Journal Information
Vol. 103. Issue 6.
Pages 453-455 (July - August 2012)
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Vol. 103. Issue 6.
Pages 453-455 (July - August 2012)
Opinion article
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Dermatology Residency Training: Past, Present, and Future
La formación de los dermatólogos: pasado, presente y futuro
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S. Vañó-Galván??
Corresponding author
sergiovano@yahoo.es

Corresponding author.
, A. Ledo, P. Jaén
Servicio de Dermatología, Hospital Ramón y Cajal, Madrid, Spain
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Nine thirty on a typical Wednesday morning. Three dermatologists from different generations are chatting over coffee after the clinical session and exchanging their thoughts about residency training over the years. Are there really that many differences?

Dermatology Residents and their Relations to Others in the Hospital

Dr Sergio Vañó-Galván (junior dermatologist): Nowadays dermatology residents are highly esteemed by their peers at the hospital. The ratio of women to men is 4:1, according to the latest figures from the Spanish medical residency system, and most of these doctors come well prepared, having earned admission to one of the most sought-after specialties. Given such good grounding, it is unsurprising that dermatology residents are often approached by others for advice as they begin to make medical decisions at work, particularly in the emergency department. Moreover, in most cases, they’re outgoing and popular with their peers, as practically everybody at one stage or another turns to a friend in dermatology to check out a skin lesion (perhaps this specialty is the most prone to “corridor consultations” from friend-patients. This means the dermatology resident is well loved and respected by colleagues, something we can be grateful for.

As for relationships within the department, cordiality reigns and there is excellent rapport between residents and the other staff physicians and the head of department. It was different in the past, when the authoritarian style of some heads and staff physicians seemed to interfere with that.

Dr Pedro Jaén (senior dermatologist): In our day, dermatology wasn’t among the top-ranked specialties, but the rest of the staff knew us and respected us—as our handling of “corridor consultations” was highly valued. The publication of T. B. Fitzpatrick's Dermatology in General Medicine had a major impact on our training. Among other things it did for us, it underlined our conviction that, though we specialized in a single organ, the skin, we should keep sight of the whole patient. We residents were on call in the internal medicine and plastic surgery departments, acquiring surgical skills that gained us more kudos within the hospital. In fact, when dermatologists went to a new hospital, one of the best ways of winning respect from colleagues and hospital management alike, and acquiring prestige, was through dermatologic surgery, particularly for skin cancer.

Dr Antonio Ledo (venerable master): My answer to the first question about whether times have changed in residency training is that learning was and will always be essentially based on clinical experience—the more patients the better and in our case the caseload was incredible. Nowadays the techniques that complement physical examination of the patient have changed radically. Once, a resident gained access to training only when an instructor or department head—who would be familiar with the candidate's background—decided to provide it. Later would come natural selection—let's call it an assimilation process—whereby anyone who was consistently conscientious would become respected and would be taken into account. What has changed radically is how the dermatologist is perceived within the context of the hospital. Colleagues used to say, “Could you take a quick look at this patient and tell me what cream you think would work best?” and show surprise at being asked for the patient's medical history. I found this very hard to deal with. We were seen to be in a second-tier specialty. When I graduated, I spent a year in internal medicine to gain experience before specializing. This preparation as an internist led me to consider the possibility that skin lesions could be related to general processes.

One of the happiest days of my life came at a large medical center when I was introduced to a professor from abroad as a dermatologist who knew a lot about internal medicine. Our generation witnessed and actively participated in this change. Today the high scientific level of dermatologists is beyond question.

Concerns

Dr Vañó-Galván: Probably the most worrying aspect for residents these days is the uncertainty of finding a job at the end of their residency. The economic downturn has reduced the number of new public-sector contracts. Therefore, residents’ beliefs about finding work at a public hospital, particularly at a center they consider acceptable, are that it will depend rather more on what turns up on the job market (to cover a leave of absence or replace a retiree) than on the candidates’ merits as dermatologists or their work history and accomplishments. In other words, you need to be in the right place at the right time—fortunately there are exceptions. As a result, final-year residents suffer a kind of syndrome whereby they become anxious and concerned about job opportunities, increasingly so in the last 3 to 4 months of their residency. That said, dermatology residents (and specialists) are, on the whole, cheerful people who enjoy their work and the camaraderie of companions. The proof of this is the congenial atmosphere at dermatology congresses and day or evening conferences that are organized these days.

Dr Jaén: Concern for the future was also the norm for residents as they neared the end of their training period in the past. The dermatologist was a consultant within the internal medicine department in other times, and in fact most hospitals in Spain had no dermatology departments or units unless they were university or referral hospitals. These residents found many employment opportunities in the public sector soon after completing their residencies. As a result, so-called “functional dermatology units” opened in many hospitals. These initially employed a single dermatologist but they provided the foundation for the dermatology departments and units that are currently considered vital to all hospitals in Spain. At the same time, the surgical aspect of the specialty was developing and becoming widely applied. Particular areas of development were skin cancer surgery and diagnostic and therapeutic techniques, and as a result rising numbers of dermatologists joined public hospitals. Monumental changes soon followed in our specialty.

Dermatology in the private sector was, however, reserved for the bosses. The idea of a young staff physician setting up a private practice was frowned upon. It was difficult to be accepted by insurance companies, cosmetic dermatology did not exist, and skin cancer treatment was left to surgeons.

Dr Ledo: In my day, we didn’t just live in a time of economic crisis. Spain was in a real mess—ours was crisis with a capital C. We didn’t have final-year resident syndrome. We didn’t just feel worried about not having salaries—there were no salaries. The number of hospital places weren’t reduced because there were no places to start with. Poorly equipped hospitals weren’t the problem because there were no hospitals. The few salaried positions that did exist were for the professor and the orderly. Perhaps that doesn’t sound credible today but I speak without a shred of exaggeration or word of lie. Our present was so bleak that it could only improve. We started at absolute zero but tremendous tenacity and our foolish self-confidence carried us to a much better future. That's how it was for us.

Aims During Residency

Dr Vañó-Galván: The main aim of a resident now is to acquire knowledge and skills in the different fields of dermatology to ensure he or she will be able to continue to develop professionally later on. This necessarily requires mastering clinical and surgical dermatology, dermatopathology, and research. In recent years, residents have gradually attributed more importance to gaining experience for career planning. Nowadays, all doctors acknowledge the vital role their work record and accomplishments will play in their future careers, so they begin working on it at the start of their residency. In fact, most dermatology residents end their training with several publications and numerous conference presentations under their belts. This is less common in other specialties. On that point, one of the greatest advantages of our time is doubtless the ease of accessing information and dermatology literature on the Internet.

Dr Jaén: A resident's aim as I recall it was to acquire the knowledge needed to manage patients with skin disorders. Particular emphasis was placed on clinical practice. The most esteemed instructors had superior clinical know-how, although an understanding of dermatopathology was also highly rated. This was less true of surgery or the complementary techniques being developed at that time, at least in most places.

Dr Ledo: The medical residency system did not exist for us. We were unpaid volunteer assistants and anyone wanting to specialize in dermatology (not only from Madrid, but from many parts of Spain) would come to Hospital San Juan de Dios in Madrid, the cradle of great Spanish dermatologists. The clinical training we received was astonishing. We had no Internet but we found the finest dermatological descriptions already impeccably written in the classic books. They didn’t have to be invented. As far as I’m concerned, when you write a paper, it's best to go back to the old descriptions, compare them, and then add any important advances in our understanding of the etiology or pathogenesis of the conditions. In actual fact, I don’t believe things were easier or more or less difficult than now; they were, are, and always will be tough.

Training

Dr Vañó-Galván: Today dermatology is perceived to have a very broad scope, requiring residents to be trained in medical and surgical aspects and to master certain diagnostic techniques such as dermatoscopy as well as therapeutic procedures like cryotherapy, laser, and photodynamic therapy. During residency we also acquire knowledge of dermatopathology and immunology, as well as basic notions of research design. Training in cosmetic dermatology is gradually becoming more important, particularly at the end of the residency, as this is an area of rising demand in the private sector. Such diverse areas of knowledge are what probably make this specialty so attractive. Today many more learning opportunities are available than in the past, given the technological improvements for information gathering, ease of travel, and industry grants for attending courses and conferences.

Dr Jaén: During our period of training, clinical knowledge was the basis of the specialty and considerable importance was also given to dermatopathology. However, residents received very little instruction in dermatologic surgery and even less in cosmetic dermatology.

Dr Ledo: Dermatologists are very well-prepared. We don’t need to defend our degrees, certifications, or knowledge. Those who infringe on our specialty from outside—because they see the possibility of profits and a prosperous business in this tempting field—are the ones who are required to demonstrate whether they are suitably qualified or not. But we shouldn’t forget that our fundamental role is to diagnose and treat skin disease and keep up-to-date on the scientific grounding for practice. It is not our remit to focus exclusively on economic prospects. Dermatologic practice is what unquestionably gives us the advantage. As a final message, I believe that the roles of today's generation cannot differ from the ones we played. We were called the “courageous generation” because we gave everything we had in exchange for very little, according to a code of conduct that, had we all kept it up, we wouldn’t be saddled with today's fierce economic crisis and the despondency, doubtless brought about by short-sighted politicians. This code is based on the ethic of hard work, passion for a job well done, personal integrity, and taking responsibility. These are the 4 pillars of that courage we need to see it through. I am hopeful and I genuinely believe that this generation will be able to use that same code of conduct to pull us out of the current situation. I would like them to look to the future with the same foolish optimism that we did.

We might say in summing this up that dermatology training has undergone significant changes—from the development of the medical residency system to the growing prestige that now surrounds our specialty. Every dermatology resident should receive comprehensive training in all the wide range of areas that make up the specialty. We also realize that even though time passes and there will always be difficulties, they can and must be overcome by that job well done and the rash optimism Dr Ledo spoke of—and that we cannot help but feel. Congratulations for having chosen to become a dermatologist. Take heart.

Please cite this article as: S. Vañó-Galván, A. Ledo, P. Jaén. La formación de los dermatólogos: pasado, presente y futuro. Actas Dermosifiliogr. 2012;103:453-5.

Copyright © 2011. Elsevier España, S.L. and AEDV
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