TORONTO – The implanted phrenic-nerve stimulation device that received Food and Drug Administration marketing approval in October 2017 for treating central sleep apnea has now shown safety and efficacy out to 18 months of continuous use in 102 patients.

After 18 months of treatment with the Remede System, patients’ outcomes remained stable and patients continued to see the improvements they had experienced after 6 and 12 months of treatment. These improvements included significant average reductions from baseline in apnea-hypopnea index and central apnea index and significant increases in oxygenation and sleep quality, Andrew C. Kao, MD, said at the CHEST annual meeting.

Mitchel L. Zoler/Frontline Medical News

[email protected]

On Twitter @mitchelzoler

TORONTO – The implanted phrenic-nerve stimulation device that received Food and Drug Administration marketing approval in October 2017 for treating central sleep apnea has now shown safety and efficacy out to 18 months of continuous use in 102 patients.

After 18 months of treatment with the Remede System, patients’ outcomes remained stable and patients continued to see the improvements they had experienced after 6 and 12 months of treatment. These improvements included significant average reductions from baseline in apnea-hypopnea index and central apnea index and significant increases in oxygenation and sleep quality, Andrew C. Kao, MD, said at the CHEST annual meeting.

Mitchel L. Zoler/Frontline Medical News

[email protected]

On Twitter @mitchelzoler

TORONTO – The implanted phrenic-nerve stimulation device that received Food and Drug Administration marketing approval in October 2017 for treating central sleep apnea has now shown safety and efficacy out to 18 months of continuous use in 102 patients.

After 18 months of treatment with the Remede System, patients’ outcomes remained stable and patients continued to see the improvements they had experienced after 6 and 12 months of treatment. These improvements included significant average reductions from baseline in apnea-hypopnea index and central apnea index and significant increases in oxygenation and sleep quality, Andrew C. Kao, MD, said at the CHEST annual meeting.

Mitchel L. Zoler/Frontline Medical News

[email protected]

On Twitter @mitchelzoler

Rates of postoperative hypocalcemia and recurrent laryngeal nerve (RLN) injury after thyroidectomy varied significantly from hospital to hospital in a recent large study of U.S. hospitals, suggesting to the authors that these measures could be used for quality improvement metrics.

In the study, published Nov. 29 in JAMA Surgery, hospitals with significantly lower rates of hypocalcemia were more likely to conduct postoperative parathyroid hormone level measurement as well as to prescribe vitamin D, calcium supplements, or both. Hospitals with lower RLN injury rates more frequently used energy devices and intraoperative nerve monitoring.

“Causation cannot be proven by this, but the confidence that these practice parameters are important is high,” senior author Bruce Hall, MD, PhD, vice president and chief quality officer at BJC Healthcare, and professor of surgery at Washington University, St. Louis, said in an interview. Dr. Hall is consulting director for the American College of Surgeon’s National Surgical Quality Improvement Program (NSQIP), which provided data for the analysis (JAMA Surg. 2017 Nov 29. doi: 10.1001/jamasurg.2017.4593).

Sebastian Kaulitzki/Fotolia

Rates of postoperative hypocalcemia and recurrent laryngeal nerve (RLN) injury after thyroidectomy varied significantly from hospital to hospital in a recent large study of U.S. hospitals, suggesting to the authors that these measures could be used for quality improvement metrics.

In the study, published Nov. 29 in JAMA Surgery, hospitals with significantly lower rates of hypocalcemia were more likely to conduct postoperative parathyroid hormone level measurement as well as to prescribe vitamin D, calcium supplements, or both. Hospitals with lower RLN injury rates more frequently used energy devices and intraoperative nerve monitoring.

“Causation cannot be proven by this, but the confidence that these practice parameters are important is high,” senior author Bruce Hall, MD, PhD, vice president and chief quality officer at BJC Healthcare, and professor of surgery at Washington University, St. Louis, said in an interview. Dr. Hall is consulting director for the American College of Surgeon’s National Surgical Quality Improvement Program (NSQIP), which provided data for the analysis (JAMA Surg. 2017 Nov 29. doi: 10.1001/jamasurg.2017.4593).

Sebastian Kaulitzki/Fotolia

Rates of postoperative hypocalcemia and recurrent laryngeal nerve (RLN) injury after thyroidectomy varied significantly from hospital to hospital in a recent large study of U.S. hospitals, suggesting to the authors that these measures could be used for quality improvement metrics.

In the study, published Nov. 29 in JAMA Surgery, hospitals with significantly lower rates of hypocalcemia were more likely to conduct postoperative parathyroid hormone level measurement as well as to prescribe vitamin D, calcium supplements, or both. Hospitals with lower RLN injury rates more frequently used energy devices and intraoperative nerve monitoring.

“Causation cannot be proven by this, but the confidence that these practice parameters are important is high,” senior author Bruce Hall, MD, PhD, vice president and chief quality officer at BJC Healthcare, and professor of surgery at Washington University, St. Louis, said in an interview. Dr. Hall is consulting director for the American College of Surgeon’s National Surgical Quality Improvement Program (NSQIP), which provided data for the analysis (JAMA Surg. 2017 Nov 29. doi: 10.1001/jamasurg.2017.4593).

Sebastian Kaulitzki/Fotolia

Dermatology departments in the United States have been facing challenges in recruiting and retaining dermatologists for academic positions. Accordingly, a survey study reported that academic dermatologists were more likely than those in private practice to state that their institutions were recruiting new associates.¹ Several factors could explain this phenomenon. Salary differences between jobs in academic and nonacademic settings may contribute to difficulty in recruiting dermatologists into academia, which is exacerbated by a theoretical shortage of dermatologists, leading to graduates who receive and accept private practice job offers.^1,2 Furthermore, a large survey study reported that challenges unique to academic dermatologists include longer patient wait times in addition to responsibilities such as research, hospital consultations, medical writing, and teaching. These patterns raise concerns for the future of teaching institutions because academic dermatologists not only train future physicians but also conduct clinical and basic science research necessary to advance the field and improve patient care.² Thus, it is important to evaluate the factors that affect career decisions in dermatology and to determine if these factors can be addressed. We hypothesized that student loan burden influences career plans in dermatology and that physicians are not fully educated on loan repayment options. The aims of this preliminary study were to explore the influence of student loan burden on career plans in dermatology and to determine if the Public Service Loan Forgiveness (PSLF) program could potentially encourage more dermatologists to consider academic careers.

Methods

The study aimed to investigate the factors that influence career decisions in dermatology and to assess attitudes toward the PSLF program as an option for student loan repayment. The target population included dermatology residents and attending physicians in the United States. Survey questions were adapted from a previously published study³ and were modified based on feedback from reviewers in the University of California (UC) Irvine department of dermatology. The survey was voluntary and did not collect identifying information. This study was granted exemption from oversight by the UC Irvine institutional review board.

Recruitment materials informed potential participants of the nature of the study and provided a hyperlink to the electronic survey. The UC Irvine department of dermatology emailed US dermatology residency program coordinators, requesting that they forward this study to residents and attending physicians in their programs. The survey also was distributed by one of the investigators (E.S.) on a social networking website for dermatologists. Data were collected from June 2015 to October 2015. A χ² analysis was conducted using SAS statistical software, and P<.05 was considered statistically significant.

Results

Demographics
The survey had 70 respondents including residents (56 [80.0%]) and attending physicians (14 [20.0%]). The mean age (SD) of the respondents was 32.4 (6.1) years, with 31 (44.3%) men and 39 (55.7%) women. The majority were married (38 [54.3%]) and did not have children (48 [68.6%]). Most respondents reported an annual household income of $200,000 or less (55 [78.6%]) and perceived a comfortable annual household income as greater than $200,000 (59 [84.3%])(Table 1).

Financing Medical Education
Most respondents currently had $200,000 or less in student loan debt (40 [57.1%]) and financed more than half of their medical education with student loans (53 [75.7%]). A large majority (61 [87.1%]) indicated that some portion of their medical education was funded by student loans. Other means of financing education included family assistance (29 [40.8%]), scholarships (26 [36.6%]), personal savings (18 [25.3%]), and military benefits (1 [1.4%]); 18.3% (n=13) of respondents did not accrue any educational debt. Respondents endorsed several plans for loan repayment including government-sponsored programs (34 [47.9%]), refinancing with a private company (13 [18.3%]), and the PSLF (1 [1.4%]); 12.7% (n=9) of respondents were uncertain how they were going to repay their student loans.

Career Goals in Dermatology and the Influence of Student Loans
Respondents were asked to specify their career plans before versus after starting dermatology residency training (ie, current career plan). Prior to starting residency, 36 (51.4%) and 34 (48.6%) respondents indicated they were interested in private practice and academia, respectively. After starting residency, the number of respondents interested in private practice increased to 45 (64.3%), and the number of respondents interested in academia decreased to 25 (35.7%). Fifteen (21.4%) respondents changed career trajectories from academia to private practice, 6 (8.6%) changed from private practice to academia, and 49 (70.0%) did not change career goals.

The majority of respondents (39 [55.7%]) indicated that the amount of their student loan debt did not influence their career goals (Table 2); however, those with more than $200,000 in debt were more likely to state that student loans impacted their career goals compared to those with $200,000 or less in debt (70.0% [21/30] vs 25.0% [10/40]; P<.001).

Comparison of Respondents Interested in Careers in Academia vs Private Practice
There were differences in financial circumstances between respondents interested in academia versus those interested in private practice. Compared to respondents interested in academia, those interested in private practice were more likely to have more than $200,000 in student loan debt (24 [53.3%] vs 6 [24.0%]; P<.05), have more than half of their education paid with student loans (38 [84.4%] vs 15 [60.0%]; P<.05), and state that student debt affected their career goals (28 [62.2%] vs 3 [12.0%]; P<.001)(Table 3). Demographic characteristics including gender, marital status, parental status, and current annual household income were not associated with a specific career goal.

Subgroup analysis was performed on respondents who were initially interested in academic careers but subsequently decided to pursue private practice (n=15). Compared to those who remained interested in academia, those who changed career plans from academia to private practice were more likely to have more than $200,000 in student debt (76.9% [10/13] vs 23.1% [3/13]; P<.001) and were more likely to state that loans affected their career goals (86.7% [13/15] vs 13.3% [2/15]; P<.001).

Residency program experience also may influence career trajectory. The majority (n=41 [58.6%]) of respondents indicated that their residency program experience affected their dermatology career goals. Of those, 41.7% and 58.5% stated that their residency program experiences dissuaded and persuaded them into academic positions, respectively. Those interested in academic dermatology were more likely to state that their residency program experience influenced their career goals (80.0% [20/25] vs 46.7% [21/45]; P<.05). Furthermore, those interested in academic positions responded with higher overall residency program satisfaction ratings on a scale of 1 to 10 (1 indicated the lowest satisfaction) than those interested in private practice, but the difference was not significant (mean [SD] score, 8.2 [2.3] vs 7.2 [1.9]; P=.07).

Respondents were asked to rate their interest in the following dermatology-related professional interests on a scale of 1 to 5 (1 indicated the least enjoyment): medical dermatology, dermatologic surgery, dermatopathology, cosmetics, and lasers. Those interested in private practice versus those interested in academic dermatology found more enjoyment in dermatologic surgery (mean [SD] score, 4.0 [0.8] vs 3.4 [1.3]; P<.05), cosmetics (3.4 [1.2] vs 2.6 [1.4]; P<.05), and lasers (3.7 [1.0] vs 2.8 [1.2]; P<.05)(Table 4).

Respondents also were asked to select primary motivating factors for their career goals (ie, academia or private practice) and to indicate reasons for not choosing the alternative. The majority of those pursuing academia were motivated by opportunities to collaborate with colleagues (23 [92.0%]), teach and mentor (20 [80%]), and manage complex cases (17 [68.0%]). Most of the respondents who were pursing private practice were motivated by focus on patient care and clinician duties (36 [80.0%]), flexible work hours (35 [77.8%]), higher income (33 [73.3%]), and location flexibility (29 [64.4%]). Among those interested in academic dermatology, the top factors for disinterest in private practice were running a business (9 [36.0%]) and high patient turnover (9 [36.0%]). Most of those interested in private practice indicated that they were not interested in an academic position because of lower income (31 [68.9%]) and research duties (31 [68.9%])(Table 5).

Awareness of and Attitudes Toward the PSLF Program
The majority of respondents were aware of PSLF (53 [75.7%]); however, only 1 respondent endorsed current plans to use PSLF for loan repayment. Respondents were asked how likely they would be to pursue an academic position if given the option to have their student loans forgiven by the PSLF program. Overall, 44.6% (n=25) of respondents indicated that this option would have no effect or would unlikely convince them to pursue an academic position, and 55.4% (n=31) of respondents indicated that they were somewhat likely, likely, or very likely to pursue academia if PSLF was an option. Of those who stated that they would consider enrolling in PSLF, 64.5% (20/31) of individuals were pursuing careers in private practice. Neither current student loan burden nor career goal was associated with likelihood of enrolling in the PSLF.

Comment

In 2015, 76% of medical school graduates in the United States accrued educational debt, with an average of $189,165, a number that has continued to increase over the years.⁴ In addition to the increasing cost of medical education, higher interest rates on federal student loans contribute to debt burden. Over the last 2 decades, some research has posited that debt may influence medical specialty selection, with most studies focusing on primary care.^5-9 However, there is limited information on the effect of student loan debt on career decisions within dermatology.

The results of our study suggest that financial factors including income and amount of educational debt may influence career decisions in dermatology. There is a known income gap between academic and nonacademic settings. According to the Association of American Medical Colleges, the median salaries for an assistant professor and associate/full professor in dermatology are $266,000 and $331,000, respectively.¹⁰ In contrast, for dermatologists in private clinical practice, the overall median salary is more than $450,000. These salary differences may impact career plans, as 73.3% (33/45) of survey respondents in our study who were interested in private practice stated that higher income was one of the primary motivating factors behind their career goals. Student loan burden also may impact career decisions in dermatology. Compared to those with lower student loan debt (≤$200,000), respondents with higher student loan debt (>$200,000) showed greater interest in pursuing positions in private practice and were more likely to change career goals from academia to private practice after starting residency. Thus, academic institutions are potentially losing physicians who are interested in academic careers but ultimately decide against it, at least partially due to high student loan debt.

The PSLF can potentially address this issue and be used as a recruiting tool for dermatology positions in academia. Under PSLF, borrowers can have the remainder of their loan balances forgiven after making 120 monthly payments while employed full time by public service employers, including some academic medical institutions. In our study, a large majority of respondents indicated that they are aware of the PSLF, and more than half said they would consider pursuing positions in academia if their loans could be forgiven through the program; however, when asked about plans for loan repayment, only 1 respondent endorsed current plans to enroll in PSLF. Thus, despite high interest in PSLF among the survey respondents, few had actual plans to use the service, suggesting that perhaps dermatologists are not provided enough information about PSLF to motivate enrollment. In the same way, almost a quarter of respondents were not familiar with the PSLF as a repayment option, further signifying that distribution of information about financial planning may be inadequate. If student loan burden is a notable factor in career decisions in dermatology, it is important that academic institutions provide sufficient information about repayment to encourage informed decisions. As such, it is possible that educating physicians about options such as PSLF can potentially recruit more dermatologists to academic positions.

Aside from financial reasons, residency program experience and differences in practices in academic and nonacademic settings may impact career trajectories. The majority of respondents stated their residency program experience influenced their career decisions; however, the majority of respondents did not change their minds about career goals since starting residency, suggesting that residency program experience may reinforce but not necessarily alter these choices. Interests in specific focuses within dermatology also may influence career decisions. This study suggests that those pursuing private practice positions are more interested in dermatologic surgery, lasers, and cosmetics. Roles in research, mentoring, and patient care differ between academic and nonacademic settings and also may be influential in career decisions in dermatology, mirroring the implications of other studies that posited that career decisions within medicine are complex and involve multiple factors.¹¹

In this study, we did not find an association between gender and career plans in dermatology. In 2013, more than 60% of dermatology resident physicians were female.¹² However, a recent study suggested that women face challenges in academic dermatology, including a downtrend in the number of female investigators with grants from the National Institutes of Health.¹³Taken together, female dermatologists, who currently represent the majority of resident physicians training in dermatology, may face unique challenges in academia, further highlighting the potential difficulties with recruitment of dermatologists by academic institutions in the future.

This preliminary study has several limitations. First, the small sample size limited generalizability to all dermatologists. Second, responder bias was possible, as those who have stronger opinions about this topic may have been more inclined to participate in this voluntary survey. Future studies with larger sample sizes are needed to further explore the factors that influence career decisions within dermatology and to determine if there are additional means to increase recruitment into academia.

Conclusion

It is recognized that there are challenges in recruiting dermatologists into academic positions. This study suggests that student loan burden influences career decisions in dermatology. Dermatologists may not be fully educated on options for student loan repayment. With increased awareness, the PSLF can potentially be used as a recruitment tool for positions in academic dermatology.

Dermatology departments in the United States have been facing challenges in recruiting and retaining dermatologists for academic positions. Accordingly, a survey study reported that academic dermatologists were more likely than those in private practice to state that their institutions were recruiting new associates.¹ Several factors could explain this phenomenon. Salary differences between jobs in academic and nonacademic settings may contribute to difficulty in recruiting dermatologists into academia, which is exacerbated by a theoretical shortage of dermatologists, leading to graduates who receive and accept private practice job offers.^1,2 Furthermore, a large survey study reported that challenges unique to academic dermatologists include longer patient wait times in addition to responsibilities such as research, hospital consultations, medical writing, and teaching. These patterns raise concerns for the future of teaching institutions because academic dermatologists not only train future physicians but also conduct clinical and basic science research necessary to advance the field and improve patient care.² Thus, it is important to evaluate the factors that affect career decisions in dermatology and to determine if these factors can be addressed. We hypothesized that student loan burden influences career plans in dermatology and that physicians are not fully educated on loan repayment options. The aims of this preliminary study were to explore the influence of student loan burden on career plans in dermatology and to determine if the Public Service Loan Forgiveness (PSLF) program could potentially encourage more dermatologists to consider academic careers.

Methods

The study aimed to investigate the factors that influence career decisions in dermatology and to assess attitudes toward the PSLF program as an option for student loan repayment. The target population included dermatology residents and attending physicians in the United States. Survey questions were adapted from a previously published study³ and were modified based on feedback from reviewers in the University of California (UC) Irvine department of dermatology. The survey was voluntary and did not collect identifying information. This study was granted exemption from oversight by the UC Irvine institutional review board.

Recruitment materials informed potential participants of the nature of the study and provided a hyperlink to the electronic survey. The UC Irvine department of dermatology emailed US dermatology residency program coordinators, requesting that they forward this study to residents and attending physicians in their programs. The survey also was distributed by one of the investigators (E.S.) on a social networking website for dermatologists. Data were collected from June 2015 to October 2015. A χ² analysis was conducted using SAS statistical software, and P<.05 was considered statistically significant.

Results

Demographics
The survey had 70 respondents including residents (56 [80.0%]) and attending physicians (14 [20.0%]). The mean age (SD) of the respondents was 32.4 (6.1) years, with 31 (44.3%) men and 39 (55.7%) women. The majority were married (38 [54.3%]) and did not have children (48 [68.6%]). Most respondents reported an annual household income of $200,000 or less (55 [78.6%]) and perceived a comfortable annual household income as greater than $200,000 (59 [84.3%])(Table 1).

Financing Medical Education
Most respondents currently had $200,000 or less in student loan debt (40 [57.1%]) and financed more than half of their medical education with student loans (53 [75.7%]). A large majority (61 [87.1%]) indicated that some portion of their medical education was funded by student loans. Other means of financing education included family assistance (29 [40.8%]), scholarships (26 [36.6%]), personal savings (18 [25.3%]), and military benefits (1 [1.4%]); 18.3% (n=13) of respondents did not accrue any educational debt. Respondents endorsed several plans for loan repayment including government-sponsored programs (34 [47.9%]), refinancing with a private company (13 [18.3%]), and the PSLF (1 [1.4%]); 12.7% (n=9) of respondents were uncertain how they were going to repay their student loans.

Career Goals in Dermatology and the Influence of Student Loans
Respondents were asked to specify their career plans before versus after starting dermatology residency training (ie, current career plan). Prior to starting residency, 36 (51.4%) and 34 (48.6%) respondents indicated they were interested in private practice and academia, respectively. After starting residency, the number of respondents interested in private practice increased to 45 (64.3%), and the number of respondents interested in academia decreased to 25 (35.7%). Fifteen (21.4%) respondents changed career trajectories from academia to private practice, 6 (8.6%) changed from private practice to academia, and 49 (70.0%) did not change career goals.

The majority of respondents (39 [55.7%]) indicated that the amount of their student loan debt did not influence their career goals (Table 2); however, those with more than $200,000 in debt were more likely to state that student loans impacted their career goals compared to those with $200,000 or less in debt (70.0% [21/30] vs 25.0% [10/40]; P<.001).

Comparison of Respondents Interested in Careers in Academia vs Private Practice
There were differences in financial circumstances between respondents interested in academia versus those interested in private practice. Compared to respondents interested in academia, those interested in private practice were more likely to have more than $200,000 in student loan debt (24 [53.3%] vs 6 [24.0%]; P<.05), have more than half of their education paid with student loans (38 [84.4%] vs 15 [60.0%]; P<.05), and state that student debt affected their career goals (28 [62.2%] vs 3 [12.0%]; P<.001)(Table 3). Demographic characteristics including gender, marital status, parental status, and current annual household income were not associated with a specific career goal.

Subgroup analysis was performed on respondents who were initially interested in academic careers but subsequently decided to pursue private practice (n=15). Compared to those who remained interested in academia, those who changed career plans from academia to private practice were more likely to have more than $200,000 in student debt (76.9% [10/13] vs 23.1% [3/13]; P<.001) and were more likely to state that loans affected their career goals (86.7% [13/15] vs 13.3% [2/15]; P<.001).

Residency program experience also may influence career trajectory. The majority (n=41 [58.6%]) of respondents indicated that their residency program experience affected their dermatology career goals. Of those, 41.7% and 58.5% stated that their residency program experiences dissuaded and persuaded them into academic positions, respectively. Those interested in academic dermatology were more likely to state that their residency program experience influenced their career goals (80.0% [20/25] vs 46.7% [21/45]; P<.05). Furthermore, those interested in academic positions responded with higher overall residency program satisfaction ratings on a scale of 1 to 10 (1 indicated the lowest satisfaction) than those interested in private practice, but the difference was not significant (mean [SD] score, 8.2 [2.3] vs 7.2 [1.9]; P=.07).

Respondents were asked to rate their interest in the following dermatology-related professional interests on a scale of 1 to 5 (1 indicated the least enjoyment): medical dermatology, dermatologic surgery, dermatopathology, cosmetics, and lasers. Those interested in private practice versus those interested in academic dermatology found more enjoyment in dermatologic surgery (mean [SD] score, 4.0 [0.8] vs 3.4 [1.3]; P<.05), cosmetics (3.4 [1.2] vs 2.6 [1.4]; P<.05), and lasers (3.7 [1.0] vs 2.8 [1.2]; P<.05)(Table 4).

Respondents also were asked to select primary motivating factors for their career goals (ie, academia or private practice) and to indicate reasons for not choosing the alternative. The majority of those pursuing academia were motivated by opportunities to collaborate with colleagues (23 [92.0%]), teach and mentor (20 [80%]), and manage complex cases (17 [68.0%]). Most of the respondents who were pursing private practice were motivated by focus on patient care and clinician duties (36 [80.0%]), flexible work hours (35 [77.8%]), higher income (33 [73.3%]), and location flexibility (29 [64.4%]). Among those interested in academic dermatology, the top factors for disinterest in private practice were running a business (9 [36.0%]) and high patient turnover (9 [36.0%]). Most of those interested in private practice indicated that they were not interested in an academic position because of lower income (31 [68.9%]) and research duties (31 [68.9%])(Table 5).

Awareness of and Attitudes Toward the PSLF Program
The majority of respondents were aware of PSLF (53 [75.7%]); however, only 1 respondent endorsed current plans to use PSLF for loan repayment. Respondents were asked how likely they would be to pursue an academic position if given the option to have their student loans forgiven by the PSLF program. Overall, 44.6% (n=25) of respondents indicated that this option would have no effect or would unlikely convince them to pursue an academic position, and 55.4% (n=31) of respondents indicated that they were somewhat likely, likely, or very likely to pursue academia if PSLF was an option. Of those who stated that they would consider enrolling in PSLF, 64.5% (20/31) of individuals were pursuing careers in private practice. Neither current student loan burden nor career goal was associated with likelihood of enrolling in the PSLF.

Comment

In 2015, 76% of medical school graduates in the United States accrued educational debt, with an average of $189,165, a number that has continued to increase over the years.⁴ In addition to the increasing cost of medical education, higher interest rates on federal student loans contribute to debt burden. Over the last 2 decades, some research has posited that debt may influence medical specialty selection, with most studies focusing on primary care.^5-9 However, there is limited information on the effect of student loan debt on career decisions within dermatology.

The results of our study suggest that financial factors including income and amount of educational debt may influence career decisions in dermatology. There is a known income gap between academic and nonacademic settings. According to the Association of American Medical Colleges, the median salaries for an assistant professor and associate/full professor in dermatology are $266,000 and $331,000, respectively.¹⁰ In contrast, for dermatologists in private clinical practice, the overall median salary is more than $450,000. These salary differences may impact career plans, as 73.3% (33/45) of survey respondents in our study who were interested in private practice stated that higher income was one of the primary motivating factors behind their career goals. Student loan burden also may impact career decisions in dermatology. Compared to those with lower student loan debt (≤$200,000), respondents with higher student loan debt (>$200,000) showed greater interest in pursuing positions in private practice and were more likely to change career goals from academia to private practice after starting residency. Thus, academic institutions are potentially losing physicians who are interested in academic careers but ultimately decide against it, at least partially due to high student loan debt.

The PSLF can potentially address this issue and be used as a recruiting tool for dermatology positions in academia. Under PSLF, borrowers can have the remainder of their loan balances forgiven after making 120 monthly payments while employed full time by public service employers, including some academic medical institutions. In our study, a large majority of respondents indicated that they are aware of the PSLF, and more than half said they would consider pursuing positions in academia if their loans could be forgiven through the program; however, when asked about plans for loan repayment, only 1 respondent endorsed current plans to enroll in PSLF. Thus, despite high interest in PSLF among the survey respondents, few had actual plans to use the service, suggesting that perhaps dermatologists are not provided enough information about PSLF to motivate enrollment. In the same way, almost a quarter of respondents were not familiar with the PSLF as a repayment option, further signifying that distribution of information about financial planning may be inadequate. If student loan burden is a notable factor in career decisions in dermatology, it is important that academic institutions provide sufficient information about repayment to encourage informed decisions. As such, it is possible that educating physicians about options such as PSLF can potentially recruit more dermatologists to academic positions.

Aside from financial reasons, residency program experience and differences in practices in academic and nonacademic settings may impact career trajectories. The majority of respondents stated their residency program experience influenced their career decisions; however, the majority of respondents did not change their minds about career goals since starting residency, suggesting that residency program experience may reinforce but not necessarily alter these choices. Interests in specific focuses within dermatology also may influence career decisions. This study suggests that those pursuing private practice positions are more interested in dermatologic surgery, lasers, and cosmetics. Roles in research, mentoring, and patient care differ between academic and nonacademic settings and also may be influential in career decisions in dermatology, mirroring the implications of other studies that posited that career decisions within medicine are complex and involve multiple factors.¹¹

In this study, we did not find an association between gender and career plans in dermatology. In 2013, more than 60% of dermatology resident physicians were female.¹² However, a recent study suggested that women face challenges in academic dermatology, including a downtrend in the number of female investigators with grants from the National Institutes of Health.¹³Taken together, female dermatologists, who currently represent the majority of resident physicians training in dermatology, may face unique challenges in academia, further highlighting the potential difficulties with recruitment of dermatologists by academic institutions in the future.

This preliminary study has several limitations. First, the small sample size limited generalizability to all dermatologists. Second, responder bias was possible, as those who have stronger opinions about this topic may have been more inclined to participate in this voluntary survey. Future studies with larger sample sizes are needed to further explore the factors that influence career decisions within dermatology and to determine if there are additional means to increase recruitment into academia.

Conclusion

It is recognized that there are challenges in recruiting dermatologists into academic positions. This study suggests that student loan burden influences career decisions in dermatology. Dermatologists may not be fully educated on options for student loan repayment. With increased awareness, the PSLF can potentially be used as a recruitment tool for positions in academic dermatology.

Dermatology departments in the United States have been facing challenges in recruiting and retaining dermatologists for academic positions. Accordingly, a survey study reported that academic dermatologists were more likely than those in private practice to state that their institutions were recruiting new associates.¹ Several factors could explain this phenomenon. Salary differences between jobs in academic and nonacademic settings may contribute to difficulty in recruiting dermatologists into academia, which is exacerbated by a theoretical shortage of dermatologists, leading to graduates who receive and accept private practice job offers.^1,2 Furthermore, a large survey study reported that challenges unique to academic dermatologists include longer patient wait times in addition to responsibilities such as research, hospital consultations, medical writing, and teaching. These patterns raise concerns for the future of teaching institutions because academic dermatologists not only train future physicians but also conduct clinical and basic science research necessary to advance the field and improve patient care.² Thus, it is important to evaluate the factors that affect career decisions in dermatology and to determine if these factors can be addressed. We hypothesized that student loan burden influences career plans in dermatology and that physicians are not fully educated on loan repayment options. The aims of this preliminary study were to explore the influence of student loan burden on career plans in dermatology and to determine if the Public Service Loan Forgiveness (PSLF) program could potentially encourage more dermatologists to consider academic careers.

Methods

The study aimed to investigate the factors that influence career decisions in dermatology and to assess attitudes toward the PSLF program as an option for student loan repayment. The target population included dermatology residents and attending physicians in the United States. Survey questions were adapted from a previously published study³ and were modified based on feedback from reviewers in the University of California (UC) Irvine department of dermatology. The survey was voluntary and did not collect identifying information. This study was granted exemption from oversight by the UC Irvine institutional review board.

Recruitment materials informed potential participants of the nature of the study and provided a hyperlink to the electronic survey. The UC Irvine department of dermatology emailed US dermatology residency program coordinators, requesting that they forward this study to residents and attending physicians in their programs. The survey also was distributed by one of the investigators (E.S.) on a social networking website for dermatologists. Data were collected from June 2015 to October 2015. A χ² analysis was conducted using SAS statistical software, and P<.05 was considered statistically significant.

Results

Demographics
The survey had 70 respondents including residents (56 [80.0%]) and attending physicians (14 [20.0%]). The mean age (SD) of the respondents was 32.4 (6.1) years, with 31 (44.3%) men and 39 (55.7%) women. The majority were married (38 [54.3%]) and did not have children (48 [68.6%]). Most respondents reported an annual household income of $200,000 or less (55 [78.6%]) and perceived a comfortable annual household income as greater than $200,000 (59 [84.3%])(Table 1).

Financing Medical Education
Most respondents currently had $200,000 or less in student loan debt (40 [57.1%]) and financed more than half of their medical education with student loans (53 [75.7%]). A large majority (61 [87.1%]) indicated that some portion of their medical education was funded by student loans. Other means of financing education included family assistance (29 [40.8%]), scholarships (26 [36.6%]), personal savings (18 [25.3%]), and military benefits (1 [1.4%]); 18.3% (n=13) of respondents did not accrue any educational debt. Respondents endorsed several plans for loan repayment including government-sponsored programs (34 [47.9%]), refinancing with a private company (13 [18.3%]), and the PSLF (1 [1.4%]); 12.7% (n=9) of respondents were uncertain how they were going to repay their student loans.

Career Goals in Dermatology and the Influence of Student Loans
Respondents were asked to specify their career plans before versus after starting dermatology residency training (ie, current career plan). Prior to starting residency, 36 (51.4%) and 34 (48.6%) respondents indicated they were interested in private practice and academia, respectively. After starting residency, the number of respondents interested in private practice increased to 45 (64.3%), and the number of respondents interested in academia decreased to 25 (35.7%). Fifteen (21.4%) respondents changed career trajectories from academia to private practice, 6 (8.6%) changed from private practice to academia, and 49 (70.0%) did not change career goals.

The majority of respondents (39 [55.7%]) indicated that the amount of their student loan debt did not influence their career goals (Table 2); however, those with more than $200,000 in debt were more likely to state that student loans impacted their career goals compared to those with $200,000 or less in debt (70.0% [21/30] vs 25.0% [10/40]; P<.001).

Comparison of Respondents Interested in Careers in Academia vs Private Practice
There were differences in financial circumstances between respondents interested in academia versus those interested in private practice. Compared to respondents interested in academia, those interested in private practice were more likely to have more than $200,000 in student loan debt (24 [53.3%] vs 6 [24.0%]; P<.05), have more than half of their education paid with student loans (38 [84.4%] vs 15 [60.0%]; P<.05), and state that student debt affected their career goals (28 [62.2%] vs 3 [12.0%]; P<.001)(Table 3). Demographic characteristics including gender, marital status, parental status, and current annual household income were not associated with a specific career goal.

Subgroup analysis was performed on respondents who were initially interested in academic careers but subsequently decided to pursue private practice (n=15). Compared to those who remained interested in academia, those who changed career plans from academia to private practice were more likely to have more than $200,000 in student debt (76.9% [10/13] vs 23.1% [3/13]; P<.001) and were more likely to state that loans affected their career goals (86.7% [13/15] vs 13.3% [2/15]; P<.001).

Residency program experience also may influence career trajectory. The majority (n=41 [58.6%]) of respondents indicated that their residency program experience affected their dermatology career goals. Of those, 41.7% and 58.5% stated that their residency program experiences dissuaded and persuaded them into academic positions, respectively. Those interested in academic dermatology were more likely to state that their residency program experience influenced their career goals (80.0% [20/25] vs 46.7% [21/45]; P<.05). Furthermore, those interested in academic positions responded with higher overall residency program satisfaction ratings on a scale of 1 to 10 (1 indicated the lowest satisfaction) than those interested in private practice, but the difference was not significant (mean [SD] score, 8.2 [2.3] vs 7.2 [1.9]; P=.07).

Respondents were asked to rate their interest in the following dermatology-related professional interests on a scale of 1 to 5 (1 indicated the least enjoyment): medical dermatology, dermatologic surgery, dermatopathology, cosmetics, and lasers. Those interested in private practice versus those interested in academic dermatology found more enjoyment in dermatologic surgery (mean [SD] score, 4.0 [0.8] vs 3.4 [1.3]; P<.05), cosmetics (3.4 [1.2] vs 2.6 [1.4]; P<.05), and lasers (3.7 [1.0] vs 2.8 [1.2]; P<.05)(Table 4).

Respondents also were asked to select primary motivating factors for their career goals (ie, academia or private practice) and to indicate reasons for not choosing the alternative. The majority of those pursuing academia were motivated by opportunities to collaborate with colleagues (23 [92.0%]), teach and mentor (20 [80%]), and manage complex cases (17 [68.0%]). Most of the respondents who were pursing private practice were motivated by focus on patient care and clinician duties (36 [80.0%]), flexible work hours (35 [77.8%]), higher income (33 [73.3%]), and location flexibility (29 [64.4%]). Among those interested in academic dermatology, the top factors for disinterest in private practice were running a business (9 [36.0%]) and high patient turnover (9 [36.0%]). Most of those interested in private practice indicated that they were not interested in an academic position because of lower income (31 [68.9%]) and research duties (31 [68.9%])(Table 5).

Awareness of and Attitudes Toward the PSLF Program
The majority of respondents were aware of PSLF (53 [75.7%]); however, only 1 respondent endorsed current plans to use PSLF for loan repayment. Respondents were asked how likely they would be to pursue an academic position if given the option to have their student loans forgiven by the PSLF program. Overall, 44.6% (n=25) of respondents indicated that this option would have no effect or would unlikely convince them to pursue an academic position, and 55.4% (n=31) of respondents indicated that they were somewhat likely, likely, or very likely to pursue academia if PSLF was an option. Of those who stated that they would consider enrolling in PSLF, 64.5% (20/31) of individuals were pursuing careers in private practice. Neither current student loan burden nor career goal was associated with likelihood of enrolling in the PSLF.

Comment

In 2015, 76% of medical school graduates in the United States accrued educational debt, with an average of $189,165, a number that has continued to increase over the years.⁴ In addition to the increasing cost of medical education, higher interest rates on federal student loans contribute to debt burden. Over the last 2 decades, some research has posited that debt may influence medical specialty selection, with most studies focusing on primary care.^5-9 However, there is limited information on the effect of student loan debt on career decisions within dermatology.

The results of our study suggest that financial factors including income and amount of educational debt may influence career decisions in dermatology. There is a known income gap between academic and nonacademic settings. According to the Association of American Medical Colleges, the median salaries for an assistant professor and associate/full professor in dermatology are $266,000 and $331,000, respectively.¹⁰ In contrast, for dermatologists in private clinical practice, the overall median salary is more than $450,000. These salary differences may impact career plans, as 73.3% (33/45) of survey respondents in our study who were interested in private practice stated that higher income was one of the primary motivating factors behind their career goals. Student loan burden also may impact career decisions in dermatology. Compared to those with lower student loan debt (≤$200,000), respondents with higher student loan debt (>$200,000) showed greater interest in pursuing positions in private practice and were more likely to change career goals from academia to private practice after starting residency. Thus, academic institutions are potentially losing physicians who are interested in academic careers but ultimately decide against it, at least partially due to high student loan debt.

The PSLF can potentially address this issue and be used as a recruiting tool for dermatology positions in academia. Under PSLF, borrowers can have the remainder of their loan balances forgiven after making 120 monthly payments while employed full time by public service employers, including some academic medical institutions. In our study, a large majority of respondents indicated that they are aware of the PSLF, and more than half said they would consider pursuing positions in academia if their loans could be forgiven through the program; however, when asked about plans for loan repayment, only 1 respondent endorsed current plans to enroll in PSLF. Thus, despite high interest in PSLF among the survey respondents, few had actual plans to use the service, suggesting that perhaps dermatologists are not provided enough information about PSLF to motivate enrollment. In the same way, almost a quarter of respondents were not familiar with the PSLF as a repayment option, further signifying that distribution of information about financial planning may be inadequate. If student loan burden is a notable factor in career decisions in dermatology, it is important that academic institutions provide sufficient information about repayment to encourage informed decisions. As such, it is possible that educating physicians about options such as PSLF can potentially recruit more dermatologists to academic positions.

Aside from financial reasons, residency program experience and differences in practices in academic and nonacademic settings may impact career trajectories. The majority of respondents stated their residency program experience influenced their career decisions; however, the majority of respondents did not change their minds about career goals since starting residency, suggesting that residency program experience may reinforce but not necessarily alter these choices. Interests in specific focuses within dermatology also may influence career decisions. This study suggests that those pursuing private practice positions are more interested in dermatologic surgery, lasers, and cosmetics. Roles in research, mentoring, and patient care differ between academic and nonacademic settings and also may be influential in career decisions in dermatology, mirroring the implications of other studies that posited that career decisions within medicine are complex and involve multiple factors.¹¹

In this study, we did not find an association between gender and career plans in dermatology. In 2013, more than 60% of dermatology resident physicians were female.¹² However, a recent study suggested that women face challenges in academic dermatology, including a downtrend in the number of female investigators with grants from the National Institutes of Health.¹³Taken together, female dermatologists, who currently represent the majority of resident physicians training in dermatology, may face unique challenges in academia, further highlighting the potential difficulties with recruitment of dermatologists by academic institutions in the future.

This preliminary study has several limitations. First, the small sample size limited generalizability to all dermatologists. Second, responder bias was possible, as those who have stronger opinions about this topic may have been more inclined to participate in this voluntary survey. Future studies with larger sample sizes are needed to further explore the factors that influence career decisions within dermatology and to determine if there are additional means to increase recruitment into academia.

Conclusion

It is recognized that there are challenges in recruiting dermatologists into academic positions. This study suggests that student loan burden influences career decisions in dermatology. Dermatologists may not be fully educated on options for student loan repayment. With increased awareness, the PSLF can potentially be used as a recruitment tool for positions in academic dermatology.

Multinucleate cell angiohistiocytoma (MCAH) is a rare benign, soft-tissue tumor first described in 1985 by Smith and Jones¹ that presents clinically as erythematous to violaceous papules most commonly affecting females on the dorsal aspect of the hands and face.² Multinucleate cell angiohistiocytoma is histologically characterized by vascular and histiocytic proliferations with dermal fibrosis. Few cases have been reported of lesions affecting the lower extremities. We report a case of MCAH affecting the legs.

Case Report

An 83-year-old white man with a history of basal cell carcinoma presented for evaluation of grouped, well-circumscribed, soft, red-violet, painless papules on the right anterior thigh that had been present for 8 months (Figure 1A). A review of symptoms was negative for immunologic, respiratory, and hematologic changes. The patient’s medical history also was remarkable for prostate cancer treated with radiation 18 years prior as well as right hip and left knee implants. The initial clinical impression was Kaposi sarcoma or a granulomatous disorder.

Histopathologic evaluation of a deep shave biopsy initially determined the lesion to be scar tissue without other pathologic findings. The patient returned to the clinic 12 months later for a complete skin examination given his history of skin cancer. Compared to clinical photographs taken a year prior, new violaceous papules were noted on the right thigh (Figure 1B) and left calf. Furthermore, there was no recurrence of the lesion at the prior biopsy site. Shave biopsies of the papules on the right thigh and left calf demonstrated similar histologic findings to each other. There was a mild increase in the number of small blood vessels in the superficial dermis (Figure 2A). A mild perivascular lymphocytic infiltrate surrounded some of these blood vessels. The endothelial cells had small nuclei with no evidence of nuclear pleomorphism. Careful examination of the interstitial dermis revealed scattered multinucleate cells with angulated cytoplasm (Figure 2B). Immunostaining for CD31 and human herpesvirus 8 were negative, excluding an infiltrative vascular tumor and Kaposi sarcoma, respectively. The diagnosis of MCAH was made based on the histopathologic findings.

At 1-year follow-up, the condition was stable with no gross changes in the lesions based on prior photographs. Once again, there was no recurrence of the excised lesions at both biopsy sites.

Comment

Presentation
A systematic review of published reports determined that 79% of MCAH cases occur in females, with an average age of onset of 50.1 years.² However, MCAH likely is underreported due to the overall lack of knowledge regarding this condition by physicians and pathologists. The hands and face are the most commonly affected areas, though other sites of involvement have been reported, including the lower extremities,^3,4 oral mucosa and upper lip,^5,6 and trunk,^7,8 as well as generalized distribution.^9-12 Additionally, 1 case presented as a single plaque on the trunk rather than having papular or nodular morphology.⁸ Multinucleate cell angiohistiocytoma lesions generally are asymptomatic, though pruritus may be present.¹³ The condition is regarded as benign, though a minority of cases have exhibited spontaneous resolution.^14-16

Histopathology
Multinucleate cell angiohistiocytoma histology demonstrates full-thickness dermal microvessel proliferation and fibrosis with characteristic multinucleate giant cells.^2,3 Vascular endothelial cells stained positive for CD68 in 60% of cases² as well as the normal endothelial markers (ie, factor VIII, CD31, CD34). The multinucleate giant cells exhibit immunoreactivity for macrophage/histiocytic markers factor XIIIa and CD68.

Etiology
The pathogenesis of MCAH is not yet fully understood, but it is considered to be a benign vascular or fibrohistiocytic neoplasm.¹⁷ Calderaro et al¹⁸ described a series of 8 patients who developed MCAH either within a cutaneous neoplastic process or in conjunction with various cutaneous reactive conditions, including hidradenitis suppurativa and chronic radiation dermatitis, as well as overlying a bone prosthesis placed due to degenerative arthritis. These cases suggest that MCAH, or possibly a subset of the disease, is a reactive process. Suggested inciting events include cancer with stromal inflammatory reaction, chronic inflammation (as seen in hidradenitis suppurativa), chronic radiation dermatitis, scarring, and vascular injury.¹⁸ Retrospective immunohistochemical evaluation of a series of MCAH cases demonstrated intralesional spindle cells to strongly express estrogen receptor alpha and factor XIIIa. Additionally, these cells sparsely expressed progesterone receptor and demonstrated no vascular endothelial growth factor immunoreactivity.¹⁹ This immunohistochemical profile supports MCAH as a distinct entity from dermatofibromas. These findings also suggest a role of hormone signaling, namely estrogen receptor alpha, in MCAH tumor biology and may offer an explanation for the predilection of MCAH in females. Furthermore, estrogen receptor positivity offers a possible mechanism for the highly vascular nature of the lesions, considering the angiogenic properties of estrogen signaling.²⁰ In a systematic review of 142 published cases of MCAH, CD68 positivity on multinucleate cells in MCAH lesions suggested a fibrohistiocytic origin.² However, a number of these cases exhibited CD34 positivity, thus a macrophage origin may not be excluded.

Differential Diagnosis
The differential diagnosis for MCAH includes Kaposi sarcoma clinically and dermatofibroma and fibrous papules histologically. Sass et al²¹ determined the in vitro behavior of cultured MCAH cells to contrast markedly with Kaposi sarcoma–derived cells. Although Kaposi sarcoma–derived cells exhibited invasive behavior, cells isolated from MCAH lesions were less elongated and were unable to traverse basement membranes.

Treatment
Surgical excision or cryotherapy appear to be definitive treatments of MCAH; however, a number of cases have reported light and laser modalities as successful alternatives to excision. One case of MCAH affecting the face was treated with pulsed dye laser monotherapy.²² This modality allowed selective coagulation of the vascular structures in MCAH. At 8-month follow-up, the initial lesion was noted to be completely cleared, though similar lesions had recently appeared elsewhere on the face.²² Another case of MCAH affecting the leg was treated with pulsed dye laser and both topical and intralesional corticosteroid combination therapy. In this case, the lesion failed to respond to treatment, which may suggest that facial localization could influence response in pulsed dye laser treatment.³

Intense pulsed light also has been reported as a definitive treatment in 2 cases.^2,13 Slight erythema and transient pruritus have been reported immediately following treatment. In this case, complete resolution with only residual hyperpigmentation was reported at 2-month follow-up, with no recurrence during 12 months of follow-up.¹³

Argon laser therapy has been used in 2 cases. After a single session, lesions were no longer palpable, with no scarring noted at 8 weeks follow-up.²³ Lastly, 2 cases of MCAH have been successfully treated with the CO₂ laser, with no relapse noted at 2.5- or 5-month follow-up, respectively.²⁴

Conclusion

Multinucleate cell angiohistiocytoma is a rare and likely underdiagnosed dermatologic condition that is believed to be a reactive process. Characteristic histology of MCAH demonstrates microvascular proliferations of the dermis with multinucleate giant cells amidst a fibrous background. Although surgical excision is curative, there are reports in which laser and light therapies were used to effectively treat MCAH.

Multinucleate cell angiohistiocytoma (MCAH) is a rare benign, soft-tissue tumor first described in 1985 by Smith and Jones¹ that presents clinically as erythematous to violaceous papules most commonly affecting females on the dorsal aspect of the hands and face.² Multinucleate cell angiohistiocytoma is histologically characterized by vascular and histiocytic proliferations with dermal fibrosis. Few cases have been reported of lesions affecting the lower extremities. We report a case of MCAH affecting the legs.

Case Report

An 83-year-old white man with a history of basal cell carcinoma presented for evaluation of grouped, well-circumscribed, soft, red-violet, painless papules on the right anterior thigh that had been present for 8 months (Figure 1A). A review of symptoms was negative for immunologic, respiratory, and hematologic changes. The patient’s medical history also was remarkable for prostate cancer treated with radiation 18 years prior as well as right hip and left knee implants. The initial clinical impression was Kaposi sarcoma or a granulomatous disorder.

Histopathologic evaluation of a deep shave biopsy initially determined the lesion to be scar tissue without other pathologic findings. The patient returned to the clinic 12 months later for a complete skin examination given his history of skin cancer. Compared to clinical photographs taken a year prior, new violaceous papules were noted on the right thigh (Figure 1B) and left calf. Furthermore, there was no recurrence of the lesion at the prior biopsy site. Shave biopsies of the papules on the right thigh and left calf demonstrated similar histologic findings to each other. There was a mild increase in the number of small blood vessels in the superficial dermis (Figure 2A). A mild perivascular lymphocytic infiltrate surrounded some of these blood vessels. The endothelial cells had small nuclei with no evidence of nuclear pleomorphism. Careful examination of the interstitial dermis revealed scattered multinucleate cells with angulated cytoplasm (Figure 2B). Immunostaining for CD31 and human herpesvirus 8 were negative, excluding an infiltrative vascular tumor and Kaposi sarcoma, respectively. The diagnosis of MCAH was made based on the histopathologic findings.

At 1-year follow-up, the condition was stable with no gross changes in the lesions based on prior photographs. Once again, there was no recurrence of the excised lesions at both biopsy sites.

Comment

Presentation
A systematic review of published reports determined that 79% of MCAH cases occur in females, with an average age of onset of 50.1 years.² However, MCAH likely is underreported due to the overall lack of knowledge regarding this condition by physicians and pathologists. The hands and face are the most commonly affected areas, though other sites of involvement have been reported, including the lower extremities,^3,4 oral mucosa and upper lip,^5,6 and trunk,^7,8 as well as generalized distribution.^9-12 Additionally, 1 case presented as a single plaque on the trunk rather than having papular or nodular morphology.⁸ Multinucleate cell angiohistiocytoma lesions generally are asymptomatic, though pruritus may be present.¹³ The condition is regarded as benign, though a minority of cases have exhibited spontaneous resolution.^14-16

Histopathology
Multinucleate cell angiohistiocytoma histology demonstrates full-thickness dermal microvessel proliferation and fibrosis with characteristic multinucleate giant cells.^2,3 Vascular endothelial cells stained positive for CD68 in 60% of cases² as well as the normal endothelial markers (ie, factor VIII, CD31, CD34). The multinucleate giant cells exhibit immunoreactivity for macrophage/histiocytic markers factor XIIIa and CD68.

Etiology
The pathogenesis of MCAH is not yet fully understood, but it is considered to be a benign vascular or fibrohistiocytic neoplasm.¹⁷ Calderaro et al¹⁸ described a series of 8 patients who developed MCAH either within a cutaneous neoplastic process or in conjunction with various cutaneous reactive conditions, including hidradenitis suppurativa and chronic radiation dermatitis, as well as overlying a bone prosthesis placed due to degenerative arthritis. These cases suggest that MCAH, or possibly a subset of the disease, is a reactive process. Suggested inciting events include cancer with stromal inflammatory reaction, chronic inflammation (as seen in hidradenitis suppurativa), chronic radiation dermatitis, scarring, and vascular injury.¹⁸ Retrospective immunohistochemical evaluation of a series of MCAH cases demonstrated intralesional spindle cells to strongly express estrogen receptor alpha and factor XIIIa. Additionally, these cells sparsely expressed progesterone receptor and demonstrated no vascular endothelial growth factor immunoreactivity.¹⁹ This immunohistochemical profile supports MCAH as a distinct entity from dermatofibromas. These findings also suggest a role of hormone signaling, namely estrogen receptor alpha, in MCAH tumor biology and may offer an explanation for the predilection of MCAH in females. Furthermore, estrogen receptor positivity offers a possible mechanism for the highly vascular nature of the lesions, considering the angiogenic properties of estrogen signaling.²⁰ In a systematic review of 142 published cases of MCAH, CD68 positivity on multinucleate cells in MCAH lesions suggested a fibrohistiocytic origin.² However, a number of these cases exhibited CD34 positivity, thus a macrophage origin may not be excluded.

Differential Diagnosis
The differential diagnosis for MCAH includes Kaposi sarcoma clinically and dermatofibroma and fibrous papules histologically. Sass et al²¹ determined the in vitro behavior of cultured MCAH cells to contrast markedly with Kaposi sarcoma–derived cells. Although Kaposi sarcoma–derived cells exhibited invasive behavior, cells isolated from MCAH lesions were less elongated and were unable to traverse basement membranes.

Treatment
Surgical excision or cryotherapy appear to be definitive treatments of MCAH; however, a number of cases have reported light and laser modalities as successful alternatives to excision. One case of MCAH affecting the face was treated with pulsed dye laser monotherapy.²² This modality allowed selective coagulation of the vascular structures in MCAH. At 8-month follow-up, the initial lesion was noted to be completely cleared, though similar lesions had recently appeared elsewhere on the face.²² Another case of MCAH affecting the leg was treated with pulsed dye laser and both topical and intralesional corticosteroid combination therapy. In this case, the lesion failed to respond to treatment, which may suggest that facial localization could influence response in pulsed dye laser treatment.³

Intense pulsed light also has been reported as a definitive treatment in 2 cases.^2,13 Slight erythema and transient pruritus have been reported immediately following treatment. In this case, complete resolution with only residual hyperpigmentation was reported at 2-month follow-up, with no recurrence during 12 months of follow-up.¹³

Argon laser therapy has been used in 2 cases. After a single session, lesions were no longer palpable, with no scarring noted at 8 weeks follow-up.²³ Lastly, 2 cases of MCAH have been successfully treated with the CO₂ laser, with no relapse noted at 2.5- or 5-month follow-up, respectively.²⁴

Conclusion

Multinucleate cell angiohistiocytoma is a rare and likely underdiagnosed dermatologic condition that is believed to be a reactive process. Characteristic histology of MCAH demonstrates microvascular proliferations of the dermis with multinucleate giant cells amidst a fibrous background. Although surgical excision is curative, there are reports in which laser and light therapies were used to effectively treat MCAH.

Multinucleate cell angiohistiocytoma (MCAH) is a rare benign, soft-tissue tumor first described in 1985 by Smith and Jones¹ that presents clinically as erythematous to violaceous papules most commonly affecting females on the dorsal aspect of the hands and face.² Multinucleate cell angiohistiocytoma is histologically characterized by vascular and histiocytic proliferations with dermal fibrosis. Few cases have been reported of lesions affecting the lower extremities. We report a case of MCAH affecting the legs.

Case Report

An 83-year-old white man with a history of basal cell carcinoma presented for evaluation of grouped, well-circumscribed, soft, red-violet, painless papules on the right anterior thigh that had been present for 8 months (Figure 1A). A review of symptoms was negative for immunologic, respiratory, and hematologic changes. The patient’s medical history also was remarkable for prostate cancer treated with radiation 18 years prior as well as right hip and left knee implants. The initial clinical impression was Kaposi sarcoma or a granulomatous disorder.

Histopathologic evaluation of a deep shave biopsy initially determined the lesion to be scar tissue without other pathologic findings. The patient returned to the clinic 12 months later for a complete skin examination given his history of skin cancer. Compared to clinical photographs taken a year prior, new violaceous papules were noted on the right thigh (Figure 1B) and left calf. Furthermore, there was no recurrence of the lesion at the prior biopsy site. Shave biopsies of the papules on the right thigh and left calf demonstrated similar histologic findings to each other. There was a mild increase in the number of small blood vessels in the superficial dermis (Figure 2A). A mild perivascular lymphocytic infiltrate surrounded some of these blood vessels. The endothelial cells had small nuclei with no evidence of nuclear pleomorphism. Careful examination of the interstitial dermis revealed scattered multinucleate cells with angulated cytoplasm (Figure 2B). Immunostaining for CD31 and human herpesvirus 8 were negative, excluding an infiltrative vascular tumor and Kaposi sarcoma, respectively. The diagnosis of MCAH was made based on the histopathologic findings.

At 1-year follow-up, the condition was stable with no gross changes in the lesions based on prior photographs. Once again, there was no recurrence of the excised lesions at both biopsy sites.

Comment

Presentation
A systematic review of published reports determined that 79% of MCAH cases occur in females, with an average age of onset of 50.1 years.² However, MCAH likely is underreported due to the overall lack of knowledge regarding this condition by physicians and pathologists. The hands and face are the most commonly affected areas, though other sites of involvement have been reported, including the lower extremities,^3,4 oral mucosa and upper lip,^5,6 and trunk,^7,8 as well as generalized distribution.^9-12 Additionally, 1 case presented as a single plaque on the trunk rather than having papular or nodular morphology.⁸ Multinucleate cell angiohistiocytoma lesions generally are asymptomatic, though pruritus may be present.¹³ The condition is regarded as benign, though a minority of cases have exhibited spontaneous resolution.^14-16

Histopathology
Multinucleate cell angiohistiocytoma histology demonstrates full-thickness dermal microvessel proliferation and fibrosis with characteristic multinucleate giant cells.^2,3 Vascular endothelial cells stained positive for CD68 in 60% of cases² as well as the normal endothelial markers (ie, factor VIII, CD31, CD34). The multinucleate giant cells exhibit immunoreactivity for macrophage/histiocytic markers factor XIIIa and CD68.

Etiology
The pathogenesis of MCAH is not yet fully understood, but it is considered to be a benign vascular or fibrohistiocytic neoplasm.¹⁷ Calderaro et al¹⁸ described a series of 8 patients who developed MCAH either within a cutaneous neoplastic process or in conjunction with various cutaneous reactive conditions, including hidradenitis suppurativa and chronic radiation dermatitis, as well as overlying a bone prosthesis placed due to degenerative arthritis. These cases suggest that MCAH, or possibly a subset of the disease, is a reactive process. Suggested inciting events include cancer with stromal inflammatory reaction, chronic inflammation (as seen in hidradenitis suppurativa), chronic radiation dermatitis, scarring, and vascular injury.¹⁸ Retrospective immunohistochemical evaluation of a series of MCAH cases demonstrated intralesional spindle cells to strongly express estrogen receptor alpha and factor XIIIa. Additionally, these cells sparsely expressed progesterone receptor and demonstrated no vascular endothelial growth factor immunoreactivity.¹⁹ This immunohistochemical profile supports MCAH as a distinct entity from dermatofibromas. These findings also suggest a role of hormone signaling, namely estrogen receptor alpha, in MCAH tumor biology and may offer an explanation for the predilection of MCAH in females. Furthermore, estrogen receptor positivity offers a possible mechanism for the highly vascular nature of the lesions, considering the angiogenic properties of estrogen signaling.²⁰ In a systematic review of 142 published cases of MCAH, CD68 positivity on multinucleate cells in MCAH lesions suggested a fibrohistiocytic origin.² However, a number of these cases exhibited CD34 positivity, thus a macrophage origin may not be excluded.

Differential Diagnosis
The differential diagnosis for MCAH includes Kaposi sarcoma clinically and dermatofibroma and fibrous papules histologically. Sass et al²¹ determined the in vitro behavior of cultured MCAH cells to contrast markedly with Kaposi sarcoma–derived cells. Although Kaposi sarcoma–derived cells exhibited invasive behavior, cells isolated from MCAH lesions were less elongated and were unable to traverse basement membranes.

Treatment
Surgical excision or cryotherapy appear to be definitive treatments of MCAH; however, a number of cases have reported light and laser modalities as successful alternatives to excision. One case of MCAH affecting the face was treated with pulsed dye laser monotherapy.²² This modality allowed selective coagulation of the vascular structures in MCAH. At 8-month follow-up, the initial lesion was noted to be completely cleared, though similar lesions had recently appeared elsewhere on the face.²² Another case of MCAH affecting the leg was treated with pulsed dye laser and both topical and intralesional corticosteroid combination therapy. In this case, the lesion failed to respond to treatment, which may suggest that facial localization could influence response in pulsed dye laser treatment.³

Intense pulsed light also has been reported as a definitive treatment in 2 cases.^2,13 Slight erythema and transient pruritus have been reported immediately following treatment. In this case, complete resolution with only residual hyperpigmentation was reported at 2-month follow-up, with no recurrence during 12 months of follow-up.¹³

Argon laser therapy has been used in 2 cases. After a single session, lesions were no longer palpable, with no scarring noted at 8 weeks follow-up.²³ Lastly, 2 cases of MCAH have been successfully treated with the CO₂ laser, with no relapse noted at 2.5- or 5-month follow-up, respectively.²⁴

Conclusion

Multinucleate cell angiohistiocytoma is a rare and likely underdiagnosed dermatologic condition that is believed to be a reactive process. Characteristic histology of MCAH demonstrates microvascular proliferations of the dermis with multinucleate giant cells amidst a fibrous background. Although surgical excision is curative, there are reports in which laser and light therapies were used to effectively treat MCAH.

If you haven’t started reporting quality data for the Merit-Based Incentive Payment System (MIPS), there’s still time to avoid a 4% cut to your Medicare payments.

Under the Pick Your Pace approach being offered this year, the Centers for Medicare & Medicaid Services allows clinicians to test the system by reporting on one quality measure for one patient through paper-based claims. Be sure to append a Quality Data Code (QDC) to the claim form for care provided up to Dec. 31, 2017, in order to avoid a penalty in payment year 2019.

Consider this measure:


 

Measure #109: Osteoarthritis Function and Pain Assessment

This measure is aimed at capturing the percentage of visits that included an assessment of function and pain for patients with a diagnosis of osteoarthritis (OA) who are aged 21 years or older.

What you need to do: Perform an assessment of symptoms and functional status for patients with OA and document it in the medical record. Validated scales and questionnaires may be used but are not required.

Eligible cases include patients aged 21 years and older with a diagnosis of OA and a patient encounter during the performance period. Applicable codes include (CPT): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215.

To get credit under MIPS, be sure to include a QDC that shows that you successfully performed the measure or had a good reason for not doing so. For instance, CPT II 1006F indicates that OA symptoms and functional status were assessed. Add the 8P modifier to CPT II 1006F if the assessment was not performed and the reason is not otherwise specified.

CMS has a full list measures available for claims-based reporting at qpp.cms.gov. The American Medical Association has also created a step-by-step guide for reporting on one quality measure.

Certain clinicians are exempt from reporting and do not face a penalty under MIPS:

• Those who enrolled in Medicare for the first time during a performance period.
• Those who have Medicare Part B allowed charges of $30,000 or less.
• Those who have 100 or fewer Medicare Part B patients.
• Those who are significantly participating in an Advanced Alternative Payment Model (APM).

If you haven’t started reporting quality data for the Merit-Based Incentive Payment System (MIPS), there’s still time to avoid a 4% cut to your Medicare payments.

Under the Pick Your Pace approach being offered this year, the Centers for Medicare & Medicaid Services allows clinicians to test the system by reporting on one quality measure for one patient through paper-based claims. Be sure to append a Quality Data Code (QDC) to the claim form for care provided up to Dec. 31, 2017, in order to avoid a penalty in payment year 2019.

Consider this measure:


 

Measure #109: Osteoarthritis Function and Pain Assessment

This measure is aimed at capturing the percentage of visits that included an assessment of function and pain for patients with a diagnosis of osteoarthritis (OA) who are aged 21 years or older.

What you need to do: Perform an assessment of symptoms and functional status for patients with OA and document it in the medical record. Validated scales and questionnaires may be used but are not required.

Eligible cases include patients aged 21 years and older with a diagnosis of OA and a patient encounter during the performance period. Applicable codes include (CPT): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215.

To get credit under MIPS, be sure to include a QDC that shows that you successfully performed the measure or had a good reason for not doing so. For instance, CPT II 1006F indicates that OA symptoms and functional status were assessed. Add the 8P modifier to CPT II 1006F if the assessment was not performed and the reason is not otherwise specified.

CMS has a full list measures available for claims-based reporting at qpp.cms.gov. The American Medical Association has also created a step-by-step guide for reporting on one quality measure.

Certain clinicians are exempt from reporting and do not face a penalty under MIPS:

• Those who enrolled in Medicare for the first time during a performance period.
• Those who have Medicare Part B allowed charges of $30,000 or less.
• Those who have 100 or fewer Medicare Part B patients.
• Those who are significantly participating in an Advanced Alternative Payment Model (APM).

If you haven’t started reporting quality data for the Merit-Based Incentive Payment System (MIPS), there’s still time to avoid a 4% cut to your Medicare payments.

Under the Pick Your Pace approach being offered this year, the Centers for Medicare & Medicaid Services allows clinicians to test the system by reporting on one quality measure for one patient through paper-based claims. Be sure to append a Quality Data Code (QDC) to the claim form for care provided up to Dec. 31, 2017, in order to avoid a penalty in payment year 2019.

Consider this measure:


 

Measure #109: Osteoarthritis Function and Pain Assessment

This measure is aimed at capturing the percentage of visits that included an assessment of function and pain for patients with a diagnosis of osteoarthritis (OA) who are aged 21 years or older.

What you need to do: Perform an assessment of symptoms and functional status for patients with OA and document it in the medical record. Validated scales and questionnaires may be used but are not required.

Eligible cases include patients aged 21 years and older with a diagnosis of OA and a patient encounter during the performance period. Applicable codes include (CPT): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215.

To get credit under MIPS, be sure to include a QDC that shows that you successfully performed the measure or had a good reason for not doing so. For instance, CPT II 1006F indicates that OA symptoms and functional status were assessed. Add the 8P modifier to CPT II 1006F if the assessment was not performed and the reason is not otherwise specified.

CMS has a full list measures available for claims-based reporting at qpp.cms.gov. The American Medical Association has also created a step-by-step guide for reporting on one quality measure.

Certain clinicians are exempt from reporting and do not face a penalty under MIPS:

• Those who enrolled in Medicare for the first time during a performance period.
• Those who have Medicare Part B allowed charges of $30,000 or less.
• Those who have 100 or fewer Medicare Part B patients.
• Those who are significantly participating in an Advanced Alternative Payment Model (APM).

Research Hospital

An antimalarial drug and a BH3 mimetic have demonstrated promise for treating BCR-ABL-positive acute lymphoblastic leukemia (ALL), according to work published in Clinical Cancer Research.

Investigators found the widely used antimalarial dihydroartemisinin (DHA) sensitized BCR-ABL+ ALL to the BH3 mimetic navitoclax (formerly ABT-263).

The combination therapy had a synergistic effect on mouse and human BCR-ABL+ leukemic cell death and extended the lives of mice with BCR-ABL+ ALL.

“Survival rates for children and adults with this leukemia still lag, highlighting the urgent need for new therapies,” said study author Joseph Opferman, PhD, of St. Jude Children’s Research Hospital in Memphis, Tennessee.

“Our findings suggest that combining DHA with ABT-263 can significantly improve treatment response.”

As opposed to mice that received navitoclax alone, there was no evidence of navitoclax resistance in mice treated with navitoclax and DHA.

The investigators determined that DHA worked by repressing production of MCL-1, a protein that is elevated in many cancers and helps malignant cells resist BH3 mimetics.

“MCL-1 is widely recognized as an important survival molecule in many normal cell types as well as cancer,” Dr Opferman said. “MCL-1 inhibitors are in development, but none are currently available for treating patients.”

“And because MCL-1 is essential for proper functioning of many normal cell types, there is concern about potential toxicity. We sought to identify drugs that are available now to augment treatment of BCR-ABL+ ALL.”

The search for a drug to sensitize BCR-ABL+ ALL to navitoclax and related compounds led Dr Opferman and his colleagues to DHA. A drug screen showed that DHA killed BCR-ABL+ ALL cells from mice.

The investigators showed how DHA induced expression of the protein CHOP, which is a key regulator of the endoplasmic reticulum stress pathway in cells. CHOP expression triggered the stress pathway in BCR-ABL+ ALL cells from mice and led to the suppression of MCL-1.

“MCL-1 has a short half-life, so the cell’s MCL-1 stores are rapidly depleted if the protein’s translation is repressed,” said study author Amit Budhraja, PhD, a postdoctoral fellow in Dr Opferman’s lab.

Now, the investigators are studying the mechanism in human BCR-ABL+ leukemic cells as well as in other cancers.

“Identifying the mechanism will allow us to study the pathway in detail for other points to target for anticancer drug development,” Dr Opferman said.

Research Hospital

An antimalarial drug and a BH3 mimetic have demonstrated promise for treating BCR-ABL-positive acute lymphoblastic leukemia (ALL), according to work published in Clinical Cancer Research.

Investigators found the widely used antimalarial dihydroartemisinin (DHA) sensitized BCR-ABL+ ALL to the BH3 mimetic navitoclax (formerly ABT-263).

The combination therapy had a synergistic effect on mouse and human BCR-ABL+ leukemic cell death and extended the lives of mice with BCR-ABL+ ALL.

“Survival rates for children and adults with this leukemia still lag, highlighting the urgent need for new therapies,” said study author Joseph Opferman, PhD, of St. Jude Children’s Research Hospital in Memphis, Tennessee.

“Our findings suggest that combining DHA with ABT-263 can significantly improve treatment response.”

As opposed to mice that received navitoclax alone, there was no evidence of navitoclax resistance in mice treated with navitoclax and DHA.

The investigators determined that DHA worked by repressing production of MCL-1, a protein that is elevated in many cancers and helps malignant cells resist BH3 mimetics.

“MCL-1 is widely recognized as an important survival molecule in many normal cell types as well as cancer,” Dr Opferman said. “MCL-1 inhibitors are in development, but none are currently available for treating patients.”

“And because MCL-1 is essential for proper functioning of many normal cell types, there is concern about potential toxicity. We sought to identify drugs that are available now to augment treatment of BCR-ABL+ ALL.”

The search for a drug to sensitize BCR-ABL+ ALL to navitoclax and related compounds led Dr Opferman and his colleagues to DHA. A drug screen showed that DHA killed BCR-ABL+ ALL cells from mice.

The investigators showed how DHA induced expression of the protein CHOP, which is a key regulator of the endoplasmic reticulum stress pathway in cells. CHOP expression triggered the stress pathway in BCR-ABL+ ALL cells from mice and led to the suppression of MCL-1.

“MCL-1 has a short half-life, so the cell’s MCL-1 stores are rapidly depleted if the protein’s translation is repressed,” said study author Amit Budhraja, PhD, a postdoctoral fellow in Dr Opferman’s lab.

Now, the investigators are studying the mechanism in human BCR-ABL+ leukemic cells as well as in other cancers.

“Identifying the mechanism will allow us to study the pathway in detail for other points to target for anticancer drug development,” Dr Opferman said.

Research Hospital

An antimalarial drug and a BH3 mimetic have demonstrated promise for treating BCR-ABL-positive acute lymphoblastic leukemia (ALL), according to work published in Clinical Cancer Research.

Investigators found the widely used antimalarial dihydroartemisinin (DHA) sensitized BCR-ABL+ ALL to the BH3 mimetic navitoclax (formerly ABT-263).

The combination therapy had a synergistic effect on mouse and human BCR-ABL+ leukemic cell death and extended the lives of mice with BCR-ABL+ ALL.

“Survival rates for children and adults with this leukemia still lag, highlighting the urgent need for new therapies,” said study author Joseph Opferman, PhD, of St. Jude Children’s Research Hospital in Memphis, Tennessee.

“Our findings suggest that combining DHA with ABT-263 can significantly improve treatment response.”

As opposed to mice that received navitoclax alone, there was no evidence of navitoclax resistance in mice treated with navitoclax and DHA.

The investigators determined that DHA worked by repressing production of MCL-1, a protein that is elevated in many cancers and helps malignant cells resist BH3 mimetics.

“MCL-1 is widely recognized as an important survival molecule in many normal cell types as well as cancer,” Dr Opferman said. “MCL-1 inhibitors are in development, but none are currently available for treating patients.”

“And because MCL-1 is essential for proper functioning of many normal cell types, there is concern about potential toxicity. We sought to identify drugs that are available now to augment treatment of BCR-ABL+ ALL.”

The search for a drug to sensitize BCR-ABL+ ALL to navitoclax and related compounds led Dr Opferman and his colleagues to DHA. A drug screen showed that DHA killed BCR-ABL+ ALL cells from mice.

The investigators showed how DHA induced expression of the protein CHOP, which is a key regulator of the endoplasmic reticulum stress pathway in cells. CHOP expression triggered the stress pathway in BCR-ABL+ ALL cells from mice and led to the suppression of MCL-1.

“MCL-1 has a short half-life, so the cell’s MCL-1 stores are rapidly depleted if the protein’s translation is repressed,” said study author Amit Budhraja, PhD, a postdoctoral fellow in Dr Opferman’s lab.

Now, the investigators are studying the mechanism in human BCR-ABL+ leukemic cells as well as in other cancers.

“Identifying the mechanism will allow us to study the pathway in detail for other points to target for anticancer drug development,” Dr Opferman said.

This past week, I received “appointment reminder” text messages from two separate health care clinics requesting confirmation of my attendance—a practice that has become so commonplace, I didn’t think twice about it. But there was a time, not long ago, when this would’ve seemed like a scenario from the far-off future (like the flying cars on The Jetsons).

Times, they are a-changin’! Clinicians are becoming more electronically skilled and interested in connecting with patients in a more convenient, direct way. Accordingly, they are increasingly willing to embrace the world of social media—something health care institutions evaded for years and even discouraged employees from entering. Today, clinicians are starting to harness the potential of social media to increase health care awareness and improve access to care.

The popularity of social media has grown tremendously in recent years; 72% of US adults now use social media, up from 8% in 2005.¹ Facebook—one of the most commonly used social networks, along with LinkedIn and Twitter—surpassed 1 billion users in the third quarter of 2012, making it the first to achieve this milestone.^2,3 (By the second quarter of 2017, it had 2 billion monthly active users.³) In this 280-character world, members of Congress—and even the President himself—are tweeting on a daily (if not hourly) basis, reaching millions of people.

And that’s the beauty of social media: It’s a tool that’s all about speeding up and augmenting communication. Active users consider themselves part of a community and therefore tend to trust others within their social media “group.” As a result, patients—especially younger ones—are using social media to make health care decisions. They research and select their clinicians, hospitals, and even courses of treatment (for both themselves and their families) with input from this community.

Our patients are social media–savvy and expect us, as clinicians, to be equally skilled. Are we missing an opportunity by opting out of these networks? Or are we rightly avoiding a number of thorny legal and regulatory issues by staying “offline”?

Many clinicians believe that the dependability of social media can drive better quality of care. In fact, 60% of physicians are in favor of interacting with patients on social media for patient education, health monitoring, medication adherence, and promotion of behavioral change.⁴ And in a 2012 study, 56% of patients reported wanting clinicians to use “social media” (which included email) to set appointments, report diagnostic test results, send prescription notifications, provide health information, and answer questions.⁵

Social media provides a platform for the public, patients, and health care professionals to communicate about health issues and (possibly) improve health outcomes. It can be used for professional networking, education, organizational promotion, patient care, patient education, and public health programs.⁶ So, where’s the downside?

As use of social media increases, particularly in the health care industry, the risks for legal implications and noncompliance also rise. Numerous federal and state rules and regulations govern communication within the health care industry. One of the main challenges health care organizations face is the protection of the privacy of patient information (ie, HIPAA). To this end, organizations must exhibit that they are managing the activities of employees who have access to patient information (which includes social media use). Institutions planning to use social media also need to ensure that their electronic records are complete, secure, and tamper-proof for record retention and audit purposes. Noncompliance with health care regulations can not only damage the reputation of an institution, it can also impact the bottom line.

In addition, health care providers must consider legal issues related to patient privacy, litigation, and licensing before using social media. Federal and state privacy laws limit providers’ ability to interact with patients through social media, because anything that can be used to identify a patient— including pictures—is protected. Should patient information be revealed through social media without patient authorization, providers would be subject to fines and other penalties. (The table on outlines pros and cons of social media use in health care.)

It’s no wonder some providers are leery of connecting with patients via social media. Many of them, however, have tested the waters by using social networks to connect with colleagues and peers, often sharing medical knowledge and opinions this way.

As social media has evolved, medically focused professional communities have been established. One example is SERMO, a popular, private, physician-only social network. SERMO (www.sermo.com/what-is-sermo/overview) is a virtual doctors’ lounge with more than 800,000 verified and credentialed physician members; it includes physicians from 150 countries, with plans for continued expansion. Another, the Medical Directors Forum (https://medicaldirectorsforum.com/site), is a verified, secure, closed-loop environment for peer-to-peer interaction between medical directors, which features discussion groups, calendar postings, and alerts. Finally, Doximity (www.doximity.com/review) is a social network for physicians, NPs, and PAs, which allows clinicians to call patients (with the physician’s office number displayed on caller ID), review pertinent medical articles, communicate with colleagues, and even fax and/or email documents. Additionally, the American Association of Nurse Practitioners (AANP), the American Academy of Physician Assistants (AAPA), and Clinician Reviews all have accounts on Facebook and Twitter, among other social media sites.

When it comes down to it, if used wisely, social media has the potential to promote individual and public health, as well as professional development and advancement. But carelessness can result in legal, ethical, and logistical issues, causing serious ramifications for the clinician—and possibly even the practice. So, which side of the social media debate are you on? Send your tips—or warnings—about integrating social media into your workplace to [email protected]

This past week, I received “appointment reminder” text messages from two separate health care clinics requesting confirmation of my attendance—a practice that has become so commonplace, I didn’t think twice about it. But there was a time, not long ago, when this would’ve seemed like a scenario from the far-off future (like the flying cars on The Jetsons).

Times, they are a-changin’! Clinicians are becoming more electronically skilled and interested in connecting with patients in a more convenient, direct way. Accordingly, they are increasingly willing to embrace the world of social media—something health care institutions evaded for years and even discouraged employees from entering. Today, clinicians are starting to harness the potential of social media to increase health care awareness and improve access to care.

The popularity of social media has grown tremendously in recent years; 72% of US adults now use social media, up from 8% in 2005.¹ Facebook—one of the most commonly used social networks, along with LinkedIn and Twitter—surpassed 1 billion users in the third quarter of 2012, making it the first to achieve this milestone.^2,3 (By the second quarter of 2017, it had 2 billion monthly active users.³) In this 280-character world, members of Congress—and even the President himself—are tweeting on a daily (if not hourly) basis, reaching millions of people.

And that’s the beauty of social media: It’s a tool that’s all about speeding up and augmenting communication. Active users consider themselves part of a community and therefore tend to trust others within their social media “group.” As a result, patients—especially younger ones—are using social media to make health care decisions. They research and select their clinicians, hospitals, and even courses of treatment (for both themselves and their families) with input from this community.

Our patients are social media–savvy and expect us, as clinicians, to be equally skilled. Are we missing an opportunity by opting out of these networks? Or are we rightly avoiding a number of thorny legal and regulatory issues by staying “offline”?

Many clinicians believe that the dependability of social media can drive better quality of care. In fact, 60% of physicians are in favor of interacting with patients on social media for patient education, health monitoring, medication adherence, and promotion of behavioral change.⁴ And in a 2012 study, 56% of patients reported wanting clinicians to use “social media” (which included email) to set appointments, report diagnostic test results, send prescription notifications, provide health information, and answer questions.⁵

Social media provides a platform for the public, patients, and health care professionals to communicate about health issues and (possibly) improve health outcomes. It can be used for professional networking, education, organizational promotion, patient care, patient education, and public health programs.⁶ So, where’s the downside?

As use of social media increases, particularly in the health care industry, the risks for legal implications and noncompliance also rise. Numerous federal and state rules and regulations govern communication within the health care industry. One of the main challenges health care organizations face is the protection of the privacy of patient information (ie, HIPAA). To this end, organizations must exhibit that they are managing the activities of employees who have access to patient information (which includes social media use). Institutions planning to use social media also need to ensure that their electronic records are complete, secure, and tamper-proof for record retention and audit purposes. Noncompliance with health care regulations can not only damage the reputation of an institution, it can also impact the bottom line.

In addition, health care providers must consider legal issues related to patient privacy, litigation, and licensing before using social media. Federal and state privacy laws limit providers’ ability to interact with patients through social media, because anything that can be used to identify a patient— including pictures—is protected. Should patient information be revealed through social media without patient authorization, providers would be subject to fines and other penalties. (The table on outlines pros and cons of social media use in health care.)

It’s no wonder some providers are leery of connecting with patients via social media. Many of them, however, have tested the waters by using social networks to connect with colleagues and peers, often sharing medical knowledge and opinions this way.

As social media has evolved, medically focused professional communities have been established. One example is SERMO, a popular, private, physician-only social network. SERMO (www.sermo.com/what-is-sermo/overview) is a virtual doctors’ lounge with more than 800,000 verified and credentialed physician members; it includes physicians from 150 countries, with plans for continued expansion. Another, the Medical Directors Forum (https://medicaldirectorsforum.com/site), is a verified, secure, closed-loop environment for peer-to-peer interaction between medical directors, which features discussion groups, calendar postings, and alerts. Finally, Doximity (www.doximity.com/review) is a social network for physicians, NPs, and PAs, which allows clinicians to call patients (with the physician’s office number displayed on caller ID), review pertinent medical articles, communicate with colleagues, and even fax and/or email documents. Additionally, the American Association of Nurse Practitioners (AANP), the American Academy of Physician Assistants (AAPA), and Clinician Reviews all have accounts on Facebook and Twitter, among other social media sites.

When it comes down to it, if used wisely, social media has the potential to promote individual and public health, as well as professional development and advancement. But carelessness can result in legal, ethical, and logistical issues, causing serious ramifications for the clinician—and possibly even the practice. So, which side of the social media debate are you on? Send your tips—or warnings—about integrating social media into your workplace to [email protected]

This past week, I received “appointment reminder” text messages from two separate health care clinics requesting confirmation of my attendance—a practice that has become so commonplace, I didn’t think twice about it. But there was a time, not long ago, when this would’ve seemed like a scenario from the far-off future (like the flying cars on The Jetsons).

Times, they are a-changin’! Clinicians are becoming more electronically skilled and interested in connecting with patients in a more convenient, direct way. Accordingly, they are increasingly willing to embrace the world of social media—something health care institutions evaded for years and even discouraged employees from entering. Today, clinicians are starting to harness the potential of social media to increase health care awareness and improve access to care.

The popularity of social media has grown tremendously in recent years; 72% of US adults now use social media, up from 8% in 2005.¹ Facebook—one of the most commonly used social networks, along with LinkedIn and Twitter—surpassed 1 billion users in the third quarter of 2012, making it the first to achieve this milestone.^2,3 (By the second quarter of 2017, it had 2 billion monthly active users.³) In this 280-character world, members of Congress—and even the President himself—are tweeting on a daily (if not hourly) basis, reaching millions of people.

And that’s the beauty of social media: It’s a tool that’s all about speeding up and augmenting communication. Active users consider themselves part of a community and therefore tend to trust others within their social media “group.” As a result, patients—especially younger ones—are using social media to make health care decisions. They research and select their clinicians, hospitals, and even courses of treatment (for both themselves and their families) with input from this community.

Our patients are social media–savvy and expect us, as clinicians, to be equally skilled. Are we missing an opportunity by opting out of these networks? Or are we rightly avoiding a number of thorny legal and regulatory issues by staying “offline”?

Many clinicians believe that the dependability of social media can drive better quality of care. In fact, 60% of physicians are in favor of interacting with patients on social media for patient education, health monitoring, medication adherence, and promotion of behavioral change.⁴ And in a 2012 study, 56% of patients reported wanting clinicians to use “social media” (which included email) to set appointments, report diagnostic test results, send prescription notifications, provide health information, and answer questions.⁵

Social media provides a platform for the public, patients, and health care professionals to communicate about health issues and (possibly) improve health outcomes. It can be used for professional networking, education, organizational promotion, patient care, patient education, and public health programs.⁶ So, where’s the downside?

As use of social media increases, particularly in the health care industry, the risks for legal implications and noncompliance also rise. Numerous federal and state rules and regulations govern communication within the health care industry. One of the main challenges health care organizations face is the protection of the privacy of patient information (ie, HIPAA). To this end, organizations must exhibit that they are managing the activities of employees who have access to patient information (which includes social media use). Institutions planning to use social media also need to ensure that their electronic records are complete, secure, and tamper-proof for record retention and audit purposes. Noncompliance with health care regulations can not only damage the reputation of an institution, it can also impact the bottom line.

In addition, health care providers must consider legal issues related to patient privacy, litigation, and licensing before using social media. Federal and state privacy laws limit providers’ ability to interact with patients through social media, because anything that can be used to identify a patient— including pictures—is protected. Should patient information be revealed through social media without patient authorization, providers would be subject to fines and other penalties. (The table on outlines pros and cons of social media use in health care.)

It’s no wonder some providers are leery of connecting with patients via social media. Many of them, however, have tested the waters by using social networks to connect with colleagues and peers, often sharing medical knowledge and opinions this way.

As social media has evolved, medically focused professional communities have been established. One example is SERMO, a popular, private, physician-only social network. SERMO (www.sermo.com/what-is-sermo/overview) is a virtual doctors’ lounge with more than 800,000 verified and credentialed physician members; it includes physicians from 150 countries, with plans for continued expansion. Another, the Medical Directors Forum (https://medicaldirectorsforum.com/site), is a verified, secure, closed-loop environment for peer-to-peer interaction between medical directors, which features discussion groups, calendar postings, and alerts. Finally, Doximity (www.doximity.com/review) is a social network for physicians, NPs, and PAs, which allows clinicians to call patients (with the physician’s office number displayed on caller ID), review pertinent medical articles, communicate with colleagues, and even fax and/or email documents. Additionally, the American Association of Nurse Practitioners (AANP), the American Academy of Physician Assistants (AAPA), and Clinician Reviews all have accounts on Facebook and Twitter, among other social media sites.

When it comes down to it, if used wisely, social media has the potential to promote individual and public health, as well as professional development and advancement. But carelessness can result in legal, ethical, and logistical issues, causing serious ramifications for the clinician—and possibly even the practice. So, which side of the social media debate are you on? Send your tips—or warnings—about integrating social media into your workplace to [email protected]

This past Thanksgiving weekend I left a message on my office machine that we were closed because my staff and I were camping in a tent outside a store to save $3 on socks on Black Friday.

Of course, I had the usual legal disclaimers about calling 911 for emergencies and how to reach the doctor on call, but the message was just silly.

This isn’t anything new for my practice. My patients are used to the occasional humor. Most of them probably expect it by now.

Although things may change, right now I just can’t see myself as part of a large institution. I know my patients. I see each of them myself. I try to understand their concerns and backgrounds so I can treat them appropriately. I don’t try to cram them through in 10 minutes while checking off electronic medical record boxes to document “meaningful use” requirements.

Of course, the flip side is that I don’t make as much money as I could. But as long as I can stay open and support my family, I don’t care. I came here to help in a way that’s meaningful to both my patients and myself, and I’ve found it.

In the November 2017 issue of Medscape Business of Medicine was an article about physicians choosing private practice. Dr. Richard May, a nephrologist in Ohio, said: “We’ve opted to stay with this model because we control our lives. We know the cost of doing that is that we are probably not making as much as we could if we were with a system, but we get up every morning feeling good about how we practice medicine. We’re happy answering to no one but ourselves and not feeling any pressure to meet patient-load quotas and hit monetary goals.”

And all I can say to that is: “Amen, brother.”
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

This past Thanksgiving weekend I left a message on my office machine that we were closed because my staff and I were camping in a tent outside a store to save $3 on socks on Black Friday.

Of course, I had the usual legal disclaimers about calling 911 for emergencies and how to reach the doctor on call, but the message was just silly.

This isn’t anything new for my practice. My patients are used to the occasional humor. Most of them probably expect it by now.

Although things may change, right now I just can’t see myself as part of a large institution. I know my patients. I see each of them myself. I try to understand their concerns and backgrounds so I can treat them appropriately. I don’t try to cram them through in 10 minutes while checking off electronic medical record boxes to document “meaningful use” requirements.

Of course, the flip side is that I don’t make as much money as I could. But as long as I can stay open and support my family, I don’t care. I came here to help in a way that’s meaningful to both my patients and myself, and I’ve found it.

In the November 2017 issue of Medscape Business of Medicine was an article about physicians choosing private practice. Dr. Richard May, a nephrologist in Ohio, said: “We’ve opted to stay with this model because we control our lives. We know the cost of doing that is that we are probably not making as much as we could if we were with a system, but we get up every morning feeling good about how we practice medicine. We’re happy answering to no one but ourselves and not feeling any pressure to meet patient-load quotas and hit monetary goals.”

And all I can say to that is: “Amen, brother.”
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

This past Thanksgiving weekend I left a message on my office machine that we were closed because my staff and I were camping in a tent outside a store to save $3 on socks on Black Friday.

Of course, I had the usual legal disclaimers about calling 911 for emergencies and how to reach the doctor on call, but the message was just silly.

This isn’t anything new for my practice. My patients are used to the occasional humor. Most of them probably expect it by now.

Although things may change, right now I just can’t see myself as part of a large institution. I know my patients. I see each of them myself. I try to understand their concerns and backgrounds so I can treat them appropriately. I don’t try to cram them through in 10 minutes while checking off electronic medical record boxes to document “meaningful use” requirements.

Of course, the flip side is that I don’t make as much money as I could. But as long as I can stay open and support my family, I don’t care. I came here to help in a way that’s meaningful to both my patients and myself, and I’ve found it.

In the November 2017 issue of Medscape Business of Medicine was an article about physicians choosing private practice. Dr. Richard May, a nephrologist in Ohio, said: “We’ve opted to stay with this model because we control our lives. We know the cost of doing that is that we are probably not making as much as we could if we were with a system, but we get up every morning feeling good about how we practice medicine. We’re happy answering to no one but ourselves and not feeling any pressure to meet patient-load quotas and hit monetary goals.”

And all I can say to that is: “Amen, brother.”
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

SAN DIEGO – The sooner immunotherapy is started for faciobrachial dystonic seizures, the better, according to a retrospective review presented at the American Neurological Association annual meeting.

Only recently described, patients with faciobrachial dystonic seizures (FBDS) have frequent episodes – sometimes hundreds a day – of abrupt, involuntary, stereotypical movements lasting 1-5 seconds and typically involving one half of their face and the arm on the same side, such as a left-sided grimace and arm flex. It’s closely associated with antibodies against leucine-rich glioma, inactivated 1 (LGI-1), a protein that plays a role in synaptic transmission and myelination.

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SAN DIEGO – The sooner immunotherapy is started for faciobrachial dystonic seizures, the better, according to a retrospective review presented at the American Neurological Association annual meeting.

Only recently described, patients with faciobrachial dystonic seizures (FBDS) have frequent episodes – sometimes hundreds a day – of abrupt, involuntary, stereotypical movements lasting 1-5 seconds and typically involving one half of their face and the arm on the same side, such as a left-sided grimace and arm flex. It’s closely associated with antibodies against leucine-rich glioma, inactivated 1 (LGI-1), a protein that plays a role in synaptic transmission and myelination.

[email protected]

SAN DIEGO – The sooner immunotherapy is started for faciobrachial dystonic seizures, the better, according to a retrospective review presented at the American Neurological Association annual meeting.

Only recently described, patients with faciobrachial dystonic seizures (FBDS) have frequent episodes – sometimes hundreds a day – of abrupt, involuntary, stereotypical movements lasting 1-5 seconds and typically involving one half of their face and the arm on the same side, such as a left-sided grimace and arm flex. It’s closely associated with antibodies against leucine-rich glioma, inactivated 1 (LGI-1), a protein that plays a role in synaptic transmission and myelination.

[email protected]

WASHINGTON – The high rate of new onset epilepsy during the period surrounding menarche has been strengthened in a data analysis that suggests surging hormones may be a treatable trigger of epileptogenic activity, according to a new analysis of the Epilepsy Birth Control Registry (EBCR) presented at the annual meeting of the American Epilepsy Society.

“The evidence connecting neuroactive sexual maturation hormones with the onset of epilepsy and seizure activity is becoming strong enough that we can at least conceptualize how hormonal interventions might be used for prevention or treatment,” reported Andrew G. Herzog, MD, director of the neuroendocrine unit at Beth Israel Deaconess Hospital, Boston.

Ted Bosworth/Frontline Medical News

WASHINGTON – The high rate of new onset epilepsy during the period surrounding menarche has been strengthened in a data analysis that suggests surging hormones may be a treatable trigger of epileptogenic activity, according to a new analysis of the Epilepsy Birth Control Registry (EBCR) presented at the annual meeting of the American Epilepsy Society.

“The evidence connecting neuroactive sexual maturation hormones with the onset of epilepsy and seizure activity is becoming strong enough that we can at least conceptualize how hormonal interventions might be used for prevention or treatment,” reported Andrew G. Herzog, MD, director of the neuroendocrine unit at Beth Israel Deaconess Hospital, Boston.

Ted Bosworth/Frontline Medical News

WASHINGTON – The high rate of new onset epilepsy during the period surrounding menarche has been strengthened in a data analysis that suggests surging hormones may be a treatable trigger of epileptogenic activity, according to a new analysis of the Epilepsy Birth Control Registry (EBCR) presented at the annual meeting of the American Epilepsy Society.

“The evidence connecting neuroactive sexual maturation hormones with the onset of epilepsy and seizure activity is becoming strong enough that we can at least conceptualize how hormonal interventions might be used for prevention or treatment,” reported Andrew G. Herzog, MD, director of the neuroendocrine unit at Beth Israel Deaconess Hospital, Boston.

Ted Bosworth/Frontline Medical News