Derm vs. Rheum

[RedValerian]

Current MS3 having a hard time choosing between derm and rheum. Searched for previous topics but didn't find an answer to my question specifically.

A major motivation of mine is an interest in immunology, especially autoimmunity. Ideally I'd like to be an academic and do some amount of research (10-20%). Based on that, I feel that both derm and rheum would be good fits. Plus it has always seemed to me that the division between derm and rheum is rather arbitrary because a lot of derm diseases are probably on the same spectrum as, rather than being distinct entities from rheum diseases, like morphea vs. scleroderma and cutaneous vs. systemic vasculitis.

Reasons that derm could be a great fit include the clinicopathologic correlation. Another point towards derm is that I don't find IM all that interesting, although I understand the need for the training in order to help manage, say, scleroderma renal crisis or lupus pneumonitis. Derm also has fewer patients who have nebulous pain symptoms or at least you're not expected to fix that. Lifestyle is pretty similar -- both are primarily outpatient with some consults. Follow-up of someone with stable RA and someone with stable psoriasis is probably not that different (correct me if I'm wrong). Derm pays more (though the difference in academic settings is not as stark?) but it's equally if not more important to me that the field is intellectually fulfilling.

However, I'm confused about how much "ownership" a dermatologist specialized in med derm has over their patients. I understand there are derm-rheum multidisciplinary clinics at many top academic centers. There are derm-rheum fellowships. (My school doesn't have these so I haven't met any dermatologists who are specialized like this.) But for a patient with scleroderma, for example, what does the dermatologist contribute to the management? Will the patient be primarily a rheum patient, and (not to be disparaging) the dermatologist contributes some topicals? Likewise for other complex medical derm conditions. What are the leaders who are practicing dermatology doing? Plus, any other thoughts on picking a specialty?

Thanks in advance for your insights!

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[TMP-SMX]

Dermatologists don't need to do extra fellowships to do complex medical dermatology. With how few of us primary seeing those patients being an expert doesn't take much. These patients do not pay well and many private dermatologists are happy to send them to academic centers as a learning case or where there are more resources care for them. We are well trained in systemic treatments for diseases and many of those diseases such as autoimmune blistering diseases we are the primary physicians taking care of them. For cutaneous T cell lymphoma it's also in our domain until nodal involvement or Sezary. We have the capabilities of doing both procedures and medical management for many diseases so we are not limited in our scope. If a patient has widespread cutaneous limited discoid lupus could a rheumatologist blast them with systemic immunosuppressants? Sure but skin directed therapies have a high chance of at least limiting the dosage of immunosuppression but could aid in managing their symptoms.

I have respect for rheumatologists but there's too much subjectivity in my opinion because their organs are internal and labs don't always tell the whole story. As dermatologists we are hands on and patients can show us their concerns so we can feel and see their diseases. The issue I foresee in rheumatology is infusion centers are going to get regulated and profits cut. This has happened to some dermatologists who run cryo mills and there is more issues on the horizon with midlevels potentially taking over many of the skillsets of physician dermatologists.

 

[Dral]

You likely wouldn't have too much trouble getting a derm-rheum spot worked out at an academic center. You'd be surprised at the number of 'nebulous' rashes we get in derm (papular dermatitis/itchy red bump disease for example). These normally are the main cause of our clinical frustration (other than the delusions/derm psych pts). If you would do it, we'd be happy to send the tough rash patients to you.

Basically you would either do that and derm sometimes or that and rheum sometimes.

If you are more visually oriented and kinda like skin, you might be happier with derm. If you like more of the medical mysteries and lab value correlation, Rheum might be better (understanding that in both, the success rate of sleuthing cases likely isn't anywhere near 100% success). My guess is that rheum may have a little more in the way of long term patient relationships, if that is important to you...but remember, that also means lasting patient relationships with difficult patients. I have a lot of long term pts, but they are mostly in for periodic skin checks...think sorta how things are with a dentist...yearly check, chat a bit, do a biopsy for a suspected skin cancer if needed (like getting a cavity filled to flesh out the metaphor).

Allergy may be another thing for you to consider as well (personally probably would have done that or path if didn't get into derm).

Both have their B&B, both have their great patients, both have their problem patients.