The Real Derm: Episode 1, Get to Know Us

"The Real Derm: Residency Unplugged" is a podcast looking at advanced dermatology residency and clinical insights. 

In this inaugural episode, Dr Adam Friedman interviews "The Real Derm" podcast stars, Dr Kamaria Nelson and Dr Emily Murphy, who get real about their dermatology residencies in D.C. They share how their first few weeks of residency have gone and how they unwind after a long day in the clinic. Stay tuned for Episode 2!

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

Emily Murphy, MD, and Kamaria Nelson, MD, are both first-year dermatology residents at the George Washington University.

TRANSCRIPT-

Dr Adam Friedman: Hello, and welcome to The Real Derm, where residents stop studying and start getting real. I'm your host, Dr Adam Friedman, professor and chair of dermatology at GW School of Medicine and Health Sciences. I am joined by our wonderful and daring, and I would say almost experimental, fresh first-year residents, Dr Kamaria Nelson and Dr Emily Murphy, who are going to be the subject of this interesting journey where we follow them throughout their residency training and get a glimpse real-time what it's like to be a derm resident throughout the 3-year experience. Welcome, Drs Nelson and Murphy.

Dr Emily Murphy: Thank you.

Dr Kamaria Nelson: Hi. Thank you.

Dr Friedman: One month in, super exciting. I know starting derm residency can be somewhat tumultuous, and it's a different way of life. Certainly, straight out of whether it be internship or research fellowship, you're thrown into the mix quickly. Being 1 month in, and Dr Nelson, I'll start with you. What do you wish you knew prior to starting, now that you've been doing this roughly about a month?

Dr Nelson: Something I wish I knew. Still I knew going in that it was going to be a steep learning curve. Everybody says that. All the residents hint at it. I didn't realize it's a new language that we have to learn, like the lexicon and the different skin conditions and the different treatments. Just knowing that before would prep you as you start residency. Then, our new program director, Dr Zahn recently said this, "Starting derm is like moving to a whole new, different country where you can't speak the language, you can't understand [laughs] anything that's going on." I can definitely relate to that, for sure.

Dr Friedman: Great point. Dr Zahn hit it perfectly. Dr Murphy, what are your thoughts?

Dr Murphy: Definitely agree with Dr Nelson. The other big thing I wish I knew was that it's OK to not know anything. At the end of my intern year, people kept telling me about this steep learning curve. I felt like, "Oh, maybe I should start trying to learn." Then intern year was so busy, and so I did nothing related to dermatology.

Then, on my first day and it's still now, I'm presenting patients, and I'm like, "I really honestly have zero idea." Then the attendants are all like, "That's OK. Let's walk through it. Let's go see the patient, and let's figure out a plan." People understand this learning curve and no one's upset when you're totally overwhelmed.

Dr Friedman: You've hit such an important point that it's very hard for new residents to recognize. This may sound callous, but no one expects much from you guys, and that's okay. There's been so much pressure, especially as you know, med students performing on away rotations or in fellowships.

Then you start, and it's almost like you're thrown back into those visiting rotations, but it is quite different. The perception of a faculty member is, you're a blank slate, and it's our job and our opportunity to fill your bucket, so to speak.

Especially, when it comes to the language, which if there's one thing I could highlight as a first-year, first-month, or even several-month resident is learn the language of dermatology. Someone said the exact same thing to me when I was at first year, and I was freaking out. The very first day, we had our orientation, and in the afternoon, I would hit patients.

I didn't even know the computer system, let alone what was a plaque versus papule. Everyone told me, like, "You know what? We recognize absolutely nothing and that's not going to change for some time."

That was a great point that don't beat yourself up because all first-year, first-month residents don't know a whole lot. Sticking with you, Dr Murphy and in line with that, on a scale of 1 to 10, how stressful is starting derm residency, and why? [laughs]

Dr Murphy: I would put it high, but not at 10. I would go at 7 because I feel like if you were saying information needed and looking at how much we need to learn over three years, I put it at 10. The part that brought me back a little bit was that we do have so much support from our chief residents, from the attendings, whereas during my intern year, I started on nights on the cardiac team. There was a Code Heart, and I was apparently going to it. No one was around, and it was just me. There was not as much support because people were busier and more overworked, I guess, in the hospital, especially during the pandemic where they feel like at GW, especially we're eased into it. We were given less patients. We were given time to absorb the information at least.

Dr Friedman: Dr Nelson, what about you? We got a 7 out of 10 from Dr Murphy. Dr Nelson, [laughs] where do you fall on that spectrum?

Dr Nelson: The day before we started in the clinic, I was at a 9 or a 10.

[laughter]

Just because it's a new environment, a new hospital. I'm at the VA, so it's a new EMR system. I didn't know what to expect per se, but like Dr Murphy was saying, the residents and the attendings have been super patient and super helpful with all of us first-years. Asking us throughout the day if we need help in seeing patients, or if we need help with EMR, and stuff. I'm definitely back down to maybe a 6 or 7, but definitely, before I started, it was very high.

Dr Friedman: Just admitting that it's so important. It's good to know when you're starting up that you're not alone and feeling less stressed and everyone does feel it. I absolutely felt that too. I still remember that feeling even more than a decade later. It's important to know that.

In line with that, and given there is such a focus on wellness, Dr Nelson, what do you do to help mitigate that stress when you were either 9 out of 10 or now maybe 6 or 7 out of 10? What do you do to help manage that so you can have your cake and eat it too?

Dr Nelson: Stress management is super important for me, especially in residency. During the pandemic, I downloaded Headspace, which is a meditation app. When I'm feeling a little anxious or super stressed out, I'll put on a meditation. I also use it to go to sleep too, and it puts me right to sleep.

Definitely meditation, and then work out a couple of times a week. I try to increase it [laughs] to a little bit more, but at least twice a week, I try to do some exercise, and that helps relieve some stress, too.

Dr Friedman: Dr Murphy, what about you?

Dr Murphy: Definitely, the exercise helps. One of the nice things about dermatology so far is my schedule is, for the most part, the same every day. I can get into a good routine as opposed to switching around in different rotations in med school and during my intern year. It has been nice to have a routine and know that each morning I can wake up and still work out.

I also think talking to my co-residents. It's nice at GW to have the cohort where you're paired with two of the same residents. At the end of the day, we shut the door and have some time to chat about difficult patients and experiences that weren't good for the day and just vent. That helps at the end of a busy clinic day.

Dr Friedman: I completely agree. Not holding in and getting it out. Dr Murphy, what is one thing that has surprised you this far in the past month that you were not expecting?

Dr Murphy: That's a good question. I would say, the diversity of pathology we're seeing. I did away rotations and such, but being in clinic every day now, I've seen so many cool cases and getting to incorporate pediatric derm and more surgery. I feel each day is totally different, whereas as a med student, you may not do as much of the surgery, and you don't always get so much piece exposure. Diversity has been awesome.

Dr Friedman: Dr Nelson, what about you?

Dr Nelson: It's DC-specific, but I didn't realize how much of a family the different dermatology residency programs are in the DC area. At the VA, we often work with the Howard residents, and then a lot of our didactics are also shared. That's something that was a surprise to me. It's nice to have other residents going through the same thing that we can discuss and talk about different cool cases.

Dr Friedman: I agree with you. When I came down here from New York, I was surprised by this historical collaborative environment, very much inspired by the NIH and the DC Derm Society. It's evolved in the past five to six years where, you're right, we share a lot of the didactics.

The residents spend a lot of time together now virtually, but even before, in person, where you're not sure one program ends and the other one begins, which is nice. I always say when we do our interview day, it's a one big program, which is nice.

I've encouraged residents elsewhere to try to somehow do more with the other programs if there are those in the area if you're there in a city, because it adds such an extra dynamic from an educational, but even from a work-life balance perspective.

I know a lot of the residents in different programs do things after hours as well, not just in our residency program. I agree with you. We've heard about diversity of cases, what's the best case you've seen this far, Dr Nelson?

Dr Nelson: That's so hard.

[laughter]

Dr Friedman: They are all amazing.

[laughter]

Dr Friedman: If you had to pick one. I sound like a parent.

[laughter]

Dr Nelson: This is recent. Earlier this week, we had a patient, history of HIV, who had leukodystrophy, and he was in our procedure clinic. We got to treat him with filler. We had Sculptra and Juvederm that we got to put in his cheeks and his temples. The end result, he was extremely happy. Seeing his reaction after we completed the filler, and the change from when he first came in to after, you could tell in his self-esteem, it had improved and everything. That was a meaningful case. He was almost in tears when he left. So far that's been interesting if I had to pick one.

Dr Friedman: That's great. It's very often underestimated the impact of the immediate effect of something like you're describing, and how that can affect someone's self-esteem, and everything's connected. How we feel about ourselves affects our medical well-being as well. Being able to intervene like that and get that immediate gratification can be not just rewarding, but especially given this is a new experience for you, that could be very exciting, and surprising truthfully also, in that you may not necessarily realize how that can impact the patient. Dr Murphy, what about you?

Dr Murphy: I would say, I saw a case of pyoderma gangrenosum that was really large.

Dr Friedman: [laughs] It was big. [laughs]

Dr Murphy: Her whole leg, it was so big. It was super affecting her life. She had to start using a cane because the pain was so severe. She couldn't walk. I left the room, and I was like, "Oh, my God. Dr Zahn, what is happening?" He came in. Apparently, it looked good. He's like, "Oh, that's healing well." I'm like, "Well, news to me."

Dr Friedman: [laughs]

Dr Murphy: He was impressive, looking and talking to her about how much it was affecting her life. Hopefully, we're doing something to help. She's going to see you soon, Dr Friedman.

Dr Friedman: [laughs] Foreshadow in there, and you're welcome.

[laughter]

Fantastic. Thank you. [laughs] Dr Murphy, in this exact moment in time, several weeks in, what advice do you have for future first-month, first-year resident?

Dr Murphy: I would say, try to take it all in and not worry too much about how much there is to learn, because I feel both Dr Nelson and I have been talking a lot about, "How are we going to study? What's our tactic going to be? Should we read this chapter in Andrews? What's happening?"

I don't know, I feel like if we focus too much on that as opposed to learning from patients, then we're going to stress ourselves out. Clinic can be busy and stressful, but taking time to absorb it and learning clinic. Even if you're busy and you're backed up, but if you have a cool patient, so take the time to absorb what your attendings teaching you and try to learn in the moment as opposed to focusing on all this stuff we have to learn.

Dr Friedman: That's great advice. You mentioned something that reminded me an important point about getting backed up. A big chunk of resident clinic is learning. Yes, it is a clinic, patients want to be seen on time and in a timely manner, and there is a balance there, but don't let that undermine your educational experience. I've seen many residents get very stressed about falling behind, not keeping up.

To me, it's almost more important to be behind, but get something out of that because, as a trainee, you're getting something that will make you a better physician for all the patients you will see in the future, but also the patient probably will ultimately get a better experience of their outcome because of the time spent.

Don't beat yourself up if you fall behind because, newsflash, everybody does. That's an important point to make. I'm glad you brought that up. Dr Nelson, what about you in terms of advice for that first-month, first-year?

Dr Nelson: I would say, breathe, everything is going to be fine. You're going to do great. You're here for a reason. Also, don't be afraid to ask questions. Don't be afraid to ask silly questions because you have to learn some way, and the only way to learn is either to ask or to try. I would say, definitely ask questions.

Then, another piece of advice was what Dr Murphy was saying, soak up all the information from all the patients that you're seeing. Even if you're looking at something that you saw in clinic, looking up VisualDx, or in Bolognia if you have time, just so you're learning as you're in clinic, so you get that clinical correlation.

Dr Friedman: Very good advice. You mentioned silly questions, so I've to end on one. I'll start with you, Dr Nelson. What is your favorite reality show, and why?

Dr Nelson: [laughs] This is silly, but I like The Bachelor franchise. [laughs]

Dr Friedman: Oh, God. Sorry, I asked. [laughs]

Dr Nelson: The Bachelorette, The Bachelor, The Bachelor in Paradise, all of those. We have a group of residents who watch it once a week. [laughs] I like it. It's something light, keeps your mind off of the serious things and just something to laugh at.

Dr Friedman: I can't unhear that, unfortunately.

[laughter]

Dr Murphy, what about you?

Dr Murphy: I will say I'm not a huge reality TV fan, but I'm a big teen drama fan. I'm going to pretend you asked that because I've seen everything from out there. My very favorite is Gossip Girl. It is the silliest show and the most unrealistic show. I've seen it three times, not exaggerating, and loved it each time.

Dr Friedman: I'll allow that extension beyond the scope of the question. I'm with you. I don't watch reality TV. I have periodically, but if I have to answer it the right way, Dr Murphy, I would say Real Housewives of New Jersey because I'm from New Jersey. I loved how they flipped tables, and some of the things they said were unbelievable. I think half of them are in jail right now, which makes it even more fun.

With that, we will wrap this up. Those of you tuning in, make sure to do so again. Check out future episodes of The Real Derm. Check out the testimonials from our amazing first-year doctors, Kamaria Nelson and Emily Murphy. Thanks so much, and tune in again.