Dr. Erin Warshaw: Dermatologist & Professor

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This week, we had the opportunity to interview Dr. Erin Warshaw, a dermatologist, professor, allergen expert and (spoiler alert!) my mom. Dr. Warshaw is a woman of many talents and has served as Chief of Dermatology at the V.A. Medical Center, Professor of Dermatology at the University of Minnesota, and most recently opened up her dream clinic in Minneapolis, a cold case unit for previously unsolvable skin allergies. Can you tell I’m proud?! She is full of insight on creating a career out of a passion for science, leading a team, and pursuing meaning-based work. And if that isn’t enough--she also shares some truly earth-shattering skin care advice. Read on!

Let’s start with the basics. What is your official title?
My official job title, well I wear several different hats, so my job title at the University is Professor of Dermatology, my title and role at the V.A. Medical Center is Staff Physician, and my title at Park Nicollet is Co-Director of the Park Nicollet Contact Dermatitis Clinic.

Could you explain what contact dermatitis is?
Sure, so when most people think of allergy, they think of a life threatening type of allergy, probably like allergy to peanuts or a bee sting, but that’s actually only one type of allergy. That’s what’s called Type One allergy or Immediate Type hypersensitivity. Contact dermatitis is what’s called Type Four hypersensitivity, or Delayed Type allergy, and it’s the type of allergy that results in a rash, just like what many people get when they come in contact with poison ivy. Another common allergen is nickel, so people who are allergic to nickel might get a rash on their earlobes from reaction to nickel in their earrings, or around their belly button from nickel in their belt.

A contact dermatitis reaction can take up to five days to develop after the initial exposure and lasts around three weeks before your body’s immune system goes through its normal allergic cycle and shuts it down. It’s very itchy, so patients can be pretty miserable and irritable; they usually haven’t been able to sleep and have basically been living with poison ivy, not knowing what the allergy is until they come to our clinic.

So my understanding is that you and your clinic are kind of the last stop for allergens that people haven’t been able to figure out elsewhere, and you use patch-testing to determine those allergies. Is that right? Could you talk a little bit about patch testing?
So there is a pre-packaged kit of 35 allergens called the True Test, and that is what most dermatologists and allergists use. It contains the most common allergens that we see, like nickel, other metals like cobalt and gold, fragrances, preservatives, steroids like the antibiotic medications niacin and bacitracin—those all are on the True Test. Many times, patients will have had the True Test done by their general dermatologist or allergist and then if it doesn’t make sense or the rash doesn’t get better, they’re sent to us for specialized testing.

Did you always want to be a doctor? What lead you to medicine, and dermatology specifically?
I did not always want to be a doctor. I loved the book A Wrinkle in Time by Madeleine L’Engle and when I read it as a young girl, I wanted to be a scientist. I wanted to be the mother in that book who had a lab right off of the kitchen. That was, I thought, the most incredible thing.

I loved cell biology, so naturally that kind of leads to medicine. But I got very disenchanted with traditional medicine and kind of the whole pre-med vibe in college and decided that I wasn’t going to be a doctor. Instead, I wanted to study alternative medicine. So I took a year, and part of that year was spent in India where I went to a yoga hospital. I was really excited about it before going, but when I got there it was a little disappointing because it really wasn’t much of a hospital.

I met an American doctor there who was associated with the ashram at the hospital and he really convinced me to go back for medical school. He said if you ever want do anything in alternative medicine, no one will really respect you unless you have that degree. So, my goal in medical school was to go to a third world country afterwards and do international aid work. I did some of that in India, working with a physician who had a sidewalk clinic, and worked at two of Mother Teresa’s centers there. What I realized while doing that work is that a lot of what is needed in the third world isn’t actually individualized medical care, it’s public health. It’s vaccines, it’s clean water, birth control, it’s getting people out of poverty—human rights. And I saw a lot of the frustration of working on the individual level; it felt like putting a bandaid on a bigger problem.

So, I didn’t really know what I wanted to do and I definitely never thought about dermatology. But I knew that I didn’t want to be in the operating room, and I didn’t really like emergency situations, and I also realized I liked being an expert. Dermatology had a combination where you could do surgery in an outpatient setting, but it also had a lot of specialized facets to it.

How does alternative medicine and what you learned during that year factor into your practice now?
It doesn’t really play a role in what I do currently, and I feel kind of funny about that in some way, but I actually use a lot of it for myself and using those practices makes me more grounded and better for my patients.

What type of training was needed for your job?
Four years of college, then four years of medical school, one year of internship, and three years of dermatology residency, so twelve years total. Dermatology residency requires a total of four years but that first year is what’s called an internship and it’s kind of like general medicine, so you work at a hospital and admit patients with congestive heart failure, diabetic coma, all different kinds of things so you get the basics.

Then it’s three years of speciality training just in dermatology. Then there’s some specialties that require a fellowship after that, for example if you want to specialize in surgery, you can do a surgery fellowship which is usually one or two years, same for children’s dermatology, pediatric dermatology. And if you want to become a dermatopathologist, so someone who is not only in the clinic seeing patients, but also creating the pathology slides of biopsy specimens, that usually takes one or two additional years.

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You also have a master’s degree in public health. What inspired you to do that?
I had finished residency and I was working at the V.A. and every year we interview applicants for the residency program and I just loved hearing so much about the different things all of the applicants were doing, taking a year off studying something or another. A couple of them had gotten a masters in public health which I thought that would be really cool to do, and we were working on a study and I realized I really didn’t know how to design a study.

I didn’t know anything about statistics really, how to do a double blind study, what randomization was about, so I was really motivated to go back [to school] because it was directly applicable to doing clinical trials. I actually loved doing that, it took four, maybe five years to complete because I did it part time. But all of the classes were exactly what I was doing in the clinic in clinical trials so it was really cool, I loved that.

How were able to do that part time as a practicing physician?
I applied for a career development award through the VA and that protected my time to take the classes, I still had to run clinic but I wasn’t there everyday, I was half-time in clinic, half-time in classes.

You were in school when we (my brother Gregg and I) were born. What was that like?
The key was having that protected time, because I could do most of the studying I needed during the day and not have it affect my time after work. And a huge factor was that Grams, my mother, your grandmother, helped along with Grampers to take care of you guys everyday, and that was a tremendous help. You don’t really ever remember me studying, do you Madeline?

No.
Yeah, I was really able to get most of it done during the day and then after you would go to sleep sometimes I would work a little bit after that.

You’ve worked at the V.A. for many years. How is working at a government hospital different from a private practice or private hospital?
Working at the VA, there’s definitely bureaucracy and it’s a different patient population. There’s no children, it’s historically been mostly men but now we see women too. Something I love about working at the VA is that when i see a patient and think a medical treatment is appropriate, the VA will pretty much cover it and we can get almost whatever medicine we want, except for cosmetic things obviously. That is a huge difference compared to the private practice world where there is so much money involved with the choice of treatment and the co-payments and conflict of interest, which I believe is a huge problem.

For example, at the VA, I never have to think about how much I’m going to receive if I do a biopsy on a patient, I just do what is needed for that patient. Whereas in private practice, even if physicians don’t really want to talk about it, I think there is conflict of interest when the higher number of procedures they do, the more money they make. And there is always a temptation, I think, for a little abuse there; so I love the freedom I have at the VA to just do what’s right for the patient. But the bureaucracy of it can get old.

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As a professor, a big part of your job is also mentorship. What role has mentorship played in your career so far?
I think mentoring others has been a huge part of what has made medicine fun for me because it’s fun to show your enthusiasm to other people and really discuss it. Like right now, we have three research fellows that work with us for a year--they have fresh eyes to look at clinical problems and they actually come up with really good questions and help us look at things differently.

They have questions that come up and I can say, “Do you want to write a paper on that? Let’s look at the literature and synthesize it because I bet other people probably have the same question” or “Let’s write a protocol and see if we can get funding to answer that question.” So I love that part in the clinic--the nitty gritty--and it’s really, really fun to see those mentees now in their careers, whether it’s private practice or academics, to see where they go. It’s really cool, it makes me really proud of them.

What’s been a part of this job that you didn’t expect?
I did not expect the level of, sort of, personnel management that is required. You go to medical school thinking you’re just going to take care of patients, but there’s a lot more to running a clinic or a research unit and working with other people, motivating a team, keeping communication open, and at the same time maintaining a professional distance, to the job, which I think is actually really hard for women in workplaces.

I think women leaders are more often seen as a confidant. Like people will come to me and talk about personal problems whereas I think if I was a man, they wouldn’t do that. Sometimes you have to step back and say I am the Chief or the Director of this clinic and maintain some professionalism, and I think that balance is really hard. I didn’t expect that the personnel management bit would be such a big part of my career.

On a different note, What is your biggest advice for taking care of your skin?
(Laughs) My biggest piece of advice is to wear sunscreen. And START young! So many of the common skin problems are just related to UV damage. So basically sunscreen, minimal soap, and a basic moisturizer, ideally one with SPF in it so you don’t even have to think about putting it on. You don’t need a major cleansing routine with toners and exfoliants and multi- step processes, you want your natural skin oils to do some moisturizing and just use a gentle soap.

Ok finally, if you weren’t a dermatologist, what else would you be doing?
Well if you had asked me that when I was in college I would have said a yoga instructor or something in holistic health. If you asked me now, I might be a biostatistician. That’s someone who does the mathematical analysis of data, runs statistical tests to see if there are differences and models epidemiological data, I think that’s pretty cool.

I’m surprised you didn’t say being Bug (our dog’s) personal assistant!
Well that’s my side thing.

Okay, but what do you do? Please write your answer as if you’re explaining to your ten-year-old self.

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Thanks so much, Dr. Mom! This was so special for me, and I feel so lucky to share it with our readers. If there’s anything I know, it’s that moms rock and sunscreen is IMPORTANT, and this interview strongly affirms the both. For more from the world’s coolest dermatologist, stay tuned next week for Dr. Warshaw’s super science How-To.