I worked as a physician assistant (PA) in family medicine for 3 years prior to becoming a dermatology PA. Dermatology was always my ultimate goal, but I wanted to broaden my knowledge in general medicine before specializing. I thought that family medicine would be a good way to do that, and it absolutely was! And now that I am working in dermatology I can reflect on how it prepared me for this specialty as well.
First of all, both family medicine and dermatology are typically in the outpatient setting. Working in family medicine helped me learn the ins and outs of an outpatient clinic which is relevant for my dermatology position. Specifics include the role of each individual in the office (e.g. administrative manager, billing, receptionist), learning about different types of insurance, and developing a leadership role in the office as one of the providers. Both specialties include a lot of autonomy, and the relationship with my supervising physician (SP) is very similar. There were days in family medicine three years out where my SP and I were so busy and I was so confident in my day’s schedule that we would pass each other in the hall and barely speak aside from small talk, and there were days when I would grab him all day asking him questions and/or having him come into the room to see my patient. Although I am not yet seeing my own patients in my new dermatology position, the autonomy that I will have will be the same. There will be many patients that I will see without my SP, and I am sure there will be many that I will talk to him about or have him come into the room to examine.
My schedule is similar in both specialties as well. I work a 9-hour day with a 1-hour lunch break Monday through Thursday and I work a half day on Friday. In both family medicine and dermatology we have 15-minute appointment slots. In family medicine, we allotted 30 minutes for physicals. In dermatology we allot 30 minutes for surgical excisions.
Charting is something that I learned to do between patients when I can, and catch up on during lunch hour or at the end of the day if needed. This has not changed. Similarly, I can go through labs and catch up on calling patients if needed.
Okay, so now let’s get into the medicine!
Common rashes that I would see in family medicine included atopic dermatitis, contact dermatitis, seborrheic dermatitis, dishydrotic eczema, molluscum, shingles, pityriasis rosea, and drug eruptions to name a few. As in family medicine, in dermatology we see the “common” rashes very often!
Procedures that I often performed in family medicine included laceration repairs, incision & drainage (I&Ds), cryotherapy of skin lesions such as warts or actinic keratoses, and skin tag removals. I do these much more often now that I have specialized, but laceration repairs typically don’t get to me because they (appropriately) seek more immediate treatment from their primary care provider (PCP), an urgent care center or even the emergency department. Instead of laceration repairs I get my suturing in during excisions.
In family medicine I would evaluate the skin when the patient came in with a skin complaint. During physicals I would evaluate the skin, but there was simply not enough time to do a thorough, complete skin exam. For this reason I urged my patients to see a dermatologist once a year for a complete skin exam, and I often provided a referral. If I saw a suspicious lesion I would let my patient know, refer them, and then follow up on that.
An imperative thing that I learned in family medicine is how to work up a patient for autoimmune diseases if I suspect that the rash may be related. Because of my prior experience I also understand how to interpret those labs when I get them back, which is an obvious necessary next step.
I developed a fundamental understanding of how chronic diseases can affect the skin. For example, my patients with heart problems often have signs of venous insufficiency, or patients may have pitting edema related to their chronic kidney disease. Many elderly patients develop skin discoloration related to chronic use of Coumadin and easy bruising.
Medications and medication interactions. Need I say more? Family medicine was key.
Psychiatry was a large part of family medicine. I spent hours listening to my patients talk about their depression or anxiety. I often felt like a counselor. This is not lacking in dermatology. Patients need to be counseled especially when there is no cure for their skin disease and it’s something that they will simply need to live with and treat symptomatically. Compassion is crucial. Also, have you heard of the “itch that scratches”? Some skin conditions can be exacerbated by psychological distress.
And last but not least, preventative medicine. This was probably the most important thing in family medicine, and it’s no less important in dermatology. Just like it’s necessary to have your physical, bloodwork, pap smear, colonoscopy, etc. it’s imperative that patients actually come in for skin exams. Early detection of skin cancer is vital. Staying on top of pre-cancerous lesions (actinic keratoses) can lessen the burden for the patient in the long run because these can become painful, they can bleed, and most importantly they can develop into skin cancer. Many patients already have tons of them and they keep developing more and more of them due to years and years of previous sun damage. We typically have them come in every 4-6 months to treat these with liquid nitrogen and patients will say that it improves their quality of life.
Truthfully, the list of how family medicine prepared me for dermatology could go on and on. But the most important thing for me is feeling like I can care for my patients beyond the skin. I will listen to my patient tell me that he or she feels bad as an honest answer to my initial question, “How are you?”. I always thought I would quickly say, “you need to see your PCP”, but I find myself asking all those questions that I used to ask in family medicine, giving some suggestions of what may be going on, talking on the subject a lot longer than expected, and ultimately urging my patient to get the proper care needed whether it be seeing his or her PCP or another specialist. And let me tell you, they really appreciate that. One patient told me that he felt bad, and he wondered if it could be due to his blood pressure. So I blew some dust off of my stethoscope and a blood pressure cuff and I told him that his blood pressure was just fine and he was so glad to learn that. I have learned that your relationship with your patient is what you make it. You can just treat the skin and keep it moving, or you can build up a level of trust and compassion. Merely giving your patient another set of ears can mean the world to them. That is the most significant thing that family medicine has taught me: treat the patient and not just the skin and always practice medicine with sincerity.