Malignancy at Michigan Dermatology

[Microsporum Canis]

As a former resident of the program, I wish to shed light on different facets of this residency. Many of my old co-residents suffered through three years of misery and I’ve heard through the grapevine that current residents are going through the exact same things. Here are some of those issues

• Your main responsibility as a resident is to run the clinics. The faculty do not see patients on their own--and are completely unwilling to. Dermatology is the only residency program at Michigan where the entire burden of documentation, outpatient lab monitoring, medication refills, patient phone calls, and insurance issues falls squarely on the residents, which takes hours of time outside of clinic. We often missed what little didactics we had due to these "service obligations."

• Staff turnover is high. Very few, if any, of the support staff in general dermatology clinic last for the full 3 years of residency. Many have quit and emailed the program stating it is because the clinic volume and burden is just too high

• There is non-existent cosmetics training. You will need to learn how to perform cosmetics outside of your training if you want this to be part of your practice. This hurt me while I was interviewing for jobs

• The surgical training is very poor. You only get 6 weeks on Mohs during which your role is that of a medical student. Expect to do around 40-50 wide local excisions during your three year span, which is hundreds less than other programs in the country. Some of my coresidents ended up fabricating procedures in the last month of residency to meet the minimum requirement. It took me several months to get up to speed on my surgical skills after graduation

• One prominent faculty member in particular is anti-resident. His main goal is to jam as many patients through the clinic so the department can make money. He regularly books 50 patients into his clinic for three residents to see. During these times, he fails to actually address the concerns of the patients. He will either ask the resident what to do or just tell the patient they have eczema and give them a topical steroid. He does not exam the patient and suspicions have been raised regarding this attending’s visual acuity. Despite numerous complaints to the department and hospital administration regarding his lack of competency, he is still allowed to see patients. The faculty in the department are too afraid to take action despite him missing multiple life threatening diagnoses. In addition, through the years, he has made racist and sexist comments publically

• Pregnancy is looked down upon. Residents have been shamed for becoming pregnant and staff have said to residents that “babies are not allowed”

• The faculty are not involved in resident education. You will go weeks if not months without a faculty lecture. All lectures are given by residents except for a few drug lectures. There are very few faculty who seem truly invested in resident education

• The residents do very poorly on mock boards every year, mostly because they are not given time to study and the faculty do not teach

• Residents are coached on how to fill out the annual ACGME survey and are strongly discouraged against leaving negative feedback

• Residents are only given 3 conference days during their entire residency

This is just the tip of the iceberg

Mods, due to fear of retribution (as we all know, dermatology is a small world) this is a throwaway account

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[PatsyStone]

View attachment 228563

As a former resident of the program, I wish to shed light on different facets of this residency. Many of my old co-residents suffered through three years of misery and I’ve heard through the grapevine that current residents are going through the exact same things. Here are some of those issues

• Your main responsibility as a resident is to run the clinics. The faculty do not see patients on their own--and are completely unwilling to. Dermatology is the only residency program at Michigan where the entire burden of documentation, outpatient lab monitoring, medication refills, patient phone calls, and insurance issues falls squarely on the residents, which takes hours of time outside of clinic. We often missed what little didactics we had due to these "service obligations."

• Staff turnover is high. Very few, if any, of the support staff in general dermatology clinic last for the full 3 years of residency. Many have quit and emailed the program stating it is because the clinic volume and burden is just too high

• There is non-existent cosmetics training. You will need to learn how to perform cosmetics outside of your training if you want this to be part of your practice. This hurt me while I was interviewing for jobs

• The surgical training is very poor. You only get 6 weeks on Mohs during which your role is that of a medical student. Expect to do around 40-50 wide local excisions during your three year span, which is hundreds less than other programs in the country. Some of my coresidents ended up fabricating procedures in the last month of residency to meet the minimum requirement. It took me several months to get up to speed on my surgical skills after graduation

• One prominent faculty member in particular is anti-resident. His main goal is to jam as many patients through the clinic so the department can make money. He regularly books 50 patients into his clinic for three residents to see. During these times, he fails to actually address the concerns of the patients. He will either ask the resident what to do or just tell the patient they have eczema and give them a topical steroid. He does not exam the patient and suspicions have been raised regarding this attending’s visual acuity. Despite numerous complaints to the department and hospital administration regarding his lack of competency, he is still allowed to see patients. The faculty in the department are too afraid to take action despite him missing multiple life threatening diagnoses. In addition, through the years, he has made racist and sexist comments publically

• Pregnancy is looked down upon. Residents have been shamed for becoming pregnant and staff have said to residents that “babies are not allowed”

• The faculty are not involved in resident education. You will go weeks if not months without a faculty lecture. All lectures are given by residents except for a few drug lectures. There are very few faculty who seem truly invested in resident education

• The residents do very poorly on mock boards every year, mostly because they are not given time to study and the faculty do not teach

• Residents are coached on how to fill out the annual ACGME survey and are strongly discouraged against leaving negative feedback

• Residents are only given 3 conference days during their entire residency

This is just the tip of the iceberg

Mods, due to fear of retribution (as we all know, dermatology is a small world) this is a throwaway account

Thank you for sharing this. I remember when I interviewed I got a horrible vibe from the faculty and residents. But you have a dedicated Merkel cell clinic so that makes up for everything, right?

 

[asmallchild]

View attachment 228563

As a former resident of the program, I wish to shed light on different facets of this residency. Many of my old co-residents suffered through three years of misery and I’ve heard through the grapevine that current residents are going through the exact same things. Here are some of those issues

• Your main responsibility as a resident is to run the clinics. The faculty do not see patients on their own--and are completely unwilling to. Dermatology is the only residency program at Michigan where the entire burden of documentation, outpatient lab monitoring, medication refills, patient phone calls, and insurance issues falls squarely on the residents, which takes hours of time outside of clinic. We often missed what little didactics we had due to these "service obligations."

• Staff turnover is high. Very few, if any, of the support staff in general dermatology clinic last for the full 3 years of residency. Many have quit and emailed the program stating it is because the clinic volume and burden is just too high

• There is non-existent cosmetics training. You will need to learn how to perform cosmetics outside of your training if you want this to be part of your practice. This hurt me while I was interviewing for jobs

• The surgical training is very poor. You only get 6 weeks on Mohs during which your role is that of a medical student. Expect to do around 40-50 wide local excisions during your three year span, which is hundreds less than other programs in the country. Some of my coresidents ended up fabricating procedures in the last month of residency to meet the minimum requirement. It took me several months to get up to speed on my surgical skills after graduation

• One prominent faculty member in particular is anti-resident. His main goal is to jam as many patients through the clinic so the department can make money. He regularly books 50 patients into his clinic for three residents to see. During these times, he fails to actually address the concerns of the patients. He will either ask the resident what to do or just tell the patient they have eczema and give them a topical steroid. He does not exam the patient and suspicions have been raised regarding this attending’s visual acuity. Despite numerous complaints to the department and hospital administration regarding his lack of competency, he is still allowed to see patients. The faculty in the department are too afraid to take action despite him missing multiple life threatening diagnoses. In addition, through the years, he has made racist and sexist comments publically

• Pregnancy is looked down upon. Residents have been shamed for becoming pregnant and staff have said to residents that “babies are not allowed”

• The faculty are not involved in resident education. You will go weeks if not months without a faculty lecture. All lectures are given by residents except for a few drug lectures. There are very few faculty who seem truly invested in resident education

• The residents do very poorly on mock boards every year, mostly because they are not given time to study and the faculty do not teach

• Residents are coached on how to fill out the annual ACGME survey and are strongly discouraged against leaving negative feedback

• Residents are only given 3 conference days during their entire residency

This is just the tip of the iceberg

Mods, due to fear of retribution (as we all know, dermatology is a small world) this is a throwaway account

I don't doubt that some of this, if not all of it, is true. I didn't have the luxury of having a long rank order list and was just happy to match. But for those superstar applicants out there, it's worth noting that sometimes it is better to pick a place where you feel there's a better fit as opposed to the best "name" program. Posts like these really highlight why.

It's also worth noting that many of these complaints can be applied to almost all residency programs (big name, non-malignant, etc)

I did not go to a program with as big a name as Michigan but we had the same complaints from residents about being used as workload mules. While I can understand the frustration, my take is to just suck it up and it'll be over in 3 years. The more you see, the more you'll learn. Most medical students when attempting to match into dermatology are willing to do whatever it takes. It's interesting how that work ethic can recede once actually matched.

Ancillary staff turnover is typically high across all academic programs. And even in private practice, it's better but not that much better. If you think about how much they make and what they're asked to do, it's a losing proposition.

Cosmetic training is tough. I had some exposure as a resident but certainly not enough to make me feel confident. I would guess that few programs in the country would really give you enough cases to truly feel confident. Surgical exposure is a much bigger problem IMO. I think you can attend cosmetic conferences and courses and pick up what you need to know for basic filler / botox / laser. I've met plenty of graduating residents with just abysmal surgical skills and I'm not sure there's an avenue to pick up that kind of experience. This is something I urge medical students to strongly consider. Programs with VA or county hospital exposure (while typically busier) hopefully will provide for larger surgical volume, experience, and hopefully autonomy. If you can feel comfortable walking a junior resident through a surgery, you are probably in good shape. If you are insecure about basic excision technique, I definitely agree this will be a problem upon graduating.

Most, if not all, programs will have a malignant attending or at least one that is difficult to get along with.

While obviously not legal, pressure to not get pregnant does exist at many programs.

Residents at my program also complained about lack of faculty lectures and lack of time to prep for mock boards or the real boards. We all ended up passing the real boards. In an ideal world, it would be nice to have faculty that is invested in resident education. I will say that there is so much material within dermatology that no matter how great the faculty lectures are, a lot of the learning has to come from being a self-starter and churning through the books yourself.

 

[Trichophyton rubrum]

View attachment 228563

As a former resident of the program, I wish to shed light on different facets of this residency. Many of my old co-residents suffered through three years of misery and I’ve heard through the grapevine that current residents are going through the exact same things. Here are some of those issues

• Your main responsibility as a resident is to run the clinics. The faculty do not see patients on their own--and are completely unwilling to. Dermatology is the only residency program at Michigan where the entire burden of documentation, outpatient lab monitoring, medication refills, patient phone calls, and insurance issues falls squarely on the residents, which takes hours of time outside of clinic. We often missed what little didactics we had due to these "service obligations."

• Staff turnover is high. Very few, if any, of the support staff in general dermatology clinic last for the full 3 years of residency. Many have quit and emailed the program stating it is because the clinic volume and burden is just too high

• There is non-existent cosmetics training. You will need to learn how to perform cosmetics outside of your training if you want this to be part of your practice. This hurt me while I was interviewing for jobs

• The surgical training is very poor. You only get 6 weeks on Mohs during which your role is that of a medical student. Expect to do around 40-50 wide local excisions during your three year span, which is hundreds less than other programs in the country. Some of my coresidents ended up fabricating procedures in the last month of residency to meet the minimum requirement. It took me several months to get up to speed on my surgical skills after graduation

• One prominent faculty member in particular is anti-resident. His main goal is to jam as many patients through the clinic so the department can make money. He regularly books 50 patients into his clinic for three residents to see. During these times, he fails to actually address the concerns of the patients. He will either ask the resident what to do or just tell the patient they have eczema and give them a topical steroid. He does not exam the patient and suspicions have been raised regarding this attending’s visual acuity. Despite numerous complaints to the department and hospital administration regarding his lack of competency, he is still allowed to see patients. The faculty in the department are too afraid to take action despite him missing multiple life threatening diagnoses. In addition, through the years, he has made racist and sexist comments publically

• Pregnancy is looked down upon. Residents have been shamed for becoming pregnant and staff have said to residents that “babies are not allowed”

• The faculty are not involved in resident education. You will go weeks if not months without a faculty lecture. All lectures are given by residents except for a few drug lectures. There are very few faculty who seem truly invested in resident education

• The residents do very poorly on mock boards every year, mostly because they are not given time to study and the faculty do not teach

• Residents are coached on how to fill out the annual ACGME survey and are strongly discouraged against leaving negative feedback

• Residents are only given 3 conference days during their entire residency

This is just the tip of the iceberg

Mods, due to fear of retribution (as we all know, dermatology is a small world) this is a throwaway account

I'm a current resident at the University of Michigan Dermatology Residency Program. It's unfortunate that some of us have borne witness to the truth of some of these comments by M. canis, and some of us have had to contend with the conditions described above in our time here. Historically, Michigan has been one of the best Dermatology residency programs in the country, but unfortunately, the program may have rested (too long!) on its laurels and allowed some of these systemic issues to go unaddressed for years. However, the publication of the ACGME survey and the prior year's match result (the power of the Internet, and the spunk of the Millenials in speaking their minds) have forced the program to take a hard look at what's been happening and begin to effect significant and meaningful changes to address these issues. (It perhaps also speaks to the importance of residents answering the ACGME surveys honestly!) While it's also unfortunate that it has taken those kinds of drastic negative feedback as a "wake-up call" to force changes in the program, I think it's important to point out that changes have been made, and are continually being made to improve the residency experience. With some of the changes that have been implemented, although some way too slowly still, I don't doubt the sincerity of at least *some* faculty members and members of the department leadership in trying to improve the residency program. That said, I think it's sometimes hard for them to understand our frustration because we are the ones in the trenches, and things that seem trivial to them actually impact our lives profoundly because we have to deal with theses issues day in and day out. It's therefore critically important for people to continue to dialogue frankly with the program leadership and answer the ACGME surveys honestly (implemented precisely as a safeguard for all residents' educational interest) so meaningful changes will be made.

I will list some of the changes that have been implemented, not as a refutation of what has been posted, but as a reflection of progress made. I'm writing here in the hope that the faculty and leadership will continue to make the changes that are needed for the program, and that these comments will allow applicants who likely will be reading these pages to make informed and balanced decisions about their residency choices. I do still believe Michigan is one of the best programs in the country, despite the "rebuilding" that it's currently undergoing. Hopefully, by the time you as the reader steps through the door to this residency program, you will find one of the best programs to train at in the world!

"Your main responsibility as a resident is to run the clinics. The faculty do not see patients on their own--and are completely unwilling to. Dermatology is the only residency program at Michigan where the entire burden of documentation, outpatient lab monitoring, medication refills, patient phone calls, and insurance issues falls squarely on the residents, which takes hours of time outside of clinic. We often missed what little didactics we had due to these "service obligations."

- One of the main problems we have been facing is the severe administrative burdens that have been imposed on the residents (because the buck stopped with us...) to address lab monitoring. As a tertiary referral center, we see some of the most medically complex patients in dermatology, and as such manage complex and serious conditions that require many powerful and potentially dangerous systemic medications unless monitoring is done appropriately. This provides great learning opportunities in managing difficult conditions and using cutting edge biologic drugs, it also comes with a LOT of work far exceeding the capacity of residents to handle alone. Part of the problem is that the department was not using available resources efficiently and allowing the doctors to practice at their level of training "doctors doing doctor work." To address this issue, the department has hired on full time nurses to help with these responsibilities. We continue to review the lab results (as we should as physicians) in monitoring the patients, but as the fruits of one of our QI projects by residents, a workflow has been created where we are now able to delegate a significant amount of the responsibility for calling patients, tracking down labs, and making sure patients are compliant with monitoring to the newly hired nursing staff. This system has worked wonderfully (I used to stay at work way past 8 pm handling all the monitoring, paper work, and fielding calls I couldn't make during the day), and I have been able to go home at a more reasonable hour so I'm able to get some studying done -- although compared to programs where residents go home at 4:30 pm, I still feel a little behind. However, I do feel that the diversity and complexity of cases certainly prepare me really well to handle tough cases once I graduate residency. I also see the importance of developing a good support staff and I plan to do that in my future practice.
- New nursing staff has also been hired to help triage patients phone calls, and the messages we are getting from them are now much more helpful, less like "The patient is upset with his treatment. Call him" and more like, "So and so with XYZ is having trouble with dizziness. You saw hime recently. He wants to know whether you think it's related to the CellCept that you started him on. I reviewed his medications, and he also mentioned he started taking a new blood pressure pill by his PCP a couple weeks ago. Please let me know if I can help, and I can give him a call back." Night and day.
- There are now dedicated MA staff to help with filling out prior auth forms. You still need to review these, but now these go to our MA staff first and they help populate them with clinic notes if needed, and we have graduated from filling out these forms, to signing them after reviewing them, and generating appeal letters if needed. Definitely an improvement.

"Staff turnover is high. Very few, if any, of the support staff in general dermatology clinic last for the full 3 years of residency. Many have quit and emailed the program stating it is because the clinic volume and burden is just too high"
- The clinic volume is heavy, but the department has hired some new faculty members who are beginning to see patients on their own without residents at some of our satellite clinic locations, and we have been promised this will help decrease the numbers in the resident clinics at the main training sites.
- In terms of staff morale, we do have some long-serving, very experienced MAs that have been with us for many years, and some of them have been given the recognition that they deserved and promoted to taking on more of a leadership role with the support staff; attention has been paid to sharing some of their experiences to help new hires become more efficient in our clinics, so it seems the morale has improved somewhat. We are continuing to hire new MAs, it's tough.

"There is non-existent cosmetics training. You will need to learn how to perform cosmetics outside of your training if you want this to be part of your practice. This hurt me while I was interviewing for jobs."
- Historically this is true (and is the case at quite a few other programs), but is hopefully changing for us. We formed a Cosmetic Education Committee consisting of the core cosmetic faculty and resident reps from each class to address this issue. Our new curriculum has been implemented and residents are now able to rotate through cosmetic clinics beginning in the first year, with hands on experience in the second and third years. Additionally, in the works are resident cosmetic clinic/workshop (1 hour at lunch time on Thursdays) with prescreened patients that people can sign up for. This will start in the spring. Not sure how this will work out yet because we have not experienced it, and it being over lunch is not ideal... Bottom line is, hopefully there is now more opportunities for residents to perform cosmetic procedures, which are a critical skill set to have in today's practice environment, and this is on the radar of the residency administration. And I believe the experience of this program alum has actually left an impression with our PD.

"The surgical training is very poor. You only get 6 weeks on Mohs during which your role is that of a medical student. Expect to do around 40-50 wide local excisions during your three year span, which is hundreds less than other programs in the country. Some of my coresidents ended up fabricating procedures in the last month of residency to meet the minimum requirement. It took me several months to get up to speed on my surgical skills after graduation"
- As far as surgical education is concerned, after the ACGME survey debacle, our surgical faculty actually took charge in helping to improve the resident experience. Our new program APD is actually an accomplished Mohs surgeon, who has been pushing for changes that benefit resident training. Surgical exposure now starts in the first year, in addition to the dedicated 6 weeks of Mohs. New curriculum also pairs up the resident with one single attending on any given day during those times, so they can work together and develop surgical skills. The people who have gone through the experience have given very positive feedback about this new system. Additionally, seniors now have occasional slots back in the Mohs unit to work with Mohs unit faculty one-on-one as the main operating surgeon doing excisions. I would imagine surgical exposure would only improve over time.

"One prominent faculty member in particular is anti-resident. His main goal is to jam as many patients through the clinic so the department can make money. He regularly books 50 patients into his clinic for three residents to see. During these times, he fails to actually address the concerns of the patients. He will either ask the resident what to do or just tell the patient they have eczema and give them a topical steroid. He does not exam the patient and suspicions have been raised regarding this attending’s visual acuity. Despite numerous complaints to the department and hospital administration regarding his lack of competency, he is still allowed to see patients. The faculty in the department are too afraid to take action despite him missing multiple life threatening diagnoses. In addition, through the years, he has made racist and sexist comments publically."
- This is a tough situation -- a lot of feedback has been given to the administration about this faculty member.

"Pregnancy is looked down upon. Residents have been shamed for becoming pregnant and staff have said to residents that “babies are not allowed”
- Maternity leave is part of our HOA contract. Residents are actually quite supportive of their fellow residents that become moms during residency. But I suspect some of the problem in the past had to do with the distribution of the clinic burden when a resident went on leave. In the past, this was not managed very well and the burden fell disproportionately to one particular class of residents, rather than shared across the program, and this bred resentment. This has been much less of an issue with the new chiefs. When a resident went on maternity leave recently, her workload was shared, and as a big 24 resident program, it barely registered.

"The faculty are not involved in resident education. You will go weeks if not months without a faculty lecture. All lectures are given by residents except for a few drug lectures. There are very few faculty who seem truly invested in resident education"
- We are beginning to see many more faculty-led lectures, who are able to share their great breadth and depth of expertise precisely because of feedback such as this one. We now average about one 1-hour long faculty lecture a week, ranging from surgical workshops, phototherapy and drugs, to contact dermatitis. Some faculty are still much more involved than others though and we appreciate the ones who are much more involved. Overall, we have 1 hour each day of protected didactic time, including faculty lectures or QI time (Monday), dermpath case conference (Tuesday), faculty lectures/drug review (Wed), Diagnostic Conference (Thurs, 2 hours), Book club review (Friday AM) and kodachrome review (Friday noon). The last of these is still hard because clinics still run over and impact on time to attend the kodachrome review. The real solution is to cut back a bit on the patient number in the clinics before the noon kodachromes on Friday so clinics don't run over, but it will likely impact faculty compensation in those clinics, so it remains to be seen how much the administration is willing to do this for the sake of resident education.

"The residents do very poorly on mock boards every year, mostly because they are not given time to study and the faculty do not teach"
- This was true historically, and the residency leadership is taking this seriously. I harbor a glimmer of hope that with people now able to go home at a more reasonable hour than before (with reduction in administrative load and increased faculty involvement), we will hopefully begin to see improved performance. Our first year class has seemed much more knowledgeable than some of us were at the same point in our training, and the 2nd and 3rd years also seem to feel more confident with their prospects on the standardized tests. I am cautiously optimistic. I believe by the time the current crop of applicants enter residency, they will face a much more learner friendly environment and do better on their mocks and actually Boards. That said, no one who has graduated from Michigan has ever failed the Boards (and apparently one who did not pass because he chose not to take it, took it last year and passed).

"Residents are coached on how to fill out the annual ACGME survey and are strongly discouraged against leaving negative feedback"
-The truth eventually comes out, so it's important for everyone to answer honestly. I'm glad the safeguards worked in this case, and I doubt the program would dare to do that again.

"Residents are only given 3 conference days during their entire residency"
-This is still true, and remains a pain point, and people may need to use vacation time for some conferences. But in context, residents have all federal holidays, plus 21 days of vacation time (2 weeks plus 7 Flex days) to be scheduled at a time of choice based on seniority, plus 1-3 days of additional holiday time to use around holidays (so-called "Yule days," allotment based on seniority in the program: first years get 1 day, second years get 2 days, third years get 3 days). We now also all have protected time to attend Tampa Board Review in addition to the conference days and holidays, and AAD attendance does not count against conference days. In addition, all residents now attend Michigan Dermatologic Society Meetings (3 days a year), except the person on inpatient consult on the day of the meeting. I think we are at "industry average" if not better.

This has been a really long post, and I'm sure it hasn't addressed everything, but I hope that it gives a somewhat more nuanced view of the state of U of M Dermatology Residency Program. That the program is open to feedback and is actively addressing known issues gives me hope for the future trainees here. As a current resident here, I appreciate the work those who have come before us put in to make this place better for us, the courage they've had in giving feedback to those in power (and in a post such as the one I'm responding to), and what the faculty (with residents) have started doing to improve the program. And if and when you have the chance to train here, please continue to be honest and truthful in addressing issues to the administration to continue to make our program better. For the applicants, as you consider your rank list, U of M Dermatology is not perfect (and I don't know if any program is) but far from "malignant." In my opinion, it remains a strong and premier program, where you will be challenged to do your best, receive great training, and grow to be a great dermatologist, and I only hope it will be even better when you come here.

 

[Clap MD]

I imagine you’d see quite a bit of malignancy at any good derm program...

Sorry, I’ll see myself out.

 

[PatsyStone]

I imagine you’d see quite a bit of malignancy at any good derm program...

No, not really. This type of thinking perpetuates that malignancy should be tolerated because one is at a “top” program. “Low tier” programs can be just as malignant as a “top tier” program

 

[Navy1234]

No, not really. This type of thinking perpetuates that malignancy should be tolerated because one is at a “top” program. “Low tier” programs can be just as malignant as a “top tier” program

I think it was a joke.

 

[PatsyStone]

I think it was a joke.

Oops

 

[doctalaughs]

Interesting airing of dirty laundry.

I can tell you also having graduated from a "top 5 reputation" "very large" program (albeit 10 years ago) that not all high-tier places are malignant.

The main reason we didn't have the issues listed above were:
- even with 20+ residents, there were over 150 attendings, so only a small proportion of attending clinics were staffed with residents. Those attendings couldn't schedule additional patients on their resident days, which meant they needed to be able to handle their daily patient load solo. Which means the resident may see a lot of patients and they are there to teach, not use the resident as a workhorse.
- residents also started a ton of systemic meds- so much CSA, rituxan, imuran, infliximab, MTX, cellcept, injectable biologic etc that I was super-comfortable with all these on graduation. But we didn't have to follow the labs regularly (except in continuity clinic) since that doesn't have a ton of value. It was enough to do the ones in continuity and attendings would pull the abnormals they follow at the end of clinic to do some teaching.
- same thing with biopsies- we kept a log book to keep track of everything we saw (and definitely looked up every result) - but only called back the continuity patients ourselves. And there was always a backup tracking system for the attending to make sure nothing was missed.
- There is no excuse for getting that poor procedural and cosmetic exposure. I think I did over 100 excisions solo (with the attending just peeking in occasionally) my first year alone.
- There were plenty of days staying late, but never for "scut work"- always for seeing interesting/rare/learning pathology
- Faculty lectures were at least 3/4 of all lectures and there was at least 1 per day on average.

Sounds like Michigan is trying to change the culture but applicants beware and ask specific questions and look at those resident surveys if possible.

 

[dermathalon]

I sense a scramble coming if Michigan doesn't rank enough applicants. Hopefully they learned their lesson from last year and interviewed more people.

Now why are derms all up in arms about nurse injectors and PAs injecting cosmetics if we can even teach our residents enough to get them comfortable with cosmetics...obviously some programs get a lot (I had done about 100+ injections of botox and fillers by the end and was very comfortable)...we need to take care of our own a bit better.

 

[dermariffic]

Sounds a lot like USF Dermatology unfortunately. As a (fairly) recent grad, I sadly see many similarities. I feel lucky to be on the other side and don't feel USF is nearly as bad as what is being described about Michigan however it's eery how reminiscent some of the examples are of my residency training.

Cons:
- Clinics completely dependent on residents; none of the attendings had their own clinic or saw their own patients without a resident to do all the work. I thought this was changing when I was a senior however the younger faculty who originally had independent clinics slowly began demanding residents until once again, all clinics were resident dependent. When residents pushed back, asking to conserve what little educational time was available or spend that time performing the many menial tasks (see below) required of them, those residents were called lazy and uncooperative. All clinics were fast-paced, overbooked and always running behind (unless by some miracle there were no-shows or cancellations which we prayed for for clinics to run smoothly) so there was very little if any teaching during clinics, yet new clinics continued to be added that were resident-dependent. Residents definitely felt like work-horses and that education came secondary to the department making money and the attendings meeting their "quotas."
- Residents take all patient phone calls, refill prescriptions, review labs, pathology and complete all prior authorizations for medications. If the patient wants to speak to the provider they are listed as having seen rather than a resident they don't recognize, good luck to them because I can't remember a time during my residency when an attending actually called a patient back to have a discussion or answer a question. That was all on the residents. Unless of course the patient was a "VIP" and then the resident was expected to bend over backward to assist the patient, often breaking the rules set by the institution so as not to upset the attendings social standing or standing in the medical community.
- Faculty rarely taught. We taught each other nearly everything. The older faculty actually taught the most with monthly kodachromes. One attending had been faculty for several years and before he ever lectured residents. I've heard the faculty are lecturing more however it's taken years of complaints for this to occur. As clinics start earlier and earlier, lectures are shortened since clinic is the predominant concern of the faculty, not the resident's education. The glaring exception to this was the amazing dermpath faculty who taught us religiously twice weekly, one dermpath faculty led lecture and one unknown session at the multi headed scope. The dermpath faculty were amazing and by far my favorite people in the program.
- Very high nurse turnover. I can count on one hand the number of nurses that were there when I started AND when I graduated. Nurses frequently communicated to residents that the they felt under appreciated and that they were always scapegoated by the attendings when clinic wasn't running smoothly, something we had in common.
- Residents are strongly discouraged from giving honest feedback in the ACGME surveys and told (verbatim from the PD himself) that it will only hurt them in the end if the program loses it's accreditation.

Pros:
- lots of exposure to mohs although only actually get to perform linear closures and grafts and no supervision or teaching from the mohs attending who is also the program director and very much focused on production and numbers rather than education. He is very moody, some would say bi-polar, and this has cost him plenty of good nurses over the years. He doesn't like when you talk or ask questions in the patient room which I always thought was odd for an "educator."
- busy consult service and multiple work sites with exposure to many different patient populations. A former resident has taken over the consult service and refreshed it, I'm sure it's more educational now although when I was there, the consult service was run by an older doctor who barely looked at the patient before mumbling and walking out of the room. Similar to michigan, many complaints about this older doctor poured in over the years as he behaved similarly in the clinic setting, barely examining the patient or participating in any meaningful way in the encounter, however he is still working there to this day, I'm sure exhibiting the same behavior or possibly even worse.
- i saw multiple sites as an advantage for learning however some viewed it as a disadvantage as it does require travel time between clinics which is a challenge when the last patient in once clinic is scheduled at noon and then first patient at the clinic across town is scheduled at 12:45. And when attendings are unwilling to see even a patient or two on their own, if clinic runs over, the residents are not allowed to leave and then end up running late to the next clinic and are invariably blamed for this lateness. Never occurred to either attending to pick up a chart and help out by seeing a patient or two on their own if residents need to leave or are running late from a busy clinic.
- many surgical procedures. Again not much teaching or supervision but I figured it out on my own and felt more than confident in surgical skills once I graduated.
- good complex medical derm experience. I left feeling very comfortable prescribing and monitoring patients on biologics and other immunosuppressive medications
- decent cosmetic exposure. cosmetic clinic has multiple lasers and residents get basic training with botox and fillers taught by an excellent, experienced ARNP. No attendings perform cosmetics themselves unfortunately. I learned so much from this ARNP and heard she left after being there for years (presumably because she hated the chairman of the department so much she couldn't stand to work there any longer; it was a well-known fact since the residents spent lots of time with her and she would vent to us about how awful he treated her despite what an asset she was). I imagine this is a huge loss for their cosmetic department.

Despite having anonymous letters written to the ACGME and residents having met with the GME Dean of the medical school on different occasions, not much changed in the time I was there or seems to have changed in recent years from what I hear. As residents we were always close knit and made the best of it but USF could truly be a great program if there wasn't such poor performance by the attendings who do not seem to truly care about the residents or their education. I thought long and hard about transferring during my time there but decided I could make it through the three years because while there were many cons, there were also many pros and I felt I would leave well-prepared for real life practice. And I did, but it was sure hard and lonely sometimes feeling unsupported by your program. I post this mainly to say things I've wanted to say for years and to make sure future applicants investigate programs long and hard before ranking as this one fooled me. In the end, it's derm so what are you complaining about? (another quote from this infamous PD)

Of course, also a throw away account as derm is too small and people are too crazy!

 

[cableguy555]

I'm a current resident at the University of Michigan Dermatology Residency Program. It's unfortunate that some of us have borne witness to the truth of some of these comments by M. canis, and some of us have had to contend with the conditions described above in our time here. Historically, Michigan has been one of the best Dermatology residency programs in the country, but unfortunately, the program may have rested (too long!) on its laurels and allowed some of these systemic issues to go unaddressed for years. However, the publication of the ACGME survey and the prior year's match result (the power of the Internet, and the spunk of the Millenials in speaking their minds) have forced the program to take a hard look at what's been happening and begin to effect significant and meaningful changes to address these issues. (It perhaps also speaks to the importance of residents answering the ACGME surveys honestly!) While it's also unfortunate that it has taken those kinds of drastic negative feedback as a "wake-up call" to force changes in the program, I think it's important to point out that changes have been made, and are continually being made to improve the residency experience. With some of the changes that have been implemented, although some way too slowly still, I don't doubt the sincerity of at least *some* faculty members and members of the department leadership in trying to improve the residency program. That said, I think it's sometimes hard for them to understand our frustration because we are the ones in the trenches, and things that seem trivial to them actually impact our lives profoundly because we have to deal with theses issues day in and day out. It's therefore critically important for people to continue to dialogue frankly with the program leadership and answer the ACGME surveys honestly (implemented precisely as a safeguard for all residents' educational interest) so meaningful changes will be made.

I will list some of the changes that have been implemented, not as a refutation of what has been posted, but as a reflection of progress made. I'm writing here in the hope that the faculty and leadership will continue to make the changes that are needed for the program, and that these comments will allow applicants who likely will be reading these pages to make informed and balanced decisions about their residency choices. I do still believe Michigan is one of the best programs in the country, despite the "rebuilding" that it's currently undergoing. Hopefully, by the time you as the reader steps through the door to this residency program, you will find one of the best programs to train at in the world!

"Your main responsibility as a resident is to run the clinics. The faculty do not see patients on their own--and are completely unwilling to. Dermatology is the only residency program at Michigan where the entire burden of documentation, outpatient lab monitoring, medication refills, patient phone calls, and insurance issues falls squarely on the residents, which takes hours of time outside of clinic. We often missed what little didactics we had due to these "service obligations."

- One of the main problems we have been facing is the severe administrative burdens that have been imposed on the residents (because the buck stopped with us...) to address lab monitoring. As a tertiary referral center, we see some of the most medically complex patients in dermatology, and as such manage complex and serious conditions that require many powerful and potentially dangerous systemic medications unless monitoring is done appropriately. This provides great learning opportunities in managing difficult conditions and using cutting edge biologic drugs, it also comes with a LOT of work far exceeding the capacity of residents to handle alone. Part of the problem is that the department was not using available resources efficiently and allowing the doctors to practice at their level of training "doctors doing doctor work." To address this issue, the department has hired on full time nurses to help with these responsibilities. We continue to review the lab results (as we should as physicians) in monitoring the patients, but as the fruits of one of our QI projects by residents, a workflow has been created where we are now able to delegate a significant amount of the responsibility for calling patients, tracking down labs, and making sure patients are compliant with monitoring to the newly hired nursing staff. This system has worked wonderfully (I used to stay at work way past 8 pm handling all the monitoring, paper work, and fielding calls I couldn't make during the day), and I have been able to go home at a more reasonable hour so I'm able to get some studying done -- although compared to programs where residents go home at 4:30 pm, I still feel a little behind. However, I do feel that the diversity and complexity of cases certainly prepare me really well to handle tough cases once I graduate residency. I also see the importance of developing a good support staff and I plan to do that in my future practice.
- New nursing staff has also been hired to help triage patients phone calls, and the messages we are getting from them are now much more helpful, less like "The patient is upset with his treatment. Call him" and more like, "So and so with XYZ is having trouble with dizziness. You saw hime recently. He wants to know whether you think it's related to the CellCept that you started him on. I reviewed his medications, and he also mentioned he started taking a new blood pressure pill by his PCP a couple weeks ago. Please let me know if I can help, and I can give him a call back." Night and day.
- There are now dedicated MA staff to help with filling out prior auth forms. You still need to review these, but now these go to our MA staff first and they help populate them with clinic notes if needed, and we have graduated from filling out these forms, to signing them after reviewing them, and generating appeal letters if needed. Definitely an improvement.

"Staff turnover is high. Very few, if any, of the support staff in general dermatology clinic last for the full 3 years of residency. Many have quit and emailed the program stating it is because the clinic volume and burden is just too high"
- The clinic volume is heavy, but the department has hired some new faculty members who are beginning to see patients on their own without residents at some of our satellite clinic locations, and we have been promised this will help decrease the numbers in the resident clinics at the main training sites.
- In terms of staff morale, we do have some long-serving, very experienced MAs that have been with us for many years, and some of them have been given the recognition that they deserved and promoted to taking on more of a leadership role with the support staff; attention has been paid to sharing some of their experiences to help new hires become more efficient in our clinics, so it seems the morale has improved somewhat. We are continuing to hire new MAs, it's tough.

"There is non-existent cosmetics training. You will need to learn how to perform cosmetics outside of your training if you want this to be part of your practice. This hurt me while I was interviewing for jobs."
- Historically this is true (and is the case at quite a few other programs), but is hopefully changing for us. We formed a Cosmetic Education Committee consisting of the core cosmetic faculty and resident reps from each class to address this issue. Our new curriculum has been implemented and residents are now able to rotate through cosmetic clinics beginning in the first year, with hands on experience in the second and third years. Additionally, in the works are resident cosmetic clinic/workshop (1 hour at lunch time on Thursdays) with prescreened patients that people can sign up for. This will start in the spring. Not sure how this will work out yet because we have not experienced it, and it being over lunch is not ideal... Bottom line is, hopefully there is now more opportunities for residents to perform cosmetic procedures, which are a critical skill set to have in today's practice environment, and this is on the radar of the residency administration. And I believe the experience of this program alum has actually left an impression with our PD.

"The surgical training is very poor. You only get 6 weeks on Mohs during which your role is that of a medical student. Expect to do around 40-50 wide local excisions during your three year span, which is hundreds less than other programs in the country. Some of my coresidents ended up fabricating procedures in the last month of residency to meet the minimum requirement. It took me several months to get up to speed on my surgical skills after graduation"
- As far as surgical education is concerned, after the ACGME survey debacle, our surgical faculty actually took charge in helping to improve the resident experience. Our new program APD is actually an accomplished Mohs surgeon, who has been pushing for changes that benefit resident training. Surgical exposure now starts in the first year, in addition to the dedicated 6 weeks of Mohs. New curriculum also pairs up the resident with one single attending on any given day during those times, so they can work together and develop surgical skills. The people who have gone through the experience have given very positive feedback about this new system. Additionally, seniors now have occasional slots back in the Mohs unit to work with Mohs unit faculty one-on-one as the main operating surgeon doing excisions. I would imagine surgical exposure would only improve over time.

"One prominent faculty member in particular is anti-resident. His main goal is to jam as many patients through the clinic so the department can make money. He regularly books 50 patients into his clinic for three residents to see. During these times, he fails to actually address the concerns of the patients. He will either ask the resident what to do or just tell the patient they have eczema and give them a topical steroid. He does not exam the patient and suspicions have been raised regarding this attending’s visual acuity. Despite numerous complaints to the department and hospital administration regarding his lack of competency, he is still allowed to see patients. The faculty in the department are too afraid to take action despite him missing multiple life threatening diagnoses. In addition, through the years, he has made racist and sexist comments publically."
- This is a tough situation -- a lot of feedback has been given to the administration about this faculty member.

"Pregnancy is looked down upon. Residents have been shamed for becoming pregnant and staff have said to residents that “babies are not allowed”
- Maternity leave is part of our HOA contract. Residents are actually quite supportive of their fellow residents that become moms during residency. But I suspect some of the problem in the past had to do with the distribution of the clinic burden when a resident went on leave. In the past, this was not managed very well and the burden fell disproportionately to one particular class of residents, rather than shared across the program, and this bred resentment. This has been much less of an issue with the new chiefs. When a resident went on maternity leave recently, her workload was shared, and as a big 24 resident program, it barely registered.

"The faculty are not involved in resident education. You will go weeks if not months without a faculty lecture. All lectures are given by residents except for a few drug lectures. There are very few faculty who seem truly invested in resident education"
- We are beginning to see many more faculty-led lectures, who are able to share their great breadth and depth of expertise precisely because of feedback such as this one. We now average about one 1-hour long faculty lecture a week, ranging from surgical workshops, phototherapy and drugs, to contact dermatitis. Some faculty are still much more involved than others though and we appreciate the ones who are much more involved. Overall, we have 1 hour each day of protected didactic time, including faculty lectures or QI time (Monday), dermpath case conference (Tuesday), faculty lectures/drug review (Wed), Diagnostic Conference (Thurs, 2 hours), Book club review (Friday AM) and kodachrome review (Friday noon). The last of these is still hard because clinics still run over and impact on time to attend the kodachrome review. The real solution is to cut back a bit on the patient number in the clinics before the noon kodachromes on Friday so clinics don't run over, but it will likely impact faculty compensation in those clinics, so it remains to be seen how much the administration is willing to do this for the sake of resident education.

"The residents do very poorly on mock boards every year, mostly because they are not given time to study and the faculty do not teach"
- This was true historically, and the residency leadership is taking this seriously. I harbor a glimmer of hope that with people now able to go home at a more reasonable hour than before (with reduction in administrative load and increased faculty involvement), we will hopefully begin to see improved performance. Our first year class has seemed much more knowledgeable than some of us were at the same point in our training, and the 2nd and 3rd years also seem to feel more confident with their prospects on the standardized tests. I am cautiously optimistic. I believe by the time the current crop of applicants enter residency, they will face a much more learner friendly environment and do better on their mocks and actually Boards. That said, no one who has graduated from Michigan has ever failed the Boards (and apparently one who did not pass because he chose not to take it, took it last year and passed).

"Residents are coached on how to fill out the annual ACGME survey and are strongly discouraged against leaving negative feedback"
-The truth eventually comes out, so it's important for everyone to answer honestly. I'm glad the safeguards worked in this case, and I doubt the program would dare to do that again.

"Residents are only given 3 conference days during their entire residency"
-This is still true, and remains a pain point, and people may need to use vacation time for some conferences. But in context, residents have all federal holidays, plus 21 days of vacation time (2 weeks plus 7 Flex days) to be scheduled at a time of choice based on seniority, plus 1-3 days of additional holiday time to use around holidays (so-called "Yule days," allotment based on seniority in the program: first years get 1 day, second years get 2 days, third years get 3 days). We now also all have protected time to attend Tampa Board Review in addition to the conference days and holidays, and AAD attendance does not count against conference days. In addition, all residents now attend Michigan Dermatologic Society Meetings (3 days a year), except the person on inpatient consult on the day of the meeting. I think we are at "industry average" if not better.

This has been a really long post, and I'm sure it hasn't addressed everything, but I hope that it gives a somewhat more nuanced view of the state of U of M Dermatology Residency Program. That the program is open to feedback and is actively addressing known issues gives me hope for the future trainees here. As a current resident here, I appreciate the work those who have come before us put in to make this place better for us, the courage they've had in giving feedback to those in power (and in a post such as the one I'm responding to), and what the faculty (with residents) have started doing to improve the program. And if and when you have the chance to train here, please continue to be honest and truthful in addressing issues to the administration to continue to make our program better. For the applicants, as you consider your rank list, U of M Dermatology is not perfect (and I don't know if any program is) but far from "malignant." In my opinion, it remains a strong and premier program, where you will be challenged to do your best, receive great training, and grow to be a great dermatologist, and I only hope it will be even better when you come here.

Are you a chief resident or a program director at Michigan? Usually derms are the least likely to complain and this just shows how terrible of a program Michigan has. It is far from a "strong and premier" program and when I interviewed there I got a terrible vibe. One of the residents, who happens to be my fiancee's cousin, told me the program was terrible because some residents would falsify records to keep up with the administrative burden. In addition, I personally know of two residents who failed their derm boards, despite graduating from top 20 med schools, due to the lack of support. Usually program directors get furious when someone fails but it seems that the PD didn't even know about it...

Its quite unfair to residents because if they complain as a collective group, their program may no longer be accredited. making matters worse. But I do applaud Microsporum Canis for posting this because it may encourage future residents not to apply to this pathetic program.

 

[brocephalic]

How bad can a derm residency really be, in terms of hours and scut? Wonder what the hours were like?

 

[asmallchild]

How bad can a derm residency really be, in terms of hours and scut? Wonder what the hours were like?

It's all relative.

It's human nature though, you see residents at other programs putting in 40 hours/week, having plenty of time to read, and having strong ancillary staff to handle scutwork and you get upset that your program doesn't offer those things even though your overall workload probably pales in comparison to a surgical residency.

That being said, I have heard horror stories where certain consult months for certain residency programs will exceed 80 hours/week.

I attended a program that was probably on the cushier side already, I'd estimate I probably spent 50 hours/week in clinic (more on more rigorous months like pediatrics / consults), 8 hours/week of didactics (the kind where faculty and senior residents felt the only way you would learn is by humiliation so you had better come very well prepared), and 30 hours/week (at minimum) of reading (I realize this does not count towards actual workhours)

It's not anywhere close to the difficulty of a surgical residency but I much prefer my life now than my time as a resident.

 

[Skindoc83]

Usually derms are the least likely to complain and this just shows how terrible of a program Michigan has.

To be fair derm residents probably complain the most out of all resident fields. Most residencies have very little autonomy so you basically just act as a scribe and gopher for the attending whose clinic you are in. Couple that with the overall low acuity of patients and all of the reading you are expected to do at home, it can be grinding, monotonous, and unfulfilling. A lot of residents start to worry that they made a huge mistake. The good news is that once you finally start practicing on your own things get better and the job more fulfilling. But derm residency sometimes made me feel like a 30 year old teenager. You want to make your own decisions but you’re allowed to do is do exactly what the attending tells you. So while I don’t doubt that Michigan is malignant, it’s rare to find a residency program where everyone is excited and passionate to be there.

 

[username456789]

To be fair derm residents probably complain the most out of all resident fields. Most residencies have very little autonomy so you basically just act as a scribe and gopher for the attending whose clinic you are in. Couple that with the overall low acuity of patients and all of the reading you are expected to do at home, it can be grinding, monotonous, and unfulfilling. A lot of residents start to worry that they made a huge mistake. The good news is that once you finally start practicing on your own things get better and the job more fulfilling. But derm residency sometimes made me feel like a 30 year old teenager. You want to make your own decisions but you’re allowed to do is do exactly what the attending tells you. So while I don’t doubt that Michigan is malignant, it’s rare to find a residency program where everyone is excited and passionate to be there.

Man, I lucked out in some ways. 100% of my clinics were continuity clinic from day 1. Obviously the attendings has greater input on plans early on, but with graduated levels of autonomy with decision making. At times it was annoying because we also did all patient call backs and such, but our faculty was real supportive overall and our role was definitely not a scribe or gopher role.

I have definitely heard plenty of stories about residents feeling like glorified servants/scribes. It’s a real shame, and makes the transition into attending practice a bit rockier as you get used to a drastic shift in autonomy.

What I have seen in my former program and I imagine in others is a push from higher up admins to move more meat through clinic. Longer clinic hours or more patients per hour. The former cuts into reading (and personal) time outside of clinic; the latter cuts into education/learning per patient.