Dermpath Programs created Equal?

[Whiskeyjack]

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I know that the current belief is to get into a dermpath program anywhere. But are all programs really good? Is the training at Ackerman with Elston or UCSF with LeBoit the same as training at smaller less known programs or are they appreciably different in quality?

 

[caffeinegirl]

As with most answers..it all depends on what you want to do, and also where you want to practice. If you'd like to stay in academics, then training with the most renown names is better, since you can use them to network and get a position. If you're geographically restricted, then training in the program in your desirable geographic location is better IMHO. Given that this is such a competitive fellowship, in the end getting into a fellowship is better than no fellowship at all...and I know of few people who had more than one fellowship offer.
And the experience of a dermpath fellowship as a pathologist differs on the institution, given how much exposure you'll get in dermatology clinic..everything from virtual "shadowing" to being on your own as a de facto resident. I think that the dermpath experience differs too, regarding how much time you have with attendings, how much preview time, and also the dermpath volume and variety.
Given that there are markedly fewer positions than candidates, take whatever you get. And if you have the opportunity to choose between multiple offers, then weigh them considering your future practice goals.

As for the inevitable "ranking" question, I would suggest a ranking hybrid of not only the "notorious" dermpath attendings but also in conjunction with the best dermatology departments (since training is split between the two areas).

 

[Whiskeyjack]

As with most answers..it all depends on what you want to do, and also where you want to practice. If you'd like to stay in academics, then training with the most renown names is better, since you can use them to network and get a position. If you're geographically restricted, then training in the program in your desirable geographic location is better IMHO. Given that this is such a competitive fellowship, in the end getting into a fellowship is better than no fellowship at all...and I know of few people who had more than one fellowship offer.
And the experience of a dermpath fellowship as a pathologist differs on the institution, given how much exposure you'll get in dermatology clinic..everything from virtual "shadowing" to being on your own as a de facto resident. I think that the dermpath experience differs too, regarding how much time you have with attendings, how much preview time, and also the dermpath volume and variety.

Given that there are markedly fewer positions than candidates, take whatever you get. And if you have the opportunity to choose between multiple offers, then weigh them considering your future practice goals.

As for the inevitable "ranking" question, I would suggest a ranking hybrid of not only the "notorious" dermpath attendings but also in conjunction with the best dermatology departments (since training is split between the two areas).

Thanks for the insight as always. But regarding your "ranking" comment, with dermatology being even arguably more competitive than dermpath wouldn't ALL dermatology departments be pretty top notch also?😕

 

[caffeinegirl]

Thanks for the insight as always. But regarding your "ranking" comment, with dermatology being even arguably more competitive than dermpath wouldn't ALL dermatology departments be pretty top notch also?😕

There is an informal ranking of dermatology departments out there....such as Hopkins, NYU, Harvard, UCSF, Stanford, Yale etc etc etc. So, if you combine the big names in dermpath with the big names in dermatology then you can go from there. Look at the powerhouses at the AAD meetings, which dermatology depts are considered to be on the frontier of academics, etc.

 

[icpshootyz]

Everyone can be ranked. If you take the cream of the crop, separate them from the herd, you can then look at them individually and see who's the "cream" of the cream of the crop, no? Likewise every dermatology program is not going to be full of academic marvels and astoundingly good physicians. There's plenty of people in derm who kissed the right rearends to get where they are without great merit, just like in all walks of life.

Plus, like caffeinegirl said, it isn't just the people you work with but the system you work under. Personally I think the derm component of a dermpath fellowship for a path-trained fellow needs to expose you to the most patients with the highest yield diagnoses. I think the ACGME requirement about being treated more like a derm resident is assinine, as I will never practice dermatology. I need to SEE more diagnoses and how they present/evolve, not re-learn how to write prescriptions and clinic notes. But maybe that's just me. If I had my choice of programs I would have leaned towards one that gave me more of a shadowing role in derm clinic instead of a resident role. But that would have required lots of offers!

 

[KCShaw]

If it was that easy medical school would teach one how to be a good physician by shadowing and hand-holding instead of all this requirement for residency in the first place. Unfortunately it happens that a lot of people don't "really" learn a thing well unless/until they become directly responsible for it. So while I totally agree a dermpath resident shouldn't become a temporary dermatology intern doing essentially nothing but paperwork and scut, I do think there's merit in the concept of having the responsibilities of a derm resident. There's also a significant amount to be gained from understanding the management of many of the things one may diagnose, the problems faced on the clinical derm side, etc., not -just- diagnosis. Of course, those are some of the same reasons we used to have a "5th year," and look how well that went..

 

[icpshootyz]

That sounds good in theory. But in practice it's just scut. Let's face it, in derm clinic the overwhelming majority of what is seen each day is banal and uneducational. Warts, basic skin cancers, moles, and rashes. But each day there's probably 10% of the patients that come in with something interesting and really worth seeing. I lose out by not seeing those cases if I'm doing more scut-type work. I'm just saying that there's something to be said for the fact that I'm NOT a derm resident. I'm a specially trained pathologist who is doing dermpath, and my time in dermatology is meant to reinforce my diagnostic skills by providing me better insight into the presentation and evolution of dermatologic disease. I'm not saying that it isn't useful to be in derm clinic, as I think it's incredibly useful to see the lesions in person. But it is not useful to reconcile medication lists, dictate clinic notes, and other scut-type work. Besides, I'm barely getting 6 months of dermatology. That's a sparse amount of time to try and learn a heckuva lot of derm. Rapid fire, shadowing-style learning I think is best in that situation.

 

[mlw03]

What about the other side, dermatologists looking at prostate biopsies? Trying to act likes path intern and previewing/writing up a colectomy for cancer? Think they consider that scut? Not saying it is, but just adding something for consideration.

 

[Enkidu]

What about the other side, dermatologists looking at prostate biopsies? Trying to act likes path intern and previewing/writing up a colectomy for cancer? Think they consider that scut? Not saying it is, but just adding something for consideration.

Yep. This post pretty much sums up why pathology will always be way more awesome than dermatology.

As far as scutwork goes, the worst it gets in pathology is grossing? That's not as bad as the garbage that any clinicians goes through.

 

[mlw03]

Yep. This post pretty much sums up why pathology will always be way more awesome than dermatology.

As far as scutwork goes, the worst it gets in pathology is grossing? That's not as bad as the garbage that any clinicians goes through.

While I agree,numbers suggest plenty do not.

But what is the purpose of the derm doing surg path? Never had that explained well. Some make sense: heme, soft tissue. Perineal skin in gi or gyn make sense, but pancreatic ipmns or mcns? I dunno.

 

[icpshootyz]

What about the other side, dermatologists looking at prostate biopsies? Trying to act likes path intern and previewing/writing up a colectomy for cancer? Think they consider that scut? Not saying it is, but just adding something for consideration.

Personally I think the only reason derm residents doing dermpath are forced to do general path is so pathology residents doing dermpath don't complain that they're getting more dermpath in the year than we are. No, there's no reason for them to do most general path at all. Heme, soft tissue, and some basic Onc path is fine. Maybe a little cytology to get a grasp of high-power cellular detail. But not everything. And I certainly know that the derm residents at specific places DON'T do all general path. I can speak for ones that get focused Heme and Soft Tissue path training. I would bet it's the rare dermpath fellowship that makes the derm residents act like true path 1st years.

 

[caffeinegirl]

The dermatology aspect for pathology trained fellows does vary, as I mentioned earlier. By "de facto resident' I meant that you will be seeing patients on your own (without a resident), be presenting to attendings, doing the skin exam, differential diagnosis and treatment. And although the patient load in clinic should be less than a first year resident, the responsibilities are the same. This is in contrast to the "shadow" experience, in which the fellow tags along with a resident or attending and doesn't have to work up the patient, order labs, write scripts, write referral letters, call patients with bx results, doing foot ulcer clinic etc etc etc. And there are programs where the fellow does consults on the floor as well.

Again, I think the distinction is there, but the significance is minimal. That's because unless you're one of the rare candidates out there, you'll only get one offer, and you'll take it. And you'll adapt to the schedule because it's only one year (six months clinic), and because the ends justify the means.

As for the derm-trained fellows..well...let's just say their year doesn't compare to the path-trained fellows who have busy clinic duties. Few if any of the surg path depts allow derm trained fellows to gross specimens and preview independently. But the reason they do need a surg path background is because there are random non-dermatology questions on the dermpath boards.

 

[KCShaw]

And there are things that, albeit rarely, turn up in skin which one might never see in 1 year of dermpath fellowship but might see commonly in general surg path. Derm-origin dermpaths sometimes need a little fear struck into them that not everything they'll end up seeing under the microscope is of skin/skin adnexal origin. And that, tongue in cheek, sometimes people apply definitive rather than descriptive/categorized diagnoses.

I think people have different ideas of what "scut" is, too. To some it's doing administrative work and donkey work by simply shuttling things around the department or hospital which normally would be handled by a layperson, secretary, or perhaps a tech, phlebotomist, etc. To others it's just the boring, but perhaps bread-and-butter, parts of medicine, like documenting what you do with/to a patient or grossing. It's those parts of the job some have happily divvied out to physician assistants so they can focus on what they find interesting or useful to them, then get all uppity about other specialists using PA's to see -their- referred patients. But, perhaps I digress. My point is that there is "high-yield" and there is "scut" and there is "useful in the big picture but boring and seemingly tangential in the moment." Hopefully most programs have found a suitable middle ground in there.

 

[caffeinegirl]

Agreed KC regarding the derm trained fellows. They definitely need the surg path background to gain perspective onto how to actually read a slide and interpret histological findings (rather than pattern recognition).
A dermpath fellowship is not a replacement for pathology residency training or dermatology residency training. It's just meant as a limited time to focus exposure on the "other side" of the field of dermatopathology which the path or derm trained fellow didn't have during their respective residencies.
I don't expect to be able to treat psoriasis patients, just as I hope my derm trained cofellow isn't diagnosing ovarian sex cord stromal tumors. 🙂

 

[KCShaw]

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