14 Things I Wish I Knew Before I Became a Dermatologist

1. You don't need to focus on dermatology from the beginning. I went to college and majored in microbiology and then went to graduate school because, originally, I had only wanted to do research in a lab. But as I went through graduate school, I wanted to do clinical research with patients, and in order to do that, I needed to go to medical school. I wanted to do multiple sclerosis research and go into neurology, but I never wanted to practice clinical medicine. I did my first neurology rotation at the very beginning of my last year of medical school and I found it so depressing. I did two more neurology rotations thinking somewhere else, things would be better, but it just was a very depressing specialty and I didn't think I would be able to do that as a career. Because of my background in research, I did a rotation with a dermatologist — who was also an immunologist — doing age research, and he said I should go into dermatology because it's a fun specialty. I found that in derm, I could do a lot of different things and still use my research background while working with patients.

2. A lot of people want to be in this field, so you will need to find a way to stand out if you want this as a career. Dermatology is a really good specialty for a lot of reasons. You work pretty normal hours (I work 8:30 a.m. to 5:00 p.m. Monday through Friday), your patients generally aren't dying all the time like they are in oncology or medicine, and people are usually pretty happy because you're making them look better and feel better. It's a lifestyle you can't really beat, so it's a very competitive residency to get. The best thing people can do is do dermatology rotations during medical school. After medical school, if you really know derm is what you want to do, you have to be persistent. Visit the residency programs, spend time at the local universities, go to conferences. There are a lot of people who don't get into a residency the first year they apply, so they do a year of medicine or a year of surgery, and then apply again to do dermatology.

3. Establishing relationships with patients is key to making your job enjoyable. I've been in practice about 18 years. I have patients who have followed me for those 18 years and I have patients I see once. I have patients who tell me I feel like I'm family and I know all about their families because I've known them for so long. I prefer the patients I've known longer versus the ones who are in and out, and I never see again.

4. The work people want done won't be as extreme as you expected. We have a lot of people who want bigger lips, but they're worried they'll look like a lot of those actresses you see on TV. We thought we would have a lot of people coming in wanting Kylie Jenner lips, but most people that we see, if they mention her, specifically say that they don't want their lips to end up like Kylie Jenner's.

5. You will feel pressure to have perfect skin throughout your career. I really feel that in cosmetics dermatology, I have to try to look the best I can look. Because if I don't, how are patients going to believe that I can make them look better? I can use any prescription or non-prescription creams that I want. I think most of the people in our clinic use the products that we have. Everyone who works there pretty much gets something, whether it's Botox or laser treatment. We always need test patients for new products or techniques, so we do Botox or fillers on the staff. And most of the time, we don't pay at all.

6. Your patients in cosmetic dermatology will be younger than you'd think. It's less common, but I do have a couple of people in their 20s who come in for Botox. Sometimes they're people who are out looking for jobs — if you're someone that frowns all the time, it's not a good look when you're interviewing for a position. The biggest thing with people in their 30s is preventing wrinkles instead of getting rid of them. You can't stop yourself from frowning or wrinkling your forehead, because that's just a habit that people can't turn off. So they start getting Botox preventatively and it works. I have a few that come in in their 20s because they never want to have a wrinkle, so they start early.

7. People will ask you to look at their skin problems — outside of work. I don't mind my family and friends asking, but I do mind when I see my patients out in public and they ask me to look at lesions. One of the worst experiences I've had was at a Mother's Day buffet at a country club. This woman brought her daughter over and rolled up her sleeves and asked me to look at a mole. I was with my mother, my mother-in-law, and all my friends. I also had a guy in a bank pull up his shirt to show me a mole. That kind of stuff really bugs me. When that happens, I tell them they need to make an appointment, that I really need to look in better lighting and use a little scope that lets me see pigment. I would never give an opinion without documenting what I see.

8. Dermatology encompasses way more than dealing with acne.  We do see a lot of acne patients, but we probably see far more skin cancer patients than we do acne patients. A lot of people see dermatology as an easy specialty because the patients aren't having heart problems, lung problems, or kidney problems. But being a good dermatologist can be difficult. You get people with melanomas with poor survival rates. If people have a blistering disorder for years or they're having recurrent rashes, taking the time to figure out the cause and try to help them get their life under control makes it more difficult and for me, more interesting.

9. Having a background in research can help you become a better physician. My career path is a little different than a lot of doctors' because I went to graduate school, and I would say a majority go straight to medical school after undergrad. I could have started all of this earlier, but I really do think [research] made me a better physician. It helped me get into derm in the first place because it really set me apart while I was applying. But it's also helped me in my approach to patients. The time I spent in research during graduate school has definitely impacted my approach to figuring out the cause of rashes and the best way to control them, instead of just giving a cream or a shot to make them feel better as a temporary solution.

10. You will have to deliver awful, life-changing news more often than you'd think. A patient recently came in for us to take a cyst off his scalp, and as soon as I saw it, I thought, This isn't a cyst. So we took a piece of it, and it came back as metastatic cancer from colon cancer. Even though the majority of skin cancer patients are older, we see patients in their 20s and 30s with melanoma or basal cell cancers. Those are probably the two most common that we see in younger patients. I never give those diagnoses over the phone. I always want to have more time with the patients and have [next steps] lined up for them. 

11. No matter how long you're in this specialty, there will still be things that shock you. Dermatology is a very visual specialty. I had a patient who was a little boy and he was born as a collodion baby — when they're born, they almost look like they're wrapped in plastic wrap — and the skin on his face was so tight and inflamed that it pulled his lower eyelids down. His skin is red and it just peels off, and he just flakes all the time. As an infant, there were some mistakes made in the hospital and he lost his hand. But you can't ever let your "oh my god" reaction to patients that are dripping and oozing stuff show. You just can't.

13. It's better to be honest with patients if you know you can't help them. Rather than tell people it's going to be OK when you know it's not going to get better, just assure them that you will be there to help them manage the disease along the way. Psoriasis, for example, is so common, and there's a reason it's referred to as the "heartbreak of psoriasis": for most people it doesn't get better. I think just being there to let them know you're on their side and that you're going to do whatever you can to make it better is the best thing you can do.

14. Just because a skin condition might not be life-threatening doesn't mean your work can't change lives. I recently had a young woman with one of the worst cases of psoriasis that I've ever seen. She had it since she was maybe 8 or 10 years old, and her entire body is covered, and it really affects everything about her life. She had decided to never have children because she never wanted to have a child that had to go through what she went through. When I met her, she was really bad and we had been through so many drugs and nothing seemed to work for her. I called [other experts] and talked to them about different treatment options for her and finally — finally — we have her on a drug and she's clear. She came in just about two weeks ago and she is a different person. That is really a good feeling, because it is life-changing for her to be able to wear shorts and to be able to wear short sleeves without having to cover up all year.

Terry P. Morris, M.D., Ph.D is a board-certified dermatologist with her own practice in Virgina.