Wanted Dermatology, but it's out of reach. What is the best alternative for me?

[Capillaroscopy]

Hey 🙂

I've finished medical school in a European country.
I can basically choose any speciality other than Dermatology, Ophthalmology and Plastic Surgery. The only problem is that for the past few years I was absolutely dead set on Dermatology and, honestly, there was no other speciality that I enjoyed as much as Derm during my rotations. I would love if anyone could give me some feedback on specialities that might be a fit for me but I'm missing. I'm proceeding to explaining what I love about Dermatology, other specialities I've been considering and their (+) and (-). I'd really appreciate it if you could show me if I'm wrong. Consider that I'm set on working in academics and pursuing a PhD during residency.

TL;DR: I wanted to go into Dermatology for the variety, independence, lifestyle and expertise (see bolded items below). Unfortunately, that's not possible. Which other speciality most closely resembles Derm in these aspects?

What I love about Dermatology and why I think it would be the perfect fit for me:

• The huge variety of pathologies. There is infectious disease (e.g. causes by bacterial, fungi and viruses), autoimmune diseases (e.g. scleroderma, SLE, psoriasis, vitiligo), cancer (melanoma, SCC, BCC), allergic diseases (e.g. atopic dermatitis, contact dermatitis, urticaria), weird drug reactions (e.g. DRESS, SJS/TEN, ...), weird skin rashes (e.g. phytophotodermatitis). Even though of course the bread and butter will be acne and other mundane stuff, I love how a skin lesion could possibly mean anything, and it's the dermatologist's job to correctly diagnose the issue at hand.
• Getting to play diagnostician. In many specialities, most referred patients are already assigned a diagnosis. On the contrary, in dermatology, most doctors are clueless and it's the dermatologist's job to figure out exactly what's wrong.
• The visual diagnosis. Dermatologist's can make a diagnosis just by looking at the patient entering their office, and I think that's pretty cool.
• The fact that basically no other specialists know anything about the skin. I think this is only comparable to ophthalmology. What I mean is that while doctors usually have at least a basic grasp on cardiology, pulmonology, infectious diseases, etc., most doctors simply do not know enough to adequately manage more complicated or rare skin problems, and dermatologists frequently have to be consulted on skin issues.
• Getting to make a big difference in patient's lives, quickly. Don't get me wrong — I know dermatologists won't be saving lives. But they can efficiently treat several skin diseases which often have a huge impact on the patient's self-esteem. Patients leave the dermatologist's office happier.
• The cool procedures/treatments. I'm not very procedure-oriented, but loved watching the dermatologists perform skin biopsies, spraying liquid nitrogen onto the skin (cryosurgery), performing electrodessication and curettage. Even phototherapy is cool.
• The innovative drugs. Sure, most skin diseases are treated with a topical corticosteroid/retinol/antifungal angent. But there's a lot going on the treatment of melanoma with immunotherapy and new monoclonal antibodies for psoriasis. I was also amazed by how the dermatologists really knew their way around corticosteroids and other immunosupressants.
• The independence. Most of the times, dermatologists can practice pretty independently. They get to see the patient, diagnose the patients (even get to perform prick tests, patch tests, wood light, dermatoscopy, etc.) and treat the patients on their own (e.g. drugs, cryosurgery, phototherapy, etc.). This is matched by ophthalmology, but that's about it.
• It's one of the shortest residencies (4 years).
• And, of course, the lifestyle.

Other specialities I have considered:

Rheumatology [5 years residency] (it's a separate speciality from IM in my country):

What's I find interesting about it:

• There's a fair bit of diagnosing involved.
• There's a variety of disease (even if the bread and butter is rheumatoid arthritis, which I'm not crazy about).
• There is some sort of visual diagnosis (inflammed joints, capillaroscopy, nails in psoriatic arthritis, etc.).
• Diseases can be complex and most doctors stay away from autoimmune disease.
• MSK US is nice and growing. There are also some procedures, such as injections.
• Rheumatologists also know their way around immunosupressants, and research on new drugs is ongoing.

The downsides:

• Managing chronic diseases, unlike dermatology in which there are many first (and single) visits.
• Patients can be very hard to manage. In Dermatology, the patients definitely feel better faster than in Rheum.
• In many hospitals and private practices, Internal Medicine doctors compete with Rheum for the autoimmune diseases.
• There is a possibility that I would have to move away for residency.

Allergy & Immunology [5 years residency] (also a separate speciality from IM and Peds in my country):

What I find interesting about it:

• There's a fair bit of skin involvement (e.g. allergic/contact eczema, urticaria, angioedema, drug reactions, etc.).
• Won't be saving people's lives, but will make them breathe again, which is cool.
• Can see improvement quickly.
• It's a somewhat independent speciality, since most of the diagnosing/managing the patient does not depend on consulting other specialists.
• I've also already done some research with top researchers in the allergy field (people with > 100k citations). I want to do a PhD, and I already have a good research network/contacts in the Allergy field.

The downsides:

• Not that much variety. It's basically asthma, rhinitis and skin allergies.
• Does not seem very intellectually stimulating. I know most people feel this way about Derm, but I don't — but I sometimes feel this way about Allergy.
• I think the major issue for is that there is lots of overlap with other fields and most diseases can be adequately treated by primary care and other specialists (rhinitis - ENT, asthma - Pulmonology, skin - Derm). Furthermore, in the same way that many Internal Medicine specialists manage autoimmune diseases, many Pediatricians manage the allergies in their patients and end up subspecializing in Pediatrics Allergy.
• I don't particularly enjoy pediatrics and there's a fair bit of that in allergy.

If Allergy & Immunology actually had a good chunk of the "immunology" part other than allergies, the decision would be easy. Unfortunately, A&I is basically just Allergies — and primary immunodeficiencies, which are rare anyway. Autoimmune diseases are seen by Rheum (and IM in my country) and the field in which immunology is the most prominent is probably Hem&Onc, definitely not A&I.

Primary Care (GP) [4 years residency]:
I consider this for the sole reason that I'd get to see a fair bit of skin disease, since most people will first go to their primary care physician before consulting a dermatologist. I guess I could tailor my education and practice to see more and more skin pathology? I'd have to deal with all the other primary care bureaucracy, and diabetics and hypertensive patients during residency (at least), though. The goal would be to, perhaps, move to a rural area after residency and try to get people to come see me for their skin diseases.

I'm not very keen on radiology or pathology. I've shadowed a pathology resident and overall I'm not a big fan of spending the day looking at slides — the group meetings are cool, though.

I did the Medical Speciality Selector Quiz for fun and the top result was actually Allergy & Immunology (mainly based on the fact that I like to ask "Why", become bored with repetitive activity, like problem solving, enjoy research and being known as an expert and value independence highly). Neurology was second mostly for the same reasons. However, I know better than to choose a speciality based on a quiz — I will be shadowing A&I specialists and Rheumatologists within the next few months.

That's basically it. If you read it this far, thanks for that, and I'd appreciate any feedback you may have.

Sorry for the long post.

---

Members don't see this ad.

 

[Bobblehead]

In virtually all of the internal medicine and subspecialty care panels you will have your "bread and butter" cases with a small percentage of "interesting" cases that you appear to be focusing on.

You should pick the field where you can handle the boring things. Otherwise you will not be happy.

 

[DrMetal]

Internal Medicine . . .it's clearly the best specialty. Come on over to the dark side.

 

[Capillaroscopy]

In virtually all of the internal medicine and subspecialty care panels you will have your "bread and butter" cases with a small percentage of "interesting" cases that you appear to be focusing on.

You should pick the field where you can handle the boring things. Otherwise you will not be happy.

Thanks! I'm aware. As strange as it may seem, that field was Dermatology. I was fine dealing with acne, nevi, eczema and scabies. I know the bread and butter for Allergy is asthma, rhinitis, eczema and food allergies. These are ok, but overlap with other practitioners (pulm, ENT, derm, pediatrics). For Rheumatology, it's probably RA, SLE and pain/no diagnosis. Also ok, but the patients are definitely more complicated to manage.

 

[Bobblehead]

Thanks! I'm aware. As strange as it may seem, that field was Dermatology. I was fine dealing with acne, nevi, eczema and scabies. I know the bread and butter for Allergy is asthma, rhinitis, eczema and food allergies. These are ok, but overlap with other practitioners (pulm, ENT, derm, pediatrics). For Rheumatology, it's probably RA, SLE and pain/no diagnosis. Also ok, but the patients are definitely more complicated to manage.

Why is overlap with other specialties an issue? Is there a lack of patients where you intend to practice? Do you want to be better than others or more exclusive? Generally this is accomplished by focusing on some particular sub-part of the field where it gets out that you're the person to send those patients to.

Keep in mind most of internal medicine is longitudinal care which you stated you didn't care for. As such you should be wary of what you're signing up for, especially if you intend to be the sub-specialist that focuses narrowly on particularly challenging cases.

 

[hotsaws]

Allergy is an amazing field (very biased). Probably more in common with derm than other fields you mentioned. But I know nothing about how it plays out it other countries. A lot of the fields you mentioned are different "on paper" than they are in actual practice.

Some things I like about allergy:
-mostly healthy, normal to high functioning patients
-rhinitis is a blast to treat. People get better and are very grateful. If they are not compliant, that's on them, rhinitis isn't gonna lead to a mess of comorbidities.
-Other bread and butter stuff we see is also fulfilling to treat: ie atopic derm, chronic urticaria, asthma, etc.
- Biologics are a game changer and the pipeline looks very promising.
- hours and lifestyle are amazing. Most of us just don't work weekends, nights, or holidays. Many of us work 4 days a week.
- the job market in the U.S. is better than most people talk about on these forums. Overall, we are a well compensated field for the hours we work and the amount of scut we deal with. The ceiling is quite high and the median is solid.
- lots of autonomy. There are some multi-state, corporate style practices but, for the most part, we are not overrun with midlevels or on the radar for acquisition by private equity. The most common practices are small, single specialty groups. People practice quite differently from group to group. Good or bad, depending on how you value evidence based medicine. I say this in contrast to something like cardiology, where they have huge RTCs to drive guidelines and solid gold-standard diagnostics for a lot of things.
- we get our share of functional illnesses (Mast cell activation, "allergic" to whatever and everything, toxic mold, food "intolerance", etc.). We can try and help them but overall don't have to get too involved. I don't treat pain. (that's a bold period at the end of that sentence and its worth noting).


the immuno stuff is interesting but most of us don't do much of it in practice. That's by choice. Honestly, clinical immunology is sort of it's own subspecialty within allergy. The people who are really interested in that tend to stay in academics and work at big tertiary care centers. They are also sadly underpaid and work much harder. Same with the overlap with heme/onc (say hypereosinophilic syndromes, mastocytosis) and rheum (periodic fevers, auto inflammatory stuff). I will gladly let a hematologist or a rheumatologist take those cases if they're willing to.

No matter what you choose, don't be naive. You have to consider lifestyle, job markets, money, and day-to-day stuff regarding these fields. That stuff matters a lot when you're older, married, have a family, and basically just working a job. There's no shame in that. It's cool to choose a field based on the underlying science but it's also cool to be home every Christmas and tuck your kids into bed every. single. night.

Hope this is helpful. Again, this is a biased opinion from an allergy fellow who's going into private practice.

 

[AlbinoHawk DO]

How about FM then one of those derm fellowships?

 

[Skindoc83]

How about FM then one of those derm fellowships?

What derm fellowships?

 

[AlbinoHawk DO]

What derm fellowships?

They have one in San Antonio, TX. I forget where the other ones are. I think there's like 3 or 4 of them

 

[Splenda88]

What derm fellowships?

I think it's a 1-yr fellowship after FM residency, though you won't be able to be boarded in dermatology. Not sure how insurance reimbursement is like since you are not a true dermatologist

I remember seeing one practicing is south FL; I guess she found a way to get reimbursed for practicing dermatology with a FM board certification.

 

[hotsaws]

I think it's a 1-yr fellowship after FM residency, though you won't be able to be boarded in dermatology. Not sure how insurance reimbursement is like since you are not a true dermatologist

I remember seeing one practicing is south FL; I guess she found a way to get reimbursed for practicing dermatology with a FM board certification.

I'm sure they end up getting most of the revenue from cosmetics. Plus, anyone can biopsy a lesion and send to path. PCPs do their own biopsies and bill for them. Doubt these FM-trained docs are doing any complex derm stuff. Although, in my area (large metro), PP derm doesn't wanna do any complex derm stuff either.

I've seen some of the more sketchy allergy practices out there (the kind that are just raking in cash by putting everyone on SLIT/SCIT) who have FM or other non-fellowship trained docs doing this. These are usually very large groups, lots of ENT infiltration, and run like a business. There's a lot of shade thrown their way by academic allergists and plenty of community allergists. I respect the hustle though.

Anyways, I'm pretty sure OP is not in the U.S., so some of these more niche training pathways or practice settings may not be available.

OP, go for lifestyle and money if you're having trouble deciding. You don't wanna spend 5-10 years training and find out you don't really love the practical aspects of a field and be stuck in one that has you working lots of hours, nights, weekends, and holidays. Much better to find out you don't really love a field and be working 4 days a week with no nights, weekends, or holidays.