Episode Transcript
[00:00:00] A patient walked in the room where his skin was actually purple.
[00:00:04] She had stopped taking care of herself. Probably more than 50% of her face was skin cancer. I'm not sure if I would even call it a town because it's under 4,000 people and it's not accessible by road or water. You actually have to fly in. Besides orthopedic surgery, dermatology has the least number of minorities. I like to think of myself with the 50 licenses and my involvement in the indigenous communities as America's dermatologist. That's my ultimate goal for welcome to skin deep. I'm Dr. Ana Chacon and today we have a very special guest joining us. Get ready for some expert insights you won't want to miss.
[00:00:42] Hi, I'm Dr. Ana Chacon, a board certified dermatologist. I've been a doctor since 2012, over 10 years now. I work in all 50 states, D.C. guam, the Virgin Islands and Puerto Rico. And I love what I do. I would say a lot of things sparked my interest in medicine. I've been wanting to be a doctor since pretty much I could think. I think my dad is a physician.
[00:01:09] He started the pediatrics critical care unit at Baptist Hospital here in South Florida. He was in practice for almost three decades.
[00:01:17] I went to work with him a lot. I saw him help a lot of people during Hurricane Andrew. He was often called on during natural disasters such as hurricanes, which are common here in South Florida. And I really just enjoyed it. I love the teamwork aspect. I love being able to be helpful. Being involved in important events such as hurricanes and any natural disasters are. You feel very fulfilled being involved in those and just seeing progress and knowing that your work and your decisions really make a difference.
[00:01:55] I liked to study at the time. I don't like studying as much anymore. I'm kind of burnt out from studying. But I really enjoyed going to school and there's obviously a lot of years of school involved in becoming a physician. I think I was in school for over a decade, but it's a goal that I had been working on since childhood. Always took science, math classes, biology classes, things that were related, such as medical Spanish, and worked as a candy striper at Baptist and volunteered a lot.
[00:02:30] Traveled not just throughout the United States for my career, but also throughout the world. I did conferences in Kuwait. I just came back from a conference in Canada this weekend. I'm part of the European Academy of Dermatology where I go to more conferences.
[00:02:45] You can have a really big reach in medicine, you know, of course I'm different In the sense that I work in all 50 states. Most doctors are not like that. That. But it just makes me feel like I can reach more people. And of course, that's very rewarding and fulfilling.
[00:03:00] My dad definitely did play a big role in my interest in medicine.
[00:03:05] He did not play a role in my interest as a dermatologist. I'm the only dermatologist as of in my family.
[00:03:12] He did have a practice at Baptist Hospital Pediatric Critical Care and was very much a leader. The practice owner there, I believe he started that unit, which no longer exists as they. They took it away after Covid and converted it to a Covid center, mostly for financial reasons. Pediatrics doesn't reimburse as well as other aspects of medicine. And it was a decision the hospital made.
[00:03:38] It was really my passion, sort of watching him work that drove me towards this field. It was certainly very difficult. And there were times where I studied so much or went through so many failures that my family told me to choose something else or choose an another career. Especially being a Hispanic female. It was very, very hard. Very long. Had to make a lot of sacrifices, like, should I focus on family, should I spend time with more time with this person, nurture these relationships or really go for what I'm passionate for? Because I did find it hard to do or try to do everything.
[00:04:18] So it's still my primary goal in life and my primary focus is being the best physician I can be. I definitely let some things, you know, in order to achieve that. So I think there was a lot of discouragement. But overall, there's still a lot of pride that I was able to get to where I wanted to after so many years. But it was. It was definitely very difficult.
[00:04:42] I've put myself through the challenge of going through dermatology because I really love it and I'm passionate about it. You know, work doesn't feel like work. It feels like you're appreciating every moment because you're fortunate enough to be doing it, but you're also learning. And I tell everyone I learned so much from my patients just as much as they learn for me. And it's a beautiful field because there's so many aspects about it. You know, you can see the diseases on one's skin instead of having to dig for them, which is. Is very important in medicine. There's a lot of physical manifestations on the surface of the skin that you wouldn't know about other organ systems. The other challenging aspect, you know, going back to your question about what were some of the Challenges is there's really not a lot of minorities. I think besides orthopedic surgery, dermatology, the least number of minorities. And it's important for me to mention that I think someone quoted a rough percentage of about 3% of dermatologists are Latina or Hispanic origin, which is a very small number considering the large number of Hispanics in the United States. It's disproportionately low.
[00:05:54] It is very difficult when you are applying or competing for a very small number of spaces.
[00:06:01] There really is no affirmative action in dermatology because it's very subjective. Yes, you have to. It helps if you do well on your exams and you do well in school.
[00:06:12] But ultimately it's the decision, the very subjective decision of a small group of people.
[00:06:19] Whether you get in or not. You're pretty much at their mercy. It's not as objective as, let's say, taking an SAT test or an ACT test, getting your score and passing. You still have to depend on a very small group of humans for, you know, the opportunity to, to finish your career.
[00:06:40] And a lot of those spaces sometimes are driven by connections like, oh, if we accept this person, our department is going to do better, or this person's family member brings us a lot of business.
[00:06:53] There was a lot of that, especially locally. And sometimes you also have to really, really travel to finish your career. Like I traveled to different states to finish where I no family.
[00:07:06] It was very expensive.
[00:07:08] It was just hard to sometimes even adapt. Culture shock and everything. Whole different group of patients from what I would typically see back home. And then of course it gets complicated because if you have a spouse, if you have a family, you've got to get up and move and go over there. And so it gets very difficult to kind of integrate all of that. But you do it and you live through it and ultimately you end up with what you wanted or make sacrifices to end up with what you want.
[00:07:37] I definitely did face a lot of challenges just being a minority, period.
[00:07:41] So I'm Hispanic and I'm also of indigenous origin.
[00:07:46] I a little bit about my background. I went to public school here in Miami, Kenwood elementary, for a lot of it. And then I transferred to a private all girls school, Carrollton, which is extremely, extremely expensive. It's in Coconut Grove. Very good school. They're both really great schools, but completely different.
[00:08:06] With private school, there was definitely a lot of emphasis on what you had economically.
[00:08:13] Took me a while to fit in. Got made fun of a lot.
[00:08:17] Part of, I guess the mockery was that I was Actually very much minority, indigenous. I would eat beans on a tortilla. A lot of the times I would wear ethnic clothing and they unfortunately made fun of me. Kids can sometimes not process cultural differences very well when they're young and they haven't been exposed to that. And so that was definitely a shocker. And then just in medicine overall, a lot of times where I went to school or where I trained, I was the only resident that spoke a different language and could communicate with a certain group of patients, which is of course obviously very, very important.
[00:09:01] When you're treating a group of patients, if understand the patient, there's not a lot of times, a lot that you will be able to do to help them. And of course it slows things down if you enter a room and just first thing is you just can't communicate. And that has spurred like a whole genre of jobs, right, Translation services and all that that have just evolved with just the different cultures.
[00:09:25] But you know, it's been, it's helped me connect just having cultural competency and it's been helpful that people are recognizing how important this is aspect is to medicine and dermatology as well.
[00:09:39] So my early years in the hospital, I really don't know really where to start because I had been shadowing my dad for a long time throughout childhood, just would go to work with him wherever he was working, learning, studying with him when I could.
[00:09:53] And then of course, whenever I had the opportunity, I signed up as a volunteer or as a candy striper in different hospitals and did stuff with them. One of the most memorable experiences I had was working in the ob GYN department.
[00:10:07] Actually helped deliver babies. I'm not even sure if they would allow that anymore, but I definitely helped a lot. Got very close and it was really, really rewarding. And I liked OB GYN a lot. That's definitely a field I really, really like. Very meaningful. So OB GYN stands for obstetrics and Gynecology. It's just a different specialty in medicine where you deliver babies, do women's health, things like that.
[00:10:31] And then dermatology isn' as much hospital based, but I did do some hospital based rotations and experiences. I went to the Philippines, I studied leprosy there at a tropical dermatology center or tropical hospital. It's called Research Institute of Tropical Medicine where I worked with a lot of patients with hiv, different fungal diseases, fungal infections which were common in the tropics, and leprosy. Things that you wouldn't normally see here unless someone's not from here. Things that are not endemic to here, but endemic to more third world countries in Southeast Asia. I also went to Tanzania, also learned from a group of physicians there that have a training center in Moshi, Tanzania. And their focus was more on albinism. They have a place where they make sunscreen. And then I always like to travel and learn about the environment I'm in. As I'm learning to try to do, you know, do both things at the same time and make it an awesome learning experience all around.
[00:11:33] I don't really work as much in a hospital setting. It's mostly outpatient. As a dermatologist, of course, I do a lot of teledermatology, try to use all my licenses because they were hard to get and they're very expensive. And they're also enjoyable meeting people from all 50 states.
[00:11:50] But it's not as much hospital based, which is probably a good thing because there is a lot of paperwork involved in just maintaining hospital privileges and stuff.
[00:12:00] Traveling to other countries, Southeast Asia, Africa, Latin America, you sometimes realize that just because you need it doesn't mean it's there or accessible to you. So cryotherapy, we use it a lot here. It is still very expensive. In the United States. I think a disposable can cost me about $400 from McKesson and I could use it just on a couple patients because it evaporates pretty quickly. It's a gas there. It's just really not accessible. It's pretty much non existent. If you have to get rid of a wart, you have to either shave it off, burn it, use cheaper methods because they won't have cryotherapy. I also saw a lot of parasites I did for World Skin Health Day, worked in guinea, volunteered with some native tribes in West Africa with another dermatologist who's a professor there. And we went to an island. I'm blanking out on the name of the island right now, but it used to be a British colony like a lot of Africa was. And there were a lot of parasites. Onchocerciasis. It caught, it kind of invades the lymphatics and causes a lot of problems like hanging tissue, lots of itching.
[00:13:13] And you can typically treat this parasite very easily with ivermectin, which is not a new medication. It's, you know, generic ivermectin. It's used to treat a lot of parasites, scabies, however, we wrote prescriptions and there was just no medication. So people can get evaluated. You can use your knowledge, but at the end of the day, if there's no, not just equipment, but medication that can be dispensed to them. People can't get better. So sometimes you find yourself stuck because your knowledge can only take you so far. If there's no funding for essential items, you would face significant limitations on trying to help people. And I think that unfortunately goes on in a lot of third world countries. I've heard the same about Cuba. Never been there, but certainly being part Cuban, I have a lot of family there and that's what I've heard about the hospital system there. People very educated, but they hit a wall when it comes to helping patients because they just run out of just essential items that people actually need to get better. If not, they won't. I'm going to backtrack a little bit into my interest, my evolving interests in indigenous communities. As I mentioned in private school, it was something I was often made fun of is being part indigenous. And now it's something I cherish and value a lot. And my grandfather who's Guatemalan, spoke actually many indigenous dialects. He's not alive today, but at least five.
[00:14:44] And he grew up in a very indigenous town, had about two pairs of shoes that he got when he was 8 and had a huge family and 99% of his community was indigenous.
[00:14:57] And when I left my first hospital based job, which was very much a traditional hospital based dermatologist job, working at Cleveland Clinic, I didn't really know what to do with myself. I knew I wanted to be more independent, which I think is really important in medicine. We're taught to be autonomous.
[00:15:16] And I remember scrolling through my computer, my inbox and seeing an email from Indeed. It was either Indeed or Google advertising this job in Alaska in a place I had never heard of, called Barrow. Its indigenous name is Utkavik.
[00:15:36] And I just applied. I was like, okay, you know, this isn't full time, it's part of the time. It's a great learning experience. And then I did more research on the community and I realized, whoa, this is really far out. It's a northernmost town in the United States. I'm not sure if I would even call it a town because it's under 4,000 people and it's not accessible by road or water. You actually have to fly in. The water around it is frozen most of the time. The roads are just not drivable. There is no road from the mainland that goes directly there and it's over 90% Inupac, which is an Inuit community.
[00:16:16] I was the first dermatologist there through the Arctic Slope. Native association asna. And it made me really appreciate the different diverse Indigenous communities that are not just in the United States, but in the world and feel more connected to that part of my culture.
[00:16:35] Because at that point I no longer had my grandfather and I. I started to do some more discovery of, of what other indigenous communities are there. I started working in California for a tribe there and really bonded with a group of dermatologists. A lot of them are. Well, there's not a lot of them actually, because there's not.
[00:16:57] There's even less indigenous dermatologists than there are any other minority worldwide, I believe. But I did bond with a dermatologist in Canada in Regina, Saskatchewan, that is one of the only indigenous dermatologists in Canada who also goes out to communities and does lots of telehealth, lots of in person work, whose dad is a scholar and he was an alum of the boarding schools in Canada, Indigenous boarding schools, one in Australia, one in New Zealand, one that even goes to Greenland, which has a lot of similarities with the Inuit culture.
[00:17:36] And we formed a group of called Indigenous Dermatology. We have a conference every year.
[00:17:43] And I just really seek out those opportunities because I think sometimes you can really make a difference by exploring the unexplored and focusing on things that maybe no one's done before and also bringing things to light that are still really important but not as delved into.
[00:18:01] And so, yeah, this is also an area of focus for me. And of course it ties in with the 50 states because we have a lot of tribes. I mean, just Alaska has, I think, more tribes than anywhere else in the United States. And a lot of these areas are really far out, hard to get to underserved, hard to get specialists too. And so telehealth is a big component of their care.
[00:18:24] I have a lot of goals with being a dermatologist that partially focuses on Indigenous communities as well. Number one, I really enjoy it. I enjoy the people I meet. I learn so much from them. I learn a lot from every single patient. I also learn a lot about the communities, the culture, and I have fun with it as well. The indigenous communities usually are in places that are very isolated.
[00:18:48] They're very far out and very far removed. A lot of times it's hard to find reception or specialists.
[00:18:54] If you've ever driven through, for example, Arizona, the reservations there, you're not going to find a lot of good reception, a lot of specialists, a lot of resources, and it's very difficult. There's a lot of funding issues in getting people like dermatologists to provide care there.
[00:19:11] I believe there was one dermatologists in all of the Indian health services last time I checked. And there's. They're also becoming more independent, like the place I work at in California. Like tribal county Health Consortium almost works like a private practice. And they've gotten that approval years ago to be a little bit more independent so they can bring their specialists and run themselves more like a private practice instead of a much bigger a bureaucratic organization.
[00:19:41] Basically having or sharing the knowledge, sharing what I've learned and how beautiful the communities are with everyone is also one of my goals because it was a really great learning experience for me to experience these cultures and learn so much from them. I did consider myself really well traveled until I went to Barrow, Alaska and realized how little I know about a distant culture and just everything I was able to learn and absorb from them, from their whaling to their food and trying things like seal, seal oil, all its medicinal purposes, how difficult it was to hunt a whale. It could be life threatening. I had never really seen or experienced things like that. And it's certainly something I value a lot and would love to share it with others.
[00:20:30] I like to think of myself with the 50 licenses and my involvement in the indigenous communities as America's dermatologist. That's my ultimate goal.
[00:20:39] So from Miami Derm, which is my primary name on social media, to America's dermatologist is kind of an evolution that I've just made over the years.
[00:20:50] I really sparked an interest in telehealth during COVID during that time. I think it was a critical time for everyone. But you know, if you think about it, a lot of basic services, even healthcare services, down from dermatology to ob GYN to any elective surgery, was pretty much shut down and a lot of that was converted into telehealth. For a while I saw no patience as everyone was transitioning over thinking, well, what am I going to do next to getting the systems built out for telehealth, which a lot of practices didn't have in place.
[00:21:28] And I realized how much I enjoyed just communicating across video audio, meeting patients in different who were in different locations. For me, being able to resolve things without having to drive an hour to a different county, which at that time I did work in a different county and I drove 80 miles a day. I'm used to driving a lot, you know, just throughout my career. But it does get tiring after a while.
[00:21:55] I realized I wanted a much bigger reach and I could have a much bigger reach through telehealth. And it was a part of medicine. I thought that was definitely going to keep growing and going to keep evolving. And of course it's also more cost effective, right? Because I can say having a practice. A lot of my practice expenses are equipment. As I was talking about with the cryotherapy. Each canister is about $400.
[00:22:20] A lot of my surgical instruments are straight from Germany. I've got to sharpen them, I've got to sterilize them, I've got to, you know, pay staff to constantly keep them up. And a lot of those expenses you can save on through telehealth. And of course, if a pat patient needs to be seen in the office. Having an in person office was a critical part of my structure and something I still very much love to do in this to this day, because I love doing procedures. But I definitely love the, the telehealth aspect as well.
[00:22:52] So the process of getting licensed in all 50 states was definitely very hard, long, expensive.
[00:22:59] It's a job in and of itself and it spurred off a lot of different industries. It took years to do.
[00:23:07] So sometimes you've got to take tests, there's a lot of fees, there's renewals, CMES requirements, you've got to notarize certain documents. There's a lot of additional fees that just kind of are hidden initially that you don't realize exist till much later.
[00:23:24] Lots of rules and regulations. Sometimes you do have to actually even do interviews. So I had a fly into Puerto Rico and do an interview in person, stay there for a couple days, get things notarized on the island. It requires lots of background checks, fingerprinting, original diplomas, certificates, answering lots of questions that you can't even imagine.
[00:23:48] And if you let one lapse, it's a pretty big problem because you lose basically the right to work in that state.
[00:23:57] Gotta reapply.
[00:23:58] You also gotta verify as you're applying to these states, send verifications from all the other states. And it just kind of is a cascade of requirements.
[00:24:08] Typically they expire or, you know, you gotta renew them about every couple years.
[00:24:14] And it also creates a lot of risk for doctors, unfortunately, because if something happens, it could affect the rest of them. But it's wonderful to have that. You can have a big reach with a huge, you know, population of people and work pretty much everywhere. And if you value working remotely and doing telehealth, it's definitely a necessity. Each state is different in terms of what they require. I remember for Oklahoma I had to take a couple tests, Louisiana for Example, a couple of courses for Puerto Rico I had to go in person and I also had to hire two attorneys there, not just one, but two, to help me complete the paperwork. And some of them just are really non responsive. I remember California's a lot like that, the more bureaucratic states, Puerto Rico, you could call their phone, you know, 100 times a day and you just, you might get one response. And so I had to actually put an ad out. And indeed, and initially it was for doctors to kind of guide me through the whole process.
[00:25:22] Of course I had to pay them a consulting fee. And then there's industries that kind of spur off or companies that spur off into helping you do this because it can be so hard.
[00:25:33] So there is a company that I used for Puerto Rico that was a few thousand dollars where pretty much if I didn't use them, I wasn't going to get it. And I knew I wasn't going to get it because I tried to do it on my own for three years before that. And it just was too bureaucratic in terms of what they want, interviews, people not answering. And so at the end of the day it was worth it. But it's certainly a challenge, especially when you're a busy practicing physician. I think it's a combination of both things. Both my interests in indigenous communities, my need for independence at the time, and my interest in telehealth with the pandemic evolving, that really just all connected at the same time. So I think they have a lot to do with each other. As I mentioned, the more rural the area is, the harder it is to get, get specialists out there and the more there will be a need for remote care.
[00:26:26] Despite the fact that we were in a pandemic just a couple years ago, a lot of doctors actually lost their jobs, including my own father who was self employed, but he still was mostly a hospital based physician. And because they closed that entire department at the end of the day, he didn't have a place to practice.
[00:26:47] Unlike me that I actually have a location here in Coral Gables. If you're dependent on a hospital, they're almost like your landlord. They're still, you've got to answer to them. And if one day they just decide to do away with the whole department, you've got nowhere else to go. So it's also a way of kind of protecting myself that I won't have to be dependent on a bigger institution like a hospital, which as much as they say they want to help people, at the end of the day they're a business and sometimes they just make decisions purely based on, on business matters with sometimes little insight as to how it can affect someone else's life and career.
[00:27:31] Going with the mentality of a patient, first mentality and doing what the patient needs at the end of the day is the best way. There's a lot of ethics in medicine and I certainly believe in if you do a great job and you try your best, people will follow. And so, you know, you'll build a good reputation.
[00:27:52] Patients will tell their family, their friends, they'll come back, not just because they need to come back, but because they, you know, they value you as a physician.
[00:28:02] Other doctors will refer patients to you if you do a great job. And of course, there's a lot more profitable things in medicine you can be into. Like, you know, there are a lot of costs, right, with being a telehealth physician or also going to remote areas because they're hard to get to. You've got to take time.
[00:28:22] Lots of times you can't do anything else while you're traveling. Like I remember when I would travel to where I worked in Alaska, it would just take two full days of travel where I couldn't do anything else. It was just on a plane traveling. And so you are investing a lot to do that, whereas you could be possibly doing something else more lucrative, but maybe less fulfilling. So I think putting the patient first, you will win in the long run, both you and the patient.
[00:28:54] I actually like to think of myself as a dermatologist that does a little bit of everything. I do do some cosmetics, but I do really what people need. And I find that I thrive when I help people in need. And there's really so many people in need of such basic things. Skin checks, skin cancer surgery, biologics, removal of growths that are bothering them. That I almost have time to focus on something that may not be as essential to someone. But at the same time we don't turn anyone away. And I'm trained in that skill set, so of course I will accept those patients. And then I also love doing a lot of procedures. But you know, a lot of times I like to do, you know, what people need, not necessarily what they may just want that is not as necessary, but we really do a combination of all things. So I'd like to be well rounded and use pretty much everything I learn and study to help others.
[00:30:00] One of the things that stands out seeing patients in all 50 states is sometimes the dire need that people are in of care.
[00:30:10] And sometimes they'll come to you.
[00:30:12] Patients will come to you because they're very far removed from a dermatologist or a specialist hundreds of miles away, which is common in places like Alaska or the parts of the west coast that are rural.
[00:30:26] Other times they'll come to you sometimes because of embarrassment, they don't want to go outside. So one case that's very, very memorable to me is recently I saw a patient who had been taking care of her father and she had stopped taking care of herself and had probably more than 50% of her face was most likely a skin cancer. And it was very impressive. To the extent that it had grown, it had taken over lots of essential functions. Basically deformed in the nose, deformed the eyes, even taken over part of the mouth. And so it was very hard for someone like that to even leave her house and seek care in person.
[00:31:07] And so a lot of times you're the first line doctor for these people as a stepping stone of where they can go for further higher levels of care or educational purposes. Because obviously some things will just require an in person visit, an in person exam, an in person procedure. And there's only so much you can do online, but you can educate.
[00:31:31] So one of the other memorable cases I have is also unique case on the west Coast.
[00:31:38] One of the only cases in the country that a patient who came to me with tumor's disease and really wanted to try out a treatment. It's an injectable treatment called Dupilumab. And he had seen case reports based in China and Asia on this treatment being used and the condition resolving. I went ahead and went with the treatment. After doing a few things like prior authorizations, trying out some other less expensive, more accessible alternatives, he didn't improve. And ultimately we went with his suggestion.
[00:32:13] As long he was counseled on the indications for his side effects, alternatives of treatment, and he actually did significantly better. He had already been through multiple surgeries. And Kimura's disease is rare in the United States.
[00:32:28] There's only a few cases. We learn about it in school, but we hardly see it.
[00:32:33] It's not treated surgically because if you treat it surgically, these large lumps that are often in the face just come right back. And that's actually what had happened to this patient. And so we knew we couldn't just operate on it. It was just gonna come right back. And we tried the treatment dupixent or dupilumab, basically as almost like based on case reports so off label.
[00:33:00] And he's done remarkably well. He hasn't had the need for Further procedures. And it's a lot of his masses are actually rescinding with basically the power of a single treatment. And so I do very much believe that patients can be their own advocate and make a case of why a certain treatment that may sound esoteric, might. Might work, as long as they're informed of the indications and side effects, there's some sort of evidence out there that you could use to justify your treatment. And as long as they're closely monitored, which of course, this patient was, it can really be a success.
[00:33:43] I think it definitely can disrupt your life to have really any health problem. So not just a disease where you're constantly making masses, but also any sort of condition. So if you have, you know, we have sometimes a set plan in place, whether it's marriage or a job or a career lined up, and all of a sudden you get diagnosed with this rare condition where you start growing masses all over your face and require surgery or require further treatment or no one knows what's going on. It's very disruptive. And especially when you got to involve other people, like family or other specialists, or you don't know where to go, or you're limited in resources because you're located in a rural place, or you're not of a medical background and you don't know where to start. So I think anyone with a health problem is going to experience disruptions.
[00:34:37] There's definitely a human aspect to medicine.
[00:34:42] You know, we're definitely very, very much held to those standards. And of patient first, patient oriented medicine has evolved a lot into sometimes forgetting to put that aspect first. But it's something that, at least where I went to school at Brown, it was very much emphasized and it's ingrained in you.
[00:35:03] It's very difficult to be a doctor if you're not doing that first, and it'll show over time. The clinical aspect is really an integration of both of those things merged together into how to make it work best. I think what's challenging sometimes is how expensive it is to practice here, the involvement of external factors like insurance companies.
[00:35:25] I realized firsthand how difficult that was when I opened my practice, just how difficult it was to work. A lot of times what I was getting compensated was much less than what I was investing in the clinic. And I was like, well, how am I. How am I going to make this work?
[00:35:42] And eventually I did join a group. We haven't joined yet. We haven't started yet. I'll let you know how that goes. But I couldn't even remain fully independent because of the insurance aspect. And I think independence is so critical in decision making in medicine because we're taught to be autonomous and make the decision ourselves. Right. So when you're part of a group or when you're part of someone that's constantly telling you what to do, like. Like a hospital, whatever it is, you kind of are removing some of that independence that you just had to have for medical decision making throughout your career.
[00:36:20] Cultural environments definitely affect patients, but I think more than anything, they affect doctors, because I think regardless of where you're in, whether you're in Southeast Asia, Alaska, California, or Miami working, you've got to adapt to the patient. You can't have the patient adapt to you. They're essentially why you're there. So it's very important to really understand them, not just from a language perspective, but where they came from, where they're coming from, what they're trying to say, what they're trying to relay to you.
[00:36:53] So it's essential that the cultural aspect be something that you just adapt to as a physician, regardless of what your background is, you've got to learn about the community.
[00:37:04] I remember reading about Alaska Val Barrow before I traveled there and thinking, wow, this is so different from Miami. I'm going to be freezing. There's no trees. The. The ground is frozen. It's tundra, basically.
[00:37:19] And also, I can't even get there. So, you know, I had thought about ordering an Uber when I was there. Well, there's no Uber. There's no roads to drive, so. And of course, I picked out the wrong clothing because I was freezing to death. I couldn't even wear scrubs. It was too cold. Had to dress pretty much like the Pillsbury Doughboy just to get off the plane. So I think learning as much about where you're going to work is essential.
[00:37:44] If they speak a different language, you know, a lot of people do cultural immersion programs or learn about that language.
[00:37:52] They actually do teach a different language. In Barrow, Alaska, they teach the Inupac language at the local colleges there. A lot of the elders speak that, and that was also a culture shock for me. And it's also a different Alphabet. In Inuit places like Greenland, they actually use a different Alphabet entirely for communication. And that was also something very unique that I really learned to appreciate, but unfortunately didn't learn completely because it takes a lot of time.
[00:38:21] There's a lot of aspects about the patient environment that can present in the skin, whether it's heat from being here in Miami. You know, there's. We have a lot of skin cancer. A lot of inflammatory conditions such as rosacea, autoimmune conditions such as lupus that get worse with sun exposure. And of course, pigmentary disorders. That's huge here.
[00:38:43] A lot of those become more pronounced in the sun with chronic sun exposure. But there's also conditions that will evolve with diverse temperatures. So in arid environments, you can get fungal microorganisms that can manifest in the lungs and then in the skin, like coccidiomycosis, which is really common in Arizona, places of California, the, the deserts there, Southwest deserts in Alaska. One really memorable moment I had with a patient was a patient walked in the room where his skin was actually purple and I was like, okay, you know, what's going on here? And then after doing some research, purple and reticulated, actually that's, that's the medical description for it kind of looks like a spider web. With chronic cold exposure, you can have permanent libido reticularis. That's a condition where your skin's mostly violaceous, reticulated, and it actually won't go away if you don't take care of yourself to normalize basically your skin temperature. So if you're going outdoors constantly and you're freezing and you're not putting warm enough clothing, this can actually happen. And so I saw that for the first time in Alaska. I was very impressed by it. But that just goes to show you how our environment can affect our skin and present in different ways.
[00:40:05] There's a lot of different aspects to dermatology. It's not just cosmetic. It's definitely not easy, although it's fulfilling, you know, it's challenging and it's constantly evolving and there's many different aspects to. To it. You could be a skin cancer surgeon mostly. You could be a medical dermatologist. You could be at a hospital based, university based, based institution. You could be community based or rurally based, a combination of both. You could really touch a lot of people, like, you know, being a 50 stater like I am, or 50 state plus four others because I do work in D.C. and some of the territories. It also, despite it being hard, it's. It's worth it at the end or hard to get into. It's worth it at the end and very fulfilling.
[00:40:53] And then there's constant learning. So just because you did a lot of years of school, you will be hit by things that you may have never seen before or may have challenges treating and you know, have to consult other things or really just trust your journey with the patient, as I did.
[00:41:11] With a patient with Kimura's disease, which has really been a success.
[00:41:15] And there's a lot of different aspects to it. It's cosmetic dermatology is just a small aspect and you can do it and still make a difference to lots of people.
[00:41:26] As I mentioned, we really do everything in our office, both online and in person.
[00:41:32] And so, yeah, that's been definitely very rewarding over time.
[00:41:36] I think it's definitely a balance with social media and medicine. I think in terms of at least my media, I like to use it as a learning opportunity and not.
[00:41:48] And it's obviously a touchy subject because a lot of people sometimes want to see your work as a surgeon or they want to see your work as a dermatologist.
[00:41:59] And, you know, in order to showcase that, you obviously need consents, permission. Patients need to feel comfortable.
[00:42:07] But it's also a balance into putting what's appropriate online. So sometimes doing, you know, complete surgeries is not.
[00:42:14] It may not even be permitted on places like YouTube or Instagram without getting blocked. Just being yourself is really important.
[00:42:23] Not doing things because it's going to get more likes, more views or popularity, but it's going to be a teaching opportunity for others.
[00:42:32] It may also be important to put certain things out there, like, for example, with rare diseases where people can't get any help. Well, going online is often the first place people go for help. So imagine how difficult it was years ago when we didn't have the Internet and you were diagnosed with something rare. Where would you go? You know, you might go to your local primary care doctor, but they may not have ever seen this before, or they may not have enough contacts in their circles to reach out to other specialists. So some of these conditions that have just a handful of people in the United States or in the world, it's essential that they go online to seek further information for their knowledge and further care. And a lot of times, if you're the only physician that's seeing this, it's extremely helpful to put your experiences out there so you can help others basically seek, seek cure or seek a treatment. And that's also a very important aspect that's evolved over the time with social media, the Internet. There's a lot of support groups on Reddit. So one of my patients, he went to Reddit for just, you know, finding a community.
[00:43:44] Hidradenitis is. It's very common to do that, and that's not even that uncommon of a disorder. There's much more uncommon disorders where people really need support, not just from other patients. But from anyone they can find in the community. What's worked, what hasn't worked, who do you go to for care, what do I do? And so, you know, I believe knowledge is power and having that tie in with social media from an educational perspective is helpful. And I just became a, what is it? A YouTube health. I got approved for that. So that's one of the reasons I got approved, is to be able to educate others. So putting an educational spin and not a I just want to grow and become more popular spin is very important when you're online. As a physician, in terms of what I think about my legacy, I think it's always evolving, but I like to think of myself and a physician that focuses on what's necessary but uncommon or not as explored, like the indigenous aspects of dermatology, the teledermatology. Not many people do it. And I also like to do things that I have an interest in and that are rewarding and fun to me and fulfilling. So I have fun actually working every day as a physician. And I wouldn't do it, wouldn't put this many hours into it if it wasn't. That's the legacy I try to move forward and to focus on the unexplored because I believe identifying an area of need, focusing on that, making it grow into something and flourish into something that's helpful to others is really the legacy I'm trying to leave behind.
[00:45:27] And essentially I'm evolving from what I thought I was going to be, which was Miami, Durham, a community based dermatologist, to America's dermatologist is my ultimate goal.
[00:45:37] How my, my legacy or my story will inspire other students, other female Latinas trying to and indigenous, you know, natives to go into dermatology, to go into medicine is really important and something I hope to leave behind. We constantly have students reaching out to us, us to do rotations. We actually have one rotating with us right now, a medical student.
[00:46:01] And we're always accepting students to learn and help in the clinic. We always need help in the clinic. But because we're such a small minority, it is really important for me to help others grow and get into this field. And recently I was actually asked to give a lecture at Harvard and also at UIC Chicago for one was on indigenous dermatology, one was on the Latino Medical Student Association. And so I kind of am leaving a legacy that's evolving over time and I'm very grateful that I can do that for others.
[00:46:36] I would love to be America's dermatologist and also to be the first dermatologist someone's ever met.
[00:46:47] Sam.
