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The Successful Match: Getting into Dermatology

Created 10.18.09 by Samir P. Desai, MD, and Rajani Katta, MD
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As the Paul Gross Professor and Vice Chair of the Department of Dermatology at the University of Pennsylvania, Dr. William James directs the dermatology residency program at the University of Pennsylvania, which recently was found to be the highest ranked academic dermatology department in the United States.1

He is widely regarded as an outstanding clinician, teacher, and researcher, having received numerous honors and awards. He has published over 200 peer-reviewed publications, served as the editor-in-chief emeritus of the emedicine dermatology section, and been on a variety of national committees.  We recently had the opportunity to speak with him about the dermatology residency selection process.

In a recent survey of dermatology residency program directors, 87% of programs cited a letter of recommendation from the department chair as an important factor in selecting applicants to interview.2  How can students interact and work with the chair in such a way that the chair is able to write a productive and meaningful letter?

First of all, the Chair is certainly a great person to be able to work with and get a letter from. In many circumstances, though, that’s not going to be the person who is most involved with students, especially depending on the size of the program. Your letter doesn’t necessarily need to be from the Chair. It could be from one of the academic dermatologists in the program, either the Program Director or one of the faculty members.

It should be from someone with whom you’ve worked and who knows you in some meaningful way. That would usually mean at least working in a clinic with the letter-writer. Specifically, not just observing in clinic but actually interacting with patients and discussing diseases. It may involve rounding with the inpatient team and presenting patients in follow-up. It could be writing or participating in a project, such as a clinical project or a case report. There should be some meaningful interaction. There needs to be information about how the applicant works, what kind of ideas they have, and how they interact with patients and the team. That really is the key: being able to get to know your letter-writer long enough so that they can take examples and then detail how an applicant would be a good person to have in the residency program. For the people reading the letters, they’re going to be looking for some meaningful pieces of information that is based on personal observation.

Audition electives have been found to be very important in the dermatology residency selection process.3 What sets apart students who shine during these rotations from those that are average?

First of all, enthusiasm. There are students, believe it or not, who show up and look a little bored. I think enthusiasm for the work and the subject is very important. The way students interact with others is certainly a key. You can have all the brains in the world, but if you can’t get along with people, that doesn’t say much for your ability to work on a team or work with patients. Sometimes students can be a little too aggressive in their interactions, probably because they’re trying to either come across as enthusiastic or they’re trying to show off their smarts. There is a fine line regarding what is appropriate for the level of training. At the same time, I think faculty members do take into account that students are trying to make a good impression, so I think there is some leeway there.

Hopefully, there will be opportunities to demonstrate their knowledge base or get involved with a project. If you find that the dermatologists are getting excited about a case and saying “I haven’t seen this before” or “I don’t really know what is a good treatment for this condition; let’s go look it up”, this would a great opportunity for the student to follow up by reporting “This is a case that I learned something from; I looked it up, I thought about it, and I’d like to pursue it a little further.”

Dr. Miller, who is Vice Chair of Clinical and Educational Affairs in the department of dermatology at Penn State College of Medicine, has encouraged applicants to make their personal statement unique.4 Too often, he has read statements where an applicant writes about “being a visual person” or is drawn to the specialty because of the “ability to do procedures.” Having read thousands of statements, what advice can you offer for the dermatology applicant seeking to create a unique statement?

I think the main point is that this can’t be a recitation of what’s already in other parts of the application. I’ll get to the positive side, but one of the main things that bothers me with personal statements is reading about that first I did this, and then I did that, and I wrote this paper, and I did this research, and I published it in this journal, and I did this volunteer work. It’s all in the CV already and the whole statement becomes “I, I, I.”

But while the personal statement is just that – personal – if it’s all going to be about delineating accomplishments that are covered in other places, then that simply isn’t helpful. What is helpful is to draw a picture of yourself that can’t be obtained from anywhere else in the application. It should be personal – this is who you are, this is what makes you excited, these are your special interests. Sometimes it may be outside of medicine, sometimes it may be a volunteer experience that is expanded upon, or it could be a personal connection that stimulated the applicant to want to do something more, such as a specific part of Dermatology down the line. You might express your future goal, as that is something that wouldn’t be revealed in other parts of the application.

It certainly has to be sincere. If everyone just says at the end of their statement “I want to be an academic dermatologist” and there’s nothing else in the application that tells a reason for this, it’s not believable. It would help if you can describe your personal background and bring in information about your life that isn’t available in other places, and then transfer that into a future plan.

Overall, your statement has got to be personal, sincere, and bring out information not available in other places.

Students recognize the importance of research in the dermatology residency selection process and hope to participate and, perhaps, become published in the field.  Although there are over 100 dermatology residency programs in the United States, some programs are more prolific than others in terms of scholarly activity. For example, between 2001 and 2004, your program produced 318 publications, placing it among the top dermatology programs in the country.1 What recommendations do you have for students who wish to do research but are either at schools lacking a dermatology residency program or for those whose dermatology department focus is largely clinical?

I would expand the idea of research. If a student doesn’t have any background in laboratory-based basic science research, then they could work in a lab to see what it’s like. However, most of the time people that don’t have that type of background, and don’t have advanced degrees, are not going to end up in that situation.

Most of the time, students are going to be looking for more of a clinical-based project. Protocol-based projects and clinical research do require a fair amount of time in order to get things off the ground and move through the process. For the person that you’re describing, they could get involved with a review article, a case report, or a small case series. Other possibilities could be a review of charts or a review of pathologic specimens. With that type of background, these are the types of projects that such a student would be both capable of and interested in, and would make the most sense for their background.

There is a growing shortage of academic dermatologists with fewer residents pursuing a career in academics.5 Years ago, your program developed the unique Dermatology Fellowship for Academic Clinician-Teachers, with the goal being “to develop future leaders in dermatology who will attain positions such as residency program directors, professors in clinician-educator tracts, and departmental chairman.”6 As a lifelong academician, what are some misconceptions that students have about academic dermatology?

Students are, of course, being taught in an academic setting, and depending upon the people they’re exposed to, some may tend to see the bright side of things, while others will focus on a less attractive side. There are pluses for academic Dermatology and pluses for private practice, but there are also negatives for both. If someone is more negative they may assume that “since this is what academic medicine is about, private practice must be better.” However, they don’t have the knowledge base about what actually goes on in private practice, and they don’t know the negative aspects.  In other words, they think it’s greener on the other side of the fence, but they don’t really look on that other side to see what’s there.

I think that some of the misconceptions are that academicians don’t make such a good living – but I don’t really know any academic dermatologists that are living out of their car.  I think we make a better living than 99% of the citizenship in the United States, so I think that that’s underappreciated.

I sometimes hear things like “there’s too much politics in academics” and I can’t say I don’t understand, but personally I think it’s an overstatement. In my opinion, it’s all about interactions with others, and if you have good interaction skills, then you’ll do fine.

Certainly there are concerns about independence and the size of organizations, or what some people might call bureaucracy. I think that you have to be able to operate in a larger setting. If you are someone who is an entrepreneur and wants to be in charge all the time, then you probably aren’t built to go into academics.  But if you are more able to accept some bureaucracy, then certainly in exchange for that you get a lot of infrastructure. You have a lot of the business side of medicine that you don’t have to deal with, and in return you can concentrate on patients.  In private practice, you’re responsible for hiring and firing, balancing the books, and complying with the regulatory requirements. Private practitioners are small business operators and good business sense is necessary.

You have to be self-aware of what kind of arena your personality would best operate in, and in the end that’s something you are going to have to figure out for yourself.

Dermatology residency programs routinely receive hundreds of applications for just a few positions. As the years have passed, the academic credentials of applicants have become more impressive. In the 2007 Match, 47% of U.S. seniors who matched were members of AOA and the mean USMLE Step 1 score was 238.7 While strong credentials are certainly important to secure interviews, it is the interview that ultimately makes the difference. What advice can you offer students as they prepare for interviews? 

One of the things I find is that people tend to want to downplay what they have done. If it’s done out of modesty, that’s fine, but I think there are people that have a pretty darn good record, and unfortunately they say things like “Well, my boards could have been better, but you know I had this happen in my personal life.” Basically, they’re apologizing. They may have gotten 80% honors grades and yet they’re apologizing for this one rotation that they didn’t honor, and trying to come up with a reason or excuse. That’s just not a good way to approach an interview.

The way to approach an interview is to be self-confident and to accentuate the positives. They’re clearly there, because if you’re interviewing for a program, you must have a lot of positives. We don’t just interview anybody. You’ve got a good record, so you want to go in and be self-confident about that. You want to look good, and you want to come in sharp and enthusiastic.

You should also treat everybody well. Some applicants will bow down before the Chair and then are rude to the residency program coordinator. That’s just not a good practice. I also think there’s something to be said for a practice interview if you’re nervous.

Ultimately, you want to be honest and open during your interview.

In 2007, out of 407 U.S. seniors applying to dermatology, 158 failed to match (39% of U.S. senior applicants).7 Applicants who fail to match often wish to reapply the following year. What can these applicants do to strengthen their application?

There are certainly a number of dermatology fellowships out there. It’s been documented that applicants who complete these fellowships have a higher match rate the second time around. I think that’s probably because you get to know the director well, and since they know how you work and how you produce results, they can write you a better letter of recommendation. I’ve also seen some individuals plan to do degree-producing programs, such as a Masters of Public Health, or a program with a focus in biostatistics or epidemiology.

There are certain objective measures that can’t be changed. You can’t change the Dean’s letter, you can’t change your board scores, and you can’t be AOA the second time around. However, you can publish and get new letters of recommendation. These are ways to strengthen your application.

Some applicants who fail to match pursue a pre-residency dermatology fellowship. In a recent survey of fellowship directors, it was learned that 92% of past fellows (176/190) were able to match successfully following completion of the fellowship.8  How can applicants make the most of these fellowships?

Most of these fellowships are directed by individuals that are fairly well-known in their specialty. A letter of recommendation from a faculty member that spent months, or sometimes a year, with an applicant is a very valuable resource. That’s going to be more information than the prior application, and the letter writer is able to be very rich in their detail about what supports the positive things that they say about the applicant. We look very closely at that.

Many fellowships are directed by some very productive members of our specialty. If the director is known for publishing, putting abstracts in meetings, and making headway in addressing different questions, then it’s expected that the applicant will have participated in those results.

There may be interview questions such as “why do you think you didn’t match?” There are certainly applicants who don’t match who have fantastic records, and for some reason they just didn’t make it. There may be cases where you cannot say that’s the reason I didn’t get in. But if there were an item or items that weren’t so good, then you have to plan to address those. You can’t change those items, but another way to address prior performance is to demonstrate in a more current job that you can do the work, and you can do it well.

References

1Wu JJ, Ramirez CC, Alonso CA, Berman B, Tyring SK. Ranking the dermatology programs based on measurements of academic achievement. Dermatol Online J 2007; 13(3): 3.

2Results of the 2008 NRMP Program Director Survey. Available at http://www.nrmp.org/data/programresultsbyspecialty.pdf.   Accessed June 12, 2009.

3Clarke JT, Miller JJ, Sceppa J, Goldsmith LA, Long E. Success in the dermatology resident match in 2003: perceptions and importance of home institutions and away rotations. Arch Dermatol 2006; 142(7): 930-2.

4Miller J, Miller OF 3rd, Freedberg I. Dear dermatology applicant. Arch Dermatol 2004; 140(7): 884.

5Resneck, J Jr, Kimball AB. The dermatology workforce shortage. J Am Acad Dermatol 2004; 50: 50-4.

6Available at the University of Pennsylvania Department of Dermatology website (http://www.uphs.upenn.edu/dermatol/education/clinician-educator.html).  Accessed on June 12, 2009.

7Charting outcomes in the match: characteristics of applicants who matched to their preferred specialty in the 2007 National Resident Matching Program main residency match (2nd edition). Available at http://www.nrmp.org/data/chartingoutcomes2007.pdf.  Accessed June 12, 2009.

8Wasong SH, Miller JJ, Zaenglein AL. Does a predermatology fellowship increase the chance to match in dermatology? J Am Acad Dermatol 2008; 59(3): 535-6.

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Comments

  1. Shawn Shukla says:

    Great Article Dr. Desai I’m actually an NRI Indian Medical Student from the State of Texas looking to get into Dermatology. I’ve pretty much witnessed a lot of skin related diseases in my family and have never been able to do anything about it so I knew from childhood that this is the type of Doctor I wanted to become. I know my chances are probably slim to none of being able to enter a Derm program but I will do ANYTHING it takes to get in, please give me some advice

  2. Dermonymous says:

    What if you do a pre-graduation unpaid fellowship, and still dont match, do you think its worth doing a post internship paid fellowship, or is your fate pretty much sealed.

    Lets assume you got a derm god to write you an outstanding letter of the get go in that first time around…..but you are an US student who has studied abroad (I dont know what the term is anymore FMG/IMG).

  3. Samir Desai says:

    Dear Shawn, Doctor, and Dermonymous,

    Thank you for your feedback about our article. We are glad that you found the information helpful. Shawn, I would like to answer your question but need to clarify first – are you an international medical graduate?

    Dermonymous, you can strengthen your application through a pre-graduation fellowship. This, of course, assumes that you perform at a high level. To make the most of a fellowship for residency selection purposes, you will want to publish as much as you can – doing so will show the program that you have been productive. The program will also look very closely at the recommendation letter written by the academic dermatologist with whom you work.

    Even this may not be enough, given the competitiveness of dermatology as a specialty choice. If you fail to match, you have to assess your credentials – ask yourself how do you stack up against the typical applicant. You can access this information by visiting http://www.nrmp.org and reading the dermatology section of their document, “Charting outcomes of the match.” This will give you a good idea of the credentials of the typical U.S. medical graduate who has recently matched into the field. Discussing the strengths and weaknesses of your application with an academic dermatologist/program director can be very helpful.

    Matching into dermatology is extremely competitive for U.S. medical graduates. It is even more so for international medical graduates. As of 2007, of the 1069 total residents training in 112 dermatology residency programs, only 3% were international medical graduates.

    Samir Desai

    1. Nandini says:

      Dear Dr. Desai,

      I am in medical school now, and am wondering if dermatology residents look at whether students do medical mission trips or have leadership positions in medschool. Please let me know your thoughts on this as it is not mentioned anywhere.

  4. dermonymous says:

    Thank you for the reply,

    I am a US student studying abroad (in Israel i.e. not the Carribean or Mexico).

    The problem with the fellowship (unpaid) that I am currently enrolled in, is that despite the numerous studies I am involved in, and protocols I have written (most recently the one that has been accepted an investigator initiated one) is that some publications have been submitted, some are in progress, and the rest depend on the studies.

    This means time, I mean the average turn around for a paper once submitted is 2-3 months.

    So publications are rather difficult to obtain in one-year, what about presentations and abstracts. These are more readily produced and foreshadow publications, are those equally valid. For instance presentations at the AAD the ACDS etc.

    I understand the competitiveness of Dermatology, but I also know a majority of applicants do not take a year off prior to graudation to do clinical research, and while many have publications, most have not done the actual research, unless it is a case report.

    Thank you,

  5. Samir Desai says:

    Dear dermonymous,

    Not too long ago, a study was done looking at students who took a year off between their third and fourth years of medical school to participate in a NIH research program. The goal of the study was to determine if and when these students were able to publish the results of their original research. Often, the results were not published by the time residency applications had to be submitted.

    When the investigators looked at the group who did publish before submitting applications, they found that a fair number of these publications were case reports and review articles.

    Since it can take awhile to publish the results of some research projects, consider doing abstracts, presentations, case reports, and review articles. All of these are ways in which you can show programs that you have been productive.

    Samir Desai

  6. Jpreet says:

    I am a IMG/FMG and I have about a year left until I complete my internal medicine residency here in the United States at a university based program. I applied for a dermatology residency for the 2011 match however I did not receive even an interview. In your opinion does completing an internal medicine residency do more harm than good when trying to obtain a dermatology residency?

  7. arc says:

    I am a first year student and was wondering if you might have any suggestions as far as what can I do besides good grades and scores to be able to be a strong candiate for matching in dermatology residency.

  8. Louis Dee says:

    Dear Doctors Desai and Katta,

    Thank you for writing this article, it was both interesting and informative. I also appreciate that you have included statistics with your statements. Unfortunately, you have made a few statements that I believe will put me at a disadvantage and I would like to hear your advice on my circumstance. I am currently attending a new medical school in Pennsylvania and since my school is not well established, we do not have a Dermatology Department, academic dermatologists or grades during year 1 and year 2 for that matter. I have became very close to the dermatology faculty in my area but my clinical years will be in a city very far from these faculty members. I am a second year medical student and for the next two years I will not have the opportunity to gain a close relationship with anyone in the dermatology field except for my electives. I will be taking a year off to pursue my interest in dermatology research, but other than this do you have any advice on how to gain more exposure in the field of dermatology and establish a relationship with an academic dermatologist?

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