[Marxism] Skewed priorities

[Louis Proyect <lnp3@xxxxxxxxx>]

NY Times, March 19, 2008
The Price of Beauty
For Top Medical Students, an Attractive Field
By NATASHA SINGER

BOSTON — March Madness has a different meaning for Thomas Hocker and 
Meena Singh, a married couple in their final year at the Harvard Medical 
School, who are waiting to learn Thursday if they have been accepted 
into their residency programs of choice.

Already saddled with about $330,000 in education loans, they borrowed 
$20,000 more so they could fly around the country this winter for about 
two dozen residency interviews each. All told, each applied to 90 such 
training programs.

Ms. Singh, pregnant during interview season, gave birth to their second 
daughter in early January. Three days later, she flew to Miami for an 
interview.

The search has been difficult not because they are mediocre students; 
indeed, each has a brand-name education, academic honors and published 
research on disease. No, it has been hard because they aspire to be 
dermatologists.

As thousands of medical students await word this week on residency 
programs, two specialties concerned with physical appearance — 
dermatology and plastic surgery — are among the most competitive.

Only 61 percent of seniors at American medical schools whose first 
choice was dermatology received a residency in that field last year, 
compared with 98 percent for those whose first choice was internal 
medicine and 99 percent for those seeking family medicine, according to 
a report by the Association of American Medical Colleges and the 
National Resident Matching Program, which pairs candidates and programs. 
Although there are far fewer positions in dermatology (320 residencies 
in 2007) than in internal medicine (5,517) and family medicine (2,603), 
the field is attracting some of the best and brightest future doctors.

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 report 
said.

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 — and the 
lives of physicians, with better pay, more autonomy and 
more-controllable hours.

“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.

Medical school professors and administrators say such discrepancies are 
dissuading some top students at American medical schools from entering 
fields, like family medicine, that manage the most prevalent serious 
illnesses. They are being replaced in part by graduates of foreign 
medical schools, some of whom return to their home countries to practice.

“We have a shortage in America of primary-care or family-type doctors,” 
said Dr. Joel M. Felner, a cardiology professor who is the associate 
dean for clinical education at Emory University School of Medicine in 
Atlanta. Last year, the school enlarged its incoming class, hoping more 
students would specialize in the major diseases and preventative care, 
he said. “We do need dermatologists, but I am more worried about the 
really sick people and dermatologists aren’t taking care of them,” Dr. 
Felner said.

Until recently, saving skin did not have the cachet of saving lives. 
Doctors in other fields jokingly dismissed dermatology as a province of 
red-spot diseases that could not really be cured, but weren’t going to 
kill patients. Twenty-five years ago, the fiercest competition among 
medical students was for internal medicine and general surgery.

But dermatology’s status is rising, not just for the pay, hours and 
independence, but also because of the growing variety of treatments and 
devices in this fast-developing field that can help people in a 
looks-obsessed world. At a time of increased discussion of enhancing 
beauty, as well as narrowing standards for skin perfection, the public 
has a newfound esteem for doctors who treat appearance.

“People greatly value the skin because it is what is on the outside that 
is the face you present to the world,” Mr. Hocker said one evening last 
month after coming off a hospital shift in which he dealt with 
afflictions like heart failure and kidney failure. “Most dermatological 
diseases won’t kill you, but they can greatly affect your quality of life.”

Some dermatology professors said the growing allure of their field among 
medical students has raised the bar for applicants over the last decade. 
“Dermatology has always attracted bright students,” said Dr. Harley A. 
Haynes, a dermatology professor at the Harvard Medical School who has 
been mentoring medical students there since 1970. “But now we are 
getting more of the brightest and the best.”

Dr. Haynes likes to joke that even faculty members might not be accepted 
for a residency if they applied today.

A Psychological Lifeline

For an idea of the competition facing dermatology aspirants, consider 
the application numbers. Last fall, 383 people applied for 6 places — an 
average of about 64 applicants per spot — in Harvard’s dermatology 
program. By comparison, Harvard College received an average of 11 
applications per offer of admission in the class of 2010.

Mr. Hocker and Ms. Singh were well prepared for the Darwinian process of 
landing a dermatology residency when they met as classmates at the 
Harvard Medical School in 2003. Mr. Hocker, 27, holds a graduate degree 
from Cambridge University and an undergraduate degree in chemistry from 
Yale, where he was a champion hurdler. Ms. Singh, 26, was in several 
honor societies as a biomedical engineering student at the University of 
Southern California.

During her senior year, she competed on an MTV reality show called 
“Sorority Life,” but was ejected midseason for being too studious.

“In one scene, you see her all happy getting the acceptance letter from 
Harvard and in the next scene, you see her crying up a storm because she 
has been de-pledged from the sorority,” Mr. Hocker recalled fondly.

Neither student had planned to become a skin specialist.

Growing up in Kansas City, Kan., Ms. Singh loved visiting the hospital 
with her mother, an internist with long relationships with a diverse 
group of patients. Ms. Singh said she initially planned to emulate her 
mother, a physician who focuses on treating major adult diseases.

A lecture on skin-pigment conditions like vitiligo changed her mind.

“Nobody can see if you have hypertension or asthma, but everybody knows 
if you have a pigmentary disorder and these changes are a lot more 
obvious and devastating to patients with skin of color,” Ms. Singh said. 
“Having something on your skin is not life or death for people, but it 
can be equally important for them emotionally as a life-threatening 
disease.”

Indeed, dermatology can be a psychological lifeline for people with 
severe skin problems. At pools or the beach, some people shun those with 
psoriasis who have scaly skin, fearing the condition is contagious, 
doctors said. People with deep acne scars say it affects their personal 
and professional lives.

Then there is the growing popularity among otherwise healthy people of 
tweaking one’s appearance with cosmetic treatments, from Botox 
injections to lip plumping and laser hair removal. Plastic surgeons, 
dermatologists and facial surgeons in the United States performed about 
9.6 million such nonsurgical treatments in 2007, almost nine times the 
number a decade earlier, according to the American Society for Aesthetic 
Plastic Surgery.

‘Your Input Is Valued’

Mr. Hocker was finally sold on dermatology last year, while on a 
clinical rotation during which neurosurgeons called him and a 
dermatology resident to an intensive-care ward for a consultation. A 
patient, in a coma after surgery, was covered with mysterious red 
half-moon-shaped blisters. They could not determine the cause. Then Dr. 
Haynes of Harvard arrived.

“Dr. Haynes comes in and he is like a walking CAT scan, who eyeballs her 
from head to toe and has the diagnosis in 15 seconds,” Mr. Hocker said. 
The verdict: a rare blistering disorder caused by an allergy to an 
antibiotic.

Mr. Hocker said he liked the idea of drawing independent conclusions 
without tests or consultations with other doctors.

“The No. 1 thing that is going to save your life is the humdrum 
preventative stuff like blood pressure and cholesterol,” Mr. Hocker 
said. “But there is not a lot of respect for doctors who do that because 
anyone can get into it. But if you are an expert where no one else is, 
like the eye or the skin, your input is valued.”

Dermatology also attracts students like Mr. Hocker because of the 
potential for basic research on skin diseases that can lead to new 
treatments. Mr. Hocker said he plans to focus his career on researching 
the role of genetics in problems like skin cancer and abnormal scarring; 
he took a year off during medical school to conduct melanoma research.

While students like Mr. Hocker choose dermatology planning on research 
careers, others end up focusing on cosmetic treatments like skin 
tightening and resurfacing. Half of the dermatology residents graduating 
over the last five years from the program at the Boston Medical Center 
have chosen postgraduate fellowships that teach a combination of 
skin-cancer operations and cosmetic procedures, according to Dr. Barbara 
A. Gilchrest, the chairwoman of dermatology at Boston University School 
of Medicine.

Work Less, Earn More

Dermatologists say they enjoy the variety of a specialty that 
encompasses serious illnesses like skin cancer and psoriasis as well as 
conditions like uncombable hair syndrome.

But students interested in such work also often factor in personal 
benefits. Internists, for example, worked an average of 50 hours a week 
in 2006 while dermatologists worked about 40 hours, according to an 
annual survey by Medical Economics magazine. Dermatology also offers 
more independence from the bureaucracy of managed care, because patients 
pay up front for cosmetic procedures not covered by health insurance.

And while an internist earns an average of $191,525, a dermatologist 
earns an average of $390,274, according to an annual survey conducted by 
the Medical Group Management Association, whose membership includes more 
than 21,000 managers of medical practices. Dermatologists who specialize 
in cosmetic treatments or in skin-cancer operations can earn much more.

For thousands of medical students nationwide, especially those trying to 
enter the most competitive fields, this week — when residency 
acceptances are announced — has been fraught with tension. The National 
Resident Matching Program uses an algorithm to pair applicants with the 
one program they have ranked highest that also preferred them, a system 
that leaves some applicants disappointed.

Mr. Hocker and Ms. Singh face even longer odds because they entered the 
match process as a couple, seeking positions at the same program, or at 
least in the same region.

On Monday, when applicants learned whether they had been paired with a 
program at all, Mr. Hocker and Ms. Singh found out they will each obtain 
a residency. Thursday, they find out where.

“My friends going into general medicine and general surgery pretty much 
have an idea that they are going to be at their No. 1 or No. 2 school,” 
Ms. Singh said. “But we really could be anywhere in the country, 
together or not together.”

She added: “We would have a better chance of winning ‘American Idol.’ ”

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