Dermatology Online Journal

Advice for medical students interested in dermatology: Perspectives from fourth year students who matched
Ali Alikhan MD¹, Raja K Sivamani MD¹, Misha M Mutizwa MD², Bishr Aldabagh MD³
Dermatology Online Journal 15 (7): 4

1. University of California at Davis, School of Medicine, Sacramento, California. alialikhan1@yahoo.com
2. Duke University School of Medicine, Durham, North Carolina
3. Case Western Reserve University, School of Medicine, Cleveland, Ohio

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Abstract

We present perspectives from four fourth year medical students who matched into dermatology that highlight the factors they believed helped them most. The purpose is to offer advice to medical students interested in dermatology. We divide the paper into four areas of discussion: academics, extracurricular activities, research, and mentorship. All four factors are crucial for a strong dermatology application. We believe the paper provides valuable suggestions and guidance to students considering a career in dermatology.

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Introduction

Dermatology has become the most competitive specialty in medicine [1]. As a result, dermatology applicants are typically of extremely high caliber, from an academic, extracurricular, and investigative standpoint. Unfortunately, much of the information and advice students interested in dermatology receive can be generic, nonspecific, and sometimes incorrect. In light of this fact, we have compiled the advice and opinions of four fourth year medical students who matched into dermatology residencies regarding what they believe were the most important factors in their success.

Discussion

Academics

Conventional wisdom is that preclinical grades are relatively unimportant in the application process. Whereas they may be less important as a stand-alone factor, the benefits of a sound preclinical performance trickle down to other key aspects of the application. The importance of grades largely depends on the grading system employed at your school. In a pass/fail system, simply passing is sufficient; no one will know the applicant's actual rank in a particular class. However, in schools with non-pass/fail grading systems, high grades may be an important factor in class ranking for nomination to the Alpha Omega Alpha (AOA) honor society and for the residency application. Additionally, because the vast majority of dermatology applicants are outstanding, there is no need to take students with low basic science grades. Besides their effect on AOA membership, low preclinical grades could be interpreted as evidence of a lack of industriousness or relative weakness compared to students without such a deficiency.

Even more important than grades for a dermatology applicant will be the USMLE Step 1 score, the bottom line for years one and two. Sustained efforts in preclinical classes will facilitate preparation for Step 1, but significant study outside of the regular curriculum taught will still be required. A high Step 1 score will not ensure a match into a dermatology residency, but is important to help your application pass through the initial screening process and increase your number of interviews. Although there is no general "minimum" score, a score above 240 should enable you to pass most Step 1 screening filters. If you do not achieve this score it does not mean that you cannot match into a dermatology residency because there are many other factors at play. However, your odds are likely to be reduced considerably with scores below 220.

If you have done well enough on your Step 1 examination, there is probably no benefit in taking Step 2 Clinical Knowledge early; defer this to the latter half of the fourth year. If, however, your Step 1 examination score is "low" by dermatology standards, the Step 2 CK examination may give you a chance to effectively demonstrate your knowledge base and critical thinking skills. Note that it will require about a month of dedicated studying to perform well.

Clerkship grades from third year are undeniably important – this is the most important year academically. It is the year that is responsible for stratifying students to provide a measure of clinical competence and significantly affects assessment of competitiveness for residency directors. Obtaining as many "honors" grades as possible should be your goal. This will greatly improve the chances for election into AOA, which provides a significant advantage in the dermatology application process. Whereas internal medicine, surgery, and pediatric clerkships are scrutinized most closely, given their significant overlap with dermatology, do not overlook the importance of other clerkships. During each rotation, it is important to stay focused the particular duties and curriculum at hand. When on medicine, think medicine; when on pediatrics, think pediatrics; etc.

During the third year, keep track of the faculty members you would like to ask for letters of recommendation. Letters from faculty in medicine or surgery may be the most important, but a strong, personalized letter from a faculty member in any department can be powerful. Several dermatology programs require at least one letter from a non-dermatologist. Toward the end of the third year, speak with your mentor and advisors to plan your fourth year rotations, specifically if you are interested in pursuing away rotation(s).

Fourth year rotations should not be brushed off – receiving "honors" grades should continue to be a priority. However, unlike the third year, some strategy should be involved in planning the fourth year. Away rotations in dermatology come in two flavors: clinical and research. Do not spend more than two to four months pursuing dermatology-related rotations. A combination of both types of rotations, perhaps one or two months of each, may be optimal. Depending on your school's requirements, you may be able to postpone one of your third year clerkships to complete a dermatology rotation early. This may be especially valuable if your school does not have a dermatology department, allowing for earlier exposure to a dermatology department at another institution.

Choosing which dermatology rotations to complete may also be difficult. Always do a rotation at your home program, if you have one, because it is where you are statistically most likely to match [2]. Also, do this rotation first – preferably during the third year if your school allows for elective time. In choosing an away rotation, consider the following factors: 1. Location, 2. Emphasis of the program as it relates to one's own interests (active ares of research vs. clinical strengths), 3. Current residents (i.e., Where did they come from? What did they do?), 4. Number of residents, and 5. Your school's connections to the program (relationships with your mentor or other faculty). Talk to your mentors, other faculty members, and previous dermatology applicants from your school to get more advice on where to do away rotations. These advisors should take an honest look at your grades, scores, and curriculum vitae to give you practical advice on which away rotations may be the best fit. If you have a home dermatology program, one away rotation is sufficient; if this is not the case then two or three away rotations are justified.

Before starting dermatology rotations, read a basic dermatology text (many options are available, several targeted towards medical students and non-dermatology residents). For both home and away rotations, show genuine enthusiasm and interest without being overly aggressive or annoying. The student role varies tremendously both within and between rotations at different institutions; some are almost entirely observational and others are almost entirely hands-on. The task of impressing residents and faculty is in some ways easier at institutions that allow students to become more involved. Quite simply, on these rotations you can shine mainly through your presentations – by being able to accurately describe lesions, formulate appropriate differentials, and show evidence of nightly reading. Because patient turnover in dermatology clinics is high, being able to work at a reasonably quick pace is important as well.

For students whose dermatology rotations turn out to be more observational in nature, the task is a bit more difficult. When you are simply observing, your main goal should be to avoid asking too many questions and/or annoying your resident or attending. This is not to suggest that you should not ask questions when you are genuinely interested in the subject matter at hand. Instead, this is meant to serve as a warning against asking questions for the sake of being heard. Residents and faculty members are used to students interested in dermatology vying for face time. Asking excessive or unnecessary questions simply slows them down and is a quick way to irritate your instructors. In settings in which you are working with another student, avoid being overly aggressive by trying to monopolize the resident or physician's attention such as jumping in to answer every question. Residency programs are looking for team players and one clear red flag is a student who does not work well with peers. One way to be helpful on observation-based rotations is by being prepared to assist during procedures (e.g., helping to set up for biopsies, putting gloves on, and being prepared with the necessary tools) This type of assistance may seem trivial, but anything you can do to facilitate your resident or attending physician's work is likely to be noticed and viewed positively. Finally, try to meet with the program director or the chairman during your rotation to better understand the philosophy of the department and to express your interest in dermatology. Remember that on any rotation you are always being evaluated. The whole rotation, both the workday and any social periods, essentially serves as a month-long interview.

Clinical dermatology rotations should be done early – before October if possible. If you are able to do one or more rotations in May or June, you will be able to work with residents who are seasoned and relaxed because they will have completed their annual in-service exams. Furthermore, there are likely to be fewer medical students on the dermatology services at this time of year, giving you more face time with faculty and residents. This can translate into more opportunities and an overall better learning experience. Finally, completing rotations early will allow for ample time to obtain letters of recommendation. Most letter writers prefer at least one or two months advance notice.

Similarly, rotations in dermatology research are best done early to afford enough time to work on projects that can be accepted by the time of application submission. During the rotation, your focus should be on projects that are relatively easy to complete such as case reports, review articles, small original articles, and book chapters; time is of the essence. Do not forget to ask your research mentor for a letter of recommendation – a letter of recommendation from someone you spend a month or two with is far more valuable than someone you spent a few half days with on a clinical rotation.

Concerning non-dermatology rotations that one should complete in the fourth year, there is no "typical" curriculum for fourth year medical students applying in dermatology. Some will advise students to pursue rotations in other specialties that are relevant to dermatology (e.g., rheumatology, allergy/immunology, plastic surgery, hematology/oncology, infectious disease). Others will say that the fourth year is a student's last opportunity to gain an appreciation for and familiarity with the full spectrum of medical disciplines. Proponents of this school of thought recommend a curriculum that has little overlap with a student's intended specialty. There is a third view that students should enroll in electives that prepare them for internship, in which case enrolling in a variety of electives relevant to one's chosen PGY-1 discipline would be advisable. In truth, there is value in each of these approaches and pursuing a combination of the three would seem sensible as well. Many schools have requirements for a subinternship in medicine, surgery, pediatrics, or another core discipline. When this subinternship should be completed depends on each student. A student who did well in the third year rotations may reserve this for the latter half of fourth year.

Extracurricular Activities (Organizations and Community Service)

Be honest with yourself about your ability to juggle your time between extracurricular activities and academics; remember that academics should always be the first priority. That being said, there is more free time to engage in these activities in the first two years than during the third year. Be involved in any extracurricular activities that genuinely interest you and that you have time for. Do not limit yourself to dermatology-related activities. Some examples include medical societies, organizations and interest groups, student-run clinics, community outreach activities, and student government positions and committees. Leadership roles are always looked upon favorably. Almost all dermatology applicants have phenomenal grades and Step scores, so these experiences will help distinguish you from your peers. However, trivial extracurricular pursuits can distract you from your academic responsibilities, which are exponentially more important for the residency application. This is not to say that you should be solely focused on academics while in medical school – dermatology programs are interested in people who are as accomplished and well-developed personally as they are professionally. Rather than participating in several activities in which you are variably interested and have a limited role, consider participation in a select few extracurricular pursuits about which you are truly passionate. Indeed, interesting extracurricular pursuits can make a difference as residency programs attempt to sort through hundreds of extremely well-qualified applicants each year. Beware that any activity included on your residency application is fair game for discussion during interviews. Many of our interview questions focused on our extracurricular activities, particularly in those activities that exhibited leadership. Knowledge of this fact should further motivate you to avoid extracurricular pursuits that you are not truly interested in. Your level of involvement, and presumably your lack of interest, will quickly become apparent during the interview.

As third year rolls around, extracurricular activities will usually take a backseat. However, if there are particular activities that you are passionate about, by all means continue them. One author sat on committees and was involved in community service during the third year; another remained involved in planning a medical student research conference.

The fourth year schedule allows more time to become involved in organizational and community service work. One author continued his involvement in a local environmental conservation group, his medical school's admissions committee, and his medical school's pediatrics education committee. He was asked extensively about participation in these activities during his interviews, demonstrating that programs wanted well-rounded, interesting people, not simply bookworms.

Research

Academic dermatology programs are highly involved in basic investigative endeavors; almost all applicants have performed some degree of research. The importance of this cannot be overstated: research experience is an essential part of the dermatology application. There will be a few applicants who match with minimal research experience, but this is rare. The choice between basic science research versus clinical research is not as important as the demonstration of the fact that you are an intellectually curious person who loves to investigate, ask and answer questions, and further the understanding of dermatology by expanding our knowledge base. However, do not take these research projects lightly – they are a program's first glimpse at what you can contribute. It is also an important opportunity to develop a strong relationship with a mentor throughout the course of medical school. The mentor will prove to be invaluable in the residency application process by writing letters and emails vouching for your abilities and strengths. Although dedicated research in any field will be impressive, it is ideal to be able to engage in dermatology-related research. Ally yourself early with a mentor in your dermatology department, or a nearby dermatology department, who conducts research, and begin working on projects in your free time. However, do not be afraid to take opportunities to do something out of the ordinary. One author had the opportunity to conduct research abroad in a discipline only peripherally related to dermatology. As an applicant, he felt his unique travel experience set him apart from the pack and was looked at quite favorably on the interview trail.

There are several flavors of research. Basic science research projects are the most time consuming but tend to be the most impressive when published. This involves work in a laboratory. Clinical research involves patient-based research and can involve anything from analysis of data from patient charts to direct patient contact as part of clinical trials research. Review articles require review and synthesis of the literature regarding a particular topic but do not require any new data collection. Case reports depict review of a particular patient case or series of cases and tend to be the least rigorous form of research. Publications are proof of both research and dedication. These come in several forms including book chapters, abstracts, and journal articles. Journal articles represent the higher quality publications and can be case reports, review articles or original research. Original research articles, either clinical or basic science, represent the highest quality publications and can take several years to complete when considering the time to perform the research as well as the peer-review and publication process. The ability to present research in the form of posters and oral presentations at conferences is also valuable and respected. Be prepared to speak knowledgeably about your research with enthusiasm if it comes up in an interview.

For those applicants who discover their interest in dermatology at a later point during medical school, original research projects may not be feasible. Nonetheless, there are always case reports and review articles to be written. Whereas these types of publications carry less weight because they require a smaller time commitment, they allow students further exposure to topics within the field and the preparation provides more one-on-one time with a faculty member.

Many grants and fellowship opportunities are available for medical student research, offering funding for several months to an entire year. Sources of funding for summer and short-term research include the national AOA organization and the American Dermatological Association. Another option is to dedicate an entire year for research as several of the authors did. Students typically do this either between the second and third or the third and fourth years of medical school. This allows for a more intense research experience and allows for more time to publish. Some respectable programs that offer a funded year-long research experience are the Howard Hughes Medical Institute (HHMI) – National Institutes of Health (NIH) Research Scholars Program, the HHMI Medical Fellows Program, the NIH Clinical Research Training Program, and the Doris Duke Clinical Research Fellowship. If you decide to pursue a yearlong research experience, spend time working on the application and possibly a project proposal – depending on which program or grant you apply for – so you may want to approach possible mentors early.

Although the focus of the third year is clinical rotations, there are still some research projects that can be started. However, be creative and efficient with your time. It is entirely possible to complete short review papers and case reports even in the rigorous third year schedule – several authors did this during their third year. Given the limited time, projects will primarily be accomplished during lighter rotations such as family medicine and psychiatry. Hold off on major research commitments during the third year.

As was stated in the "Academics" section, try to spend one or two months doing clinical research projects during the fourth year. Case reports, review papers, or small original research studies are good. The first place to inquire about such opportunities is your home program – speak to your program director or clinical research guru. If they do not feel that there are opportunities at home, ask if they would recommend other places to go. Most large dermatology programs have people who are prolific in clinical research and usually have multiple projects in progress. If your school does not have a dermatology program, contacting a prolific researcher at another institution may be a good idea.

Mentorship

Mentorship is one of the most crucial, if not the most crucial, element for the successful dermatology applicant. The old adage "it's not what you know, it's who you know" is quite important for matching into this highly sought-after specialty. Mentors offer invaluable support and advice; meeting a supportive mentor early in medical school gives one a significant advantage over other applicants who do not find a mentor until much later. Try to develop relationships with dermatologists early on and continue to work with them – their support will be invaluable when you apply. A good place to start is by asking senior medical students (who matched into dermatology) and dermatology residents which faculty members they worked closely with in the clinic or laboratory. Find out which faculty members gave them solid advice. Select mentors who have worked with many students in the past and who are innovative, clever, personable, and well-published. Good mentors will not only advise you but will secure research opportunities, help you obtain grant funding, and write strong letters of recommendation. They also advise you on where to apply, where to do away rotations, how to handle interview questions, and how to craft a solid personal statement. Although both academic and private dermatologists can offer valuable insight into the field, academic dermatologists will have a greater ability to help in the application process because almost all dermatology residencies are university-based. The earlier you are able to find a mentor, the better prepared you will be for the dermatology application.

It would be to your advantage to introduce yourself to your home dermatology department – if you have one – as soon as you know that you are interested in dermatology. This introduction could begin through meetings with the program director or chairman. If you do not have a dermatology department at you medical school, consider setting up research opportunities with dermatology mentors at other institutions. A good time is between the first and second year or during a year off for research. Institutions at close proximity to your medical school are probably the best bet. Apart from the research funding opportunities mentioned earlier, there are several funding sources dedicated toward pairing medical students with dermatology mentors, including the Women's Dermatologic Society and the American Academy of Dermatology. Additionally, you may want to think about giving up vacation time to spend an extra month conducting research with a particular mentor if you do not have much research background or decided late on a career path into dermatology.

Senior medical students and residents can serve as valuable mentors too. Talk to students (entering dermatology) and residents about which away dermatology rotations they would suggest and particular faculty members they found to be responsive and helpful. Your relationships with these residents can significantly influence faculty members' opinions.

Conclusion

Taken together, there are many factors that can facilitate a match in dermatology. A combination of academics, research, mentorship, networking, and extracurricular activities is essential. We have provided a compilation of the experiences and strategies that helped us in the process, but ultimately the decisions you make will be your own. We do, however, hope the discussion above answers some of your questions and prompts you to consider the wide variety of avenues that can lead to a successful dermatology application.

Acknowledgments: We thank Dr. Steven R. Feldman for his valuable editing, suggestions, and ideas.

References

1. Wu JJ and Tyring SK. The academic strength of current dermatology residency applicants. Dermatol Online J. 2003; 9(3):22. [PubMed]

2. Clarke 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 Jul; 142(7):930-2. [PubMed]

© 2009 Dermatology Online Journal