Hello all,

I've found this website to be an amazing resource, and my thanks go out to Jeff Barson and the contributors who have shared their knowledge and expertise here.

I'm a 4th year student at a well-known U.S. allopathic medical school. I have just finished residency interviews for dermatology and preliminary IM positions, and I will find out if/where I match in dermatology on March 20th, 2008.

I'd like to ask for advice from the physicians on this forum, if I may, as I have a long-standing desire to own a mainly cosmetic private practive. Recently, going the MedSpa route has become increasingly attractive to me.

I have good grades and recommendation letters, research experience and some academic awards, etc., and thus I'm set up for a future in academic medicine. This, however, has had less and less appeal to me in recent months. The business side of medicine has always been interesting to me, and MedSpa ownership seems to come with the right combination of business challenges and cosmetic medical issues to keep me interested. This is first and foremost, as I don't have any illusions that my business would be an instant success.

I also see the austere lives lived by many physicians (even dermatologists, occasionally), and I have no desire to spend the next 4-6 years killing myself working for peanuts on the wards of some hospital, only to immediately begin the payback of my $250,000+ of student loan debt (from undergrad and med school). This is especially true when I realize that I don't want to put up with insurance companies as a practicing doc, and I really don't want to spend any time treating Medicaid psoriasis patients (noble though that is) when I could be filling that seat (and time) with OOP botox patients, for example.

This may sound greedy, but I think that best describes my mindset. My questions, then, are the following:

1. Suppose I just did ONE year of a preliminary IM residency (starting July 2008), and then applied for and received my state medical license. Could I then find work with a MedSpa training and becoming comfortable with procedures?

2. Would the fact that I had only one year of residency under my belt be a hindrance to finding employment? It seems to be that most cosmetic procedures are not that technically difficult, although they DO require experience and good clinical judgement, which is what I'm hoping to gain.

3. Suppose that after some time, I move to a different market, and set up my own MedSpa. How does the fact that I'm not board certified in any specialty realistically affect my practice and income?

*4. This is more of a philisophical question, but I'd appreciate input from all comers: Am I crazy to abandon the academic path this far into my education? Should I tough out the next few years of residency? What if I don't match in derm - should I really spend FIVE more years working 70-80 hrs/week for 42k a year (with that student debt accruing interest, I might add)?

Sorry for such a long post. All comments and advice are very much appreciated. Thank you very much!

I think you have chosen the wrong profession. You can make alot more money by going back to school for an MBA than trying to bypass a real medical education - which comes through a residency. Medspas are not a quick and easy way to make money. If your heart is not in medicine look elsewhere, now, before its really too late.

since when is derm a 5 yr program?

Dr. Lu,

Thanks for your comments. Your point is well-taken, but as I stated, I don't think of MedSpas as a quick and easy way to make money - I just want to approach it practically. Although I've considered it before, I don't think it's practical for me to invest more time, effort and money into an MBA after 4 years of med school. Furthermore, a "real" medical education will not teach me anything about cosmetic medicine, which IS something that I have my heart in and want to practice. There are plenty of private practice docs who, once having found a niche, forget or ignore most of what they've learned in residency. I'm not saying that that's always a good thing, but what was true 20 years ago is not completely true today: Completing a residency does not necessarily equal finanical and professional success.

If we were to compare two docs: one who completed a 3-year IM residency and went straight into a hospitalist position, and one who finished that same residency and went into the medspa industry, who would be making more (and working less) after five years? My feeling is that it would be the medspa doc. Did that same physician learn or gain anything in the final two years of his residency that made him better at performing cosmetic procedures and caring for medspa patients? I don't know the answer to that, but I suspect not.

So, I'd like to reframe my earlier questions in the sense of whether that plan (of one year of residency and then out the door) is practical, plausible and likely to be successful, rather than whether it's "right" or "wrong."

Again, thanks for feedback! :)

Calidoc,

Derm is 4 years: 1 required year of preliminary IM + 3 years derm.

If, however, I don't match this year, it would be 1 year of prelim IM + 1 year of research during the "lag" year (since you apply to derm programs two years in advance) + 3 years derm = 5 years of my life before board certification.

SkiFreeMD2b,
The Medspa business may not be all you think. You could lose everything overnight and then some. Take a look at Dermacare blogs. A majority of a derm residency will NOT teach you cosmetic procedures those are only learned on elective rotations if at all. My advise would be completing the entire residency, get board certified in your specialty and concentrate on aesthetics. BTW some resources for you: American Board of Laser Surgery probably one of the most comprehensive I've come across and most laser operating physicians have no clue, including derms and plastics.

skifreemd2b:

There's nothing wrong with wanting to go into the cosmetic derm business. It can be a personally and financially rewarding career. However, running a medspa, like running any business, is a risk in itself. The typical start up cost for a medspa can run you $250,000 to $300,000 which only includes the most basic laser equipment. Expertise with Botox and filler injection comes with practice and you only get better with these procedures the longer you are in the business.
My recommendation to you would be to finish your residency first whether it be dermatology or IM. Get board certifed in your specialty then go into the cosmetic derm / medspa business. AT least you have something to fall back on in case things don't work out in the future. The cosmetic derm business is changing all the time. No on can predict where this field would be at in 5 years. This field is getting more competitive by the days. I have already seen a few medspas out of business in 2007.
Final word of advice is to take the time to learn things right the first time. Be dedicated to your profession and put in the long hours. Resideny is the best time to learn any procedure. Ask your laser equipment, botox, resylane sales rep to arrange for live demonstrations or workshop for you during your derm rotations. You can start early by moon lighting at medspas once you obtain your license / DEA#. Reading on the discussions posted on medicalspamd is also a great way to learn about this business.

I'd recommend looking at Plastic Surgery, if you are surgically-minded. It's a great field, you aren't limited by anatomic area, and it attracts some very creative minds. You really get to make a big difference for people. If the medspa business isn't working for you, there are plenty of other great things you can do as a general reconstructive, microsurgical, craniofacial, or hand surgeon - all within the field of plastic surgery.

On the minus side, it is a long training period, and it is very competitive to get into a residency program. It's not for wimps.

As for the previous comments, to each his own, but I don't think a general IM residency would really have much applicability for you. Also, the American Board of Laser Surgery is not an ABMS-sanctioned Board. So they won't get you anywhere when it comes to hospital credentialling.

TF,
Yes American Board of Laser Surgery is NOT. However, there is nothing available nationally. We (ASLMS) are currently in the process of a certification or examination process that will be presented and data gathered at this years conference. In my experience, I have found that many top physicians do not have a basic understanding of the physics/optics of lasers, no matter what specialty; maybe these questions will prove otherwise? We will see.....

Sure, bring on your laser physics questions - I'm up for the challenge!

But don't get all hot-under-the-collar about what I said about the American Board of Laser Surgery. The med student needs honest advice, and shouldn't make a plan for the next 5-8 years of his life based on things that could present a problem down the road. He should get certified by an ABMS board, so that he won't have a problem getting hospital privileges, and won't have a problem with things like Florida's "Truth in Medical Education" program.

MedspaMD, Kenneth Wang, TF, hmm,

Thanks a lot for your responses. You've definitely given me some food for thought.

I feel like I'm getting good advice from you guys, though it errs on the side of caution. Sure, finishing a derm residency does give me that boost in terms of board certification and a healthy degree of job security. But, it seems like people agree that you don't learn cosmetic procedures until you actually go out there and do it, or specifically seek out the training from an outside source. Again, I agree that finishing a residency is a good thing - there's no doubt about that. I'm just trying to distill this to its most practical elements - Will medspas hire me early on with just one year of IM and a medical license? Can I still be a proficient aesthetic physician if I forgo a derm residency to start my business earlier? (This is what I'm considering doing!)

I should mention that I do have some business experience, although I don't want to post the specifics on here just in case a program director of a school I interviewed at is reading this (it would make me easily identifiable). :) I imagine that the first year I'm in private practice will be very tough indeed. I have a business model that I'm working out, and I'm in tentative discussions with an old friend who is a commericial realtor in my preferred location (wealthy area, lots of growth, little competition that I've surveyed). So, I'm already looking at keeping my starting costs low, with the exception of advertising, which I think will be key for establishing myself over the first two years and forward. So, my point is that residency/board certification does nothing to improve my baseline business acumen, does nothing to lower my startup costs, does nothing to make me a better cosmetic practitioner (that I can tell), and seems to only delay the inevitable challenge of starting a small business.

It also seems to me that though ANY business venture is risky, medspa has a number of things going for it that give it a unique advantage over other medical industries. We live in a time where physical beauty is glorified and personal appearance is more important than ever before. This trend is not going to reverse itself in my lifetime. U.S. culture has changed fundamentally over the past 40-50 years, and superficial traits such as wealth and attractiveness are FAR more valued than education or even professional status. Just turn on the T.V. if you need confirmation of this. The medical industry has only awoken to this fact, I think, in the past ten years (still well before my time, admittedly). The paradigm has shifted, and this is why I'm considering such a radical course of action - *actually* turning away from derm (which is supposed to be the end-all be-all in the world of medical students and residents) to take what seems to be kind of a lowball route. I do not see a happy future for traditional docs, and I think that by doing something that's rather bold and counterintuitive now, I'll end up ahead of the curve in the long haul. Thoughts? Comments? Criticisms?

Also, TF, I considered plastics early on, but I made a tough decision after my second year to pursue the derm route instead of plastic surgery. This was based on my preference for a medically- (as opposed to surgically-)based specialty and a lack of interest in pursuing a 7 year residency (especially if that were to entail 5 years of general surgery...oof). This is a decision I've been happy with, so while derm is still a possibility for me, plastic surg is not.

Thanks again for your input everyone! Keep it coming!

You also want to look at your state laws. Many states will not let you practice unless you have finished a residency although some states do allow it.

I didn't learn any aesthetic medicine during my residency except for 2 months of elective rotations I set up myself. Most of what I know comes from learning once I decided to go into this field -courses, colleagues, meetings,self study, etc.... So sure you can do this and get by some state laws without a full residency training. However, some patients do care about credentials. They want a board certified someone. Saying you did not do a residency would almost sound you dropped out of med school when people start talking such as your future competition. I hear what you're saying and if you're business savvy, I'm sure you can work it out but I don't think you'll be the top guy or at least for long.

I think 3 years to become board certified in IM, FP, Psych any of which might interest you is worth the extra 2 years given you'd do a year of internship regardless. 2 years in end is not that big of a deal in the grand scheme of things (and neither is 4 extra years if you'd be board certified in derm!). Dermatologists make a ton of money and have it relatively easy off of regular moles, warts, fungus on the nails, etc. So it's not a waste of time to make yourself marketable as a board certified dermatologist. From a marketing and a profitability standpoint.

I have a combined general dermatology and cosmetic dermatology practice with a medical spa in my office.I find that patients feel much better knowing that a board certifed dermatologist is either performing or directly overseeing their procedures.

Consider that by the time that you finish your dermatology residency, that the entire scope of this practice of medicine will have changed. That being said, I love my practice and I love my patients, and that comes through loud and clear to them.

I am not sure that your heart is in the right place to go into this field. Patients will see right through you if you are trying to make a quick buck. Do it because you love it, and not for any other reason.

Ski Free: Some feedback from Minnesota-- in the Twin Cities there is a 3 month wait for anyone wanting an appointment to see a derm. On the other hand, the number one problem for ALL the med spas I know in the MSP area is getting enough people in the door. There is an obvious disconnect here. Check the area you are planning t practice in to se if there is a similar supply/demand situation going on. I believe that you will have a golden opportunity if you make the right moves.

All,

Thanks for your feedback. I can see where it makes more sense, in terms of job security, to complete a residency. One thing I don't think I'm making clear is that I DO like working with patients and I do not see any chance of making a "quick buck" in the medspa industry or otherwise. That being said, I'm relatively business-minded and I LIKE the challenges inherent to the business world. And, I'm convinced that the #1 cause of job dissatisfaction/financial hardship among physicians of all stripes is failure to recognize early on (i.e. before life-altering commitments are made) that medicine IS a business.

So, given my interest aesthetic medicine, medspa seems to offer a good synthesis of my personal goals and interests. I just want to pursue it as practically and effectively as possible. One bit of advice I’ve heard that makes sense is that patients really do care about your credentialing and board certification… Do you all think that rings true “across the board” and in all cities?

If I lacked IM or derm board certification, I don’t think I would try to set up a medspa in Seattle, for example – the most educated city in the country (~50% of residents have a college education) – on the grounds that people there would be more likely to ask me the hardball questions about why I forwent a residency, etc., and I think that would ultimately hurt business. [Not that I would set up shop in Seattle anyway; the market is oversaturated]. Then again, I can think of several communities where, generally speaking, patients would not scrutinize my training as much, and would not be as concerned about my lack of, say, IM certification. (Note: I would make no attempt to conceal my lack of board certification). As I’ve said in earlier posts, I don’t think the extra training is going to improve my clinical skill or judgment when it comes to botox, and my abilities – not my educational background – are what my future patients will benefit from the most.

Med Spa Doc,

What do you think accounts for the “disconnect” you’ve noticed in the MSP area? Is it:

A) A genuine public preference for dermatologists when it comes to cosmetic procedures?

B) A result of medspa oversaturation and/or shortage of dermatologists?

C) Due to a high ratio of actual dermatologic disease in the population to demand for cosmetic procedures?

D) Poor medspa marketing in MSP?

E) Some combination of the above?

I’m always baffled when I hear that dermatologists in an area have 3 (or more typically, 6) month waiting lists, and the medspas are floundering. Has anyone had this problem in their practices? If so, how did you address it?

Thanks again!

As a derm groing increasing more depressed with the state of medicine and who has been strung along by a medispa franchise or two I would give this advice to a young doctor who really wants to help people, and really love going to work every day:

Never ever ever sign any insurance company contract and never ever ever sign up for Medicare participation.

If I had only done that when I first started, I would not be stuck ina situation of ever diminishing income. Servitude to the corporate socialist model of healthcare we have in the US is very demeaning. PS if you think you can open a medispa and patients will come a running to give you cash, you are sorely mistaken. I have been working on increasing the cosmetic side of my otherwise very busy derm practice and still only have 1/2 day a week devoted strictly to cosmetics. Good luck.

Here's another doc's experience if anyone is interested. I did two years of a gen. surg residency. I was thinking seriously of going in to plastics, but, as an "older" medical student, I found the 9 year residency a little intimidating. Having finished med school at 35 y.o., I would have been well into middle age before going into practice. And the idea of taking Q3-4 call for 6 more years wasn't very appealing. Instead, I opted for an easier route. I did another 3 years of FP which was MUCH less taxing and gave me several options.
I wasn't too keen on FP though. Probably because I didn't find it challanging enough. I actually found myself missing trauma call beleive it or not.
I gravitated to the ER which was a nice mix of adrenaline with a decent lifestyle. But, that too was a abit of a burn-out. Mostly because of the shift changes.
In enters cosmetics. I started doing a few botox and resylane pts on the side, then gradually grew into laser vein removal, hair removal, etc. I learned liposuction from a colleague, and now do tumescent lipo. as well.
I have a very busy practice, some days are absolutely crazy. But, I love it. Its hard to put a price on the face a pt. who just had her hips done. Lipo's not hard but, you have to be good at it. And that takes experience.
I've seen some pretty nasty stuff out there. I've had several pts with deformities from previous lipo which I was able to fix with a fat transfer. They told me they had it done by a dermatologist. I'm not putting anyone down here, but wish to emphasize that being board certified in something, doesn't by default mean your good at it.
I am streight up with my pts. If they ask, I tell them that I was an ER physician and now doing cosmetics. Most of my pts. don't really care. All they are concerned with are results. There are some of course that prefer a plastic surgeon to do their lipo. Those patient's I refer to the plastic surgeon up the road. But most plastic surgeons, I find, don't really like doing lipo anyway.
During my surgery residency, I did about 6 months on the plastics service. We did a lot of reconstruction. As a second year resident, I got all the burn and skin grafts. We also did a lot of decubitus ulcer flaps. I scrubbed in on one lipo case in the entire 6 months. But back then, before the Klien's solution, it was a pretty messy surgery.
So whats an ER doc doing cosmetics? the walls, it seems are slowly eroding.
I find it ironic, however, that one of my ER colleagues was a plastic surgeon, another, a neurosurgeon.
There are some who still protest it seems. I got a call a few months back from an anonymous caller asking what I was boarded in. He was taken aback when I told him I had residency training in gen surg. but boarded in FP and 10 years as an attending ER physician. I suspect it was a plastic surgeon checking up on me.
Eventhough I've done hundreds of lipo cases and probably injected more Botox than I can even remember, I guess the politics of medicine is still alive and well.
There is always the question: Is it safe to have someone like myself performing cosmetics? I would like to answer that with a simple yes. A few days ago, I had a pt. develope a hyprtensive crisis while I was tumescing her. Normally the Klein solution which contains epi doesn't cause an elevation in BP. But, for some reason, in this pt. whether it was due to the klien's or was something else went into HTN crisis. Because of my ER background, I keep a fully stocked crash cart in my procedure room AND I know how to use it. It took a few drugs, ie. propanolol, clonidine, NTG, but yes, her bp normalized and I finished the case without incident.
Anyway, that is pretty much my story if anyone is interested. I really caution anyone going into the med-spa industry however, to do a lot of research and even take a business class. Its a whole different ball-game running a cash only medical practice. You have to treat it first as a business and second as a medical practice. You have to be very well financed, because like any business, it can take upwards of a year before you ever make a profit. And the overhead can be astonomical particularly if you hire estheticians, laser techs., office managers, etc.
I've been somewhat lucky, in that my clinic is very busy, but still after 6 months I have yet to make a profit. Like any business success or failure depends on how well organized you are. Learn about marketing, learn about business fundamentals, and most importantly, be damn good at what you do because word of mouth is going to make or break you.

botoxdoc: this has nothing to do with advice for the med student. i was wondering about your last comment that you stay very busy but have yet to make a profit after 6 months. does this mean you have yet to draw a paycheck for yourself? I hope you don't mind me asking about your personal business finances but I'm just wondering what I'm experiencing is normal. I started 4 months ago with a 100,000 investment not including my laser leases or the building I'm currently renting with the option to buy in an year. So far,I've been able to pay all the bills and increase my inventory of supplies and retail to approx 50,000. Just last month, I was able to "pocket" a couple thousand. It's still worth it because I love what I do and the business write-offs help with my family tax return and I save a lot of disposable income by not having to go others for my own treatments but it worries me that I might be doing things wrong to be making so little 4 months into this.

Ski Free: Sorry for the late reply (I have been traveling). In my opinion, there are several reasons for the "disconnect" I have seen in MSP regarding derm practice vs. med spas--

1. Shortage of derms: Hats off to the docs for keeping supply low - and demand continues to increase due to an increasing population (particular Baby Boomers who really need help).

2. Too many med spas and docs offering esthetic procedures.

3. Poor marketing (external AND internal) -- I believe the average Joes and Joannes out there stil has no idea what can be done to help improve the appearance of their skin (and bodies).

4. Lack of business knowledge, experience and education.

Botox Doc and Pmdoc:

1. Make sure you are escrowing any "package" dollars you take in until the treatments are actually performed.

2. Have you been making a concerted effort to educate and cross promote your esthetic services to your medical patients? DVD loops in the waiting room, LCD screens in the treatmen rooms, POP brochures and handouts, quarterly newsletters??? Have you tried small workshops and wine/cheese seminars?? All these things are far less risky than overpriced advertising. Work the warm market to the bone-- the folks who already know you. It's too expensive to pay the big dollars to recruit new people all the time.

med spy guy:

BTW, I made a mistake and my email above was signed pmdoc but i'm jmd. Yes, we are actively doing all of the above recommendations. Does this mean that I should be doing better financially compared to others?

jmd

To PMdoc (or jmd):

I guess my post isn't really advice to the 4th year med student. But, when I was a young pup, just starting out in medicine, I listened to the stories my then elder colleagues told during rounds. I learned a great deal from their experience. So I offered my own story.
Of course, like all things there are cycles. The medical environment 15 years ago is nothing like it is today. And in 15 years, I suspect it will change again. 15 years ago many plastic surgeons couldn't find jobs after they finished their residency and aneasthesiologists were having a difficult time as well. Today, PS is a hot speciality, and so is aneasthesiology. What will tomorrow bring? Who knows.
Perhaps we're at the end of the cosmetics cycle, perhaps it will get stronger.
But, what I do know is that it is a cash business and under the same laws of supply and demand that any retail business is. It can take upward of a year to get into the black for any retail business. So at 4 months and pocketing a few thousand, I would say you are doing very well indeed.

JMD: I was part of a franchised operation and I observed many of my brethren generating huge monthly revenues (after spending huge dollars on ads) and also watched many of the "flame out" due to a faulty business model. Most entrepreneurial med spas start from scratch with zero clients and have to pay (through the nose) to recruit clients. Since many physicians start with patient populations ranging from 5000 to upwards of 20,000, I really believe they have a real advantage over non-physicians who are trying to get into the business. If you are doing all the things I mentioned above, just keep doing them and I really believe you will succeed in the long run. There is nothing wrong with starting slowly and gradually building the business. The main thing is to make sure you are making a small profit each month (i.e., putting some dollars in your own pocket) and not deluding yourself with prepaid package dollars. Keep a close eye on your monthly P & L statement. Rome wasn't built in a day.

botoxdoc & med spa guy:

thank you for your advice. I feel encouraged. I do love what I do and I'd do it for free but I just want to make sure I don't do it for free.

jmd

Why bother even doing the internship?

You are not going to learn anything about the procedures you will be doing during your internship. If you work in a state that does not require you to be board certified in order to perform medical procedures (California, for example), then maybe you should just get right to it.

The business part will be the most difficult, but apparently you have an understanding of what it takes to start up your own business. I have done it; it is tough and far more expensive than even the best business plan will project, so have some back-up funds if you're not just independently wealthy.

My only other advice is that if you go into business with non-physicians (your realtor buddy), there are numerous legal obstacles in some states. You can actually go to jail in California for aiding and abetting the practice of medicine by a non-licensed person, which is what they will consider your friend/partner.

You will also essentially BE the product, so you will have to put in the majority of the actual work on a day to day basis, so look out for your interests up front vis-a-vis any non-medical investors/partners. Just speaking from experience.

Good luck.

Of course you should do your internship!!...everyone needs a couple years of clinical experience to refine and apply what you learned in med school.

The more experience & education you have, the better.

Doesn't matter what state he's in, an internship is required to get a license.

An older Family Practice friend once told me "you need five years of general practice before you can know anything"

I later realized he meant you should have a good understanding of general medicine because every specialty is interrelated.

I think to be so streamlined without an internship would be doing yourself and your patients a disservice.

I think LADOC is correct. You dont have to be Board Certified in some states, but all require an internship after med school

Hi All!

I like to have your sincere opinion, from those who have their medspa...is it worth to invest on a MedSpa? How long it takes until you make some profit? Which laser equipment I shall buy(since they are so many different equipments out there, in terms of Brands and prices!) Some say it's more logical to get a Hair Removal laser first, due to higher demand!

Any information from anyone is greatly appreciated!

Thank you so much in advance