We’ve all heard the phrase, “survival of the fittest.” It suggests that in the competitive, “free market” world, it is the “best” who survives and it’s “the cream” that rises to the top.  But is that true for doctors?  Do patients get better care when competition rules the health care marketplace?

A few years ago, a doctor from a large primary care group contacted me to give a talk to the staff and to potentially become part of their referral network.  “It’s so hard to find a good dermatologist in New York!” the doctor complained.

“Really?”  I thought to myself.  In New York?

New York City has the highest concentration of dermatologists in the nation—if not the world.  Whereas in many parts of the country, there are indeed “dermatology deserts” where people wait 4 to 6 months, and/or have to drive two hours, to see a board-certified dermatologist, in Manhattan, patients can often find a specialist to see them the same day.  In the Big Apple, if patients cannot get in within a couple of weeks, they can go somewhere else.  As a doctor, you are never too popular to get no shows if people have to schedule appointments too far out.  They don’t have to wait.  I once found skin allergy patches on the back of a new patient who had come in for a second opinion.  He had scheduled the same day and had just seen another dermatologist … a few hours prior.

Sometimes patients complained that it was hard to find a good dermatologist — but I figured it was because they didn’t work in health care.  But still, the statement seemed dissonant.  I had excellent, young colleagues leave New York because they couldn’t fill their schedules.  Why then were patients who complained they couldn’t find a good doctor not flocking to their offices? How were patients, and even referring doctors, perceiving such scarcity in what felt like a saturated market? Here are some possibilities:

1. Blocking doctors. Sometimes health care systems refuse to make patients aware of all their options. Years ago, an internist who used to send a significant number of patients to my office suddenly stopped.  We had always received great feedback. Shortly after, I met her at a social event and pulled me aside.  “I’m so sorry I had to stop referring to you,” she said, blushing. “The hospital administrators got upset with me and said that I was only allowed to refer to the doctors at our hospital,” she whispered.  Sometimes systems don’t let new board-certified doctors join, yet, midlevel providers with a fraction of the training are instead available.

2. Marketing. In a competitive market, marketing becomes more significant.  Marketing is simply making the public aware of your service.  Many think of marketing as unethical.  If you think your service benefits the public, however, one could argue it’s unethical not to market.  The problem is that when the choice of doctors is driven by marketing, it can ironically make it harder to find the good doctor, or a doctor at all, versus the good marketer.  Anyone can market.  Not just anyone is a good doctor.  With marketing, a patient has to be savvy.  Does the patient know the difference between someone marketed as a board-certified dermatologist (a physician who has accredited training) versus a “dermatologist” who may, or may not be, board-certified in some other specialty but want to practice dermatology?  Does the patient know the difference between board-certified doctors and mid-level providers who may have had only two years of school and no accredited training?  Sometimes we perceive that there is no “good” board-certified dermatologist although they are there because of all the noise.

3. “Dermatologists don’t take insurance.” For some reason, there is a popular myth that “no dermatologists take insurance.” If you look at most insurance directories, however, that is clearly not true.  Yes, of course, some don’t.  Even then, sometimes, the cash fees are affordable.  Get the facts.  And by the way, even when a doctor participates in your health insurance, cosmetic procedures are not covered.

4. Valuing perceived convenience over expertise. Shortly before the coronavirus pandemic, a long-time patient started her visit with the comment, “you’re gonna be mad at me.” I asked her why. A month prior, she had had a flare-up of a condition I had diagnosed and treated years ago.  Instead of coming to me, or another dermatologist, to manage it had she gone to a nearby walk-in clinic.  “There were no appointments here,” she defended. That wasn’t true.  “What happened?” I asked.  They said they didn’t know what she had.  This was not a surprise as it was a specialist level problem.  She was not, however, referred to a board-certified dermatologist.  She was instead given multiple prescriptions.  She didn’t get better.  She sought help, again, this time at a dermatology office — but one staffed by a physician assistant.  “It was so convenient,” she defended.  There she got a diagnosis, but it was incorrect.  Even if it had been the right one, the dosing of the medication was off.  There was no improvement, so she came back to see me.  She had always had access to expertise — but it was out marketed by perceived convenience.  But, in fact, it was less convenient and more expensive.  Treatment was delayed.  There was a convenience fee.  She paid extra copays for visits and prescriptions.  It exposed her to potential medication side effects.  “It’s not that I should be mad at you,” I said to her.  “You should be mad at you.”  We laughed although it really wasn’t funny.  It’s a shame that in “free market medicine” that patients have to be such savvy “consumers,” even when they do have access to good care.

One expects it to be hard to find a “good doctor” where there are few.  But, ironically, in competitive markets it can be hard to access one even where there are many.

Dina Strachan is a dermatologist and author of Moxie Mindset: Secrets of Building a Profitable, Independent Physicians Practice in a Competitive Market.  She can be reached at her self-titled site, Dr. Dina Strachan, and on Twitter @drdinamd.

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