Derm or IM

[mdjo]

I'm a prelim medicine PGY-1 at a nice academic medical center. I applied to derm last year as a senior and only matched to intern year. I'm reapplying this year, but I'm having second thoughts about my career choice.

I did a short 2-week academic derm elective earlier this year, and I felt a little disappointed. The field seemed different as a resident than it did as a medical student--the residents were so stressed out with overbooked clinics and high expectations from faculty, and I felt a little disappointed with all the boring "let's switch this ointment to this other one" on a PsA patient when the rheumatologists got to do all the cool stuff with biologics. On the other hand, as a resident, I appreciate the derm lifestyle way more than I did as a student. I also appreciated how fun it is to mix the day up with surgeries and procedures, and I'm even more impressed than I ever was as a student at the awesome diagnostic prowess of most derms. I still love the subject matter of derm. But I struggled with not feeling like a "real doctor" compared to my other IM rotations this year.

Basically, what I'm trying to say is that I think I would still be very happy with a career in derm, but for the first time, I can actually see myself being okay with something else.

I reapplied this year and started getting some interviews (so far I'm at 2, for what that's worth). My IM PD is really happy with my performance in the program and offered to let me stay on to finish a categorical IM residency. I would say that I would probably be equally happy in derm, rheum, or ID. Obviously the stressfulness of the training and the reimbursement as an attending are way better for derm than for rheum or ID, and since I like all three fields, that's kind of swaying me. I'm now deciding whether I should give up on derm (doing so would be the path of least resistance, but the thought of an extra two years in IM is pretty intimidating), or whether I should keep pushing for derm. The worst outcome of all would be turning down this chance to finish a residency and become board-certified in at least something that I like, then not matching in derm either, and ending up with nowhere to go next year, my loans due, and my career in the toilet. My PD wants to know my decision by the end of the December, and since creating a new residency spot for me entails sticking his neck out, he only wants to do it if I am absolutely sure that IM is what I want.

The number of people I can speak freely to about this is very limited, so I would really love advice from anyone on this.

How many derm interviews would you have to get to feel confident turning down the offer to finish a categorical IM residency? And what would you do in my shoes? Has anyone else struggled to choose between derm and IM?

P.S. As far as stats, my steps are ~260, I'm AOA, have 4 pubs and 2 posters, half derm. So derm is not some crazy reach for me at least given the stats.

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[PatsyStone]

and I felt a little disappointed with all the boring "let's switch this ointment to this other one" on a PsA patient when the rheumatologists got to do all the cool stuff with biologics.

I don't know if this is playing into your "pros and cons" lists, but I think it's program dependent. There are some departments where derms give out biologics for Ps and PsA like candy, and some programs are more hands-on with CTDz and autoimmune diseases than others

 

[Dral]

Oh man, that's a tough spot. I wonder if your IM PD set that date because they know they want a committed decision to IM and not just a "I'll try Derm once more and if not, then I'll stay here in IM". Kinda hard ball if so. heh.

You've seen IM for a while now and if you like what you are doing, then maybe it's what is for you. I have some ok fond memories of intern year, but then I think...I applied to Med/derm and didn't get a spot...THANK GOD...I dodged that bullet. I don't think I could have handled two more years of IM (ICU).

So maybe it's what your calling is. If you're ok with helping people and making people feel better and feel better about themselves, then Derm is great. If you really want that 'stethoscope saving lives' kinda feeling, then maybe IM is for you. Remember though, if you go into Rheum it's going to feel a lot like Derm in terms of clinic. As Patsy pointed out, if you are a Derm (especially at an academic center) you can do a lot of decent derm medical management.

However, most Dermatologists don't typically enjoy that type of thing. I think most of us actually like the quickness of visits...helping people without having to manage complex things. I'm not afraid to admit that. Not all dermatologists are like that of course.

If you are more into complex management, then maybe IM is for you. I will say, I always thought I would love the complex stuff (I applied med/derm for instance), but when I started residency, I realized I really did like the quick visit thing that Derms mostly do. I guess that probably just makes the decision more difficult for you.

 

[dermie1985]

Well, I'd say if you still only have 2 interviews by the end of December, it might not be a bad idea to take the IM residency offer, especially if you feel you like the work. 2 interviews doesn't seem like good odds and if you already like the program/location you might be better off in the long run. I don't think outpatient ID or rheum will be much different than derm in terms of lifestyle/pathology. Training would be much longer as you'd do 2 more years of IM + 3 years of fellowship. In terms of "prescribing biologics, etc" it's more on physician comfort. I know plenty of derms who do, and plenty who just send the more complicated patients to a specialty clinic. Also. Derms are "real doctors".

 

[doctalaughs]

I'm a prelim medicine PGY-1 at a nice academic medical center. I applied to derm last year as a senior and only matched to intern year. I'm reapplying this year, but I'm having second thoughts about my career choice.

I did a short 2-week academic derm elective earlier this year, and I felt a little disappointed. The field seemed different as a resident than it did as a medical student--the residents were so stressed out with overbooked clinics and high expectations from faculty, and I felt a little disappointed with all the boring "let's switch this ointment to this other one" on a PsA patient when the rheumatologists got to do all the cool stuff with biologics. On the other hand, as a resident, I appreciate the derm lifestyle way more than I did as a student. I also appreciated how fun it is to mix the day up with surgeries and procedures, and I'm even more impressed than I ever was as a student at the awesome diagnostic prowess of most derms. I still love the subject matter of derm. But I struggled with not feeling like a "real doctor" compared to my other IM rotations this year.

Basically, what I'm trying to say is that I think I would still be very happy with a career in derm, but for the first time, I can actually see myself being okay with something else.

I reapplied this year and started getting some interviews (so far I'm at 2, for what that's worth). My IM PD is really happy with my performance in the program and offered to let me stay on to finish a categorical IM residency. I would say that I would probably be equally happy in derm, rheum, or ID. Obviously the stressfulness of the training and the reimbursement as an attending are way better for derm than for rheum or ID, and since I like all three fields, that's kind of swaying me. I'm now deciding whether I should give up on derm (doing so would be the path of least resistance, but the thought of an extra two years in IM is pretty intimidating), or whether I should keep pushing for derm. The worst outcome of all would be turning down this chance to finish a residency and become board-certified in at least something that I like, then not matching in derm either, and ending up with nowhere to go next year, my loans due, and my career in the toilet. My PD wants to know my decision by the end of the December, and since creating a new residency spot for me entails sticking his neck out, he only wants to do it if I am absolutely sure that IM is what I want.

The number of people I can speak freely to about this is very limited, so I would really love advice from anyone on this.

How many derm interviews would you have to get to feel confident turning down the offer to finish a categorical IM residency? And what would you do in my shoes? Has anyone else struggled to choose between derm and IM?

P.S. As far as stats, my steps are ~260, I'm AOA, have 4 pubs and 2 posters, half derm. So derm is not some crazy reach for me at least given the stats.

If you need to run to codes and deal with critically ill patients to feel like a real doctor than definitely don't go into dermatology. However, if you end up in rheum or ID you will rarely do this anyway.

If you want to deal with biologics for skin, terrible drug rashes, oncology patients with skin complications, chronic cutaneous vasculitis, skin connective tissue disease - believe me, there is plenty of opportunity as most dermatologists don't like dealing with these patients the physician community (including the rheumatologists) will get "wind" that you are good at it and start to refer them all to you (I know from experience).

Unfortunately you definitely lose money and take more risk on these patients....but if its what you like there will be no shortage.

 

[Giovanotto]

Why not consider a pathology fellowship after your derm residency? That way you get to not only do the "superficial" stuff, but also the more technical diagnosing.

 

[asmallchild]

Why not consider a pathology fellowship after your derm residency? That way you get to not only do the "superficial" stuff, but also the more technical diagnosing.

The OP seems to be drawn in by the management of complex medical cases, not making diagnoses through a microscope...

 

[DoctorDermis]

As said above, strongly agree w/ program dependence and your personal career goals as well as tolerance for complicated cases.
In my training at my program, derms are treating everything from sezary syndrome to crusted scabies and erythrodermic psoriasis, and often the primary prescriber for biologics, immunologics, pheresis therapies, targeted therapies, chemo wraps, etc etc. An endless plethora of complicated cases that are "referred" from outside practitioners.

At our program, Derms are essential for inpatient diagnosis and management of severe dermatoses, and also for saving untold tens of thousands in cost of care with situations such as correctly diagnosing stasis dermatitis in patients undergoing treatment for cellulitis, identifying DRESS / DIHS syndrome early on, etc etc.

If you want complicated hard cases that most other specialties are not adept at managing, then Derm may be a great fit for you...assuming that you dont mind some heckling derms from other specialties, the potential lack of equal professional respect, lower pay in academic settings to do complicated derm and inpatient consults, etc.