The Real Derm: Episode 5, Diving Deep Into the DermPath Pathway: A Candidate's Perspective

Climbing the mountain to get to dermatology residency is bone breaking enough, but what about the next apex, even more specialized training such as a Dermatopathology Fellowship? Great rhetorical question and we have the real answer. Tune in to hear from Dr Adam Rosenfeld, incoming chief resident and dermpath fellow hopeful from the GW School of Medicine and Health Sciences, on his journey, lessons learned, and what he wishes he knew way back when.

Adam Friedman, MD, FAAD, is the Chair of Dermatology at GW School of Medicine and Health Sciences.

Transcript:

Dr Adam Friedman: Welcome back to the Real Derm Podcast, where residents duck out of DermPath, sign out, and start getting real. I'm Dr Adam Friedman, professor and chair of dermatology at GW School of Medicine and Health Sciences, and I am joined by our amazing, almost third year, still second year, maybe wanting, maybe not wanting to be one of our chief residents, Adam Rosenfeld, who is here to talk to us today about pursuing a career in dermatopathology. Welcome, Adam.

Dr Adam Rosenfeld: Thank you, Dr Friedman.

Dr Adam Friedman: Yeah, I know it's been like almost a year since we've done this, so it's time to be back in action. Well, let's jump right in. Why on earth do you want to do dermatopathology?

Dr Adam Rosenfeld: It’s a great question, to be honest with you, it goes back to the med school. I had a couple awesome DermPath mentors at Mizzou where I did med school with Dr Braudis, and Dr Emily Smith. And when I got a little bit of exposure, at that point, they were just amazing teachers, super engaging, really made it fun. And at that point where I had limited, you know, dermatology knowledge, let alone DermPath knowledge, just the way they approached it and made it interesting definitely kind of sparked my initial interest. And then since being at GW, of course, Dr Zanz are amazing, you know, for DermPath.

And then we get great exposure at our VA as well. But I just think it's so interesting to be able to, like, truly be a diagnostician. and I mean, there's over 3,000 dermatologic diseases and as skilled as our colleagues are in diagnosing things, oftentimes we have to biopsy. And just being able to play that kind of critical role in diagnosing has just been fascinating and just something I've kind of gravitated towards, let alone the people that I've done sign out with have just made it so interesting. Like I said, I keep saying that word because I just find it so fascinating, maybe in a nerdy way. But I'd say those are a lot of the reasons.

Dr Adam Friedman: Let's be real. If we've made it this far into dermatology, we're all a bunch of big nerds. And there's nothing wrong with that whatsoever. You know, I agree. I think the fact that we can do true bedside to bench to bedside practice, not even research, is really quite remarkable.

And one of the things I always try to encourage is when you're looking at the skin to actually envision what could be going on if you had a slide of what you're seeing, what cell types, what structures are creating that clinical morphology and certainly having a mastery of dramatic pathology can aid with that. What are the challenges and on the flip side opportunities with respect to pursuing this path as a resident and of course beyond?

Dr Adam Rosenfeld: I was going to say I have to give you credit, Dr Friedman, because you kind of definitely encourage us to start thinking about what's going on under the microscope from the jump, even we're looking at, you know, different things on the skinning clinic.

So, I feel like, I don't know if that's happening across the country, but the way you kind of encourage that and kind of have definitely developed my way of thinking in that regard. So, I think I don't want to leave you out in terms of playing a role. But yeah, the challenges, I would say the kind of obvious one is that you typically would apply two years ahead of time for fellowship.

So as a second year, I'm kind of a little bit off the more traditional path, although there's a lot of ways to get to fellowship. But because the process lines up with the pathology trained residents, you essentially apply for a DermPath Fellowship two years in advance to finishing residency, which is more atypical compared to the other Derm fellowships. I know other residencies, I think of like orthopedic surgery comes to mind when they, you know, match fellowship multiple years in advance.

But I think just having to feel confident that this is something you want to pursue as early as first year when you're still kind of getting your bearings on residency, I think was a challenge for me. Even though I was very interested from the beginning, it's hard to kind of think about fellowship and your career so early on in residency. So, I think that's, you know, a major challenge.

Dr Adam Friedman: And let's say you get there out into the wilderness with that additional certification. What opportunities are out there for those who, to your point, are flirting with the idea early in their residency career? Which is hard to know, right? You're making a big decision that affects your future. It might be hard to know that early on.

What do you see as the opportunity taking this path? I mean, obviously, you're passionate about it. It's clearly interesting. That is the buzzword of the podcast. But what opportunity do you see for yourself and thereby definition for others pursuing this?

Dr Adam Rosenfeld: I was going to say, it's a great question. I think, you know, having some flexibility in the way you practice. And for someone who wants to just do DermPath, there's ways to do that.

But from what I've heard from a lot of mentors and people that are already well established as dermatopathologists who also want to do some clinical work as well, it's an awesome way to kind of have variety within your work week to do a couple days of DermPath sign up at a couple days of clinic. When you're coming from the dermatology trained background. I don't want to speak from the pathology train because they have their own, you know, kind of career goals in itself.

But I think from a dermatology standpoint, having that balance. And for me personally, it would probably be working in an academic setting because the camaraderie of having multiple dermatopathologists. I know Dr Zahn and Dr Cardis work super closely and having people that bounce ideas off of within an academic setting and having the opportunity to teach residents, fellows, and obviously I'm far away from even getting a spot that I'd be really fortunate to. But if I'm able to, I think being in an academic setting where not only are you maybe more likely to have that balance of clinic in DermPath, but having all the people that kind of work with on difficult cases is super exciting.

Dr Adam Friedman: So, what does this look like? So, let's say you're in your first year, or maybe even before, you had a wonderful DermPath mentor on your path to even Derm residency, and you're like, I'm doing this. How do you get started in terms of prepping for your application, prepping for this kind of early onset application process?

Dr Adam Rosenfeld: I think trying to get as much exposure as early as possible, if you're interested as a med student or if you kind of think about it at all during your intern year or even early on. And I mean, there is plenty of time, although I make it sound like it's a challenge. But if you are interested, it's certainly doable to try to get as much exposure as possible early on to feel like you, you know, you don't have to necessarily know a lot.

But just to feel like you feel more comfortable around the scope and that you feel like this is something you want to pursue. And then I think just definitely trying to have mentors, get to know if there is a fellowship at your program or fellowships within the city that you're doing in residency, definitely try to get to know them and kind of understand the path and what it sort of takes to apply. And then try to familiarize yourself with the process.

It hasn't gotten to a point where it's a standardized application. A lot of programs have signed up to do the sort of standard application form that you fill out, not to get into the kind of the nitty gritty, but—

Dr Adam Friedman: Oh, get into the nitty gritty. Get into the weeds, man.Let's hear it. Rip it apart. Let's learn what you got to do.

Dr Adam Rosenfeld: No, I know. That's part of it. But the timeline, I think, was the biggest piece when it comes to everyone's sort of aligning or a lot of the lining to kind of accept applications July 1st, and then it kind of leads into late summer, early fall.

So, from what I've seen. The majority of programs have signed up to do that. And then there's a DermPath conference every year. Last year it was in Chicago.

So, that's a great opportunity to network. They have like this awesome kind of, it's early in the morning, which everyone kind of jokes about where you get to meet with program directors from across the country. I think it was at like 7 a.m.

It's a great networking opportunity, and you can do that kind of the year before you apply. So, if you are a first year interested, if you go to the conference in the fall of your first year, you can kind of make some connections. If you were able to submit something like an abstract and do a poster presentation, that's great.

But even going and just networking and just kind of being around the DermPath world. I remember they had like kind of the history of traumatic pathology, just like important people. And you just get the feel for the kind of field and how small it is and how amazing everyone is and kind and wanting to kind of ingratiate the younger kind of generation.

So, it was really cool to experience that. I think that's something I'd definitely recommend if you're interested.

Dr Adam Friedman: So, what I'm hearing key messages, and I totally agree, collect as many mentors as possible. You don't need just one, actually, you need many more. You need a cabinet because everyone brings something different to the table.

So, reaching out, and I think one of the great things about our specialty is, I'd say, like, 99.5% of our colleagues are wonderful, amicable, warm, welcoming, wanting to pay it forward individuals. And it sometimes just takes an email to or ask someone to introduce you. And that can set you on a path of a pretty much lifelong mentor, mentee relationship, knowing the deadlines when things are due because it's obviously a bit early.

Go to the DermPath conference. It sounds like they kind of have an understanding that the timing is a little interesting when it comes to applications, and they have to decide early. And so, they create an environment that really supports that timeline.

So being in the know of that as well. This might be a tough question, but I think it's always a good one. What do you wish you knew now having kind of like being in the middle of it, doing all the things that you're recommending everyone else who's listening to do if they're interested in DermPath? What is one thing you wish someone told you knew when you first started that you know now?

Dr Adam Rosenfeld: That is a great question. You know, the easy answer--it's not to cop out—is definitely just the timeline and how early the process is.

Because to be honest with you, as a med student, I didn't know that. And I wasn't familiar with really any of the fellowships with the dermatology in the sense of kind of what goes into it. So, it wasn't specific to DermPath, I think this is more of a broader thing, but I think just trying to find your niche or your passion within dermatology, because it's easy and because I kind of loved everything. I feel like that's kind of a common thread I see in a lot of residents or even students applying is you're not so quick because dermatology is already a specialty in itself. It's already kind of a niche. Is it niche or niche?

Dr Adam Friedman: Tomato, tomatoes…

Dr Adam Rosenfeld: I think there was a French painting by someone named niche. I think it’s a real strong “e” at the end?

Dr Adam Friedman: It's more niche, I think... I think it’s a real strong “e” at the end?

Dr Adam Rosenfeld: However, you want to say it… But I think trying to figure it out, whatever it is. This is kind of maybe broader advice is just like, it’s easy to get to the finish line in dermatology and kind of happy of these so many ways to go about grading and structuring your career. But I think trying to figure out if you have the passion or the smallest inkling that you love something, even just a little bit more than something else even in dermatology. Just explore that and like really dive into it as soon as possible, whatever that is. And, if it's within DermPath, we already kind of talked about some of the things you would at least want to try to do. But I think if I had one piece of advice to give myself, it's just to explore all of those things as soon as humanly possible amidst the chaos of the whole new language and complexity and everything that comes with being a new Derm resident, but I hope that kind of answers your question.

Dr Adam Friedman: No, it does, it's a great point. I think day one of residency, it seems like you have years ahead of you. Three years fly by, and residency is a protective environment. It is sheltered from a lot of the pressures that you face in the real world in terms of jobs, even maintenance of certification, licensures. There's a lot that you don't have to deal with as a resident.

So, it really is an opportunity, to your point, to go down that rabbit hole and explore a potential career opportunity or career trajectory. And once you graduate, I'm not saying it's impossible, people shift gears, and I give anyone who does it a lot of credit because it's not easy. It is definitely easier in that nurturing environment where you have faculty, colleagues, students, infrastructure at an academic center. So, I agree if you have an itch, scratch the hell out of it.

I mean, that's almost the polar opposite of what we tell our patients. Do not scratch from the intellectual perspective I want to see neurotic excoriations when it comes to a potential interest because you don't have a lot of time to figure that out. I think you can kind of drag your feet and be like, yeah, maybe yes, maybe no.

And the longer you wait, the harder it will be because in that time, you can develop a network of mentors. You can get your name out there at the national level, at a society meeting or even at general derm meetings. You know, you can present a DermPath case as part of gross and micro of AD, for example.

You present a case at some of the more regional slash national meetings like ODAC and Fall Clinical and Las Vegas Derm, but there's such a, there's such a lag between when you need to submit and when it actually happens that you need to know early. So, I think that's actually great advice, not just for DermPath, but for anything. MOHs surgery is a great example—also very competitive, and even cosmetic surgery fellowships. If you have an inkling, try to figure out one way or another. Even if you decide, no, that's valuable data. Data is still data. So, I think that's great advice.

Dr Adam Rosenfeld: Yeah. And to your point, we always like kind of tell med students, I feel like to not say that they're kind of pitching holding themselves. And they're only going into dermatology to do cosmetics or MOHs or obviously I encourage DermPath. But still, it's like you never want to just kind of frankly come out and say, “hey, I'm only doing, or we want you to be interested in everything.” So, it's kind of that balance of not feeling like, oh, day one, I need to just make myself even more specialized.

But I think we're kind of, it's easy to get bogged down into the business and the stresses that come with being a resident, but you said it best, I mean, scratch that itch, and just explore your interests as soon as possible in whatever that kind of means for you.

Dr Adam Friedman: Well said, well, thank you, Dr Rosenfeld, for your insight and for your openness about your own experiences as you pursue this course. And of course, best of luck. We have all of our appendages and phalanges crossed for you.

And thank you, everyone, for joining us for this edition of The Real Derm Podcast.