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March 19, 2008
Understanding the Flight to Cosmetic Surgery
An article by Natasha Singer has documented the increasing attractiveness of cosmetic medical practices in the US:
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 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 . . . . “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.
I think the article's explanations for the "best and brightest"'s migration to the more superficial specialties are good, as far as they go. But larger economic forces also play a role.
As Robert Kuttner has explained, the key starting point in any analysis of contemporary American health care is the trend to allocate in response "to profit opportunities rather than medical need." Thomas Pogge's important recent article "Growth and Inequality" helps illuminate how that trend, while perhaps defensible in some limited situations, has been thoroughly corrupted by rising levels of inequality:
When growth is accompanied by rising inequality, this matters for the poor in two ways: It reduces or even negates gains in their absolute share that would otherwise result from economic growth. And it also diminishes their relative share. Many things money can buy are positional or competitive: political influence, for instance, and access to education and even health care depend not merely on how much money one has to spend but also on how much others are willing and able to spend on those same goods.
I have explored this dynamic in more detail with respect to primary care here, dentistry here, and with respect to political power here. If current trends continue, perhaps we will see the rise of teams of courtier doctors and specialists, paid a handsome retainer to be at the beck and call of, say, one tycoon's family, or a small gated community.
Posted by Frank Pasquale at March 19, 2008 08:27 PM
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Comments
the trend to allocate in response "to profit opportunities rather than medical need."
As if the two were mutually exclusive.
Which is the preferable paradigm if you're concerned about having an adequate supply of physicians: (a) where the best and the brightest flock to medical school because of "profit opportunities," or (b) where the best and the brightest flock to law school for the same reason?
Posted by: KipEsquire at March 20, 2008 08:28 AM
This is also unfair to residents in these three fields. While they are "appearance related," ENT's, plastic surgeons, and dermatologists also do a lot of straight medicine. (And if you think plastic surgeons don't count, ask who helps put your face together or fixes terrible scarring after trauma).
My ENT did a lot of good clearing my breathing passages and dermatologists treat skin cancer and many other genuinely harmful things.
So we need to know how many of these residents are choosing these fields to do "cosmetic things" and how many go in for the fact that they can do medical good and rarely get paged at 3 am.
Posted by: Sean M. at March 20, 2008 06:01 PM
@KipEsquire
Of course, there is only a meager barrier (bar exams which sometimes have 90% pass rates) to entry in law, and apart from patent, no real barriers to moving into specialties.
The AMA and state medical associations have been much more successful than law at cartelizing and limiting supply.
Just because profit motives might work well in a competitive market does not necessarily mean they improve a market that's at an inferior equilibrium.
Posted by: bill at March 20, 2008 06:49 PM
It's interesting that there are at least four dimensions of substantive inequality at work here, and they don't all cut in the same direction.
First, there's inequality of access to medical care. People with more money can and do pay more, which gives them better access to cosmetic procedures while diverting medical resources from procedures that do more to improve actual health outcomes for people in greater medical need.
This cosmetic channeling has a secondary effect within the medical profession, which is where this article comes in. All other things being equal, doctors would rather go into these named specialties: greater demand and a reasonably restricted supply lead to higher incomes for doctors in those fields.
But third, unlike some (e.g. surgical) specialties with high incomes that require exceedingly long hours, the cosmetic specialties also have a reputation as "lifestyle" fields. The procedures are primarily outpatient, comparatively short, and are rarely urgent. That means doctors performing them have relatively regular hours and less need to be available to respond to emergencies 24/7. That means they often attract doctors trying to get off the treadmill; ones who want to opt out of a system of constant competition and increasing work pressures, who want to have a balance between work and family.
The irony, of course, is that since the cosmetic specialties are so attractive for physicians, the competition to get into them becomes especially severe. Thus, to get a job in medicine with a balanced lifestyle often requires living as unbalanced a lifestyle as you can stand while in medical school (or really, in medical school. college, and high school) so that you can get into that hyper-selective residency.
It's a bit like the tenure system.
Posted by: James Grimmelmann at March 20, 2008 10:40 PM
