Is dermatology just primary care with a better salary?

[doing_all_the_things]

I realize dermatology is an exceptionally competitive specialty to match into. Derm is also known to have one of the larger salaries in medicine and a relatively relaxed lifestyle. However, primary care specialties are often criticized for being monotonous, uneventful, boring, and simple. Given the little experience I had when shadowing dermatologists, it seemed that they could be considered well paid primary care doctors.

Have I got it wrong? Is there a whole lot more to derm than mole biopsy and acne management? Or are people drawn to derm exclusively for the money and lifestyle?

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[deleted564680]

I realize dermatology is an exceptionally competitive specialty to match into. Derm is also known to have one of the larger salaries in medicine and a relatively relaxed lifestyle. However, primary care specialties are often criticized for being monotonous, uneventful, boring, and simple. Given the little experience I had when shadowing dermatologists, it seemed that they could be considered well paid primary care doctors.

Have I got it wrong? Is there a whole lot more to derm than mole biopsy and acne management? Or are people drawn to derm exclusively for the money and lifestyle?

Yes.

 

[sholamd]

Yes, you've got it wrong. When I get a simple mole biopsy or acne, it's like a vacation. Here are three cases I saw today:
1. Patient with diffuse severe spontaneous ecchymoses, we all thought it was vasculitis but biopsy and labs were negative. Now he's recovering which is great, but after I examined him my attending asked, "What do you think of the facial rash?" which I totally missed. She thinks it's discoid lupus.
2. Patient I biopsied last week for orange-red plaques on the bilateral soles, report came in today: nodular amyloidosis.
3. Patient in his 70s with EBA, surprisingly well-controlled but now we need to figure out how to keep his hand contractures from destroying his ability to do ADLs.

I saw zero patients with acne. Less than 5 simple skin checks. I think derm can seem boring when you look at it from the surface as a med student, but the more you know the more you realize the nuances are deep and actually important - a subtle difference can mean a life-altering change in management. I'm biased but I'd never call my job monotonous, uneventful, boring, or simple. And the best part is that, unlike PCPs, we see a patient in 15-20 minutes so the pace keeps things moving and challenging. I love my job!

 

[Promethean]

And the best part is that, unlike PCPs, we see a patient in 15-20 minutes so the pace keeps things moving and challenging. I love my job!

Your response has me wondering... what do you think PCPs do and in what kind of timeframe?

 

[PatchA]

I think it depends on where you work. At a busy, hospital, derm may be very complicated, varied and interesting. N of 1 here l, but I currently work at a private derm office. Absolutely 90% of what we see day to day is acne, biopsies, or skin checks. It's been a great clinical learning experience but definitely monotonous. The docs do have an excellent lifestyle though and make good money.

So yeah, I think a lot of what you see is determined by the the setting in which you practice.

 

[Mad Jack]

Yes, you've got it wrong. When I get a simple mole biopsy or acne, it's like a vacation. Here are three cases I saw today:
1. Patient with diffuse severe spontaneous ecchymoses, we all thought it was vasculitis but biopsy and labs were negative. Now he's recovering which is great, but after I examined him my attending asked, "What do you think of the facial rash?" which I totally missed. She thinks it's discoid lupus.
2. Patient I biopsied last week for orange-red plaques on the bilateral soles, report came in today: nodular amyloidosis.
3. Patient in his 70s with EBA, surprisingly well-controlled but now we need to figure out how to keep his hand contractures from destroying his ability to do ADLs.

I saw zero patients with acne. Less than 5 simple skin checks. I think derm can seem boring when you look at it from the surface as a med student, but the more you know the more you realize the nuances are deep and actually important - a subtle difference can mean a life-altering change in management. I'm biased but I'd never call my job monotonous, uneventful, boring, or simple. And the best part is that, unlike PCPs, we see a patient in 15-20 minutes so the pace keeps things moving and challenging. I love my job!

What sucks is that the bad dermatologists kind of wreck it for the rest of them. Case in point, patient presents with intractable acne x2 years, been seen by a dermatologist for the entire duration. Adult onset, in 30s. Ask if she has noticed any facial hair around the time the acne began to present, and if she was heavier when it started than she is now. Yes and yes. Turns out it was a simple case of PCOS, mistreated for literally years because someone was practicing wet it/dry it dermatology and would only see her for two minutes a visit and prescribe her some creams while asking basically zero questions, which really makes me sad because dermatology is a wonderful specialty when practiced right and I really respect a good dermatologist.

 

[PatsyStone]

In primary care, you have to listen to people complain about numerous things that span multiple organ systems (my chest/knees/head/poops/stomach hurts). In derm--like other specialties--it's a huge relief to only have to deal with one organ system.

There is a lot of flexibility in derm, and depending on where you work, you can tailor your practice. The nice things about skin cancer/acne checks is that they give you a break from the more complex cases.

 

[PhillyMed777]

Oh look another misinformed derm related thread. Very little exposure is given to medical students. And if it's the lifestyle factors that irks people, you as a medical student have the choice to outcompete others to get it. If you can't compete or decide it's not for you, then that is that. It makes no sense as an outsider with no knowledge to think your own work is superior. It's not as if any of my clerkship fields had mind blowing patient management or phenomenal diagnostics. In fact I was taken back by the generic formulaic approach through and through. Nothing intellectual to see at all. Just because they are there for 16 hrs a day it doesn't mean what they accomplished was genius or had better "value."

 

[Azete]

Location matters a bit, I think. I shadowed a dermatologist in Florida for a week, and I can count on one hand the number of cases that weren't skin cancer checks. Oddly enough I didn't see an acne check the entire week.

 

[doing_all_the_things]

Yes, you've got it wrong. When I get a simple mole biopsy or acne, it's like a vacation. Here are three cases I saw today:
1. Patient with diffuse severe spontaneous ecchymoses, we all thought it was vasculitis but biopsy and labs were negative. Now he's recovering which is great, but after I examined him my attending asked, "What do you think of the facial rash?" which I totally missed. She thinks it's discoid lupus.
2. Patient I biopsied last week for orange-red plaques on the bilateral soles, report came in today: nodular amyloidosis.
3. Patient in his 70s with EBA, surprisingly well-controlled but now we need to figure out how to keep his hand contractures from destroying his ability to do ADLs.

I saw zero patients with acne. Less than 5 simple skin checks. I think derm can seem boring when you look at it from the surface as a med student, but the more you know the more you realize the nuances are deep and actually important - a subtle difference can mean a life-altering change in management. I'm biased but I'd never call my job monotonous, uneventful, boring, or simple. And the best part is that, unlike PCPs, we see a patient in 15-20 minutes so the pace keeps things moving and challenging. I love my job!

That is certainly more unique compared to what I saw in the brief time I shadowed! Do you as a dermatologist provide the patient all of the subsequent treatment and procedures for things like those or are some of those cases referred to other specialists?

 

[doing_all_the_things]

Oh look another misinformed derm related thread. Very little exposure is given to medical students. And if it's the lifestyle factors that irks people, you as a medical student have the choice to outcompete others to get it. If you can't compete or decide it's not for you, then that is that. It makes no sense as an outsider with no knowledge to draw conclusions or to think your own work is superior. It's not as if any of my clerkship fields had mind blowing patient management or phenomenal diagnostics. In fact I was taken back by the generic formulaic approach through and through. Nothing intellectual to see at all. Just because they are there for 16 hrs a day it doesn't mean what they accomplished was genius or had better "value."

I'm not really sure what you're trying to say. Could you elaborate?

 

[Lexicon0]

Oh look another misinformed derm related thread. Very little exposure is given to medical students. And if it's the lifestyle factors that irks people, you as a medical student have the choice to outcompete others to get it. If you can't compete or decide it's not for you, then that is that. It makes no sense as an outsider with no knowledge to draw conclusions or to think your own work is superior. It's not as if any of my clerkship fields had mind blowing patient management or phenomenal diagnostics. In fact I was taken back by the generic formulaic approach through and through. Nothing intellectual to see at all. Just because they are there for 16 hrs a day it doesn't mean what they accomplished was genius or had better "value."

Triggered...? Why not try educating those of us that are 'misinformed'?

 

[doing_all_the_things]

Location matters a bit, I think. I shadowed a dermatologist in Florida for a week, and I can count on one hand the number of cases that weren't skin cancer checks. Oddly enough I didn't see an acne check the entire week.

My experience was also in Florida! Gobs and Gobs of skin cancer checks! The dermatologist also saw each patient for 2-4 minutes and then had the PAs take over 100% of the actual biopsy or nevus removal. Is that normal?

 

[PhillyMed777]

I'm not really sure what you're trying to say. Could you elaborate?

Triggered...? Why not try educating those of us that are 'misinformed'?

I'm guessing you haven't completed a clerkship year, doing-all-the-things?
Because if you did, you would understand how the conventionally appointed "hard-working" specialties don't do anything intellectually special, per se. The majority of what they do ends up being taking consults at odd hours, doing endless paperwork, and following treatment algorithms without much need for intellectual creativity. Their work is just as routine and repetitive as any other odd field. I've just started to gain an appreciation how they repeat the same things. They pimp each batch of students the same things over and over.
Read: Being monotonous and boring is not unique to any field. That being said, derm can be pretty exciting. There is some incredible pathology and variety of paths to take.

 

[doing_all_the_things]

I'm guessing you haven't completed a clerkship year, doing-all-the-things?
Because if you did, you would understand how the conventionally appointed "hard-working" specialties don't do anything intellectually special, per se. The majority of what they do ends up being taking consults at odd hours, doing endless paperwork, and following treatment algorithms without much need for intellectual creativity. Their work is just as routine and repetitive as any other odd field. I've just started to gain an appreciation how they repeat the same things. They pimp each batch of students the same things over and over.
Read: Being monotonous and boring is not unique to any field. That being said, derm can be pretty exciting. There is some incredible pathology and variety of paths to take.

Oh OK I see what you mean. That is a good point about every specialty having their own aspects of monotony. And also true I haven't done a clerkship or anything close to it. I was just discussing specialty preferences with friends and the popularity of dermatology came up. They stated that they wanted to do anything besides primary care because it was so monotonous but then they said dermatology was their top choice. I wanted to get some other perspectives on it from SDN and expand my perspective on dermatology.

 

[Lexicon0]

I'm guessing you haven't completed a clerkship year, doing-all-the-things?
Because if you did, you would understand how the conventionally appointed "hard-working" specialties don't do anything intellectually special, per se. The majority of what they do ends up being taking consults at odd hours, doing endless paperwork, and following treatment algorithms without much need for intellectual creativity. Their work is just as routine and repetitive as any other odd field. I've just started to gain an appreciation how they repeat the same things. They pimp each batch of students the same things over and over.
Read: Being monotonous and boring is not unique to any field. That being said, derm can be pretty exciting. There is some incredible pathology and variety of paths to take.

Fourth year here applying into ENT, so I definitely understand that every specialty has it's bread and butter. Having done a derm elective during my clinical year, I'm still skeptical that the pathology is so 'incredible' and that there are a 'variety of paths to take' (all my opinion of course). I find a lot of my derm-aspiring classmates rave about the 'pathology' and 'variety' even though their underlying motivations are purely lifestyle/monetary (which in my opinion is a completely acceptable reason to go into a specialty if you've put in the work and obtained the grades). Wish they would just be honest with themselves and me.

 

[Raryn]

I'm guessing you haven't completed a clerkship year, doing-all-the-things?
Because if you did, you would understand how the conventionally appointed "hard-working" specialties don't do anything intellectually special, per se. The majority of what they do ends up being taking consults at odd hours, doing endless paperwork, and following treatment algorithms without much need for intellectual creativity. Their work is just as routine and repetitive as any other odd field. I've just started to gain an appreciation how they repeat the same things. They pimp each batch of students the same things over and over.
Read: Being monotonous and boring is not unique to any field. That being said, derm can be pretty exciting. There is some incredible pathology and variety of paths to take.

Sounds like someone really hated his medicine rotation. Or his prelim.

Look, in general, no matter your field you'll get used to the common stuff. The OP has a jab at primary care ("monotonous, uneventful, boring, and simple"), which has the absolute widest variety of possible things that can walk in the door. People who actually do primary care don't spend all day just titrating antihypertensives. They also deal with common and uncommon issues with every organ system, up to and including the skin. It can be monotonous in certain environments with certain practice patterns, but so can everything.

The common practice of (particularly community) dermatology has a ton of skin checks, "mole" biopsies, eczema, and acne treatment. The practice of dermatology also includes everything from pyoderma to SJS to different vasculitidies etc, etc. But you'd find it difficult to convince me that it has MORE variety than primary care.

The important thing with medicine is, you do have to be aware of the rare things. Not everything about them, but enough to know that something is off and how to look further. That's the hard part, and the fact that it looked easy when you did your rotations in the general fields doesn't mean it actually is (or is uninteresting).

 

[PhillyMed777]

Sounds like someone really hated his medicine rotation. Or his prelim.

Look, in general, no matter your field you'll get used to the common stuff. The OP has a jab at primary care ("monotonous, uneventful, boring, and simple"), which has the absolute widest variety of possible things that can walk in the door. People who actually do primary care don't spend all day just titrating antihypertensives. They also deal with common and uncommon issues with every organ system, up to and including the skin. It can be monotonous in certain environments with certain practice patterns, but so can everything.

The common practice of (particularly community) dermatology has a ton of skin checks, "mole" biopsies, eczema, and acne treatment. The practice of dermatology also includes everything from pyoderma to SJS to different vasculitidies etc, etc. But you'd find it difficult to convince me that it has MORE variety than primary care.

The important thing with medicine is, you do have to be aware of the rare things. Not everything about them, but enough to know that something is off and how to look further. That's the hard part, and the fact that it looked easy when you did your rotations in the general fields doesn't mean it actually is (or is uninteresting).

I'm not trying to convince anyone that derm has more variety.

I did actually like my 3rd year medicine clerkship, conceptually more than practically though

 

[Psai]

That is certainly more unique compared to what I saw in the brief time I shadowed! Do you as a dermatologist provide the patient all of the subsequent treatment and procedures for things like those or are some of those cases referred to other specialists?

Treatment for all of those things? Steroids.

 

[BeddingfieldMD]

I think a lot of the replies here apply to most specialties. Yes, in private practice (which includes most dermatologists), much of the day is going to be filled with acne, cancer checks, eczema, etc. You're not going to deal with a lot of esoteric, debilitating derm diseases. Contrast that with an academic specialty clinic, where you may see nothing but severe EB cases, allopecia, burns, etc.

Hardly any dermatologists could argue that the specialty generally has good hours, clinic settings, few emergencies, and above-average compensation. Is that a factor for people who choose the field? Of course! Do most of them also find the field interesting and stimulating? I would wager they do--admittedly maybe less with each passing year of practice.

But is dermatology like primary care? And is primary care boring, repetitive, and monotonous? I'm not sure if either of those statements is true.

Generally, you will see more variety in primary care fields--though the acuity and complexity may be less. That said, sorting through the many comorbidities of a 90-year-old is certainly complex!

So are dermatologists routinely rushing in and saving lives in emergency settings? No. But is it just popping pimples all day? No. Like most clinic-based specialties, it's a focused practice that deals with a mostly outpatient population in a non-urgent setting.

Are most private practice dermatologists dealing with a handful of diseases? Most definitely. But on that note, most PP cardiac surgeons deal with at most three diseases (CAD, AS, and MR). Is it monotonous and boring? Some may think so, but not if you like the work.


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[username456789]

I just diagnosed a man with multiple myeloma last week.

I am a dermatologist.

He came in complaining of "new small hairs" on his nose. I instantly knew to order an SPEP/UPEP because I'm not stupid, and by now he's had most of his full work up and is plugged in with the right docs.

The patient, his PCP, and his heme/onc doc think I am a golden god. But I just paid attention and worked hard in residency, and understand the rare stuff that has bizarre skin presentations.

Dermatology is ****ing awesome sometimes.

 

[username456789]

I will add that this same hematologist now cares for another patient in whom I rather quickly diagnosed mast cell leukemia. Presented for a routine boring mundane mole check like the ones the OP has seen. I saw a subtle rash on her legs that had been there "for years" and was asymptomatic/of no note or concern to her.

Realizing it was probably TMEP, I did a biopsy which confirmed this, then checked her tryptase levels which were off the charts. Got her hooked up with heme/onc quickly and she's doing great.

The midlevels with whom I work never even heard of her skin condition, and would have had no clue A) what it was, B) the correct stain on path to request to confirm the suspected dx, or C) the next step in management.

Again, community derm can be repetitive like many other things. But sometimes it's not.