I’m in my last year of dermatology residency and feeling the pressure of applying for jobs. Perhaps you’re in the same position! The majority of graduates go into private practice. Others choose to pursue academic medicine, work for a hospital-owned practice, or maybe even the VA. A growing number choose to work for private equity-backed practices. Some go on to do additional fellowship training.
For many, the path one takes after graduation is heavily influenced by the experiences received during residency, which makes it all the more important to choose a residency carefully. Choosing a dermatology residency continues to be one of the most important decisions I have ever made.
Dermatology residency programs can generally be divided into traditional university-based academic programs, community-based programs, or some hybrid of the two. Most dermatology residents train at traditional university-based academic programs. Academic programs often emphasize complex medical dermatology, inpatient consults, research, and subspecialty teaching, offering deep exposure to rare or high-acuity conditions. Community-based programs often mirror the pace and structure of real-world practice, with high-volume outpatient clinics, hands-on procedures, close collaboration with support staff, and frequent interaction with industry partners.
I am a PGY-4 dermatology resident in an ACGME-accredited, three-year, community-based dermatology residency program. I wanted to share insights into training at a community-based program, some of my favorite aspects of it, and how these experiences may shape my future practice. I hope this will be helpful for medical students applying for residency and insightful for residents who do not train at community-based dermatology programs as they apply for jobs.
Clinical Training
Clinical training at community-based residencies largely takes place at outpatient offices that may be centered around private practices or non-university-affiliated hospitals. Clinical sites may be spread out across town. Driving between various clinical sites can be cumbersome; however, one advantage is being able to serve and care for a wide range of patient populations across urban, suburban, and rural communities. In addition, we see patients at the local VA, take consults at a local hospital, read slides with a dermatopathologist, spend time in the OR, and even care for patients in a free medical clinic. We care for patients with a variety of insurance types, including commercial, Medicare, Medicaid, and some self-pay patients. This exposure to different payer mixes gives us practical insight into the nuances of healthcare delivery, including access, insurance barriers, realistic treatment options, and our patients’ abilities to follow through with treatment recommendations. For example, for a self-pay patient with severe nodulocystic acne, isotretinoin may be the treatment most likely to improve their condition. However, it may be more difficult for a patient to receive financial assistance to pay for necessary labs and monthly office visits in a private practice setting than in a university-based academic center that has more robust patient assistance programs.
Practice Management Exposure
As important as it is to know how to manage the various conditions in dermatology, knowing how to work together with office staff to deliver high-quality, coordinated care for patients can be just as important. In our program, we are often exposed to the business and operational side of dermatology. Clinics are usually fast-paced with high patient volumes. We work closely with medical assistants, aestheticians, front desk staff, office managers, and district managers. Many of our medical assistants are pre-medical students who value the opportunity to work with residents, are eager to learn, and seek out our mentorship. We often think about scheduling, billing, and coding. For example, because I know I will one day be an attending who must do these things to be successful, I challenge myself even as a resident to optimize my documentation in such a way that accurately reflects the complex decision-making involved in the patient’s care, rather than inappropriately undercoding a patient visit. I have learned valuable lessons in leadership, communication, and practice management. This fast-paced and dynamic learning environment may reflect what many will eventually encounter in their practice as attendings.
Industry Interactions
In addition to interacting with various practice personnel, there is a significant opportunity to interact with pharmaceutical, cosmeceutical, and specialty pharmacy representatives. These personnel work closely with the residents and office staff on a regular basis to ensure we are aware of resources available to get patients the care they need. It doesn’t matter if we are able to appropriately select the best treatments if we are not able to get them into the hands of patients. For questions about prior authorizations, denials, and appeals, I’m often aware of who to ask to help guide me. Because it can take a while for some specialty medications to become approved by insurance, we are often able to administer in-office samples of these medications that are provided as a courtesy by pharmaceutical companies. Patients experience relief of their conditions sooner rather than later, and as a clinician, I also get to develop a comfort level for prescribing certain medications by seeing how my own patients respond to them. We are often aware of new medications on the horizon to treat patients even before they receive FDA approval. I believe industry partners significantly shape real-world dermatology, and my residency training has provided me ample opportunities to learn how to ethically and responsibly partner with industry to help patients achieve their treatment goals.
Resident Autonomy and Procedural Experience
Autonomy and procedural experience are other strengths of our program. Residents in their second year have one full day of continuity clinic per week, while third years have two full days of continuity clinic per week. Patients are scheduled under our name. Attendings review our notes, provide feedback, and are available for questions, but are otherwise hands-off, which helps to foster independence and confidence in clinical decision-making, while still ensuring robust oversight, mentorship, and patient safety. Beyond routine excisions, residents also get frequent hands-on experience performing Mohs micrographic surgery as well as cosmetic procedures, like lasers and injectables, which can sometimes be more limited in academic settings.
Implications for Future Practice
Training in a community-based program provides practical skills in patient care, productivity, and business literacy. This environment closely mirrors the realities of many post-residency practice settings, helping residents transition smoothly into their careers. This can be helpful when it comes time for negotiating contracts and knowing what to look for in those contracts, including salary expectations, production models, non-competes, schedule and workload expectations, practice resources, and more. These insights can be helpful for residents applying for jobs and medical students applying for dermatology residency alike.
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Artificial intelligence tools were utilized during the creation of this article.