Quick, Call the Dermatologist! An Insight into Pursuing a Dermatology Career
Many healthcare professionals typically regard dermatologists as having a relaxed 9-5 job, with few on-calls and dominated by females who are keen to strike a work-life balance that falls overwhelmingly in the favour of life. Thus few doctors will ever anticipate the need to yell “quick, call the dermatologist” and moreover many will regard the demand somewhat paradoxical. After all what emergency event can ever require the urgent attention of a skin doctor.
Having set the scene of dermatologists being below par doctors who do little work and are overrated in their title and pay, it would be great if I could blow you away with a time I saw a dermatologist gracefully glide in to the emergency department and in one sweeping movement explain to bewildered colleagues why the patient was at deaths doors and then proceed to rub some life-saving cream onto the patient’s chest, whilst all the department observes in awe. The truth is no such event has occurred in my time in the hospital. Indeed there was a shift one late Friday evening in the Emergency Department, a young man arrived by helicopter having had the misfortune of his face being caught in and crushed by a piece of industrial machinery. The trauma lead quickly directed his team and turned to me saying “you there, quick, go call the maxillofacial surgeon, the plastic surgery registrar. Oh and we may very well need the ophthalmologist”.
As I rushed towards the phone, I heard one of the trainees sweep past me towards the patient, putting his gloves on and muttering, “This is why I’m going to do dermatology”. In context of this episode, it seems exceptionally unlikely that a dermatologist would be summoned in an emergency an even less likely that they could provide a valuable contribution to any emergency scenario.
More recently I have spent some time in dermatology witnessing some of the great work a dermatologist does. I believe the greatness of their work is really found in the way they deal with the mindset of the patient entering their dermatology department. Whether it would be for grade 1 acne on a teenage boy or for erythematous, itchy plaques of psoriasis, the effect that the patient’s appearance or their appearance they perceive to have, is completely detrimental to their life. So much so, that I noted a patient who was uncomfortable with her cancer treatment as it flared up her psoriasis. It is at this point the dermatologist plays their card and skilfully handles the patients emotional stress whilst ensuring they maintain a realistic scope of what is occurring.
So is dermatology a desirable career or not? Working unsociable hours and the stresses of handling acute medical and surgical conditions leads to strains on the work-life balance for a junior doctor. Returning from a shift at work, the junior doctor may often be found face down on the dinner table in deep sleep. They then must heroically drag their tired, aching limbs up the stairs and then crash their bodies onto their beds, knowing that the cycle will be repeated tomorrow. Small wonder then that junior doctors are turning more and more to family friendly careers. For those also wishing to continue working in secondary care, dermatology provides an opportunity to be exploited.
Dermatology utilises the practice of both medicine and surgery, and so provides a middle avenue to clinicians who are unsure as to which speciality to pursue. Due to the diverse nature that skin pathologies present, there is ample time to teach both colleagues and students. Moreover there is more than an extra penny to be earned by doing private work. Finally the doctor generally has to work a 9 till 5 day followed by the occasional on-call shift.
With the relative lack of dermatology emergencies, these are usually not strenuous. However, it would be prudent for all students, whether they have aspirations for a career in dermatology or not, to at the least familiarise themselves with the acute dermatological emergencies. Listed below are a couple of examples WITH A BRIEF OVERVIEW:
Steven-Johnsons Syndrome (SJS) and Toxic Epidermal Necrosis (TENS) is one such dermatological emergency. Depending on the classification being used, SJS is when less than 10% of skin sloughs off compared to 30% of skin in TENS. It is an adverse drug reaction which presents as atypical flat targets or spots.
SJS-TENS usually starts with flu-like illness progressing to a painful, itchy rash (flat lesions with darker centres) that affects the face, followed by the trunk and extremities. Large areas are Nikolsky’s sign positive and oedema or swelling is common. SJS-TENS carries 5-15% mortality usually due to organ failure, secondary to sepsis, and thus it is essential that it is promptly recognised and treated by the clinician.
Necrotising fasciitis is another fatal skin condition commoner in the immunocompromised. Causative agents include group A Streptococci and Staphylococcus Aureus. As the name suggests, these infectious organisms can cause muscle, skin and other tissue to necrose and die. Patients may present with an erythematous swelling which progresses to blistered lesions with gangrene. Typically patients will demonstrate signs of systemic involvement and septic shock upon presentation.
The list of dermatological skin conditions by no means ends with these 2 conditions and although I could go on, it would be ambitious to say that the list is exhaustive. Nevertheless it is important to remember that these emergencies exist and specialist help should be taken when appropriate. What is more, with the increased attractiveness of dermatology to clinicians and consequently the more widespread availability of said clinicians, there should be little hesitation in shouting, “quick call the dermatologist”.