The Real Derm: Episode 2, The First Hand Off

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

In this 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.
The Doctors discuss switching sites, the differences between working at GW and the VA, what helps them overcome challenges, guilty pleasure foods, and who they’d choose to play them in a movie.
Stay tuned for Episode 3!

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:  Hi. Welcome back to "The Real Derm" podcast, where residents stop doing their clinic notes 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'm joined again by our daring and fearless first-year residents, Dr. Kamaria Nelson and Emily Murphy. Welcome back, guys.

Dr. Kamaria Nelson:  Hi.

Dr. Emily Murphy:  Thank you.

Dr. Nelson:  Thanks for having us.

Dr. Friedman:  Kamaria, it feels like I haven't seen you in more than an hour and a half. We were late tonight.

Dr. Nelson:  [laughs]

Dr. Friedman:  Which is going to be some of the conversation, about clinic experience, exposure, and the first couple months. We're right just after the three-month switcheroo. No question, every program does it a little differently. Many programs have multiple clinical sites. That change can be somewhat jarring, especially for a first-year.

You're trying to get in the swing of things. You know all your logins. You know where the lidocaine is kept, or at least you know who to ask, where to find it. All of a sudden, you're thrown to a completely new site. It can be disarming.

To that effect...Dr. Nelson, I'll start with you. How did you prepare for the switch?

Dr. Nelson:  That's a good question.

Dr. Friedman:  Well, thank you.

[laughter]

Dr. Nelson:  What I did is I talked to my upper-level. Dr. LA and Dr. Caitlin are chief. They're very open. If you have any questions about anything, to call us, text us whenever. I basically reached out to them, reached out to the other upper-level residents. Ask what to expect at GW. How's it different from the VA? How's the EMR like? How does call work? All of that.

Basically, they were like, "GW is more complicated med derm versus the VA. You'll see more of your bread and butter dermatology." Talking [laughs] and asking questions. Getting the backstory about GW versus the VA helped me prepare to start at GW.

Dr. Friedman:  Did you guys set up part-time to actually go over all this? Was this on the fly? How organized, or dare I say, disorganized is our program? How did you actually coordinate going through all this?

Dr. Nelson:  It wasn't anything formal. We didn't set up a time to meet. It was one day after didactics, Jess pulled me to the side and was like, "All right, this about GW. This is what you need to know." Then I would text Claire too to ask her a couple of things since she was there.

We do sign-out, where we sign out our complicated patients or biopsies that we need to follow up on. Me and Emily had a dialogue, too. That was helpful in preparing.

Dr. Friedman:  Sign-out is so hugely important, especially when you go in a completely different site. That handoff, it can be the difference between dropping important biopsy result. Whether it's talking about the VA. Could it be a melanoma or a prior authorization? Which I know is all-encompassing and pretty much everything evil on this planet boiled down into a single document.

Setting aside that time to do that transfer is so hugely important. Now we're past that point. You both have been at your new sites for a couple of days now. Dr. Murphy, how's it been, now on the other side of things?

Dr. Murphy:  It is a lot different. It's very busy. At GW, I love the continuity clinic. That's been a bit of an adjustment at the VA. Just because we have a list of patients still, but it's a bit more flexible. You see who is ready. It's less looking up patients. You have to be on the fly. Looking people up, taking them back to the room.

It's definitely busy. Whereas for GW, I always felt I could prepare the night before. I would look up my patients so I had a bit of a sense of what I was walking into. At the VA, you can walk into anything. Dr. LA was saying she did six biopsies today. I also have a paraneoplastic pemphigus patient. It's so all over the place. You don't know what you're walking into whatsoever.

Dr. Friedman:  That's actually very important from a training perspective. Every clinical experience is somewhat different. Obviously, you would imagine, whether it be in private practice, group practice, that you're right, you have your set schedule. There are many different types of jobs these days.

There's locums, where you can fly around the country and you walk into whatever. There's urgent care style, in terms of walk-in appointments. Having that exposure is so important in learning the fundamentals of those.

Being able to pivot when you're thrown that paraneoplastic pemphigus after six shave biopsies prepares you for almost anything. That's the goal of residency, is to set you off, take off the leash, and go running into the wilderness. To not just survive but also thrive.

Back to you, Dr. Murphy, over the last three months, what stands out to you the most? I remember early first year, and this is a long time ago, was certainly overwhelming and daunting. There were wins. There were ups and downs. What stands out to you the most from your first three months during residency?

Dr. Murphy:  What stands out the most is going back to the continuity clinic, is already feeling like I had patients that were my own. I actually mentioned that on the first podcast, the pyoderma gangrenosum patient. I saw her every two weeks in clinic. We developed a good relationship.

Her last visit, she was actually scheduled with you, Dr. Friedman. Then I saw her in the hallway, she's like, "Wait, where are you? What's going on?"

[laughter]

Dr. Friedman:  Actually saw her again recently. She's doing pretty well.

Dr. Murphy:  Good.

Dr. Friedman:  That's an aside. [laughs]

Dr. Murphy:  I feel like those relationships. It was nice coming from internal medicine in the hospital, where you take care of patients for a couple of days and you never see them again. It's been nice to get to know some patients and see them over and over again.

Dr. Friedman:  Dr. Nelson, for you, having come from more the very busy, take what you get mix of maybe continuity. I know one of the great things about the VA, there's so many different types of rotation. There's the telehealth rotation. There's walk-ins. There's general med derm clinic. What stands out to you the most from your first three months having spent time at a VA?

Dr. Nelson:  I would say what stands out to me the most is how diverse dermatology is. I know on the interview trail, everybody says, "I want to go into derm. It's so diverse. It's so well-rounded." It's actually true.

Dr. Friedman:  [laughs]

Dr. Nelson:  Once you get there, you'll see all kinds of things. Like Dr. Murphy was talking about. One day is not the same. One day I saw the complicated CTCL patient on bacteria team. Same day, I saw a complicated CCCA patient. The next patient was a skin tag removal.

You never know what you're going to get. That's something that stood out, how diverse dermatology actually is.

Dr. Friedman:  That's such an important point, that you also need to be prepared for that diversity. Not in your first three months of residency. Don't freak out. You need to get exposed to everything. You have three years to do that. That is where the real pressure is. Seeking out those opportunities to be in front of the breadth and full spectrum of dermatology.

With that in mind, and back to you, Dr. Nelson, what were some of the best resources? Maybe there's one or maybe none at all. Best resource to help you acclimate to your first couple months. What did you turn to when you went home?

If you saw that interesting case and you heard about a medication that you could barely spell, let alone pronounce, what did you turn to to help get you up to speed?

Dr. Nelson:  I would say the resource that I've been using the most is actually VisualDX. For those who are not familiar with it, it's a dermatology encyclopedia, basically. You type in a diagnosis, it gives you the workup, different tests to order, differential diagnosis, what it actually looks like.

At the VA, we'll actually pull up the source. Patients that are confused about what the same condition might look like, we'll pull up the pictures and go through that together. When I go back home and I see a DRESS patient on consult this week, I may pull up VisualDX to see what the standard workup is and treatment options.

Dr. Friedman:  What about you, Dr. Murphy?

Dr. Murphy:  I definitely use VisualDX a lot in the clinic. Even sometimes when I leave a patient's room and I'm like, "Oh, gosh, what the heck is that?" I'll look up quickly whilst I walk to staff with the attending to try to get my bearings a little bit.

When I go home, I try to be good and use some of the textbooks. I have bookmarked Bolognia, Wolverton. If I do see something complex, reading a bit about it in Bolognia at least. Wolverton too for pharmacology has been helpful. Looking up what to counsel patients on and things like that.

If you do have the time, it is helpful to look at some of those textbooks. Definitely, VisualDX gives you a quick rundown. Then like Dr. Nelson mentioned, it still cites everything, which is nice, so that you can pull the citation if you do want to read more.

Dr. Friedman:  In line with the concept of see one, do one, teach one, that mantra is more about repetition. One of the most efficient things is if you see something, whether it be unique or even run-of-the mill, and there's some unique element about that condition, solidify it by reading up that night.

You even two times. Seeing in the clinic, following up at night. Quick five minutes, even less. That will then at least help you remember some of it when it comes up again. Again, it gets etched in stone. There's a happy middle ground.

I don't think you have to especially go home and read 1,000 pages every night. That actually would be futile. It won't do much. You won't remember any of it. I remember trying to read through, for us, it was Andrews'. You read a couple pages or more of that, whatever came first, calls out the other side.

I realize this is a podcast. No one could see stuff coming out of my ear as I'm using my hands. Repetition is hugely important. Dr. Murphy, is there anything missing? Would there be a resource? In your ideal world of early residency, is there something that could be out there that'd make your life easier?

Dr. Murphy:  Something I've been struggling with, and I'm sure there's resource is out there but I haven't found a good one, is dermoscopy. We're doing this longitudinal lecture series right now. Each time I watch a lecture, I'm like, "Great. I know some of this stuff." Then I get to the patient's room, I'm like, "Wait, what is going on?"

I try to look at each spot and point out ones that I'm concerned about. Most times, the attending is like, "Oh, they're fine for this reason." A more condensed guide to dermoscopy. If that exists, it would be nice for me. That's something that I, even three months in, don't feel too comfortable with.

Dr. Friedman:  I'm with you. When I see a dermoscopy lecture, half the time, I'm like, "Oh, my God, I missed a melanoma. Oh, my God. I just saw that and I didn't..." It's terrifying. I've had a dermosco for over 10 years. Still, I feel like it's tough. It's not perfect science. I echo that.

There are a lot of good resources out there. A good beginner's practical, translatable resource would be wonderful. What about you, Dr. Nelson? What do you wish someone handed to you in the first couple months?

Dr. Nelson:  I would say maybe the derm/pharm pocketbook, your pocket in between rooms. If you need dosing recommendations or what labs to order. Something that's derm-specific. I know they have one for internal medicine, but I haven't seen one for dermatology. That'd be helpful.

Dr. Friedman:  That's one of the reason I'm asking these is hopefully, someone will listen to this and be inspired to create this and share it with the world. Make it a better place for you and for me, and the entire dermatology community.

Let's get into something a little more fun. Dr. Murphy, any fire alarms? Any crazy, first three months things that you're like, "Oh, my God, what is happening?" that you would like to share with everybody? [laughs]

Dr. Murphy:  I feel like the biggest frustration is fire offs. That's something that got my blood pressure up in certain scenarios. I had this one patient that had really bad psoriasis. He was covered 75 percent of his body. Miserable. Had joint disease and all this stuff.

I wanted to skip HUMIRA. I didn't want to do HUMIRA. It felt like he needed something more. I did the appeal. I did the peer-to-peer. They wouldn't budge. It was frustrating. I got a little...Not rude. I was being a little terse with the peer-to-peer physician I was speaking to. I was like, "What was the point of this?"

I spent all this time talking about this data about how other things are better than HUMIRA. I was like, "You didn't do anything." He's like, "I'm sorry you feel that way." I'm like, "OK."

[laughter]

Dr. Friedman:  Was this person a podiatrist? [laughs]

Dr. Murphy:  I don't know what they were. They didn't say. I thought the whole peer-to-peer was you have a conversation with a peer. No, there was no exception. I have to realize that I can't get so annoyed about every time that happens, because it's out of our hands to a certain degree. I have to learn to deal with a bit more.

Dr. Friedman:  We got to fight the good fight and advocate for a patient. Even if you got a little terse, it was probably warranted. We need to roll up our sleeves sometimes.

Maybe that's another resource, especially for first-years, of the 101 to prior authorization, step therapy, copay accumulators, and all the lovely roadblocks that are put in our way and want us to set our hair on fire that limit our ability to take care of our patients. That's something else maybe someone or some thing out there could create for us.

Dr. Nelson, what about you? Any fire alarms? Any explosions in your first three months?

Dr. Nelson:  I don't think I've had any explosions, fire alarms. I would say dermpath is the bane of my existence. Don't tell Dr. Vaughn.

[laughter]

Dr. Friedman:  We won't tell him. This is just a national podcast. He'll never hear about it. Way to go.

[laughter]

Dr. Nelson:  It's a nice learning experience. When I get at the stop, I'm like, "Oh my god, where am I? What is going on?" He takes his time and tells us to start from top to bottom. Identify anything that you see, just colors. That's my fire alarm. [laughs]

Dr. Friedman:  That's persistent. Especially as first-years, it's so important to remember, take a breath, take a step back. There's no way anyone can expect you to know even a small morsel of the mass of body information in dermatology.

Dermpath is a pain point for many. Though, obviously, hope by time you finish your training, you do feel good about it enough to pass the certification exam, but also to have an appreciation with the CPC connection.

Quick reminder, don't beat yourself up if you can't even recognize blue cells. You're definitely on the right track. Next fun question. We are people beyond residents and dermatologists. We need to find a way to disconnect as well as to recharge. Dr. Nelson, what is your favorite guilty pleasure to reward yourself after a long day of dermatopathology?

Dr. Nelson:  Let's see. I really like Jeni's ice cream. For those who don't know, it's specialty ice cream. My favorite is brown butter almond brittle. On a hard day, I'll probably go get a scoop of ice cream. [laughs]

Dr. Friedman:  That is not a bad decision. Bethesda's office is right next door to one. That's very dangerous.

Dr. Nelson:  Dangerous. [laughs]

Dr. Friedman:  Dr. Murphy, what about you?

Dr. Murphy. I would have to say I'm also a desert person. Lately, I've been on these things called peanut butter balls made with Skippy peanut butter. It's peanut butter surrounded by peanut butter. I dog sat for my aunt. She knows I love these. She bought me a giant, they sell at BJs, a BJ-sized bag of them.

I'll come home and have a handful of peanut butter balls. They're amazing. I'm running out. It's a problem.

Dr. Friedman:  I thought the greatest invention at one point was bacon-wrapped bacon. We've been one-upped here. Peanut butter wrapped in peanut butter. I'm going to have to unpack that for a bit, because my mind is visually melting right now.

Dr. Murphy:  [laughs]

Dr. Friedman:  That sounds incredible. Wow. That's a showstopper. Is it really? We got one more question for you guys. Dr. Murphy, if someone was to play you in a made-for-TV movie about the first three months of residency, who would it be? Why?

Dr. Murphy:  Bringing it back to the first episode, I talked about "Gossip Girl" is my favorite show. I have the biggest girl crush on Blake Lively. I love her. She's so pretty. She's so sweet. I would want her to play me. When I was in college, I was in a sorority. As part of a skit, I played her. Somebody told me, "Wow, you actually look like her." I was like, "Life made."

Dr. Friedman:  [laughs]

Dr. Murphy:  I'm good.

Dr. Friedman:  Drop the microphone. You're done.

Dr. Murphy:  [laughs]

Dr. Friedman:  [inaudible 16:68] . [laughs]

Dr. Murphy:  I was like, "Thank you." That's a superficial answer. She has gorgeous hair. I love her.

Dr. Friedman:  Listen to the question. It has to be fun. [laughs] Answer has to fit with that. Dr. Nelson, you had some time to think about this one.

Dr. Nelson:  It hasn't really helped. [laughs] I would say probably Gabrielle Union. Honestly know her from "Bring It On" and stuff. I feel like she keeps it composed. It's hard to tell if she's stressed or not. She could play me as a resident.

Dr. Friedman:  She'd bring it, is what you're saying.

Dr. Nelson:  Gabrielle Union. Yeah, she would bring it.

[laughter]

Dr. Friedman:  Those are great answers. Thank you for the entertainment and for playing along with this experiment. Make sure, everyone, to tune in to Episode 3 in the near future.