
Basic dermatologic health procedures, like total body skin checks, mole assessment, and sun exposure advice, should be the foundation of any cosmetic dermatologist's work. No amount of wrinkle reduction, laser resurfacing, or complexion correction can ever make up for a missed skin cancer, according to cosmetic dermatologists.
"I take this responsibility very seriously," said Dr. Elizabeth Tanzi, a Washington, D.C. dermatologist who specializes in laser surgery. "All our patients, whether new or returning, get a full head-to-toe exam for skin cancer. It would be tragic to be talking about wrinkles and crepey skin when there’s a skin cancer."
Dr. Tanzi said that health should be center of any dermatologic procedure – and that cosmetic procedures are no exception.
"We have to look at it like this: Number one, make sure your skin is healthy. Number two: beautify it."
Dermatologic practices are split into three categories: all cosmetic, all medical, or a combination of the two. Purely medical dermatologists tend to cluster in academic institutions, while purely cosmetic dermatologists are most often seen in large cities. Dual-therapy dermatologists are the workhorses who serve most communities.
All dermatologists need to know when to proceed and when to say "no," Dr. Tanzi said. Referral to a medical dermatologist may cost a patient in the short term, but will serve everyone well in the long term.
"If a patient comes to me with an issue in my area of expertise and I know I can do a great job, I’ll take it," said Dr. Tanzi, codirector of the Washington Institute of Dermatologic Laser Surgery. "If they come in with something where I’m not up on the latest, or something I haven't seen in years and feel I won’t be best for the job, I refer. An urban setting really allows this to happen. In D.C. we have the luxury of saying that there is someone nearby who is an expert in any field. It is a different story in communities where you need to be a jack of all trades."
A Jack of All Trades
Dr. Margaret "Peggy" Fitch fills that bill. "I’m a surgical and cosmetic dermatologist in the morning and a medical dermatologist in the afternoon," said Dr. Fitch, founder of Aiken Dermatology, Aiken, S.C.
She didn't always split her time between the disciplines, however. When she began practicing 30 years ago, she focused on medical and surgical dermatology. Then things began to change.
"Over time, peels, fillers, Botox, and sclerotherapy came along. They were on the front page of Cosmopolitan. Patients were asking about them. And I was seeing the results of bad outcomes – procedures done by physicians who shouldn’t have been doing them."
Taking a weekend course in a cosmetic procedure does not make an expert, Dr. Fitch said.
"Let’s be honest – there are lots of doctors out there who do this just to make a quick buck, and I was seeing the results of that. So I thought, 'I'm a dermatologist. I know skin and the anatomic structure of the face. I should be doing this.' So gradually I learned and added to my practice."
She doesn't shy away from discussing the financial benefits of cosmetic work.
"Sure, it's a revenue builder. But I let patients decide what they want. If someone comes to me for a medical issue, I will never, ever bring up a cosmetic issue. I think that is foraging in the forest for a buck. If a patient asks about Botox while we're talking, that's another issue. But as a doctor, I would never bring up someone’s wrinkles."
She isn’t afraid to say "no" either. "I say no all the time. I’m not above saying, 'Look you don’t need this.' "
For example, she said, a 27-year-old bride-to-be asked her for filler for her lips. Dr. Fitch refused, telling her the lines were too fine to be treated, and that she was too young to be looking at the procedure. "I could have made $500 for that. But I think I'm the exception to the rule here. Most people would have gone and done it."
As a surgical dermatologist, she concentrates on skin cancers, using her own in-office pathology lab to assess the specimens. "I do flaps and grafts, but I would never attempt a full Mohs. That’s all part of knowing when you must say to a patient, 'I'm a good doctor and a good surgeon, but I'm not the best person for this.' "
Taking on New Roles
Dr. Sue Ellen Cox is another dermatologist who enjoys mixing it up. While 80% of her practice is cosmetic, the rest of her patients have medical issues. "If a patient comes to me and doesn't already have a general dermatologist, I'll take on that role without a problem. I really enjoy doing that – it gives me some variety and keeps me sharp."
When she began her 16-year-old practice in Chapel Hill, N.C., she did outreach to local dermatologists. With several years of specialized training in collagen, lasers, and liposuction, and a research study on chemical peels, Dr. Cox felt like she could bring something new and valuable to the medical community.
"I went to all the dermatologists in the area and told them about my specialized training and asked them to send me any cosmetic cases they weren't comfortable with. My practice just took off from there," she said.
At the same time, she never bites the hand that feeds her. "If someone is referred to me for laser and I see a basal cell carcinoma, for example, I'll tell them to talk to their referring physician before I do anything. Referrals are a lifeline, and I don't want to cut that."
Dermatologists who combine both medical and cosmetic work need to be scrupulous in their billing, she warned.
"If I'm doing a laser treatment for rosacea, that's a fee for service procedure. If I'm diagnosing rosacea for the first time, I bill insurance. If I diagnose lentigoes and precancerous lesions and treat them, I bill insurance. But if the main benefit is cosmetic, it's self pay. The same with moles – removal of a benign mole for cosmetic reasons is one thing, removal and biopsy of a suspicious mole is another."
"We Treat Cosmetic Issues, Not Health Issues"
Dr. Eliot Battle has no issues with insurance billing. As a completely cosmetic dermatologist, his business is all self pay. And his patients know that from the beginning.
"There is no confusion about what we do. We treat cosmetic issues – not health issues. I don't take insurance, and our advertising and website are very clear about this. If we see someone with medical issues, we push them to a medical dermatologist – that saves them money, and we know that medical derms are better for these things than we would ever be."
Dr. Battle has built his practice on four areas – laser hair removal, complexion blending, textural rejuvenation, and antiaging procedures. About 100 patients, primarily women, come through his office every day, 6 days a week. Dr. Battle specializes in treating darker skin, which is much more prone to the scarring and pigmentation changes that can result from inexpert cosmetic treatment.
Dr. Battle does few of the procedures. He conducts all of the consultations and designs the treatment plans, but registered nurses perform the procedures. "I work with six full-time nurses, who undergo a strict internal training program and participate in ongoing medical education. I send them to every possible meeting that could be of help, and I support all this education financially."
Dr. Battle brings a unique set of business skills to his medical practice. After working as a marketing director for a large computer firm, he decided to enroll in medical school.
"I took my first science course at age 33 and was a dermatology resident at age 41," he said. "When I finally finished, my passion was cosmetic dermatology. At that point lasers were still in their infancy, and I worked for 3 years in research about laser safety – especially for skin of color."
He designed his cosmetic work as not only a practice but as a business, with his children's future in mind. "I wanted to make sure they could inherit my own success," he said. "Children cannot inherit a physician's practice, but they can inherit a business." Dr. Battle does not treat patients himself, so the Cultura Cosmetic Dermatology and Laser Center in Washington, is considered a business rather than a practice.
Because he offers limited procedures, his staff has become expert in performing them, he said. But when he encounters anything beyond what he is prepared to offer, Dr. Battle refers to a medical dermatologist.
"My medical oath says to do no harm, and that rules all that I do. We are always looking out for the patient's best interest. If I see a suspicious mole or a concerning flare of lupus, I refer. I am not geared to help that person."
Dr. Battle hasn't completely foresworn either medical or academic work, however. He conducts research at Howard University, Washington, and teaches residents who are interested in cosmetic dermatology.
His business background puts him in a position to offer business advice, and his age, he said, allows him to give personal counsel as well.
"One thing I tell residents is that just because they might generate a lot of revenue with a cosmetic practice doesn't necessarily mean they'll generate a lot of profit. It's also important for people to be true to themselves. I encourage them to look deeply into this and not be blinded by the idea that they'll make tons of money doing cosmetic work. A lot of residents really enjoy the academic side of medicine, and cosmetic dermatology will not bring them that. If academics are your passion, you should not forego that for the temporary dollar."
Dr. Tanzi is on the medical advisory board for Zeltiq. Dr. Cox is a consultant for Medisys and Allergan. Dr. Battle and Dr. Fitch reported having no conflicts of interest.
Medical and cosmetic dermatologists may bring different views to the discussion of skin care, but they do agree on one thing – health should always come before beauty.
Basic dermatologic health procedures, like total body skin checks, mole assessment, and sun exposure advice, should be the foundation of any cosmetic dermatologist's work. No amount of wrinkle reduction, laser resurfacing, or complexion correction can ever make up for a missed skin cancer, according to cosmetic dermatologists.
"I take this responsibility very seriously," said Dr. Elizabeth Tanzi, a Washington, D.C. dermatologist who specializes in laser surgery. "All our patients, whether new or returning, get a full head-to-toe exam for skin cancer. It would be tragic to be talking about wrinkles and crepey skin when there’s a skin cancer."
Dr. Tanzi said that health should be center of any dermatologic procedure – and that cosmetic procedures are no exception.
"We have to look at it like this: Number one, make sure your skin is healthy. Number two: beautify it."
Dermatologic practices are split into three categories: all cosmetic, all medical, or a combination of the two. Purely medical dermatologists tend to cluster in academic institutions, while purely cosmetic dermatologists are most often seen in large cities. Dual-therapy dermatologists are the workhorses who serve most communities.
All dermatologists need to know when to proceed and when to say "no," Dr. Tanzi said. Referral to a medical dermatologist may cost a patient in the short term, but will serve everyone well in the long term.
"If a patient comes to me with an issue in my area of expertise and I know I can do a great job, I’ll take it," said Dr. Tanzi, codirector of the Washington Institute of Dermatologic Laser Surgery. "If they come in with something where I’m not up on the latest, or something I haven't seen in years and feel I won’t be best for the job, I refer. An urban setting really allows this to happen. In D.C. we have the luxury of saying that there is someone nearby who is an expert in any field. It is a different story in communities where you need to be a jack of all trades."
A Jack of All Trades
Dr. Margaret "Peggy" Fitch fills that bill. "I’m a surgical and cosmetic dermatologist in the morning and a medical dermatologist in the afternoon," said Dr. Fitch, founder of Aiken Dermatology, Aiken, S.C.
She didn't always split her time between the disciplines, however. When she began practicing 30 years ago, she focused on medical and surgical dermatology. Then things began to change.
"Over time, peels, fillers, Botox, and sclerotherapy came along. They were on the front page of Cosmopolitan. Patients were asking about them. And I was seeing the results of bad outcomes – procedures done by physicians who shouldn’t have been doing them."
Taking a weekend course in a cosmetic procedure does not make an expert, Dr. Fitch said.
"Let’s be honest – there are lots of doctors out there who do this just to make a quick buck, and I was seeing the results of that. So I thought, 'I'm a dermatologist. I know skin and the anatomic structure of the face. I should be doing this.' So gradually I learned and added to my practice."
She doesn't shy away from discussing the financial benefits of cosmetic work.
"Sure, it's a revenue builder. But I let patients decide what they want. If someone comes to me for a medical issue, I will never, ever bring up a cosmetic issue. I think that is foraging in the forest for a buck. If a patient asks about Botox while we're talking, that's another issue. But as a doctor, I would never bring up someone’s wrinkles."
She isn’t afraid to say "no" either. "I say no all the time. I’m not above saying, 'Look you don’t need this.' "
For example, she said, a 27-year-old bride-to-be asked her for filler for her lips. Dr. Fitch refused, telling her the lines were too fine to be treated, and that she was too young to be looking at the procedure. "I could have made $500 for that. But I think I'm the exception to the rule here. Most people would have gone and done it."
As a surgical dermatologist, she concentrates on skin cancers, using her own in-office pathology lab to assess the specimens. "I do flaps and grafts, but I would never attempt a full Mohs. That’s all part of knowing when you must say to a patient, 'I'm a good doctor and a good surgeon, but I'm not the best person for this.' "
Taking on New Roles
Dr. Sue Ellen Cox is another dermatologist who enjoys mixing it up. While 80% of her practice is cosmetic, the rest of her patients have medical issues. "If a patient comes to me and doesn't already have a general dermatologist, I'll take on that role without a problem. I really enjoy doing that – it gives me some variety and keeps me sharp."
When she began her 16-year-old practice in Chapel Hill, N.C., she did outreach to local dermatologists. With several years of specialized training in collagen, lasers, and liposuction, and a research study on chemical peels, Dr. Cox felt like she could bring something new and valuable to the medical community.
"I went to all the dermatologists in the area and told them about my specialized training and asked them to send me any cosmetic cases they weren't comfortable with. My practice just took off from there," she said.
At the same time, she never bites the hand that feeds her. "If someone is referred to me for laser and I see a basal cell carcinoma, for example, I'll tell them to talk to their referring physician before I do anything. Referrals are a lifeline, and I don't want to cut that."
Dermatologists who combine both medical and cosmetic work need to be scrupulous in their billing, she warned.
"If I'm doing a laser treatment for rosacea, that's a fee for service procedure. If I'm diagnosing rosacea for the first time, I bill insurance. If I diagnose lentigoes and precancerous lesions and treat them, I bill insurance. But if the main benefit is cosmetic, it's self pay. The same with moles – removal of a benign mole for cosmetic reasons is one thing, removal and biopsy of a suspicious mole is another."
"We Treat Cosmetic Issues, Not Health Issues"
Dr. Eliot Battle has no issues with insurance billing. As a completely cosmetic dermatologist, his business is all self pay. And his patients know that from the beginning.
"There is no confusion about what we do. We treat cosmetic issues – not health issues. I don't take insurance, and our advertising and website are very clear about this. If we see someone with medical issues, we push them to a medical dermatologist – that saves them money, and we know that medical derms are better for these things than we would ever be."
Dr. Battle has built his practice on four areas – laser hair removal, complexion blending, textural rejuvenation, and antiaging procedures. About 100 patients, primarily women, come through his office every day, 6 days a week. Dr. Battle specializes in treating darker skin, which is much more prone to the scarring and pigmentation changes that can result from inexpert cosmetic treatment.
Dr. Battle does few of the procedures. He conducts all of the consultations and designs the treatment plans, but registered nurses perform the procedures. "I work with six full-time nurses, who undergo a strict internal training program and participate in ongoing medical education. I send them to every possible meeting that could be of help, and I support all this education financially."
Dr. Battle brings a unique set of business skills to his medical practice. After working as a marketing director for a large computer firm, he decided to enroll in medical school.
"I took my first science course at age 33 and was a dermatology resident at age 41," he said. "When I finally finished, my passion was cosmetic dermatology. At that point lasers were still in their infancy, and I worked for 3 years in research about laser safety – especially for skin of color."
He designed his cosmetic work as not only a practice but as a business, with his children's future in mind. "I wanted to make sure they could inherit my own success," he said. "Children cannot inherit a physician's practice, but they can inherit a business." Dr. Battle does not treat patients himself, so the Cultura Cosmetic Dermatology and Laser Center in Washington, is considered a business rather than a practice.
Because he offers limited procedures, his staff has become expert in performing them, he said. But when he encounters anything beyond what he is prepared to offer, Dr. Battle refers to a medical dermatologist.
"My medical oath says to do no harm, and that rules all that I do. We are always looking out for the patient's best interest. If I see a suspicious mole or a concerning flare of lupus, I refer. I am not geared to help that person."
Dr. Battle hasn't completely foresworn either medical or academic work, however. He conducts research at Howard University, Washington, and teaches residents who are interested in cosmetic dermatology.
His business background puts him in a position to offer business advice, and his age, he said, allows him to give personal counsel as well.
"One thing I tell residents is that just because they might generate a lot of revenue with a cosmetic practice doesn't necessarily mean they'll generate a lot of profit. It's also important for people to be true to themselves. I encourage them to look deeply into this and not be blinded by the idea that they'll make tons of money doing cosmetic work. A lot of residents really enjoy the academic side of medicine, and cosmetic dermatology will not bring them that. If academics are your passion, you should not forego that for the temporary dollar."
Dr. Tanzi is on the medical advisory board for Zeltiq. Dr. Cox is a consultant for Medisys and Allergan. Dr. Battle and Dr. Fitch reported having no conflicts of interest.
Medical and cosmetic dermatologists may bring different views to the discussion of skin care, but they do agree on one thing – health should always come before beauty.
Basic dermatologic health procedures, like total body skin checks, mole assessment, and sun exposure advice, should be the foundation of any cosmetic dermatologist's work. No amount of wrinkle reduction, laser resurfacing, or complexion correction can ever make up for a missed skin cancer, according to cosmetic dermatologists.
"I take this responsibility very seriously," said Dr. Elizabeth Tanzi, a Washington, D.C. dermatologist who specializes in laser surgery. "All our patients, whether new or returning, get a full head-to-toe exam for skin cancer. It would be tragic to be talking about wrinkles and crepey skin when there’s a skin cancer."
Dr. Tanzi said that health should be center of any dermatologic procedure – and that cosmetic procedures are no exception.
"We have to look at it like this: Number one, make sure your skin is healthy. Number two: beautify it."
Dermatologic practices are split into three categories: all cosmetic, all medical, or a combination of the two. Purely medical dermatologists tend to cluster in academic institutions, while purely cosmetic dermatologists are most often seen in large cities. Dual-therapy dermatologists are the workhorses who serve most communities.
All dermatologists need to know when to proceed and when to say "no," Dr. Tanzi said. Referral to a medical dermatologist may cost a patient in the short term, but will serve everyone well in the long term.
"If a patient comes to me with an issue in my area of expertise and I know I can do a great job, I’ll take it," said Dr. Tanzi, codirector of the Washington Institute of Dermatologic Laser Surgery. "If they come in with something where I’m not up on the latest, or something I haven't seen in years and feel I won’t be best for the job, I refer. An urban setting really allows this to happen. In D.C. we have the luxury of saying that there is someone nearby who is an expert in any field. It is a different story in communities where you need to be a jack of all trades."
A Jack of All Trades
Dr. Margaret "Peggy" Fitch fills that bill. "I’m a surgical and cosmetic dermatologist in the morning and a medical dermatologist in the afternoon," said Dr. Fitch, founder of Aiken Dermatology, Aiken, S.C.
She didn't always split her time between the disciplines, however. When she began practicing 30 years ago, she focused on medical and surgical dermatology. Then things began to change.
"Over time, peels, fillers, Botox, and sclerotherapy came along. They were on the front page of Cosmopolitan. Patients were asking about them. And I was seeing the results of bad outcomes – procedures done by physicians who shouldn’t have been doing them."
Taking a weekend course in a cosmetic procedure does not make an expert, Dr. Fitch said.
"Let’s be honest – there are lots of doctors out there who do this just to make a quick buck, and I was seeing the results of that. So I thought, 'I'm a dermatologist. I know skin and the anatomic structure of the face. I should be doing this.' So gradually I learned and added to my practice."
She doesn't shy away from discussing the financial benefits of cosmetic work.
"Sure, it's a revenue builder. But I let patients decide what they want. If someone comes to me for a medical issue, I will never, ever bring up a cosmetic issue. I think that is foraging in the forest for a buck. If a patient asks about Botox while we're talking, that's another issue. But as a doctor, I would never bring up someone’s wrinkles."
She isn’t afraid to say "no" either. "I say no all the time. I’m not above saying, 'Look you don’t need this.' "
For example, she said, a 27-year-old bride-to-be asked her for filler for her lips. Dr. Fitch refused, telling her the lines were too fine to be treated, and that she was too young to be looking at the procedure. "I could have made $500 for that. But I think I'm the exception to the rule here. Most people would have gone and done it."
As a surgical dermatologist, she concentrates on skin cancers, using her own in-office pathology lab to assess the specimens. "I do flaps and grafts, but I would never attempt a full Mohs. That’s all part of knowing when you must say to a patient, 'I'm a good doctor and a good surgeon, but I'm not the best person for this.' "
Taking on New Roles
Dr. Sue Ellen Cox is another dermatologist who enjoys mixing it up. While 80% of her practice is cosmetic, the rest of her patients have medical issues. "If a patient comes to me and doesn't already have a general dermatologist, I'll take on that role without a problem. I really enjoy doing that – it gives me some variety and keeps me sharp."
When she began her 16-year-old practice in Chapel Hill, N.C., she did outreach to local dermatologists. With several years of specialized training in collagen, lasers, and liposuction, and a research study on chemical peels, Dr. Cox felt like she could bring something new and valuable to the medical community.
"I went to all the dermatologists in the area and told them about my specialized training and asked them to send me any cosmetic cases they weren't comfortable with. My practice just took off from there," she said.
At the same time, she never bites the hand that feeds her. "If someone is referred to me for laser and I see a basal cell carcinoma, for example, I'll tell them to talk to their referring physician before I do anything. Referrals are a lifeline, and I don't want to cut that."
Dermatologists who combine both medical and cosmetic work need to be scrupulous in their billing, she warned.
"If I'm doing a laser treatment for rosacea, that's a fee for service procedure. If I'm diagnosing rosacea for the first time, I bill insurance. If I diagnose lentigoes and precancerous lesions and treat them, I bill insurance. But if the main benefit is cosmetic, it's self pay. The same with moles – removal of a benign mole for cosmetic reasons is one thing, removal and biopsy of a suspicious mole is another."
"We Treat Cosmetic Issues, Not Health Issues"
Dr. Eliot Battle has no issues with insurance billing. As a completely cosmetic dermatologist, his business is all self pay. And his patients know that from the beginning.
"There is no confusion about what we do. We treat cosmetic issues – not health issues. I don't take insurance, and our advertising and website are very clear about this. If we see someone with medical issues, we push them to a medical dermatologist – that saves them money, and we know that medical derms are better for these things than we would ever be."
Dr. Battle has built his practice on four areas – laser hair removal, complexion blending, textural rejuvenation, and antiaging procedures. About 100 patients, primarily women, come through his office every day, 6 days a week. Dr. Battle specializes in treating darker skin, which is much more prone to the scarring and pigmentation changes that can result from inexpert cosmetic treatment.
Dr. Battle does few of the procedures. He conducts all of the consultations and designs the treatment plans, but registered nurses perform the procedures. "I work with six full-time nurses, who undergo a strict internal training program and participate in ongoing medical education. I send them to every possible meeting that could be of help, and I support all this education financially."
Dr. Battle brings a unique set of business skills to his medical practice. After working as a marketing director for a large computer firm, he decided to enroll in medical school.
"I took my first science course at age 33 and was a dermatology resident at age 41," he said. "When I finally finished, my passion was cosmetic dermatology. At that point lasers were still in their infancy, and I worked for 3 years in research about laser safety – especially for skin of color."
He designed his cosmetic work as not only a practice but as a business, with his children's future in mind. "I wanted to make sure they could inherit my own success," he said. "Children cannot inherit a physician's practice, but they can inherit a business." Dr. Battle does not treat patients himself, so the Cultura Cosmetic Dermatology and Laser Center in Washington, is considered a business rather than a practice.
Because he offers limited procedures, his staff has become expert in performing them, he said. But when he encounters anything beyond what he is prepared to offer, Dr. Battle refers to a medical dermatologist.
"My medical oath says to do no harm, and that rules all that I do. We are always looking out for the patient's best interest. If I see a suspicious mole or a concerning flare of lupus, I refer. I am not geared to help that person."
Dr. Battle hasn't completely foresworn either medical or academic work, however. He conducts research at Howard University, Washington, and teaches residents who are interested in cosmetic dermatology.
His business background puts him in a position to offer business advice, and his age, he said, allows him to give personal counsel as well.
"One thing I tell residents is that just because they might generate a lot of revenue with a cosmetic practice doesn't necessarily mean they'll generate a lot of profit. It's also important for people to be true to themselves. I encourage them to look deeply into this and not be blinded by the idea that they'll make tons of money doing cosmetic work. A lot of residents really enjoy the academic side of medicine, and cosmetic dermatology will not bring them that. If academics are your passion, you should not forego that for the temporary dollar."
Dr. Tanzi is on the medical advisory board for Zeltiq. Dr. Cox is a consultant for Medisys and Allergan. Dr. Battle and Dr. Fitch reported having no conflicts of interest.