Derm Sux

[Cesar]

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This thread is for everyone that thinks dermatopathology sux. Not as an entity but as a specialty. Why do many dermatopathologists think that they are brilliant?
Do most dermatopathologists make that much more than other specialties?
Whats so great about signing out basal cell carcinomas and SK's all day?

Why do really intelligent residents get suckered into doing derm?

So many dermatopathology wanabe's come accross like used car salesmen talking about how interesting the field is when it all comes down to making lots of money.

Why is a field where diseases are treated predominately by wide excision or just a handful of meds (steroids and jacked up antiinflamm. meds) become the be all and end all of pathology.

Please feel free to rant. 😉 😛

 

[yaah]

Haha, yeah I know what you mean. At least 90% of derm can be signed out by someone with one week of path training. It's the 10% that is the problem. Of course, other areas do have their easy cases too.

Intelligent residents get suckered into derm because they can make more money and get better job offers. Also, most of the cases are done on one or two slides, as opposed to the three tray prostate core extravaganza you get.

A good dermpath really does make a difference in patient care though, I don't want everyone to think I am anti dermpath. I am more anti the dermpath system. This is because it is a system where there are not enough training programs to support the need, and a lot of the spots go to non pathologists. And everyone wants to do it so it becomes competitive and you have to focus on it from day one of residency.

They could solve a lot of problems by letting people just take dermpath boards without making them go through the whole fellowship process. Impractical, maybe, but why? If I looked at enough slides, study sets, textbooks, and went to an occasional derm clinic to shadow, I could pass it.

 

[b&ierstiefel]

Haha, yeah I know what you mean. At least 90% of derm can be signed out by someone with one week of path training. It's the 10% that is the problem. Of course, other areas do have their easy cases too.

Yeah, those BCCs, SKs, SCCs, are pretty straightforward. But the few cases that especially require clinical correlations are tough. The inflammatory lesions especially considering that the differential is pretty vast.

Intelligent residents get suckered into derm because they can make more money and get better job offers.

Agreed.

I did a few weeks of dermpath this year and I had a great time. Of course, I must admit that the dermpath attendings are really cool here and the signout experiences were awesome. And I'm sure that contributed heavily to my enjoyment of the dermpath rotation.

 

[LADoc00]

This thread is for everyone that thinks dermatopathology sux. Not as an entity but as a specialty. Why do many dermatopathologists think that they are brilliant?
Do most dermatopathologists make that much more than other specialties?
Whats so great about signing out basal cell carcinomas and SK's all day?

Why do really intelligent residents get suckered into doing derm?

So many dermatopathology wanabe's come accross like used car salesmen talking about how interesting the field is when it all comes down to making lots of money.

Why is a field where diseases are treated predominately by wide excision or just a handful of meds (steroids and jacked up antiinflamm. meds) become the be all and end all of pathology.

Please feel free to rant. 😉 😛

I could write a 200 page treatise on dermpath. Im too tired right now to do it right now tho. Needless to say, as pathology falls apart as a business, dermpath is very much to blame.

 

[PathOne]

Haha, yeah I know what you mean. At least 90% of derm can be signed out by someone with one week of path training. It's the 10% that is the problem. Of course, other areas do have their easy cases too.

Intelligent residents get suckered into derm because they can make more money and get better job offers. Also, most of the cases are done on one or two slides, as opposed to the three tray prostate core extravaganza you get.

A good dermpath really does make a difference in patient care though, I don't want everyone to think I am anti dermpath. I am more anti the dermpath system. This is because it is a system where there are not enough training programs to support the need, and a lot of the spots go to non pathologists. And everyone wants to do it so it becomes competitive and you have to focus on it from day one of residency.

They could solve a lot of problems by letting people just take dermpath boards without making them go through the whole fellowship process. Impractical, maybe, but why? If I looked at enough slides, study sets, textbooks, and went to an occasional derm clinic to shadow, I could pass it.

Very good post. However, with the fail rates of fellowship-trained ppl at the dermpath boards, I doubt if you'd be able to pass without spending some serious time on the 'scope. Also, remember that you'd have to have clinical dermatology if you come from the path side.

Frankly, it's my experience that the average dermpath IS a better pathologist than the average non-dermpath (of course with clear exceptions), and that the best dermpaths can easily hold their own against the best pathologists, even though dermpath is actually a tiny subspec.

Such generalizations aside, you'd be amazed how many super-experienced dermpaths, even top dawgs at places like Ackerman, UCSF, Harvard and MSKCC, will be entirely baffled by specimens on a daily basis. Its true that 90%+ of what a dermpath sees is pretty, if not very, basic. But the residual can be a hard nut to crack. Also, there's not really any help from either IHC, FISH or other techniques which can be helpful in other parts of pathology. So training, and experience, counts. A lot.
Remember, you don't need to be a dermpath, or even a pathologist, to read a derm slide. But there's actually a reason why people send their stuff on to the dermpaths (and no, it's not just a malpractise issue. That's actually a fairly benign issue in dermpath).

 

[akaz]

Very good post. However, with the fail rates of fellowship-trained ppl at the dermpath boards, I doubt if you'd be able to pass without spending some serious time on the 'scope. Also, remember that you'd have to have clinical dermatology if you come from the path side.

Frankly, it's my experience that the average dermpath IS a better pathologist than the average non-dermpath (of course with clear exceptions), and that the best dermpaths can easily hold their own against the best pathologists, even though dermpath is actually a tiny subspec.

Such generalizations aside, you'd be amazed how many super-experienced dermpaths, even top dawgs at places like Ackerman, UCSF, Harvard and MSKCC, will be entirely baffled by specimens on a daily basis. Its true that 90%+ of what a dermpath sees is pretty, if not very, basic. But the residual can be a hard nut to crack. Also, there's not really any help from either IHC, FISH or other techniques which can be helpful in other parts of pathology. So training, and experience, counts. A lot.
Remember, you don't need to be a dermpath, or even a pathologist, to read a derm slide. But there's actually a reason why people send their stuff on to the dermpaths (and no, it's not just a malpractise issue. That's actually a fairly benign issue in dermpath).

I must day that I am only coming from a graduate student's perspective. I worked in derm oriented labs at Harvard Med during grad school. Now, I thought as researchers the dermatopaths were rock stars. Seriously, I learned so much from them, that I was able to later make huge calls and land a big paper from what they taught me. They were awesome and as researchers I wanted to be like them. Now as a clinician I know nothing.

 

[yaah]

Such generalizations aside, you'd be amazed how many super-experienced dermpaths, even top dawgs at places like Ackerman, UCSF, Harvard and MSKCC, will be entirely baffled by specimens on a daily basis. Its true that 90%+ of what a dermpath sees is pretty, if not very, basic. But the residual can be a hard nut to crack. Also, there's not really any help from either IHC, FISH or other techniques which can be helpful in other parts of pathology. So training, and experience, counts. A lot.

I agree with this (well, I haven't signed out cases at those places, but I can imagine given that we have a busy service and some very good dermpath attendings).

I wonder, though, how often the really baffling specimens have a specific diagnosis that makes a difference. If you get a specific enough description and can say what features favor what condition (and what features suggest against what condition) cannot that be equally helpful? I tend to wonder if some of the borderline inflammatory lesions are borderline for a specific reason, not just because they defy histologic diagnosis but because they don't fit a known category anyway. Like calling something lupus panniculitis vs lymphoma - sounds like it should be a significant call - but for the borderline lesions shouldn't they be treated similarly anyway? I am curious.

 

[PathOne]

Oh, no... The questionable dx can often be anything-but-academic. I.e. is it malignant melanoma or isn't it? Immunos aren't really that helpful in Dermpath, since the most common one out there is S-100, which colors for benign lesions just as beautiful as it does for those nasty malignant ones. Diagnostic problems are of course not rare in Pathology, but in my experience you tend to see more of them in Dermpath, although, as stated before, the vast majority of the caseload would almost inevitably be pretty straight shots.