For Residents

With today’s technology, it is easier than ever to access web-based tools that enrich traditional dermatology education. The literature supports the use of these innovative platforms to enhance learning at the student and trainee levels. A controlled study of pediatric residents showed that online modules effectively supplemented clinical experience with atopic dermatitis.¹ In a randomized diagnostic study of medical students, practice with an image-based web application (app) that teaches rapid recognition of melanoma proved more effective than learning a rule-based algorithm.² Given the visual nature of dermatology, pattern recognition is an essential skill that is fostered through experience and is only made more accessible with technology.

With the added benefit of convenience and accessibility, mobile apps can supplement experiential learning. Mirroring the overall growth of mobile apps, the number of available dermatology apps has increased.³ Dermatology mobile apps serve purposes ranging from quick reference tools to comprehensive modules, journals, and question banks. At an academic hospital in Taiwan, both nondermatology and dermatology trainees’ examination performance improved after 3 weeks of using a smartphone-based wallpaper learning module displaying morphologic characteristics of fungi.⁴ With the expansion of virtual microscopy, mobile apps also have been created as a learning tool for dermatopathology, giving trainees the flexibility and autonomy to view slides on their own time.⁵ Nevertheless, the literature on dermatology mobile apps designed for the education of medical students and trainees is limited, demonstrating a need for further investigation.

Prior studies have reviewed dermatology apps for patients and practicing dermatologists.^6-8 Herein, we focus on mobile apps targeting students and residents learning dermatology. General dermatology reference apps and educational aid apps have grown by 33% and 32%, respectively, from 2014 to 2017.³ As with any resource meant to educate future and current medical providers, there must be an objective review process in place to ensure accurate, unbiased, evidence-based teaching.

Well-organized, comprehensive information and a user-friendly interface are additional factors of importance when selecting an educational mobile app. When discussing supplemental resources, accessibility and affordability also are priorities given the high cost of a medical education at baseline. Overall, there is a need for a standardized method to evaluate the key factors of an educational mobile app that make it appropriate for this demographic. We conducted a search of mobile apps relating to dermatology education for students and residents.

Methods

We searched for publicly available mobile apps relating to dermatology education in the App Store (Apple Inc) from September to November 2019 using the search terms dermatology education, dermoscopy education, melanoma education, skin cancer education, psoriasis education, rosacea education, acne education, eczema education, dermal fillers education, and Mohs surgery education. We excluded apps that were not in English, were created for a conference, cost more than $5 to download, or did not include a specific dermatology education section. In this way, we hoped to evaluate apps that were relevant, accessible, and affordable.

We modeled our study after a review of patient education apps performed by Masud et al⁶ and utilized their quantified grading rubric (scale of 1 to 4). We found their established criteria—educational objectives, content, accuracy, design, and conflict of interest—to be equally applicable for evaluating apps designed for professional education.⁶ Each app earned a minimum of 1 point and a maximum of 4 points per criterion. One point was given if the app did not fulfill the criterion, 2 points for minimally fulfilling the criterion, 3 points for mostly fulfilling the criterion, and 4 points if the criterion was completely fulfilled. Two medical students (E.H. and N.C.)—one at the preclinical stage and the other at the clinical stage of medical education—reviewed the apps using the given rubric, then discussed and resolved any discrepancies in points assigned. A dermatology resident (M.A.) independently reviewed the apps using the given rubric.

The mean of the student score and the resident score was calculated for each category. The sum of the averages for each category was considered the final score for an app, determining its overall quality. Apps with a total score of 5 to 10 were considered poor and inadequate for education. A total score of 10.5 to 15 indicated that an app was somewhat adequate (ie, useful for education in some aspects but falling short in others). Apps that were considered adequate for education, across all or most criteria, received a total score ranging from 15.5 to 20.

Results

Our search generated 130 apps. After applying exclusion criteria, 42 apps were eligible for review. At the time of publication, 36 of these apps were still available. The possible range of scores based on the rubric was 5 to 20. The actual range of scores was 7 to 20. Of the 36 apps, 2 (5.6%) were poor, 16 (44.4%) were somewhat adequate, and 18 (50%) were adequate. Formats included primary resources, such as clinical decision support tools, journals, references, and a podcast (Table 1). Additionally, interactive learning tools included games, learning modules, and apps for self-evaluation (Table 2). Thirty apps covered general dermatology; others focused on skin cancer (n=5) and cosmetic dermatology (n=1). Regarding cost, 29 apps were free to download, whereas 7 charged a fee (mean price, $2.56).

Comment

In addition to the convenience of having an educational tool in their white-coat pocket, learners of dermatology have been shown to benefit from supplementing their curriculum with mobile apps, which sets the stage for formal integration of mobile apps into dermatology teaching in the future.⁸ Prior to widespread adoption, mobile apps must be evaluated for content and utility, starting with an objective rubric.

Without official scientific standards in place, it was unsurprising that only half of the dermatology education applications were classified as adequate in this study. Among the types of apps offered—clinical decision support tools, journals, references, podcast, games, learning modules, and self-evaluation—certain categories scored higher than others. App formats with the highest average score (16.5 out of 20) were journals and podcast.

One barrier to utilization of these apps was that a subscription to the journals and podcast was required to obtain access to all available content. Students and trainees can seek out library resources at their academic institutions to take advantage of journal subscriptions available to them at no additional cost. Dermatology residents can take advantage of their complimentary membership in the American Academy of Dermatology for a free subscription to AAD Dialogues in Dermatology (otherwise $179 annually for nonresident members and $320 annually for nonmembers).

On the other hand, learning module was the lowest-rated format (average score, 11.3 out of 20), with only Medical Student: Dermatology qualifying as adequate (total score, 16). This finding is worrisome given that students and residents might look to learning modules for quick targeted lessons on specific topics.

The lowest-scoring app, a clinical decision support tool called Naturelize, received a total score of 7. Although it listed the indications and contraindications for dermal filler types to be used in different locations on the face, there was a clear conflict of interest, oversimplified design, and little evidence-based education, mirroring the current state of cosmetic dermatology training in residency, in which trainees think they are inadequately prepared for aesthetic procedures and comparative effectiveness research is lacking.^9-11

At the opposite end of the spectrum, MyDermPath+ was a reference app with a total score of 20. The app cited credible authors with a medical degree (MD) and had an easy-to-use, well-designed interface, including a reference guide, differential builder, and quiz for a range of topics within dermatology. As a free download without in-app purchases or advertisements, there was no evidence of conflict of interest. The position of a dermatopathology app as the top dermatology education mobile app might reflect an increased emphasis on dermatopathology education in residency as well as a transition to digitization of slides.⁵

The second-highest scoring apps (total score of 19 points) were Dermatology Database and VisualDx. Both were references covering a wide range of dermatology topics. Dermatology Database was a comprehensive search tool for diseases, drugs, procedures, and terms that was simple and entirely free to use but did not cite references. VisualDx, as its name suggests, offered quality clinical images, complete guides with references, and a unique differential builder. An annual subscription is $399.99, but the process to gain free access through a participating academic institution was simple.

Games were a unique mobile app format; however, 2 of 3 games scored in the somewhat adequate range. The game DiagnosUs, which tested users’ ability to differentiate skin cancer and psoriasis from dermatitis on clinical images, would benefit from more comprehensive content as well as professional verification of true diagnoses, which earned the app 2 points in both the content and accuracy categories. The Unusual Suspects tested the ABCDE algorithm in a short learning module, followed by a simple game that involved identification of melanoma in a timed setting. Although the design was novel and interactive, the game was limited to the same 5 melanoma tumors overlaid on pictures of normal skin. The narrow scope earned 1 point for content, the redundancy in the game earned 3 points for design, and the lack of real clinical images earned 2 points for educational objectives. Although game-format mobile apps have the capability to challenge the user’s knowledge with a built-in feedback or reward system, improvements should be made to ensure that apps are equally educational as they are engaging.

AAD Dialogues in Dermatology was the only app in the form of a podcast and provided expert interviews along with disclosures, transcripts, commentary, and references. More than half the content in the app could not be accessed without a subscription, earning 2.5 points in the conflict of interest category. Additionally, several flaws resulted in a design score of 2.5, including inconsistent availability of transcripts, poor quality of sound on some episodes, difficulty distinguishing new episodes from those already played, and a glitch that removed the episode duration. Still, the app was a valuable and comprehensive resource, with clear objectives and cited references. With improvements in content, affordability, and user experience, apps in unique formats such as games and podcasts might appeal to kinesthetic and auditory learners.

An important factor to consider when discussing mobile apps for students and residents is cost. With rising prices of board examinations and preparation materials, supplementary study tools should not come with an exorbitant price tag. Therefore, we limited our evaluation to apps that were free or cost less than $5 to download. Even so, subscriptions and other in-app purchases were an obstacle in one-third of apps, ranging from $4.99 to unlock additional content in Rash Decisions to $69.99 to access most topics in Fitzpatrick’s Color Atlas. The highest-rated app in our study, MyDermPath+, historically cost $19.99 to download but became free with a grant from the Sulzberger Foundation.¹² An initial investment to develop quality apps for the purpose of dermatology education might pay off in the end.

To evaluate the apps from the perspective of the target demographic of this study, 2 medical students—one in the preclinical stage and the other in the clinical stage of medical education—and a dermatology resident graded the apps. Certain limitations exist in this type of study, including differing learning styles, which might influence the types of apps that evaluators found most impactful to their education. Interestingly, some apps earned a higher resident score than student score. In particular, RightSite (a reference that helps with anatomically correct labeling) and Mohs Surgery Appropriate Use Criteria (a clinical decision support tool to determine whether to perform Mohs surgery) each had a 3-point discrepancy (data not shown). A resident might benefit from these practical apps in day-to-day practice, but a student would be less likely to find them useful as a learning tool.

Still, by defining adequate teaching value using specific categories of educational objectives, content, accuracy, design, and conflict of interest, we attempted to minimize the effect of personal preference on the grading process. Although we acknowledge a degree of subjectivity, we found that utilizing a previously published rubric with defined criteria was crucial in remaining unbiased.

Conclusion

Further studies should evaluate additional apps available on Apple’s iPad (tablet), as well as those on other operating systems, including Google’s Android. To ensure the existence of mobile apps as adequate education tools, they should be peer reviewed prior to publication or before widespread use by future and current providers at the minimum. To maximize free access to highly valuable resources available in the palm of their hand, students and trainees should contact the library at their academic institution.

With today’s technology, it is easier than ever to access web-based tools that enrich traditional dermatology education. The literature supports the use of these innovative platforms to enhance learning at the student and trainee levels. A controlled study of pediatric residents showed that online modules effectively supplemented clinical experience with atopic dermatitis.¹ In a randomized diagnostic study of medical students, practice with an image-based web application (app) that teaches rapid recognition of melanoma proved more effective than learning a rule-based algorithm.² Given the visual nature of dermatology, pattern recognition is an essential skill that is fostered through experience and is only made more accessible with technology.

With the added benefit of convenience and accessibility, mobile apps can supplement experiential learning. Mirroring the overall growth of mobile apps, the number of available dermatology apps has increased.³ Dermatology mobile apps serve purposes ranging from quick reference tools to comprehensive modules, journals, and question banks. At an academic hospital in Taiwan, both nondermatology and dermatology trainees’ examination performance improved after 3 weeks of using a smartphone-based wallpaper learning module displaying morphologic characteristics of fungi.⁴ With the expansion of virtual microscopy, mobile apps also have been created as a learning tool for dermatopathology, giving trainees the flexibility and autonomy to view slides on their own time.⁵ Nevertheless, the literature on dermatology mobile apps designed for the education of medical students and trainees is limited, demonstrating a need for further investigation.

Prior studies have reviewed dermatology apps for patients and practicing dermatologists.^6-8 Herein, we focus on mobile apps targeting students and residents learning dermatology. General dermatology reference apps and educational aid apps have grown by 33% and 32%, respectively, from 2014 to 2017.³ As with any resource meant to educate future and current medical providers, there must be an objective review process in place to ensure accurate, unbiased, evidence-based teaching.

Well-organized, comprehensive information and a user-friendly interface are additional factors of importance when selecting an educational mobile app. When discussing supplemental resources, accessibility and affordability also are priorities given the high cost of a medical education at baseline. Overall, there is a need for a standardized method to evaluate the key factors of an educational mobile app that make it appropriate for this demographic. We conducted a search of mobile apps relating to dermatology education for students and residents.

Methods

We searched for publicly available mobile apps relating to dermatology education in the App Store (Apple Inc) from September to November 2019 using the search terms dermatology education, dermoscopy education, melanoma education, skin cancer education, psoriasis education, rosacea education, acne education, eczema education, dermal fillers education, and Mohs surgery education. We excluded apps that were not in English, were created for a conference, cost more than $5 to download, or did not include a specific dermatology education section. In this way, we hoped to evaluate apps that were relevant, accessible, and affordable.

We modeled our study after a review of patient education apps performed by Masud et al⁶ and utilized their quantified grading rubric (scale of 1 to 4). We found their established criteria—educational objectives, content, accuracy, design, and conflict of interest—to be equally applicable for evaluating apps designed for professional education.⁶ Each app earned a minimum of 1 point and a maximum of 4 points per criterion. One point was given if the app did not fulfill the criterion, 2 points for minimally fulfilling the criterion, 3 points for mostly fulfilling the criterion, and 4 points if the criterion was completely fulfilled. Two medical students (E.H. and N.C.)—one at the preclinical stage and the other at the clinical stage of medical education—reviewed the apps using the given rubric, then discussed and resolved any discrepancies in points assigned. A dermatology resident (M.A.) independently reviewed the apps using the given rubric.

The mean of the student score and the resident score was calculated for each category. The sum of the averages for each category was considered the final score for an app, determining its overall quality. Apps with a total score of 5 to 10 were considered poor and inadequate for education. A total score of 10.5 to 15 indicated that an app was somewhat adequate (ie, useful for education in some aspects but falling short in others). Apps that were considered adequate for education, across all or most criteria, received a total score ranging from 15.5 to 20.

Results

Our search generated 130 apps. After applying exclusion criteria, 42 apps were eligible for review. At the time of publication, 36 of these apps were still available. The possible range of scores based on the rubric was 5 to 20. The actual range of scores was 7 to 20. Of the 36 apps, 2 (5.6%) were poor, 16 (44.4%) were somewhat adequate, and 18 (50%) were adequate. Formats included primary resources, such as clinical decision support tools, journals, references, and a podcast (Table 1). Additionally, interactive learning tools included games, learning modules, and apps for self-evaluation (Table 2). Thirty apps covered general dermatology; others focused on skin cancer (n=5) and cosmetic dermatology (n=1). Regarding cost, 29 apps were free to download, whereas 7 charged a fee (mean price, $2.56).

Comment

In addition to the convenience of having an educational tool in their white-coat pocket, learners of dermatology have been shown to benefit from supplementing their curriculum with mobile apps, which sets the stage for formal integration of mobile apps into dermatology teaching in the future.⁸ Prior to widespread adoption, mobile apps must be evaluated for content and utility, starting with an objective rubric.

Without official scientific standards in place, it was unsurprising that only half of the dermatology education applications were classified as adequate in this study. Among the types of apps offered—clinical decision support tools, journals, references, podcast, games, learning modules, and self-evaluation—certain categories scored higher than others. App formats with the highest average score (16.5 out of 20) were journals and podcast.

One barrier to utilization of these apps was that a subscription to the journals and podcast was required to obtain access to all available content. Students and trainees can seek out library resources at their academic institutions to take advantage of journal subscriptions available to them at no additional cost. Dermatology residents can take advantage of their complimentary membership in the American Academy of Dermatology for a free subscription to AAD Dialogues in Dermatology (otherwise $179 annually for nonresident members and $320 annually for nonmembers).

On the other hand, learning module was the lowest-rated format (average score, 11.3 out of 20), with only Medical Student: Dermatology qualifying as adequate (total score, 16). This finding is worrisome given that students and residents might look to learning modules for quick targeted lessons on specific topics.

The lowest-scoring app, a clinical decision support tool called Naturelize, received a total score of 7. Although it listed the indications and contraindications for dermal filler types to be used in different locations on the face, there was a clear conflict of interest, oversimplified design, and little evidence-based education, mirroring the current state of cosmetic dermatology training in residency, in which trainees think they are inadequately prepared for aesthetic procedures and comparative effectiveness research is lacking.^9-11

At the opposite end of the spectrum, MyDermPath+ was a reference app with a total score of 20. The app cited credible authors with a medical degree (MD) and had an easy-to-use, well-designed interface, including a reference guide, differential builder, and quiz for a range of topics within dermatology. As a free download without in-app purchases or advertisements, there was no evidence of conflict of interest. The position of a dermatopathology app as the top dermatology education mobile app might reflect an increased emphasis on dermatopathology education in residency as well as a transition to digitization of slides.⁵

The second-highest scoring apps (total score of 19 points) were Dermatology Database and VisualDx. Both were references covering a wide range of dermatology topics. Dermatology Database was a comprehensive search tool for diseases, drugs, procedures, and terms that was simple and entirely free to use but did not cite references. VisualDx, as its name suggests, offered quality clinical images, complete guides with references, and a unique differential builder. An annual subscription is $399.99, but the process to gain free access through a participating academic institution was simple.

Games were a unique mobile app format; however, 2 of 3 games scored in the somewhat adequate range. The game DiagnosUs, which tested users’ ability to differentiate skin cancer and psoriasis from dermatitis on clinical images, would benefit from more comprehensive content as well as professional verification of true diagnoses, which earned the app 2 points in both the content and accuracy categories. The Unusual Suspects tested the ABCDE algorithm in a short learning module, followed by a simple game that involved identification of melanoma in a timed setting. Although the design was novel and interactive, the game was limited to the same 5 melanoma tumors overlaid on pictures of normal skin. The narrow scope earned 1 point for content, the redundancy in the game earned 3 points for design, and the lack of real clinical images earned 2 points for educational objectives. Although game-format mobile apps have the capability to challenge the user’s knowledge with a built-in feedback or reward system, improvements should be made to ensure that apps are equally educational as they are engaging.

AAD Dialogues in Dermatology was the only app in the form of a podcast and provided expert interviews along with disclosures, transcripts, commentary, and references. More than half the content in the app could not be accessed without a subscription, earning 2.5 points in the conflict of interest category. Additionally, several flaws resulted in a design score of 2.5, including inconsistent availability of transcripts, poor quality of sound on some episodes, difficulty distinguishing new episodes from those already played, and a glitch that removed the episode duration. Still, the app was a valuable and comprehensive resource, with clear objectives and cited references. With improvements in content, affordability, and user experience, apps in unique formats such as games and podcasts might appeal to kinesthetic and auditory learners.

An important factor to consider when discussing mobile apps for students and residents is cost. With rising prices of board examinations and preparation materials, supplementary study tools should not come with an exorbitant price tag. Therefore, we limited our evaluation to apps that were free or cost less than $5 to download. Even so, subscriptions and other in-app purchases were an obstacle in one-third of apps, ranging from $4.99 to unlock additional content in Rash Decisions to $69.99 to access most topics in Fitzpatrick’s Color Atlas. The highest-rated app in our study, MyDermPath+, historically cost $19.99 to download but became free with a grant from the Sulzberger Foundation.¹² An initial investment to develop quality apps for the purpose of dermatology education might pay off in the end.

To evaluate the apps from the perspective of the target demographic of this study, 2 medical students—one in the preclinical stage and the other in the clinical stage of medical education—and a dermatology resident graded the apps. Certain limitations exist in this type of study, including differing learning styles, which might influence the types of apps that evaluators found most impactful to their education. Interestingly, some apps earned a higher resident score than student score. In particular, RightSite (a reference that helps with anatomically correct labeling) and Mohs Surgery Appropriate Use Criteria (a clinical decision support tool to determine whether to perform Mohs surgery) each had a 3-point discrepancy (data not shown). A resident might benefit from these practical apps in day-to-day practice, but a student would be less likely to find them useful as a learning tool.

Still, by defining adequate teaching value using specific categories of educational objectives, content, accuracy, design, and conflict of interest, we attempted to minimize the effect of personal preference on the grading process. Although we acknowledge a degree of subjectivity, we found that utilizing a previously published rubric with defined criteria was crucial in remaining unbiased.

Conclusion

Further studies should evaluate additional apps available on Apple’s iPad (tablet), as well as those on other operating systems, including Google’s Android. To ensure the existence of mobile apps as adequate education tools, they should be peer reviewed prior to publication or before widespread use by future and current providers at the minimum. To maximize free access to highly valuable resources available in the palm of their hand, students and trainees should contact the library at their academic institution.

With today’s technology, it is easier than ever to access web-based tools that enrich traditional dermatology education. The literature supports the use of these innovative platforms to enhance learning at the student and trainee levels. A controlled study of pediatric residents showed that online modules effectively supplemented clinical experience with atopic dermatitis.¹ In a randomized diagnostic study of medical students, practice with an image-based web application (app) that teaches rapid recognition of melanoma proved more effective than learning a rule-based algorithm.² Given the visual nature of dermatology, pattern recognition is an essential skill that is fostered through experience and is only made more accessible with technology.

With the added benefit of convenience and accessibility, mobile apps can supplement experiential learning. Mirroring the overall growth of mobile apps, the number of available dermatology apps has increased.³ Dermatology mobile apps serve purposes ranging from quick reference tools to comprehensive modules, journals, and question banks. At an academic hospital in Taiwan, both nondermatology and dermatology trainees’ examination performance improved after 3 weeks of using a smartphone-based wallpaper learning module displaying morphologic characteristics of fungi.⁴ With the expansion of virtual microscopy, mobile apps also have been created as a learning tool for dermatopathology, giving trainees the flexibility and autonomy to view slides on their own time.⁵ Nevertheless, the literature on dermatology mobile apps designed for the education of medical students and trainees is limited, demonstrating a need for further investigation.

Prior studies have reviewed dermatology apps for patients and practicing dermatologists.^6-8 Herein, we focus on mobile apps targeting students and residents learning dermatology. General dermatology reference apps and educational aid apps have grown by 33% and 32%, respectively, from 2014 to 2017.³ As with any resource meant to educate future and current medical providers, there must be an objective review process in place to ensure accurate, unbiased, evidence-based teaching.

Well-organized, comprehensive information and a user-friendly interface are additional factors of importance when selecting an educational mobile app. When discussing supplemental resources, accessibility and affordability also are priorities given the high cost of a medical education at baseline. Overall, there is a need for a standardized method to evaluate the key factors of an educational mobile app that make it appropriate for this demographic. We conducted a search of mobile apps relating to dermatology education for students and residents.

Methods

We searched for publicly available mobile apps relating to dermatology education in the App Store (Apple Inc) from September to November 2019 using the search terms dermatology education, dermoscopy education, melanoma education, skin cancer education, psoriasis education, rosacea education, acne education, eczema education, dermal fillers education, and Mohs surgery education. We excluded apps that were not in English, were created for a conference, cost more than $5 to download, or did not include a specific dermatology education section. In this way, we hoped to evaluate apps that were relevant, accessible, and affordable.

We modeled our study after a review of patient education apps performed by Masud et al⁶ and utilized their quantified grading rubric (scale of 1 to 4). We found their established criteria—educational objectives, content, accuracy, design, and conflict of interest—to be equally applicable for evaluating apps designed for professional education.⁶ Each app earned a minimum of 1 point and a maximum of 4 points per criterion. One point was given if the app did not fulfill the criterion, 2 points for minimally fulfilling the criterion, 3 points for mostly fulfilling the criterion, and 4 points if the criterion was completely fulfilled. Two medical students (E.H. and N.C.)—one at the preclinical stage and the other at the clinical stage of medical education—reviewed the apps using the given rubric, then discussed and resolved any discrepancies in points assigned. A dermatology resident (M.A.) independently reviewed the apps using the given rubric.

The mean of the student score and the resident score was calculated for each category. The sum of the averages for each category was considered the final score for an app, determining its overall quality. Apps with a total score of 5 to 10 were considered poor and inadequate for education. A total score of 10.5 to 15 indicated that an app was somewhat adequate (ie, useful for education in some aspects but falling short in others). Apps that were considered adequate for education, across all or most criteria, received a total score ranging from 15.5 to 20.

Results

Our search generated 130 apps. After applying exclusion criteria, 42 apps were eligible for review. At the time of publication, 36 of these apps were still available. The possible range of scores based on the rubric was 5 to 20. The actual range of scores was 7 to 20. Of the 36 apps, 2 (5.6%) were poor, 16 (44.4%) were somewhat adequate, and 18 (50%) were adequate. Formats included primary resources, such as clinical decision support tools, journals, references, and a podcast (Table 1). Additionally, interactive learning tools included games, learning modules, and apps for self-evaluation (Table 2). Thirty apps covered general dermatology; others focused on skin cancer (n=5) and cosmetic dermatology (n=1). Regarding cost, 29 apps were free to download, whereas 7 charged a fee (mean price, $2.56).

Comment

In addition to the convenience of having an educational tool in their white-coat pocket, learners of dermatology have been shown to benefit from supplementing their curriculum with mobile apps, which sets the stage for formal integration of mobile apps into dermatology teaching in the future.⁸ Prior to widespread adoption, mobile apps must be evaluated for content and utility, starting with an objective rubric.

Without official scientific standards in place, it was unsurprising that only half of the dermatology education applications were classified as adequate in this study. Among the types of apps offered—clinical decision support tools, journals, references, podcast, games, learning modules, and self-evaluation—certain categories scored higher than others. App formats with the highest average score (16.5 out of 20) were journals and podcast.

One barrier to utilization of these apps was that a subscription to the journals and podcast was required to obtain access to all available content. Students and trainees can seek out library resources at their academic institutions to take advantage of journal subscriptions available to them at no additional cost. Dermatology residents can take advantage of their complimentary membership in the American Academy of Dermatology for a free subscription to AAD Dialogues in Dermatology (otherwise $179 annually for nonresident members and $320 annually for nonmembers).

On the other hand, learning module was the lowest-rated format (average score, 11.3 out of 20), with only Medical Student: Dermatology qualifying as adequate (total score, 16). This finding is worrisome given that students and residents might look to learning modules for quick targeted lessons on specific topics.

The lowest-scoring app, a clinical decision support tool called Naturelize, received a total score of 7. Although it listed the indications and contraindications for dermal filler types to be used in different locations on the face, there was a clear conflict of interest, oversimplified design, and little evidence-based education, mirroring the current state of cosmetic dermatology training in residency, in which trainees think they are inadequately prepared for aesthetic procedures and comparative effectiveness research is lacking.^9-11

At the opposite end of the spectrum, MyDermPath+ was a reference app with a total score of 20. The app cited credible authors with a medical degree (MD) and had an easy-to-use, well-designed interface, including a reference guide, differential builder, and quiz for a range of topics within dermatology. As a free download without in-app purchases or advertisements, there was no evidence of conflict of interest. The position of a dermatopathology app as the top dermatology education mobile app might reflect an increased emphasis on dermatopathology education in residency as well as a transition to digitization of slides.⁵

The second-highest scoring apps (total score of 19 points) were Dermatology Database and VisualDx. Both were references covering a wide range of dermatology topics. Dermatology Database was a comprehensive search tool for diseases, drugs, procedures, and terms that was simple and entirely free to use but did not cite references. VisualDx, as its name suggests, offered quality clinical images, complete guides with references, and a unique differential builder. An annual subscription is $399.99, but the process to gain free access through a participating academic institution was simple.

Games were a unique mobile app format; however, 2 of 3 games scored in the somewhat adequate range. The game DiagnosUs, which tested users’ ability to differentiate skin cancer and psoriasis from dermatitis on clinical images, would benefit from more comprehensive content as well as professional verification of true diagnoses, which earned the app 2 points in both the content and accuracy categories. The Unusual Suspects tested the ABCDE algorithm in a short learning module, followed by a simple game that involved identification of melanoma in a timed setting. Although the design was novel and interactive, the game was limited to the same 5 melanoma tumors overlaid on pictures of normal skin. The narrow scope earned 1 point for content, the redundancy in the game earned 3 points for design, and the lack of real clinical images earned 2 points for educational objectives. Although game-format mobile apps have the capability to challenge the user’s knowledge with a built-in feedback or reward system, improvements should be made to ensure that apps are equally educational as they are engaging.

AAD Dialogues in Dermatology was the only app in the form of a podcast and provided expert interviews along with disclosures, transcripts, commentary, and references. More than half the content in the app could not be accessed without a subscription, earning 2.5 points in the conflict of interest category. Additionally, several flaws resulted in a design score of 2.5, including inconsistent availability of transcripts, poor quality of sound on some episodes, difficulty distinguishing new episodes from those already played, and a glitch that removed the episode duration. Still, the app was a valuable and comprehensive resource, with clear objectives and cited references. With improvements in content, affordability, and user experience, apps in unique formats such as games and podcasts might appeal to kinesthetic and auditory learners.

An important factor to consider when discussing mobile apps for students and residents is cost. With rising prices of board examinations and preparation materials, supplementary study tools should not come with an exorbitant price tag. Therefore, we limited our evaluation to apps that were free or cost less than $5 to download. Even so, subscriptions and other in-app purchases were an obstacle in one-third of apps, ranging from $4.99 to unlock additional content in Rash Decisions to $69.99 to access most topics in Fitzpatrick’s Color Atlas. The highest-rated app in our study, MyDermPath+, historically cost $19.99 to download but became free with a grant from the Sulzberger Foundation.¹² An initial investment to develop quality apps for the purpose of dermatology education might pay off in the end.

To evaluate the apps from the perspective of the target demographic of this study, 2 medical students—one in the preclinical stage and the other in the clinical stage of medical education—and a dermatology resident graded the apps. Certain limitations exist in this type of study, including differing learning styles, which might influence the types of apps that evaluators found most impactful to their education. Interestingly, some apps earned a higher resident score than student score. In particular, RightSite (a reference that helps with anatomically correct labeling) and Mohs Surgery Appropriate Use Criteria (a clinical decision support tool to determine whether to perform Mohs surgery) each had a 3-point discrepancy (data not shown). A resident might benefit from these practical apps in day-to-day practice, but a student would be less likely to find them useful as a learning tool.

Still, by defining adequate teaching value using specific categories of educational objectives, content, accuracy, design, and conflict of interest, we attempted to minimize the effect of personal preference on the grading process. Although we acknowledge a degree of subjectivity, we found that utilizing a previously published rubric with defined criteria was crucial in remaining unbiased.

Conclusion

Further studies should evaluate additional apps available on Apple’s iPad (tablet), as well as those on other operating systems, including Google’s Android. To ensure the existence of mobile apps as adequate education tools, they should be peer reviewed prior to publication or before widespread use by future and current providers at the minimum. To maximize free access to highly valuable resources available in the palm of their hand, students and trainees should contact the library at their academic institution.

The coronavirus disease 2019 (COVID-19) pandemic has evoked extreme fear at a collective level. In the current health care climate of quick fixes and high-acuity workloads, there is a potential to value efficiency over the process. Such demands can endanger clinicians’ internal emotional needs, create conflicts, and potentially impact their relationships with patients and families. What does this mean for a psychiatry trainee? Here I share some insights about death anxiety, and how psychiatry training promotes self-reflection, which shapes our relationship with death.

The far-reaching effects of death anxiety

Postgraduate psychiatry training may expose one to stressful situations with adverse psychologic consequences.¹ Further­more, when caring for patients, psychiatry trainees frequently need to face issues of death and dying in the form of suicide risk assessments, grief and bereavement processes, near-death experiences, posttraumatic stress disorder, and psycho-oncology rotations. Because these interactions are incredibly personal, the emotions they provoke inevitably affect every interaction, theoretical discussion, diagnostic work-up, and treatment plan.

How each of us experiences death anxiety is unique. For some, it could be a fear of nonexistence, ultimate loss, disruption of the flow of life, worry about leaving loved ones behind, or fear of pain or loneliness in dying. Some might fear an untimely or violent death and subsequent judgment and retributions. The literature suggests that fear of death may be at the root of various mental health problems and, if left unaddressed, may adversely impact long-term treatment outcomes.² Despite this, many standard treatment approaches typically do not target death anxiety, which potentially contributes to a “revolving door” of mental health problems.³

American existential psychiatrist Irvin Yalom, MD, cautioned psychiatrists not to “scratch where it does not itch.”⁴ Yet death, according to Dr. Yalom, does itch. Violent death is that caused by human intent or negligence, and is characterized by feeling helpless and terrorized at the time of dying. It may occur as an acute incident that denies the dying individual and his/her family members the time and space to prepare for the death.⁵ For survivors, accommodating the mental, emotional, psychological, and spiritual effects of violent death is a complex process that rarely has a conclusion. It often is accompanied by survivors’ guilt, which is replayed in the form of flashbacks and nightmares.⁶ With this understanding, I view COVID-19 deaths as violent deaths.

Pay close attention to countertransference

As much as we influence our patients and their families, we also are profoundly influenced by them. We need to pay attention to any feelings our clinical encounters generate within us, and to carefully use these feelings in our clinical judgment, and not just make causal inferences. For instance, if a clinician thinks that a patient with suicidal ideation would be better off dead, these feelings are a reliable indicator that the patient is, indeed, at a high risk of completing suicide.⁷ It is our ethical and moral responsibility towards our patients to listen to our countertransference responses. The aim is to identify countertransference and use it to inform us, not to rule us. By taking an active role in managing our emotional responses in the face of loss, we can harness the spirit of resilience. This is not always as easy as it seems. We need our peers, experienced clinicians, and supervisors to help us explore our feelings, resistances, and counter­transference reactions.

Strategies to combat burnout

Psychiatric trainees must be encouraged to establish and maintain rigorous plans of self-care to prevent compassion fatigue and burnout. Most importantly, training programs must diversify residents’ clinical exposure by providing activities that promote mental health promotion activities, scholarly endeavors, and peer support groups. This will help trainees to restore meaning and purpose in life beyond.

The coronavirus disease 2019 (COVID-19) pandemic has evoked extreme fear at a collective level. In the current health care climate of quick fixes and high-acuity workloads, there is a potential to value efficiency over the process. Such demands can endanger clinicians’ internal emotional needs, create conflicts, and potentially impact their relationships with patients and families. What does this mean for a psychiatry trainee? Here I share some insights about death anxiety, and how psychiatry training promotes self-reflection, which shapes our relationship with death.

The far-reaching effects of death anxiety

Postgraduate psychiatry training may expose one to stressful situations with adverse psychologic consequences.¹ Further­more, when caring for patients, psychiatry trainees frequently need to face issues of death and dying in the form of suicide risk assessments, grief and bereavement processes, near-death experiences, posttraumatic stress disorder, and psycho-oncology rotations. Because these interactions are incredibly personal, the emotions they provoke inevitably affect every interaction, theoretical discussion, diagnostic work-up, and treatment plan.

How each of us experiences death anxiety is unique. For some, it could be a fear of nonexistence, ultimate loss, disruption of the flow of life, worry about leaving loved ones behind, or fear of pain or loneliness in dying. Some might fear an untimely or violent death and subsequent judgment and retributions. The literature suggests that fear of death may be at the root of various mental health problems and, if left unaddressed, may adversely impact long-term treatment outcomes.² Despite this, many standard treatment approaches typically do not target death anxiety, which potentially contributes to a “revolving door” of mental health problems.³

American existential psychiatrist Irvin Yalom, MD, cautioned psychiatrists not to “scratch where it does not itch.”⁴ Yet death, according to Dr. Yalom, does itch. Violent death is that caused by human intent or negligence, and is characterized by feeling helpless and terrorized at the time of dying. It may occur as an acute incident that denies the dying individual and his/her family members the time and space to prepare for the death.⁵ For survivors, accommodating the mental, emotional, psychological, and spiritual effects of violent death is a complex process that rarely has a conclusion. It often is accompanied by survivors’ guilt, which is replayed in the form of flashbacks and nightmares.⁶ With this understanding, I view COVID-19 deaths as violent deaths.

Pay close attention to countertransference

As much as we influence our patients and their families, we also are profoundly influenced by them. We need to pay attention to any feelings our clinical encounters generate within us, and to carefully use these feelings in our clinical judgment, and not just make causal inferences. For instance, if a clinician thinks that a patient with suicidal ideation would be better off dead, these feelings are a reliable indicator that the patient is, indeed, at a high risk of completing suicide.⁷ It is our ethical and moral responsibility towards our patients to listen to our countertransference responses. The aim is to identify countertransference and use it to inform us, not to rule us. By taking an active role in managing our emotional responses in the face of loss, we can harness the spirit of resilience. This is not always as easy as it seems. We need our peers, experienced clinicians, and supervisors to help us explore our feelings, resistances, and counter­transference reactions.

Strategies to combat burnout

Psychiatric trainees must be encouraged to establish and maintain rigorous plans of self-care to prevent compassion fatigue and burnout. Most importantly, training programs must diversify residents’ clinical exposure by providing activities that promote mental health promotion activities, scholarly endeavors, and peer support groups. This will help trainees to restore meaning and purpose in life beyond.

The coronavirus disease 2019 (COVID-19) pandemic has evoked extreme fear at a collective level. In the current health care climate of quick fixes and high-acuity workloads, there is a potential to value efficiency over the process. Such demands can endanger clinicians’ internal emotional needs, create conflicts, and potentially impact their relationships with patients and families. What does this mean for a psychiatry trainee? Here I share some insights about death anxiety, and how psychiatry training promotes self-reflection, which shapes our relationship with death.

The far-reaching effects of death anxiety

Postgraduate psychiatry training may expose one to stressful situations with adverse psychologic consequences.¹ Further­more, when caring for patients, psychiatry trainees frequently need to face issues of death and dying in the form of suicide risk assessments, grief and bereavement processes, near-death experiences, posttraumatic stress disorder, and psycho-oncology rotations. Because these interactions are incredibly personal, the emotions they provoke inevitably affect every interaction, theoretical discussion, diagnostic work-up, and treatment plan.

How each of us experiences death anxiety is unique. For some, it could be a fear of nonexistence, ultimate loss, disruption of the flow of life, worry about leaving loved ones behind, or fear of pain or loneliness in dying. Some might fear an untimely or violent death and subsequent judgment and retributions. The literature suggests that fear of death may be at the root of various mental health problems and, if left unaddressed, may adversely impact long-term treatment outcomes.² Despite this, many standard treatment approaches typically do not target death anxiety, which potentially contributes to a “revolving door” of mental health problems.³

American existential psychiatrist Irvin Yalom, MD, cautioned psychiatrists not to “scratch where it does not itch.”⁴ Yet death, according to Dr. Yalom, does itch. Violent death is that caused by human intent or negligence, and is characterized by feeling helpless and terrorized at the time of dying. It may occur as an acute incident that denies the dying individual and his/her family members the time and space to prepare for the death.⁵ For survivors, accommodating the mental, emotional, psychological, and spiritual effects of violent death is a complex process that rarely has a conclusion. It often is accompanied by survivors’ guilt, which is replayed in the form of flashbacks and nightmares.⁶ With this understanding, I view COVID-19 deaths as violent deaths.

Pay close attention to countertransference

As much as we influence our patients and their families, we also are profoundly influenced by them. We need to pay attention to any feelings our clinical encounters generate within us, and to carefully use these feelings in our clinical judgment, and not just make causal inferences. For instance, if a clinician thinks that a patient with suicidal ideation would be better off dead, these feelings are a reliable indicator that the patient is, indeed, at a high risk of completing suicide.⁷ It is our ethical and moral responsibility towards our patients to listen to our countertransference responses. The aim is to identify countertransference and use it to inform us, not to rule us. By taking an active role in managing our emotional responses in the face of loss, we can harness the spirit of resilience. This is not always as easy as it seems. We need our peers, experienced clinicians, and supervisors to help us explore our feelings, resistances, and counter­transference reactions.

Strategies to combat burnout

Psychiatric trainees must be encouraged to establish and maintain rigorous plans of self-care to prevent compassion fatigue and burnout. Most importantly, training programs must diversify residents’ clinical exposure by providing activities that promote mental health promotion activities, scholarly endeavors, and peer support groups. This will help trainees to restore meaning and purpose in life beyond.

As a psychiatry resident in the age of coronavirus disease 2019 (COVID-19), many of my educational experiences have undergone adjustments. Now, as I interview for a fellowship, I see firsthand that recruitment activities have not been spared from shifting paradigms levied by the pandemic. To adhere to social distancing guidelines and limit trainee interpersonal exposure, the American Association of Directors of Psychiatric Residency Training recommended that all psychiatry residency interviews be conducted virtually for 2020/2021.¹ Trainees and programs alike are embarking on a new frontier of virtual interviews, and it is important that we evaluate the advantages and disadvantages of this approach. Because uncertainty abounds regarding when a sense of normalcy might eventually return to psychiatry residency and fellowship recruitment activities, I also provide recommendations to interviewers and interviewees who may navigate virtual recruitment in the future.

Advantages of virtual interviews

An immediately significant advantage of virtual interviews is the lack of travel, which for some applicants can be cost-prohibitive. The costs of airfare, rental vehicles, and lodging in multiple cities can add up, sometimes requiring students to budget interview travel into already-high student loans. In some cases, applicants may have limited days to interview, which makes the flexibility afforded by the lack of travel advantageous. Furthermore, navigating new locations can add to preexisting interview stress. Without travel, applicants can consider a broader set of programs and accept more interviews.

Another advantage is that virtual interviews allow interviewees latitude to shift the interview’s “frame.” Rather than sitting in an interviewer’s office, interviewees can choose a more comfortable environment for themselves, imparting a “home-field advantage” that may put them at ease. During my fellowship interviews, controlling the room temperature, using a familiar chair, and wearing comfortable shoes helped to reduce the anxiety inherent to interviewing.

Disadvantages of virtual interviews

Any new or unfamiliar experience can impart challenges. For example, applicants and interviewers must adjust to and observe different sets of etiquette during virtual interviews. These include muting microphones to avoid talking over each other, maintaining consistent eye contact, avoiding multitasking, and following up to avoid miscommunication.

Another potential problem is that virtual interviews can dampen an applicant’s ability to appreciate a program’s culture. Observing informal interactions between trainees and faculty is often as important as the formal interviews in ascertaining which programs have a supportive culture. Because my virtual fellowship interviews have generally been limited to formal one-on-one interviews, assessing program culture has become more challenging. Conversely, programs may find it difficult to grasp an applicant’s temperament and interaction style.

Virtual interviewing, while undeniably convenient in many regards, may fall prey to its own convenience. There can be disparities in the quantity, duration, and frequency of interviews. For me, the number of and time allotted for interviews has varied widely, ranging from 2.5 to 8 hours. The amount of allotted break time has also differed, with some programs providing longer breaks between interviews (30 to 60 minutes) and others offering shorter (5 to 10 minutes) or no breaks. Minimal breaks may fatigue applicants, while longer breaks may seem like wasted time. While virtual interviews may require no physical travel between offices, breaks are a necessity that should be implemented thoughtfully.

Finally, a troublesome challenge I encountered surprisingly often was unreliable internet service and other technical difficulties. Several times, my interviewers’ (or my) screen froze or shut off due to connectivity issues. This is an obstacle unique to virtual interviews that requires both a backup plan as well as patience and calm to navigate during an already taxing situation.

Continue to: What's next?

What’s next?

As applicants and programs adjust to the realities of virtual interviewing, this is likely an unfamiliar experience for all. While the benefits and shortcomings must be considered together, I, along with many of my peers,² continue to prefer traditional in-person interviews. As the ongoing COVID-19 pandemic makes in-person interviews difficult, applicants and programs must embrace the experience of virtual interviews. However, a good understanding of the advantages and disadvantages are instrumental in preempting prospective challenges. Based on my recent experiences with virtual fellowship interviews, I have created some recommendations for applicants and psychiatry programs participating in virtual recruitment (Table).

After the COVID-19 pandemic subsides, it is conceivable that the advantages of virtual interviewing may justify its continued use. For example, applicants may be able to apply to geographically diverse programs without travel expenses. Currently, there is a paucity of evidence regarding virtual interviews specifically in psychiatry training programs, but the experiences of both applicants and psychiatry programs during this atypical time will allow us to improve the process going forward, and evaluate its utility well after COVID-19 recedes.

As a psychiatry resident in the age of coronavirus disease 2019 (COVID-19), many of my educational experiences have undergone adjustments. Now, as I interview for a fellowship, I see firsthand that recruitment activities have not been spared from shifting paradigms levied by the pandemic. To adhere to social distancing guidelines and limit trainee interpersonal exposure, the American Association of Directors of Psychiatric Residency Training recommended that all psychiatry residency interviews be conducted virtually for 2020/2021.¹ Trainees and programs alike are embarking on a new frontier of virtual interviews, and it is important that we evaluate the advantages and disadvantages of this approach. Because uncertainty abounds regarding when a sense of normalcy might eventually return to psychiatry residency and fellowship recruitment activities, I also provide recommendations to interviewers and interviewees who may navigate virtual recruitment in the future.

Advantages of virtual interviews

An immediately significant advantage of virtual interviews is the lack of travel, which for some applicants can be cost-prohibitive. The costs of airfare, rental vehicles, and lodging in multiple cities can add up, sometimes requiring students to budget interview travel into already-high student loans. In some cases, applicants may have limited days to interview, which makes the flexibility afforded by the lack of travel advantageous. Furthermore, navigating new locations can add to preexisting interview stress. Without travel, applicants can consider a broader set of programs and accept more interviews.

Another advantage is that virtual interviews allow interviewees latitude to shift the interview’s “frame.” Rather than sitting in an interviewer’s office, interviewees can choose a more comfortable environment for themselves, imparting a “home-field advantage” that may put them at ease. During my fellowship interviews, controlling the room temperature, using a familiar chair, and wearing comfortable shoes helped to reduce the anxiety inherent to interviewing.

Disadvantages of virtual interviews

Any new or unfamiliar experience can impart challenges. For example, applicants and interviewers must adjust to and observe different sets of etiquette during virtual interviews. These include muting microphones to avoid talking over each other, maintaining consistent eye contact, avoiding multitasking, and following up to avoid miscommunication.

Another potential problem is that virtual interviews can dampen an applicant’s ability to appreciate a program’s culture. Observing informal interactions between trainees and faculty is often as important as the formal interviews in ascertaining which programs have a supportive culture. Because my virtual fellowship interviews have generally been limited to formal one-on-one interviews, assessing program culture has become more challenging. Conversely, programs may find it difficult to grasp an applicant’s temperament and interaction style.

Virtual interviewing, while undeniably convenient in many regards, may fall prey to its own convenience. There can be disparities in the quantity, duration, and frequency of interviews. For me, the number of and time allotted for interviews has varied widely, ranging from 2.5 to 8 hours. The amount of allotted break time has also differed, with some programs providing longer breaks between interviews (30 to 60 minutes) and others offering shorter (5 to 10 minutes) or no breaks. Minimal breaks may fatigue applicants, while longer breaks may seem like wasted time. While virtual interviews may require no physical travel between offices, breaks are a necessity that should be implemented thoughtfully.

Finally, a troublesome challenge I encountered surprisingly often was unreliable internet service and other technical difficulties. Several times, my interviewers’ (or my) screen froze or shut off due to connectivity issues. This is an obstacle unique to virtual interviews that requires both a backup plan as well as patience and calm to navigate during an already taxing situation.

Continue to: What's next?

What’s next?

As applicants and programs adjust to the realities of virtual interviewing, this is likely an unfamiliar experience for all. While the benefits and shortcomings must be considered together, I, along with many of my peers,² continue to prefer traditional in-person interviews. As the ongoing COVID-19 pandemic makes in-person interviews difficult, applicants and programs must embrace the experience of virtual interviews. However, a good understanding of the advantages and disadvantages are instrumental in preempting prospective challenges. Based on my recent experiences with virtual fellowship interviews, I have created some recommendations for applicants and psychiatry programs participating in virtual recruitment (Table).

After the COVID-19 pandemic subsides, it is conceivable that the advantages of virtual interviewing may justify its continued use. For example, applicants may be able to apply to geographically diverse programs without travel expenses. Currently, there is a paucity of evidence regarding virtual interviews specifically in psychiatry training programs, but the experiences of both applicants and psychiatry programs during this atypical time will allow us to improve the process going forward, and evaluate its utility well after COVID-19 recedes.

As a psychiatry resident in the age of coronavirus disease 2019 (COVID-19), many of my educational experiences have undergone adjustments. Now, as I interview for a fellowship, I see firsthand that recruitment activities have not been spared from shifting paradigms levied by the pandemic. To adhere to social distancing guidelines and limit trainee interpersonal exposure, the American Association of Directors of Psychiatric Residency Training recommended that all psychiatry residency interviews be conducted virtually for 2020/2021.¹ Trainees and programs alike are embarking on a new frontier of virtual interviews, and it is important that we evaluate the advantages and disadvantages of this approach. Because uncertainty abounds regarding when a sense of normalcy might eventually return to psychiatry residency and fellowship recruitment activities, I also provide recommendations to interviewers and interviewees who may navigate virtual recruitment in the future.

Advantages of virtual interviews

An immediately significant advantage of virtual interviews is the lack of travel, which for some applicants can be cost-prohibitive. The costs of airfare, rental vehicles, and lodging in multiple cities can add up, sometimes requiring students to budget interview travel into already-high student loans. In some cases, applicants may have limited days to interview, which makes the flexibility afforded by the lack of travel advantageous. Furthermore, navigating new locations can add to preexisting interview stress. Without travel, applicants can consider a broader set of programs and accept more interviews.

Another advantage is that virtual interviews allow interviewees latitude to shift the interview’s “frame.” Rather than sitting in an interviewer’s office, interviewees can choose a more comfortable environment for themselves, imparting a “home-field advantage” that may put them at ease. During my fellowship interviews, controlling the room temperature, using a familiar chair, and wearing comfortable shoes helped to reduce the anxiety inherent to interviewing.

Disadvantages of virtual interviews

Any new or unfamiliar experience can impart challenges. For example, applicants and interviewers must adjust to and observe different sets of etiquette during virtual interviews. These include muting microphones to avoid talking over each other, maintaining consistent eye contact, avoiding multitasking, and following up to avoid miscommunication.

Another potential problem is that virtual interviews can dampen an applicant’s ability to appreciate a program’s culture. Observing informal interactions between trainees and faculty is often as important as the formal interviews in ascertaining which programs have a supportive culture. Because my virtual fellowship interviews have generally been limited to formal one-on-one interviews, assessing program culture has become more challenging. Conversely, programs may find it difficult to grasp an applicant’s temperament and interaction style.

Virtual interviewing, while undeniably convenient in many regards, may fall prey to its own convenience. There can be disparities in the quantity, duration, and frequency of interviews. For me, the number of and time allotted for interviews has varied widely, ranging from 2.5 to 8 hours. The amount of allotted break time has also differed, with some programs providing longer breaks between interviews (30 to 60 minutes) and others offering shorter (5 to 10 minutes) or no breaks. Minimal breaks may fatigue applicants, while longer breaks may seem like wasted time. While virtual interviews may require no physical travel between offices, breaks are a necessity that should be implemented thoughtfully.

Finally, a troublesome challenge I encountered surprisingly often was unreliable internet service and other technical difficulties. Several times, my interviewers’ (or my) screen froze or shut off due to connectivity issues. This is an obstacle unique to virtual interviews that requires both a backup plan as well as patience and calm to navigate during an already taxing situation.

Continue to: What's next?

What’s next?

As applicants and programs adjust to the realities of virtual interviewing, this is likely an unfamiliar experience for all. While the benefits and shortcomings must be considered together, I, along with many of my peers,² continue to prefer traditional in-person interviews. As the ongoing COVID-19 pandemic makes in-person interviews difficult, applicants and programs must embrace the experience of virtual interviews. However, a good understanding of the advantages and disadvantages are instrumental in preempting prospective challenges. Based on my recent experiences with virtual fellowship interviews, I have created some recommendations for applicants and psychiatry programs participating in virtual recruitment (Table).

After the COVID-19 pandemic subsides, it is conceivable that the advantages of virtual interviewing may justify its continued use. For example, applicants may be able to apply to geographically diverse programs without travel expenses. Currently, there is a paucity of evidence regarding virtual interviews specifically in psychiatry training programs, but the experiences of both applicants and psychiatry programs during this atypical time will allow us to improve the process going forward, and evaluate its utility well after COVID-19 recedes.

As the world grapples with the coronavirus disease 2019 (COVID-19) pandemic, the search for answers, comfort, how to cope, and how to make sense of it all has become paramount. People commonly turn to their faith in times of crisis, but this recent global public health emergency is unlike many have ever seen or could have imagined.¹ What happens when the well-intentioned journey for spiritual insight intersects with psychiatric symptomatology? Where does the line between these phenomena get crossed? As a psychiatric resident and person who was raised in the Pentecostal faith, I have observed faith and psychopathology come to a head in the last 6 months. COVID-19 has dealt a religious strain of undocumented cases; I hope to shed light on the topic by sharing my experience of navigating the assessment and treatment plan of patients with psychiatric symptoms whose spiritual beliefs are a cornerstone of life.

Piety, or pathology?

The following approaches have helped me to identify what is driven by faith vs what is psychopathology:

While taking the patient history. Obtaining a history from a patient who professes to have strong spiritual beliefs and presents with psychiatric symptoms is similar to a standard patient interview, but pay special attention to how the patient came to the emergency department. Was there a family member, friend, or emergency medical services present at that time? During the interview, patients often appear “normal,” which may lead a clinician to question the reason for the consult, yet considering the recent events preceding the presentation will be a good place to start gathering the appropriate information for investigation.

Next, compare the patient’s recent daily functioning with his/her baseline. If this information comes solely from the patient, it may be skewed, so try to retrieve information from a collateral source. If the patient was accompanied by someone, request permission from the patient to speak with him/her. It may also be best in some instances to speak with the collateral source out of earshot of the patient. Be aware that collateral information that comes from just one source also could be biased, so search for additional contacts to help acquire a comprehensive representation of the circumstances.

Information about a patient could come from a faith leader because people often rely on their faith leaders when they are ill, in need of support, or in crisis.² Faith leaders may have valuable information and insight into the patient and the history of the patient’s illness. In addition, diverse sources of collateral reports may be helpful because specific spiritual views and practices can vary even within one family or congregation. What may be an abnormal practice to some followers may be normal for others.³ When approaching these situations with parishioners, it is essential to maintain confidentiality.

While performing the clinical examination. As with any psychiatric diagnosis, other causative factors (metabolic and organic) need to be ruled out. Also, assess for the use of mood-altering substances. The patient may express offense or resistance to such questions, but maintain a matter-of-fact approach and explain that assessment for substance use is a routine part of the clinical examination. Approximately 18% of people in the United States with psychiatric disorders have a comorbid substance use disorder.⁴ However, keep in mind that a patient who refuses substance use screening is not necessarily hiding something. The road to being thorough may lead to strained rapport with the patient, and this risk must be balanced with providing the best care. As in any other clinical situation, seek evidence to both verify and clarify information without being deterred by a patient’s vocalization of spiritual tenants.

Learn about your patients’ beliefs

Do not feel defeated if you find these interviews difficult. Religion and symptomatology can overlap and fluctuate within the same faith group, which can make these types of assessments complex.⁵ In an effort to understand the patient more clearly, be sensitive to their spiritual practices and receptive to learning about unfamiliar spiritual beliefs. Be transparent about not knowing a specific belief or practice, and exhibit humility. Most patients are open to sharing their religious/spiritual views with a clinician who is sincere about wanting insight. Understanding the value of spiritual care is an important skill that many medical practitioners often lack.⁶ This understanding is especially critical when patients express worries related to the COVID-19 pandemic and how they are coping.

Continue to: Integrate your patient's spiritual requests

If you are comfortable with certain practices that do not compromise your values or beliefs or put a patient at risk, try to integrate your patients’ spiritual request(s) in their care. For a patient who serves a higher power, admitting to a problem (eg, fears related to COVID-19) or seeking professional help for symptoms (eg, anxiety, depression) may imply spiritual doubt. Patients may believe that seeking professional assistance means they are questioning the omnipotence of their deity to prevent or heal a condition. While spiritual distress can stimulate changes in behavior, it may not be pathological.

To avoid misdiagnosis, refer to the description “V62.89 (Z65.8) Religious or Spiritual Problem” in the DSM-5.⁷ If you find that it is a discord in faith that is affecting the patient’s presentation, and that this has not caused a psychiatric disorder, document this appropriately and provide the necessary resources to continue supporting the patient holistically.

As the world grapples with the coronavirus disease 2019 (COVID-19) pandemic, the search for answers, comfort, how to cope, and how to make sense of it all has become paramount. People commonly turn to their faith in times of crisis, but this recent global public health emergency is unlike many have ever seen or could have imagined.¹ What happens when the well-intentioned journey for spiritual insight intersects with psychiatric symptomatology? Where does the line between these phenomena get crossed? As a psychiatric resident and person who was raised in the Pentecostal faith, I have observed faith and psychopathology come to a head in the last 6 months. COVID-19 has dealt a religious strain of undocumented cases; I hope to shed light on the topic by sharing my experience of navigating the assessment and treatment plan of patients with psychiatric symptoms whose spiritual beliefs are a cornerstone of life.

Piety, or pathology?

The following approaches have helped me to identify what is driven by faith vs what is psychopathology:

While taking the patient history. Obtaining a history from a patient who professes to have strong spiritual beliefs and presents with psychiatric symptoms is similar to a standard patient interview, but pay special attention to how the patient came to the emergency department. Was there a family member, friend, or emergency medical services present at that time? During the interview, patients often appear “normal,” which may lead a clinician to question the reason for the consult, yet considering the recent events preceding the presentation will be a good place to start gathering the appropriate information for investigation.

Next, compare the patient’s recent daily functioning with his/her baseline. If this information comes solely from the patient, it may be skewed, so try to retrieve information from a collateral source. If the patient was accompanied by someone, request permission from the patient to speak with him/her. It may also be best in some instances to speak with the collateral source out of earshot of the patient. Be aware that collateral information that comes from just one source also could be biased, so search for additional contacts to help acquire a comprehensive representation of the circumstances.

Information about a patient could come from a faith leader because people often rely on their faith leaders when they are ill, in need of support, or in crisis.² Faith leaders may have valuable information and insight into the patient and the history of the patient’s illness. In addition, diverse sources of collateral reports may be helpful because specific spiritual views and practices can vary even within one family or congregation. What may be an abnormal practice to some followers may be normal for others.³ When approaching these situations with parishioners, it is essential to maintain confidentiality.

While performing the clinical examination. As with any psychiatric diagnosis, other causative factors (metabolic and organic) need to be ruled out. Also, assess for the use of mood-altering substances. The patient may express offense or resistance to such questions, but maintain a matter-of-fact approach and explain that assessment for substance use is a routine part of the clinical examination. Approximately 18% of people in the United States with psychiatric disorders have a comorbid substance use disorder.⁴ However, keep in mind that a patient who refuses substance use screening is not necessarily hiding something. The road to being thorough may lead to strained rapport with the patient, and this risk must be balanced with providing the best care. As in any other clinical situation, seek evidence to both verify and clarify information without being deterred by a patient’s vocalization of spiritual tenants.

Learn about your patients’ beliefs

Do not feel defeated if you find these interviews difficult. Religion and symptomatology can overlap and fluctuate within the same faith group, which can make these types of assessments complex.⁵ In an effort to understand the patient more clearly, be sensitive to their spiritual practices and receptive to learning about unfamiliar spiritual beliefs. Be transparent about not knowing a specific belief or practice, and exhibit humility. Most patients are open to sharing their religious/spiritual views with a clinician who is sincere about wanting insight. Understanding the value of spiritual care is an important skill that many medical practitioners often lack.⁶ This understanding is especially critical when patients express worries related to the COVID-19 pandemic and how they are coping.

Continue to: Integrate your patient's spiritual requests

If you are comfortable with certain practices that do not compromise your values or beliefs or put a patient at risk, try to integrate your patients’ spiritual request(s) in their care. For a patient who serves a higher power, admitting to a problem (eg, fears related to COVID-19) or seeking professional help for symptoms (eg, anxiety, depression) may imply spiritual doubt. Patients may believe that seeking professional assistance means they are questioning the omnipotence of their deity to prevent or heal a condition. While spiritual distress can stimulate changes in behavior, it may not be pathological.

To avoid misdiagnosis, refer to the description “V62.89 (Z65.8) Religious or Spiritual Problem” in the DSM-5.⁷ If you find that it is a discord in faith that is affecting the patient’s presentation, and that this has not caused a psychiatric disorder, document this appropriately and provide the necessary resources to continue supporting the patient holistically.

As the world grapples with the coronavirus disease 2019 (COVID-19) pandemic, the search for answers, comfort, how to cope, and how to make sense of it all has become paramount. People commonly turn to their faith in times of crisis, but this recent global public health emergency is unlike many have ever seen or could have imagined.¹ What happens when the well-intentioned journey for spiritual insight intersects with psychiatric symptomatology? Where does the line between these phenomena get crossed? As a psychiatric resident and person who was raised in the Pentecostal faith, I have observed faith and psychopathology come to a head in the last 6 months. COVID-19 has dealt a religious strain of undocumented cases; I hope to shed light on the topic by sharing my experience of navigating the assessment and treatment plan of patients with psychiatric symptoms whose spiritual beliefs are a cornerstone of life.

Piety, or pathology?

The following approaches have helped me to identify what is driven by faith vs what is psychopathology:

While taking the patient history. Obtaining a history from a patient who professes to have strong spiritual beliefs and presents with psychiatric symptoms is similar to a standard patient interview, but pay special attention to how the patient came to the emergency department. Was there a family member, friend, or emergency medical services present at that time? During the interview, patients often appear “normal,” which may lead a clinician to question the reason for the consult, yet considering the recent events preceding the presentation will be a good place to start gathering the appropriate information for investigation.

Next, compare the patient’s recent daily functioning with his/her baseline. If this information comes solely from the patient, it may be skewed, so try to retrieve information from a collateral source. If the patient was accompanied by someone, request permission from the patient to speak with him/her. It may also be best in some instances to speak with the collateral source out of earshot of the patient. Be aware that collateral information that comes from just one source also could be biased, so search for additional contacts to help acquire a comprehensive representation of the circumstances.

Information about a patient could come from a faith leader because people often rely on their faith leaders when they are ill, in need of support, or in crisis.² Faith leaders may have valuable information and insight into the patient and the history of the patient’s illness. In addition, diverse sources of collateral reports may be helpful because specific spiritual views and practices can vary even within one family or congregation. What may be an abnormal practice to some followers may be normal for others.³ When approaching these situations with parishioners, it is essential to maintain confidentiality.

While performing the clinical examination. As with any psychiatric diagnosis, other causative factors (metabolic and organic) need to be ruled out. Also, assess for the use of mood-altering substances. The patient may express offense or resistance to such questions, but maintain a matter-of-fact approach and explain that assessment for substance use is a routine part of the clinical examination. Approximately 18% of people in the United States with psychiatric disorders have a comorbid substance use disorder.⁴ However, keep in mind that a patient who refuses substance use screening is not necessarily hiding something. The road to being thorough may lead to strained rapport with the patient, and this risk must be balanced with providing the best care. As in any other clinical situation, seek evidence to both verify and clarify information without being deterred by a patient’s vocalization of spiritual tenants.

Learn about your patients’ beliefs

Do not feel defeated if you find these interviews difficult. Religion and symptomatology can overlap and fluctuate within the same faith group, which can make these types of assessments complex.⁵ In an effort to understand the patient more clearly, be sensitive to their spiritual practices and receptive to learning about unfamiliar spiritual beliefs. Be transparent about not knowing a specific belief or practice, and exhibit humility. Most patients are open to sharing their religious/spiritual views with a clinician who is sincere about wanting insight. Understanding the value of spiritual care is an important skill that many medical practitioners often lack.⁶ This understanding is especially critical when patients express worries related to the COVID-19 pandemic and how they are coping.

Continue to: Integrate your patient's spiritual requests

If you are comfortable with certain practices that do not compromise your values or beliefs or put a patient at risk, try to integrate your patients’ spiritual request(s) in their care. For a patient who serves a higher power, admitting to a problem (eg, fears related to COVID-19) or seeking professional help for symptoms (eg, anxiety, depression) may imply spiritual doubt. Patients may believe that seeking professional assistance means they are questioning the omnipotence of their deity to prevent or heal a condition. While spiritual distress can stimulate changes in behavior, it may not be pathological.

To avoid misdiagnosis, refer to the description “V62.89 (Z65.8) Religious or Spiritual Problem” in the DSM-5.⁷ If you find that it is a discord in faith that is affecting the patient’s presentation, and that this has not caused a psychiatric disorder, document this appropriately and provide the necessary resources to continue supporting the patient holistically.

Nail unit squamous cell carcinoma (NSCC) is a malignant neoplasm that can arise from any part of the nail unit. Diagnosis often is delayed due to its clinical presentation mimicking benign conditions such as onychomycosis, warts, and paronychia. Nail unit SCC has a low rate of metastasis; however, a delayed diagnosis often can result in local destruction and bone invasion. It is imperative for dermatologists who are early in their training to recognize this entity and refer for treatment. Many approaches have been used to treat NSCC, including wide local excision, digital amputation, cryotherapy, topical modalities, and recently Mohs micrographic surgery (MMS). This article provides an overview of the clinical presentation and diagnosis of NSCC, the role of human papillomavirus (HPV) in NSCC pathogenesis, and the evidence supporting surgical management.

NSCC Clinical Presentation and Diagnosis

Nail unit squamous cell carcinoma is a malignant neoplasm that can arise from any part of the nail unit including the nail bed, matrix, groove, and nail fold.¹ Although NSCC is the most common malignant nail neoplasm, its diagnosis often is delayed partly due to the clinical presentation of NSCC mimicking benign conditions such as onychomycosis, warts, and paronychia.^2,3 Nail unit SCC most commonly is mistaken for verruca vulgaris, and thus it is important to exclude malignancy in nonresolving verrucae of the fingernails or toenails. Another reason for a delay in the diagnosis is the painless and often asymptomatic presentation of this tumor, which keeps patients from seeking care.⁴ While evaluating a subungual lesion, dermatologists should keep in mind red flags that would prompt a biopsy to rule out NSCC (Table 1), including chronic nonhealing lesions, nail plate nodularity, known history of infection with HPV types 16 and 18, history of radiation or arsenic exposure, and immunosuppression. Table 2 lists the differential diagnosis of a persisting or nonhealing subungual tumor.

Nail unit SCC has a low rate of metastasis; however, a delayed diagnosis often can result in local destruction and bone invasion.⁵ Based on several reports, NSCC more commonly is found in middle-aged and older individuals, has a male predilection, and more often is seen on fingernails than toenails.^1,2,6 Figure A shows an example of the clinical presentation of NSCC affecting the right thumb.

Histologic Features

A biopsy from an NSCC tumor shows features similar to cutaneous SCC in the affected areas (ie, nail bed, nail matrix, nail groove, nail fold). Characteristic histologic findings include tongues or whorls of atypical squamous epithelium that invade deeply into the dermis.¹¹ The cells appear as atypical keratinocytes, exhibit distinct intracellular bridges, and possess hyperchromatic and pleomorphic nuclei with dyskeratosis and keratin pearls within the dermis.¹² Immunoperoxidase staining for cytokeratin AE1/AE3 can be helpful to confirm the diagnosis and assess whether the depth of invasion involves the bone.¹³ Figures B and C demonstrate the histopathology of NSCC biopsied from the tumor shown in Figure A.

Role of HPV in NSCC Pathogenesis

There is no clear pathogenic etiology for NSCC; however, there have been some reports of HPV as a risk factor. Shimizu et al¹⁴ reviewed 136 cases of HPV-associated NSCC and found that half of the cases were associated with high-risk HPV. They also found that 24% of the patients with NSCC had a history of other HPV-associated diseases. As such, the authors hypothesized that there is a possibility for genitodigital HPV transmission and that NSCC could be a reservoir for sexually transmitted high-risk HPV.¹⁴ Other risk factors are radiation exposure, chemical insult, and chronic trauma.¹⁵ The higher propensity for fingernails likely is reflective of the role of UV light exposure and infection with HPV in the development of these tumors.^14,15

Treatment Options for NSCC

Several nonsurgical approaches have been suggested to treat NSCC, including topical agents, cryotherapy, CO₂ laser, and photodynamic therapy.^3,16 Unfortunately, there are no large case series to demonstrate the cure rate or effectiveness of these methods.¹⁷ In one study, the authors did not recommend use of photodynamic therapy or topical modalities such as imiquimod cream 5% or fluorouracil cream 5% as first-line treatments of NSCC due to the difficulty in ensuring complete treatment of the sulci of the lateral and proximal nail folds.¹⁸

More evidence in the literature supports surgical approaches, including wide local excision, MMS, and digital amputation. Clinicians should consider relapse rates and the impact on digital functioning when choosing a surgical approach.

For wide local excisions, the most common approach is en bloc excision of the nail unit including the lateral nail folds, the proximal nail fold, and the distal nail fold. The excision starts with a transverse incision on the base of the distal phalanx, which is then prolonged laterally and distally to the distal nail fold down to the bone. After the incision is made to the depth of the bone, the matrical horns are destroyed by electrocoagulation, and the defect is closed either by a full-thickness skin graft or secondary intent.¹⁹

Topin-Ruiz et al¹⁹ followed patients with biopsy-proven NSCC without bone invasion who underwent en bloc excision followed by full-thickness skin graft. In their consecutive series of 55 patients with 5 years of follow-up, the rate of recurrence was only 4%. There was a low rate of complications including graft infection, delayed wound healing, and severe pain in a small percentage of patients. They also reported a high patient satisfaction rate.¹⁹ Due to the low recurrence rate, this study suggested that total excision of the nail unit followed by a full-thickness skin graft is a safe and efficient treatment of NSCC without bone involvement. Similarly, in another case series, wide local excision of the entire nail apparatus had a relapse rate of only 5%, in contrast to partial excision of the nail unit with a relapse of 56%.²⁰ These studies suggest that wide nail unit excision is an acceptable and effective approach; however, in cases in which invasion cannot be ruled out, histologic clearance would be a reasonable approach.²¹ As such, several case series demonstrated the merits of MMS for NSCC. de Berker et al²² reported 8 patients with NSCC treated using slow MMS and showed tumor clearance after a mean of 3 stages over a mean period of 6.9 days. In all cases, the wounds were allowed to heal by secondary intention, and the distal phalanx was preserved. During a mean follow-up period of 3.1 years, no recurrence was seen, and involved digits remained functional.²²

Other studies tested the efficacy of MMS for NSCC. Young et al²³ reported the outcomes of 14 NSCC cases treated with MMS. In their case series, they found that the mean number of MMS surgical stages required to achieve histologic clearance was 2, while the mean number of tissue sections was 4.²³ All cases were allowed to heal by secondary intent with excellent outcomes, except for 1 patient who received primary closure of a small defect. They reported a 78% cure rate with an average time to recurrence of 47 months.²³ In a series of 42 cases of NSCC treated with MMS, Gou et al¹⁷ noted a cure rate close to 93%. In their study, recurrences were observed in only 3 patients (7.1%). These recurrent cases were then successfully treated with another round of MMS.¹⁷ This study’s cure rate was comparable to the cure rate of MMS for SCC in other cutaneous areas. Goldminz and Bennett²⁴ demonstrated a cure rate of 92% in their case series of 25 patients. Two patients developed recurrent disease and were treated again with MMS resulting in no subsequent recurrence. In this study, the authors allowed all defects to heal by secondary intention and found that there were excellent cosmetic and functional outcomes.²⁴ Dika et al²⁵ evaluated the long-term effectiveness of MMS in the treatment of NSCC, in particular its ability to reduce the number of digital amputations. Fifteen patients diagnosed with NSCC were treated with MMS as the first-line surgical approach and were followed for 2 to 5 years. They found that in utilizing MMS, they were able to avoid amputations in 13 of 15 cases with no recurrence in any of these tumors. Two cases, however, still required amputation of the distal phalanx.²⁵

Although these studies suggest that MMS achieves a high cure rate ranging from 78% to 93%, it is not yet clear in the literature whether MMS is superior to wide local excision. More studies and clinical trials comparing these 2 surgical approaches should be performed to identify which surgical approach would be the gold standard for NSCC and which select cases would benefit from MMS as first-line treatment.

Final Thoughts

Nail unit SCC is one of the most common nail unit malignancies and can mimic several benign entities. Dermatologists who are early in their training should consider biopsy of subungual lesions with certain red flags (Table 1). It is important to diagnose NSCC for early intervention. Referral for wide local excision or MMS would be ideal. There are data in the literature supporting both surgical approaches as being effective; however, there are no trials comparing both approaches. Distal amputation should be considered as a last resort when wide local excision is not reasonable or when MMS fails to achieve clear margins, thereby reducing unnecessary amputations and patient morbidity.¹⁷

Nail unit squamous cell carcinoma (NSCC) is a malignant neoplasm that can arise from any part of the nail unit. Diagnosis often is delayed due to its clinical presentation mimicking benign conditions such as onychomycosis, warts, and paronychia. Nail unit SCC has a low rate of metastasis; however, a delayed diagnosis often can result in local destruction and bone invasion. It is imperative for dermatologists who are early in their training to recognize this entity and refer for treatment. Many approaches have been used to treat NSCC, including wide local excision, digital amputation, cryotherapy, topical modalities, and recently Mohs micrographic surgery (MMS). This article provides an overview of the clinical presentation and diagnosis of NSCC, the role of human papillomavirus (HPV) in NSCC pathogenesis, and the evidence supporting surgical management.

NSCC Clinical Presentation and Diagnosis

Nail unit squamous cell carcinoma is a malignant neoplasm that can arise from any part of the nail unit including the nail bed, matrix, groove, and nail fold.¹ Although NSCC is the most common malignant nail neoplasm, its diagnosis often is delayed partly due to the clinical presentation of NSCC mimicking benign conditions such as onychomycosis, warts, and paronychia.^2,3 Nail unit SCC most commonly is mistaken for verruca vulgaris, and thus it is important to exclude malignancy in nonresolving verrucae of the fingernails or toenails. Another reason for a delay in the diagnosis is the painless and often asymptomatic presentation of this tumor, which keeps patients from seeking care.⁴ While evaluating a subungual lesion, dermatologists should keep in mind red flags that would prompt a biopsy to rule out NSCC (Table 1), including chronic nonhealing lesions, nail plate nodularity, known history of infection with HPV types 16 and 18, history of radiation or arsenic exposure, and immunosuppression. Table 2 lists the differential diagnosis of a persisting or nonhealing subungual tumor.

Nail unit SCC has a low rate of metastasis; however, a delayed diagnosis often can result in local destruction and bone invasion.⁵ Based on several reports, NSCC more commonly is found in middle-aged and older individuals, has a male predilection, and more often is seen on fingernails than toenails.^1,2,6 Figure A shows an example of the clinical presentation of NSCC affecting the right thumb.

Histologic Features

A biopsy from an NSCC tumor shows features similar to cutaneous SCC in the affected areas (ie, nail bed, nail matrix, nail groove, nail fold). Characteristic histologic findings include tongues or whorls of atypical squamous epithelium that invade deeply into the dermis.¹¹ The cells appear as atypical keratinocytes, exhibit distinct intracellular bridges, and possess hyperchromatic and pleomorphic nuclei with dyskeratosis and keratin pearls within the dermis.¹² Immunoperoxidase staining for cytokeratin AE1/AE3 can be helpful to confirm the diagnosis and assess whether the depth of invasion involves the bone.¹³ Figures B and C demonstrate the histopathology of NSCC biopsied from the tumor shown in Figure A.

Role of HPV in NSCC Pathogenesis

There is no clear pathogenic etiology for NSCC; however, there have been some reports of HPV as a risk factor. Shimizu et al¹⁴ reviewed 136 cases of HPV-associated NSCC and found that half of the cases were associated with high-risk HPV. They also found that 24% of the patients with NSCC had a history of other HPV-associated diseases. As such, the authors hypothesized that there is a possibility for genitodigital HPV transmission and that NSCC could be a reservoir for sexually transmitted high-risk HPV.¹⁴ Other risk factors are radiation exposure, chemical insult, and chronic trauma.¹⁵ The higher propensity for fingernails likely is reflective of the role of UV light exposure and infection with HPV in the development of these tumors.^14,15

Treatment Options for NSCC

Several nonsurgical approaches have been suggested to treat NSCC, including topical agents, cryotherapy, CO₂ laser, and photodynamic therapy.^3,16 Unfortunately, there are no large case series to demonstrate the cure rate or effectiveness of these methods.¹⁷ In one study, the authors did not recommend use of photodynamic therapy or topical modalities such as imiquimod cream 5% or fluorouracil cream 5% as first-line treatments of NSCC due to the difficulty in ensuring complete treatment of the sulci of the lateral and proximal nail folds.¹⁸

More evidence in the literature supports surgical approaches, including wide local excision, MMS, and digital amputation. Clinicians should consider relapse rates and the impact on digital functioning when choosing a surgical approach.

For wide local excisions, the most common approach is en bloc excision of the nail unit including the lateral nail folds, the proximal nail fold, and the distal nail fold. The excision starts with a transverse incision on the base of the distal phalanx, which is then prolonged laterally and distally to the distal nail fold down to the bone. After the incision is made to the depth of the bone, the matrical horns are destroyed by electrocoagulation, and the defect is closed either by a full-thickness skin graft or secondary intent.¹⁹

Topin-Ruiz et al¹⁹ followed patients with biopsy-proven NSCC without bone invasion who underwent en bloc excision followed by full-thickness skin graft. In their consecutive series of 55 patients with 5 years of follow-up, the rate of recurrence was only 4%. There was a low rate of complications including graft infection, delayed wound healing, and severe pain in a small percentage of patients. They also reported a high patient satisfaction rate.¹⁹ Due to the low recurrence rate, this study suggested that total excision of the nail unit followed by a full-thickness skin graft is a safe and efficient treatment of NSCC without bone involvement. Similarly, in another case series, wide local excision of the entire nail apparatus had a relapse rate of only 5%, in contrast to partial excision of the nail unit with a relapse of 56%.²⁰ These studies suggest that wide nail unit excision is an acceptable and effective approach; however, in cases in which invasion cannot be ruled out, histologic clearance would be a reasonable approach.²¹ As such, several case series demonstrated the merits of MMS for NSCC. de Berker et al²² reported 8 patients with NSCC treated using slow MMS and showed tumor clearance after a mean of 3 stages over a mean period of 6.9 days. In all cases, the wounds were allowed to heal by secondary intention, and the distal phalanx was preserved. During a mean follow-up period of 3.1 years, no recurrence was seen, and involved digits remained functional.²²

Other studies tested the efficacy of MMS for NSCC. Young et al²³ reported the outcomes of 14 NSCC cases treated with MMS. In their case series, they found that the mean number of MMS surgical stages required to achieve histologic clearance was 2, while the mean number of tissue sections was 4.²³ All cases were allowed to heal by secondary intent with excellent outcomes, except for 1 patient who received primary closure of a small defect. They reported a 78% cure rate with an average time to recurrence of 47 months.²³ In a series of 42 cases of NSCC treated with MMS, Gou et al¹⁷ noted a cure rate close to 93%. In their study, recurrences were observed in only 3 patients (7.1%). These recurrent cases were then successfully treated with another round of MMS.¹⁷ This study’s cure rate was comparable to the cure rate of MMS for SCC in other cutaneous areas. Goldminz and Bennett²⁴ demonstrated a cure rate of 92% in their case series of 25 patients. Two patients developed recurrent disease and were treated again with MMS resulting in no subsequent recurrence. In this study, the authors allowed all defects to heal by secondary intention and found that there were excellent cosmetic and functional outcomes.²⁴ Dika et al²⁵ evaluated the long-term effectiveness of MMS in the treatment of NSCC, in particular its ability to reduce the number of digital amputations. Fifteen patients diagnosed with NSCC were treated with MMS as the first-line surgical approach and were followed for 2 to 5 years. They found that in utilizing MMS, they were able to avoid amputations in 13 of 15 cases with no recurrence in any of these tumors. Two cases, however, still required amputation of the distal phalanx.²⁵

Although these studies suggest that MMS achieves a high cure rate ranging from 78% to 93%, it is not yet clear in the literature whether MMS is superior to wide local excision. More studies and clinical trials comparing these 2 surgical approaches should be performed to identify which surgical approach would be the gold standard for NSCC and which select cases would benefit from MMS as first-line treatment.

Final Thoughts

Nail unit SCC is one of the most common nail unit malignancies and can mimic several benign entities. Dermatologists who are early in their training should consider biopsy of subungual lesions with certain red flags (Table 1). It is important to diagnose NSCC for early intervention. Referral for wide local excision or MMS would be ideal. There are data in the literature supporting both surgical approaches as being effective; however, there are no trials comparing both approaches. Distal amputation should be considered as a last resort when wide local excision is not reasonable or when MMS fails to achieve clear margins, thereby reducing unnecessary amputations and patient morbidity.¹⁷

Nail unit squamous cell carcinoma (NSCC) is a malignant neoplasm that can arise from any part of the nail unit. Diagnosis often is delayed due to its clinical presentation mimicking benign conditions such as onychomycosis, warts, and paronychia. Nail unit SCC has a low rate of metastasis; however, a delayed diagnosis often can result in local destruction and bone invasion. It is imperative for dermatologists who are early in their training to recognize this entity and refer for treatment. Many approaches have been used to treat NSCC, including wide local excision, digital amputation, cryotherapy, topical modalities, and recently Mohs micrographic surgery (MMS). This article provides an overview of the clinical presentation and diagnosis of NSCC, the role of human papillomavirus (HPV) in NSCC pathogenesis, and the evidence supporting surgical management.

NSCC Clinical Presentation and Diagnosis

Nail unit squamous cell carcinoma is a malignant neoplasm that can arise from any part of the nail unit including the nail bed, matrix, groove, and nail fold.¹ Although NSCC is the most common malignant nail neoplasm, its diagnosis often is delayed partly due to the clinical presentation of NSCC mimicking benign conditions such as onychomycosis, warts, and paronychia.^2,3 Nail unit SCC most commonly is mistaken for verruca vulgaris, and thus it is important to exclude malignancy in nonresolving verrucae of the fingernails or toenails. Another reason for a delay in the diagnosis is the painless and often asymptomatic presentation of this tumor, which keeps patients from seeking care.⁴ While evaluating a subungual lesion, dermatologists should keep in mind red flags that would prompt a biopsy to rule out NSCC (Table 1), including chronic nonhealing lesions, nail plate nodularity, known history of infection with HPV types 16 and 18, history of radiation or arsenic exposure, and immunosuppression. Table 2 lists the differential diagnosis of a persisting or nonhealing subungual tumor.

Nail unit SCC has a low rate of metastasis; however, a delayed diagnosis often can result in local destruction and bone invasion.⁵ Based on several reports, NSCC more commonly is found in middle-aged and older individuals, has a male predilection, and more often is seen on fingernails than toenails.^1,2,6 Figure A shows an example of the clinical presentation of NSCC affecting the right thumb.

Histologic Features

A biopsy from an NSCC tumor shows features similar to cutaneous SCC in the affected areas (ie, nail bed, nail matrix, nail groove, nail fold). Characteristic histologic findings include tongues or whorls of atypical squamous epithelium that invade deeply into the dermis.¹¹ The cells appear as atypical keratinocytes, exhibit distinct intracellular bridges, and possess hyperchromatic and pleomorphic nuclei with dyskeratosis and keratin pearls within the dermis.¹² Immunoperoxidase staining for cytokeratin AE1/AE3 can be helpful to confirm the diagnosis and assess whether the depth of invasion involves the bone.¹³ Figures B and C demonstrate the histopathology of NSCC biopsied from the tumor shown in Figure A.

Role of HPV in NSCC Pathogenesis

There is no clear pathogenic etiology for NSCC; however, there have been some reports of HPV as a risk factor. Shimizu et al¹⁴ reviewed 136 cases of HPV-associated NSCC and found that half of the cases were associated with high-risk HPV. They also found that 24% of the patients with NSCC had a history of other HPV-associated diseases. As such, the authors hypothesized that there is a possibility for genitodigital HPV transmission and that NSCC could be a reservoir for sexually transmitted high-risk HPV.¹⁴ Other risk factors are radiation exposure, chemical insult, and chronic trauma.¹⁵ The higher propensity for fingernails likely is reflective of the role of UV light exposure and infection with HPV in the development of these tumors.^14,15

Treatment Options for NSCC

Several nonsurgical approaches have been suggested to treat NSCC, including topical agents, cryotherapy, CO₂ laser, and photodynamic therapy.^3,16 Unfortunately, there are no large case series to demonstrate the cure rate or effectiveness of these methods.¹⁷ In one study, the authors did not recommend use of photodynamic therapy or topical modalities such as imiquimod cream 5% or fluorouracil cream 5% as first-line treatments of NSCC due to the difficulty in ensuring complete treatment of the sulci of the lateral and proximal nail folds.¹⁸

More evidence in the literature supports surgical approaches, including wide local excision, MMS, and digital amputation. Clinicians should consider relapse rates and the impact on digital functioning when choosing a surgical approach.

For wide local excisions, the most common approach is en bloc excision of the nail unit including the lateral nail folds, the proximal nail fold, and the distal nail fold. The excision starts with a transverse incision on the base of the distal phalanx, which is then prolonged laterally and distally to the distal nail fold down to the bone. After the incision is made to the depth of the bone, the matrical horns are destroyed by electrocoagulation, and the defect is closed either by a full-thickness skin graft or secondary intent.¹⁹

Topin-Ruiz et al¹⁹ followed patients with biopsy-proven NSCC without bone invasion who underwent en bloc excision followed by full-thickness skin graft. In their consecutive series of 55 patients with 5 years of follow-up, the rate of recurrence was only 4%. There was a low rate of complications including graft infection, delayed wound healing, and severe pain in a small percentage of patients. They also reported a high patient satisfaction rate.¹⁹ Due to the low recurrence rate, this study suggested that total excision of the nail unit followed by a full-thickness skin graft is a safe and efficient treatment of NSCC without bone involvement. Similarly, in another case series, wide local excision of the entire nail apparatus had a relapse rate of only 5%, in contrast to partial excision of the nail unit with a relapse of 56%.²⁰ These studies suggest that wide nail unit excision is an acceptable and effective approach; however, in cases in which invasion cannot be ruled out, histologic clearance would be a reasonable approach.²¹ As such, several case series demonstrated the merits of MMS for NSCC. de Berker et al²² reported 8 patients with NSCC treated using slow MMS and showed tumor clearance after a mean of 3 stages over a mean period of 6.9 days. In all cases, the wounds were allowed to heal by secondary intention, and the distal phalanx was preserved. During a mean follow-up period of 3.1 years, no recurrence was seen, and involved digits remained functional.²²

Other studies tested the efficacy of MMS for NSCC. Young et al²³ reported the outcomes of 14 NSCC cases treated with MMS. In their case series, they found that the mean number of MMS surgical stages required to achieve histologic clearance was 2, while the mean number of tissue sections was 4.²³ All cases were allowed to heal by secondary intent with excellent outcomes, except for 1 patient who received primary closure of a small defect. They reported a 78% cure rate with an average time to recurrence of 47 months.²³ In a series of 42 cases of NSCC treated with MMS, Gou et al¹⁷ noted a cure rate close to 93%. In their study, recurrences were observed in only 3 patients (7.1%). These recurrent cases were then successfully treated with another round of MMS.¹⁷ This study’s cure rate was comparable to the cure rate of MMS for SCC in other cutaneous areas. Goldminz and Bennett²⁴ demonstrated a cure rate of 92% in their case series of 25 patients. Two patients developed recurrent disease and were treated again with MMS resulting in no subsequent recurrence. In this study, the authors allowed all defects to heal by secondary intention and found that there were excellent cosmetic and functional outcomes.²⁴ Dika et al²⁵ evaluated the long-term effectiveness of MMS in the treatment of NSCC, in particular its ability to reduce the number of digital amputations. Fifteen patients diagnosed with NSCC were treated with MMS as the first-line surgical approach and were followed for 2 to 5 years. They found that in utilizing MMS, they were able to avoid amputations in 13 of 15 cases with no recurrence in any of these tumors. Two cases, however, still required amputation of the distal phalanx.²⁵

Although these studies suggest that MMS achieves a high cure rate ranging from 78% to 93%, it is not yet clear in the literature whether MMS is superior to wide local excision. More studies and clinical trials comparing these 2 surgical approaches should be performed to identify which surgical approach would be the gold standard for NSCC and which select cases would benefit from MMS as first-line treatment.

Final Thoughts

Nail unit SCC is one of the most common nail unit malignancies and can mimic several benign entities. Dermatologists who are early in their training should consider biopsy of subungual lesions with certain red flags (Table 1). It is important to diagnose NSCC for early intervention. Referral for wide local excision or MMS would be ideal. There are data in the literature supporting both surgical approaches as being effective; however, there are no trials comparing both approaches. Distal amputation should be considered as a last resort when wide local excision is not reasonable or when MMS fails to achieve clear margins, thereby reducing unnecessary amputations and patient morbidity.¹⁷

The state of Tennessee, where I worked and attended medical school, did not have legislation in place prohibiting termination of employment based on sexual orientation alone. As a lesbian, I never felt safe at work knowing that I could be fired at any time simply because of who I loved and how I identified. When I started medical school in rural Appalachia, I decided I would be “out” but remained cautious. That meant inspecting everyone I encountered for signs of acceptance and safety before sharing details about my life. As a third-year medical student, I started wearing a rainbow triangle on my white coat. One of the first patients I cared for cried and thanked me for wearing the pin. She then proceeded to tell me about her partner, her own struggles with depression, and the secrets she had to keep from her community. It was overwhelming and, yet, so familiar. I was struck by how wearing this pin, a small gesture, made this patient feel safe enough to come out to me and seek help for her depression. Although I found a supportive community in Tennessee, it was only after I moved to Massachusetts for residency—where antidiscrimination laws protected lesbian, gay, bisexual, transgender, queer/questioning, intersex, asexual, plus all other gender and sexual minority (LGBTQIA+) identified people—did I feel safe to freely share about my partner and our life together.

A landmark decision in the Supreme Court

This past June, in a 6 to 3 decision, the US Supreme Court ruled in the case of Bostock v Clayton County that Title VII’s ban on discrimination also protects LGBTQIA+ employees. Title VII is a federal law that protects employees from discrimination based on race, color, national origin, sex, and religion.¹ In this decision, the court determined that “sex” cannot be differentiated from sexual orientation. Justice Neil Gorsuch, who wrote the majority opinion, stated, “It is impossible… to discriminate against a person for being homosexual or transgender without discriminating against that individual based on sex.”² Title VII not only protects employees in hiring and firing practices but also protects against harassment and retaliation. Prior to this ruling, there were no federal antidiscrimination laws for LGBTQIA+ individuals, and only 22 states and the District of Columbia had laws in place that specified antidiscrimination protection for this community.³ Because of this landmark decision, Title VII now protects all employees in all states from discrimination, including due to an individual’s sexual orientation.

This is a huge victory in the battle for equality; however, the fight is not over. Justice Gorsuch stated, “We do not purport to address bathrooms, locker rooms or anything else of the kind…whether other policies and practices might or might not qualify as unlawful discrimination or find justifications under other provisions of Title VII are questions for future cases, not these.”² This victory sets a new precedent and will continue to be further defined with more court cases as states and employers push back against these protections.

Continue to: A worrying shift in the Court...

A worrying shift in the Court

We have already started to see the repercussions of this ruling from Supreme Court justices themselves. Justice Clarence Thomas, who dissented in the Obergefell v Hodges decision in 2015, which established the constitutional right for marriage equality, recently wrote a petition to have the Supreme Court reconsider that ruling. He wrote “Obergefell enables courts and governments to brand religious adherents who believe that marriage is between one man and one woman as bigots, making their religious liberty concerns that much easier to dismiss.”³ After the passing of Justice Ruth Bader Ginsburg, the Supreme Court became decidedly more conservative with the appointment of Judge Amy Coney Barrett, whose mentor was the late Justice Antonin Scalia, who also dissented in the 2015 case.

As we celebrate this huge win for equality in this June decision, we also must recognize that LGBTQIA+ rights are still at risk.

LGBTQIA+ patients at higher risk for litany of conditions

Even with the Bostock v Clayton County ruling, we must not forget that discrimination will continue to exist. As health care providers, we have a responsibility to advocate on behalf of our LGBTQIA+ colleagues and patients. According to the Healthy People 2020 survey, there are higher rates of obesity, tobacco dependence, and sexually transmitted infection, as well as lower adherence to cancer screening recommendations in the LGBTQIA+ community.⁴ These disparities are a result of systemic, legal, and social factors, including limited access to affirming and inclusive health care.⁵ The LGBTQIA+ community deserves better.

Take action

In the coming months and years, as the US Supreme Court hears more cases that will threaten the rights of the LGBTQIA+ community, I challenge all clinicians to take action. Even the smallest of gestures, such as wearing a rainbow pin, can be transformative for our patients and within our communities.

• Advocate for your state to enact nondiscrimination laws protecting the LGBTQIA+ community. Find out if your state has a law.
• Support your LGBTQIA+ colleagues by establishing an employee support group.
• Educate yourself and your colleagues on LGBTQIA+ inclusive medical practices.

The state of Tennessee, where I worked and attended medical school, did not have legislation in place prohibiting termination of employment based on sexual orientation alone. As a lesbian, I never felt safe at work knowing that I could be fired at any time simply because of who I loved and how I identified. When I started medical school in rural Appalachia, I decided I would be “out” but remained cautious. That meant inspecting everyone I encountered for signs of acceptance and safety before sharing details about my life. As a third-year medical student, I started wearing a rainbow triangle on my white coat. One of the first patients I cared for cried and thanked me for wearing the pin. She then proceeded to tell me about her partner, her own struggles with depression, and the secrets she had to keep from her community. It was overwhelming and, yet, so familiar. I was struck by how wearing this pin, a small gesture, made this patient feel safe enough to come out to me and seek help for her depression. Although I found a supportive community in Tennessee, it was only after I moved to Massachusetts for residency—where antidiscrimination laws protected lesbian, gay, bisexual, transgender, queer/questioning, intersex, asexual, plus all other gender and sexual minority (LGBTQIA+) identified people—did I feel safe to freely share about my partner and our life together.

A landmark decision in the Supreme Court

This past June, in a 6 to 3 decision, the US Supreme Court ruled in the case of Bostock v Clayton County that Title VII’s ban on discrimination also protects LGBTQIA+ employees. Title VII is a federal law that protects employees from discrimination based on race, color, national origin, sex, and religion.¹ In this decision, the court determined that “sex” cannot be differentiated from sexual orientation. Justice Neil Gorsuch, who wrote the majority opinion, stated, “It is impossible… to discriminate against a person for being homosexual or transgender without discriminating against that individual based on sex.”² Title VII not only protects employees in hiring and firing practices but also protects against harassment and retaliation. Prior to this ruling, there were no federal antidiscrimination laws for LGBTQIA+ individuals, and only 22 states and the District of Columbia had laws in place that specified antidiscrimination protection for this community.³ Because of this landmark decision, Title VII now protects all employees in all states from discrimination, including due to an individual’s sexual orientation.

This is a huge victory in the battle for equality; however, the fight is not over. Justice Gorsuch stated, “We do not purport to address bathrooms, locker rooms or anything else of the kind…whether other policies and practices might or might not qualify as unlawful discrimination or find justifications under other provisions of Title VII are questions for future cases, not these.”² This victory sets a new precedent and will continue to be further defined with more court cases as states and employers push back against these protections.

Continue to: A worrying shift in the Court...

A worrying shift in the Court

We have already started to see the repercussions of this ruling from Supreme Court justices themselves. Justice Clarence Thomas, who dissented in the Obergefell v Hodges decision in 2015, which established the constitutional right for marriage equality, recently wrote a petition to have the Supreme Court reconsider that ruling. He wrote “Obergefell enables courts and governments to brand religious adherents who believe that marriage is between one man and one woman as bigots, making their religious liberty concerns that much easier to dismiss.”³ After the passing of Justice Ruth Bader Ginsburg, the Supreme Court became decidedly more conservative with the appointment of Judge Amy Coney Barrett, whose mentor was the late Justice Antonin Scalia, who also dissented in the 2015 case.

As we celebrate this huge win for equality in this June decision, we also must recognize that LGBTQIA+ rights are still at risk.

LGBTQIA+ patients at higher risk for litany of conditions

Even with the Bostock v Clayton County ruling, we must not forget that discrimination will continue to exist. As health care providers, we have a responsibility to advocate on behalf of our LGBTQIA+ colleagues and patients. According to the Healthy People 2020 survey, there are higher rates of obesity, tobacco dependence, and sexually transmitted infection, as well as lower adherence to cancer screening recommendations in the LGBTQIA+ community.⁴ These disparities are a result of systemic, legal, and social factors, including limited access to affirming and inclusive health care.⁵ The LGBTQIA+ community deserves better.

Take action

In the coming months and years, as the US Supreme Court hears more cases that will threaten the rights of the LGBTQIA+ community, I challenge all clinicians to take action. Even the smallest of gestures, such as wearing a rainbow pin, can be transformative for our patients and within our communities.

• Advocate for your state to enact nondiscrimination laws protecting the LGBTQIA+ community. Find out if your state has a law.
• Support your LGBTQIA+ colleagues by establishing an employee support group.
• Educate yourself and your colleagues on LGBTQIA+ inclusive medical practices.

The state of Tennessee, where I worked and attended medical school, did not have legislation in place prohibiting termination of employment based on sexual orientation alone. As a lesbian, I never felt safe at work knowing that I could be fired at any time simply because of who I loved and how I identified. When I started medical school in rural Appalachia, I decided I would be “out” but remained cautious. That meant inspecting everyone I encountered for signs of acceptance and safety before sharing details about my life. As a third-year medical student, I started wearing a rainbow triangle on my white coat. One of the first patients I cared for cried and thanked me for wearing the pin. She then proceeded to tell me about her partner, her own struggles with depression, and the secrets she had to keep from her community. It was overwhelming and, yet, so familiar. I was struck by how wearing this pin, a small gesture, made this patient feel safe enough to come out to me and seek help for her depression. Although I found a supportive community in Tennessee, it was only after I moved to Massachusetts for residency—where antidiscrimination laws protected lesbian, gay, bisexual, transgender, queer/questioning, intersex, asexual, plus all other gender and sexual minority (LGBTQIA+) identified people—did I feel safe to freely share about my partner and our life together.

A landmark decision in the Supreme Court

This past June, in a 6 to 3 decision, the US Supreme Court ruled in the case of Bostock v Clayton County that Title VII’s ban on discrimination also protects LGBTQIA+ employees. Title VII is a federal law that protects employees from discrimination based on race, color, national origin, sex, and religion.¹ In this decision, the court determined that “sex” cannot be differentiated from sexual orientation. Justice Neil Gorsuch, who wrote the majority opinion, stated, “It is impossible… to discriminate against a person for being homosexual or transgender without discriminating against that individual based on sex.”² Title VII not only protects employees in hiring and firing practices but also protects against harassment and retaliation. Prior to this ruling, there were no federal antidiscrimination laws for LGBTQIA+ individuals, and only 22 states and the District of Columbia had laws in place that specified antidiscrimination protection for this community.³ Because of this landmark decision, Title VII now protects all employees in all states from discrimination, including due to an individual’s sexual orientation.

This is a huge victory in the battle for equality; however, the fight is not over. Justice Gorsuch stated, “We do not purport to address bathrooms, locker rooms or anything else of the kind…whether other policies and practices might or might not qualify as unlawful discrimination or find justifications under other provisions of Title VII are questions for future cases, not these.”² This victory sets a new precedent and will continue to be further defined with more court cases as states and employers push back against these protections.

Continue to: A worrying shift in the Court...

A worrying shift in the Court

We have already started to see the repercussions of this ruling from Supreme Court justices themselves. Justice Clarence Thomas, who dissented in the Obergefell v Hodges decision in 2015, which established the constitutional right for marriage equality, recently wrote a petition to have the Supreme Court reconsider that ruling. He wrote “Obergefell enables courts and governments to brand religious adherents who believe that marriage is between one man and one woman as bigots, making their religious liberty concerns that much easier to dismiss.”³ After the passing of Justice Ruth Bader Ginsburg, the Supreme Court became decidedly more conservative with the appointment of Judge Amy Coney Barrett, whose mentor was the late Justice Antonin Scalia, who also dissented in the 2015 case.

As we celebrate this huge win for equality in this June decision, we also must recognize that LGBTQIA+ rights are still at risk.

LGBTQIA+ patients at higher risk for litany of conditions

Even with the Bostock v Clayton County ruling, we must not forget that discrimination will continue to exist. As health care providers, we have a responsibility to advocate on behalf of our LGBTQIA+ colleagues and patients. According to the Healthy People 2020 survey, there are higher rates of obesity, tobacco dependence, and sexually transmitted infection, as well as lower adherence to cancer screening recommendations in the LGBTQIA+ community.⁴ These disparities are a result of systemic, legal, and social factors, including limited access to affirming and inclusive health care.⁵ The LGBTQIA+ community deserves better.

Take action

In the coming months and years, as the US Supreme Court hears more cases that will threaten the rights of the LGBTQIA+ community, I challenge all clinicians to take action. Even the smallest of gestures, such as wearing a rainbow pin, can be transformative for our patients and within our communities.

• Advocate for your state to enact nondiscrimination laws protecting the LGBTQIA+ community. Find out if your state has a law.
• Support your LGBTQIA+ colleagues by establishing an employee support group.
• Educate yourself and your colleagues on LGBTQIA+ inclusive medical practices.

 
The dermMentors™ Resident of Distinction Award™ was presented to 5 dermatology residents at the virtual 16th Annual Coastal Dermatology Symposium, October 15–16, 2020. Recipients of the award include Shaundra Eichstadt, MD, Stanford University Department of Dermatology, Redwood City, California, and  Tufts University Medical Center, Boston, Massachusetts; Nicholas Gulati, MD, PhD, NYU Grossman School of Medicine, New York, New York; Anthony K. Guzman, MD, Albert Einstein College of Medicine, Bronx, New York; Nikolai Klebanov, MD, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts; and Reid Waldman, MD, University of Connecticut, Farmington. The residents presented their research during the general sessions on October 16, 2020.

The overall grand prize was awarded to Dr. Guzman for his research entitled, “Topical Cantharidin Revisited: A Phase 2 Study Investigating a Commercially Viable Formulation of Cantharidin (VP-102) for the Treatment of Molluscum Contagiosum.” Dr. Guzman presented the results of a 12-week, open-label pilot trial at a single outpatient dermatology clinic to determine the efficacy and safety of VP-102, a novel, standardized, commercially viable cantharidin formulation produced under good manufacturing practice for the treatment of molluscum contagiosum. “VP-102 was well tolerated with either a 6- or 24-hour exposure and was associated with a significantly reduced lesion count, improved quality of life, and complete clearance of MC lesions in nearly half of the patients,” Dr. Guzman reported.

Presentations by the other residents included results of a clinical trial of gene-corrected autologous cell therapy for recessive dystrophic epidermolysis bullosa (Dr. Eichstadt), an analysis of the association between skin toxicity and better response in melanoma patients treated with immune checkpoint inhibitors (Dr. Gulati), a study of the risks of COVID-19 infection and mortality for patients on biologics (Dr. Klebanov), and a comparison of compliance rates of atopic dermatitis patients on systemic medications with those of psoriasis patients on systemic medications (Dr. Waldman). Access all of the abstracts presented by the top residents here. 

The dermMentors™ Resident of Distinction Award™ recognizes top residents in dermatology. DermMentors.org and the dermMentors™ Resident of Distinction Award™ are sponsored by Beiersdorf Inc and administered by DermEd, Inc. The 2020 dermMentors™ Residents of Distinction™ presented new scientific research during the general sessions of the virtual 16th Annual Coastal Dermatology Symposium on October 16, 2020.

 
The dermMentors™ Resident of Distinction Award™ was presented to 5 dermatology residents at the virtual 16th Annual Coastal Dermatology Symposium, October 15–16, 2020. Recipients of the award include Shaundra Eichstadt, MD, Stanford University Department of Dermatology, Redwood City, California, and  Tufts University Medical Center, Boston, Massachusetts; Nicholas Gulati, MD, PhD, NYU Grossman School of Medicine, New York, New York; Anthony K. Guzman, MD, Albert Einstein College of Medicine, Bronx, New York; Nikolai Klebanov, MD, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts; and Reid Waldman, MD, University of Connecticut, Farmington. The residents presented their research during the general sessions on October 16, 2020.

The overall grand prize was awarded to Dr. Guzman for his research entitled, “Topical Cantharidin Revisited: A Phase 2 Study Investigating a Commercially Viable Formulation of Cantharidin (VP-102) for the Treatment of Molluscum Contagiosum.” Dr. Guzman presented the results of a 12-week, open-label pilot trial at a single outpatient dermatology clinic to determine the efficacy and safety of VP-102, a novel, standardized, commercially viable cantharidin formulation produced under good manufacturing practice for the treatment of molluscum contagiosum. “VP-102 was well tolerated with either a 6- or 24-hour exposure and was associated with a significantly reduced lesion count, improved quality of life, and complete clearance of MC lesions in nearly half of the patients,” Dr. Guzman reported.

Presentations by the other residents included results of a clinical trial of gene-corrected autologous cell therapy for recessive dystrophic epidermolysis bullosa (Dr. Eichstadt), an analysis of the association between skin toxicity and better response in melanoma patients treated with immune checkpoint inhibitors (Dr. Gulati), a study of the risks of COVID-19 infection and mortality for patients on biologics (Dr. Klebanov), and a comparison of compliance rates of atopic dermatitis patients on systemic medications with those of psoriasis patients on systemic medications (Dr. Waldman). Access all of the abstracts presented by the top residents here. 

The dermMentors™ Resident of Distinction Award™ recognizes top residents in dermatology. DermMentors.org and the dermMentors™ Resident of Distinction Award™ are sponsored by Beiersdorf Inc and administered by DermEd, Inc. The 2020 dermMentors™ Residents of Distinction™ presented new scientific research during the general sessions of the virtual 16th Annual Coastal Dermatology Symposium on October 16, 2020.

 
The dermMentors™ Resident of Distinction Award™ was presented to 5 dermatology residents at the virtual 16th Annual Coastal Dermatology Symposium, October 15–16, 2020. Recipients of the award include Shaundra Eichstadt, MD, Stanford University Department of Dermatology, Redwood City, California, and  Tufts University Medical Center, Boston, Massachusetts; Nicholas Gulati, MD, PhD, NYU Grossman School of Medicine, New York, New York; Anthony K. Guzman, MD, Albert Einstein College of Medicine, Bronx, New York; Nikolai Klebanov, MD, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts; and Reid Waldman, MD, University of Connecticut, Farmington. The residents presented their research during the general sessions on October 16, 2020.

The overall grand prize was awarded to Dr. Guzman for his research entitled, “Topical Cantharidin Revisited: A Phase 2 Study Investigating a Commercially Viable Formulation of Cantharidin (VP-102) for the Treatment of Molluscum Contagiosum.” Dr. Guzman presented the results of a 12-week, open-label pilot trial at a single outpatient dermatology clinic to determine the efficacy and safety of VP-102, a novel, standardized, commercially viable cantharidin formulation produced under good manufacturing practice for the treatment of molluscum contagiosum. “VP-102 was well tolerated with either a 6- or 24-hour exposure and was associated with a significantly reduced lesion count, improved quality of life, and complete clearance of MC lesions in nearly half of the patients,” Dr. Guzman reported.

Presentations by the other residents included results of a clinical trial of gene-corrected autologous cell therapy for recessive dystrophic epidermolysis bullosa (Dr. Eichstadt), an analysis of the association between skin toxicity and better response in melanoma patients treated with immune checkpoint inhibitors (Dr. Gulati), a study of the risks of COVID-19 infection and mortality for patients on biologics (Dr. Klebanov), and a comparison of compliance rates of atopic dermatitis patients on systemic medications with those of psoriasis patients on systemic medications (Dr. Waldman). Access all of the abstracts presented by the top residents here. 

The dermMentors™ Resident of Distinction Award™ recognizes top residents in dermatology. DermMentors.org and the dermMentors™ Resident of Distinction Award™ are sponsored by Beiersdorf Inc and administered by DermEd, Inc. The 2020 dermMentors™ Residents of Distinction™ presented new scientific research during the general sessions of the virtual 16th Annual Coastal Dermatology Symposium on October 16, 2020.

An article recently was published in The New York Times with a headline that read, “Dermatology Has a Problem With Skin Color.” ¹ The article featured interviews with many well-known dermatologists who are experts in skin of color (SOC), and their points followed a similar pattern—skin disease often looks different in patients with darker skin, and diagnoses often are delayed or missed altogether as a consequence of clinical uncertainty. The article included an interview with Jenna Lester, MD, who leads the SOC clinic at the University of California, San Francisco. In the article, she discussed how dermatologists are trained to recognize findings through pattern recognition. However, if we are only trained to diagnose dermatologic diseases on white skin, we will be unable to recognize diseases in patients with darker skin, leading to suboptimal patient care. ¹

Dermatology is a visual specialty, and residents go through thousands of photographs during residency training to distinguish different presentations and unique findings of a variety of skin diseases. Nevertheless, to Dr. Lester’s point, our learning is limited by the photographs and patients that we see.

Additionally, residents training in locations without diverse patient populations rely even more on images in educational resources to recognize clinical presentations in patients with darker skin. A study was published in Cutis earlier this year that surveyed dermatology residents about multiethnic training in residency.² It showed that residents training in less ethnically diverse areas such as the Midwest and Northwest were more likely to agree that dedicated multiethnic clinics and rotations are important to gain competence compared to residents training in more ethnically diverse regions such as the Southeast, Northeast, and Southwest. Most residents believed 1 to 5 hours per month of lectures covering conditions affecting SOC and/or multiethnic skin are needed to become competent.²

Limitations of Educational Resources

The images in dermatology educational resources do not reflect the diversity of our country’s population. A research letter recently was published in the Journal of the American Academy of Dermatology (JAAD) in which the authors assessed the number of images of dark skin—Fitzpatrick skin types V and VI—in dermatology educational resources.³ The authors analyzed images from 8 resources commonly used to study dermatology, including 6 printed texts and 2 online resources. Of the printed texts, Andrews’ Diseases of the Skin had the highest percentage of images of dark skin at 19.9%. Overall, VisualDx had the highest percentage of photographs of dark skin at 28.5%, while DermNet NZ had the lowest of all resources at only 2.8%.³

Similarly, a research letter published in the British Journal of Dermatology reviewed images in 2 standard dermatology textbooks.⁴ Although images of SOC made up 22% to 32% of the overall content, the number of images of sexually transmitted infections in SOC was disproportionate (47%–58%) compared to images of non–sexually transmitted infections (28%). The authors also stated that communities of color often have legacies of mistrust with the health care system, and diagnostic uncertainty can further impair the physician-patient relationship.⁴

The lack of diversity in clinical images and research was further exemplified by recent publications regarding the perniolike eruption associated with coronavirus disease 2019 (COVID-19), commonly referred to as COVID toes. A research letter was published in the British Journal of Dermatology earlier this year about the lack of images of SOC in publications about the cutaneous manifestations of COVID-19.⁵ At that time, there were zero published images of cutaneous COVID-19 manifestations in Fitzpatrick skin types V and VI, yet COVID-19 disproportionately affects Black individuals and other people of color.^5,6 A case series recently was published in JAAD Case Reports that included images of cutaneous COVID-19 findings in patients with Fitzpatrick skin types III through V.⁷ The authors noted that the findings were more subtle on darker skin as the erythema was harder to discern. The inability to identify the perniolike eruption ultimately can delay diagnosis.⁷

Resident Education

Over the past few months, I have reflected on my role as a dermatology resident and my dedication to antiracism in my personal and professional life. It is not a valid response or excuse to say that certain diagnoses are harder to make because of darker skin tone. It is our responsibility to do better for all patients. To that end, our educational resources should reflect our entire patient population.

I have been working with my coresident Annika Weinhammer, MD, on a quality improvement project to strengthen our educational curriculum at the University of Wisconsin regarding SOC. This project aims to enhance our skills as dermatologists in diagnosing and treating diseases in SOC. Moving forward, we have set an expectation that all didactic lectures must include images of SOC. Below, I have listed some of our initiatives along with recommendations for educational resources. There are multiple dermatology textbooks focused on SOC, including the following:

• Clinical Cases in Skin of Color: Adnexal, Inflammation, Infections, and Pigmentary Disorders ⁸
• Clinical Cases in Skin of Color: Medical, Oncological and Hair Disorders, and Cosmetic Dermatology ⁹
• Dermatology Atlas for Skin of Color ¹⁰
• Fundamentals of Ethnic Hair: The Dermatologist’s Perspective ¹¹
• Light-Based Therapies for Skin of Color ¹²
• Pediatric Skin of Color ¹³
• Skin of Color: A Practical Guide to Dermatologic Diagnosis and Treatment ¹⁴
• Taylor and Kelly’s Dermatology for Skin of Color ¹⁵
• Treatments for Skin of Color ¹⁶

Our program has provided residents with Taylor and Kelly’s Dermatology for Skin of Color¹⁵ and Treatments for Skin of Color.¹⁶ Residents and medical students should search their institution’s electronic library for e-books and other resources including VisualDx, which includes many photographs of SOC that can be used and cited in resident didactics.

There also are a variety of online resources. Mind the Gap is a handbook written by Malone Mukwende, a medical student in London.^17,18 The handbook focuses on common clinical signs and how they present in black and brown skin. Another online resource with clinical images is Skin Deep (https://dftbskindeep.com/), a project aimed at improving the diversity of pediatric skin images. An additional online resource is Brown Skin Matters on Instagram (@brownskinmatters) that shows photographs of dermatologic conditions in SOC; however, these photographs are submitted by users and not independently verified.

I also encourage residents to join the Skin of Color Society, which promotes awareness and excellence within the special interest area of SOC. Some of the society's initiatives include educational series, networking events, diversity town halls, and a scientific symposium. Patient information for common dermatologic diagnoses exists on the society's website (https://skinofcolorsociety.org/). The society waives membership fees for resident applicants who provide a letter of good standing from their residency program. The society hosted the Skin of Color Update virtually this year (September 12–13, 2020). It costs $49 to attend, and the recorded lectures are available to stream through the end of 2020. Our department sponsored residents to attend virtually.

Finally, our department has been taking steps to implement antiracism measures in how we work, learn, conduct research, and treat patients. We are leading a resident book club discussing How to Be an Antiracist¹⁹ by Ibram X. Kendi. Residents are involved in the local chapter of White Coats for Black Lives (https://whitecoats4blacklives.org/). We also have compiled a list of antiracism resources that was shared with the department, including books, documentaries, podcasts, local and online Black-owned businesses to support, and local Black-led nonprofits. 

Final Thoughts

Dermatology residents must be comfortable diagnosing and treating diseases in darker skin tones to provide the best possible care for patients with SOC. Although some common dermatology educational resources have a paucity of clinical images of SOC, there are a variety of additional educational resources through textbooks and websites.

An article recently was published in The New York Times with a headline that read, “Dermatology Has a Problem With Skin Color.” ¹ The article featured interviews with many well-known dermatologists who are experts in skin of color (SOC), and their points followed a similar pattern—skin disease often looks different in patients with darker skin, and diagnoses often are delayed or missed altogether as a consequence of clinical uncertainty. The article included an interview with Jenna Lester, MD, who leads the SOC clinic at the University of California, San Francisco. In the article, she discussed how dermatologists are trained to recognize findings through pattern recognition. However, if we are only trained to diagnose dermatologic diseases on white skin, we will be unable to recognize diseases in patients with darker skin, leading to suboptimal patient care. ¹

Dermatology is a visual specialty, and residents go through thousands of photographs during residency training to distinguish different presentations and unique findings of a variety of skin diseases. Nevertheless, to Dr. Lester’s point, our learning is limited by the photographs and patients that we see.

Additionally, residents training in locations without diverse patient populations rely even more on images in educational resources to recognize clinical presentations in patients with darker skin. A study was published in Cutis earlier this year that surveyed dermatology residents about multiethnic training in residency.² It showed that residents training in less ethnically diverse areas such as the Midwest and Northwest were more likely to agree that dedicated multiethnic clinics and rotations are important to gain competence compared to residents training in more ethnically diverse regions such as the Southeast, Northeast, and Southwest. Most residents believed 1 to 5 hours per month of lectures covering conditions affecting SOC and/or multiethnic skin are needed to become competent.²

Limitations of Educational Resources

The images in dermatology educational resources do not reflect the diversity of our country’s population. A research letter recently was published in the Journal of the American Academy of Dermatology (JAAD) in which the authors assessed the number of images of dark skin—Fitzpatrick skin types V and VI—in dermatology educational resources.³ The authors analyzed images from 8 resources commonly used to study dermatology, including 6 printed texts and 2 online resources. Of the printed texts, Andrews’ Diseases of the Skin had the highest percentage of images of dark skin at 19.9%. Overall, VisualDx had the highest percentage of photographs of dark skin at 28.5%, while DermNet NZ had the lowest of all resources at only 2.8%.³

Similarly, a research letter published in the British Journal of Dermatology reviewed images in 2 standard dermatology textbooks.⁴ Although images of SOC made up 22% to 32% of the overall content, the number of images of sexually transmitted infections in SOC was disproportionate (47%–58%) compared to images of non–sexually transmitted infections (28%). The authors also stated that communities of color often have legacies of mistrust with the health care system, and diagnostic uncertainty can further impair the physician-patient relationship.⁴

The lack of diversity in clinical images and research was further exemplified by recent publications regarding the perniolike eruption associated with coronavirus disease 2019 (COVID-19), commonly referred to as COVID toes. A research letter was published in the British Journal of Dermatology earlier this year about the lack of images of SOC in publications about the cutaneous manifestations of COVID-19.⁵ At that time, there were zero published images of cutaneous COVID-19 manifestations in Fitzpatrick skin types V and VI, yet COVID-19 disproportionately affects Black individuals and other people of color.^5,6 A case series recently was published in JAAD Case Reports that included images of cutaneous COVID-19 findings in patients with Fitzpatrick skin types III through V.⁷ The authors noted that the findings were more subtle on darker skin as the erythema was harder to discern. The inability to identify the perniolike eruption ultimately can delay diagnosis.⁷

Resident Education

Over the past few months, I have reflected on my role as a dermatology resident and my dedication to antiracism in my personal and professional life. It is not a valid response or excuse to say that certain diagnoses are harder to make because of darker skin tone. It is our responsibility to do better for all patients. To that end, our educational resources should reflect our entire patient population.

I have been working with my coresident Annika Weinhammer, MD, on a quality improvement project to strengthen our educational curriculum at the University of Wisconsin regarding SOC. This project aims to enhance our skills as dermatologists in diagnosing and treating diseases in SOC. Moving forward, we have set an expectation that all didactic lectures must include images of SOC. Below, I have listed some of our initiatives along with recommendations for educational resources. There are multiple dermatology textbooks focused on SOC, including the following:

• Clinical Cases in Skin of Color: Adnexal, Inflammation, Infections, and Pigmentary Disorders ⁸
• Clinical Cases in Skin of Color: Medical, Oncological and Hair Disorders, and Cosmetic Dermatology ⁹
• Dermatology Atlas for Skin of Color ¹⁰
• Fundamentals of Ethnic Hair: The Dermatologist’s Perspective ¹¹
• Light-Based Therapies for Skin of Color ¹²
• Pediatric Skin of Color ¹³
• Skin of Color: A Practical Guide to Dermatologic Diagnosis and Treatment ¹⁴
• Taylor and Kelly’s Dermatology for Skin of Color ¹⁵
• Treatments for Skin of Color ¹⁶

Our program has provided residents with Taylor and Kelly’s Dermatology for Skin of Color¹⁵ and Treatments for Skin of Color.¹⁶ Residents and medical students should search their institution’s electronic library for e-books and other resources including VisualDx, which includes many photographs of SOC that can be used and cited in resident didactics.

There also are a variety of online resources. Mind the Gap is a handbook written by Malone Mukwende, a medical student in London.^17,18 The handbook focuses on common clinical signs and how they present in black and brown skin. Another online resource with clinical images is Skin Deep (https://dftbskindeep.com/), a project aimed at improving the diversity of pediatric skin images. An additional online resource is Brown Skin Matters on Instagram (@brownskinmatters) that shows photographs of dermatologic conditions in SOC; however, these photographs are submitted by users and not independently verified.

I also encourage residents to join the Skin of Color Society, which promotes awareness and excellence within the special interest area of SOC. Some of the society's initiatives include educational series, networking events, diversity town halls, and a scientific symposium. Patient information for common dermatologic diagnoses exists on the society's website (https://skinofcolorsociety.org/). The society waives membership fees for resident applicants who provide a letter of good standing from their residency program. The society hosted the Skin of Color Update virtually this year (September 12–13, 2020). It costs $49 to attend, and the recorded lectures are available to stream through the end of 2020. Our department sponsored residents to attend virtually.

Finally, our department has been taking steps to implement antiracism measures in how we work, learn, conduct research, and treat patients. We are leading a resident book club discussing How to Be an Antiracist¹⁹ by Ibram X. Kendi. Residents are involved in the local chapter of White Coats for Black Lives (https://whitecoats4blacklives.org/). We also have compiled a list of antiracism resources that was shared with the department, including books, documentaries, podcasts, local and online Black-owned businesses to support, and local Black-led nonprofits. 

Final Thoughts

Dermatology residents must be comfortable diagnosing and treating diseases in darker skin tones to provide the best possible care for patients with SOC. Although some common dermatology educational resources have a paucity of clinical images of SOC, there are a variety of additional educational resources through textbooks and websites.

An article recently was published in The New York Times with a headline that read, “Dermatology Has a Problem With Skin Color.” ¹ The article featured interviews with many well-known dermatologists who are experts in skin of color (SOC), and their points followed a similar pattern—skin disease often looks different in patients with darker skin, and diagnoses often are delayed or missed altogether as a consequence of clinical uncertainty. The article included an interview with Jenna Lester, MD, who leads the SOC clinic at the University of California, San Francisco. In the article, she discussed how dermatologists are trained to recognize findings through pattern recognition. However, if we are only trained to diagnose dermatologic diseases on white skin, we will be unable to recognize diseases in patients with darker skin, leading to suboptimal patient care. ¹

Dermatology is a visual specialty, and residents go through thousands of photographs during residency training to distinguish different presentations and unique findings of a variety of skin diseases. Nevertheless, to Dr. Lester’s point, our learning is limited by the photographs and patients that we see.

Additionally, residents training in locations without diverse patient populations rely even more on images in educational resources to recognize clinical presentations in patients with darker skin. A study was published in Cutis earlier this year that surveyed dermatology residents about multiethnic training in residency.² It showed that residents training in less ethnically diverse areas such as the Midwest and Northwest were more likely to agree that dedicated multiethnic clinics and rotations are important to gain competence compared to residents training in more ethnically diverse regions such as the Southeast, Northeast, and Southwest. Most residents believed 1 to 5 hours per month of lectures covering conditions affecting SOC and/or multiethnic skin are needed to become competent.²

Limitations of Educational Resources

The images in dermatology educational resources do not reflect the diversity of our country’s population. A research letter recently was published in the Journal of the American Academy of Dermatology (JAAD) in which the authors assessed the number of images of dark skin—Fitzpatrick skin types V and VI—in dermatology educational resources.³ The authors analyzed images from 8 resources commonly used to study dermatology, including 6 printed texts and 2 online resources. Of the printed texts, Andrews’ Diseases of the Skin had the highest percentage of images of dark skin at 19.9%. Overall, VisualDx had the highest percentage of photographs of dark skin at 28.5%, while DermNet NZ had the lowest of all resources at only 2.8%.³

Similarly, a research letter published in the British Journal of Dermatology reviewed images in 2 standard dermatology textbooks.⁴ Although images of SOC made up 22% to 32% of the overall content, the number of images of sexually transmitted infections in SOC was disproportionate (47%–58%) compared to images of non–sexually transmitted infections (28%). The authors also stated that communities of color often have legacies of mistrust with the health care system, and diagnostic uncertainty can further impair the physician-patient relationship.⁴

The lack of diversity in clinical images and research was further exemplified by recent publications regarding the perniolike eruption associated with coronavirus disease 2019 (COVID-19), commonly referred to as COVID toes. A research letter was published in the British Journal of Dermatology earlier this year about the lack of images of SOC in publications about the cutaneous manifestations of COVID-19.⁵ At that time, there were zero published images of cutaneous COVID-19 manifestations in Fitzpatrick skin types V and VI, yet COVID-19 disproportionately affects Black individuals and other people of color.^5,6 A case series recently was published in JAAD Case Reports that included images of cutaneous COVID-19 findings in patients with Fitzpatrick skin types III through V.⁷ The authors noted that the findings were more subtle on darker skin as the erythema was harder to discern. The inability to identify the perniolike eruption ultimately can delay diagnosis.⁷

Resident Education

Over the past few months, I have reflected on my role as a dermatology resident and my dedication to antiracism in my personal and professional life. It is not a valid response or excuse to say that certain diagnoses are harder to make because of darker skin tone. It is our responsibility to do better for all patients. To that end, our educational resources should reflect our entire patient population.

I have been working with my coresident Annika Weinhammer, MD, on a quality improvement project to strengthen our educational curriculum at the University of Wisconsin regarding SOC. This project aims to enhance our skills as dermatologists in diagnosing and treating diseases in SOC. Moving forward, we have set an expectation that all didactic lectures must include images of SOC. Below, I have listed some of our initiatives along with recommendations for educational resources. There are multiple dermatology textbooks focused on SOC, including the following:

• Clinical Cases in Skin of Color: Adnexal, Inflammation, Infections, and Pigmentary Disorders ⁸
• Clinical Cases in Skin of Color: Medical, Oncological and Hair Disorders, and Cosmetic Dermatology ⁹
• Dermatology Atlas for Skin of Color ¹⁰
• Fundamentals of Ethnic Hair: The Dermatologist’s Perspective ¹¹
• Light-Based Therapies for Skin of Color ¹²
• Pediatric Skin of Color ¹³
• Skin of Color: A Practical Guide to Dermatologic Diagnosis and Treatment ¹⁴
• Taylor and Kelly’s Dermatology for Skin of Color ¹⁵
• Treatments for Skin of Color ¹⁶

Our program has provided residents with Taylor and Kelly’s Dermatology for Skin of Color¹⁵ and Treatments for Skin of Color.¹⁶ Residents and medical students should search their institution’s electronic library for e-books and other resources including VisualDx, which includes many photographs of SOC that can be used and cited in resident didactics.

There also are a variety of online resources. Mind the Gap is a handbook written by Malone Mukwende, a medical student in London.^17,18 The handbook focuses on common clinical signs and how they present in black and brown skin. Another online resource with clinical images is Skin Deep (https://dftbskindeep.com/), a project aimed at improving the diversity of pediatric skin images. An additional online resource is Brown Skin Matters on Instagram (@brownskinmatters) that shows photographs of dermatologic conditions in SOC; however, these photographs are submitted by users and not independently verified.

I also encourage residents to join the Skin of Color Society, which promotes awareness and excellence within the special interest area of SOC. Some of the society's initiatives include educational series, networking events, diversity town halls, and a scientific symposium. Patient information for common dermatologic diagnoses exists on the society's website (https://skinofcolorsociety.org/). The society waives membership fees for resident applicants who provide a letter of good standing from their residency program. The society hosted the Skin of Color Update virtually this year (September 12–13, 2020). It costs $49 to attend, and the recorded lectures are available to stream through the end of 2020. Our department sponsored residents to attend virtually.

Finally, our department has been taking steps to implement antiracism measures in how we work, learn, conduct research, and treat patients. We are leading a resident book club discussing How to Be an Antiracist¹⁹ by Ibram X. Kendi. Residents are involved in the local chapter of White Coats for Black Lives (https://whitecoats4blacklives.org/). We also have compiled a list of antiracism resources that was shared with the department, including books, documentaries, podcasts, local and online Black-owned businesses to support, and local Black-led nonprofits. 

Final Thoughts

Dermatology residents must be comfortable diagnosing and treating diseases in darker skin tones to provide the best possible care for patients with SOC. Although some common dermatology educational resources have a paucity of clinical images of SOC, there are a variety of additional educational resources through textbooks and websites.

Since beginning my psychiatry residency, I have come to dread situations in which I feel like the antagonist in my patient’s life. These are moments when, due to psychiatric illness or intoxication, my patient does not want my help. In these situations, the patient’s condition may prevent shared decision-making to determine the best care for them. I experienced such a situation on my first day of residency, and that encounter taught me several valuable lessons.

An anxiety-filled first day

While working with my attending physician in a psychiatric emergency department, we met with a patient who had become agitated and was threatening staff members. The patient was also loudly protesting any use of medications. As a medical student, I had encountered patients who were agitated, but this moment felt vastly different because I was now tasked with addressing the problem. I still remember how my muscles tensed out of anxiety. As the attending took the lead in talking with the patient, the situation continued to escalate. The patient’s agitation was preventing them from being able to safely cooperate with staff despite our efforts at verbal de-escalation. As several staff members stayed with the patient, my attending and I went back to the workroom, where she instructed me to place orders for emergent medications. I sat there, an anxious intern with the solemn power and responsibility to order medications that might need to be administered against the will of an agitated patient. The moment was surreal.

A harsh reality

I had envisioned my first day of residency to be quite different. I had expected to sit with patients, healing them by listening to their stories and giving them the attention they deserved. But instead, I found myself nervously inputting medication orders, checking and rechecking that the doses and administration routes were accurate—all the while knowing that the patient would likely refuse the medications. If that occurred, the patient would need to be held by staff so the medications could be administered. Although I knew that administering emergent medications was the appropriate clinical decision to prevent harm to the patient and others, I felt conflicted by acting in opposition to the patient’s wishes. In that moment, intoxication or illness compromised patient autonomy for the sake of beneficence. I struggled with a creeping sense of guilt.

Although I did not have the chance to interact with this specific patient again, I often reflect on that encounter. I have learned that at times, the use of emergent medications or court commitments for medication administration or hospitalizations is necessary. Since that first shift, I have cared for many other patients who have received emergent medications under similar circumstances. I have observed that such treatment often stabilizes patients and enables me to engage them in meaningful conversation to optimize their care.

Lessons learned

While some of what I have experienced during my training has made me uncomfortable, I have taken with me several valuable lessons. When a patient’s intoxication or illness prevents shared decision-making, our focus as physicians should remain on the patient’s safety, health, and well-being. It is necessary to engage patients in conversations to enable us to understand what ails them and promptly determine the right treatment, tailored to their specific needs and goals.

Moving forward, I know that I will encounter many more similar situations. I hope to position myself quickly and safely alongside agitated patients to engage them in shared decision-making. As a physician, I will approach every encounter with my patients as an opportunity to understand their goals for care, and empower them to make informed decisions regarding their treatment.

Since beginning my psychiatry residency, I have come to dread situations in which I feel like the antagonist in my patient’s life. These are moments when, due to psychiatric illness or intoxication, my patient does not want my help. In these situations, the patient’s condition may prevent shared decision-making to determine the best care for them. I experienced such a situation on my first day of residency, and that encounter taught me several valuable lessons.

An anxiety-filled first day

While working with my attending physician in a psychiatric emergency department, we met with a patient who had become agitated and was threatening staff members. The patient was also loudly protesting any use of medications. As a medical student, I had encountered patients who were agitated, but this moment felt vastly different because I was now tasked with addressing the problem. I still remember how my muscles tensed out of anxiety. As the attending took the lead in talking with the patient, the situation continued to escalate. The patient’s agitation was preventing them from being able to safely cooperate with staff despite our efforts at verbal de-escalation. As several staff members stayed with the patient, my attending and I went back to the workroom, where she instructed me to place orders for emergent medications. I sat there, an anxious intern with the solemn power and responsibility to order medications that might need to be administered against the will of an agitated patient. The moment was surreal.

A harsh reality

I had envisioned my first day of residency to be quite different. I had expected to sit with patients, healing them by listening to their stories and giving them the attention they deserved. But instead, I found myself nervously inputting medication orders, checking and rechecking that the doses and administration routes were accurate—all the while knowing that the patient would likely refuse the medications. If that occurred, the patient would need to be held by staff so the medications could be administered. Although I knew that administering emergent medications was the appropriate clinical decision to prevent harm to the patient and others, I felt conflicted by acting in opposition to the patient’s wishes. In that moment, intoxication or illness compromised patient autonomy for the sake of beneficence. I struggled with a creeping sense of guilt.

Although I did not have the chance to interact with this specific patient again, I often reflect on that encounter. I have learned that at times, the use of emergent medications or court commitments for medication administration or hospitalizations is necessary. Since that first shift, I have cared for many other patients who have received emergent medications under similar circumstances. I have observed that such treatment often stabilizes patients and enables me to engage them in meaningful conversation to optimize their care.

Lessons learned

While some of what I have experienced during my training has made me uncomfortable, I have taken with me several valuable lessons. When a patient’s intoxication or illness prevents shared decision-making, our focus as physicians should remain on the patient’s safety, health, and well-being. It is necessary to engage patients in conversations to enable us to understand what ails them and promptly determine the right treatment, tailored to their specific needs and goals.

Moving forward, I know that I will encounter many more similar situations. I hope to position myself quickly and safely alongside agitated patients to engage them in shared decision-making. As a physician, I will approach every encounter with my patients as an opportunity to understand their goals for care, and empower them to make informed decisions regarding their treatment.

Since beginning my psychiatry residency, I have come to dread situations in which I feel like the antagonist in my patient’s life. These are moments when, due to psychiatric illness or intoxication, my patient does not want my help. In these situations, the patient’s condition may prevent shared decision-making to determine the best care for them. I experienced such a situation on my first day of residency, and that encounter taught me several valuable lessons.

An anxiety-filled first day

While working with my attending physician in a psychiatric emergency department, we met with a patient who had become agitated and was threatening staff members. The patient was also loudly protesting any use of medications. As a medical student, I had encountered patients who were agitated, but this moment felt vastly different because I was now tasked with addressing the problem. I still remember how my muscles tensed out of anxiety. As the attending took the lead in talking with the patient, the situation continued to escalate. The patient’s agitation was preventing them from being able to safely cooperate with staff despite our efforts at verbal de-escalation. As several staff members stayed with the patient, my attending and I went back to the workroom, where she instructed me to place orders for emergent medications. I sat there, an anxious intern with the solemn power and responsibility to order medications that might need to be administered against the will of an agitated patient. The moment was surreal.

A harsh reality

I had envisioned my first day of residency to be quite different. I had expected to sit with patients, healing them by listening to their stories and giving them the attention they deserved. But instead, I found myself nervously inputting medication orders, checking and rechecking that the doses and administration routes were accurate—all the while knowing that the patient would likely refuse the medications. If that occurred, the patient would need to be held by staff so the medications could be administered. Although I knew that administering emergent medications was the appropriate clinical decision to prevent harm to the patient and others, I felt conflicted by acting in opposition to the patient’s wishes. In that moment, intoxication or illness compromised patient autonomy for the sake of beneficence. I struggled with a creeping sense of guilt.

Although I did not have the chance to interact with this specific patient again, I often reflect on that encounter. I have learned that at times, the use of emergent medications or court commitments for medication administration or hospitalizations is necessary. Since that first shift, I have cared for many other patients who have received emergent medications under similar circumstances. I have observed that such treatment often stabilizes patients and enables me to engage them in meaningful conversation to optimize their care.

Lessons learned

While some of what I have experienced during my training has made me uncomfortable, I have taken with me several valuable lessons. When a patient’s intoxication or illness prevents shared decision-making, our focus as physicians should remain on the patient’s safety, health, and well-being. It is necessary to engage patients in conversations to enable us to understand what ails them and promptly determine the right treatment, tailored to their specific needs and goals.

Moving forward, I know that I will encounter many more similar situations. I hope to position myself quickly and safely alongside agitated patients to engage them in shared decision-making. As a physician, I will approach every encounter with my patients as an opportunity to understand their goals for care, and empower them to make informed decisions regarding their treatment.

My role as a mother expands and contracts in hard-won harmony with my role as a psychiatry resident. The magnitude of this responsibility compounded on itself when, seemingly overnight, the world we once trusted suddenly became unsafe. Coronavirus disease 2019 (COVID-19), deadly to immunocompromised individuals and the harbinger of a lethal autoimmune syndrome in children, was at our doorstep.

COVID-19 and parents who work in health care

After COVID-19 reached the United States, my fellow residents and I began to exchange nervous text messages, wondering what we could expect. Not only did the biological threat of the virus loom at the limited hospital entry points, but news alerts about infected front-line health care professionals and supply shortages jammed our cellphones. We quickly learned that some front-line physicians and nurses in New York had decided to live separately from their families. One article reported that a resident who was 5 months postpartum had chosen to live separately from her infant to protect her from exposure. “What a fundamental conflict of identity,” I thought as I read the article. Looking at my own young family, I felt our vulnerability overcome me. Would I have to do the same?

Difficult choices that exemplify both excitement and fear seem to define parenthood. Only months ago, I was selecting a car seat. As I scoured consumer reports, I became aware of a harrowing irony: in the excitement of nesting, I was also preparing for a collision. In March, when the quarantine began, I found myself evaluating my options for how to protect my family during a pandemic that often feels like a car crash in slow motion.

Health care professionals began to separate from their families to reduce the risk of transmission. Whether children went to live with relatives or health care workers stopped snuggling their young children, a structural boundary was formed just as the roots of attachment were taking shape. When asked about the loss inherent in this separation, these young parents expressed sadness but also said the choice was clear: their need to protect their families was absolute.

Meanwhile, some residents found themselves in a crash course on telemedicine. Safe from coronavirus exposure at work and liberated from a daily commute, these parents saw their young children more than ever before. Young child­ren saw their parents who were residents more than ever before. Perhaps the isolation of a front-line resident was sadly not a new experience.

Reassessing priorities

Now that the first wave of infections has broken over our coastal cities, residents from the front lines of COVID-19 are reuniting with their families. The sacrifices they made are re-evaluated as they begin to recognize anew the value of physical closeness with their loved ones in a dangerous world. One family that separated during the first wave said they would plan an alternate strategy, perhaps invest in a babysitter, rather than divide the household a second time.

While COVID-19 hit us hard, it has also forced a rare opportunity for self-assessment of priorities that we as trainees rarely take. We don’t have a consumer report on the safety ratings of COVID-19 plans. There is no formula for success. Instead, we each balance work and personal life with individual strategies to cope with elements outside of our control. This coping strategy may look different for each family. I hope all training departments take this plurality into account when considering the new demands on residents that have emerged during COVID-19.

My role as a mother expands and contracts in hard-won harmony with my role as a psychiatry resident. The magnitude of this responsibility compounded on itself when, seemingly overnight, the world we once trusted suddenly became unsafe. Coronavirus disease 2019 (COVID-19), deadly to immunocompromised individuals and the harbinger of a lethal autoimmune syndrome in children, was at our doorstep.

COVID-19 and parents who work in health care

After COVID-19 reached the United States, my fellow residents and I began to exchange nervous text messages, wondering what we could expect. Not only did the biological threat of the virus loom at the limited hospital entry points, but news alerts about infected front-line health care professionals and supply shortages jammed our cellphones. We quickly learned that some front-line physicians and nurses in New York had decided to live separately from their families. One article reported that a resident who was 5 months postpartum had chosen to live separately from her infant to protect her from exposure. “What a fundamental conflict of identity,” I thought as I read the article. Looking at my own young family, I felt our vulnerability overcome me. Would I have to do the same?

Difficult choices that exemplify both excitement and fear seem to define parenthood. Only months ago, I was selecting a car seat. As I scoured consumer reports, I became aware of a harrowing irony: in the excitement of nesting, I was also preparing for a collision. In March, when the quarantine began, I found myself evaluating my options for how to protect my family during a pandemic that often feels like a car crash in slow motion.

Health care professionals began to separate from their families to reduce the risk of transmission. Whether children went to live with relatives or health care workers stopped snuggling their young children, a structural boundary was formed just as the roots of attachment were taking shape. When asked about the loss inherent in this separation, these young parents expressed sadness but also said the choice was clear: their need to protect their families was absolute.

Meanwhile, some residents found themselves in a crash course on telemedicine. Safe from coronavirus exposure at work and liberated from a daily commute, these parents saw their young children more than ever before. Young child­ren saw their parents who were residents more than ever before. Perhaps the isolation of a front-line resident was sadly not a new experience.

Reassessing priorities

Now that the first wave of infections has broken over our coastal cities, residents from the front lines of COVID-19 are reuniting with their families. The sacrifices they made are re-evaluated as they begin to recognize anew the value of physical closeness with their loved ones in a dangerous world. One family that separated during the first wave said they would plan an alternate strategy, perhaps invest in a babysitter, rather than divide the household a second time.

While COVID-19 hit us hard, it has also forced a rare opportunity for self-assessment of priorities that we as trainees rarely take. We don’t have a consumer report on the safety ratings of COVID-19 plans. There is no formula for success. Instead, we each balance work and personal life with individual strategies to cope with elements outside of our control. This coping strategy may look different for each family. I hope all training departments take this plurality into account when considering the new demands on residents that have emerged during COVID-19.

My role as a mother expands and contracts in hard-won harmony with my role as a psychiatry resident. The magnitude of this responsibility compounded on itself when, seemingly overnight, the world we once trusted suddenly became unsafe. Coronavirus disease 2019 (COVID-19), deadly to immunocompromised individuals and the harbinger of a lethal autoimmune syndrome in children, was at our doorstep.

COVID-19 and parents who work in health care

After COVID-19 reached the United States, my fellow residents and I began to exchange nervous text messages, wondering what we could expect. Not only did the biological threat of the virus loom at the limited hospital entry points, but news alerts about infected front-line health care professionals and supply shortages jammed our cellphones. We quickly learned that some front-line physicians and nurses in New York had decided to live separately from their families. One article reported that a resident who was 5 months postpartum had chosen to live separately from her infant to protect her from exposure. “What a fundamental conflict of identity,” I thought as I read the article. Looking at my own young family, I felt our vulnerability overcome me. Would I have to do the same?

Difficult choices that exemplify both excitement and fear seem to define parenthood. Only months ago, I was selecting a car seat. As I scoured consumer reports, I became aware of a harrowing irony: in the excitement of nesting, I was also preparing for a collision. In March, when the quarantine began, I found myself evaluating my options for how to protect my family during a pandemic that often feels like a car crash in slow motion.

Health care professionals began to separate from their families to reduce the risk of transmission. Whether children went to live with relatives or health care workers stopped snuggling their young children, a structural boundary was formed just as the roots of attachment were taking shape. When asked about the loss inherent in this separation, these young parents expressed sadness but also said the choice was clear: their need to protect their families was absolute.

Meanwhile, some residents found themselves in a crash course on telemedicine. Safe from coronavirus exposure at work and liberated from a daily commute, these parents saw their young children more than ever before. Young child­ren saw their parents who were residents more than ever before. Perhaps the isolation of a front-line resident was sadly not a new experience.

Reassessing priorities

Now that the first wave of infections has broken over our coastal cities, residents from the front lines of COVID-19 are reuniting with their families. The sacrifices they made are re-evaluated as they begin to recognize anew the value of physical closeness with their loved ones in a dangerous world. One family that separated during the first wave said they would plan an alternate strategy, perhaps invest in a babysitter, rather than divide the household a second time.

While COVID-19 hit us hard, it has also forced a rare opportunity for self-assessment of priorities that we as trainees rarely take. We don’t have a consumer report on the safety ratings of COVID-19 plans. There is no formula for success. Instead, we each balance work and personal life with individual strategies to cope with elements outside of our control. This coping strategy may look different for each family. I hope all training departments take this plurality into account when considering the new demands on residents that have emerged during COVID-19.