Questions on the Procedural Dermatology felllowship

[Transformers]

Sort of thinking ahead...but similar to say when one is interested in doing cardiology and deciding on which IM programs to consider...in derm:

1. What factors of a derm residency program do you want to consider if you are thinking about the procedural derm fellowship (besides your derm residency program already having a fellowship program itself and having a history of taking their own)?

2. Does reputation of your derm residency program have much of a bearing (similar to why people go to top IM programs to have access to the best fellowships)?

3. Is there a variety of training received amongst procedural derm fellowships? Some strictly do predominantly Mohs, but I think it would be awesome/helpful if there was a list of diversity in training/qualifications you can get through a procedural derm training (mohs, veins, hair transplant, phototherapy, lasers, cosmetics, etc...) along with number of cases expected.

4. Is there a ranking of procedural derm fellowships?

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[Dral]

1. Pretty much what you mentioned

2. Not too much. The further you get from High School, the more it seems to be about what you have done, not where you've done it

3. Yes. This is why you interview. You figure out what you want to learn and target the fellowships that fulfill that.

4. Not that I know of

Do some google searches and use ASDS

https://www.asds.net/WorkArea/DownloadAsset.aspx?id=5123

 

[smartparts]

don't know enough about 1, 2, and 4 but the ASDS Fellowship Finder can tell you about each fellowship. it includes a list of procedures performed and number of cases.

https://www.asds.net/fellowship-finder/

 

[asmallchild]

Sort of thinking ahead...but similar to say when one is interested in doing cardiology and deciding on which IM programs to consider...in derm:

1. What factors of a derm residency program do you want to consider if you are thinking about the procedural derm fellowship (besides your derm residency program already having a fellowship program itself and having a history of taking their own)?

2. Does reputation of your derm residency program have much of a bearing (similar to why people go to top IM programs to have access to the best fellowships)?

3. Is there a variety of training received amongst procedural derm fellowships? Some strictly do predominantly Mohs, but I think it would be awesome/helpful if there was a list of diversity in training/qualifications you can get through a procedural derm training (mohs, veins, hair transplant, phototherapy, lasers, cosmetics, etc...) along with number of cases expected.

4. Is there a ranking of procedural derm fellowships?

1) Those are helpful but I wouldn't pick a residency program based on likelihood of ability to match into procedural dermatology

2) Not so much the derm program's reputation but which surgeons you get to work with and whether or not any of your faculty members have a relationship with the potential procedural derm PD

3) Yes, there can be quite a bit of variety. There isn't a list however. You'll need to interview as Dral mentioned and see whether your interests align with the program's strengths

4) No there isn't

 

[Transformers]

1) Those are helpful but I wouldn't pick a residency program based on likelihood of ability to match into procedural dermatology

2) Not so much the derm program's reputation but which surgeons you get to work with and whether or not any of your faculty members have a relationship with the potential procedural derm PD

3) Yes, there can be quite a bit of variety. There isn't a list however. You'll need to interview as Dral mentioned and see whether your interests align with the program's strengths

4) No there isn't

Ahh gotcha...UCLA just wow...the only program with straight Yesses across the board...seriously facelifts and blepheroplasties? Sounds like you're getting a facial plastics surgical fellowship that minus the nosejobs but with Mohs thrown in there. Not to mention hair transplant, vein surgery, liposuction and heck maybe some gyn/urology recon as long its restricted to the skin and requires to purely a local anesthetic.

With that in mind...if a program doesn't offer training in an area like hair transplant or say facelifts based on that database above...is that a definite no or can you squeak in some training on the side during the year during conferences/arrangements with attending or practitioners. Just not how sure the curriculum adheres to what is stated.

 

[asmallchild]

Ahh gotcha...UCLA just wow...the only program with straight Yesses across the board...seriously facelifts and blepheroplasties? Sounds like you're getting a facial plastics surgical fellowship that minus the nosejobs but with Mohs thrown in there. Not to mention hair transplant, vein surgery, liposuction and heck maybe some gyn/urology recon as long its restricted to the skin and requires to purely a local anesthetic.

With that in mind...if a program doesn't offer training in an area like hair transplant or say facelifts based on that database above...is that a definite no or can you squeak in some training on the side during the year during conferences/arrangements with attending or practitioners. Just not how sure the curriculum adheres to what is stated.

The database is a self-reporting one and is not very accurate

Many programs also offer elective time (whether it's a discrete month or certain days of the month) where you can spend some time shadowing associated physicians who may perform the types of procedures you listed

A standard caveat: it is certainly helpful to get some broad exposure. I find it's more useful to really focus on what you'd like to pursue as a career. I don't think you'll find too many locales or too many practices for that matter that will support a dermatologist performing facelifts and blephs on a regular basis. There are locales where it's a struggle to convince patients to allow me to repair the Mohs defect I've made (they want plastics for the repair). For me personally, a program that struck a balance between heavy Mohs and reconstructions and some lighter cosmetic work (neurotoxins, fillers, etc) was more desirable than one that farmed you out to watch procedures that I knew I'd be unlikely to perform as an attending (hair transplants, liposuction, etc)

 

[spicysoup55]

How competitive is it to get a procedural dermatology fellowship?

 

[Transformers]

The database is a self-reporting one and is not very accurate

Many programs also offer elective time (whether it's a discrete month or certain days of the month) where you can spend some time shadowing associated physicians who may perform the types of procedures you listed

A standard caveat: it is certainly helpful to get some broad exposure. I find it's more useful to really focus on what you'd like to pursue as a career. I don't think you'll find too many locales or too many practices for that matter that will support a dermatologist performing facelifts and blephs on a regular basis. There are locales where it's a struggle to convince patients to allow me to repair the Mohs defect I've made (they want plastics for the repair). For me personally, a program that struck a balance between heavy Mohs and reconstructions and some lighter cosmetic work (neurotoxins, fillers, etc) was more desirable than one that farmed you out to watch procedures that I knew I'd be unlikely to perform as an attending (hair transplants, liposuction, etc)

Fair point. Yeah...I guess in my dream, never get bored, procedural heavy derm world, it'd just be awesome to be the man at a bunch of things, hence the desire to learn all facets of derm. I.e. having two days of mohs/facial plastics surgery, two days of hair transplant/veins/lasers/cosmetics, and a day of medical derm. Really don't care even care about the hours as I don't think I could be bored while managing a decent family life.

But youre right, I guess it sucks to think about the referral issue and acquiring enough cases. On top of that, theres also the issue profitability...would i be making equally or more doing a strictly derm procedure than a bleph or facelift. Heck in non academia it sounds like there aren't enough cases to sustain a pure Mohs practice. Maybe teaming up with a plastics surgeon stud can lure in some of the facial plastics cases?!

 

[Dral]

I preface what I'll say by stating that it's commendable that you are looking ahead this much. However, this is one of things that you just have to wait to experience during residency to understand.

I get where you're coming from...I'm the type that always wants to do it all. However, especially in today's medical climate, that doesn't really work unless you're the only game in town (like rural small town USA).

Most places, you need to specialize and even super specialize. Peds Derm specializing in EBA, Dermpath specializing in reading spindle cell tumors, Derm surgeon specializing in treatment of recurrent DFSP and fibrosarcomas, gen Derm who specializes in hair transplant.

You have to pick one thing and do it better than everyone else. It's too difficult to be jack of all trades and get people to come to you.

Imagine when you finish residency. Unless you replace a Derm who retires, you need pts to fill your practice. They don't just *poof* appear out of nowhere (especially in saturated markets). You need a 'draw' to get people to come to your practice. "Hey Dr. Family Med, I'm really trained well in hair transplant. If you have any patients that are interested, I'd be grateful if you send them my way!"

If you are spread too thin and don't do the transplant well, the pt complains to Dr. Family med. After a few of those, they stop sending pts to you and send them instead to the guy doing transplants 3 days a week....well, having his techs do them, but that's a discussion for a separate thread.

You get the idea. I don't like to quell the idea that it has to be that way. If one wants to do it all, they can! Just realize it is difficult to do that and maintain a level of expertise in all areas.

Anyway, you'll figure it out.

 

[asmallchild]

How competitive is it to get a procedural dermatology fellowship?

Depends which program you are referring to. In general, if you apply broadly enough, it's not very difficult.

The real question (and this has been mentioned by a few attendings now) is whether or not the fellowship is in line with your future goals. It's great to do a heavy Mohs fellowship but if you aren't able to do full time Mohs in the desired location of your choice, you may end up rethinking whether or not the fellowship is worth one year of a derm attending's salary.

 

[Slack3r]

Fair point. Yeah...I guess in my dream, never get bored, procedural heavy derm world, it'd just be awesome to be the man at a bunch of things, hence the desire to learn all facets of derm. I.e. having two days of mohs/facial plastics surgery, two days of hair transplant/veins/lasers/cosmetics, and a day of medical derm. Really don't care even care about the hours as I don't think I could be bored while managing a decent family life.

But youre right, I guess it sucks to think about the referral issue and acquiring enough cases. On top of that, theres also the issue profitability...would i be making equally or more doing a strictly derm procedure than a bleph or facelift. Heck in non academia it sounds like there aren't enough cases to sustain a pure Mohs practice. Maybe teaming up with a plastics surgeon stud can lure in some of the facial plastics cases?!

Why wouldn't the plastic surgeon being doing those cases? Rhytidectomys are extremely complex procedures (when done correctly) and I highly doubt that a) a one year, "surgical" fellowship will properly train you to do these correctly and b) that anyone in their right mind would actually pay you to do so. Derms just aren't trained, nor should they be, for these larger procedures. Leave it to the PRS/FPRS/oculoplastics guys, your paying customers certainly will.

 

[asmallchild]

Why wouldn't the plastic surgeon being doing those cases? Rhytidectomys are extremely complex procedures (when done correctly) and I highly doubt that a) a one year, "surgical" fellowship will properly train you to do these correctly and b) that anyone in their right mind would actually pay you to do so. Derms just aren't trained, nor should they be, for these larger procedures. Leave it to the PRS/FPRS/oculoplastics guys, your paying customers certainly will.

True for the most part but not 100%

There are quite a few procedural derm programs that provide wide exposure to these procedures (I can't comment on rhytidectomy but a few of these programs feature high volumes of blephs and tumescent lipo)

There are certainly areas where patients will pay to have these procedures done by a dermatologist (hint: the fellowship programs will be located in that area also)

My recommendation is to a) figure out if you are interested in doing these procedures in the first place (if you predominantly want to do face lifts, blephs, and lipo, I'd submit you may have picked the wrong residency) and b) will you be in a location or practice that will allow you to incorporate those procedures into your repertoire

If the answer is no to either one, you are making an awfully expensive choice to pursue fellowship (as educational as it may be).

 

[reno911]

Why wouldn't the plastic surgeon being doing those cases? Rhytidectomys are extremely complex procedures (when done correctly) and I highly doubt that a) a one year, "surgical" fellowship will properly train you to do these correctly and b) that anyone in their right mind would actually pay you to do so. Derms just aren't trained, nor should they be, for these larger procedures. Leave it to the PRS/FPRS/oculoplastics guys, your paying customers certainly will.

More or less what asmallchild said is correct. Only things I would add are that if, as a Mohs surgeon, you do a high volume of complex skin cancer reconstruction, then doing a facelift is actually not that difficult at all. Also, as previously pointed out there are some dermatologists that do a lot of facelifts, do them very well, and have many patients that will gladly pay for their services. These people are not that numerous though, so many dermatologists make the mistake of thinking that if they were never exposed to it in their training, then it must not exist. That's not true about a lot of things, including doing facelifts well.

 

[DermatoFIGHT]

True for the most part but not 100%

There are quite a few procedural derm programs that provide wide exposure to these procedures (I can't comment on rhytidectomy but a few of these programs feature high volumes of blephs and tumescent lipo)

There are certainly areas where patients will pay to have these procedures done by a dermatologist (hint: the fellowship programs will be located in that area also)

My recommendation is to a) figure out if you are interested in doing these procedures in the first place (if you predominantly want to do face lifts, blephs, and lipo, I'd submit you may have picked the wrong residency) and b) will you be in a location or practice that will allow you to incorporate those procedures into your repertoire

If the answer is no to either one, you are making an awfully expensive choice to pursue fellowship (as educational as it may be).

Those blephs are functional upper lid blephs of just skin removal FYI. There is no orbital fat removal. You will not see a dermatologist performing lower lid blephs.

 

[asmallchild]

Those blephs are functional upper lid blephs of just skin removal FYI. There is no orbital fat removal. You will not see a dermatologist performing lower lid blephs.

My fellowship case log would indicate otherwise. On both counts.

 

[DermatoFIGHT]

My fellowship case log would indicate otherwise. On both counts.

This is the first I have heard of that. Where I am they discuss the complications being more appropriately handled by a surgeon (i.e. retro orbital bleeding). Perhaps it varies by state. Out here, we were informed in order for you to perform specific procedures in office, you must be credentialed to perform in hospital as well (per the plastic surgery department). Seems it varies by state.

 

[reno911]

Those blephs are functional upper lid blephs of just skin removal FYI. There is no orbital fat removal. You will not see a dermatologist performing lower lid blephs.

Not true. There are dermatologists that do lower lid blephs. It seems like you (and whoever told you this) are making the same mistake as the previous guy:

More or less what asmallchild said is correct. Only things I would add are that if, as a Mohs surgeon, you do a high volume of complex skin cancer reconstruction, then doing a facelift is actually not that difficult at all. Also, as previously pointed out there are some dermatologists that do a lot of facelifts, do them very well, and have many patients that will gladly pay for their services. These people are not that numerous though, so many dermatologists make the mistake of thinking that if they were never exposed to it in their training, then it must not exist. That's not true about a lot of things, including doing facelifts well.

We can add lower lid blephs to that list of things.

This is the first I have heard of that. Where I am they discuss the complications being more appropriately handled by a surgeon (i.e. retro orbital bleeding). Perhaps it varies by state. Out here, we were informed in order for you to perform specific procedures in office, you must be credentialed to perform in hospital as well (per the plastic surgery department). Seems it varies by state.

I don't know where "here" is, but as far as I'm aware that's universally untrue as a state rule. I suppose it could be an institutional rule. It does not even logically make sense. If a Mohs surgeon is qualified to do a large eyelid surgery to remove a lower lid tumor and is able to do a complicated lower eyelid reconstruction (many Mohs surgeons refer these out, but many don't), then why would there be a problem doing a bleph? Wherever it is that you are, is there a rule that Mohs surgeons can't do lower lid flaps and grafts which are at risk for similar complications?

 

[Tamahawk]

Fair point. Yeah...I guess in my dream, never get bored, procedural heavy derm world, it'd just be awesome to be the man at a bunch of things, hence the desire to learn all facets of derm. I.e. having two days of mohs/facial plastics surgery, two days of hair transplant/veins/lasers/cosmetics, and a day of medical derm. Really don't care even care about the hours as I don't think I could be bored while managing a decent family life.

But youre right, I guess it sucks to think about the referral issue and acquiring enough cases. On top of that, theres also the issue profitability...would i be making equally or more doing a strictly derm procedure than a bleph or facelift. Heck in non academia it sounds like there aren't enough cases to sustain a pure Mohs practice. Maybe teaming up with a plastics surgeon stud can lure in some of the facial plastics cases?!

I understand your dream, but as the others have said, it is exceedingly difficult in major markets to be this diversified, UNLESS you have some sort of built-in internal referral system that constantly feeds you ****loads of patients. In this scenario, your patients and referring providers would essentially have no choice but to see you, so you can expand your scope of practice a bit.

However, for most of us in private practice, our referrals are directly correlated with our (word of mouth) reputation for doing a better job at "X" procedure than your competitors. In an open (major) market, it's best if you do one thing exceptionally well (Mohs/recons vs Cosmetics vs Peds Derm). We all like to think we could be a "master of all trades," but the truth is, expertise comes with time and experience, and someone who invests a higher percentage of their time to their craft (4-5 days/wk) will be better than you if you are only dedicating 1 day/wk to that craft. This is especially true when you consider the fact that you are competing with a handicap against other dermatologists (an extremely bright and multitalented cohort) who are not splitting their time between so many different endeavors.

 

[upairman]

Sort of thinking ahead...but similar to say when one is interested in doing cardiology and deciding on which IM programs to consider...in derm:

1. What factors of a derm residency program do you want to consider if you are thinking about the procedural derm fellowship (besides your derm residency program already having a fellowship program itself and having a history of taking their own)?

2. Does reputation of your derm residency program have much of a bearing (similar to why people go to top IM programs to have access to the best fellowships)?

3. Is there a variety of training received amongst procedural derm fellowships? Some strictly do predominantly Mohs, but I think it would be awesome/helpful if there was a list of diversity in training/qualifications you can get through a procedural derm training (mohs, veins, hair transplant, phototherapy, lasers, cosmetics, etc...) along with number of cases expected.

4. Is there a ranking of procedural derm fellowships?

If you are really hoping to get "diversified" training in mohs and also complex cosmetic procedures have you looked into cosmetic surgery fellowships??? While I was looking into doing a procedural fellowship I came across these. Normally you need training in a surgical specialty, but if you do a general surgery internship and then a procedural fellowship, you can apply to be a board certified cosmetic surgeon. There is a Dermatologist about an hour away from where I bought my practice that did this, and has a full cosmetic practice where he does every concievable cosmetic surgical procedure, and has a great reputation. He did a "cosmetic surgery fellowship" for 2 years after his residency however. You cannot qualify for that title by simply doing a mohs/procedural fellowship however, I think it is a requirement that you do a surgical internship. Although that would be aweful compared to an easy transition year, it might allow you to fulfill your goals.

 

[Slack3r]

If you are really hoping to get "diversified" training in mohs and also complex cosmetic procedures have you looked into cosmetic surgery fellowships??? While I was looking into doing a procedural fellowship I came across these. Normally you need training in a surgical specialty, but if you do a general surgery internship and then a procedural fellowship, you can apply to be a board certified cosmetic surgeon. There is a Dermatologist about an hour away from where I bought my practice that did this, and has a full cosmetic practice where he does every concievable cosmetic surgical procedure, and has a great reputation. He did a "cosmetic surgery fellowship" for 2 years after his residency however. You cannot qualify for that title by simply doing a mohs/procedural fellowship however, I think it is a requirement that you do a surgical internship. Although that would be aweful compared to an easy transition year, it might allow you to fulfill your goals.

http://www.plasticsurgery.org/articles-and-videos/do-your-homework.html