A career in dermatology
BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c2687 (Published 26 May 2010) Cite this as: BMJ 2010;340:c2687
- Imran Yusuf, academic foundation doctor12,
- Richard Turner, consultant dermatologist13,
- Susan Burge, consultant dermatologist and honorary senior lecturer; former president of the British Association of Dermatologists13
- 1Oxford Department of Dermatology, Churchill Hospital, Headington, Oxford
- 2Oxford Radcliffe Hospitals NHS Trust and Oxford University
- 3Oxford Radcliffe Hospitals NHS Trust
- Correspondence to: I Yusuf imran.yusuf{at}medsci.ox.ac.uk
Abstract
Dermatology offers an interesting clinical or surgical career in combination with a balanced and flexible working life, write Imran Yusuf and colleagues
Some medical specialties, such as dermatology, are allocated a very modest amount of teaching during undergraduate training1—not only in the United Kingdom, but around the world.2 Dermatology also suffers from the common assumption that because its primary diseases have low mortality rates, the specialty isn’t important and, therefore, is not as fulfilling as a career choice. This can lead junior doctors to neglect dermatology as a career possibility without genuinely considering its numerous advantages.
Is skin interesting or important?
The skin is the largest organ in the human body, with an average surface area of 1.8 m2, and its three layers constitute 16% of a person’s total body weight3—far heavier than the healthy human brain or liver. It is, therefore, unsurprising that skin is the organ system that hosts the greatest number of diseases, with more than 2000 estimated primary or systemic cutaneous diseases.4 If an interesting specialty should boast clinical variety, logic would rank dermatology among the most fascinating.
In the Western world and in Australasia, skin cancers are the most common malignancies, and the three major forms are increasing in incidence.567 Malignant melanoma is considered among the most lethal of skin cancers, and it kills more than 1500 people a year in the UK; squamous cell carcinoma kills 500 more a year,3 but can be cured with early detection and surgical excision.8 Patients need not be acutely unwell for clinical interventions to be lifesaving, and although the satisfaction may be more subtle, it is no less significant.
The overt nature of dermatological disease such as eczema and psoriasis results in an often profound impact on quality of life.9 Consider, for example, the distress that alopecia (hair loss) causes—it is grossly out of proportion with the physiological function that hair serves.1011 A dermatologist is thus presented with plenty of opportunities to improve a patient’s physical and psychological wellbeing—and, naturally, along with this comes a high level of job satisfaction.
The scope of dermatology
Disorders of the skin, hair, and nails fall within the remit of a dermatologist. The specialty is divided broadly into medical and surgical fields, with clinicians in secondary care often practising both. It should be noted that in some countries, training and practice in dermatology are combined with venereology, whereas in the United Kingdom, genitourinary medicine is a separate specialty.
Dermatology is chiefly an outpatient specialty, and most patient referrals request an initial diagnosis and treatment of an unknown skin disease or review of more complex and chronic cases beyond the skill of the general practitioner. Occasionally, patients are very unwell or incapable of applying therapies at home and require inpatient admission under the care of a dermatologist until they can be managed in the community. Patients are also admitted to day case units for the infusion of novel biologic therapies to manage psoriasis and other skin diseases.12
A dermatologist will assess emergency referrals from general practice and skin disease in hospital inpatients, and will provide advice to other clinicians, such as general practitioners, over the phone. Weekend on-call duties are less demanding than in other medical specialties; typically a registrar can be expected to cover one in four weekends.
Dermatologists manage acute and chronic disorders of the skin. There are many subspecialties in dermatology (box 1), and a consultant in a tertiary referral centre will often have an interest in one or two of these in addition to practising general dermatology or holding a surgical interest.
Box 1: Subspecialties and interests
Medical dermatology
Surgical dermatology
Dermatopathology
Hair and nail disorders
Genital skin disease
Paediatric dermatology
Immunodermatology, including patch testing
Blistering disorders
Connective tissue diseases
Photodermatology
Cosmetic dermatology
Genetic skin disease
Diagnoses are clinical in the overwhelming majority of cases, and dermatology requires relatively few investigations. Clinically diagnosing skin disorders takes skill and experience, plus a good grounding in clinical medicine. Dermatologists use a comprehensive formulary with topical therapies, systemic drugs including novel immunomodulatory drugs, phototherapies (with or without oral sensitisers), laser treatments, cryotherapy, and other treatment modalities alone or in combination—a huge variety of treatments to manage a tremendous number of diseases. Box 2 presents some of the pros and cons of a career in dermatology.
Box 2: Advantages and disadvantages of dermatology
Advantages
Variety of patients; all ages and genders
Clinical variety
Reliance on clinical diagnostic skills
Rewarding work—curable or controllable diseases
Patients rarely life threateningly unwell
Less demanding out of hours workload
Medical and surgical options
Can link clinical findings to pathological findings
Great opportunities for clinical or lab based research—skin is visible and accessible
Flexible specialist training
Disadvantages
Very large and increasing tumour workload
Busy working week, requiring good time management skills
Competition for jobs is tough at specialty trainee year 3 level
Less acute work than some other specialties
Medical dermatology
Medical dermatology, an emerging subspecialty, is the study and care of patients with:
Skin diseases that can have systemic manifestations, including connective tissue diseases, vasculitis, sarcoidosis, graft versus host disease, and severe drug reactions.
Potentially disabling or fatal skin diseases usually treated with systemic therapy, such as severe psoriasis, severe atopic eczema, cutaneous T cell lymphoma, and autoimmune blistering diseases.
Cutaneous manifestations of systemic disease.
The British Society for Medical Dermatology has been formed to advance this subspecialty in the UK.
Surgical dermatology
For those of you keen to indulge your surgical passions, there is good news. Dermatology manages a substantial turnover of skin tumours (both benign and malignant), of which surgical excision is the primary form of management. A surgical dermatologist uses clinical judgment and a dermatoscope (a hand held, illuminated magnifying instrument) to identify lesions that require excision for histological confirmation and further treatment. Occasionally, incisional or punch biopsies are taken to solve diagnostically challenging medical dermatoses.
Dermatological surgeons, like plastic surgeons, operate from scalp to sole. In specialist centres there is an overlap of these disciplines because dermatologists are able to perform technically demanding excisions from the face and close wounds with flaps of adjacent skin or skin grafts from more distant sites with proficiency equal to that of plastic surgeons.
Mohs micrographic surgery has added a further dimension to surgical dermatology by allowing microscopic confirmation of full excision of a primary tumour before surgical closure of a wound. In Mohs surgery, the patient waits with a dressing placed over the open wound while tissue is being analysed, ensuring a high rate of curative surgery while sparing healthy tissue, thereby reducing cosmetic comorbidity.13 It is offered in 11 centres in the UK, and many others around the world. It has been shown to be effective in the management of malignant melanoma8 and basal and squamous cell carcinomas.14
Compared with many surgical disciplines, surgical dermatology boasts very favourable outcomes. Operative morbidity is low, mortality is essentially nonexistent, and most individuals are cured when a tumour has been excised, adding to the rewards of the surgery.
Training in dermatology
UK postgraduate training
After obtaining a medical qualification (MB BS, MB ChB, or MB BChir equivalent), doctors wishing to become dermatologists must complete two years of foundation training and become fully registered with the General Medical Council. Thereafter, it is necessary to enter into core medical training or acute care common stem (ACCS), both of which last two years. During this time membership of the Royal College of Physicians (MRCP) examinations must be taken before applying for a training post in dermatology (applicants for specialty training year 3 need MRCP part 1). A full person specification for a specialty trainee year 3 in dermatology can be downloaded from the Modernising Medical Careers website (www.mmc.nhs.uk), as well as data on the number of specialty trainee year 3 jobs in the UK and the nature of the competition.
Dermatology training posts are awarded in competition, which is very strong. For example, often candidates have obtained a doctorate in medicine (MD) or philosophy (PhD) to enter the specialty, although this is common in other specialties such as cardiology or oncology. Specialist training is four years (specialist registrar), after which a certificate of completion of specialist training is awarded and the doctor becomes eligible to apply for a job as a consultant dermatologist. Postgraduate training outside the UK follows a similar course, although the nature of the examinations and competition may vary.15
Get involved in research
Dermatology offers a wealth of research opportunities because skin is a visible and accessible organ. The specialty receives generous research funding, and dermatologists often have an academic background—an infrastructure that facilitates clinical research.
Dermatology societies
Getting involved in societies is often the best way to express an early interest in a specialty, but also to network and meet important clinicians and academics, and to increase your clinical knowledge and appreciation of the possibilities a career in dermatology offers. Relevant societies include the British Association of Dermatologists, the British Association of Dermatological Surgeons, and the British Society for Medical Dermatology.
A career for you?
Dermatology is a fascinating specialty that offers an interesting clinical career in combination with a balanced and flexible working life, traits difficult to match in other medical specialties. If you are interested, approach your local dermatologist and find out how you can get involved—because undoubtedly, a career spent managing a choice of rashes is no rash choice.
Useful websites
British Association of Dermatologists—www.bad.org.uk
British Association of Dermatological Surgeons—www.bsds.org.uk
St John’s Dermatological Society—www.st-johns-society.co.uk
British Society for Medical Dermatology—http://medderm.co.uk
The British Skin Foundation—www.britishskinfoundation.org.uk
Footnotes
Competing interests: None declared.