Want to be a dermatologist? Persistence pays in highly competitive, lucrative field
Scott C. Wickless, DO, loves the variety of patients and responsibilities he has as a dermatopathologist and cutaneous oncologist. Dr. Wickless serves as the director of dermatopathology for Dermpath Diagnostics/Ameripath in Colorado. (Photo courtesy of Dr. Wickless)
With as many as 80 applicants for each AOA-approved residency position, dermatology is one of the profession’s most competitive specialties. Outnumbering male applicants roughly four to one, women in particular appreciate the discipline’s relatively family-friendly work hours and flexibility, notes Stanley E. Skopit, DO, a former president of the American Osteopathic College of Dermatology (AOCD).
But landing a derm position requires single-minded focus on one’s objective, the sacrifice of personal time, and persistence in the face of failure.
The specialty pays well, with U.S. dermatologists averaging more than $250,000 a year, but earnings vary widely by geographic area and practice focus, according to Dr. Skopit. Dermatologists who do a large volume of cosmetic procedures can sometimes make millions of dollars annually.
Dermatologists often do better financially by being a partner in a small group practice than by being an employed physician, says John P. Hibler, DO, the program director of the AOA-approved dermatology residency at O’Bleness Memorial Hospital in Athens, Ohio. But this is not the case in every region of the country.
Beyond the pay and manageable hours, dermatologists usually love what they do, points out David L. Grice, DO, the AOCD’s president-elect. “We do a lot of surgical procedures in addition to the evaluation and management of many different types of skin conditions and diseases, which breaks up the day,” he says.
Like primary care physicians, dermatologists engage in preventive medicine and often develop longstanding relationships with patients. But many also do life-saving surgeries.
“I like the variety, the balance,” says Scott C. Wickless, DO, who subspecializes in dermatopathology and cutaneous oncology. “As a dermatologist, you can see kids. You can see adults. You can do surgery. You can do pathology.
“I see patients probably 70% of the time and spend about 30% of my time doing dermatopathology—reading slides, looking at excisions and biopsies. I love this mix of responsibilities.”
The work can be intense at times, which adds to the specialty’s appeal, says Dr. Wickless, who has treated many patients for skin lymphomas and melanomas. As a consultant to a hospital, he regularly goes to the intensive care unit, often to see patients who are having adverse drug reactions involving skin.
Though he grew up and trained in the Midwest, Dr. Wickless practices in Durango, Colo. “Dermatology is one of those fields where you can go wherever you want,” he says. “I love the lifestyle here, the outdoor activity. We’re in a beautiful area where the high desert meets the mountains.”
Osteopathic medical students who are considering dermatology should start preparing for their uphill challenge at the beginning of med school if not earlier. While it is more difficult for DOs to get into one of the 115 dermatology residencies accredited by the Accreditation Council for Graduate Medical Education (ACGME) than into one of the 27 AOA-approved dermatology programs, prospective osteopathic dermatologists should hedge their bets and plan on taking the United States Medical Licensing Examination (USMLE) as well as the Comprehensive Osteopathic Medical Licensing Examination—USA, recommends Dr. Hibler. Many AOA-trained dermatologists have gone on to do ACGME subspecialty fellowships, he notes.
Getting into a dermatology residency normally requires high grades and board scores, but other factors may matter more. “Most dermatology residents are in the top 10% to 15% of their graduating class, but there are always exceptions,” Dr. Grice says. Someone who has shown intense interest in dermatology, who has made a favorable impression on someone in the field, or who has participated in groundbreaking research may get in despite not having stellar academic credentials, he notes.
“Some programs give board scores more weight than others do,” Dr. Hibler says. “In my experience, some of the brightest students with the highest board scores do not have good interpersonal skills and are not able to relate to patients. Therefore, I think it is unfair to exclude residency candidates with COMLEX scores in the 500 range.”
Dr. Hibler favors candidates who work well with nurses and other staff and demonstrate compassion as well as competence.
The AOCD provides a list of 14 tips for securing a dermatology residency slot. “Read a basic dermatology text,” states the first recommendation. “It must be obvious that your level of knowledge is greater than that of the average student or intern at the same level of training.”
Become a student member of the AOCD and attend the society’s annual and midyear meetings, states another tip: “Your main goal at these meetings is to learn what’s new in our specialty and to meet residents from as many of the programs as you can. This will give you the opportunity to understand the unique challenges that each program affords those who are interested in applying.”
Students should do as many dermatology electives as possible, rotating in programs where they have the best chance of gaining interviews, the AOCD further advises.
Dr. Grice suggests that medical students and interns become involved in dermatology research projects and do whatever else it takes to show their genuine passion for the field.
It is important for students to realize that they do not match into AOA-approved derm residencies during their fourth year. Beginning this academic year, AOA dermatology programs will participate in the AOA Match as an Option 3 specialty, which means that candidates will match into derm positions during their internship year or afterward. (Previously, candidates applied directly to individual residencies, which did not participate in the AOA Match.)
To maximize their chances of matching, would-be dermatologists should serve rotating internships at institutions that have dermatology residencies, the AOCD suggests.
Roughly half of AOA derm residencies are funded by the Centers for Medicare and Medicaid Services and half are self-funded, notes Dr. Skopit, the director of a new CMS-funded program at Larkin Community Hospital in South Miami, Fla.
CMS-funded residencies typically pay residents higher salaries but have more specific acceptance requirements. For example, residents who are training or have already trained in Medicare-funded programs in other specialties may not be able to serve Medicare-funded dermatology residencies.
In contrast, some self-funded residencies require dermatology candidates to have prior residency training in another specialty, especially internal medicine, Dr. Grice points out. “To recognize comorbidities, dermatologists need additional training in systemic disease,” he says. Because of the competitiveness of the discipline, some programs can command extensive prior training and experience.
Thus, it is critical for dermatology candidates to understand the specific requirements of any program they are considering.
Some programs tap particular rotating internships for candidates. For example, a new AOA-approved derm residency in Spanish Fork, Utah, that is part of OPTI-West will look primarily at prospects from the osteopathic rotating internship at Arrowhead Regional Medical Center in Colton, Calif., says residency program director Warren A. Peterson, DO.
And Dr. Hibler’s residency is currently limiting its candidates to osteopathic interns at O’Bleness. “We were overwhelmed by too many people wanting to rotate with us for days or weeks at a time,” he says.
Try, try and try again
“Don’t give up,” exhorts the AOCD in its final tip for candidates. “Many successful dermatologists have needed to apply several times in order to get into a program.”
Nailing a derm position requires no small measure of luck as well as drive. Dr. Grice, who earned his DO degree in 1989, did a rotating internship followed by a year in an internal medicine program at an institution that also had a dermatology residency.
“When I was an internal medicine resident, I volunteered for several hours a week at a dermatologist’s office,” he remembers. “I was offered a dermatology residency position in March of my first year in the IM residency, when one of the dermatology residents, an Army reservist, was called to active duty. But I had to decline the offer because I was still under contract with the hospital in internal medicine.”
To avoid repeating this scenario, Dr. Grice left the internal medicine residency after completing his first year. He practiced in primary care for about a year until he finally succeeded in landing another dermatology residency spot.
DOs in dermatology
While the road to residency can be arduous, DO dermatologists are highly skilled and respected out in practice, notes Dr. Wickless, who served an ACGME dermatopathology fellowship through the Northwestern University Feinberg School of Medicine in Chicago. “The holistic approach you get from a DO program helps you ask the right questions to arrive at a diagnosis,” he says. “If you talk to patients long enough, they’ll tell you the diagnosis. We’re trained to think not just about the disease but about what else is going on in a patient’s life.”
DO dermatologists advocate on many issues of pressing concern, Dr. Grice says. One problem is the increased use of tanning beds, which has caused an explosion of malignant melanoma cases among middle-aged women. The AOCD would like lawmakers to ban the use of tanning beds for those under age 18.
Dr. Hibler is personally concerned that dermatologists increasingly do not accept Medicaid and are running cash-only cosmetic practices that focus on botox injections, chemical peels and similar treatments. Dermatologists have a moral obligation to treat poor and indigent individuals who are suffering from skin diseases, he says.
“When I look at candidates for my residency program, I appreciate great COMLEX scores. But I also want to see individuals who interact warmly and enthusiastically with a diverse patient population, including those who are indigent and on Medicaid,” Dr. Hibler reflects. “The character of a caring, compassionate physician cannot be revealed by standardized examinations.”