if a residency program lacks in certain aspects of training...

[blackcoffee]

Hey everyone,

Been worrying about a if a residency program is known to be lacking in certain aspects of the training such as procedures (no VA), how would you go about trying to make up for that during residency? undecided if I'm interested in any type of fellowship, but I just hope that after 3 years I'll be at least competent in procedures, dermpath, etc in case I want to fly solo right after residency. Obviously every program has its strengths and weaknesses, but just wondering if I should go into residency accepting the fact that my training or exposure to various procedures will be less than ideal, or if I can do anything on my part to increase my skills. Any thoughts appreciated!

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[PatsyStone]

Hey everyone,

Been worrying about a if a residency program is known to be lacking in certain aspects of the training such as procedures (no VA), how would you go about trying to make up for that during residency? undecided if I'm interested in any type of fellowship, but I just hope that after 3 years I'll be at least competent in procedures, dermpath, etc in case I want to fly solo right after residency. Obviously every program has its strengths and weaknesses, but just wondering if I should go into residency accepting the fact that my training or exposure to various procedures will be less than ideal, or if I can do anything on my part to increase my skills. Any thoughts appreciated!

Programs without VAs or a county were fairly straight-forward on the interview trail: you'll be OK-ish at doing simple excisions. I chose to rank several programs with a VA and/or county above others in a more desirable location. You may chose differently. However, it's not just about having access to more proceduers: you'll usually have more autonomy at the VA and county.

The VA issue isn't cut-and-dry. Michigan staffs two VAs, but the residents have essentially zero continuity with patients. Hopkins does not have a VA, but they do derm-rheum better than most programs (derm manages psoriaitc arthritis/scleroderma and they write ECP orders).

I know people say "there are no bad programs" or "everyone will get what they need out of a program," but I don't buy it. You have no idea where you'll get interviews, and you'll have no idea which programs you will or won't like. Sorry if this was not more hepful.

 

[Dral]

I tend to stand by the "no bad program" thing for SOME things. Here's why:

Is one really going to use their time to do anything more than simple excisions out in practice? It's not too pragmatic.

If one wants to do that, they should probably be doing a procedural fellowship, which you can get regardless of residency...if you do the right things.

Same for path. Is one gonna waste their time reading the tough stuff in practice if they're not fellowship trained?

Now cosmetics and especially peds? If a program is weak in those, it may be a bit more problematic. However, every cosmetic/laser supplier has reps who are more than happy to come teach you to use their products/wares once you're out in practice. Though I do know of some programs that don't seem to even get good baseline cosmetics.

Peds? If you really like it and want to incorporate it, I think you should really find a program that is strong in peds. Peds fellowship tends to lead to academics opposed to focusing on it in private practice...although I'm sure some do it for that reason.

My program is pretty good in peds, but I'll personally be happy to send out tougher peds stuff to colleagues who will gave better stickers and lollipops than I plan to have in my office.


It's tough to get all that stuff in one program. Add in things like skin of color, good inpatient, research, and networking. You're pretty much down to the large metropolitan programs. I was lucky enough to train at one of those, but those aren't for everybody either.

 

[doctalaughs]

I tend to stand by the "no bad program" thing for SOME things. Here's why:

Is one really going to use their time to do anything more than simple excisions out in practice? It's not too pragmatic.

If one wants to do that, they should probably be doing a procedural fellowship, which you can get regardless of residency...if you do the right things.

Same for path. Is one gonna waste their time reading the tough stuff in practice if they're not fellowship trained?

Now cosmetics and especially peds? If a program is weak in those, it may be a bit more problematic. However, every cosmetic/laser supplier has reps who are more than happy to come teach you to use their products/wares once you're out in practice. Though I do know of some programs that don't seem to even get good baseline cosmetics.

Peds? If you really like it and want to incorporate it, I think you should really find a program that is strong in peds. Peds fellowship tends to lead to academics opposed to focusing on it in private practice...although I'm sure some do it for that reason.

My program is pretty good in peds, but I'll personally be happy to send out tougher peds stuff to colleagues who will gave better stickers and lollipops than I plan to have in my office.


It's tough to get all that stuff in one program. Add in things like skin of color, good inpatient, research, and networking. You're pretty much down to the large metropolitan programs. I was lucky enough to train at one of those, but those aren't for everybody either.

I would argue its better to lack in cosmetics than path or inpatient (or peds). Unless you are planning to do mostly cosmetics, anyone can refine their botox or filler skills and do a little pulse dye laser- enough for most private practice settings.

If your path experience sucks you may not read a single slide after residency but you will not think outside the box interpreting reports (ie they read lichenoid tissue reaction on this rash, what is in the differential etc)

If you lack in inpatient experience you may do very few hospital consults but you will suck at managing some important things in our specialty (i cannot tell you how many dermatologists are terrible at working up or managing cutaneous vasculitis, immunobullous dz, erythroderma, disseminated cutaneous infections, serious drug eruptions etc - mainly things you get good at seeing a high volume of hospital patients but these things present outpatient when you leave the ivory tower)

If you lack in peds obviously thats a big problem because in most of the usa there isn't a pediatric dermatologist easily available - you are it.

 

[Tamahawk]

Hey everyone,

Been worrying about a if a residency program is known to be lacking in certain aspects of the training such as procedures (no VA), how would you go about trying to make up for that during residency? undecided if I'm interested in any type of fellowship, but I just hope that after 3 years I'll be at least competent in procedures, dermpath, etc in case I want to fly solo right after residency. Obviously every program has its strengths and weaknesses, but just wondering if I should go into residency accepting the fact that my training or exposure to various procedures will be less than ideal, or if I can do anything on my part to increase my skills. Any thoughts appreciated!

No residency is perfect. You will be deficient in some aspects of dermatology regardless of how carefully you try to avoid it. Fortunately, most programs will prepare you well enough for the basic stuff you will do in private practice.

That said, here are some benchmark skills I'd make sure the senior residents have:
1) Procedural: senior residents feel comfortable excising melanomas with 1cm margins on the trunk and extremities, doing eyelid biopsies, and excisions on the cheek/forehead/scalp/neck. Vascular laser experience. Botox and filler are so easy you don't need exposure during residency for this.
2) Dermpath: senior residents should be comfortable with Barron's top 200 Dermpath diagnoses and should be able to talk through basic histologic differentials (lichenoid vs vacuolar, pagetoid DDx, perivascular dermatitis DDx, tadpole DDx, etc)
3) Inpatient: comfort evaluating and treating GVHD, drug eruption, vasculitis, SJS/TEN, erythroderma.
4) Medical Derm: the most important thing is having some sort of continuity clinic so you can see how pts in the real world respond to your treatment regimens (assessment of your "intention to treat"). This helps you know the time frame in which certain diseases respond/don't respond and patient non-compliance helps you formulate better/easier to follow treatment plans. Secondly, senior residents should feel comfortable prescribing systemic immunosuppressants (most important), biologics (secondary importance) and phototherapy (critical IMHO).

 

[gurlyderm77]

I agree with Tamahawk. No residency program is perfect and each will have is deficiencies. Certain programs have a lot more deficiencies than others however. I think it is important to consider where you see yourself after training. Do you want to be a generalist in private practice, do you want to pursue fellowship, and/or do you want to be in academics.

If you plan to enter private practice, I think following Tamahawk's advice is sound. If you want to pursue a fellowship, obviously look at larger centers that offer the fellowship in your area of interest. Same for academics, you want to look at larger programs that have the resources (faculty, money, specility clinics, etc.) as well as allowing the residencts to have some dedicated time for research.

Probably one of the most important things for the general med student looking for dermatology residency programs is to try and find a program that you see yourself being happy traiing there. Do you like the faculty and residents? Can you live where the progam is? I agree with Dral and the others about the "there is no bad program" when it comes to training. HOWEVER, there are plenty of BAD programs out there when in comes to the work environment. I have talked to several residents at meetings from some of these "BAD" programs. While their training is adequate, they have endured a miserable traininig environment and wish they would have considered this more when raking programs rather than training location. In fact, I know a resident that decided to quit their program because the environment was so terrible.

 

[Transformers]

I agree with Tamahawk. No residency program is perfect and each will have is deficiencies. Certain programs have a lot more deficiencies than others however. I think it is important to consider where you see yourself after training. Do you want to be a generalist in private practice, do you want to pursue fellowship, and/or do you want to be in academics.

If you plan to enter private practice, I think following Tamahawk's advice is sound. If you want to pursue a fellowship, obviously look at larger centers that offer the fellowship in your area of interest. Same for academics, you want to look at larger programs that have the resources (faculty, money, specility clinics, etc.) as well as allowing the residencts to have some dedicated time for research.

Probably one of the most important things for the general med student looking for dermatology residency programs is to try and find a program that you see yourself being happy traiing there. Do you like the faculty and residents? Can you live where the progam is? I agree with Dral and the others about the "there is no bad program" when it comes to training. HOWEVER, there are plenty of BAD programs out there when in comes to the work environment. I have talked to several residents at meetings from some of these "BAD" programs. While their training is adequate, they have endured a miserable traininig environment and wish they would have considered this more when raking programs rather than training location. In fact, I know a resident that decided to quit their program because the environment was so terrible.

On that note:

1.) What is the value of telederm as part of training both short and long term? Does it translate into much? I've seen dedicated VA months strictly telederm and I was wondering if doing that vs. Actually seeing patients is more worthwhile.

2.) If the end goal is say Mohs surgery and you have a department that has a strong Mohs peogram takes its own fellows historically but say the department lacking in other areas....should you judge the program on what it can provide you/what you want short term or long term as a resident? I ask this because some programs with Mohs fellowship might not have all the features of training mentioned above vs. Other major metropolitan programs but still has ultimately what you are looking for long term, career wise.

3.) Lot of places I have seen involve a VA, main(and peds) hospital for consults, and clinics. That has been my sort of threshold for a "good" program training-wise. How important is the county hospital aspect of training (often to me equates to training in ethnic/pigmented skin)? Does the VA suffice for this patient population?

4.) In big cities, I have seen residents do consults at up to like 3 different main hospitals (non-county). What does this translate to? It sounds hectic if anything, but does it truly translate into a wider range of clinical experience?

 

[Slack3r]

3.) Lot of places I have seen involve a VA, main(and peds) hospital for consults, and clinics. That has been my sort of threshold for a "good" program training-wise. How important is the county hospital aspect of training (often to me equates to training in ethnic/pigmented skin)? Does the VA suffice for this patient population?

In my experience in multiple VAs across the country, the VA tends to skew more towards the whiteys.

 

[Tamahawk]

1.) What is the value of telederm as part of training both short and long term? Does it translate into much? I've seen dedicated VA months strictly telederm and I was wondering if doing that vs. Actually seeing patients is more worthwhile.
Wouldn't worry or place much value on telederm.


2.) If the end goal is say Mohs surgery and you have a department that has a strong Mohs peogram takes its own fellows historically but say the department lacking in other areas....should you judge the program on what it can provide you/what you want short term or long term as a resident? I ask this because some programs with Mohs fellowship might not have all the features of training mentioned above vs. Other major metropolitan programs but still has ultimately what you are looking for long term, career wise.

This is potentially risky. Many residents are now interested in Mohs and if it's a program with more residency spots than Mohs fellowship slots, then you may end up competing with your classmate for the one spot--this can be really stressful. If you DONT get the fellowship slot at your home program, then you will be competing for outside fellowship positions against applicants from better residency programs. If on the other hand, there is only 1 residency slot per year then this is a good approach.

3.) Lot of places I have seen involve a VA, main(and peds) hospital for consults, and clinics. That has been my sort of threshold for a "good" program training-wise. How important is the county hospital aspect of training (often to me equates to training in ethnic/pigmented skin)? Does the VA suffice for this patient population?
Your assessment is correct partially. County = minorities. VA however = older white guys mainly. If ethnic Derm is a major component of your desired training program, seek an urban program or one with a county hospital.

4.) In big cities, I have seen residents do consults at up to like 3 different main hospitals (non-county). What does this translate to? It sounds hectic if anything, but does it truly translate into a wider range of clinical experience?
It makes stuff hectic. Not sure if it adds much value honestly.

 

[doctalaughs]

1.) What is the value of telederm as part of training both short and long term? Does it translate into much? I've seen dedicated VA months strictly telederm and I was wondering if doing that vs. Actually seeing patients is more worthwhile.
Wouldn't worry or place much value on telederm.


2.) If the end goal is say Mohs surgery and you have a department that has a strong Mohs peogram takes its own fellows historically but say the department lacking in other areas....should you judge the program on what it can provide you/what you want short term or long term as a resident? I ask this because some programs with Mohs fellowship might not have all the features of training mentioned above vs. Other major metropolitan programs but still has ultimately what you are looking for long term, career wise.

This is potentially risky. Many residents are now interested in Mohs and if it's a program with more residency spots than Mohs fellowship slots, then you may end up competing with your classmate for the one spot--this can be really stressful. If you DONT get the fellowship slot at your home program, then you will be competing for outside fellowship positions against applicants from better residency programs. If on the other hand, there is only 1 residency slot per year then this is a good approach.

3.) Lot of places I have seen involve a VA, main(and peds) hospital for consults, and clinics. That has been my sort of threshold for a "good" program training-wise. How important is the county hospital aspect of training (often to me equates to training in ethnic/pigmented skin)? Does the VA suffice for this patient population?
Your assessment is correct partially. County = minorities. VA however = older white guys mainly. If ethnic Derm is a major component of your desired training program, seek an urban program or one with a county hospital.

4.) In big cities, I have seen residents do consults at up to like 3 different main hospitals (non-county). What does this translate to? It sounds hectic if anything, but does it truly translate into a wider range of clinical experience?
It makes stuff hectic. Not sure if it adds much value honestly.

Agree with all the comments above except #4. Multiple (large) sites means you see more pathology and more rare/ infrequent diagnoses. If you cover 3 major burn units you'll see way more cases of TEN, horrible pemphigus and bullous drug eruptions than if you cover 1 (or none). Same goes for being more likely to rotate in all subspecialty and multi-disciplinary clinics.