The Specialty Stories Podcast is Live!

Introduction

Dr. Ryan Gray: The Old Premeds Podcast, session number 52.

You’re a nontraditional student entering the medical field on your terms. You may have had some hiccups along the way, but now you’re now ready to change course and go back and serve others as a physician. This podcast is here to help answer your questions and help educate you on your nontraditional journey to becoming a physician.
Alright we are going to break protocol today, just like we did a couple months ago when we launched The MCAT Podcast. I am launching the fourth podcast that is available on the Med Ed Media network. You can find everything we do over at www.MedEdMed.com. That’s www.MedEdMedia.com.

Our newest podcast was something that I’d been thinking about for many years, and actually something that I used to do in a site that we had called The Academy, and we had video interviews of a handful of different specialists with the thought of making a lot more. And since I closed The Academy and have been focusing more on one-on-one teaching and advising of premed students, of nontraditional premed students and premed students to help them get into medical school, the thought was that I want to take those conversations that I was having with different specialists and release them as their own podcast. And so the Specialty Stories idea has been born, and now it’s been hatched. This is going to be the first episode of the Specialty Stories podcast. I’m going to play it in full, and I’m going to end it, and I won’t be back after that. I hope you enjoy it and I’ll be back next week with another question from the www.OldPremeds.org forums.

Dr. Ryan Gray: Specialty Stories, session number 1.

Whether you are premed or a medical student, you’ve answered the calling to become a physician. Soon you’ll have to start deciding what type of medicine you’ll want to practice. This podcast will tell you the stories of specialists from every field to give you the information you need to make sure you make the most informed decision possible when it comes to choosing your specialty.

My name is Dr. Ryan Gray, and in this podcast we are going to talk to a lot of people, a lot of physicians to be exact. I want to use this podcast to help you, the medical student and the premed student, figure out what is out there for you in the future? I know as you entered your medical career you had the great aspirations of helping people and loving science. I think that’s what everybody says when they enter medicine, they love to help people, and they love science, and so they’re marrying the two and want to be a physician. Many students go into medical school thinking they’re interested in one thing and then after being exposed to all of the different aspects of medicine, they come out thinking about something else. I was one of those students that went in to medical school knowing I wanted to be an orthopedic surgeon. That was all that I wanted to do. And I came out of medical school knowing that orthopedic surgery was still right for me. Unfortunately the Air Force had different plans for me, and you can hear my story, I’ve told my story on The Premed Years Podcast which is part of the Med Ed Media network, which is what this podcast, the Specialty Stories Podcast is on, the Med Ed Media Network. You can find all of our shows at www.MedEdMedia.com. So go check out The Premed Years. I told my story about going to medical school, taking the HPSP scholarship from the Air Force, and having them tell me they don’t want me to be an orthopedic surgeon. So even though I went through medical school, went to medical school, went through medical school, and never wavered on wanting to be an orthopedic surgeon, I ultimately didn’t practice orthopedics. But that’s my story and I may tell that more in this podcast, but this podcast is here to tell the stories of other physicians, and the stories that they are going to share with us are going to shed some light into how you, the premed and medical student, can start formulating your own thoughts about what specialty you may want to practice in the future. We’re going to talk to every specialty out there, we’re going to talk to community physicians, academic physicians, women physicians, and male physicians from every specialty. We’re going to try to get them all on to give different perspectives, different points of view, what led them to their career, their specialty. What traits they find good specialists in their specialty- what traits those specialists have. What they think traits in them led them to their specialty, what a typical day looks like, so on and so forth. Tons of great questions I think, and if you have any other questions maybe that you want me to add to the mix, ultimately I want to be able to have you listen to episode 1, episode 2, episode 3 and be able to compare them using a very set and pretty standard set of questions so that you can really compare and contrast and not just have random conversations. So if you have questions that you think I should be asking, email me, Ryan@medicalschoolhq.net.

This podcast I’m hoping will be a weekly podcast, but I have a feeling that it’s going to be harder to get interviews with different physicians to fill a weekly podcast. If you followed any of my other podcasts, and this is my fourth one, my other three podcasts have been weekly. The Premed Years has been out for four plus years as we’re recording this, Old Premeds has been out for a year weekly, haven’t missed an episode yet, and the MCAT Podcast has been out for a couple months now and is a weekly podcast as well. But those shows don’t require me to speak to someone every week, and have somebody else that I’m talking to and interview every single week. So this podcast is going to be a little bit harder to keep on a weekly basis, so if I miss a week or two here or there, don’t worry, I’m still ticking and I’ll get episodes out as often as I can. And so as we progress I may try to ratchet back and maybe promise one episode every other week versus hoping I get one out every week. But that’s neither here nor there. I know you want to dive right in. The podcast episode- let me just tell you for a second, I am excited not just for you, the premed and medical student listening to this, I’m excited for me to talk to all these specialists and to hear different specialties that maybe I didn’t even know existed. Today’s podcast is an example of that, speaking to a dermatopathologist.

Dr. Hury – Dermatopathology & Dermatology

Dr. Michelle Hury: My name is Michelle Cathleen Hury, MD, and I also have a Master’s in Science, and I practice dermatology and certified in dermatopathology and anatomic pathology. So I do clinical dermatology as well as dermatopathology. So I have my own solo practice in the community.

Dr. Ryan Gray: When did you know you wanted to be a dermatologist?

Dr. Michelle Hury: I wanted for so long to do something totally different, and it wasn’t until really my fourth year of medical school that I knew I wanted to do derm and dermatopathology. For the longest time I was going to be a trauma surgeon, so it’s like a huge shift from that to where I am now.

Dr. Ryan Gray: And what led you to make that shift?

Dr. Michelle Hury: I realized once you get into medical school, and you get to your third year, and you get into the clinicals and you’re on the wards that it’s not this image that you had when you were growing up, and you wanted to be a doctor for so long, and it’s just not that idealistic picture that you had in your head. And you sort of have to balance what you want professionally with the life, and I realized if I wanted to become a surgeon- a trauma surgeon at that, that that would be my life. And even though I had told myself, ‘I want to devote my entire life, and I won’t get married, I won’t have kids because I want to be a trauma surgeon,’ once you actually get there you realize that may not be the best life. And maybe I do want to get married, maybe I do want to have kids. And sometimes you have to make that decision. There are a lot of surgeons that are moms and wives, but I knew for me I don’t think that it would have worked out. And that’s unfortunate women have to choose sometimes which path they want to take, but in the end I decided this is probably the best route for me. I have a great work life balance, and it’s very interesting to me. I went through a lot of turmoil in my third and fourth year when I realized I don’t really know what to do. I don’t know what specialty I want now. I based my whole life that I was going to do trauma surgery and now I have no idea what I’m going to do. And I went through my rotations, and I tried to figure out what I liked, and finally I hit on something that just excited me, and it wasn’t until my fourth year and I was doing a dermatology rotation, and I was doing a dermatopathology rotation at University of California Davis. And it was like a light went off. It was like this is it. This is it. I get to change people’s lives, I cure cancer every day, I get to do surgery and I get to go home at 5:00. It was amazing. It was amazing. And pathology is fantastic because you get to use your brain every day. It’s always a puzzle, and you really- it’s a very academic educational sort of specialty, and dermatology is fantastic. You get to change people’s lives on a daily basis. And like I said, the work life balance is unbeatable.

Dr. Ryan Gray: So if you’re talking to a premed student or maybe a medical student who’s trying to figure this out, what would you tell them a dermatologist, or even more specifically what a dermatopathologist does?

Dr. Michelle Hury: A dermatopathologist, you can go through two different routes. You can do a dermatology residency or you can do a pathology residency, but then you do a fellowship in dermatopathology. And exactly what you do is you look at slides from biopsies or excisions or something like that, and you look at the pathology under the microscope and you diagnose what the condition is; whether it’s an inflammatory- like a rash, whether it’s skin cancer, whether it’s melanoma, and you then tell the clinician exactly what the diagnosis is, and that really- I mean that is the key to their treatment plan. So if you diagnose melanoma on the slide, then you’re also giving them the stage, and the prognosis, that sort of thing because there are certain characteristics on the slide that will determine the prognosis of that patient. And so as a pathologist, you are really the doctor’s doctor. So they rely on you for treatment plan. They rely on you for prognosis, for staging, these sort of things. And you really are behind the scenes unless you also practice clinical medicine which is a lot of the dermatopathologists that are derm trained do that, and it’s like a nice hybrid. You do both clinical and you do the pathology. Otherwise a straight pathologist can really never be seen by the patient, but they are the most critical- one of the most critical parts to patient care, which a lot of people don’t realize. But for me as a dermatopathologist, I interpret the biopsies that I personally take, as well as a lot of the dermatologists in my community will send me their biopsies because they trust that I know- that I’m qualified and I know what to look for. A lot of people will send biopsies to say like some large lab where a general pathologist reads it and they may not get the correct diagnosis. So I get a lot of other dermatologists that need things, and then I also see patients too.

A Day in the Life

Dr. Ryan Gray: So describe a typical day for you.

Dr. Michelle Hury: Oh a typical day, I will come in and I’ll read my slides that came in from my biopsies from the day before, and so some of them are mine and some of them are outside doctors. And then I will start my day usually around- seeing patients usually around 10:00 or so. And because I also do derm path, I don’t have to see thirty patients or forty patients in a day which a lot of dermatologists will have to do in order to make their overhead. So I get to take a lot of time with my patients, and I see a wide range of patients, everyone from young to old, rashes, skin cancer. Cosmetic patients too, but I try to really be focused on medical dermatology patients so ones that I can really make a difference. And one in particular always sticks out in my head, when I first started my office earlier this year I had a teenager who never wanted to look in the mirror because he had horrible acne, and so he covered his mirrors with newspaper, and he never left the house except to go to school, and basically over the course of about two or three months I was able to totally clear his skin and now he’s like a new person. And that’s why- like that’s why I do it. I get to affect people’s lives. I get to change how they see themselves and how they feel about themselves. And so that’s my typical day. I get to really touch people’s lives.

Dr. Ryan Gray: Wow, sounds great. What traits do you think lead to being a good dermatopathologist?

Traits of Successful Dermatopathologists

Dr. Michelle Hury: I think one of the most important things is to be very [Inaudible 00:14:20] and also to think about all possibilities. So if you are sort of married to an idea, you may not have the right diagnosis. So I’ve seen this on a couple of occasions where you may start looking at a slide and you have an idea of what you should be looking for, so then maybe you don’t look for actually what’s there, you sort of look for what you’re trying to find, and you miss something. So I always try to- I think one of the most important things is to look at slides as if you’re looking blindly. Like you want to look as if you don’t have anything that’s bias in you. Of course you need to know the clinical history, you need to- because a lot of it is clinical pathologic relation, you need to know exactly what the history is but I like to look at the slide first because you need to have an open mind. So that’s a very important thing for all pathologists, is to look at the slide and just look at it and see what you can find. Just be curious like, ‘I wonder what this is over here. What’s this?’ And don’t be married to a particular idea. That’s very important in pathology. And then of course you correlate with the clinical later, but it’s very important to start out with an open mind. And then really a good pathologist will sort of know a lot of the differentials and they’ll kind of go down those paths of like, ‘Well it could be this, it could be that,’ and then they do certain tests and stains to figure out if that is indeed the case. And it’s very important to think about all these differentials. So pathologists- and there are so many different pathologists; brain pathologists, and breast pathologists, and GYN pathologists. You really have to know so much clinical information because you have to know all the differential diagnoses that that particular entity could be on your slide. So it’s very important to be good clinicians even though you’re pathologists and you don’t really see patients that often. So there’s a couple of different things that you need to be. You need to be very curious, you need to know a lot of medicine as well- like clinical medicine, and you need to be open to different differential diagnoses, and not be closed off. It’s a lot of thinking in pathology, a lot of investigation which is nice.

Dr. Ryan Gray: Interesting. What makes a competitive applicant to dermatology first, and then to dermatopathology as a fellowship?

Dr. Michelle Hury: Yeah well first off, dermatopathology is really tough to get into. Really, really tough because there aren’t that many programs and the programs that are around are very, very competitive. So it’s probably even more competitive than dermatology; there are a lot of dermatology programs and spots. Basically with any sort of highly competitive specialty, you need to do a lot of research, you need to have papers, you need to have presentations, go to national conferences, and present whether it’s oral presentation or poster presentation, if you have novel research that’s fantastic, if you do a lot of sub-I clinical clerkships and they get to know you and they see you, then it’s a lot easier to match into a competitive program. So I know a lot of people that did their sub-I’s and a lot of fourth year clerkships for- in dermatology, and they’re just present, they’re there every day, they do 100%, they go the extra mile, they’re always doing something. They’re giving little presentations, they’re always on their game, they don’t slack off. They’re just always there and people see that. The attendings see that. They want someone who’s going to be a thoughtful resident, they want someone who’s hardworking, they want someone who’s talented. I mean if you have an aptitude for that particular field, and they know you, and they trust you, and they would like for you to be one of their residents, then obviously you’re going to match there. So I always tell people do rotations at a place where you are really interested in doing your residency, and I think you really have a chance of getting in. And the same thing for fellowship. If you really want to go to a particular derm path program, you need to go there and do your rotation. You need to ask if they have any research opportunities for you to collaborate with, and just go that extra mile. No one is going to ask you to do these things, you have to take the initiative and do it, and it’s tough. It takes a lot of effort but if you’re serious about it then that’s what you have to do.

Dermatology Residency

Dr. Ryan Gray: What was residency like?

Dr. Michelle Hury: Residency was great. I was at University of Massachusetts and it was very- it was very tough. It was a very good program but it was a lot of work, and- but you know what? It’s the people that you’re with, your co-residents that make it worthwhile. It’s like a big family, and it’s a team, and you just do it. And obviously it’s not a surgery residency, you’re not going to be awake for however many hours a week and just work yourself crazy, but it’s tough. Residency is tough, especially if you’re away from family and you’re in a place where it snows constantly and maybe that’s not what you’re used to growing up in California, but it was fantastic. And then I stayed and I did my fellowship at the same place, so that was also nice because you know the system, you know the people, and you don’t have to pick up and move somewhere. That’s something I also tell a lot of people. Try to pick a program for residency- if you know you want to do a particular fellowship, and that fellowship is very competitive, then try to pick your residency at the particular institution where that fellowship is because you will most likely get the fellowship because they know you. They know you, they’re used to you, if you’re doing a good job they want to keep you, and you have the most possibility of getting into that competitive fellowship if you do your residency there. That’s one of the reasons why I picked University of Massachusetts; obviously they’re a great center but I also knew that they were starting a brand new dermatopathology fellowship, and that was my- I knew I wanted to do that before I started so that’s why I went there mostly. And of course my husband was in Massachusetts too, so I sort of had to match in that area. So that was a big, big bonus for me.

What Dr. Hury Wishes She Knew

Dr. Ryan Gray: Yeah. Looking back now, what do you wish you know going into dermatology and now dermatopathology?

Dr. Michelle Hury: Oh well gosh I wish that- I wish that I had- I wish I had known that it’s possible- I know this is kind of a little bit off the topic of medicine, but I wish I knew that it was possible that you could have a family earlier on. So this is more for like maybe your female premeds and med students, is that there’s never a right time to have a family and so when I started residency I thought, ‘Oh my gosh, there’s no way.’ We just kept waiting, and waiting, and waiting, and waiting, and that’s not probably- that wasn’t the best course of action and it’s not necessary. So I wish I had known that you just live your life the way you want to live, and there’s not going to be a good time. And so your priorities should be family, and then residency and fellowship and all of that should be second. It’s nice to sort of keep that in perspective. It’s easier said than done. I think a lot of people may be like, ‘No this is my career, this is what I have to do,’ but you should not lose sight on your family. So family should have come first and then you can always work hard and still have a family. But I’m not saying you slack off just because it’s second, but I wish I hadn’t put family on hold. Let’s just say that.

Dr. Ryan Gray: Okay.

Dr. Michelle Hury: Yeah.

Dr. Ryan Gray: What do you wish primary care providers knew more about dermatopathology?

Dr. Michelle Hury: Oh well dermatology in general, yeah. I mean unfortunately I don’t know why, but I feel that a lot of primary care physicians, they just have no training for dermatology, and in general most specialties. And I have to say even surgeons don’t have a great grasp on what pathologists do in general. So here I am, I’m doing both, and so I get a lot of referrals from primary care physicians where they’ve tried managing a derm condition and obviously they just don’t have the training. They don’t know exactly what’s going on, and they’ve sort of mismanaged the patient for awhile, and then I also get- especially in training, so many specialties that had no idea what pathologists did. They thought pathology was just like a lab test, and pathologists maybe aren’t even real doctors, so they think- they take a sample, a biopsy or something, and then it gets- like a lattice, like a blood test or something, and then you get the result a couple hours later. So they have no idea what pathologists in general do. So I sort of get it from both ends; both the clinicians for the dermatology that aren’t quite sure what’s going on, and I get doctors that just don’t know what pathologists do. So a lot of my job is actually educating, so I try to educate my primary care physicians that refer to me. Some of them like to take their own biopsies so I’ve gone to their offices and actually give them little lectures about these are common skin conditions, this is what this is, and this is how you biopsy, and then what a biopsy is. What does that mean? What happens to that piece of tissue after you take it, and how I make a diagnosis? So a lot of my job is actually educating, but I wish that primary care physicians would get more of a background in dermatology. Mostly they just try to throw some Cortisone on it and then think that it’s going to be okay. It’s not, that’s not what dermatology is.

Dr. Ryan Gray: If it’s wet, keep it dry. If it’s dry, keep it wet.

Dr. Michelle Hury: And when in doubt, cut it out. I know that’s not- unfortunately that’s not the way it goes. But for the most part it works out except when they overlook something like a melanoma and they think that it’s nothing, and I’ve had that happen many times where they think that it’s, ‘Oh this is fine, this is fine,’ and then the patient comes to me and now they have a high stage melanoma because it’s been missed. And that- all joking aside that’s what I’m trying to prevent. It’s okay if you want to mismanage a rash for several months, but when you miss the melanoma and you tell the patient, ‘Oh it’s nothing,’ then that’s where we run into problems. That’s when people die, so yeah I wish they got training.

Best Parts of Working in Dermatopathology

Dr. Ryan Gray: Okay so I’m assuming it’s primary care providers and other dermatologists that you work closely with the most?

Dr. Michelle Hury: Exactly.

Dr. Ryan Gray: Okay.

Dr. Michelle Hury: Exactly. Yeah that’s about it, yeah.

Dr. Ryan Gray: What do you like most about being a dermatopathologist?

Dr. Michelle Hury: Honestly I love the intellectual stimulation, I have to say. I love looking at slides and figuring out what the diagnosis is, and I also love talking to patients. I love interacting with patients and- about skin. I love talking to them about their skin. I am not a general practitioner, I am not going to talk to you about your diabetes, that’s like just way too much. But I love sitting down and talking to them because a lot of the times we just start talking about whatever, like what they did last weekend or whatever, and then I just get to know them, they send me cards, they send me flowers whatever, and I take care of their skin and I make them look good, I make them feel good, I give them healthy skin and I love that aspect. So I love the sort of dichotomy where I see the patients, I take care of them, I interact with them, and then I also have this like intellectual stimulation by looking at the slides and figuring out their diagnoses, and I love that dichotomy in my practice. That’s my favorite thing. And then of course I get to do surgery too, which is- I love surgery and I love starting my morning off cutting out skin cancer, and that’s a huge rush for me. ‘I just cured your cancer.’ That’s awesome! Who can say that on a daily basis? Right?

Dr. Ryan Gray: That is pretty cool.

Dr. Michelle Hury: Fantastic.

Least Favorite Parts of Dermatology

Dr. Ryan Gray: On the flipside, what do you like the least?

Dr. Michelle Hury: Oh I mean hands down dealing with insurance companies. There’s- I mean I don’t like being told that I can’t prescribe a certain medication for a patient, or the patient is out of my network therefore they have to pay a lot of money, or their deductible is high that they’re going to have to pay out of pocket for their biopsy that I just did. I can’t stand that sort of thing. It really gets in the way of patient care, and I don’t really see a way out of it, but that’s- hands down. Dealing with insurance, dealing with the sort of thing is a real headache. And I don’t actually have to deal with it as much as other specialties, when they really- prior authorizations for something as simple as like a topical steroid is just insane. It’s ridiculous. So that’s the least favorite, and especially being on my own- a solo practitioner, and I do everything myself. So I don’t have staff that’s going to be doing that sort of stuff for me. So that’s also kind of a big headache.

Dr. Ryan Gray: I think it’s safe to say that if you had to do it all over again you would choose the same specialty?

Dr. Michelle Hury: Oh yeah, definitely. I don’t see myself doing anything else. Once in a while I get these sort of twinges of like, ‘I wonder what it would have been like to have been a trauma surgeon in the hospital, some big shot.’ And then it’s like well yeah but I get to go home to my family and two little girls at 5:00, and I’m super happy about that, and I love my patients, and I love what I do.

What the Future of Dermatopathology Looks Like

Dr. Ryan Gray: What do you see is the future of dermatopathology?

Dr. Michelle Hury: It’s a little bit scary. I feel like a lot of clinicians don’t realize that the interpretations that they get from these big laboratories are not done by experts, and so I really feel that the specialty as a whole is a bit under pressure to make themselves more noticeable to people, and make it such that clinicians understand that they should have their biopsies interpreted by experts in the field instead of big box general pathologists who may not give the correct diagnoses. And I feel that it’s all about money, so it’s obviously cheaper for them- a big lab to have a ton of general pathologists reading slides than it is to have like an expert derm path read it. So I feel like that’s something that we really have to stress, that it’s not about money, it’s about patient care and what’s the best thing. And I’ve seen a lot of missed diagnosed slides, and misdiagnosed melanoma, this and that from general pathologists from these big labs, and that’s a problem for patient care but obviously for bottom line, for money, for the insurance companies it’s cheaper for them, right? So that’s like a big thing for derm paths, and I think there are also a lot of programs that are trying to start- have more derm path spots, and so if you have more derm path spots then obviously you saturate the field, because one derm path can read hundreds of biopsies a day. So if you saturate the field then supply and demand, right? And so that’s a problem and you may not get the best people training because you’re trying to get as many out there as possible. Not everyone can do this job, and not everyone should do this job. There are a lot of issues with derm path, but as a whole, as of right now I think it’s still a great field- it’s a great field to go into.

Words of Wisdom to Premeds & Medical Students

Dr. Ryan Gray: Any last words of wisdom for those wanting to be or thinking about becoming a dermatopathologist?

Dr. Michelle Hury: I think that one of the main things you should be thinking of is not money, it should be work life balance. You need to be happy in the specialty you pick, and dermatopathology and dermatology, they’re two fields where you will do well whether you are a solo practitioner or you’re in a group. You will do well money-wise, and- you’re not going to make a crazy amount of money so those days are over, but you’re going to have a good work life balance which I think should be one of the most important things when you consider going into a field, like which field to go into. I think that’s super important, and I think those two specialties, derm and derm path will offer that. They’ll give you a good quality of life, they’ll give you a good work life balance, and a good pay, and that should be what you’re looking for. This is not an altruistic profession. It is still a business and people lose sight of that. You have to pick a specialty that you’re going to do well in and that you’re going to be happy with.

Final Thoughts

Dr. Ryan Gray: So that’s episode 1 in the books. If you have a specialty that you really want me to cover sooner rather than later, and you know a physician that you think would make a great guest on this podcast, shoot me an email, Ryan@medicalschoolhq.net. That’s our main website, www.MedicalSchoolHQ.net. You can find everything that we do there, you can find a list of all the podcasts that we do over at www.MedEdMedia.com. Again that’s the network of all the podcasts that we’re doing. Specialty Stories is now our fourth podcast which is awesome, and fun, and crazy. So I hope you learned something today. I know not all of you are interested in dermatopathology, or even dermatology, or pathology separately, but understanding what other physicians are doing I think is key to teamwork, which is what everything I do is based on. Collaboration, not competition. And understanding what these other specialists are doing, and how you can make their job easier so that they can give you the information that you need to make your job easier, I think is going to be key in the long run.

So I hope I get the information out to you that you need, that you want, to help you make the decisions so that as you are going through your premed journey, you’re shadowing the types of physicians maybe you hear on here, as a medical student you’re rotating and picking sub-I’s based on awesome specialists and specialties that you hear on this podcast, and when it comes to matching I hope that this podcast will help you make that decision much easier.
So I hope this podcast has helped you in that journey, and we will be back hopefully next week with another episode here at The Specialty Stories. In the meantime go check out all of the other podcasts that we’re doing over at www.MedEdMedia.com. Thanks for joining me on this first episode of The Specialty Stories.