Question on what makes "harder/malignant" derm programs

[Transformers]

-As an outpatient specialty, just curious as to what makes the derm residency harder/malignant at some places vs. other places. I feel like most people, having the option/interest/credentials, would take a "malignant" derm program over doing an internal medicine or gen surgery residency any day of the week.

-Additionally, I'm just trying to think of the intrinsic factors as to what motivates one person choose (or not choose) a more prestigious derm program over another. Matching into derm is hard in itself and certain factors are definitely pretty important in medicine/surgery (volume and types of cases, autonomy, hospital resources, didactics, better fellowship opportunities, academic career, etc...) but usually not discussed when applying to derm.

Hence my two questions really are:
1.) If you're not going into academia, what pushes someone to lean towards or rank higher, based solely on intrinsic qualities, a "more prestigious" program such as UCSF Penn Yale Michigan NYU Harvard? As a means to an end, does it translate to better opportunities in landing a better procedural fellowship or ultimately job prospects anywhere in the country? Because if not, all I can think about is just...well ego. I may be pessimistic but I just find it hard that harvard can churn out the better community dermatologist than the dermatologist from puerto rico...ok maybe that was extreme but I feel like you get the point.

2.) Just trying to dispel another myth or fact. Why are top tier-research heavy programs (UCSF Penn Yale Michigan NYU Harvard) reputed to have the toughest, most brutal hours (medicine-like) because I am having a tough time understanding this from a curriculum standpoint...Derm clinics (adults, procedural, peds, dermpath) by nature are 8-5/6. Having rotated at some decent mid-tier programs (n of 2), the resident's rotation hours seem relatively standard (8-5/6 at the latest; no weekends). The inpatient consult block, which can last from 8-8/9 mostly with seeing the consults starting in the afternoon, seem to be the busiest aspect of the derm residency.

Take Harvard for example...its curriculum (below) looks similar to the programs (and I am sure many programs elsewhere) that I have rotated at so far (the mix of outpatient services, inpatient, peds, dermpath, procedural, consult service for hospitals, and VA). Not to mention, it looks like harvard has half-day of resident didactics off per week, and some nice, seemingly cush research and teaching months thrown in there.

So really, the only possible reason why I can think of a derm program being "malignant" or "more difficult," correct me if I am naive, are possibly a.) working on weekends or b.) The consult service: having more consult months/longer consult days/consult services stacked on top of doing clinic. Harvard has about 11 required consult months over the span of 3 years but it seems like you strictly do solely just consult.

Schedule:
http://www.hms.harvard.edu/dermatology/training/residency/clinicalrotations/clinicalrotations.html

Didactics:
http://www.hms.harvard.edu/dermatol...onalcurriculum/didacticeducationschedule.html

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[PatsyStone]

I have a few thoughts.

First, derm is competitive, and even if you are a TP, you have no idea where you will get interviews at.

Second, people change their minds. Someone may enter residency intending to enter academics and leaves going into PP. It doesn't mean the program failed, it just means that one changed their mind.

Third, here is a piece of advice I wish I knew last year: picking a program is more difficult than you think. On paper, it may seem obvious that you want to train at NYU or Harvard, but do they have what you need. Do you like the area? Do you like the training? Do you like the people? No program is perfect for everyone. Some people want to go into private practice and want to work as little as possible. Other people plan on doing peds derm, and they want to train at a program that has plenty of peds derm opportunities. Some people want a 2+2 program, while others want to be close to their family. A program may look good on paper, but you may end up hating it when you interview. None of these issues are exclusive to derm, but they may not be apparent when you are selecting programs on ERAS.

Despite how short they are, you learn a ton about a program on your interview day. You can learn a lot about the day-to-day operations of a program from their website, but you get a sense of the culture of the program during your interview. Do the attendings treat the residents well or do they use them as cheap labor? How many clinic sites are there? Is there a dedicated consult resident or do you have to cross-cover from clinic? Are all the clinics always overbooked or is it only the clinic of a particular attending? Derm may not work as many hours as medicine, but the clinic pace is non-stop. If your program has friendly, easy-going attendings, the process will be OK, but if the attendings are rude, unpleasant, or overly critical, a half-day in clinic may feel like an eternity. During my interviews, I was amazed that residents tended to be very straight-forward, and they tended to not sugar coat how great or terrible the faculty and the hours are. No one wants to recruit a resident who complains for three years because they didn't know what they were getting themselves into. If a program is going to work you hard, you'll get a sense of it at the interview.

 

[smartparts]

Derm may not work as many hours as medicine, but the clinic pace is non-stop.

agree 100%. also patients in derm clinic are usually more upset about their problem than the average medicine patient.

malignancy is totally dependent on your likes/dislikes. you seem to talk a lot about hours worked which is only one definition. as patsy noted, short hours with bad attendings/coresidents can by much worse than longer days with people you like.

 

[Tamahawk]

Programs that append hospital consults to the end of clinic days tend to have the longest and most unpredictable hours. This makes perfect sense, because there are almost no Derm clinics that see patients after 430-5pm. However, if you have to see ANY consults after clinic, your day is automatically extended an hour or more. I had childcare issues to consider during residency, so it was important for me to be done with work at a predictable time each day--hence, I had to rank some programs (eg. Harvard) lower than I otherwise would have.

 

[doctalaughs]

Programs that append hospital consults to the end of clinic days tend to have the longest and most unpredictable hours. This makes perfect sense, because there are almost no Derm clinics that see patients after 430-5pm. However, if you have to see ANY consults after clinic, your day is automatically extended an hour or more. I had childcare issues to consider during residency, so it was important for me to be done with work at a predictable time each day--hence, I had to rank some programs (eg. Harvard) lower than I otherwise would have.

Agree with above. In general, the higher volume of hospital consults the longer and more unpredictable your hours. I trained at a high volume consult program and the hours were not fun (ie seeing 5-10 consults a day on top of clinic sometimes, and 5-10 each weekend day you were on call). However I'd argue you get invaluable experience from that which is harder to get at a lower volume program.

After seeing your 50th TEN case in the burn unit and your hundredth rare variant of pemphigus or deep fungal infection, nothing scares you.

 

[gurlyderm77]

I agree with PatsyStone.

The whole application process is so random. Derm is very competative and you have no idea where you will get invites to. I am from the SW and thought I would get most my invites in the SW and where I rotated. I only got an invite at my home institution and one where I did an away rotation in the SW. The rest of the places I got invites were all over the map...except the SW.

You will get adequate training at most programs. The most important thing to consider about "malignant" programs is the environment you work in. You can always work a little harder to address deficiences of a program (ie, spend more time self studying dermpath if the training is laking), but you can't change the leadership, faculty, or residents with which you will work

Wherever you get your invite, take a close look at the dynamics of the program, the chair, the program director, and the residents. Are they happy? Does the program seem functional?? Sometimes it is difficult to evaluate this during your interview day. It can be difficult to ask these questions and even if you do, the residents may not answer them truthfully. I think I got the most honest advice from talking to other medical students on the interview trail, meetings, and during aways. They are more likely to give you some honest insight about their home institution or where they did aways.