Career: Skin deep

IT has been predicted that by the year 2024 skin cancer rates among 60 to 79-year-olds will rise by a third in the UK – this on top of statistics suggesting that people in the same age group are today five times more likely to be diagnosed with malignant melanoma than their parents were, thanks to an increase in sunny foreign holidays and the use of sunbeds.

Just these figures alone attest to the growing profile of dermatology as a medical specialty and the need for competent practitioners in the coming decades. But that’s not to say that competition for dermatology NTNs (National Training Numbers) isn’t stiff and the training demanding.

Overview

Dermatologists manage diseases of the skin, hair and nails. These are extremely common and account for around 15 per cent of GP consultations. The number of possible dermatological diagnoses has been estimated at 3,000 and includes inflammatory, inherited, environmental, occupational or malignant skin disorders.

The specialty requires an in-depth knowledge of skin physiology and pharmacology, internal medicine and other specialties including immunology, pathology and genetics. It is mainly an out-patient specialty although some patients need hospital admission and dermatologists are often on the wards seeing patients in other departments.

Some skin conditions are chronic and intractable but many are curable and most are at least treatable. Dermatology is said to have the largest formulary in the hospital ranging from ancient tar preparations to the latest immunomodulatory drugs.

Most dermatologists are also skin surgeons and responsible for treating approximately three-quarters of all skin cancers, identifying lesions that require excision for histological confirmation and providing further treatment. A growing number of other subspecialties are also emerging in dermatology including dermatopathology, hair and nail disorders, paediatric dermatology, cutaneous allergy, immunodermatology, photodermatology, cosmetic dermatology and genetic skin disease.

Personal qualities required in dermatology include reliability, self-motivation, punctuality, flexibility and an ability to work well in a team. Dermatologists must also possess good communication and interpersonal skills because of the considerable psychological impact of some skin conditions.

A typical day for a dermatologist might involve an outpatient clinic, followed by ward visits and a surgical list. Dermatologists work with other consultant dermatologists and nurse consultants and due to a high volume of skin cancer work there may be close liaisons with histopathology, plastic, ENT and maxillofacial surgery colleagues and clinical and medical oncology. Weekend on-call duties are generally less demanding than in other medical specialties.

Training

Entry into specialty training for dermatology requires two years of foundation training and then a further two years in core medical training or the acute care common stem (ACCS). Trainees must have passed the full MRCP (UK) for entry to ST3.

The programme is highly competitive and some experience in dermatology at ST1 or ST2 level or as a locum specialty registrar is certainly beneficial. Most trainees will also try to get involved in some research or audits to improve their chances. Specialist training takes four years (specialty registrar) with the award of a certificate of completion of training (CCT), after which a doctor can apply for a job as a consultant dermatologist.

Because dermatology is a well-structured outpatient based specialty with a relatively low on-call commitment it is well suited to flexible training. In 2006, 13 per cent of specialty registrars were training flexibly.

Making the choice

A recent article in BMJ Careers offered a list of the advantages and disadvantages of dermatology as a profession*.

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

Further information

Getting involved in societies is a good way of exploring an early interest in dermatology and this can also provide a network to meet clinicians and academics and to increase clinical knowledge, along with gaining an appreciation of the possibilities a career in dermatology can offer.

Relevant societies include:

• British Association of Dermatologists – http://www.bad.org.uk/. The BAD website has a whole section devoted to medical students and how to attend dermatology meetings through their DermSchool initiative.

• British Society for Dermatological Surgery – http://www.bsds.org.uk/  

• British Society for Medical Dermatology – http://www.medderm.org.uk/

• The British Skin Foundation – http://www.britishskinfoundation.org.uk/  

* Yusuf I, Turner R, Burge S. A career in dermatology. BMJ Careers 26 May 2010

Q&A Dr Alastair Kerr, SpR in dermatology, just attained CCT

What attracted you to dermatology?

I was interested in the skin as a medical student but didn’t get as much teaching as I had hoped for. After obtaining my MRCP, I was lucky enough to get an SHO job in dermatology and found it was even more interesting than I had imagined. The low acute workload out of hours is also appealing, and lends itself to flexible training for family and for research.

What do you find most challenging about the job?

There are a lot of diagnoses (about 3,000) so you’re always reading to try to keep up-to-date. There are also a lot of patients referred to out-patients, so you are very busy between 9-5 and have to be good at time management.

Has anything surprised you about the role?

When I first started, I didn’t know that dermatologists did any surgery. Even in the time I’ve been in training, the amount of surgery dermatologists do has increased a lot. There is always going to be a great demand for dermatological surgeons in any department, with the current epidemic of skin cancer. I was also surprised about the amount of blood tests and other investigations that dermatologists did, as I thought it was all just recognising patterns and prescribing creams. Dermatologists are physicians, and doing my MRCP stood me in good stead.

What do you consider the most important personal characteristic in a good dermatologist?

You have to be empathic towards those with skin disease, as there is a lot of morbidity and psychological upset that goes with having some skin conditions. Although rarely life-threatening, many are chronic in nature, which requires patience. Some of your patients will be with you for your whole career.

What is your most memorable experience so far?

Being given the opportunity to work in a friendly unit which is very research-active, and to publish several papers which have clinical relevance. I have also travelled to several international meetings to disseminate my work.

Is there any advice you could give to a final year or FY trainee considering dermatology?

I think there is a perception that it can be an easy option and the phrase “derma-holiday” is well known. However, the reality of it is like any other hospital specialty. It’s competitive at entry level and busy on a day-to-day basis. There are relatively few FY jobs which have dermatology placements, but you may be lucky to find one. If you really are interested, it can be a very rewarding specialty, with many subspecialties to choose from.