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Expanding Your Horizons After Residency

The end of my residency was not the end of my story, said Jennifer Holman, MD, during her presentation “What I Didn’t Learn In Residency” at the 2019 SDPA Conference.

At the end of residency, Dr Holman said she was a really well-trained medical dermatologist and she encouraged attendees to also start in that area before branching out into aesthetics and surgical fields. However, she now spends one-third of her time performing aesthetic procedures and surgical procedures in addition to medical dermatology. She also noted that knows more about the business side of dermatology than she ever thought she would.

“At the end of my residency we only had etanercept (Enbrel) and adalimumab (Humira), and now we have multiple biologics for psoriasis,” Dr Holman said. “In another 10 years, I hope to say the same thing about atopic dermatitis,” she added.

Knowing how to interact with pharmaceutical representatives is important, said Dr Holman. She said she had boundaries with her representatives, but also had good relationships with them because they can help support trainings for cosmetic procedures and assist nurses when they need help navigating the system if there is a problem with a patient’s medication. “If you are anti-pharma, at least be nice to them,” she added.

One practical pearl that Dr Holman shared was the use of IM Kenalog as a rescue. I rarely used this during my residency and also rarely used systemic prednisone, she said. IM Kenalog is a big part of her practice. She makes sure her patients have calcium and vitamin D supplements, or are using Fosamax if needed, and also notifies the patient’s primary care physician and recommends they undergo annual eye screenings while using the therapy.

Dr Holman also discussed the use of saline for treating steroid atrophy. “It hurts like hell,” she said, but flooding the area works the best for addressing this complication. If a patient can tolerate it, she recommended 5 to 10 ccs every 5 days. She also reviewed the use of intralesional 5-FU for eruptive AKs and keloids.

The pulley stitch, Dr Holman said, can help with any wound under tension and provides good hemostasis. She places the stitch in the middle of the wound, like a figure 8, as her first stitch before placing a middle buried dermal, then removes the pulley stitch. “I use it for scalp punch biopsies,” she stated.

She also strongly recommended providers start using trichloroacetic acid (TCA) in their office. She said she uses it for ice pick scars, placing little dots on the scar until it frosts. It is a 7- to 14-day healing process, and the area will stay red and scab for 5 to 7 days, Dr Holman said. However, it can be used on all skin types, she noted.

Dr Holman recommended providers get to know their electronic medical record codes. The best way to see how you are doing in a practice is by using bell curves to benchmark your costs with everyone else in the practice, she said. This will help prevent an audit, she added. The same method can be used to for biopsies as well.

In addition, not charging patients does not benefit anyone, she said. In private pay, she will downcode instead of issue a no-charge. When patients invest or set up a payment plan, she said, they are more likely to adhere to treatment plans because it is a financial commitment.

Dr Holman also said discussing money is an important part of patient care. She recommended knowing what the costs of treatment and goods are. Always get a quote, she stressed, and take the time to get it instead of guessing.



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