The Real Derm: Episode 4, Residency Insights

"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, Drs Adam Rosenfeld, and Alexis Carrington, who get real about their dermatology residencies by discussing what they wished they knew before going through this year, and what conferences they found, as a first-years, to be helpful, This and more can be found in this episode, and we hope you stay tuned for Episode 5!

Transcript:

Dr Adam Friedman: All right. Welcome back to the Real Derm podcast, where derm residents finally lock down their program director for an interview and start getting real. I am joined by two new members to the podcast, our rising GW second-years, Drs Alexis Carrington and Adam Rosenfeld. Welcome to the Real Derm.

Dr Alexis Carrington: Thanks for having us.

Dr Adam Rosenfeld: Yeah, very excited to be here.

Dr Adam Friedman: Well, let's just dive right in. You guys are literally wrapping up your first year of residency. Congrats. You are days away from being called second-years. Alexis, let's start with you, what are things you wish you knew before going through this year? What are things you wish someone else had passed down, whether it be in two stone tablets, etched in that stone, that would've made this year maybe easier, smoother, or anything like that?

Dr Alexis Carrington: I will say that the residents ahead of me, the attendings, you guys definitely prepared us well. For me, I would say it would be to trust the process, because you're new, you don't know anything as a first year, and you hear it all the time, but for me, I was like, "Oh, I have to at least know something." And, going through the year, I realized, "Oh, wait, there is a learning curve and it's supposed to be a learning curve." And looking back at it, I'm like, "Okay, I should have just trusted that it's going to take some time in learning, take some time in getting used to things." And again, this was something that was told, but just what I would tell first-year Alexis a year ago is just relax and it'll come to you, and that's what I'm telling myself now as second year is coming.

Dr Adam Friedman: What about you, Adam, what do you think?

Dr Adam Rosenfeld: Yeah, I would say probably that this is hard. And we're the type of people, in going through our training, that we like to pick up on things fast and get good at things, and I feel like just acknowledging that derm residency is hard. And, especially as a first year when you're really entering it, coming out of intern year, really have never done derm every day, all day, like Alexis said, trust the process, but just going in with the expectation you have to work hard. This is not going to be something that just clicks overnight, just have patience with it, but just knowing this is hard, and being okay with that, and working towards increasing your knowledge. And it's much more enjoyable if you have that expectation, I feel like, instead of thinking everything's going to go smoothly and it's going to be easy, which not that I thought that, but it could be easy maybe to think that.

Dr Adam Friedman: Yeah, I completely agree. I can even remember my first month, let alone year of residency, and I was in clinic the second part of the very first day with patients already, and I was like, "What on earth is going on? I don't know how to speak the language. I don't even know where I am right now." And I think the recommendations, or advice, you both gave of it's your first year, it's tough. It's hard, go easy on yourself. I think we are so used to believing we need to know everything yesterday that trying to take that approach to dermatology ... there's no cramming in dermatology. We manage over 3,000 diseases. It's a foreign language. It's a foreign approach to how you even approach a patient. I think giving yourself some grace and accepting that you know very little, and everyone knows that you know very little, and it's okay.

It's okay to be called on in grand rounds, and have no idea what you're talking about. That's expected. If you already knew everything, why are you in residency? I couldn't agree more, giving yourself the time to learn the fundamentals, learn the lexicon, learn how to use all of those wonderful words to describe what you're seeing, to then come up with a reasonable and organized differential diagnosis. That is really the goal of first year is get the basics down so then you can pack on all the esoteric stuff you need to know.

Along those lines, Adam, was there an aha moment during your first year that stands out to you when things started to click, and you were like, "I actually know something, The whole process is actually working?" Would you remember a moment that really stands out to you?

Dr Adam Rosenfeld: It was when I was on consults this past block over the last three months. We had this patient who was actually erythrodermic. Really, they came in not able to give much of a history. It was a very complex patient. But, for whatever reason, I just felt like, although there was all this chaos, not really having his records, just based on his presentation and looking at his skin, I felt like I had a really good differential. And, from a lot of the studying I had, I actually felt comfortable thinking this could be CTCL actually, just given some of the classic distributions for this patient, these scaly, psoriasiform-type eruption, and for whatever reason, it just clicked.

And I told Dr. Saardi, and he actually, at that point, didn't fully cross his mind, and then, after we did all this chart reviewing and found out where this patient had received care in the past, we found out he had a known diagnosis of CTCL. It's kind of a humblebrag, but it was just more of not getting lost into the weeds, which is easy as a first-year too, when you have all this to learn. But just the fact that I could recognize that and have a lot of differentials come to mind, that was just a proud moment for me.

Dr Adam Friedman: That's awesome. Alexis, what about you?

Dr Alexis Carrington: Actually, I had a moment like that. It was this past Monday. And I'm at the VA, and I was working with Dr. Boger, and we had this patient who just came in with a rash on his shin, and he was like, "Oh, it started off as a bug bite a couple months ago, and then I just noticed these blisters appeared, and now this is what it looks like today." And I looked at it and I'm like, "Oh, it's violaceous, it's plantar, things like that." I'm like, "That's lichen planus. I can't think of anything other than that." And I did think of a differential, and that sort of thing, but at that moment, I was like, "Wait, I actually recognize that and I'm pretty confident in what I saw."

And I presented it to Dr. Boger, and she saw the same thing and she's like, "Yeah, that's lichen planus. Great job, Alexis. You did it." It's like, "Okay. It's like I'm getting there. I know something." I would say more of those moments are coming, and now that I'm starting consults, I'm looking forward to more of those aha moments. Yeah.

Dr Adam Friedman: No, well said. I ask this question because every resident, every first-year resident, has that moment. It could be mid-year, end of year, and it is such a rewarding ... Everyone who's listening can hear how rewarding that moment is. And, very often, you remember that moment. Sometimes it's at grand rounds, clinic, consult service, but the point is everyone has that moment at some point, and that highlights that progress and really supports the process.

Along those lines, obviously, the aha moment is very supportive and nurturing. What about resources? Alexis, what resources as a first-year did you find helpful in solidifying that basic fund of knowledge?

Dr Alexis Carrington: For me, there was Baby Bolognia. That was very helpful. Of course, Alikhan, that's the bible in dermatology, and honestly, the Kodachromes that we did, seeing that in grand rounds, I feel like it helps. You hear it, especially at the beginning of the year, it's like, "What the heck is that? I've never even heard of that word before," but seeing the Kodachromes and getting that repetition that we do at GW at the VA, I feel like it's a great resource for me. And moving forward, as our knowledge increases, I feel like that gave me a great basis.

Dr Adam Friedman: Adam, what about you?

Dr Adam Rosenfeld: Yeah, I totally agree. I like Andrews's Kodachromes. I felt like, especially studying for the basic exam, there's a ton of good images if you have the hard copy or the online version. Elston's dermpath book, I think different programs use a variety of resources for dermpath, but I really like the way he approaches things. And then, yeah, I agree with a lot of what Alexis said, even just on your own, finding kodies, or if you're struggling with a particular thing. I'm very interested in dermpath, so I would use ... his first name's Jared, I don't know why I'm blanking on his last name, but he does amazing dermpath videos on YouTube. Even before bed, just watching videos of that nature, I felt like was really helpful.

Dr Adam Friedman: Yeah. I think one of the downfalls of too many resources is that it's easy to get spread thin. I think this is even more true as you ascend the ranks and you're studying for the applied exam and the core exams is you have so many things, what do you actually use? I think some basic rules are very important in that repetition, as was just mentioned, repetition is the best way to remember things. For example, as a first-year, you see something in clinic, you see something in grand rounds, you then go home and look at as many images as humanly possible across the spectrum of skin tones to lock that information in.

I think one of the things I really like about how we formulated book club in that it is PowerPoint-based is you have the ability to preview the PowerPoint as you read, you review it as a group, and then you can review it again, and that's actually what I did during my residency training. My first-year book club was really, you just read and answer questions. That didn't work. I was flailing. I was near drowning in terms of really solidifying that fund of knowledge. And then, in my second year, our chief resident at the time, Dave Ciocon, who I'll give the hugest shout-out, he's the Director of Mohs Surgery at Albert Einstein College of Medicine, as a sole chief resident, mind you, completely revamped the entire curriculum and made it PowerPoint-based and all image-based, and that made all the difference for me.

And I think the reality is everyone has a different way of learning, but at the end of the day, for derm, you got to look at images. Getting in your hands as many atlases, images, and once again, being inclusive in those images to make sure you recognize everything on every one is probably one of the most important things to even getting the lexicon down. I recommend looking at an image and describe out loud what you see, as that's just really great practice.

Beyond physical resources, I find conferences could actually be very helpful, not just for learning, but also networking. Adam, what conferences did you find, as a first-year, to be helpful and really stand out in terms of developing your path?

Dr Adam Rosenfeld: In terms of not grand rounds, more national type conferences?

Dr Adam Friedman: You know what? Buyer's choice, whichever, from the most regional or local conference, quote-unquote, with grand rounds or CPC conferences to even the national level. What did you, as a first-year, find to be really helpful?

Dr Adam Rosenfeld: Yeah, I actually thought grand rounds was super helpful personally, because we were able to present a lot actually. And I think I mentioned this to you earlier in the year, by actually coming up with a case yourself and having to dive deep into that topic or that disease process, especially early on in first year, and really into the weeds, it's an actually amazing experience, because you get really good knowledge on that particular disease.

And because it can be so overwhelming, you mentioned we have 3000 diseases, you're like, "Where do we start?" But, when you start to get comfortable even with a few and you feel like you're an expert, and we're fortunate enough to do grand rounds and host frequently at GW, and I feel like, as first-years, we present maybe the most, and getting thrown into that is such a valuable experience. And the camaraderie and being able to talk at these grand rounds with other members of the community, other programs, I found that to be actually the most valuable educational experience in terms of conferences for me as a first-year.

Dr Adam Friedman: Embrace the challenge, don't be scared off from the assignments that trickle down from the chief residents is what you're saying.

Dr Adam Rosenfeld: Exactly. It can be easy to.

Dr Adam Friedman: Alexis, what about you? What's your perspective on conferences and your experiences at any level?

Dr Alexis Carrington: I would say that ODAC was actually a really good conference. Before I came to GW, it was like I heard of the conference, but I'd never been to it, so I didn't know what to expect. But the thing that I loved about ODAC was it was a wide range, from med derm to cosmetics to surgery. They had some sessions where we could do hands-on practice on fillers and things like that. There were just plenty of other sessions. I felt like it was a breadth of knowledge, and I still remember some of the facts that were discussed, and it's like, "Oh wait, that actually helps me in clinic." I really love that.

And I also agree with Adam, grand rounds, that is very helpful, especially how we present. It, not forces you, but it makes you delve into the topics. And for me, when I presented IGA vasculitis, I was just able to learn so much about it. I feel like delving even into review papers, I feel like it allows you to dedicate time to do that, where you won't be able to do that for every other disease, has just so much to learn.

Dr Adam Friedman: Adam?

Dr Adam Rosenfeld: I had this thought actually, I did DFSP for my first grand rounds, and I think I talked to you in clinic, I was like, "I really learned a lot," and you're like, "That's the point." And I was thinking, if I had to present every week in residency over a different disease, I'd really get good at dermatology. That crossed my mind.

But I was going to say another conference I really enjoyed was the Legislative Conference, which was early in the year, where we get to go on Capitol Hill and meet with members of the House and Senate and their teams. And I had never done any form of advocacy in the sense of dermatology specifically, and I just thought that exposure and just realizing that these are things that are happening where you can do those sorts of things, especially as a first-year, was a valuable experience because, up until now, I just had no idea that those things even necessarily happened or how that all occurs.

Dr Adam Friedman: No, it's a wonderful comment. I think certainly being down the street from it doesn't hurt, but I think it's one of those conferences that, as a resident, at some point in your training, it's a great opportunity. And that's another thing to say about this, about conferences. When you're a resident, your ability to go to conferences and have support for those conferences, whether it be from a society or an organization or even your own home program, is somewhat unparalleled. Once you're out in the real world, very much it's on your time and dime.

And so, I highly recommend to all residents, whatever the construct is in your program in terms of being able to go to conferences, maybe you need to be presenting something in order to go or to go to more than the typical, take full advantage because you're in the protective envelope of residency that allows you to do those things. But, once you're out in the real world, it's all on you, and so I almost think, like college, taking advantage of all the cool things that are going on. Often you think about, after you graduate, oh, would've, should've, could've been in this club or did this thing, and too bad, too late, so definitely take advantage of that.

And, with that in mind, now you're finishing your first year, you guys are going to be second-years. Alexis, what are you excited about, or I'll even throw out terrified about, becoming a second year?

Dr Alexis Carrington: We have a lot to learn, so I know that's going to be another mountain to climb, but I will say that's also what I'm excited for because I want to learn all of this stuff. And I feel like, first year, it's like, okay, you're, as you said, learning the lexicon, the vocab, everything. Now it's like, "Okay, what does this vocab mean? How can I think of these diseases?" I'm really looking forward to that, but also, I would say, being able to think more critically, so when you see a patient, just formulating a very good differential diagnosis. I feel like second year we really get to focus more on that.

I'm really excited to essentially learn more the practice of dermatology and learning how to form a differential diagnosis and learn everything. And I'm also really excited for the conferences coming up. Yes, the Legislative Conference is amazing, but also excited for things like ASDS, ODAC again, AD, because now that we have this vocab and basic understanding, now we get to build on it by hearing experts from around the country. I'm really excited for building my knowledge that way.

Dr Adam Friedman: Well said. Adam, round it out.

Dr Adam Rosenfeld: Yeah, I would say, first year is stressful because you're trying to get good at presenting, not only evaluating the patient yourself, but the way you communicate with your attendings. And I feel like, when you're more comfortable with that at the end of first year, now, like Alexis said, being able to actually really think about your management, really hone in on the details a little bit more, and you can not be so nervous or anxious about the more logistical aspect of patient care, but really thinking about what we're really trying to do, which is make people better.

The other thing is teaching. I'm really excited to have the new residents behind us, both at GW and our Howard colleagues at the VA. I think it'll be really fun to have the ability to pass some knowledge along, even though, like Alexis said, we don't know nearly enough, but we know some things, and they're going to really be relying on us. And I feel like that's a really great opportunity for us to support them and something that I'm really looking forward to.

Dr Adam Friedman: I think second year's the sweet spot because you're not the newbies. You have a fund of knowledge. To your point, there's now a group behind you that's going to look to you as experts to some degree, and for guidance and support and education. You're also not having to stress too much just yet about a job, though, Adam. I know, with dermpath, you are, so that doesn't really apply to anyone going into dermpath. But, in general, you get to focus on becoming a dermatologist without all the pressures of it being new and not knowing anything, or having to think about becoming a real person finally.

I agree there's a lot to be excited for when it comes to second year, and certainly we will check in and find out how things are going in the next couple of months. And all of you tuning in right now, make sure to check out the next podcast in the series, hearing from Doctors Carrington and Rosenfeld about their experiences as a second-year. Thank you so much for joining us. Guys, thanks for being here.

Dr Adam Rosenfeld: Thank you so much for having us. It was a true honor.

Dr Alexis Carrington: Thank you.