PracticalDermatology

Expert Advice from Leading Dermatologists

A new crop of residents is getting ready to begin a dermatology residency. Others are continuing on in this phase. It is a very exciting—and likely nerve-racking—time in one’s career. Residents probably have a lot of questions and aren’t all that sure who to ask. Practical Dermatology® magazine reached out to a handful of established and respected dermatologists to find out what they wish they knew during this chapter of their career.

Ahead is the first in a series of articles sharing expert insights.

Find a Niche Within a Niche

I think young people entering dermatology should realize the wealth of opportunities within the field, and explore a range of options for their career paths. Since dermatology addresses an organ system, one can focus on dermatologic manifestations of systemic disease, pediatric dermatology, dermatologic surgery, laser surgery, psoriasis treatment and a whole range of options. I personally fell in love with physics and photobiology and dermatology was the field leading the way in development of medical lasers and exploring photobiology. I pursued my interests in light from the start.

Eric F. Bernstein, MD, MSE
Main Line Center for Laser Surgery

Ardmore, PA  

Patients Before Paperwork

I wish I knew these two things: How to code my visits and procedures (i.e., the business of medicine) and how important it is to defer as much income as possible to retirement—starting now!

What every resident completing their training should focus on is finding a job where you come in, do what you’re trained to do, and go home. Find a job with the fewest administrative responsibilities—these are what lead to burn out.

Spend as much time seeing patients, doing Mohs, or whatever it is you are trained to do, and you will be happy!

Mark D. Kaufmann, MD, FAAD
Associate Clinical Professor, Dept of Dermatology
Icahn School of Medicine at Mount Sinai New York, NY

You Know Nothing…Yet

Congrats on making it to the promised land! You’ve worked so hard to get to this point, crossed the desolate land of intern year, and now you are a derm resident. Here are a couple tips to help you enjoy the sweet nectar of victory versus suffering the agonizing defeat of imposter syndrome or FOKA (fear of not knowing anything).

You know nothing: Just say that to yourself. Yes, you have been on medical student rotations and likely did a year of research, but accept the fact that your fund of knowledge is extremely limited. It’s OK. This is expected and normal. Often new dermatology residents come in the first month hungry to learn and self-expecting to know every bit of minutia by the end of month one. I vividly recall this as well from my own residency.

Realize you will not really feel comfortable until the end of year one or early year two at best. Do not beat yourself up about it. This is why you are a resident: to learn. The majority of faculty get this, and those who don’t and place undue and unrealistic stress on you? Forget them. Remember, you worked hard to be there to learn dermatology (not just haul butt to see a ton of patients). Pace yourself.

Adam Friedman, MD, FAAD
Associate Professor of Dermatology, Residency Program Director, Director of Translational Research, Director of the Supportive Oncodermatology Clinic, Department of Dermatology 
George Washington School of Medicine
and Health Sciences
Washington, DC

Enjoy It All!

While you have had four years of exposure to patients, this has been in an unrealistic environment where you are among teachers who have great reputations in an institution that is most likely the best in your area, if not the country. Now you are in a practice where people arrive with a healthy dose of disbelief. It is your job to reassure them that they have come to the right place. You will have to try harder to do this and will take some lumps in the beginning. Additionally, you will have some frustrating days as well as some of the best days of your life. 

Enjoy it all and remember that this is the beginning of your lifelong career and it is the “first impression” you give to the community.  Be wise, giving, and charitable in your interactions and you won’t go wrong.

Joel Schlessinger MD, FAAD, FAACS
Board-certified Dermatologist and Cosmetic Surgeon,
Founder Cosmetic Surgery Forum; Chief Cosmetic Surgery
Editor, Practical Dermatology® Magazine
Omaha, NE

Respect Experience

Respect experience. You may have 30,000 Instagram followers, but that doesn’t mean you are an expert in dermatology. Becoming board certified is a start, but becoming a true expert in the field requires experience. The word “expert” comes from “experience.” Focus your energy during your first year on learning general and surgical dermatology. Learn to think like a dermatologist and then build your aesthetic knowledge and ability.

Heidi Waldorf, MD
Associate Clinical Professor, Department of Dermatology
Icahn School of Medicine at Mount Sinai, New York, NY
Waldorf Dermatology & Laser Associates PC, Nanuet, NY

Heed 5 Tips

Take seminars on how to successfully negotiate and how to have difficult conversations. You will need these skills throughout your hopefully long career for everything from new and extended contracts, asking for a raise, or leading your team in the day-to-day joys of clinical practice. What’s working against you? As a group, physicians are trained cynics. It is our job to distrust new information to keep our patients safe from the harms caused by bad science or unfounded fads. Add to that the fact that we tend to be conflict avoidant and, to put it mildly, a bit headstrong; now, you have a recipe for communication disaster.

I have not found the physician-led seminars on these topics to be all that worthwhile. A class designed specifically for executives or even one that offers a psychology-based approach, for me, is much more enlightening and practical.

Rage against signing a “geographical” non-compete. You just spent the last three years training to be a board certified dermatologist—with skills very few people in the world possess. Why allow someone to leverage your proficiencies against you when, in fact, it is your expertise that they are looking to hire in the first place?

Instead of a conventional non-compete covenant based solely on geographical location, I prefer a non-solicitation agreement in which the person being hired agrees not to actively recruit patients away from the hiring practice if there ever is a parting of ways. Such an agreement makes sense based on the hiring practice’s outlay of resources on recruiting, marketing, and developing the newly hired dermatologist around town. A non-solicitation also speaks more directly to what should be the true concerns of the hiring practice and still allows for flexibility down the line.

Stop hiring, training, and agreeing to supervise your eventual replacements. I read someone’s profile on LinkedIn the other day where the person claimed to be a “board-certified physician assistant dermatologist.” I laughed and cried at the same time because, honestly, we did this to ourselves.

At some point, it will boil down to a bean counter and an Excel file: A mid-level working at 25-50 percent of a board certified dermatologist’s salary, seeing the same number of “Patients Per Day” as the dermatologist (or, perhaps, even two-to-three times more in some unscrupulous settings)—even with a 15% hit in reimbursement rates—looks highly profitable in a board room. For that reason, new dermatologists will have to decide if they are going to hire and train mid-levels to perform specialty-level services. If they do, are the dermatologists prepared for the possibility that mid-levels might be preferentially chosen to do our job because they deliver the goods financially and operationally?

I would rather not even make that scenario an option. Alternatively, if you are trying to grow your practice or extend your reach, then consider hiring a fellow board certified dermatologist as a part-time employee. It might be worth it in the long-term.

Insist on transparency and then remember that, well, “you asked for it!” In this era of data-driven everything, you should have full and open access to your own professional and financial data: Total Revenue, # of Encounters, Revenue Per Encounter, No Show Rates, Re-Book Rates, % New Patients, Third Next Available, Internal Referrals (i.e., to Mohs or a sub-specialist or particular service line), Patient Satisfaction Scores, Coding Audit results, MIPS data, E&M bell curves for both new and return patients are all very helpful, and you can use them to better yourself and your practice.

The downside is that the numbers do not lie, and you may be faced with a statistic that bruises your ego or paints you in an unflattering light. Resist the urge to kill the messenger when you see that your Revenue Summary is off budget, and do not get depressed that your collections dipped a bit during the week of Spring Break. Instead, use your practice’s resources to learn from prior data and start to anticipate the dips and surges so that you can adjust to them proactively. It’s not personal. It’s just data.

NOW PLAYING

Watch Dr. Waldorf share “Heideas” for residents and young dermatologists on our sister site.

Watch now at ModernAesthetics.com/series/heideas-for-aesthetic-practices/

Get out and promote yourself. No one knows you better than you, and at the end of the day you are the dermatologist—the face of your clinical practice. Your business manager does not generate $1 worth of revenue, and the CEO of the hospital or private equity group does not get personally reviewed on Vitals.com or Yelp.com. But you do, so take every issue and small detail personally! Create some “you-specific” service lines. Develop your personal brand, and build a following around it on social media. Travel to the offices of every potential referring physician around your area and grind out the “meet and greets” that will lead to a full patient panel sooner than anticipated and/or budgeted.

Andrew C. Krakowski, MD
Pediatric & Adolescent Dermatologist
Founder, Peds Derm LLC 
Bryn Mawr Hospital, Bryn Mawr, PA
PedsDerm.org

Cosmetic Surgery Forum Grants: Application Deadline Looms

Cosmetic Surgery Forum is offering fellow and resident grants to this year’s meeting. The grants cover meeting registration ($750), hotel (four nights in a shared room or half the cost of a single room), a $150 travel stipend, breakfast and lunch Thursday through Saturday, and inclusion in ancillary social and education events (Wednesday through Friday evenings). 

Grants are available to fellows and residents in the core specialties. To qualify, fellows and residents must submit a 500-700 word abstract covering a dermatology or cosmetic surgery topic that has not previously been submitted for publication elsewhere.

For every program with a grant recipient for the 2018 meeting, there will also be made available one grant to that recipient’s Program Director or appropriate program representative.

For details or to apply, visit https://www.cosmeticsurgeryforum.com/grants/