Med-Derm-Rheum

Discussion in 'Dermatology' started by testanxiety, 05.20.14.

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  1. testanxiety

    testanxiety 2+ Year Member

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    Hi Everyone,

    What are your thoughts on triple board certification in med-derm-rheum? I know I would have to go the med-derm residency route [and fellowship in rheumatology] but does having such broad training have any real utility, especially in larger US cities where there are plenty of specialists? I'm a first year medical student with a true interest in dermatology, and I especially like the overlap between derm and rheum (regarding treatment of autoimmune/connective tissue diseases) but I wouldn't necessarily be happy just doing rheumatology. Does anyone know how realistic it is to attain this kind of training and how it would be managing a practice with both general/medical/cosmetic dermatology + rheumatology?

    Thanks for your input!
     
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  3. asmallchild

    asmallchild Lifetime Donor SDN Moderator 10+ Year Member

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    I don't think you'll find many people signing up for this. If this is your interest, I would find a dermatology program with strong focus on connective tissue disease sub-specialty clinics (UPenn comes to mind but I'm sure there are plenty more out there). I don't think I would advocate spending the additional time to complete a med-derm residency and then tacking on a rheum fellowship.

    Now if that's your true passion, go for it. I find most people end up (either by desire or necessity from employer pressure) practicing bread and butter dermatology once they are done with residency so my opinion is that the extra training would likely go to waste.
     
  4. DermViser

    DermViser 5+ Year Member

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    You might want to ask this guy: http://physiciandirectory.brighamandwomens.org/Details/426

    But seriously, it's definitely not the norm for most. I can't imagine the cost and hassle of having to certify and recertify in IM, Derm, AND Rheum.
     
  5. testanxiety

    testanxiety 2+ Year Member

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    I guess it's too early to claim something as my passion, it's just something I was thinking about. I spend a lot of time reading JAAD/JAMA Dermatology and many interesting cases consist of an overlap between these two fields.


    Ya I guess I haven't thought much about the costs and hassle of maintaining certification in those fields. I found another physician at NYU's Dermatology department [http://www.med.nyu.edu/biosketch/franka02] who is triple certified in med-derm-rheum but that's about it.
     
  6. WaylonS

    WaylonS 2+ Year Member

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    Here is another example http://www.ucsfhealth.org/kari.connolly

    Similar to the rheum people enumerated above, a lot of the famous CTCL specialists did IM residencies before derm (granted they all trained in the 70s and 80s).

    I'm still a med student, but having talked to several attendings on whether additional training in IM is necessary to handle complex med-derm cases, they have all told me essentially two things. First, it doesn't matter if you just train in derm or derm and IM; what is important is that you have adequate training and exposure to complex cases. Second, when you finish residency, do not expect that you will automatically be qualified to handle all complex cases. It is important to realize that it may take several years of experience until one is qualified to manage refractory or rare diseases
     
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  7. Dral

    Dral 7+ Year Member

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    IMO, the only way this would make any sort of sense is if one planned to stay in academic practice.

    I'm not trying to be rude at all, but the idea you put forth is a combination of youthful exuberance and lack of experience (neither necessarily being a bad thing). I have an interest in cutaneous oncology (but not interested in Mohs as a career...but I do find it interesting)...and as late as the interview trail I had this grand idea to to IM/Derm, then do a heme/onc fellowship to eventually manage tough melanoma cases. This wasn't my main path of choice, but one I strongly considered. Now I look back and think "What....the....heck...was I thinking?!".

    I thought I loved loved loved complicated patients. Now when a psoriatic arthritis patient comes in and they tell me Rheum is managing their Humira, I breathe like five sighs of relief. Not because I can't or don't know how to manage Humira patients (or quickly refresh any lapse in memory by a quick look at Wolverton), but because I get to just manage their skin disease and move on to the next patient. I'm not saying everyone enjoys Derm the same way, but that's my deal.

    While one could practice Derm like you mention in the private practice setting, you would be spending a lot of time with each patient and not pulling in as much for your practice. I'm not trying to promote the Derm = $$$ stigma, but it's just how things end up. Again, it sounds like it could be done for academic purposes, but even then, just get through Derm residency, then find a place that has a rheum/derm clinic and work your way into it...much easier path. Route A and route B both get to point C, but route B takes you through 5 extra months of ICU, 8 extra ward months, an extra fellowship (albeit easy process) app cycle, and two extra exams every 10 years...route A all the way, baby.
     
    Last edited: 05.20.14
    DermViser likes this.
  8. DermViser

    DermViser 5+ Year Member

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    @testanxiety,

    As an MS-1, it's early but if Derm and Rheum are your interests, then get involved in clinical research that brings the 2 fields together. There are many derm diseases that have a strong rheum & immunology component. So by MS-4, when you're applying, you will have research if you're still wanting to apply to Derm and you already have research if you decide instead to go for Rheum through the IM route (at this time, vast amounts of Rheum research is not necessary to match for a Rheum fellowship)

    The ones I know who liked the intersection of Derm-Rheum did a Derm residency first and then did a clinical research fellowship afterwards: http://www.brighamandwomens.org/Departments_and_Services/dermatology/fellowship.aspx. Obviously, their career goals were also to stay in academics.
     
  9. testanxiety

    testanxiety 2+ Year Member

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    Sorry guys, I was caught up with finals....neuro down, 2 more to go!

    @WaylonS

    Thanks for the advice. Yes, I agree with your attending's advice. The reason I was thinking of pursuing rheum because, for right now, I think managing broad and complicated cases is appealing to me. But there's definitely no substitute for experience!


    @Dral
    Thanks for your candid advice! I get that I am way too early in my training to understand the complexities and nuances in modern-day practice, but I can't help but be attracted to the complex and difficult cases that I've seen [for now..]. Based on my limited shadowing experience, the most fascinating cases have been those complicated in-patient consultations or the patient dealing with SLE and a battery of skin issues that the dermatologist is able to manage effectively. I thought going into medical school, Cardiology was it for me--I liked working with complex patients. But after shadowing a cardiologist all year also, I realized it's not what I thought it would be. Dermatology, as far as I know, gives me what I'm looking for as it varies in the breadth and complexities of the conditions, and involves virtually every body system. But I see what you're saying...in private practice, med-derm-rheum might not be able to pay the bills nor would re-certification be something pleasant to deal with. I like your idea of finding a residency with a combined clinic though.

    @DermViser
    I will look into those fellowships. Because we had to commit to research earlier in the year, I am working on a melanoma project [another one of my interests], but I will see if I can find someone in the department who is interested in the combined fields. Thanks for the tip!
     
  10. GalenVesalius

    GalenVesalius Longtime observer

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    Hi testanxiety,

    It's good to be considering your options early, though you have time to figure this out. One thing to think about as you try to figure out which route to go is whether you want to be a dermatologist primarily and also focus on cutaneous manifestations of rheumatic diseases or be a rheumatologist with attention to the cutaneous aspects of rheumatic diseases. There are cutaneous manifestations of the majority of the connective tissue / collagen vascular disorders. The SLE, sjogrens, scleroderma, RA, PsA, dermatomyositis patients will be referred to the rheumatologist for management so your practice will have ample supply of cutaneous findings to investigate. These diseases also involve multiple organ systems, which you said you find interesting. Your IM training will be useful to you in that regard. If you are also interested in managing CTCL, melanoma, bullous skin disease, atopic skin disease etc, then dermatology makes sense. If you do go the rheum route, then be aware that it is one of the most intellectual and research-driven subspecialties of medicine. Thus you should do good quality research projects to get a fellowship at institutions where you will work with the nation's top immunologists and rheumatologists. You seem like you'll be a competitive candidate, so I suspect you'd want to do your fellowship at a place with high-powered faculty. Same for the internal medicine part; there are tons of spots around the country but getting into the top academic programs is competitive work. If you know you are interested in academic rheumatology, there are ways to shorten the IM component (if that is a concern) and set yourself up for a junior faculty position (these are even more competitive spots where research is a must).

    Good luck with whichever path you choose. Just continue to ask questions and do electives and research to figure out what YOU want to do.
     
  11. exeunt

    exeunt 7+ Year Member

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    does anyone know which other derm programs are strong in CTDs other than Penn, Harvard, and Stanford?
     
  12. testanxiety

    testanxiety 2+ Year Member

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    I believe NYU is strong in CTD as well.
     
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  13. smartparts

    smartparts 7+ Year Member

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    I suppose I'll play devils advocate here because the opposite holds true as well: if you're at a place with a rheum dept and a tiny derm dept, you WILL get to manage severe skin disease (BP, erythrodermic psoriasis, DRESS, SJS/TEN etc.) and deal with a good chunk of outpatient atopy/DLE/pemphigus as a rheumatologist just like a dermatologist would. There is a place for super-specialists, but unless you have a real (and I mean NIH-funded-bench-research-real) interest in it, I'd just go one way or the other. You'll see cool cases either way.
     
  14. dermisawesome

    dermisawesome

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    There are few others fields where the difference between academics and private practice is so vast. This makes following your true passions difficult. I am facing the same problem and find it hard to resist a more balanced work schedule and marked increase in salary. After all the time we invested and hundreds of thousands of dollars in debt, it is hard to give up a great opportunity. True passions dissipate and remember that academics unfortunately has a lot of politics and paperwork which makes this not as appealing as is often imagined.
    That being said, if you have specific research goals then academics makes sense.
    Derm Rheum must be purely academic since in private practice you will be highly unlikely to benefit from all the extra training. Rheumatological diseases have complications which a general dermatologists are not ready to manage and doing the extra time to get rheum fellowship seems unrealistic.
    I am not sure, and please let me know if this is incorrect, whether derm/rheum would be practical if you plan on pursuing a mostly outpatient route?
     
  15. asmallchild

    asmallchild Lifetime Donor SDN Moderator 10+ Year Member

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    Not necessarily, I agree if you ONLY want to see complex derm/rheum/connective tissue disease cases that academics is the way to go (particularly if you want anything to do with an inpatient/consult service)

    But you'll find plenty of people happy to refer complex derm cases to you in private practice as well, might take a little longer to build up to the caseload that you want. (At least in my neck of the woods, general dermatologists/Mohs surgeons/cosmetic dermatologists are a dime a dozen. It's the pediatric dermatologists, psych-derm, and rheum-derms with the long wait times)
     

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