First, let me start this by saying - I pinch myself every single day that I get to do a job I love for the rest of my life. I have somehow been blessed with, in my opinion (and the opinion of many well respected dermatologists), the best training program in the country. I'm treating a diverse patient population in terms of socioeconomic profile, ethnicity, and disease burden. My coworkers are all hard working, interesting team players. My attendings are some of the best dermatologist in the world, and my program director is too perfect for words.
Now that we've gotten that out of the way..
Dermatology residency is way harder than I expected it to be. The common thought is that dermatology residency should be easy after a general medicine intern year. I had the privilege of watching Alex (my boyfriend) go through dermatology residency, so I understood that it was a lot more work and reading than anticipated. I thought I was prepared, but I didn't really understand.
Although my hours are in general shorter than my hours on general medicine (9 to 11 hour shifts compared to 10-14 hour shifts on medicine), the time is much busier. My typical day of medicine wards consisted of me drinking coffee as I checked patients' morning labs, rounding on all of my patients, writing their notes in the resident lounge, rounds with my attending and coresidents, putting in final orders and discharge summaries, lunch with my cointerns, and then the afternoons were spent following up on notes left by consultants, checking in on patients after procedures, making sure discharged patients got out smoothly, checking in on my remanding patients and then going home if not on call that day. My intern year was at a community hospital, so my case load was lower than an academic center, but the most patients I carried on a wards month at a given time was 7. It was usually closer to 5 or 6. At academic hospitals the case load is usually around 10 patients a day - which is a lot of work.
Still, contrast this with dermatology where I'm seeing 12-16 patients a day. There's no down time of sipping coffee as I write my note. There's no down time of table rounds where I academically discuss my patient with a team of colleagues. There's no down time of placing orders from the calm of the residency room. It all happens in real time.
My clinic is very busy, so there's no previewing charts. I walk into a room. I open a chart. I quickly read the patient's previous note if they're not a new patient. I then discuss how they've been in the interim. Unlike inpatient medicine, there's no medication administration record to tell me what medications the patients have actually been using for their skin (only a record of what was previously prescribed). If the patient is new, I take a detailed history from them instead and start to formulate a differential. After processing all of the information for the patient, I then present the history, physical exam, and my tentative plan to my attending. My attending will then review the patient with me, teach me a clinical pearl or two, and then adjunct my plan as appropriate. Then, I place the orders for lab work, imaging, and prescriptions and educate the patient on the diagnosis and plan. Once this is wrapped up, I put that clinical encounter behind me and go on to give the next patient my full attention.
If you're thinking to yourself, "how hard can it be? If it's wet, make it dry. It it's dry, make it wet" - stop it. For one, I don't know why that saying is so popular. What does "make it wet" even mean? It doesn't sound like something you should be doing in a clinical setting, at least.
It is true that some of our cases are very simple, but there are also very severe cases. For example, today I saw a very sweet patient with breast cancer metastasized to the skin and toenails falling off because of her chemotherapy. I also saw one of my regular follow-up patients with pemphigus vulgaris - a rare and serious blistering disease, that I have seen relatively often during my first three months of training.
Topical steroids are the backbone of what we do, but we prescribe way more than topical steroids. As a resident, I regularly prescribe serious immunosupressive medications with serious potential complications, such as high dose prednisone, thallidomide, mycophenolate mofetil, rituximab, and methotrexate to name a few. These medications require precise prescribing habits, close lab monitoring, and follow-up outside of the clinic encounter. Typically if a patient is on one of these medications, their lab work is done the day of the clinic encounter. Their results return the next day. I review them, and if they are within normal limits for that patients, I then send the prescription to the pharmacy.
I also spend time outside of clinic completing insurance prior authorization forms - which is when the insurance company makes me justify a prescription I wrote - usually for an antifungal cream or tretinoin.
Biopsy follow-up is another important area of my job. It's my job to make sure any skin cancer I biopsied in clinic receives definitive treatment.
Of course, as busy as clinic is, I still can't compare it to my colleagues who are working 24+ hour shifts multiple times a week. Also, every weekend is a golden weekend in dermatology, which makes the week even easier. (We do have to start taking call in January, but it's not even close to as much call as other specialties)
So, that's clinic. Then there's learning.
One of the great things about dermatology is our field is so diverse, but that means there's a lot to learn. I will need to show proficiency in the following areas to pass my dermatology boards at the end of residency.
1. Medical dermatology
2. Pediatric dermatology
3. Basics of dermatologic surgery
Of course, that's what makes the field so much fun! The mix of diseases and people I see in clinic is different every day. Also, I get great training in all four areas.
As you can maybe tell by my day, learning comes in small bits during clinic. It's my job to read and learn outside of clinic and our hourly morning lectures. I spend at least 10 hours a weekend reading. It should be more. There is so much to learn. (every "erythematous maculopapular" rash is not the same. Also, dermatologist don't use such generic descriptions) For example - I just finished reading the Bolognia chapter of benign melanocytic lesions. Do you know how many benign melanocytic lesions there are according to Bolongnia? 19 - ephelides (freckles), cafe-au-lait macules, Becker's melanosis, solar lentigines, lentigo simplex and mucosal melanocytic lesions, dermal melanocytosis, nevus of ota, blue nevus and its variants, common acquired melanocytic nevi, melanocytic nevi of genital and flexural skin, melanocytic nevus of acral skin, spitz (spindle and epitheliod cell) nevus/tumor, pigmented spindle cell nevus, atypical (dysplastic) melanocytic envus, congenital melanocytic nevus, nevus spilus, halo nevus, combined nevus, recurrent melanocytic nevus. Clinically these all look slightly different and on pathology these all look slightly different.
I absolutely love my job. Even though it's overwhelming to know so little at my current stage, I'm excited to learn the information and I enjoy the difference I'm making in people's lives. Three months in, I have days where I feel like I'm killing it knowledge wise and then I have days where I feel completed defeated. On those defeated days, I'm comforted by reading a description written by the upper levels or listening to them throw out seemingly random genetic mutations related to a skin disease. I know that I'll get there as long as I continue to work hard, and luckily I really like working hard. Overall, I think I have one of the coolest jobs out there.
Just thought I'd update you guys on how things are going.
I'll update you in another 3 months or so on here, but follow along on instagram or snapchat (@elyse.love)to see in real time - although I do post more about my life outside of medicine than work. <3
Post coming soon on an example of a day in dermatology clinic. <3