For Residents

In recent years, the delivery of mental health services in Ghana has expanded substantially, especially since the passing of the Mental Health Act in 2012. In this article, I reflect on my experience as a visiting psychiatry resident in August 2018 at 2 Ghanaian hospitals located in Accra and Navrongo. Evident strengths of the mental health system were family support for patients and the scope of psychiatrists, while the most prominent weakness was the inadequate funding. As treatment of mental illness expands, more funding, psychiatrists, and mental health workers will be critical for the continued success of Ghana’s mental health system.

Psychiatric treatment in Ghana

Ghana has a population of approximately 28 million people, yet the country has an estimated 18 to 25 psychiatrists, up from 11 psychiatrists in 2011.^1-3 Compared with the United States, which has 10.54 psychiatrists per 100,000 people (approximately 1 psychiatrist per 9,500 people), Ghana has .058 psychiatrists per 100,000 people (approximately 1 psychiatrist per 1.7 million people).⁴ In Ghana, most psychiatric care is delivered by mental health nurses, community mental health officers (CMHOs), and clinical psychiatric officers; supervision by psychiatrists is limited.³ Due to low public awareness, a scarcity of clinicians, and limited access to diagnostic services and medications, individuals with psychiatric illness in Ghana are often stigmatized, undertreated, and mistreated. To address this, in March 2012, Ghana passed Mental Health Act 846, which established a mental health commission and outlined protections for individuals with mental health needs.⁵ Since then, the number of people seeking treatment and the number of clinicians have expanded, but there are still significant challenges, such as a lack of funding for medications and facilities, and limited clinicians.⁶

During my last year of psychiatry residency at Mount Sinai Hospital in New York, I spent several weeks in Ghana at 2 institutions, observing and supervising the provision of psychiatric services. This was my first experience with the country’s health care system; therefore, my objectives were to:

• assess the current state of psychiatric services through observation and interviews with clinical staff
• provide instruction to clinicians in areas of need.

Two-thirds of my time was spent at the Accra Psychiatric Hospital, 1 of only 3 psychiatric hospitals in Ghana, all of which are located in the southern region of the country. The remainder of my time was spent at the Navrongo War Memorial Hospital in Ghana’s Northern Region.

The Accra Psychiatric Hospital is a sprawling complex near the center of the capital city. Every morning I walked through a large outdoor waiting area to the examination room, which was filled with at least 30 patients by 9 am. What was most striking was the volume of patients seen by the physicians for medication management within a typical 6-hour period. On average, a physician saw 20 to 25 patients a day, although it would sometimes increase to 30 to 40 patients. Many follow-up visits lasted <10 minutes, but visits could easily last 30 minutes or longer if necessary when there had been significant interval changes, or the physician was providing psychoeducation to the patient and his/her family. There seemed to be no rush by the clinicians, and patients seemed to maintain their patience. One factor that contributed to the efficiency was that notes were typically handwritten in real time and contained only the patient’s pertinent clinical history, assessment, and treatment plan, and lacked the extraneous templated information that now makes many medical charts in the United States more complex. However, paper charts have limitations; such records cannot be accessed remotely and simultaneously, and if a chart is lost, there is no back-up or way to recover lost information.

Navrongo War Memorial Hospital. There are no practicing psychiatrists in the northern region of the country; therefore, all mental health care is delivered by mental health nurses and CMHOs. CMHOs have 1 year of training plus a minimum of 2 years of service. They focus on identifying psychiatric cases in the community and coordinating treatment. Nurses have prescribing rights. A psychiatrist should be scheduled to visit the various districts in the region every 6 months to provide supervision, but this is not always feasible.

When I visited, I was the only psychiatrist who had been to this hospital in more than 1 year. During my time there, I reviewed the treatment protocols and gave lectures on the management of psychiatric emergencies and motivational interviewing, because addiction to alcohol and tramadol are 2 of the most pressing mental health problems in the country.⁷ I also saw patients with nurses, and supervised them on their assessment and treatment.

Continue to: In Ghana...

In Ghana, psychiatric services are often delivered using the community mental health model, in which many patients are visited in their homes. One morning, we went to a prayer camp to see if there were any individuals who would benefit from psychiatric services. There were no cases that day, but during the visit I sat under a tree where a few years before it was not uncommon to find a person who was psychotic or agitated chained to the tree. Several years of outreach by the local nurses has resulted in the camp leaders better recognizing mental illness early and contacting the nurses, as opposed to locking a person in chains for an extended period.

On one occasion, we answered a crisis call where a person experiencing a psychotic episode had locked himself in his house. The team talked with the individual through a locked screen door for 30 minutes, after which he eventually came out of the home to speak with us. A few days later, the patient accepted fluphenazine decanoate injection at his home. Two weeks later, he came to the outpatient clinic to continue treatment. Four months later, the patient was still in treatment and had started an apprenticeship for repairing cars.

As I was walking out of the hospital on my last day, I was called back to see a woman with a seizure who had been brought to the hospital. Unfortunately, there was no more diazepam in stock with which to treat her. This event highlighted the lack of resources available in this setting.

3 Take-home messages

My experience at both hospitals led me to reflect on 3 important factors impacting the mental health system in Ghana:

Family support. For at least 80% of appointments, patients were accompanied by family members or friends. The family hierarchy is still dominant in the Ghanaian culture, and clinicians often need the buy-in of the family, especially when financial support is required. More often than not, families enhanced patients’ treatment, but in some instances, they were a barrier.

Continue to: The types of cases

The types of cases. Most of the patients coming to both hospitals had diagnoses of bipolar disorder, schizophrenia, substance use disorder, or epilepsy. My impression was that patients or family members sought treatment for disorders that were conspicuous. I saw <5 cases of depression or anxiety. I wonder if this was because:

• patients with these disorders were referred to psychologists
• patients sought out faith-based treatment
• there was a lower incidence of these disorders, or these disorders were detected less frequently.

Inadequate funding. Despite the clinicians’ astute observations and diagnoses, they faced challenges, including a lack of access to medications because pharmacies were out of stock, or the patient or hospital could not afford the medication. At times, these challenges resulted in patients admitted to the hospital not receiving medications. When Mental Health Act 846 was implemented, it was widely purported that mental health care would be available to everyone, but the funding mechanism was not firmly established.^8,9 Currently, laboratory workup, mental health treatment, and medications are not covered by health insurance, and government funding for mental health is insufficient. Therefore, in most areas, the entire cost burden of psychiatric care falls on patients and their families, or on hospitals.

Making progress despite barriers

In her inaugural address, former American Psychiatric Association President Altha J. Stewart, MD, named expanding the organization’s work in global mental health as one of her 3 primary goals.¹⁰ There are several means by which American psychiatrists can support the work of psychiatrists in Ghana and elsewhere. One way is by helping the mental health commission and other entities within the country petition the government and health insurance companies to expand coverage for mental health services. Teleconferencing, in which psychiatrists in Ghana or other parts of the world provide supervision to mid-level clinicians, has been piloted in other countries such as Liberia and could be implemented to address the critical shortages of psychiatrists in certain regions.¹¹

In the past 7 years, Ghana has made significant strides in destigmatizing mental illness, and as a result more individuals are seeking treatment and more clinicians at all levels are being trained. Despite significant barriers, physicians, nurses, and other mental health workers deliver empathic and evidence-based treatment in a manner that defies the mental health system’s current limitations.

In recent years, the delivery of mental health services in Ghana has expanded substantially, especially since the passing of the Mental Health Act in 2012. In this article, I reflect on my experience as a visiting psychiatry resident in August 2018 at 2 Ghanaian hospitals located in Accra and Navrongo. Evident strengths of the mental health system were family support for patients and the scope of psychiatrists, while the most prominent weakness was the inadequate funding. As treatment of mental illness expands, more funding, psychiatrists, and mental health workers will be critical for the continued success of Ghana’s mental health system.

Psychiatric treatment in Ghana

Ghana has a population of approximately 28 million people, yet the country has an estimated 18 to 25 psychiatrists, up from 11 psychiatrists in 2011.^1-3 Compared with the United States, which has 10.54 psychiatrists per 100,000 people (approximately 1 psychiatrist per 9,500 people), Ghana has .058 psychiatrists per 100,000 people (approximately 1 psychiatrist per 1.7 million people).⁴ In Ghana, most psychiatric care is delivered by mental health nurses, community mental health officers (CMHOs), and clinical psychiatric officers; supervision by psychiatrists is limited.³ Due to low public awareness, a scarcity of clinicians, and limited access to diagnostic services and medications, individuals with psychiatric illness in Ghana are often stigmatized, undertreated, and mistreated. To address this, in March 2012, Ghana passed Mental Health Act 846, which established a mental health commission and outlined protections for individuals with mental health needs.⁵ Since then, the number of people seeking treatment and the number of clinicians have expanded, but there are still significant challenges, such as a lack of funding for medications and facilities, and limited clinicians.⁶

During my last year of psychiatry residency at Mount Sinai Hospital in New York, I spent several weeks in Ghana at 2 institutions, observing and supervising the provision of psychiatric services. This was my first experience with the country’s health care system; therefore, my objectives were to:

• assess the current state of psychiatric services through observation and interviews with clinical staff
• provide instruction to clinicians in areas of need.

Two-thirds of my time was spent at the Accra Psychiatric Hospital, 1 of only 3 psychiatric hospitals in Ghana, all of which are located in the southern region of the country. The remainder of my time was spent at the Navrongo War Memorial Hospital in Ghana’s Northern Region.

The Accra Psychiatric Hospital is a sprawling complex near the center of the capital city. Every morning I walked through a large outdoor waiting area to the examination room, which was filled with at least 30 patients by 9 am. What was most striking was the volume of patients seen by the physicians for medication management within a typical 6-hour period. On average, a physician saw 20 to 25 patients a day, although it would sometimes increase to 30 to 40 patients. Many follow-up visits lasted <10 minutes, but visits could easily last 30 minutes or longer if necessary when there had been significant interval changes, or the physician was providing psychoeducation to the patient and his/her family. There seemed to be no rush by the clinicians, and patients seemed to maintain their patience. One factor that contributed to the efficiency was that notes were typically handwritten in real time and contained only the patient’s pertinent clinical history, assessment, and treatment plan, and lacked the extraneous templated information that now makes many medical charts in the United States more complex. However, paper charts have limitations; such records cannot be accessed remotely and simultaneously, and if a chart is lost, there is no back-up or way to recover lost information.

Navrongo War Memorial Hospital. There are no practicing psychiatrists in the northern region of the country; therefore, all mental health care is delivered by mental health nurses and CMHOs. CMHOs have 1 year of training plus a minimum of 2 years of service. They focus on identifying psychiatric cases in the community and coordinating treatment. Nurses have prescribing rights. A psychiatrist should be scheduled to visit the various districts in the region every 6 months to provide supervision, but this is not always feasible.

When I visited, I was the only psychiatrist who had been to this hospital in more than 1 year. During my time there, I reviewed the treatment protocols and gave lectures on the management of psychiatric emergencies and motivational interviewing, because addiction to alcohol and tramadol are 2 of the most pressing mental health problems in the country.⁷ I also saw patients with nurses, and supervised them on their assessment and treatment.

Continue to: In Ghana...

In Ghana, psychiatric services are often delivered using the community mental health model, in which many patients are visited in their homes. One morning, we went to a prayer camp to see if there were any individuals who would benefit from psychiatric services. There were no cases that day, but during the visit I sat under a tree where a few years before it was not uncommon to find a person who was psychotic or agitated chained to the tree. Several years of outreach by the local nurses has resulted in the camp leaders better recognizing mental illness early and contacting the nurses, as opposed to locking a person in chains for an extended period.

On one occasion, we answered a crisis call where a person experiencing a psychotic episode had locked himself in his house. The team talked with the individual through a locked screen door for 30 minutes, after which he eventually came out of the home to speak with us. A few days later, the patient accepted fluphenazine decanoate injection at his home. Two weeks later, he came to the outpatient clinic to continue treatment. Four months later, the patient was still in treatment and had started an apprenticeship for repairing cars.

As I was walking out of the hospital on my last day, I was called back to see a woman with a seizure who had been brought to the hospital. Unfortunately, there was no more diazepam in stock with which to treat her. This event highlighted the lack of resources available in this setting.

3 Take-home messages

My experience at both hospitals led me to reflect on 3 important factors impacting the mental health system in Ghana:

Family support. For at least 80% of appointments, patients were accompanied by family members or friends. The family hierarchy is still dominant in the Ghanaian culture, and clinicians often need the buy-in of the family, especially when financial support is required. More often than not, families enhanced patients’ treatment, but in some instances, they were a barrier.

Continue to: The types of cases

The types of cases. Most of the patients coming to both hospitals had diagnoses of bipolar disorder, schizophrenia, substance use disorder, or epilepsy. My impression was that patients or family members sought treatment for disorders that were conspicuous. I saw <5 cases of depression or anxiety. I wonder if this was because:

• patients with these disorders were referred to psychologists
• patients sought out faith-based treatment
• there was a lower incidence of these disorders, or these disorders were detected less frequently.

Inadequate funding. Despite the clinicians’ astute observations and diagnoses, they faced challenges, including a lack of access to medications because pharmacies were out of stock, or the patient or hospital could not afford the medication. At times, these challenges resulted in patients admitted to the hospital not receiving medications. When Mental Health Act 846 was implemented, it was widely purported that mental health care would be available to everyone, but the funding mechanism was not firmly established.^8,9 Currently, laboratory workup, mental health treatment, and medications are not covered by health insurance, and government funding for mental health is insufficient. Therefore, in most areas, the entire cost burden of psychiatric care falls on patients and their families, or on hospitals.

Making progress despite barriers

In her inaugural address, former American Psychiatric Association President Altha J. Stewart, MD, named expanding the organization’s work in global mental health as one of her 3 primary goals.¹⁰ There are several means by which American psychiatrists can support the work of psychiatrists in Ghana and elsewhere. One way is by helping the mental health commission and other entities within the country petition the government and health insurance companies to expand coverage for mental health services. Teleconferencing, in which psychiatrists in Ghana or other parts of the world provide supervision to mid-level clinicians, has been piloted in other countries such as Liberia and could be implemented to address the critical shortages of psychiatrists in certain regions.¹¹

In the past 7 years, Ghana has made significant strides in destigmatizing mental illness, and as a result more individuals are seeking treatment and more clinicians at all levels are being trained. Despite significant barriers, physicians, nurses, and other mental health workers deliver empathic and evidence-based treatment in a manner that defies the mental health system’s current limitations.

In recent years, the delivery of mental health services in Ghana has expanded substantially, especially since the passing of the Mental Health Act in 2012. In this article, I reflect on my experience as a visiting psychiatry resident in August 2018 at 2 Ghanaian hospitals located in Accra and Navrongo. Evident strengths of the mental health system were family support for patients and the scope of psychiatrists, while the most prominent weakness was the inadequate funding. As treatment of mental illness expands, more funding, psychiatrists, and mental health workers will be critical for the continued success of Ghana’s mental health system.

Psychiatric treatment in Ghana

Ghana has a population of approximately 28 million people, yet the country has an estimated 18 to 25 psychiatrists, up from 11 psychiatrists in 2011.^1-3 Compared with the United States, which has 10.54 psychiatrists per 100,000 people (approximately 1 psychiatrist per 9,500 people), Ghana has .058 psychiatrists per 100,000 people (approximately 1 psychiatrist per 1.7 million people).⁴ In Ghana, most psychiatric care is delivered by mental health nurses, community mental health officers (CMHOs), and clinical psychiatric officers; supervision by psychiatrists is limited.³ Due to low public awareness, a scarcity of clinicians, and limited access to diagnostic services and medications, individuals with psychiatric illness in Ghana are often stigmatized, undertreated, and mistreated. To address this, in March 2012, Ghana passed Mental Health Act 846, which established a mental health commission and outlined protections for individuals with mental health needs.⁵ Since then, the number of people seeking treatment and the number of clinicians have expanded, but there are still significant challenges, such as a lack of funding for medications and facilities, and limited clinicians.⁶

During my last year of psychiatry residency at Mount Sinai Hospital in New York, I spent several weeks in Ghana at 2 institutions, observing and supervising the provision of psychiatric services. This was my first experience with the country’s health care system; therefore, my objectives were to:

• assess the current state of psychiatric services through observation and interviews with clinical staff
• provide instruction to clinicians in areas of need.

Two-thirds of my time was spent at the Accra Psychiatric Hospital, 1 of only 3 psychiatric hospitals in Ghana, all of which are located in the southern region of the country. The remainder of my time was spent at the Navrongo War Memorial Hospital in Ghana’s Northern Region.

The Accra Psychiatric Hospital is a sprawling complex near the center of the capital city. Every morning I walked through a large outdoor waiting area to the examination room, which was filled with at least 30 patients by 9 am. What was most striking was the volume of patients seen by the physicians for medication management within a typical 6-hour period. On average, a physician saw 20 to 25 patients a day, although it would sometimes increase to 30 to 40 patients. Many follow-up visits lasted <10 minutes, but visits could easily last 30 minutes or longer if necessary when there had been significant interval changes, or the physician was providing psychoeducation to the patient and his/her family. There seemed to be no rush by the clinicians, and patients seemed to maintain their patience. One factor that contributed to the efficiency was that notes were typically handwritten in real time and contained only the patient’s pertinent clinical history, assessment, and treatment plan, and lacked the extraneous templated information that now makes many medical charts in the United States more complex. However, paper charts have limitations; such records cannot be accessed remotely and simultaneously, and if a chart is lost, there is no back-up or way to recover lost information.

Navrongo War Memorial Hospital. There are no practicing psychiatrists in the northern region of the country; therefore, all mental health care is delivered by mental health nurses and CMHOs. CMHOs have 1 year of training plus a minimum of 2 years of service. They focus on identifying psychiatric cases in the community and coordinating treatment. Nurses have prescribing rights. A psychiatrist should be scheduled to visit the various districts in the region every 6 months to provide supervision, but this is not always feasible.

When I visited, I was the only psychiatrist who had been to this hospital in more than 1 year. During my time there, I reviewed the treatment protocols and gave lectures on the management of psychiatric emergencies and motivational interviewing, because addiction to alcohol and tramadol are 2 of the most pressing mental health problems in the country.⁷ I also saw patients with nurses, and supervised them on their assessment and treatment.

Continue to: In Ghana...

In Ghana, psychiatric services are often delivered using the community mental health model, in which many patients are visited in their homes. One morning, we went to a prayer camp to see if there were any individuals who would benefit from psychiatric services. There were no cases that day, but during the visit I sat under a tree where a few years before it was not uncommon to find a person who was psychotic or agitated chained to the tree. Several years of outreach by the local nurses has resulted in the camp leaders better recognizing mental illness early and contacting the nurses, as opposed to locking a person in chains for an extended period.

On one occasion, we answered a crisis call where a person experiencing a psychotic episode had locked himself in his house. The team talked with the individual through a locked screen door for 30 minutes, after which he eventually came out of the home to speak with us. A few days later, the patient accepted fluphenazine decanoate injection at his home. Two weeks later, he came to the outpatient clinic to continue treatment. Four months later, the patient was still in treatment and had started an apprenticeship for repairing cars.

As I was walking out of the hospital on my last day, I was called back to see a woman with a seizure who had been brought to the hospital. Unfortunately, there was no more diazepam in stock with which to treat her. This event highlighted the lack of resources available in this setting.

3 Take-home messages

My experience at both hospitals led me to reflect on 3 important factors impacting the mental health system in Ghana:

Family support. For at least 80% of appointments, patients were accompanied by family members or friends. The family hierarchy is still dominant in the Ghanaian culture, and clinicians often need the buy-in of the family, especially when financial support is required. More often than not, families enhanced patients’ treatment, but in some instances, they were a barrier.

Continue to: The types of cases

The types of cases. Most of the patients coming to both hospitals had diagnoses of bipolar disorder, schizophrenia, substance use disorder, or epilepsy. My impression was that patients or family members sought treatment for disorders that were conspicuous. I saw <5 cases of depression or anxiety. I wonder if this was because:

• patients with these disorders were referred to psychologists
• patients sought out faith-based treatment
• there was a lower incidence of these disorders, or these disorders were detected less frequently.

Inadequate funding. Despite the clinicians’ astute observations and diagnoses, they faced challenges, including a lack of access to medications because pharmacies were out of stock, or the patient or hospital could not afford the medication. At times, these challenges resulted in patients admitted to the hospital not receiving medications. When Mental Health Act 846 was implemented, it was widely purported that mental health care would be available to everyone, but the funding mechanism was not firmly established.^8,9 Currently, laboratory workup, mental health treatment, and medications are not covered by health insurance, and government funding for mental health is insufficient. Therefore, in most areas, the entire cost burden of psychiatric care falls on patients and their families, or on hospitals.

Making progress despite barriers

In her inaugural address, former American Psychiatric Association President Altha J. Stewart, MD, named expanding the organization’s work in global mental health as one of her 3 primary goals.¹⁰ There are several means by which American psychiatrists can support the work of psychiatrists in Ghana and elsewhere. One way is by helping the mental health commission and other entities within the country petition the government and health insurance companies to expand coverage for mental health services. Teleconferencing, in which psychiatrists in Ghana or other parts of the world provide supervision to mid-level clinicians, has been piloted in other countries such as Liberia and could be implemented to address the critical shortages of psychiatrists in certain regions.¹¹

In the past 7 years, Ghana has made significant strides in destigmatizing mental illness, and as a result more individuals are seeking treatment and more clinicians at all levels are being trained. Despite significant barriers, physicians, nurses, and other mental health workers deliver empathic and evidence-based treatment in a manner that defies the mental health system’s current limitations.

Mohs micrographic surgery (MMS) has been met with controversy since its inception in the 1930s. Current debate centers on the types of tumors treated with MMS, increasing utilization, third-party payer reimbursement, the Appropriate Use Criteria (AUC), and subspecialty certification.

Controversies in Applications

Controversy surrounding treatment with MMS for certain tumor types is abundant, in large part due to a lack of well-designed studies. Perhaps most notably, the surgical management of melanoma has been hotly contested for decades.¹ An increasing number of Mohs surgeons advocate the use of MMS for treatment of melanoma. Advocates reason that tumor margins may be ill-defined, necessitating histologic examination of the margin for tumor clearance. In a study by Zitelli et al,² 5-year survival and metastatic rates for 535 patients with melanomas treated by MMS with frozen sections were the same or better when compared to historical controls treated with conventional wide local excision. Melanoma-associated antigen recognized by T cells (MART-1) immunostaining may offer improved diagnostic accuracy.³ Others believe that staged excision with permanent sections processed vertically, en face, or horizontally (“slow Mohs”) is more accurate and efficacious for the treatment of melanoma.¹ Advocates of this approach maintain that when compared to MMS with frozen sections, staged excision with permanent sections enables more accurate interpretation of residual melanoma and atypical junctional melanocytic hyperplasia as well as circumvents difficulty in interpreting freeze artifact.⁴

Although Merkel cell carcinoma has traditionally been treated with wide local excision, MMS with or without adjuvant radiotherapy has gained traction as a treatment option. Advocates for treatment by MMS hold that Merkel cell carcinoma is a contiguous tumor with a high rate of residual tumor persistence, making histologic margin control an ideal characteristic of treatment. However, in the absence of large randomized controlled studies comparing MMS to wide local excision, controversy surrounds the most appropriate surgical approach.¹ In a retrospective study of 86 patients by O’Connor et al,⁵ MMS was demonstrated to compare favorably to standard surgical excision. Standard surgical excision was associated with a 31.7% (13/41) local persistence rate and 48.8% (20/41) regional metastasis rate compared to 8.3% (1/12) and 33.3% (4/12) for MMS, respectively.⁵

Controversies in Increasing Utilization

The incidence of skin cancers has increased in recent years. As a result, it is reasonable to expect the rates of MMS to increase. Nonetheless, there is escalating concern among groups of third-party payers, the public, and physicians that MMS is being overused.⁶ Growth of the body of evidence supporting the appropriateness of MMS remains essential. Such studies continue to support reasons for increased MMS usage, demonstrating the stability of the percentage of skin cancers treated with MMS in the setting of increasing skin cancer incidence, the procedure’s superior efficacy for appropriately chosen cases, its expanding application to melanoma and other tumors, and an emphasis of MMS in residency training programs.^6-9

A current hot topic of controversy focuses on the wide variation among Mohs surgeons in the mean number of stages used to resect a tumor. Overuse among outliers has been proposed to stem from lack of technical expertise or from abuse of the current fee-for-service payment model, which bases compensation on the number of stages performed. A study by Krishnan et al¹⁰ determined that the mean number of stages per tumor in the studied population (all physicians [N=2305] receiving Medicare payments for MMS from January 2012 to December 2014) was 1.74, with a range of 1.09 to 4.11. Persistently high outliers were more likely to perform MMS in a solo practice, with an odds ratio of 2.35.¹⁰ In response to the wide variation in mean stages used to resect a skin cancer and its implications on increased financial burden and surgery to individual patients, intervention has been proposed. Notably, it has been demonstrated that mailing out individual reports of practice patterns to high-outlier physicians resulted in a reduction in mean stages per tumor as well as an associated cost savings when compared to outlier physicians who did not receive these reports.¹¹

Controversies in Reimbursement

Mohs micrographic surgery also has been in the spotlight for debate regarding reimbursement. The procedure has been targeted partly in response to its substantial contribution to total Medicare reimbursements paid out. In 2013, primary MMS billing codes constituted nearly 19% of total reimbursements to dermatologists and approximately 0.5% of total reimbursements to all physicians participating in Medicare.¹² Mohs micrographic surgery codes have correspondingly received frequent review by the Relative Value Scale Update Committee and remained on a list of potentially misvalued services according to the Centers for Medicare & Medicaid Services for years.¹³ Due to continued scrutiny and review, especially by the Relative Value Scale Update Committee and Centers for Medicare & Medicaid Services, reimbursement to perform MMS and reconstructive surgery has gone down by more than 20% in the last 15 years.¹⁴ Public perception mirrors third-party payer concerns for overcompensation. An article title in the New York Times theatrically postures “Patients’ Costs Skyrocket, Specialists’ Incomes Soar.” The article recounts an MMS patient’s “outrage at charges” associated with treatment of her “minor medical problem” and the simultaneous “sharp climb” in dermatologist income over the last 2 decades.¹⁵

However, studies continue to demonstrate the cost-effectiveness of MMS. A study by Ravitskiy et al¹⁶ demonstrates the cost-effectiveness of MMS, regardless of place of service or type of tumor. Of 406 tumors studied, MMS was the least expensive surgical procedure evaluated ($805 per tumor) when compared to standard surgical excision with permanent margins ($1026 per tumor), standard surgical excision with frozen margins ($1200 per tumor), and ambulatory surgery center standard surgical excision ($2507 per tumor). Furthermore, adjusted for inflation, the cost of MMS was lower in 2009 vs 1998.¹⁶ Similar results have been consistently demonstrated.¹⁷

Controversies in the AUC

To provide clinicians, policy makers, and insurers guidance for utilization of MMS in the setting of concerns for overutilization, overcompensation, and inappropriate application, the MMS AUC were established in 2012. The guidelines were developed by a process integrating evidence-based medicine, clinical experience, and expert opinion and is applicable to 270 clinical scenarios.¹⁸

A unique set of debate accompanies the guidelines. Namely, controversy has surrounded the classification of most primary superficial basal cell carcinomas as appropriate for treatment by MMS. These tumors have comparable cure rates when treated by MMS or curettage and cryosurgery, are often multifocal and require more Mohs stages than other basal cell carcinoma subtypes, and largely lack data on recurrence and invasion.¹⁹ The guidelines also have been scrutinized for including only studies from the United States.²⁰ Furthermore, the report is largely based on expert opinion rather than evidence.

Some Mohs surgeons have concerns that the guidelines will minimize clinical judgment. Nonetheless, deviations from the AUC practiced by Mohs surgeons have been reported where clinical judgment supplants guideline criteria. The most commonly cited reasons for performing MMS on tumors classified as uncertain or inappropriate, according to one study by Ruiz et al,²¹ included performing multiple MMSs on the same day, tumor location on the lower legs, and incorporation into an adjacent wound. Reported discrepancies in the AUC further emphasize the importance of clinical judgment and call into question the need for future revision of the criteria.²² For example, a primary squamous cell carcinoma in situ greater than or equal to 2 cm located on the trunk and extremities (excluding pretibial surfaces, hands, feet, nail units, and ankles) in a healthy patient is categorized as appropriate, while a recurrent but otherwise identical squamous cell carcinoma in situ is categorized as uncertain. These counterintuitive criteria are unsupported by existing studies.

Controversies in Subspecialty Certification

Recently, debate also has surfaced regarding subspecialty certification. Over the last decade, proponents of subspecialty certification have argued that board certification would bring consistency and decrease divisiveness among dermatologists; help to prevent exclusion of Mohs surgeons from insurance networks and teaching opportunities at the Veterans Administration; and demonstrate competence to patients, the media, and payers. Those in opposition contest that practices may be restricted by insurers using lack of certification to eliminate dermatologists from their networks, economic credentialing may be applied to dermatologists such that those without the subspecialty certification may not be deemed qualified to manage skin cancer, major limitations may be set determining which dermatologists can sit for the certification examination, and subspecialty certification could create disenfranchisement of many dermatologists. A 2017 American Academy of Dermatology member survey demonstrated ambivalence regarding subcertification, with 51% of respondents pro-subcertification and 48% anti-subcertification.²³

Nonetheless, after years of debate the American Board of Dermatology proposed subspecialty certification in Micrographic Dermatologic Surgery, which was approved by the American Board of Medical Specialties on October 26, 2018. The first certification examination will likely take place in 2 years, and a maintenance of certification examination will be required every 10 years.²⁴

Final Thoughts

Further investigation is needed to elucidate and optimize solutions to many of the current controversies associated with MMS.

Mohs micrographic surgery (MMS) has been met with controversy since its inception in the 1930s. Current debate centers on the types of tumors treated with MMS, increasing utilization, third-party payer reimbursement, the Appropriate Use Criteria (AUC), and subspecialty certification.

Controversies in Applications

Controversy surrounding treatment with MMS for certain tumor types is abundant, in large part due to a lack of well-designed studies. Perhaps most notably, the surgical management of melanoma has been hotly contested for decades.¹ An increasing number of Mohs surgeons advocate the use of MMS for treatment of melanoma. Advocates reason that tumor margins may be ill-defined, necessitating histologic examination of the margin for tumor clearance. In a study by Zitelli et al,² 5-year survival and metastatic rates for 535 patients with melanomas treated by MMS with frozen sections were the same or better when compared to historical controls treated with conventional wide local excision. Melanoma-associated antigen recognized by T cells (MART-1) immunostaining may offer improved diagnostic accuracy.³ Others believe that staged excision with permanent sections processed vertically, en face, or horizontally (“slow Mohs”) is more accurate and efficacious for the treatment of melanoma.¹ Advocates of this approach maintain that when compared to MMS with frozen sections, staged excision with permanent sections enables more accurate interpretation of residual melanoma and atypical junctional melanocytic hyperplasia as well as circumvents difficulty in interpreting freeze artifact.⁴

Although Merkel cell carcinoma has traditionally been treated with wide local excision, MMS with or without adjuvant radiotherapy has gained traction as a treatment option. Advocates for treatment by MMS hold that Merkel cell carcinoma is a contiguous tumor with a high rate of residual tumor persistence, making histologic margin control an ideal characteristic of treatment. However, in the absence of large randomized controlled studies comparing MMS to wide local excision, controversy surrounds the most appropriate surgical approach.¹ In a retrospective study of 86 patients by O’Connor et al,⁵ MMS was demonstrated to compare favorably to standard surgical excision. Standard surgical excision was associated with a 31.7% (13/41) local persistence rate and 48.8% (20/41) regional metastasis rate compared to 8.3% (1/12) and 33.3% (4/12) for MMS, respectively.⁵

Controversies in Increasing Utilization

The incidence of skin cancers has increased in recent years. As a result, it is reasonable to expect the rates of MMS to increase. Nonetheless, there is escalating concern among groups of third-party payers, the public, and physicians that MMS is being overused.⁶ Growth of the body of evidence supporting the appropriateness of MMS remains essential. Such studies continue to support reasons for increased MMS usage, demonstrating the stability of the percentage of skin cancers treated with MMS in the setting of increasing skin cancer incidence, the procedure’s superior efficacy for appropriately chosen cases, its expanding application to melanoma and other tumors, and an emphasis of MMS in residency training programs.^6-9

A current hot topic of controversy focuses on the wide variation among Mohs surgeons in the mean number of stages used to resect a tumor. Overuse among outliers has been proposed to stem from lack of technical expertise or from abuse of the current fee-for-service payment model, which bases compensation on the number of stages performed. A study by Krishnan et al¹⁰ determined that the mean number of stages per tumor in the studied population (all physicians [N=2305] receiving Medicare payments for MMS from January 2012 to December 2014) was 1.74, with a range of 1.09 to 4.11. Persistently high outliers were more likely to perform MMS in a solo practice, with an odds ratio of 2.35.¹⁰ In response to the wide variation in mean stages used to resect a skin cancer and its implications on increased financial burden and surgery to individual patients, intervention has been proposed. Notably, it has been demonstrated that mailing out individual reports of practice patterns to high-outlier physicians resulted in a reduction in mean stages per tumor as well as an associated cost savings when compared to outlier physicians who did not receive these reports.¹¹

Controversies in Reimbursement

Mohs micrographic surgery also has been in the spotlight for debate regarding reimbursement. The procedure has been targeted partly in response to its substantial contribution to total Medicare reimbursements paid out. In 2013, primary MMS billing codes constituted nearly 19% of total reimbursements to dermatologists and approximately 0.5% of total reimbursements to all physicians participating in Medicare.¹² Mohs micrographic surgery codes have correspondingly received frequent review by the Relative Value Scale Update Committee and remained on a list of potentially misvalued services according to the Centers for Medicare & Medicaid Services for years.¹³ Due to continued scrutiny and review, especially by the Relative Value Scale Update Committee and Centers for Medicare & Medicaid Services, reimbursement to perform MMS and reconstructive surgery has gone down by more than 20% in the last 15 years.¹⁴ Public perception mirrors third-party payer concerns for overcompensation. An article title in the New York Times theatrically postures “Patients’ Costs Skyrocket, Specialists’ Incomes Soar.” The article recounts an MMS patient’s “outrage at charges” associated with treatment of her “minor medical problem” and the simultaneous “sharp climb” in dermatologist income over the last 2 decades.¹⁵

However, studies continue to demonstrate the cost-effectiveness of MMS. A study by Ravitskiy et al¹⁶ demonstrates the cost-effectiveness of MMS, regardless of place of service or type of tumor. Of 406 tumors studied, MMS was the least expensive surgical procedure evaluated ($805 per tumor) when compared to standard surgical excision with permanent margins ($1026 per tumor), standard surgical excision with frozen margins ($1200 per tumor), and ambulatory surgery center standard surgical excision ($2507 per tumor). Furthermore, adjusted for inflation, the cost of MMS was lower in 2009 vs 1998.¹⁶ Similar results have been consistently demonstrated.¹⁷

Controversies in the AUC

To provide clinicians, policy makers, and insurers guidance for utilization of MMS in the setting of concerns for overutilization, overcompensation, and inappropriate application, the MMS AUC were established in 2012. The guidelines were developed by a process integrating evidence-based medicine, clinical experience, and expert opinion and is applicable to 270 clinical scenarios.¹⁸

A unique set of debate accompanies the guidelines. Namely, controversy has surrounded the classification of most primary superficial basal cell carcinomas as appropriate for treatment by MMS. These tumors have comparable cure rates when treated by MMS or curettage and cryosurgery, are often multifocal and require more Mohs stages than other basal cell carcinoma subtypes, and largely lack data on recurrence and invasion.¹⁹ The guidelines also have been scrutinized for including only studies from the United States.²⁰ Furthermore, the report is largely based on expert opinion rather than evidence.

Some Mohs surgeons have concerns that the guidelines will minimize clinical judgment. Nonetheless, deviations from the AUC practiced by Mohs surgeons have been reported where clinical judgment supplants guideline criteria. The most commonly cited reasons for performing MMS on tumors classified as uncertain or inappropriate, according to one study by Ruiz et al,²¹ included performing multiple MMSs on the same day, tumor location on the lower legs, and incorporation into an adjacent wound. Reported discrepancies in the AUC further emphasize the importance of clinical judgment and call into question the need for future revision of the criteria.²² For example, a primary squamous cell carcinoma in situ greater than or equal to 2 cm located on the trunk and extremities (excluding pretibial surfaces, hands, feet, nail units, and ankles) in a healthy patient is categorized as appropriate, while a recurrent but otherwise identical squamous cell carcinoma in situ is categorized as uncertain. These counterintuitive criteria are unsupported by existing studies.

Controversies in Subspecialty Certification

Recently, debate also has surfaced regarding subspecialty certification. Over the last decade, proponents of subspecialty certification have argued that board certification would bring consistency and decrease divisiveness among dermatologists; help to prevent exclusion of Mohs surgeons from insurance networks and teaching opportunities at the Veterans Administration; and demonstrate competence to patients, the media, and payers. Those in opposition contest that practices may be restricted by insurers using lack of certification to eliminate dermatologists from their networks, economic credentialing may be applied to dermatologists such that those without the subspecialty certification may not be deemed qualified to manage skin cancer, major limitations may be set determining which dermatologists can sit for the certification examination, and subspecialty certification could create disenfranchisement of many dermatologists. A 2017 American Academy of Dermatology member survey demonstrated ambivalence regarding subcertification, with 51% of respondents pro-subcertification and 48% anti-subcertification.²³

Nonetheless, after years of debate the American Board of Dermatology proposed subspecialty certification in Micrographic Dermatologic Surgery, which was approved by the American Board of Medical Specialties on October 26, 2018. The first certification examination will likely take place in 2 years, and a maintenance of certification examination will be required every 10 years.²⁴

Final Thoughts

Further investigation is needed to elucidate and optimize solutions to many of the current controversies associated with MMS.

Mohs micrographic surgery (MMS) has been met with controversy since its inception in the 1930s. Current debate centers on the types of tumors treated with MMS, increasing utilization, third-party payer reimbursement, the Appropriate Use Criteria (AUC), and subspecialty certification.

Controversies in Applications

Controversy surrounding treatment with MMS for certain tumor types is abundant, in large part due to a lack of well-designed studies. Perhaps most notably, the surgical management of melanoma has been hotly contested for decades.¹ An increasing number of Mohs surgeons advocate the use of MMS for treatment of melanoma. Advocates reason that tumor margins may be ill-defined, necessitating histologic examination of the margin for tumor clearance. In a study by Zitelli et al,² 5-year survival and metastatic rates for 535 patients with melanomas treated by MMS with frozen sections were the same or better when compared to historical controls treated with conventional wide local excision. Melanoma-associated antigen recognized by T cells (MART-1) immunostaining may offer improved diagnostic accuracy.³ Others believe that staged excision with permanent sections processed vertically, en face, or horizontally (“slow Mohs”) is more accurate and efficacious for the treatment of melanoma.¹ Advocates of this approach maintain that when compared to MMS with frozen sections, staged excision with permanent sections enables more accurate interpretation of residual melanoma and atypical junctional melanocytic hyperplasia as well as circumvents difficulty in interpreting freeze artifact.⁴

Although Merkel cell carcinoma has traditionally been treated with wide local excision, MMS with or without adjuvant radiotherapy has gained traction as a treatment option. Advocates for treatment by MMS hold that Merkel cell carcinoma is a contiguous tumor with a high rate of residual tumor persistence, making histologic margin control an ideal characteristic of treatment. However, in the absence of large randomized controlled studies comparing MMS to wide local excision, controversy surrounds the most appropriate surgical approach.¹ In a retrospective study of 86 patients by O’Connor et al,⁵ MMS was demonstrated to compare favorably to standard surgical excision. Standard surgical excision was associated with a 31.7% (13/41) local persistence rate and 48.8% (20/41) regional metastasis rate compared to 8.3% (1/12) and 33.3% (4/12) for MMS, respectively.⁵

Controversies in Increasing Utilization

The incidence of skin cancers has increased in recent years. As a result, it is reasonable to expect the rates of MMS to increase. Nonetheless, there is escalating concern among groups of third-party payers, the public, and physicians that MMS is being overused.⁶ Growth of the body of evidence supporting the appropriateness of MMS remains essential. Such studies continue to support reasons for increased MMS usage, demonstrating the stability of the percentage of skin cancers treated with MMS in the setting of increasing skin cancer incidence, the procedure’s superior efficacy for appropriately chosen cases, its expanding application to melanoma and other tumors, and an emphasis of MMS in residency training programs.^6-9

A current hot topic of controversy focuses on the wide variation among Mohs surgeons in the mean number of stages used to resect a tumor. Overuse among outliers has been proposed to stem from lack of technical expertise or from abuse of the current fee-for-service payment model, which bases compensation on the number of stages performed. A study by Krishnan et al¹⁰ determined that the mean number of stages per tumor in the studied population (all physicians [N=2305] receiving Medicare payments for MMS from January 2012 to December 2014) was 1.74, with a range of 1.09 to 4.11. Persistently high outliers were more likely to perform MMS in a solo practice, with an odds ratio of 2.35.¹⁰ In response to the wide variation in mean stages used to resect a skin cancer and its implications on increased financial burden and surgery to individual patients, intervention has been proposed. Notably, it has been demonstrated that mailing out individual reports of practice patterns to high-outlier physicians resulted in a reduction in mean stages per tumor as well as an associated cost savings when compared to outlier physicians who did not receive these reports.¹¹

Controversies in Reimbursement

Mohs micrographic surgery also has been in the spotlight for debate regarding reimbursement. The procedure has been targeted partly in response to its substantial contribution to total Medicare reimbursements paid out. In 2013, primary MMS billing codes constituted nearly 19% of total reimbursements to dermatologists and approximately 0.5% of total reimbursements to all physicians participating in Medicare.¹² Mohs micrographic surgery codes have correspondingly received frequent review by the Relative Value Scale Update Committee and remained on a list of potentially misvalued services according to the Centers for Medicare & Medicaid Services for years.¹³ Due to continued scrutiny and review, especially by the Relative Value Scale Update Committee and Centers for Medicare & Medicaid Services, reimbursement to perform MMS and reconstructive surgery has gone down by more than 20% in the last 15 years.¹⁴ Public perception mirrors third-party payer concerns for overcompensation. An article title in the New York Times theatrically postures “Patients’ Costs Skyrocket, Specialists’ Incomes Soar.” The article recounts an MMS patient’s “outrage at charges” associated with treatment of her “minor medical problem” and the simultaneous “sharp climb” in dermatologist income over the last 2 decades.¹⁵

However, studies continue to demonstrate the cost-effectiveness of MMS. A study by Ravitskiy et al¹⁶ demonstrates the cost-effectiveness of MMS, regardless of place of service or type of tumor. Of 406 tumors studied, MMS was the least expensive surgical procedure evaluated ($805 per tumor) when compared to standard surgical excision with permanent margins ($1026 per tumor), standard surgical excision with frozen margins ($1200 per tumor), and ambulatory surgery center standard surgical excision ($2507 per tumor). Furthermore, adjusted for inflation, the cost of MMS was lower in 2009 vs 1998.¹⁶ Similar results have been consistently demonstrated.¹⁷

Controversies in the AUC

To provide clinicians, policy makers, and insurers guidance for utilization of MMS in the setting of concerns for overutilization, overcompensation, and inappropriate application, the MMS AUC were established in 2012. The guidelines were developed by a process integrating evidence-based medicine, clinical experience, and expert opinion and is applicable to 270 clinical scenarios.¹⁸

A unique set of debate accompanies the guidelines. Namely, controversy has surrounded the classification of most primary superficial basal cell carcinomas as appropriate for treatment by MMS. These tumors have comparable cure rates when treated by MMS or curettage and cryosurgery, are often multifocal and require more Mohs stages than other basal cell carcinoma subtypes, and largely lack data on recurrence and invasion.¹⁹ The guidelines also have been scrutinized for including only studies from the United States.²⁰ Furthermore, the report is largely based on expert opinion rather than evidence.

Some Mohs surgeons have concerns that the guidelines will minimize clinical judgment. Nonetheless, deviations from the AUC practiced by Mohs surgeons have been reported where clinical judgment supplants guideline criteria. The most commonly cited reasons for performing MMS on tumors classified as uncertain or inappropriate, according to one study by Ruiz et al,²¹ included performing multiple MMSs on the same day, tumor location on the lower legs, and incorporation into an adjacent wound. Reported discrepancies in the AUC further emphasize the importance of clinical judgment and call into question the need for future revision of the criteria.²² For example, a primary squamous cell carcinoma in situ greater than or equal to 2 cm located on the trunk and extremities (excluding pretibial surfaces, hands, feet, nail units, and ankles) in a healthy patient is categorized as appropriate, while a recurrent but otherwise identical squamous cell carcinoma in situ is categorized as uncertain. These counterintuitive criteria are unsupported by existing studies.

Controversies in Subspecialty Certification

Recently, debate also has surfaced regarding subspecialty certification. Over the last decade, proponents of subspecialty certification have argued that board certification would bring consistency and decrease divisiveness among dermatologists; help to prevent exclusion of Mohs surgeons from insurance networks and teaching opportunities at the Veterans Administration; and demonstrate competence to patients, the media, and payers. Those in opposition contest that practices may be restricted by insurers using lack of certification to eliminate dermatologists from their networks, economic credentialing may be applied to dermatologists such that those without the subspecialty certification may not be deemed qualified to manage skin cancer, major limitations may be set determining which dermatologists can sit for the certification examination, and subspecialty certification could create disenfranchisement of many dermatologists. A 2017 American Academy of Dermatology member survey demonstrated ambivalence regarding subcertification, with 51% of respondents pro-subcertification and 48% anti-subcertification.²³

Nonetheless, after years of debate the American Board of Dermatology proposed subspecialty certification in Micrographic Dermatologic Surgery, which was approved by the American Board of Medical Specialties on October 26, 2018. The first certification examination will likely take place in 2 years, and a maintenance of certification examination will be required every 10 years.²⁴

Final Thoughts

Further investigation is needed to elucidate and optimize solutions to many of the current controversies associated with MMS.

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 2019 dermMentors™ Residents of Distinction™ presented new scientific research during the general sessions of the 15th Annual Coastal Dermatology Symposium on October 5, 2019.

Overall Grand Prize
Chronic Inflammatory Skin Diseases Are Associated With Herpes Zoster in US Inpatients

Raj Chovatiya, MD, PhD; Jonathan I. Silverberg MD, PhD, MPH, Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
Disclosures: None.
 

Background
Herpes zoster (HZ) is a vaccine-preventable, viral eruption that affects 1 of every 3 people in the United States in their lifetime. Despite evidence-based guidelines and public health advocacy, many high-risk individuals remain unvaccinated and at risk for significant morbidity from HZ. Patients with chronic inflammatory skin diseases (CISDs), including allergic and autoimmune conditions, have potential risk factors for HZ, including long-term use of systemic corticosteroids and immunosuppressants, and immune dysregulation in the skin and periphery. We sought to determine whether CISDs are associated with HZ in hospitalized patients in the US.

Methods
Data were analyzed from the 2002-2012 Nationwide Inpatient Sample, a representative 20% cross-sectional cohort of US hospitalizations (N=68,490,364 children and adults).

Results
The estimated incidence of primary hospitalization for HZ in the US population was 5.0 per 100,000 persons from 2002-2012. In multivariable weighted logistic regression models including age, sex, race/ethnicity, insurance, mean household income, and long-term systemic corticosteroid use, primary hospitalization for HZ was associated with multiple CISDs: atopic dermatitis (adjusted odds ratio [95% confidence interval]: 1.38 [1.14-1.68]), psoriasis (4.78 [2.83-8.08]), pemphigus (1.77 [1.01-3.12]), bullous pemphigoid (1.77 [1.01-3.12]), mycosis fungoides (3.79 [2.55-5.65]), dermatomyositis (7.31 [5.27-10.12]), systemic sclerosis (1.92 [1.47-2.53]), cutaneous lupus erythematosus (1.94 [1.10-3.44]), vitiligo (2.00 [1.04-3.85]), and sarcoidosis (1.52 [1.22-1.90]). Lichen planus (3.01 [1.36-6.67]), Sézary syndrome (12.14 [5.20-28.31]), morphea (2.74 [1.36-5.51]), and pyoderma gangrenosum (2.44 [1.16-5.13]) showed increased odds in bivariable models but not in multivariable models. Whereas, hidradenitis suppurativa, chronic idiopathic/spontaneous urticaria, and alopecia areata were not associated with HZ. Similar results were seen in sensitivity analyses among adults age <60 and <50 years. Significant predictors of primary hospitalization for HZ among patients with CISDs included older age, female sex, non-white race/ethnicity, decreasing number of chronic comorbid conditions, and long-term systemic corticosteroid use. Inpatient length of stay and/or inflation adjusted cost of care were significantly higher in inpatients with CISD with vs. without a primary diagnosis of HZ.

Conclusion
CISDs are associated with increased hospitalization for HZ, prolonged length of inpatient stay and increased cost of hospital care. The associations of CISDs and HZ were significant even below the recommended ages (<60 and <50 years) for vaccination with live and recombinant HZ vaccine, respectively. Additional studies are needed to confirm these findings and determine the mechanisms of VZV reactivation. Patients with CISDs constitute a significant, previously under-recognized group that is high-risk for hospitalization for HZ. Dermatologists are the primary physicians who manage the vulnerable population of CISDs. They should be on the forefront of screening, intervention, and most importantly, vaccination for their patients. Future studies should explore implementation of outpatient HZ vaccination by dermatologists and revised disease-specific guidelines to cover the spectrum of CISDs.

Up next: Buyer Beware or You Might Get Burned...→

Buyer Beware or You Might Get Burned: Unregulated Photosensitizing Agents Available Without Prescription From Major Online Retailers 

Kimberly Huerth, MD, MEd, Department of Dermatology, Howard University Hospital, Washington, DC; Olivia Ware, BA, Howard University College of Medicine, Washington, DC; Ginette A. Okoye, MD, Department of Dermatology, Howard University Hospital, Washington, DC; Sharon Bridgeman-Shah, MD, Department of Dermatology, Howard University Hospital, Washington, DC
Disclosures: None.

Background
According to the World Health Organization, the vast majority of the world’s population relies on plant-derived medicine as their primary form of healthcare. Closer to home, these alternative therapies are growing in popularity among American healthcare consumers, in concert with increasing access to such products by means of globalization and the growth of Internet retail. There are numerous reasons why an individual might eschew Western medicine in favor of a more naturopathic approach, including perceived health benefits, cost, prior failure of physician guided treatment, a lack of awareness about the risks these products carry, cultural norms, and desperation born of the psychosocial burden of one’s disease. 

A 73-year-old Eritrean man presented to our outpatient dermatology clinic with a severe, acute, phototoxic reaction following the ingestion of Athamanta decoction for the self-directed treatment of vitiligo. The genus Athamanta is in the Apiaceae family and consists of 6 species of flowering plants native to Europe and North Africa. Furanocoumarins are the phototoxic compounds present in these plants, among which psoralen is perhaps the most notorious. The desiccated Athamanta leaves, sought in the absence of medical consultation, had been obtained from a mail order vendor in Egypt which had advertised them as a “miracle effect for curing vitiligo.” 

Objective
To determine the extent to which unregulated photosensitizing agents for the treatment of vitiligo are available to consumers from online retailers, including major ones such as Amazon and eBay. 

Methods
An online product search of eBay and Amazon, as well as an Internet pharmacy by the name of Cheap Generic, was conducted using search terms “vitiligo treatment,” “psoralen for vitiligo,” “furanocoumarin treatment,” “Athamanta vitiligo,” “Apiaceae vitiligo,” and “leukoderma.” Products generated by the search terms were examined for their route of delivery (topical vs systemic), key photosensitizing ingredient, parent plant, cost to consumer, and country of manufacture. Products that did not identify a known photosensitizing compound, or a plant known to contain a photosensitizing compound, on the list of ingredients were excluded from the analysis. 

Results
We identified a total of 11 products—6 listed on Amazon, 3 listed on eBay, and 2 listed by Cheap Generic pharmacy—that had either a photosensitizing compound, or a plant known to contain a photosensitizing compound, on its list of ingredients. 27.3% of products were available in formulations intended for ingestion, such as tablets or powders. 90.9% of products listed psoralen, or a plant known to contain psoralen, as a major ingredient. Of the products that identified the main photosensitizing plant ingredient (72.7%), Psoralea corylifolia was the most common (75%). Products ranged in cost from $3 to $28. The terms “herbal” (54.5%) and “natural” (36.3%) were used most frequently on the packaging and/or website for promotional purposes. While 45.4% of products did not identify a country of origin, of those that did, 66.7% were manufactured in India, while the remainder were prepared in China. 

Conclusion
Topically and systemically administered psoralen-containing products for the treatment of vitiligo are widely available without a prescription from several online vendors. These products are affordable and utilize suggestive packaging to tout the benefits of the products, without mention of their risks.

Up next: Collagen VII: A Link Between the Skin and Bone Marrow...→

Collagen VII: A Link Between the Skin and Bone Marrow Via Extracellular Vesicles

Jeffrey D. McBride, MD, PhD, Department of Dermatology and Cutaneous Surgery, University of Miami, Miami, Florida
Disclosures: Dr. McBride has been a consultant with Aegle Therapeutics.

Extracellular vesicles—exosomes, microvesicles, and apoptotic bodies—are ubiquitous in human tissues, circulation, and body fluids. Of these vesicles, exosomes are of growing interest among investigators across multiple fields, including dermatology. The characteristics of exosomes, their associated cargo (nucleic acids, proteins, and lipids), and downstream functions are vastly different, depending on the cell of origin. Specifically, we have discovered that these extracellular vesicles from the bone marrow–derived mesenchymal stem cells stimulate production of basement membrane components by cells that genetically lacked the ability to do so before (ie, collagen VII from fibroblasts derived from patients with recessive dystrophic epidermolysis bullosa). In other words, our work shows that the bone marrow can replenish collagen VII by directly delivering protein but also by transferring messenger RNA, coding for collagen VII, to the epidermolysis bullosa fibroblasts, allowing them to make collagen VII for the first time. Extracellular vesicles, including exosomes, have immediate potential for serving as therapeutics in dermatology over the next decade.

Up next: Genetic Variations in Non-coding Regulatory Regions in Linear Morphea...→

Genetic Variations in Non-coding Regulatory Regions in Linear Morphea
Dawn Zhang Eichenfield, MD, PhD, University of California, San Diego, Medical Center, La Jolla, California
Disclosures: This research was funded by the Women’s Dermatologic Society and the Pediatric Dermatology Research Alliance.

Linear morphea is a chronic inflammatory and pro-fibrotic disease that can be debilitating and disfiguring. It generally presents at an earlier age of onset than other subtypes of morphea. Like other autoimmune diseases, linear morphea presents predominantly in females, has a familial contribution, and has been associated with particular environmental triggers. Beyond this, however, the full pathogenesis of this disease remains unknown. A more thorough understanding of the causes of linear morphea—genetic and environmental—is the first step toward improved diagnosis and treatment.

Lesions of linear morphea predominantly follow Blaschko’s lines, a pattern of lines on the skin thought to represent pathways of epidermal cell migration and proliferation during fetal development. This presentation suggests that genetic mosaicism may be at play, although studies utilizing whole exome sequencing have not found causative somatic genetic mutations in protein-coding regions.^1,2 Recent studies, however, have increasingly shown that genetic diseases, including autoimmune disorders, can be caused by mutations in non-protein coding regions. For example, Castellanos-Rubio et al³ recently identified a long non-coding RNA that plays an essential role in the maintenance of intestinal mucosal immune homeostasis and its genetic polymorphisms contribute to inflammation in celiac disease. New sequencing technologies further highlight the complexities of gene regulation. Recent studies of the ENCODE project estimate hundreds of thousands of non-promoter genomic elements that are regulated in a cell-specific and signal-dependent manner through different transcription factors, non-coding RNAs, as well as other transcriptional regulatory elements.⁴ Taken together, this data suggests that genetic mutations in non-coding regulatory regions have the potential to initiate and perpetuate autoimmune disease.

Our hypothesis is that key somatic genetic mutations in non-coding regulatory regions result in altered transcription factor binding and downstream changes in gene expression, which produce a predisposition to development of linear morphea. To test this hypothesis, we are utilizing whole genome sequencing and Assay for Transposase-Accessible Chromatin using sequencing (ATAC-Seq) on normal and lesional skin in a cohort of patients with linear morphea to identify disease-specific regulatory variants. If initial experiments yield candidate genes or regulatory regions, we will validate these loci through functional assays to identify variants that stimulate a pro-fibrotic response.

Altogether, these studies will help identify new insights into key genetic contributions to the pathogenesis and transcriptional regulation of linear morphea. Understanding the molecular and genetic basis of linear morphea is significant as it is the first step toward improved pharmacological treatments and preventive strategies for linear morphea.

References

1. Higgins R, Smith A, Walchli R, et al. Absence of somatic mutations in linear localized scleroderma. J Investig Dermatol. 2017;137:S271.
2. Higgins R, Theiler M, Smith A, et al. Genetic architecture of linear localized scleroderma. J Investig Dermatol. 2018;138:S138.
3. Castellanos-Rubio A, Fernandez-Jimenez N, Kratchmarov R, et al. A long noncoding RNA associated with susceptibility to celiac disease. Science. 2016;352:91-95.
4. Hoffman MM, Ernst J, Wilder SP, et al. Integrative annotation of chromatin elements from ENCODE data. Nucleic Acids Res. 2013;41:827-841.

Up next: Increasing Evidence for Omalizumab in the Treatment of Bullous Pemphigoid→

Increasing Evidence for Omalizumab in the Treatment of Bullous Pemphigoid

Sarah Lonowski, MD, MBA, Division of Dermatology, University of California Los Angeles, Los Angeles, California
Disclosures: None.

Introduction
Bullous pemphigoid (BP) is a common, debilitating autoimmune blistering disease which is often managed with prednisone and other systemic immunosuppressive medications. Here, we present the largest case series to date evaluating the use of omalizumab for the treatment of BP, providing novel insight and further support for use of this well-tolerated, minimally immunosuppressive agent.

Objective
To review and analyze the experience of patients with BP treated with omalizumab at a single academic institution.

Methods
Retrospective chart analysis of eleven patients with BP treated at a single academic institution over a 32-month period (April 2016–December 2018). Data was obtained through comprehensive review of pathology reports, laboratory data, and physician documentation. Standard descriptive statistics were performed on the data.

Results
Eleven patients were included in the analysis, 5 females (45.5%) and 6 males (54.5%) with a mean age of 78 years (range, 57-95 years). Patients had failed a mean of 2.3 systemic agents prior to initiation of omalizumab. Seven of 11 patients (63.6%) had experienced adverse effects related to prednisone prior to initiation of omalizumab. Six patients (54.5%) had complete clearance of skin lesions after a median duration of 4.4 months on omalizumab, 3 patients (27.3%) had partial response, and 2 patients (18.2%) did not respond to treatment. The median duration of treatment in all patients at the time of analysis was 12.6 months. All 10 patients on prednisone at the time of omalizumab initiation were able to reduce the dose of prednisone, and 5 of 10 patients (50%) were able to discontinue systemic steroids completely. Baseline serum immunoglobulin E (IgE) and eosinophil levels did not predict treatment response. There were no serious treatment-related adverse effects during the treatment period. 

Conclusions/Relevance
Omalizumab is a well-tolerated, steroid-sparing agent which has a significant disease-modifying effect in the majority of patients. Baseline serum IgE and eosinophil levels do not appear to predict treatment response, therefore patient selection should not hinge on these lab values. Omalizumab should be considered as a treatment option for any patient requiring systemic treatment for BP, but especially for those who have experienced or are at risk for experiencing adverse effects from systemic steroids.

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 2019 dermMentors™ Residents of Distinction™ presented new scientific research during the general sessions of the 15th Annual Coastal Dermatology Symposium on October 5, 2019.

Overall Grand Prize
Chronic Inflammatory Skin Diseases Are Associated With Herpes Zoster in US Inpatients

Raj Chovatiya, MD, PhD; Jonathan I. Silverberg MD, PhD, MPH, Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
Disclosures: None.
 

Background
Herpes zoster (HZ) is a vaccine-preventable, viral eruption that affects 1 of every 3 people in the United States in their lifetime. Despite evidence-based guidelines and public health advocacy, many high-risk individuals remain unvaccinated and at risk for significant morbidity from HZ. Patients with chronic inflammatory skin diseases (CISDs), including allergic and autoimmune conditions, have potential risk factors for HZ, including long-term use of systemic corticosteroids and immunosuppressants, and immune dysregulation in the skin and periphery. We sought to determine whether CISDs are associated with HZ in hospitalized patients in the US.

Methods
Data were analyzed from the 2002-2012 Nationwide Inpatient Sample, a representative 20% cross-sectional cohort of US hospitalizations (N=68,490,364 children and adults).

Results
The estimated incidence of primary hospitalization for HZ in the US population was 5.0 per 100,000 persons from 2002-2012. In multivariable weighted logistic regression models including age, sex, race/ethnicity, insurance, mean household income, and long-term systemic corticosteroid use, primary hospitalization for HZ was associated with multiple CISDs: atopic dermatitis (adjusted odds ratio [95% confidence interval]: 1.38 [1.14-1.68]), psoriasis (4.78 [2.83-8.08]), pemphigus (1.77 [1.01-3.12]), bullous pemphigoid (1.77 [1.01-3.12]), mycosis fungoides (3.79 [2.55-5.65]), dermatomyositis (7.31 [5.27-10.12]), systemic sclerosis (1.92 [1.47-2.53]), cutaneous lupus erythematosus (1.94 [1.10-3.44]), vitiligo (2.00 [1.04-3.85]), and sarcoidosis (1.52 [1.22-1.90]). Lichen planus (3.01 [1.36-6.67]), Sézary syndrome (12.14 [5.20-28.31]), morphea (2.74 [1.36-5.51]), and pyoderma gangrenosum (2.44 [1.16-5.13]) showed increased odds in bivariable models but not in multivariable models. Whereas, hidradenitis suppurativa, chronic idiopathic/spontaneous urticaria, and alopecia areata were not associated with HZ. Similar results were seen in sensitivity analyses among adults age <60 and <50 years. Significant predictors of primary hospitalization for HZ among patients with CISDs included older age, female sex, non-white race/ethnicity, decreasing number of chronic comorbid conditions, and long-term systemic corticosteroid use. Inpatient length of stay and/or inflation adjusted cost of care were significantly higher in inpatients with CISD with vs. without a primary diagnosis of HZ.

Conclusion
CISDs are associated with increased hospitalization for HZ, prolonged length of inpatient stay and increased cost of hospital care. The associations of CISDs and HZ were significant even below the recommended ages (<60 and <50 years) for vaccination with live and recombinant HZ vaccine, respectively. Additional studies are needed to confirm these findings and determine the mechanisms of VZV reactivation. Patients with CISDs constitute a significant, previously under-recognized group that is high-risk for hospitalization for HZ. Dermatologists are the primary physicians who manage the vulnerable population of CISDs. They should be on the forefront of screening, intervention, and most importantly, vaccination for their patients. Future studies should explore implementation of outpatient HZ vaccination by dermatologists and revised disease-specific guidelines to cover the spectrum of CISDs.

Up next: Buyer Beware or You Might Get Burned...→

Buyer Beware or You Might Get Burned: Unregulated Photosensitizing Agents Available Without Prescription From Major Online Retailers 

Kimberly Huerth, MD, MEd, Department of Dermatology, Howard University Hospital, Washington, DC; Olivia Ware, BA, Howard University College of Medicine, Washington, DC; Ginette A. Okoye, MD, Department of Dermatology, Howard University Hospital, Washington, DC; Sharon Bridgeman-Shah, MD, Department of Dermatology, Howard University Hospital, Washington, DC
Disclosures: None.

Background
According to the World Health Organization, the vast majority of the world’s population relies on plant-derived medicine as their primary form of healthcare. Closer to home, these alternative therapies are growing in popularity among American healthcare consumers, in concert with increasing access to such products by means of globalization and the growth of Internet retail. There are numerous reasons why an individual might eschew Western medicine in favor of a more naturopathic approach, including perceived health benefits, cost, prior failure of physician guided treatment, a lack of awareness about the risks these products carry, cultural norms, and desperation born of the psychosocial burden of one’s disease. 

A 73-year-old Eritrean man presented to our outpatient dermatology clinic with a severe, acute, phototoxic reaction following the ingestion of Athamanta decoction for the self-directed treatment of vitiligo. The genus Athamanta is in the Apiaceae family and consists of 6 species of flowering plants native to Europe and North Africa. Furanocoumarins are the phototoxic compounds present in these plants, among which psoralen is perhaps the most notorious. The desiccated Athamanta leaves, sought in the absence of medical consultation, had been obtained from a mail order vendor in Egypt which had advertised them as a “miracle effect for curing vitiligo.” 

Objective
To determine the extent to which unregulated photosensitizing agents for the treatment of vitiligo are available to consumers from online retailers, including major ones such as Amazon and eBay. 

Methods
An online product search of eBay and Amazon, as well as an Internet pharmacy by the name of Cheap Generic, was conducted using search terms “vitiligo treatment,” “psoralen for vitiligo,” “furanocoumarin treatment,” “Athamanta vitiligo,” “Apiaceae vitiligo,” and “leukoderma.” Products generated by the search terms were examined for their route of delivery (topical vs systemic), key photosensitizing ingredient, parent plant, cost to consumer, and country of manufacture. Products that did not identify a known photosensitizing compound, or a plant known to contain a photosensitizing compound, on the list of ingredients were excluded from the analysis. 

Results
We identified a total of 11 products—6 listed on Amazon, 3 listed on eBay, and 2 listed by Cheap Generic pharmacy—that had either a photosensitizing compound, or a plant known to contain a photosensitizing compound, on its list of ingredients. 27.3% of products were available in formulations intended for ingestion, such as tablets or powders. 90.9% of products listed psoralen, or a plant known to contain psoralen, as a major ingredient. Of the products that identified the main photosensitizing plant ingredient (72.7%), Psoralea corylifolia was the most common (75%). Products ranged in cost from $3 to $28. The terms “herbal” (54.5%) and “natural” (36.3%) were used most frequently on the packaging and/or website for promotional purposes. While 45.4% of products did not identify a country of origin, of those that did, 66.7% were manufactured in India, while the remainder were prepared in China. 

Conclusion
Topically and systemically administered psoralen-containing products for the treatment of vitiligo are widely available without a prescription from several online vendors. These products are affordable and utilize suggestive packaging to tout the benefits of the products, without mention of their risks.

Up next: Collagen VII: A Link Between the Skin and Bone Marrow...→

Collagen VII: A Link Between the Skin and Bone Marrow Via Extracellular Vesicles

Jeffrey D. McBride, MD, PhD, Department of Dermatology and Cutaneous Surgery, University of Miami, Miami, Florida
Disclosures: Dr. McBride has been a consultant with Aegle Therapeutics.

Extracellular vesicles—exosomes, microvesicles, and apoptotic bodies—are ubiquitous in human tissues, circulation, and body fluids. Of these vesicles, exosomes are of growing interest among investigators across multiple fields, including dermatology. The characteristics of exosomes, their associated cargo (nucleic acids, proteins, and lipids), and downstream functions are vastly different, depending on the cell of origin. Specifically, we have discovered that these extracellular vesicles from the bone marrow–derived mesenchymal stem cells stimulate production of basement membrane components by cells that genetically lacked the ability to do so before (ie, collagen VII from fibroblasts derived from patients with recessive dystrophic epidermolysis bullosa). In other words, our work shows that the bone marrow can replenish collagen VII by directly delivering protein but also by transferring messenger RNA, coding for collagen VII, to the epidermolysis bullosa fibroblasts, allowing them to make collagen VII for the first time. Extracellular vesicles, including exosomes, have immediate potential for serving as therapeutics in dermatology over the next decade.

Up next: Genetic Variations in Non-coding Regulatory Regions in Linear Morphea...→

Genetic Variations in Non-coding Regulatory Regions in Linear Morphea
Dawn Zhang Eichenfield, MD, PhD, University of California, San Diego, Medical Center, La Jolla, California
Disclosures: This research was funded by the Women’s Dermatologic Society and the Pediatric Dermatology Research Alliance.

Linear morphea is a chronic inflammatory and pro-fibrotic disease that can be debilitating and disfiguring. It generally presents at an earlier age of onset than other subtypes of morphea. Like other autoimmune diseases, linear morphea presents predominantly in females, has a familial contribution, and has been associated with particular environmental triggers. Beyond this, however, the full pathogenesis of this disease remains unknown. A more thorough understanding of the causes of linear morphea—genetic and environmental—is the first step toward improved diagnosis and treatment.

Lesions of linear morphea predominantly follow Blaschko’s lines, a pattern of lines on the skin thought to represent pathways of epidermal cell migration and proliferation during fetal development. This presentation suggests that genetic mosaicism may be at play, although studies utilizing whole exome sequencing have not found causative somatic genetic mutations in protein-coding regions.^1,2 Recent studies, however, have increasingly shown that genetic diseases, including autoimmune disorders, can be caused by mutations in non-protein coding regions. For example, Castellanos-Rubio et al³ recently identified a long non-coding RNA that plays an essential role in the maintenance of intestinal mucosal immune homeostasis and its genetic polymorphisms contribute to inflammation in celiac disease. New sequencing technologies further highlight the complexities of gene regulation. Recent studies of the ENCODE project estimate hundreds of thousands of non-promoter genomic elements that are regulated in a cell-specific and signal-dependent manner through different transcription factors, non-coding RNAs, as well as other transcriptional regulatory elements.⁴ Taken together, this data suggests that genetic mutations in non-coding regulatory regions have the potential to initiate and perpetuate autoimmune disease.

Our hypothesis is that key somatic genetic mutations in non-coding regulatory regions result in altered transcription factor binding and downstream changes in gene expression, which produce a predisposition to development of linear morphea. To test this hypothesis, we are utilizing whole genome sequencing and Assay for Transposase-Accessible Chromatin using sequencing (ATAC-Seq) on normal and lesional skin in a cohort of patients with linear morphea to identify disease-specific regulatory variants. If initial experiments yield candidate genes or regulatory regions, we will validate these loci through functional assays to identify variants that stimulate a pro-fibrotic response.

Altogether, these studies will help identify new insights into key genetic contributions to the pathogenesis and transcriptional regulation of linear morphea. Understanding the molecular and genetic basis of linear morphea is significant as it is the first step toward improved pharmacological treatments and preventive strategies for linear morphea.

References

1. Higgins R, Smith A, Walchli R, et al. Absence of somatic mutations in linear localized scleroderma. J Investig Dermatol. 2017;137:S271.
2. Higgins R, Theiler M, Smith A, et al. Genetic architecture of linear localized scleroderma. J Investig Dermatol. 2018;138:S138.
3. Castellanos-Rubio A, Fernandez-Jimenez N, Kratchmarov R, et al. A long noncoding RNA associated with susceptibility to celiac disease. Science. 2016;352:91-95.
4. Hoffman MM, Ernst J, Wilder SP, et al. Integrative annotation of chromatin elements from ENCODE data. Nucleic Acids Res. 2013;41:827-841.

Up next: Increasing Evidence for Omalizumab in the Treatment of Bullous Pemphigoid→

Increasing Evidence for Omalizumab in the Treatment of Bullous Pemphigoid

Sarah Lonowski, MD, MBA, Division of Dermatology, University of California Los Angeles, Los Angeles, California
Disclosures: None.

Introduction
Bullous pemphigoid (BP) is a common, debilitating autoimmune blistering disease which is often managed with prednisone and other systemic immunosuppressive medications. Here, we present the largest case series to date evaluating the use of omalizumab for the treatment of BP, providing novel insight and further support for use of this well-tolerated, minimally immunosuppressive agent.

Objective
To review and analyze the experience of patients with BP treated with omalizumab at a single academic institution.

Methods
Retrospective chart analysis of eleven patients with BP treated at a single academic institution over a 32-month period (April 2016–December 2018). Data was obtained through comprehensive review of pathology reports, laboratory data, and physician documentation. Standard descriptive statistics were performed on the data.

Results
Eleven patients were included in the analysis, 5 females (45.5%) and 6 males (54.5%) with a mean age of 78 years (range, 57-95 years). Patients had failed a mean of 2.3 systemic agents prior to initiation of omalizumab. Seven of 11 patients (63.6%) had experienced adverse effects related to prednisone prior to initiation of omalizumab. Six patients (54.5%) had complete clearance of skin lesions after a median duration of 4.4 months on omalizumab, 3 patients (27.3%) had partial response, and 2 patients (18.2%) did not respond to treatment. The median duration of treatment in all patients at the time of analysis was 12.6 months. All 10 patients on prednisone at the time of omalizumab initiation were able to reduce the dose of prednisone, and 5 of 10 patients (50%) were able to discontinue systemic steroids completely. Baseline serum immunoglobulin E (IgE) and eosinophil levels did not predict treatment response. There were no serious treatment-related adverse effects during the treatment period. 

Conclusions/Relevance
Omalizumab is a well-tolerated, steroid-sparing agent which has a significant disease-modifying effect in the majority of patients. Baseline serum IgE and eosinophil levels do not appear to predict treatment response, therefore patient selection should not hinge on these lab values. Omalizumab should be considered as a treatment option for any patient requiring systemic treatment for BP, but especially for those who have experienced or are at risk for experiencing adverse effects from systemic steroids.

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 2019 dermMentors™ Residents of Distinction™ presented new scientific research during the general sessions of the 15th Annual Coastal Dermatology Symposium on October 5, 2019.

Overall Grand Prize
Chronic Inflammatory Skin Diseases Are Associated With Herpes Zoster in US Inpatients

Raj Chovatiya, MD, PhD; Jonathan I. Silverberg MD, PhD, MPH, Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
Disclosures: None.
 

Background
Herpes zoster (HZ) is a vaccine-preventable, viral eruption that affects 1 of every 3 people in the United States in their lifetime. Despite evidence-based guidelines and public health advocacy, many high-risk individuals remain unvaccinated and at risk for significant morbidity from HZ. Patients with chronic inflammatory skin diseases (CISDs), including allergic and autoimmune conditions, have potential risk factors for HZ, including long-term use of systemic corticosteroids and immunosuppressants, and immune dysregulation in the skin and periphery. We sought to determine whether CISDs are associated with HZ in hospitalized patients in the US.

Methods
Data were analyzed from the 2002-2012 Nationwide Inpatient Sample, a representative 20% cross-sectional cohort of US hospitalizations (N=68,490,364 children and adults).

Results
The estimated incidence of primary hospitalization for HZ in the US population was 5.0 per 100,000 persons from 2002-2012. In multivariable weighted logistic regression models including age, sex, race/ethnicity, insurance, mean household income, and long-term systemic corticosteroid use, primary hospitalization for HZ was associated with multiple CISDs: atopic dermatitis (adjusted odds ratio [95% confidence interval]: 1.38 [1.14-1.68]), psoriasis (4.78 [2.83-8.08]), pemphigus (1.77 [1.01-3.12]), bullous pemphigoid (1.77 [1.01-3.12]), mycosis fungoides (3.79 [2.55-5.65]), dermatomyositis (7.31 [5.27-10.12]), systemic sclerosis (1.92 [1.47-2.53]), cutaneous lupus erythematosus (1.94 [1.10-3.44]), vitiligo (2.00 [1.04-3.85]), and sarcoidosis (1.52 [1.22-1.90]). Lichen planus (3.01 [1.36-6.67]), Sézary syndrome (12.14 [5.20-28.31]), morphea (2.74 [1.36-5.51]), and pyoderma gangrenosum (2.44 [1.16-5.13]) showed increased odds in bivariable models but not in multivariable models. Whereas, hidradenitis suppurativa, chronic idiopathic/spontaneous urticaria, and alopecia areata were not associated with HZ. Similar results were seen in sensitivity analyses among adults age <60 and <50 years. Significant predictors of primary hospitalization for HZ among patients with CISDs included older age, female sex, non-white race/ethnicity, decreasing number of chronic comorbid conditions, and long-term systemic corticosteroid use. Inpatient length of stay and/or inflation adjusted cost of care were significantly higher in inpatients with CISD with vs. without a primary diagnosis of HZ.

Conclusion
CISDs are associated with increased hospitalization for HZ, prolonged length of inpatient stay and increased cost of hospital care. The associations of CISDs and HZ were significant even below the recommended ages (<60 and <50 years) for vaccination with live and recombinant HZ vaccine, respectively. Additional studies are needed to confirm these findings and determine the mechanisms of VZV reactivation. Patients with CISDs constitute a significant, previously under-recognized group that is high-risk for hospitalization for HZ. Dermatologists are the primary physicians who manage the vulnerable population of CISDs. They should be on the forefront of screening, intervention, and most importantly, vaccination for their patients. Future studies should explore implementation of outpatient HZ vaccination by dermatologists and revised disease-specific guidelines to cover the spectrum of CISDs.

Up next: Buyer Beware or You Might Get Burned...→

Buyer Beware or You Might Get Burned: Unregulated Photosensitizing Agents Available Without Prescription From Major Online Retailers 

Kimberly Huerth, MD, MEd, Department of Dermatology, Howard University Hospital, Washington, DC; Olivia Ware, BA, Howard University College of Medicine, Washington, DC; Ginette A. Okoye, MD, Department of Dermatology, Howard University Hospital, Washington, DC; Sharon Bridgeman-Shah, MD, Department of Dermatology, Howard University Hospital, Washington, DC
Disclosures: None.

Background
According to the World Health Organization, the vast majority of the world’s population relies on plant-derived medicine as their primary form of healthcare. Closer to home, these alternative therapies are growing in popularity among American healthcare consumers, in concert with increasing access to such products by means of globalization and the growth of Internet retail. There are numerous reasons why an individual might eschew Western medicine in favor of a more naturopathic approach, including perceived health benefits, cost, prior failure of physician guided treatment, a lack of awareness about the risks these products carry, cultural norms, and desperation born of the psychosocial burden of one’s disease. 

A 73-year-old Eritrean man presented to our outpatient dermatology clinic with a severe, acute, phototoxic reaction following the ingestion of Athamanta decoction for the self-directed treatment of vitiligo. The genus Athamanta is in the Apiaceae family and consists of 6 species of flowering plants native to Europe and North Africa. Furanocoumarins are the phototoxic compounds present in these plants, among which psoralen is perhaps the most notorious. The desiccated Athamanta leaves, sought in the absence of medical consultation, had been obtained from a mail order vendor in Egypt which had advertised them as a “miracle effect for curing vitiligo.” 

Objective
To determine the extent to which unregulated photosensitizing agents for the treatment of vitiligo are available to consumers from online retailers, including major ones such as Amazon and eBay. 

Methods
An online product search of eBay and Amazon, as well as an Internet pharmacy by the name of Cheap Generic, was conducted using search terms “vitiligo treatment,” “psoralen for vitiligo,” “furanocoumarin treatment,” “Athamanta vitiligo,” “Apiaceae vitiligo,” and “leukoderma.” Products generated by the search terms were examined for their route of delivery (topical vs systemic), key photosensitizing ingredient, parent plant, cost to consumer, and country of manufacture. Products that did not identify a known photosensitizing compound, or a plant known to contain a photosensitizing compound, on the list of ingredients were excluded from the analysis. 

Results
We identified a total of 11 products—6 listed on Amazon, 3 listed on eBay, and 2 listed by Cheap Generic pharmacy—that had either a photosensitizing compound, or a plant known to contain a photosensitizing compound, on its list of ingredients. 27.3% of products were available in formulations intended for ingestion, such as tablets or powders. 90.9% of products listed psoralen, or a plant known to contain psoralen, as a major ingredient. Of the products that identified the main photosensitizing plant ingredient (72.7%), Psoralea corylifolia was the most common (75%). Products ranged in cost from $3 to $28. The terms “herbal” (54.5%) and “natural” (36.3%) were used most frequently on the packaging and/or website for promotional purposes. While 45.4% of products did not identify a country of origin, of those that did, 66.7% were manufactured in India, while the remainder were prepared in China. 

Conclusion
Topically and systemically administered psoralen-containing products for the treatment of vitiligo are widely available without a prescription from several online vendors. These products are affordable and utilize suggestive packaging to tout the benefits of the products, without mention of their risks.

Up next: Collagen VII: A Link Between the Skin and Bone Marrow...→

Collagen VII: A Link Between the Skin and Bone Marrow Via Extracellular Vesicles

Jeffrey D. McBride, MD, PhD, Department of Dermatology and Cutaneous Surgery, University of Miami, Miami, Florida
Disclosures: Dr. McBride has been a consultant with Aegle Therapeutics.

Extracellular vesicles—exosomes, microvesicles, and apoptotic bodies—are ubiquitous in human tissues, circulation, and body fluids. Of these vesicles, exosomes are of growing interest among investigators across multiple fields, including dermatology. The characteristics of exosomes, their associated cargo (nucleic acids, proteins, and lipids), and downstream functions are vastly different, depending on the cell of origin. Specifically, we have discovered that these extracellular vesicles from the bone marrow–derived mesenchymal stem cells stimulate production of basement membrane components by cells that genetically lacked the ability to do so before (ie, collagen VII from fibroblasts derived from patients with recessive dystrophic epidermolysis bullosa). In other words, our work shows that the bone marrow can replenish collagen VII by directly delivering protein but also by transferring messenger RNA, coding for collagen VII, to the epidermolysis bullosa fibroblasts, allowing them to make collagen VII for the first time. Extracellular vesicles, including exosomes, have immediate potential for serving as therapeutics in dermatology over the next decade.

Up next: Genetic Variations in Non-coding Regulatory Regions in Linear Morphea...→

Genetic Variations in Non-coding Regulatory Regions in Linear Morphea
Dawn Zhang Eichenfield, MD, PhD, University of California, San Diego, Medical Center, La Jolla, California
Disclosures: This research was funded by the Women’s Dermatologic Society and the Pediatric Dermatology Research Alliance.

Linear morphea is a chronic inflammatory and pro-fibrotic disease that can be debilitating and disfiguring. It generally presents at an earlier age of onset than other subtypes of morphea. Like other autoimmune diseases, linear morphea presents predominantly in females, has a familial contribution, and has been associated with particular environmental triggers. Beyond this, however, the full pathogenesis of this disease remains unknown. A more thorough understanding of the causes of linear morphea—genetic and environmental—is the first step toward improved diagnosis and treatment.

Lesions of linear morphea predominantly follow Blaschko’s lines, a pattern of lines on the skin thought to represent pathways of epidermal cell migration and proliferation during fetal development. This presentation suggests that genetic mosaicism may be at play, although studies utilizing whole exome sequencing have not found causative somatic genetic mutations in protein-coding regions.^1,2 Recent studies, however, have increasingly shown that genetic diseases, including autoimmune disorders, can be caused by mutations in non-protein coding regions. For example, Castellanos-Rubio et al³ recently identified a long non-coding RNA that plays an essential role in the maintenance of intestinal mucosal immune homeostasis and its genetic polymorphisms contribute to inflammation in celiac disease. New sequencing technologies further highlight the complexities of gene regulation. Recent studies of the ENCODE project estimate hundreds of thousands of non-promoter genomic elements that are regulated in a cell-specific and signal-dependent manner through different transcription factors, non-coding RNAs, as well as other transcriptional regulatory elements.⁴ Taken together, this data suggests that genetic mutations in non-coding regulatory regions have the potential to initiate and perpetuate autoimmune disease.

Our hypothesis is that key somatic genetic mutations in non-coding regulatory regions result in altered transcription factor binding and downstream changes in gene expression, which produce a predisposition to development of linear morphea. To test this hypothesis, we are utilizing whole genome sequencing and Assay for Transposase-Accessible Chromatin using sequencing (ATAC-Seq) on normal and lesional skin in a cohort of patients with linear morphea to identify disease-specific regulatory variants. If initial experiments yield candidate genes or regulatory regions, we will validate these loci through functional assays to identify variants that stimulate a pro-fibrotic response.

Altogether, these studies will help identify new insights into key genetic contributions to the pathogenesis and transcriptional regulation of linear morphea. Understanding the molecular and genetic basis of linear morphea is significant as it is the first step toward improved pharmacological treatments and preventive strategies for linear morphea.

References

1. Higgins R, Smith A, Walchli R, et al. Absence of somatic mutations in linear localized scleroderma. J Investig Dermatol. 2017;137:S271.
2. Higgins R, Theiler M, Smith A, et al. Genetic architecture of linear localized scleroderma. J Investig Dermatol. 2018;138:S138.
3. Castellanos-Rubio A, Fernandez-Jimenez N, Kratchmarov R, et al. A long noncoding RNA associated with susceptibility to celiac disease. Science. 2016;352:91-95.
4. Hoffman MM, Ernst J, Wilder SP, et al. Integrative annotation of chromatin elements from ENCODE data. Nucleic Acids Res. 2013;41:827-841.

Up next: Increasing Evidence for Omalizumab in the Treatment of Bullous Pemphigoid→

Increasing Evidence for Omalizumab in the Treatment of Bullous Pemphigoid

Sarah Lonowski, MD, MBA, Division of Dermatology, University of California Los Angeles, Los Angeles, California
Disclosures: None.

Introduction
Bullous pemphigoid (BP) is a common, debilitating autoimmune blistering disease which is often managed with prednisone and other systemic immunosuppressive medications. Here, we present the largest case series to date evaluating the use of omalizumab for the treatment of BP, providing novel insight and further support for use of this well-tolerated, minimally immunosuppressive agent.

Objective
To review and analyze the experience of patients with BP treated with omalizumab at a single academic institution.

Methods
Retrospective chart analysis of eleven patients with BP treated at a single academic institution over a 32-month period (April 2016–December 2018). Data was obtained through comprehensive review of pathology reports, laboratory data, and physician documentation. Standard descriptive statistics were performed on the data.

Results
Eleven patients were included in the analysis, 5 females (45.5%) and 6 males (54.5%) with a mean age of 78 years (range, 57-95 years). Patients had failed a mean of 2.3 systemic agents prior to initiation of omalizumab. Seven of 11 patients (63.6%) had experienced adverse effects related to prednisone prior to initiation of omalizumab. Six patients (54.5%) had complete clearance of skin lesions after a median duration of 4.4 months on omalizumab, 3 patients (27.3%) had partial response, and 2 patients (18.2%) did not respond to treatment. The median duration of treatment in all patients at the time of analysis was 12.6 months. All 10 patients on prednisone at the time of omalizumab initiation were able to reduce the dose of prednisone, and 5 of 10 patients (50%) were able to discontinue systemic steroids completely. Baseline serum immunoglobulin E (IgE) and eosinophil levels did not predict treatment response. There were no serious treatment-related adverse effects during the treatment period. 

Conclusions/Relevance
Omalizumab is a well-tolerated, steroid-sparing agent which has a significant disease-modifying effect in the majority of patients. Baseline serum IgE and eosinophil levels do not appear to predict treatment response, therefore patient selection should not hinge on these lab values. Omalizumab should be considered as a treatment option for any patient requiring systemic treatment for BP, but especially for those who have experienced or are at risk for experiencing adverse effects from systemic steroids.

The practice of dermatology is rife with bedside tools: swabs, smears, and scoring systems. First popularized in specialties such as emergency medicine and internal medicine, clinical scoring systems are now emerging in dermatology. These evidence-based scores can be calculated quickly at the bedside—often through a free smartphone app—to help guide clinical decision-making regarding diagnosis, prognosis, and management. As with any medical tool, scoring systems have limitations and should be used as a supplement, not substitute, for one’s clinical judgement. This article reviews 4 clinical scoring systems practical for dermatology residents.

SCORTEN Prognosticates Cases of Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis

Perhaps the best-known scoring system in dermatology, the SCORTEN is widely used to predict hospital mortality from Stevens-Johnson syndrome/toxic epidermal necrolysis. The SCORTEN includes 7 variables of equal weight—age of 40 years or older, heart rate of 120 beats per minute or more, cancer/hematologic malignancy, involved body surface area (BSA) greater than 10%, serum urea greater than 10 mmol/L, serum bicarbonate less than 20 mmol/L, and serum glucose greater than 14 mmol/L—each contributing 1 point to the overall score if present.¹ The involved BSA is defined as the sum of detached and detachable epidermis.¹

The SCORTEN was developed and prospectively validated to be calculated at the end of the first 24 hours of admission; for this calculation, use the BSA affected at that time, and use the most abnormal values during the first 24 hours of admission for the other variables.¹ In addition, a follow-up study including some of the original coauthors recommends recalculating the SCORTEN at the end of hospital day 3, having found that the score’s predictive value was better on this day than hospital days 1, 2, 4, or 5.² Based on the original study, a SCORTEN of 0 to 1 corresponds to a mortality rate of 3.2%, 2 to 12.1%, 3 to 35.3%, 4 to 58.3%, and 5 or greater to 90.0%.¹

Limitations of the SCORTEN include its ability to overestimate or underestimate mortality as demonstrated by 2 multi-institutional cohorts.^3,4 Recently, the ABCD-10 score was developed as an alternative to the SCORTEN and was found to predict mortality similarly when validated in an internal cohort.⁵

PEST Screens for Psoriatic Arthritis

Dermatologists play an important role in screening for psoriatic arthritis, as an estimated 1 in 5 patients with psoriasis have psoriatic arthritis.⁶ To this end, several screening tools have been developed to help differentiate psoriatic arthritis from other arthritides. Joint guidelines from the American Academy of Dermatology and the National Psoriasis Foundation acknowledge that “. . . these screening tools have tended to perform less well when tested in groups of people other than those for which they were originally developed. As such, their usefulness in routine clinical practice remains controversial.”⁷ Nevertheless, the guidelines state, “[b]ecause screening and early detection of inflammatory arthritis are essential to optimize patient [quality of life] and reduce morbidity, providers may consider using a formal screening tool of their choice.”⁷

With these limitations in mind, I have found the Psoriasis Epidemiology Screening Tool (PEST) to be the most useful psoriatic arthritis screening tool. One study determined that the PEST has the best trade-off between sensitivity and specificity compared to 2 other psoriatic arthritis screening tools, the Psoriatic Arthritis Screening and Evaluation (PASE) and the Early Arthritis for Psoriatic Patients (EARP).⁸

The PEST is comprised of 5 questions: (1) Have you ever had a swollen joint (or joints)? (2) Has a doctor ever told you that you have arthritis? (3) Do your fingernails or toenails have holes or pits? (4) Have you had pain in your heel? (5) Have you had a finger or toe that was completely swollen and painful for no apparent reason? According to the PEST, a referral to a rheumatologist should be considered for patients answering yes to 3 or more questions, which is 97% sensitive and 79% specific for psoriatic arthritis.⁹ Patients who answer yes to fewer than 3 questions should still be referred to a rheumatologist if there is a strong clinical suspicion of psoriatic arthritis.¹⁰

The PEST can be accessed for free in 13 languages via the GRAPPA (Group for Research and Assessment of Psoriasis and Psoriatic Arthritis) app as well as downloaded for free from the National Psoriasis Foundation’s website (https://www.psoriasis.org/psa-screening/providers).

ALT-70 Differentiates Cellulitis From Pseudocellulitis

Overdiagnosing cellulitis in the United States has been estimated to result in up to 130,000 unnecessary hospitalizations and up to $515 million in avoidable health care spending.¹¹ Dermatologists are in a unique position to help fix this issue. In one retrospective study of 1430 inpatient dermatology consultations, 74.32% of inpatients evaluated for presumed cellulitis by a dermatologist were instead diagnosed with a cellulitis mimicker (ie, pseudocellulitis), such as stasis dermatitis or contact dermatitis.¹²

The ALT-70 score was developed and prospectively validated to help differentiate lower extremity cellulitis from pseudocellulitis in adult patients in the emergency department (ED).¹³ In addition, the score has retrospectively been shown to function similarly in the inpatient setting when calculated at 24 and 48 hours after ED presentation.¹⁴ Although the ALT-70 score was designed for use by frontline clinicians prior to dermatology consultation, I also have found it helpful to calculate as a consultant, as it provides an objective measure of risk to communicate to the primary team in support of one diagnosis or another.

ALT-70 is an acronym for the score’s 4 variables: asymmetry, leukocytosis, tachycardia, and age of 70 years or older.¹⁵ If present, each variable confers a certain number of points to the final score: 3 points for asymmetry (defined as unilateral leg involvement), 1 point for leukocytosis (white blood cell count ≥10,000/μL), 1 point for tachycardia (≥90 beats per minute), and 2 points for age of 70 years or older. An ALT-70 score of 0 to 2 corresponds to an 83.3% or greater chance of pseudocellulitis, suggesting that the diagnosis of cellulitis be reconsidered. A score of 3 to 4 is indeterminate, and additional information such as a dermatology consultation should be pursued. A score of 5 to 7 corresponds to an 82.2% or greater chance of cellulitis, signifying that empiric treatment with antibiotics be considered.¹⁵

The ALT-70 score does not apply to cases involving areas other than the lower extremities; intravenous antibiotic use within 48 hours before ED presentation; surgery within the last 30 days; abscess; penetrating trauma; burn; or known history of osteomyelitis, diabetic ulcer, or indwelling hardware at the site of infection.¹⁵ The ALT-70 score is available for free via the MDCalc app and website (https://www.mdcalc.com/alt-70-score-cellulitis).

Mohs AUC Determines the Appropriateness of Mohs Micrographic Surgery

In 2012, the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and American Society for Mohs Surgery published appropriate use criteria (AUC) to guide the decision to pursue Mohs micrographic surgery (MMS) in the United States.¹⁶ Based on various tumor and patient characteristics, the Mohs AUC assign scores to 270 different clinical scenarios. A score of 1 to 3 signifies that MMS is inappropriate and generally not considered acceptable. A score 4 to 6 indicates that the appropriateness of MMS is uncertain. A score 7 to 9 means that MMS is appropriate and generally considered acceptable.¹⁶

Since publication, the Mohs AUC have been criticized for classifying most primary superficial basal cell carcinomas as appropriate for MMS¹⁷ (which an AUC coauthor¹⁸ and others^19,20 have defended), excluding certain reasons for performing MMS (such as operating on multiple tumors on the same day),²¹ including counterintuitive scores,²² and omitting trials from Europe²³ (which AUC coauthors also have defended²⁴). As with any clinical scoring system, the Mohs AUC has limitations; the creators acknowledge that “. . . these criteria should not be interpreted as setting a standard of care, or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results, even for those indications scored as inappropriate.”¹⁶ The Mohs AUC app (https://www.aad.org/members/aad-apps/mohs-auc) is free and allows users to enter tumor and patient characteristics to determine the score for their specific scenario.

Final Thoughts

Scoring systems are emerging in dermatology as evidence-based bedside tools to help guide clinical decision-making. Despite their limitations, these scores have the potential to make a meaningful impact in dermatology as they have in other specialties.

The practice of dermatology is rife with bedside tools: swabs, smears, and scoring systems. First popularized in specialties such as emergency medicine and internal medicine, clinical scoring systems are now emerging in dermatology. These evidence-based scores can be calculated quickly at the bedside—often through a free smartphone app—to help guide clinical decision-making regarding diagnosis, prognosis, and management. As with any medical tool, scoring systems have limitations and should be used as a supplement, not substitute, for one’s clinical judgement. This article reviews 4 clinical scoring systems practical for dermatology residents.

SCORTEN Prognosticates Cases of Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis

Perhaps the best-known scoring system in dermatology, the SCORTEN is widely used to predict hospital mortality from Stevens-Johnson syndrome/toxic epidermal necrolysis. The SCORTEN includes 7 variables of equal weight—age of 40 years or older, heart rate of 120 beats per minute or more, cancer/hematologic malignancy, involved body surface area (BSA) greater than 10%, serum urea greater than 10 mmol/L, serum bicarbonate less than 20 mmol/L, and serum glucose greater than 14 mmol/L—each contributing 1 point to the overall score if present.¹ The involved BSA is defined as the sum of detached and detachable epidermis.¹

The SCORTEN was developed and prospectively validated to be calculated at the end of the first 24 hours of admission; for this calculation, use the BSA affected at that time, and use the most abnormal values during the first 24 hours of admission for the other variables.¹ In addition, a follow-up study including some of the original coauthors recommends recalculating the SCORTEN at the end of hospital day 3, having found that the score’s predictive value was better on this day than hospital days 1, 2, 4, or 5.² Based on the original study, a SCORTEN of 0 to 1 corresponds to a mortality rate of 3.2%, 2 to 12.1%, 3 to 35.3%, 4 to 58.3%, and 5 or greater to 90.0%.¹

Limitations of the SCORTEN include its ability to overestimate or underestimate mortality as demonstrated by 2 multi-institutional cohorts.^3,4 Recently, the ABCD-10 score was developed as an alternative to the SCORTEN and was found to predict mortality similarly when validated in an internal cohort.⁵

PEST Screens for Psoriatic Arthritis

Dermatologists play an important role in screening for psoriatic arthritis, as an estimated 1 in 5 patients with psoriasis have psoriatic arthritis.⁶ To this end, several screening tools have been developed to help differentiate psoriatic arthritis from other arthritides. Joint guidelines from the American Academy of Dermatology and the National Psoriasis Foundation acknowledge that “. . . these screening tools have tended to perform less well when tested in groups of people other than those for which they were originally developed. As such, their usefulness in routine clinical practice remains controversial.”⁷ Nevertheless, the guidelines state, “[b]ecause screening and early detection of inflammatory arthritis are essential to optimize patient [quality of life] and reduce morbidity, providers may consider using a formal screening tool of their choice.”⁷

With these limitations in mind, I have found the Psoriasis Epidemiology Screening Tool (PEST) to be the most useful psoriatic arthritis screening tool. One study determined that the PEST has the best trade-off between sensitivity and specificity compared to 2 other psoriatic arthritis screening tools, the Psoriatic Arthritis Screening and Evaluation (PASE) and the Early Arthritis for Psoriatic Patients (EARP).⁸

The PEST is comprised of 5 questions: (1) Have you ever had a swollen joint (or joints)? (2) Has a doctor ever told you that you have arthritis? (3) Do your fingernails or toenails have holes or pits? (4) Have you had pain in your heel? (5) Have you had a finger or toe that was completely swollen and painful for no apparent reason? According to the PEST, a referral to a rheumatologist should be considered for patients answering yes to 3 or more questions, which is 97% sensitive and 79% specific for psoriatic arthritis.⁹ Patients who answer yes to fewer than 3 questions should still be referred to a rheumatologist if there is a strong clinical suspicion of psoriatic arthritis.¹⁰

The PEST can be accessed for free in 13 languages via the GRAPPA (Group for Research and Assessment of Psoriasis and Psoriatic Arthritis) app as well as downloaded for free from the National Psoriasis Foundation’s website (https://www.psoriasis.org/psa-screening/providers).

ALT-70 Differentiates Cellulitis From Pseudocellulitis

Overdiagnosing cellulitis in the United States has been estimated to result in up to 130,000 unnecessary hospitalizations and up to $515 million in avoidable health care spending.¹¹ Dermatologists are in a unique position to help fix this issue. In one retrospective study of 1430 inpatient dermatology consultations, 74.32% of inpatients evaluated for presumed cellulitis by a dermatologist were instead diagnosed with a cellulitis mimicker (ie, pseudocellulitis), such as stasis dermatitis or contact dermatitis.¹²

The ALT-70 score was developed and prospectively validated to help differentiate lower extremity cellulitis from pseudocellulitis in adult patients in the emergency department (ED).¹³ In addition, the score has retrospectively been shown to function similarly in the inpatient setting when calculated at 24 and 48 hours after ED presentation.¹⁴ Although the ALT-70 score was designed for use by frontline clinicians prior to dermatology consultation, I also have found it helpful to calculate as a consultant, as it provides an objective measure of risk to communicate to the primary team in support of one diagnosis or another.

ALT-70 is an acronym for the score’s 4 variables: asymmetry, leukocytosis, tachycardia, and age of 70 years or older.¹⁵ If present, each variable confers a certain number of points to the final score: 3 points for asymmetry (defined as unilateral leg involvement), 1 point for leukocytosis (white blood cell count ≥10,000/μL), 1 point for tachycardia (≥90 beats per minute), and 2 points for age of 70 years or older. An ALT-70 score of 0 to 2 corresponds to an 83.3% or greater chance of pseudocellulitis, suggesting that the diagnosis of cellulitis be reconsidered. A score of 3 to 4 is indeterminate, and additional information such as a dermatology consultation should be pursued. A score of 5 to 7 corresponds to an 82.2% or greater chance of cellulitis, signifying that empiric treatment with antibiotics be considered.¹⁵

The ALT-70 score does not apply to cases involving areas other than the lower extremities; intravenous antibiotic use within 48 hours before ED presentation; surgery within the last 30 days; abscess; penetrating trauma; burn; or known history of osteomyelitis, diabetic ulcer, or indwelling hardware at the site of infection.¹⁵ The ALT-70 score is available for free via the MDCalc app and website (https://www.mdcalc.com/alt-70-score-cellulitis).

Mohs AUC Determines the Appropriateness of Mohs Micrographic Surgery

In 2012, the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and American Society for Mohs Surgery published appropriate use criteria (AUC) to guide the decision to pursue Mohs micrographic surgery (MMS) in the United States.¹⁶ Based on various tumor and patient characteristics, the Mohs AUC assign scores to 270 different clinical scenarios. A score of 1 to 3 signifies that MMS is inappropriate and generally not considered acceptable. A score 4 to 6 indicates that the appropriateness of MMS is uncertain. A score 7 to 9 means that MMS is appropriate and generally considered acceptable.¹⁶

Since publication, the Mohs AUC have been criticized for classifying most primary superficial basal cell carcinomas as appropriate for MMS¹⁷ (which an AUC coauthor¹⁸ and others^19,20 have defended), excluding certain reasons for performing MMS (such as operating on multiple tumors on the same day),²¹ including counterintuitive scores,²² and omitting trials from Europe²³ (which AUC coauthors also have defended²⁴). As with any clinical scoring system, the Mohs AUC has limitations; the creators acknowledge that “. . . these criteria should not be interpreted as setting a standard of care, or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results, even for those indications scored as inappropriate.”¹⁶ The Mohs AUC app (https://www.aad.org/members/aad-apps/mohs-auc) is free and allows users to enter tumor and patient characteristics to determine the score for their specific scenario.

Final Thoughts

Scoring systems are emerging in dermatology as evidence-based bedside tools to help guide clinical decision-making. Despite their limitations, these scores have the potential to make a meaningful impact in dermatology as they have in other specialties.

The practice of dermatology is rife with bedside tools: swabs, smears, and scoring systems. First popularized in specialties such as emergency medicine and internal medicine, clinical scoring systems are now emerging in dermatology. These evidence-based scores can be calculated quickly at the bedside—often through a free smartphone app—to help guide clinical decision-making regarding diagnosis, prognosis, and management. As with any medical tool, scoring systems have limitations and should be used as a supplement, not substitute, for one’s clinical judgement. This article reviews 4 clinical scoring systems practical for dermatology residents.

SCORTEN Prognosticates Cases of Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis

Perhaps the best-known scoring system in dermatology, the SCORTEN is widely used to predict hospital mortality from Stevens-Johnson syndrome/toxic epidermal necrolysis. The SCORTEN includes 7 variables of equal weight—age of 40 years or older, heart rate of 120 beats per minute or more, cancer/hematologic malignancy, involved body surface area (BSA) greater than 10%, serum urea greater than 10 mmol/L, serum bicarbonate less than 20 mmol/L, and serum glucose greater than 14 mmol/L—each contributing 1 point to the overall score if present.¹ The involved BSA is defined as the sum of detached and detachable epidermis.¹

The SCORTEN was developed and prospectively validated to be calculated at the end of the first 24 hours of admission; for this calculation, use the BSA affected at that time, and use the most abnormal values during the first 24 hours of admission for the other variables.¹ In addition, a follow-up study including some of the original coauthors recommends recalculating the SCORTEN at the end of hospital day 3, having found that the score’s predictive value was better on this day than hospital days 1, 2, 4, or 5.² Based on the original study, a SCORTEN of 0 to 1 corresponds to a mortality rate of 3.2%, 2 to 12.1%, 3 to 35.3%, 4 to 58.3%, and 5 or greater to 90.0%.¹

Limitations of the SCORTEN include its ability to overestimate or underestimate mortality as demonstrated by 2 multi-institutional cohorts.^3,4 Recently, the ABCD-10 score was developed as an alternative to the SCORTEN and was found to predict mortality similarly when validated in an internal cohort.⁵

PEST Screens for Psoriatic Arthritis

Dermatologists play an important role in screening for psoriatic arthritis, as an estimated 1 in 5 patients with psoriasis have psoriatic arthritis.⁶ To this end, several screening tools have been developed to help differentiate psoriatic arthritis from other arthritides. Joint guidelines from the American Academy of Dermatology and the National Psoriasis Foundation acknowledge that “. . . these screening tools have tended to perform less well when tested in groups of people other than those for which they were originally developed. As such, their usefulness in routine clinical practice remains controversial.”⁷ Nevertheless, the guidelines state, “[b]ecause screening and early detection of inflammatory arthritis are essential to optimize patient [quality of life] and reduce morbidity, providers may consider using a formal screening tool of their choice.”⁷

With these limitations in mind, I have found the Psoriasis Epidemiology Screening Tool (PEST) to be the most useful psoriatic arthritis screening tool. One study determined that the PEST has the best trade-off between sensitivity and specificity compared to 2 other psoriatic arthritis screening tools, the Psoriatic Arthritis Screening and Evaluation (PASE) and the Early Arthritis for Psoriatic Patients (EARP).⁸

The PEST is comprised of 5 questions: (1) Have you ever had a swollen joint (or joints)? (2) Has a doctor ever told you that you have arthritis? (3) Do your fingernails or toenails have holes or pits? (4) Have you had pain in your heel? (5) Have you had a finger or toe that was completely swollen and painful for no apparent reason? According to the PEST, a referral to a rheumatologist should be considered for patients answering yes to 3 or more questions, which is 97% sensitive and 79% specific for psoriatic arthritis.⁹ Patients who answer yes to fewer than 3 questions should still be referred to a rheumatologist if there is a strong clinical suspicion of psoriatic arthritis.¹⁰

The PEST can be accessed for free in 13 languages via the GRAPPA (Group for Research and Assessment of Psoriasis and Psoriatic Arthritis) app as well as downloaded for free from the National Psoriasis Foundation’s website (https://www.psoriasis.org/psa-screening/providers).

ALT-70 Differentiates Cellulitis From Pseudocellulitis

Overdiagnosing cellulitis in the United States has been estimated to result in up to 130,000 unnecessary hospitalizations and up to $515 million in avoidable health care spending.¹¹ Dermatologists are in a unique position to help fix this issue. In one retrospective study of 1430 inpatient dermatology consultations, 74.32% of inpatients evaluated for presumed cellulitis by a dermatologist were instead diagnosed with a cellulitis mimicker (ie, pseudocellulitis), such as stasis dermatitis or contact dermatitis.¹²

The ALT-70 score was developed and prospectively validated to help differentiate lower extremity cellulitis from pseudocellulitis in adult patients in the emergency department (ED).¹³ In addition, the score has retrospectively been shown to function similarly in the inpatient setting when calculated at 24 and 48 hours after ED presentation.¹⁴ Although the ALT-70 score was designed for use by frontline clinicians prior to dermatology consultation, I also have found it helpful to calculate as a consultant, as it provides an objective measure of risk to communicate to the primary team in support of one diagnosis or another.

ALT-70 is an acronym for the score’s 4 variables: asymmetry, leukocytosis, tachycardia, and age of 70 years or older.¹⁵ If present, each variable confers a certain number of points to the final score: 3 points for asymmetry (defined as unilateral leg involvement), 1 point for leukocytosis (white blood cell count ≥10,000/μL), 1 point for tachycardia (≥90 beats per minute), and 2 points for age of 70 years or older. An ALT-70 score of 0 to 2 corresponds to an 83.3% or greater chance of pseudocellulitis, suggesting that the diagnosis of cellulitis be reconsidered. A score of 3 to 4 is indeterminate, and additional information such as a dermatology consultation should be pursued. A score of 5 to 7 corresponds to an 82.2% or greater chance of cellulitis, signifying that empiric treatment with antibiotics be considered.¹⁵

The ALT-70 score does not apply to cases involving areas other than the lower extremities; intravenous antibiotic use within 48 hours before ED presentation; surgery within the last 30 days; abscess; penetrating trauma; burn; or known history of osteomyelitis, diabetic ulcer, or indwelling hardware at the site of infection.¹⁵ The ALT-70 score is available for free via the MDCalc app and website (https://www.mdcalc.com/alt-70-score-cellulitis).

Mohs AUC Determines the Appropriateness of Mohs Micrographic Surgery

In 2012, the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and American Society for Mohs Surgery published appropriate use criteria (AUC) to guide the decision to pursue Mohs micrographic surgery (MMS) in the United States.¹⁶ Based on various tumor and patient characteristics, the Mohs AUC assign scores to 270 different clinical scenarios. A score of 1 to 3 signifies that MMS is inappropriate and generally not considered acceptable. A score 4 to 6 indicates that the appropriateness of MMS is uncertain. A score 7 to 9 means that MMS is appropriate and generally considered acceptable.¹⁶

Since publication, the Mohs AUC have been criticized for classifying most primary superficial basal cell carcinomas as appropriate for MMS¹⁷ (which an AUC coauthor¹⁸ and others^19,20 have defended), excluding certain reasons for performing MMS (such as operating on multiple tumors on the same day),²¹ including counterintuitive scores,²² and omitting trials from Europe²³ (which AUC coauthors also have defended²⁴). As with any clinical scoring system, the Mohs AUC has limitations; the creators acknowledge that “. . . these criteria should not be interpreted as setting a standard of care, or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results, even for those indications scored as inappropriate.”¹⁶ The Mohs AUC app (https://www.aad.org/members/aad-apps/mohs-auc) is free and allows users to enter tumor and patient characteristics to determine the score for their specific scenario.

Final Thoughts

Scoring systems are emerging in dermatology as evidence-based bedside tools to help guide clinical decision-making. Despite their limitations, these scores have the potential to make a meaningful impact in dermatology as they have in other specialties.

A physician’s mental health is important for the delivery of quality health care to his/her patients. Early identification and treatment of physicians with mental illnesses is challenging because physicians may neglect their own mental health due to the associated stigma, time constraints, or uncertainty regarding where to seek help. Physicians often worry about whom to confide in and harbor a fear that others will doubt his/her competence after recovery.¹ Physicians have higher rates of suicide than the general population.² According to data from the National Violent Death Reporting System, a diagnosed mental illness or a job problem significantly contribute to suicide among physicians.³ Additionally, physicians also have high rates of substance use and affective disorders.^1,4

Here, we present the case of a physician we treated on an inpatient psychiatry unit who stirred profound emotions in us as trainees, and discuss how we managed this complicated scenario.

CASE REPORT

Dr. P, a 35-year-old male endocrinologist, was admitted to our inpatient psychiatry unit with a diagnosis of bipolar disorder, manic, severe, with psychotic features. Earlier that day, Dr. P had walked out of his private outpatient practice where he still had several appointments. After he had been missing for several hours, he was picked up by the police. Dr. P had 2 prior psychiatric admissions; the last one had occurred >10 years ago. A few weeks before this admission, he stopped taking lithium, while continuing escitalopram. He had not been keeping his appointments with his outpatient psychiatrist.

At admission, Dr. P had pressured speech, grandiose delusions, an expansive affect, and aggressive behavior. He was responding to internal stimuli with no insight into his illness. He was evasive when asked about hallucinations. Dr. P believed he was superior in intelligence and physical prowess to everyone in the emergency department (ED), and for that reason, the ED staff was persecuting him. His urine toxicology was negative.

On the inpatient unit, because Dr. P exhibited posturing, mutism, and negativism, catatonia associated with bipolar disorder was added to his diagnosis. For the first 2 days, his catatonia was managed with oral lorazepam, 2 mg twice daily. Dr. P was also observed giving medical advice to other patients on the unit, and was told to stop. Throughout his hospitalization, he dictated his own treatment and would frequently debate with his treatment team on the pharmacologic basis for treatment decisions, asserting his expertise as a physician and claiming to have a general clinical knowledge of the acute management of bipolar disorder.

Dr. P was eventually stabilized on oral lithium, 450 mg twice daily, and aripiprazole, 10 mg/d. He also received oral clonazepam, as needed for acute agitation, which was eventually tapered and discontinued. He gradually responded to treatment, and demonstrated improved insight. The treatment team met with Dr. P’s parents, who also were physicians, to discuss treatment goals, management considerations, and an aftercare plan. After spending 8 days in the hospital, Dr. P was discharged home to the care of his immediate family, and instructed to follow up with his outpatient psychiatrist. We do not know if he resumed clinical duties.

Managing an extremely knowledgeable patient

During his hospitalization, Dr. P frequently challenged our clinical knowledge; he would repeatedly remind us that he was a physician and that we were still trainees, which caused us to second-guess ourselves. Eventually, the attending physician on our team was able to impress upon Dr. P the clearly established roles of the treatment team and the patient. It was also important to maintain open communication channels with Dr. P and his family, and to address his anxiety by discussing the treatment plan in detail.⁵

Continue to: Although his queries on medication...

Although his queries on medication pharmacodynamics and pharmacokinetics were daunting, we empathized with him, recognizing that his knowledge invariably contributed to his anxiety. We engaged with Dr. P and his parents and elaborated on the rationale behind treatment decisions. This earned his trust and tremendously facilitated his recovery.

We were also cautious about using benzodiazepines to treat Dr. P’s catatonia because we were concerned that his knowledge could aid him in feigning symptoms to obtain these medications. Physicians have a high rate of prescription medication abuse, mainly opiates and benzodiazepines.² The abuse of prescription medications by physicians is related to several psychological and psychiatric factors, including anxiety, depression, stress at work, personality problems, loss of loved ones, and pain. While treating physician patients, treatment decisions that include the use of opiates and benzodiazepines should be carefully considered.⁴

A complicated scenario

Managing a physician patient can be a rewarding experience; however, there are several factors that can impact the experience, including:

• The treating physicians’ anxiety and countertransference/transference dynamics. We repeatedly imagined ourselves in Dr. P’s position and thought long and hard about how this scenario could happen to anyone in the medical profession; these thoughts induced significant anxiety in each of us. Further, interacting with Dr. P was reminiscent of our training under senior residents and attendings. Dr. P viewed us—his treatment team—as his trainees and challenged our clinical knowledge and actions.
• The physician-patient’s emotional responses, which may include anxiety, despair, denial, and an inability to accept role reversal.

Our medical culture needs a paradigm shift. We need a model designed to encourage early self-disclosure and treatment-seeking among physicians with mental illness. This will reduce the stigma towards mental illness in our profession.

A physician’s mental health is important for the delivery of quality health care to his/her patients. Early identification and treatment of physicians with mental illnesses is challenging because physicians may neglect their own mental health due to the associated stigma, time constraints, or uncertainty regarding where to seek help. Physicians often worry about whom to confide in and harbor a fear that others will doubt his/her competence after recovery.¹ Physicians have higher rates of suicide than the general population.² According to data from the National Violent Death Reporting System, a diagnosed mental illness or a job problem significantly contribute to suicide among physicians.³ Additionally, physicians also have high rates of substance use and affective disorders.^1,4

Here, we present the case of a physician we treated on an inpatient psychiatry unit who stirred profound emotions in us as trainees, and discuss how we managed this complicated scenario.

CASE REPORT

Dr. P, a 35-year-old male endocrinologist, was admitted to our inpatient psychiatry unit with a diagnosis of bipolar disorder, manic, severe, with psychotic features. Earlier that day, Dr. P had walked out of his private outpatient practice where he still had several appointments. After he had been missing for several hours, he was picked up by the police. Dr. P had 2 prior psychiatric admissions; the last one had occurred >10 years ago. A few weeks before this admission, he stopped taking lithium, while continuing escitalopram. He had not been keeping his appointments with his outpatient psychiatrist.

At admission, Dr. P had pressured speech, grandiose delusions, an expansive affect, and aggressive behavior. He was responding to internal stimuli with no insight into his illness. He was evasive when asked about hallucinations. Dr. P believed he was superior in intelligence and physical prowess to everyone in the emergency department (ED), and for that reason, the ED staff was persecuting him. His urine toxicology was negative.

On the inpatient unit, because Dr. P exhibited posturing, mutism, and negativism, catatonia associated with bipolar disorder was added to his diagnosis. For the first 2 days, his catatonia was managed with oral lorazepam, 2 mg twice daily. Dr. P was also observed giving medical advice to other patients on the unit, and was told to stop. Throughout his hospitalization, he dictated his own treatment and would frequently debate with his treatment team on the pharmacologic basis for treatment decisions, asserting his expertise as a physician and claiming to have a general clinical knowledge of the acute management of bipolar disorder.

Dr. P was eventually stabilized on oral lithium, 450 mg twice daily, and aripiprazole, 10 mg/d. He also received oral clonazepam, as needed for acute agitation, which was eventually tapered and discontinued. He gradually responded to treatment, and demonstrated improved insight. The treatment team met with Dr. P’s parents, who also were physicians, to discuss treatment goals, management considerations, and an aftercare plan. After spending 8 days in the hospital, Dr. P was discharged home to the care of his immediate family, and instructed to follow up with his outpatient psychiatrist. We do not know if he resumed clinical duties.

Managing an extremely knowledgeable patient

During his hospitalization, Dr. P frequently challenged our clinical knowledge; he would repeatedly remind us that he was a physician and that we were still trainees, which caused us to second-guess ourselves. Eventually, the attending physician on our team was able to impress upon Dr. P the clearly established roles of the treatment team and the patient. It was also important to maintain open communication channels with Dr. P and his family, and to address his anxiety by discussing the treatment plan in detail.⁵

Continue to: Although his queries on medication...

Although his queries on medication pharmacodynamics and pharmacokinetics were daunting, we empathized with him, recognizing that his knowledge invariably contributed to his anxiety. We engaged with Dr. P and his parents and elaborated on the rationale behind treatment decisions. This earned his trust and tremendously facilitated his recovery.

We were also cautious about using benzodiazepines to treat Dr. P’s catatonia because we were concerned that his knowledge could aid him in feigning symptoms to obtain these medications. Physicians have a high rate of prescription medication abuse, mainly opiates and benzodiazepines.² The abuse of prescription medications by physicians is related to several psychological and psychiatric factors, including anxiety, depression, stress at work, personality problems, loss of loved ones, and pain. While treating physician patients, treatment decisions that include the use of opiates and benzodiazepines should be carefully considered.⁴

A complicated scenario

Managing a physician patient can be a rewarding experience; however, there are several factors that can impact the experience, including:

• The treating physicians’ anxiety and countertransference/transference dynamics. We repeatedly imagined ourselves in Dr. P’s position and thought long and hard about how this scenario could happen to anyone in the medical profession; these thoughts induced significant anxiety in each of us. Further, interacting with Dr. P was reminiscent of our training under senior residents and attendings. Dr. P viewed us—his treatment team—as his trainees and challenged our clinical knowledge and actions.
• The physician-patient’s emotional responses, which may include anxiety, despair, denial, and an inability to accept role reversal.

Our medical culture needs a paradigm shift. We need a model designed to encourage early self-disclosure and treatment-seeking among physicians with mental illness. This will reduce the stigma towards mental illness in our profession.

A physician’s mental health is important for the delivery of quality health care to his/her patients. Early identification and treatment of physicians with mental illnesses is challenging because physicians may neglect their own mental health due to the associated stigma, time constraints, or uncertainty regarding where to seek help. Physicians often worry about whom to confide in and harbor a fear that others will doubt his/her competence after recovery.¹ Physicians have higher rates of suicide than the general population.² According to data from the National Violent Death Reporting System, a diagnosed mental illness or a job problem significantly contribute to suicide among physicians.³ Additionally, physicians also have high rates of substance use and affective disorders.^1,4

Here, we present the case of a physician we treated on an inpatient psychiatry unit who stirred profound emotions in us as trainees, and discuss how we managed this complicated scenario.

CASE REPORT

Dr. P, a 35-year-old male endocrinologist, was admitted to our inpatient psychiatry unit with a diagnosis of bipolar disorder, manic, severe, with psychotic features. Earlier that day, Dr. P had walked out of his private outpatient practice where he still had several appointments. After he had been missing for several hours, he was picked up by the police. Dr. P had 2 prior psychiatric admissions; the last one had occurred >10 years ago. A few weeks before this admission, he stopped taking lithium, while continuing escitalopram. He had not been keeping his appointments with his outpatient psychiatrist.

At admission, Dr. P had pressured speech, grandiose delusions, an expansive affect, and aggressive behavior. He was responding to internal stimuli with no insight into his illness. He was evasive when asked about hallucinations. Dr. P believed he was superior in intelligence and physical prowess to everyone in the emergency department (ED), and for that reason, the ED staff was persecuting him. His urine toxicology was negative.

On the inpatient unit, because Dr. P exhibited posturing, mutism, and negativism, catatonia associated with bipolar disorder was added to his diagnosis. For the first 2 days, his catatonia was managed with oral lorazepam, 2 mg twice daily. Dr. P was also observed giving medical advice to other patients on the unit, and was told to stop. Throughout his hospitalization, he dictated his own treatment and would frequently debate with his treatment team on the pharmacologic basis for treatment decisions, asserting his expertise as a physician and claiming to have a general clinical knowledge of the acute management of bipolar disorder.

Dr. P was eventually stabilized on oral lithium, 450 mg twice daily, and aripiprazole, 10 mg/d. He also received oral clonazepam, as needed for acute agitation, which was eventually tapered and discontinued. He gradually responded to treatment, and demonstrated improved insight. The treatment team met with Dr. P’s parents, who also were physicians, to discuss treatment goals, management considerations, and an aftercare plan. After spending 8 days in the hospital, Dr. P was discharged home to the care of his immediate family, and instructed to follow up with his outpatient psychiatrist. We do not know if he resumed clinical duties.

Managing an extremely knowledgeable patient

During his hospitalization, Dr. P frequently challenged our clinical knowledge; he would repeatedly remind us that he was a physician and that we were still trainees, which caused us to second-guess ourselves. Eventually, the attending physician on our team was able to impress upon Dr. P the clearly established roles of the treatment team and the patient. It was also important to maintain open communication channels with Dr. P and his family, and to address his anxiety by discussing the treatment plan in detail.⁵

Continue to: Although his queries on medication...

Although his queries on medication pharmacodynamics and pharmacokinetics were daunting, we empathized with him, recognizing that his knowledge invariably contributed to his anxiety. We engaged with Dr. P and his parents and elaborated on the rationale behind treatment decisions. This earned his trust and tremendously facilitated his recovery.

We were also cautious about using benzodiazepines to treat Dr. P’s catatonia because we were concerned that his knowledge could aid him in feigning symptoms to obtain these medications. Physicians have a high rate of prescription medication abuse, mainly opiates and benzodiazepines.² The abuse of prescription medications by physicians is related to several psychological and psychiatric factors, including anxiety, depression, stress at work, personality problems, loss of loved ones, and pain. While treating physician patients, treatment decisions that include the use of opiates and benzodiazepines should be carefully considered.⁴

A complicated scenario

Managing a physician patient can be a rewarding experience; however, there are several factors that can impact the experience, including:

• The treating physicians’ anxiety and countertransference/transference dynamics. We repeatedly imagined ourselves in Dr. P’s position and thought long and hard about how this scenario could happen to anyone in the medical profession; these thoughts induced significant anxiety in each of us. Further, interacting with Dr. P was reminiscent of our training under senior residents and attendings. Dr. P viewed us—his treatment team—as his trainees and challenged our clinical knowledge and actions.
• The physician-patient’s emotional responses, which may include anxiety, despair, denial, and an inability to accept role reversal.

Our medical culture needs a paradigm shift. We need a model designed to encourage early self-disclosure and treatment-seeking among physicians with mental illness. This will reduce the stigma towards mental illness in our profession.

Ms. G, a 36-year-old woman, presented to the emergency department (ED) requesting a neurologic evaluation. She told clinicians she had “NMDA receptor encephalitis.”

Ms. G reported successful self-treatment of “life-long” body pain that was precipitated by multiple external stimuli (food, social encounters, interpersonal conflict, etc.). Through her own research, she had learned that both ketamine and magnesium could alter nociception in rats through N-methyl-d-aspartic acid (NMDA) receptor antagonism, and so she decided to try treating her pain with Delsym, an over-the-counter cough syrup containing dextromethorphan polistirex (DXM), which at high doses acts as an NMDA receptor antagonist. She said she was taking Delsym, 120 mg/d, and magnesium oxide, 600 mg/d.

In the ED, Ms. G had a labile affect, pressured speech, and flight of ideas. She denied any history of psychiatric treatment, suicide attempts, or substance abuse. Ms. G’s family reported she had been unusually social, talkative, and impulsive. She was admitted to the inpatient psychiatric unit with a diagnosis of mania.

On psychiatric evaluation, Ms. G was grandiose, irritable, and perseverative about her aberrant symptoms. She felt she did not experience the world as other people did, but found relief from her chronic pain after taking Delsym. She was not taking other medications. Ms. G did not report a family history of bipolar disorder or psychosis. Her laboratory results, including a comprehensive metabolic panel, complete blood count, lipid panel, thyroid studies, urine drug screening, and urinalysis, were unremarkable. Her blood pressure was mildly elevated (141/82 mm Hg).

Ms. G’s eventual diagnosis was substance-induced mania (DXM). The DXM-containing cough syrup and magnesium were discontinued in the hospital. She was stabilized on lithium extended-release, 900 mg/d (blood level 0.8 mmol/L), and olanzapine, 10 mg/d at bedtime. However, after discharge, Ms. G resumed using Delsym, which resulted in 3 subsequent psychiatric hospitalizations for mania during the next year.

I first treated Ms. G as an outpatient after her second hospitalization. At that point, she was stable. Her mental status was calm and cooperative, and she had a linear thought process. At her baseline, in the absence of mania, she had a blunted affect. She understood that DXM caused her to have manic symptoms, but she continued to believe that Delsym and magnesium cured her physical suffering and social inhibition. I noticed Ms. G would use figurative language inappropriately. I later learned she had sensitivities to food textures and a specialized interest in electronics. Because of this, I suspected Ms. G was on the autism spectrum; she met several DSM-5 criteria for autism spectrum disorder (ASD), particularly deficits in social-emotional reciprocity, highly restricted interests, and hyperreactivity to sensory input.

Upon routine lab screening, Ms. G was found to have hypothyroidism, with a thyroid-stimulating hormone level of 6.67 mcIU/mL. This resolved after discontinuing lithium. Olanzapine caused adverse metabolic effects and also was discontinued. Ms. G remained euthymic without any mood-stabilizing medication, except during periods when she abused DXM, when she would again become manic. Eventually, her motivation to avoid hospitalization would promote her abstinence.

Continue to: Implications of NMDA receptor antagonism

Implications of NMDA receptor antagonism

The use of ketamine as an NMDA receptor antagonist for treating depression and other psychiatric illnesses has gained momentum. Esketamine, the S-enantiomer of racemic ketamine, is now available as an FDA-approved intranasal formulation for treatment-resistant depression. Ketamine stops afferent nociception to the brain and is used as an analgesic (at low concentrations) and anesthetic (at high concentrations).¹

Dextromethorphan is abused as a recreational drug because at high doses it works similarly to both ketamine and phencyclidine. Individuals who abuse DXM can develop psychosis, motor/cognitive impairment, agitation, fevers, hypertension, tachycardia, and death.² In patients with ASD, researchers have identified genetic variations of NMDA receptors that are linked to dysfunction of these receptors.³ In animal models, as well as in humans, researchers have found that suppression or excitation of the NMDA receptor can ameliorate ASD symptoms, including social withdrawal and repetitive behaviors.³

Many individuals with ASD suffer from sensory abnormalities, including a reduced sensitivity to pain or a crippling sensitivity to various stimuli. Patients with ASD may have difficulty describing these abnormalities, and as a result, they may be misdiagnosed. One case report described a 15-year-old girl diagnosed with social anxiety and chronic generalized pain when in social situations.⁴ Pediatric rheumatologists had diagnosed her with “amplified pain syndrome.” When she presented to a mental health clinic for a neurodevelopmental evaluation, she explained to clinicians how she simply “did not ‘get’ people; they are just empty shells” and subsequently was given a diagnosis of ASD.⁴

In psychiatric patients who have comorbid substance use disorders, it is vital for clinicians to not only detect the presence of substance misuse, but also to understand what drives the patient toward abuse. Ms. G’s case, with its combination of substance abuse and ASD, illustrates the importance of listening to our patients for more precise diagnostic formulations, which then shape our treatment recommendations.

Ms. G, a 36-year-old woman, presented to the emergency department (ED) requesting a neurologic evaluation. She told clinicians she had “NMDA receptor encephalitis.”

Ms. G reported successful self-treatment of “life-long” body pain that was precipitated by multiple external stimuli (food, social encounters, interpersonal conflict, etc.). Through her own research, she had learned that both ketamine and magnesium could alter nociception in rats through N-methyl-d-aspartic acid (NMDA) receptor antagonism, and so she decided to try treating her pain with Delsym, an over-the-counter cough syrup containing dextromethorphan polistirex (DXM), which at high doses acts as an NMDA receptor antagonist. She said she was taking Delsym, 120 mg/d, and magnesium oxide, 600 mg/d.

In the ED, Ms. G had a labile affect, pressured speech, and flight of ideas. She denied any history of psychiatric treatment, suicide attempts, or substance abuse. Ms. G’s family reported she had been unusually social, talkative, and impulsive. She was admitted to the inpatient psychiatric unit with a diagnosis of mania.

On psychiatric evaluation, Ms. G was grandiose, irritable, and perseverative about her aberrant symptoms. She felt she did not experience the world as other people did, but found relief from her chronic pain after taking Delsym. She was not taking other medications. Ms. G did not report a family history of bipolar disorder or psychosis. Her laboratory results, including a comprehensive metabolic panel, complete blood count, lipid panel, thyroid studies, urine drug screening, and urinalysis, were unremarkable. Her blood pressure was mildly elevated (141/82 mm Hg).

Ms. G’s eventual diagnosis was substance-induced mania (DXM). The DXM-containing cough syrup and magnesium were discontinued in the hospital. She was stabilized on lithium extended-release, 900 mg/d (blood level 0.8 mmol/L), and olanzapine, 10 mg/d at bedtime. However, after discharge, Ms. G resumed using Delsym, which resulted in 3 subsequent psychiatric hospitalizations for mania during the next year.

I first treated Ms. G as an outpatient after her second hospitalization. At that point, she was stable. Her mental status was calm and cooperative, and she had a linear thought process. At her baseline, in the absence of mania, she had a blunted affect. She understood that DXM caused her to have manic symptoms, but she continued to believe that Delsym and magnesium cured her physical suffering and social inhibition. I noticed Ms. G would use figurative language inappropriately. I later learned she had sensitivities to food textures and a specialized interest in electronics. Because of this, I suspected Ms. G was on the autism spectrum; she met several DSM-5 criteria for autism spectrum disorder (ASD), particularly deficits in social-emotional reciprocity, highly restricted interests, and hyperreactivity to sensory input.

Upon routine lab screening, Ms. G was found to have hypothyroidism, with a thyroid-stimulating hormone level of 6.67 mcIU/mL. This resolved after discontinuing lithium. Olanzapine caused adverse metabolic effects and also was discontinued. Ms. G remained euthymic without any mood-stabilizing medication, except during periods when she abused DXM, when she would again become manic. Eventually, her motivation to avoid hospitalization would promote her abstinence.

Continue to: Implications of NMDA receptor antagonism

Implications of NMDA receptor antagonism

The use of ketamine as an NMDA receptor antagonist for treating depression and other psychiatric illnesses has gained momentum. Esketamine, the S-enantiomer of racemic ketamine, is now available as an FDA-approved intranasal formulation for treatment-resistant depression. Ketamine stops afferent nociception to the brain and is used as an analgesic (at low concentrations) and anesthetic (at high concentrations).¹

Dextromethorphan is abused as a recreational drug because at high doses it works similarly to both ketamine and phencyclidine. Individuals who abuse DXM can develop psychosis, motor/cognitive impairment, agitation, fevers, hypertension, tachycardia, and death.² In patients with ASD, researchers have identified genetic variations of NMDA receptors that are linked to dysfunction of these receptors.³ In animal models, as well as in humans, researchers have found that suppression or excitation of the NMDA receptor can ameliorate ASD symptoms, including social withdrawal and repetitive behaviors.³

Many individuals with ASD suffer from sensory abnormalities, including a reduced sensitivity to pain or a crippling sensitivity to various stimuli. Patients with ASD may have difficulty describing these abnormalities, and as a result, they may be misdiagnosed. One case report described a 15-year-old girl diagnosed with social anxiety and chronic generalized pain when in social situations.⁴ Pediatric rheumatologists had diagnosed her with “amplified pain syndrome.” When she presented to a mental health clinic for a neurodevelopmental evaluation, she explained to clinicians how she simply “did not ‘get’ people; they are just empty shells” and subsequently was given a diagnosis of ASD.⁴

In psychiatric patients who have comorbid substance use disorders, it is vital for clinicians to not only detect the presence of substance misuse, but also to understand what drives the patient toward abuse. Ms. G’s case, with its combination of substance abuse and ASD, illustrates the importance of listening to our patients for more precise diagnostic formulations, which then shape our treatment recommendations.

Ms. G, a 36-year-old woman, presented to the emergency department (ED) requesting a neurologic evaluation. She told clinicians she had “NMDA receptor encephalitis.”

Ms. G reported successful self-treatment of “life-long” body pain that was precipitated by multiple external stimuli (food, social encounters, interpersonal conflict, etc.). Through her own research, she had learned that both ketamine and magnesium could alter nociception in rats through N-methyl-d-aspartic acid (NMDA) receptor antagonism, and so she decided to try treating her pain with Delsym, an over-the-counter cough syrup containing dextromethorphan polistirex (DXM), which at high doses acts as an NMDA receptor antagonist. She said she was taking Delsym, 120 mg/d, and magnesium oxide, 600 mg/d.

In the ED, Ms. G had a labile affect, pressured speech, and flight of ideas. She denied any history of psychiatric treatment, suicide attempts, or substance abuse. Ms. G’s family reported she had been unusually social, talkative, and impulsive. She was admitted to the inpatient psychiatric unit with a diagnosis of mania.

On psychiatric evaluation, Ms. G was grandiose, irritable, and perseverative about her aberrant symptoms. She felt she did not experience the world as other people did, but found relief from her chronic pain after taking Delsym. She was not taking other medications. Ms. G did not report a family history of bipolar disorder or psychosis. Her laboratory results, including a comprehensive metabolic panel, complete blood count, lipid panel, thyroid studies, urine drug screening, and urinalysis, were unremarkable. Her blood pressure was mildly elevated (141/82 mm Hg).

Ms. G’s eventual diagnosis was substance-induced mania (DXM). The DXM-containing cough syrup and magnesium were discontinued in the hospital. She was stabilized on lithium extended-release, 900 mg/d (blood level 0.8 mmol/L), and olanzapine, 10 mg/d at bedtime. However, after discharge, Ms. G resumed using Delsym, which resulted in 3 subsequent psychiatric hospitalizations for mania during the next year.

I first treated Ms. G as an outpatient after her second hospitalization. At that point, she was stable. Her mental status was calm and cooperative, and she had a linear thought process. At her baseline, in the absence of mania, she had a blunted affect. She understood that DXM caused her to have manic symptoms, but she continued to believe that Delsym and magnesium cured her physical suffering and social inhibition. I noticed Ms. G would use figurative language inappropriately. I later learned she had sensitivities to food textures and a specialized interest in electronics. Because of this, I suspected Ms. G was on the autism spectrum; she met several DSM-5 criteria for autism spectrum disorder (ASD), particularly deficits in social-emotional reciprocity, highly restricted interests, and hyperreactivity to sensory input.

Upon routine lab screening, Ms. G was found to have hypothyroidism, with a thyroid-stimulating hormone level of 6.67 mcIU/mL. This resolved after discontinuing lithium. Olanzapine caused adverse metabolic effects and also was discontinued. Ms. G remained euthymic without any mood-stabilizing medication, except during periods when she abused DXM, when she would again become manic. Eventually, her motivation to avoid hospitalization would promote her abstinence.

Continue to: Implications of NMDA receptor antagonism

Implications of NMDA receptor antagonism

The use of ketamine as an NMDA receptor antagonist for treating depression and other psychiatric illnesses has gained momentum. Esketamine, the S-enantiomer of racemic ketamine, is now available as an FDA-approved intranasal formulation for treatment-resistant depression. Ketamine stops afferent nociception to the brain and is used as an analgesic (at low concentrations) and anesthetic (at high concentrations).¹

Dextromethorphan is abused as a recreational drug because at high doses it works similarly to both ketamine and phencyclidine. Individuals who abuse DXM can develop psychosis, motor/cognitive impairment, agitation, fevers, hypertension, tachycardia, and death.² In patients with ASD, researchers have identified genetic variations of NMDA receptors that are linked to dysfunction of these receptors.³ In animal models, as well as in humans, researchers have found that suppression or excitation of the NMDA receptor can ameliorate ASD symptoms, including social withdrawal and repetitive behaviors.³

Many individuals with ASD suffer from sensory abnormalities, including a reduced sensitivity to pain or a crippling sensitivity to various stimuli. Patients with ASD may have difficulty describing these abnormalities, and as a result, they may be misdiagnosed. One case report described a 15-year-old girl diagnosed with social anxiety and chronic generalized pain when in social situations.⁴ Pediatric rheumatologists had diagnosed her with “amplified pain syndrome.” When she presented to a mental health clinic for a neurodevelopmental evaluation, she explained to clinicians how she simply “did not ‘get’ people; they are just empty shells” and subsequently was given a diagnosis of ASD.⁴

In psychiatric patients who have comorbid substance use disorders, it is vital for clinicians to not only detect the presence of substance misuse, but also to understand what drives the patient toward abuse. Ms. G’s case, with its combination of substance abuse and ASD, illustrates the importance of listening to our patients for more precise diagnostic formulations, which then shape our treatment recommendations.

Women increased their representation in internal medicine residencies from 1991 to 2016, but a new analysis also shows that the percentage of women in subspecialty fellowships declined.

Women made up 43.2% of the internal medicine resident population in 2016, compared with 30.2% in 1991. Over that same time, however, the percentage of women in subspecialty fellowships dropped from 33.3% to 23.6%, Anna T. Stone, MD, and associates wrote in a research letter published in JAMA Internal Medicine.

“Many factors are associated with the decisions of medical students in choosing an internal medicine residency, including their sex, educational experience, views of patient care, and lifestyle perceptions. Similar considerations apply to subspecialty training,” wrote Dr. Stone of the department of cardiology at St. Vincent Hospital and Heart Center, Indianapolis, and associates.

When the investigators focused on a subset of nine internal medicine subspecialties, they saw growth: “The percentage of women entering each of the fields [residents plus fellows] increased over time, with variations between specialty and some year-to-year variations within a specialty.”

Although none of the nine subspecialties had been majority women in 1991, by 2016 women made up more than half of the residents and fellows in four: endocrinology (71.3%), geriatric medicine (67.9%), rheumatology (60.2%), and infectious disease (54.6%), according to data from the Accreditation Council for Graduate Medical Education.

And then there’s cardiology. Its low rate of participation among women – the only one of the nine subspecialties under 35% – “is an important issue that the cardiology profession should continue to address,” they wrote.

In a survey of internal medicine residents conducted by other researchers, women were more likely than men to report that they had never considered cardiology as a career choice, Dr. Stone and associates noted, and women in the survey “had different perceptions of cardiology than men.”

[email protected]

SOURCE: Stone AT et al. JAMA Intern Med. 2019 Sep 23. doi: 10.1001/jamainternmed.2019.3833.

Women increased their representation in internal medicine residencies from 1991 to 2016, but a new analysis also shows that the percentage of women in subspecialty fellowships declined.

Women made up 43.2% of the internal medicine resident population in 2016, compared with 30.2% in 1991. Over that same time, however, the percentage of women in subspecialty fellowships dropped from 33.3% to 23.6%, Anna T. Stone, MD, and associates wrote in a research letter published in JAMA Internal Medicine.

“Many factors are associated with the decisions of medical students in choosing an internal medicine residency, including their sex, educational experience, views of patient care, and lifestyle perceptions. Similar considerations apply to subspecialty training,” wrote Dr. Stone of the department of cardiology at St. Vincent Hospital and Heart Center, Indianapolis, and associates.

When the investigators focused on a subset of nine internal medicine subspecialties, they saw growth: “The percentage of women entering each of the fields [residents plus fellows] increased over time, with variations between specialty and some year-to-year variations within a specialty.”

Although none of the nine subspecialties had been majority women in 1991, by 2016 women made up more than half of the residents and fellows in four: endocrinology (71.3%), geriatric medicine (67.9%), rheumatology (60.2%), and infectious disease (54.6%), according to data from the Accreditation Council for Graduate Medical Education.

And then there’s cardiology. Its low rate of participation among women – the only one of the nine subspecialties under 35% – “is an important issue that the cardiology profession should continue to address,” they wrote.

In a survey of internal medicine residents conducted by other researchers, women were more likely than men to report that they had never considered cardiology as a career choice, Dr. Stone and associates noted, and women in the survey “had different perceptions of cardiology than men.”

[email protected]

SOURCE: Stone AT et al. JAMA Intern Med. 2019 Sep 23. doi: 10.1001/jamainternmed.2019.3833.

Women increased their representation in internal medicine residencies from 1991 to 2016, but a new analysis also shows that the percentage of women in subspecialty fellowships declined.

Women made up 43.2% of the internal medicine resident population in 2016, compared with 30.2% in 1991. Over that same time, however, the percentage of women in subspecialty fellowships dropped from 33.3% to 23.6%, Anna T. Stone, MD, and associates wrote in a research letter published in JAMA Internal Medicine.

“Many factors are associated with the decisions of medical students in choosing an internal medicine residency, including their sex, educational experience, views of patient care, and lifestyle perceptions. Similar considerations apply to subspecialty training,” wrote Dr. Stone of the department of cardiology at St. Vincent Hospital and Heart Center, Indianapolis, and associates.

When the investigators focused on a subset of nine internal medicine subspecialties, they saw growth: “The percentage of women entering each of the fields [residents plus fellows] increased over time, with variations between specialty and some year-to-year variations within a specialty.”

Although none of the nine subspecialties had been majority women in 1991, by 2016 women made up more than half of the residents and fellows in four: endocrinology (71.3%), geriatric medicine (67.9%), rheumatology (60.2%), and infectious disease (54.6%), according to data from the Accreditation Council for Graduate Medical Education.

And then there’s cardiology. Its low rate of participation among women – the only one of the nine subspecialties under 35% – “is an important issue that the cardiology profession should continue to address,” they wrote.

In a survey of internal medicine residents conducted by other researchers, women were more likely than men to report that they had never considered cardiology as a career choice, Dr. Stone and associates noted, and women in the survey “had different perceptions of cardiology than men.”

[email protected]

SOURCE: Stone AT et al. JAMA Intern Med. 2019 Sep 23. doi: 10.1001/jamainternmed.2019.3833.

CASE Patient has adverse effects from halted estrogen pills

JR twists her hands nervously as you step into the room. “They stopped my hormones,” she sighs as you pull up her lab results.

JR recently had been admitted to an inpatient cardiology unit for several days for a heart failure exacerbation. Her ankles are still swollen beneath her floral print skirt, but she is breathing much easier now. She is back at your primary care office, hoping to get clearance to restart her estrogen pills.

JR reports having mood swings and terrible nightmares while not taking her hormones, which she has been taking for more than 3 years. She hesitates before sharing, “One of the doctors kept asking me questions about my sex life that had nothing to do with my heart condition. I don’t want to go back there.”

Providing compassionate and comprehensive care to gender-nonconforming individuals is challenging for a multitude of reasons, from clinician ignorance to systemic discrimination. About 33% of transgender patients reported being harassed, denied care, or even being assaulted when seeking health care, while 23% reported avoiding going to the doctor altogether when sick or injured out of fear of discrimination.¹

Unfortunately, now, further increases to barriers to care may be put in place. In late May of this year, the Department of Health and Human Services (HHS) proposed new regulations that would reverse previous regulations granted through section 1557 of the Affordable Care Act (ACA)—the Health Care Rights Law—which affirmed the rights of gender nonbinary persons to medical care. Among the proposed changes is the elimination of protections against discrimination in health care based on gender identity.² The proposed regulation changes come on the heels of a federal court case, which seeks to declare that hospital systems may turn away patients based on gender identity.³

Unraveling rights afforded under the ACA

The Health Care Rights Law was passed under the ACA; it prohibits discrimination based on race, color, national origin, sex, age, and disability in health programs and activities receiving federal financial assistance. Multiple lower courts have supported that the rights of transgender individuals is included within these protections against discrimination on the basis of sex.⁴ These court rulings not only have ensured the ability of gender-diverse individuals to access care but also have enforced insurance coverage of therapies for gender dysphoria. It was only in 2014 that Medicaid began providing coverage for gender-affirming surgeries and eliminating language that such procedures were “experimental” or “cosmetic.” The 2016 passage of the ACA mandated that private insurance companies follow suit. Unfortunately, the recent proposed regulation changes to the Health Care Rights Law may spark a reversal from insurance companies as well. Such a setback would affect gender-diverse individuals’ hormone treatments as well as their ability to access a full spectrum of care within the health care system.

Continue to: ACOG urges nondiscriminatory practices...

ACOG urges nondiscriminatory practices

The proposed regulation changes to the Health Care Rights Law are from the Conscience and Religious Freedom Division of the HHS Office for Civil Rights, which was established in 2018 and has been advocating for the rights of health care providers to refuse to treat patients based on their own religious beliefs.⁵ We argue, however, that providing care to persons of varying backgrounds is not an assault on our individual liberties but rather a privilege as providers. As obstetrician-gynecologists, it may be easy to only consider cis-gendered women our responsibility. But our field also emphasizes individual empowerment above all else—we fight every day for our patients’ rights to contraception, fertility, pregnancy, parenthood, and sexual freedoms. Let us continue speaking up for the rights of all those who need gynecologic care, regardless of the pronouns they use.

“The American College of Obstetricians and Gynecologists urges health care providers to foster nondiscriminatory practices and policies to increase identification and to facilitate quality health care for transgender individuals, both in assisting with the transition if desired as well as providing long-term preventive health care.”⁶

We urge you to take action

• Reach out to your local representatives about protecting transgender health access
• Educate yourself on the unique needs of transgender individuals
• Read personal accounts
• Share your personal story
• Find referring providers near your practice

CASE Patient has adverse effects from halted estrogen pills

JR twists her hands nervously as you step into the room. “They stopped my hormones,” she sighs as you pull up her lab results.

JR recently had been admitted to an inpatient cardiology unit for several days for a heart failure exacerbation. Her ankles are still swollen beneath her floral print skirt, but she is breathing much easier now. She is back at your primary care office, hoping to get clearance to restart her estrogen pills.

JR reports having mood swings and terrible nightmares while not taking her hormones, which she has been taking for more than 3 years. She hesitates before sharing, “One of the doctors kept asking me questions about my sex life that had nothing to do with my heart condition. I don’t want to go back there.”

Providing compassionate and comprehensive care to gender-nonconforming individuals is challenging for a multitude of reasons, from clinician ignorance to systemic discrimination. About 33% of transgender patients reported being harassed, denied care, or even being assaulted when seeking health care, while 23% reported avoiding going to the doctor altogether when sick or injured out of fear of discrimination.¹

Unfortunately, now, further increases to barriers to care may be put in place. In late May of this year, the Department of Health and Human Services (HHS) proposed new regulations that would reverse previous regulations granted through section 1557 of the Affordable Care Act (ACA)—the Health Care Rights Law—which affirmed the rights of gender nonbinary persons to medical care. Among the proposed changes is the elimination of protections against discrimination in health care based on gender identity.² The proposed regulation changes come on the heels of a federal court case, which seeks to declare that hospital systems may turn away patients based on gender identity.³

Unraveling rights afforded under the ACA

The Health Care Rights Law was passed under the ACA; it prohibits discrimination based on race, color, national origin, sex, age, and disability in health programs and activities receiving federal financial assistance. Multiple lower courts have supported that the rights of transgender individuals is included within these protections against discrimination on the basis of sex.⁴ These court rulings not only have ensured the ability of gender-diverse individuals to access care but also have enforced insurance coverage of therapies for gender dysphoria. It was only in 2014 that Medicaid began providing coverage for gender-affirming surgeries and eliminating language that such procedures were “experimental” or “cosmetic.” The 2016 passage of the ACA mandated that private insurance companies follow suit. Unfortunately, the recent proposed regulation changes to the Health Care Rights Law may spark a reversal from insurance companies as well. Such a setback would affect gender-diverse individuals’ hormone treatments as well as their ability to access a full spectrum of care within the health care system.

Continue to: ACOG urges nondiscriminatory practices...

ACOG urges nondiscriminatory practices

The proposed regulation changes to the Health Care Rights Law are from the Conscience and Religious Freedom Division of the HHS Office for Civil Rights, which was established in 2018 and has been advocating for the rights of health care providers to refuse to treat patients based on their own religious beliefs.⁵ We argue, however, that providing care to persons of varying backgrounds is not an assault on our individual liberties but rather a privilege as providers. As obstetrician-gynecologists, it may be easy to only consider cis-gendered women our responsibility. But our field also emphasizes individual empowerment above all else—we fight every day for our patients’ rights to contraception, fertility, pregnancy, parenthood, and sexual freedoms. Let us continue speaking up for the rights of all those who need gynecologic care, regardless of the pronouns they use.

“The American College of Obstetricians and Gynecologists urges health care providers to foster nondiscriminatory practices and policies to increase identification and to facilitate quality health care for transgender individuals, both in assisting with the transition if desired as well as providing long-term preventive health care.”⁶

We urge you to take action

• Reach out to your local representatives about protecting transgender health access
• Educate yourself on the unique needs of transgender individuals
• Read personal accounts
• Share your personal story
• Find referring providers near your practice

CASE Patient has adverse effects from halted estrogen pills

JR twists her hands nervously as you step into the room. “They stopped my hormones,” she sighs as you pull up her lab results.

JR recently had been admitted to an inpatient cardiology unit for several days for a heart failure exacerbation. Her ankles are still swollen beneath her floral print skirt, but she is breathing much easier now. She is back at your primary care office, hoping to get clearance to restart her estrogen pills.

JR reports having mood swings and terrible nightmares while not taking her hormones, which she has been taking for more than 3 years. She hesitates before sharing, “One of the doctors kept asking me questions about my sex life that had nothing to do with my heart condition. I don’t want to go back there.”

Providing compassionate and comprehensive care to gender-nonconforming individuals is challenging for a multitude of reasons, from clinician ignorance to systemic discrimination. About 33% of transgender patients reported being harassed, denied care, or even being assaulted when seeking health care, while 23% reported avoiding going to the doctor altogether when sick or injured out of fear of discrimination.¹

Unfortunately, now, further increases to barriers to care may be put in place. In late May of this year, the Department of Health and Human Services (HHS) proposed new regulations that would reverse previous regulations granted through section 1557 of the Affordable Care Act (ACA)—the Health Care Rights Law—which affirmed the rights of gender nonbinary persons to medical care. Among the proposed changes is the elimination of protections against discrimination in health care based on gender identity.² The proposed regulation changes come on the heels of a federal court case, which seeks to declare that hospital systems may turn away patients based on gender identity.³

Unraveling rights afforded under the ACA

The Health Care Rights Law was passed under the ACA; it prohibits discrimination based on race, color, national origin, sex, age, and disability in health programs and activities receiving federal financial assistance. Multiple lower courts have supported that the rights of transgender individuals is included within these protections against discrimination on the basis of sex.⁴ These court rulings not only have ensured the ability of gender-diverse individuals to access care but also have enforced insurance coverage of therapies for gender dysphoria. It was only in 2014 that Medicaid began providing coverage for gender-affirming surgeries and eliminating language that such procedures were “experimental” or “cosmetic.” The 2016 passage of the ACA mandated that private insurance companies follow suit. Unfortunately, the recent proposed regulation changes to the Health Care Rights Law may spark a reversal from insurance companies as well. Such a setback would affect gender-diverse individuals’ hormone treatments as well as their ability to access a full spectrum of care within the health care system.

Continue to: ACOG urges nondiscriminatory practices...

ACOG urges nondiscriminatory practices

The proposed regulation changes to the Health Care Rights Law are from the Conscience and Religious Freedom Division of the HHS Office for Civil Rights, which was established in 2018 and has been advocating for the rights of health care providers to refuse to treat patients based on their own religious beliefs.⁵ We argue, however, that providing care to persons of varying backgrounds is not an assault on our individual liberties but rather a privilege as providers. As obstetrician-gynecologists, it may be easy to only consider cis-gendered women our responsibility. But our field also emphasizes individual empowerment above all else—we fight every day for our patients’ rights to contraception, fertility, pregnancy, parenthood, and sexual freedoms. Let us continue speaking up for the rights of all those who need gynecologic care, regardless of the pronouns they use.

“The American College of Obstetricians and Gynecologists urges health care providers to foster nondiscriminatory practices and policies to increase identification and to facilitate quality health care for transgender individuals, both in assisting with the transition if desired as well as providing long-term preventive health care.”⁶

We urge you to take action

• Reach out to your local representatives about protecting transgender health access
• Educate yourself on the unique needs of transgender individuals
• Read personal accounts
• Share your personal story
• Find referring providers near your practice

Dermatologist Dr. Jeffrey Benabio quipped, “The phrase ‘dermatologist burnout’ may seem as oxymoronic as jumbo shrimp, yet both are real.”¹ Indeed, dermatologists often self-report as among the happiest specialists both at work and home, according to the annual Medscape Physician Lifestyle and Happiness Report.² Similarly, others in the medical field may perceive dermatologists as low-stress providers—well-groomed, well-rested rays of sunshine, getting out of work every day at 5:00 pm to catch happy hour and live the #dermlife. However, the reality is that the syndrome of burnout does not spare our specialty. In fact, the low-stress perception of dermatologists may instead make recognizing burnout within others and ourselves challenging. Awareness of the notable prevalence of burnout within dermatology may facilitate identification and modification of associated predictors.

Burnout in Dermatology Residents

Burnout is a syndrome of emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment that affects residents of all specialties³; however, there is a paucity of literature on burnout as it relates to dermatology. Although long work hours and schedule volatility have captured the focus of resident burnout conversations, a less discussed set of factors may contribute to dermatology resident burnout, such as increasing patient load, intensifying regulations, and an unrelenting pace of clinic. A recent survey study by Shoimer et al³ found that 61% of 116 participating Canadian dermatology residents cited examinations (including the board certifying examination) as their top stressor, followed by work (27%). Other stressors included family, relationships, finances, pressure from staff, research, and moving. More than 50% of dermatology residents surveyed experienced high levels of emotional exhaustion and depersonalization, while 40% demonstrated a low sense of personal accomplishment, all of which are determinants of the burnout syndrome.³

Comparison to Residents in Other Specialties

Although dermatology residents experience lower burnout rates than colleagues in other specialties, the absolute prevalence warrants attention. A recent study published in the Journal of the American Medical Association of 3588 second-year medical residents in the United States found that rates of burnout symptoms across clinical specialties ranged from 29.6% to 63.8%. The highest rates of burnout were found in urology (63.8%), neurology (61.6%), and ophthalmology (55.8%), but the lowest reported rate of burnout was demonstrated in dermatology (29.6%).⁴ Although dermatology ranked the lowest, that is still nearly a whopping 1 in 3 dermatology residents with burnout symptoms. The absolute prevalence should not be obscured by the ranking among other specialties.

Preventing Burnout

Several burnout prevention and coping strategies across specialties have been suggested.

Mindfulness and Self-awareness
A study by Chaukos et al⁵ found that mindfulness and self-awareness are resilience factors associated with resident burnout. Counseling is one strategy demonstrated to increase self-awareness. Mindfulness may be practiced through meditation or yoga. Regular meditation has been shown to improve mood and emotional stress.⁶ Similarly, yoga has been shown to yield physical, emotional, and psychological benefits to resdients.⁷

Work Factors
A supportive clinical faculty and receiving constructive monthly performance feedback have been negatively correlated with dermatology resident burnout.³ Other workplace interventions demonstrating utility in decreasing resident burnout include increasing staff awareness about burnout, increasing support for health professionals treating challenging populations, and ensuring a reasonable workload.⁶

Sleep
It has been demonstrated that sleeping less than 7 hours per night also is associated with resident burnout,⁷ yet it has been reported that 72% of dermatology residents fall into this category.³ Poor sleep quality has been shown to be a predictor of lower academic performance. It has been proposed that to minimize sleep deprivation and poor sleep quality, institutions should focus on programs that promote regular exercise, sleep hygiene, mindfulness, and time-out activities such as meditation.⁷

Social Support
Focusing on peers may foster the inner strength to endure suffering.¹ Venting, laughing, and discussing care with colleagues has been demonstrated to decrease anxiety.⁶ Work-related social networks may be strengthened through attendance at conferences, lectures, and professional organizations.⁷ Additionally, social supports and spending quality time with family have been demonstrated as negative predictors of dermatology resident burnout.³

Physical Exercise
Exercise has been demonstrated to improve mood, anxiety, and depression, thereby decreasing resident burnout.⁶

Final Thoughts

Burnout among dermatology residents warrants awareness, as it does in other medical specialties. Awareness may facilitate identification and prevention, the latter of which is perhaps best summarized by the words of psychologist Dr. Christina Maslach: “If all of the knowledge and advice about how to beat burnout could be summed up in 1 word, that word would be balance—balance between giving and getting, balance between stress and calm, balance between work and home.”⁸

Dermatologist Dr. Jeffrey Benabio quipped, “The phrase ‘dermatologist burnout’ may seem as oxymoronic as jumbo shrimp, yet both are real.”¹ Indeed, dermatologists often self-report as among the happiest specialists both at work and home, according to the annual Medscape Physician Lifestyle and Happiness Report.² Similarly, others in the medical field may perceive dermatologists as low-stress providers—well-groomed, well-rested rays of sunshine, getting out of work every day at 5:00 pm to catch happy hour and live the #dermlife. However, the reality is that the syndrome of burnout does not spare our specialty. In fact, the low-stress perception of dermatologists may instead make recognizing burnout within others and ourselves challenging. Awareness of the notable prevalence of burnout within dermatology may facilitate identification and modification of associated predictors.

Burnout in Dermatology Residents

Burnout is a syndrome of emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment that affects residents of all specialties³; however, there is a paucity of literature on burnout as it relates to dermatology. Although long work hours and schedule volatility have captured the focus of resident burnout conversations, a less discussed set of factors may contribute to dermatology resident burnout, such as increasing patient load, intensifying regulations, and an unrelenting pace of clinic. A recent survey study by Shoimer et al³ found that 61% of 116 participating Canadian dermatology residents cited examinations (including the board certifying examination) as their top stressor, followed by work (27%). Other stressors included family, relationships, finances, pressure from staff, research, and moving. More than 50% of dermatology residents surveyed experienced high levels of emotional exhaustion and depersonalization, while 40% demonstrated a low sense of personal accomplishment, all of which are determinants of the burnout syndrome.³

Comparison to Residents in Other Specialties

Although dermatology residents experience lower burnout rates than colleagues in other specialties, the absolute prevalence warrants attention. A recent study published in the Journal of the American Medical Association of 3588 second-year medical residents in the United States found that rates of burnout symptoms across clinical specialties ranged from 29.6% to 63.8%. The highest rates of burnout were found in urology (63.8%), neurology (61.6%), and ophthalmology (55.8%), but the lowest reported rate of burnout was demonstrated in dermatology (29.6%).⁴ Although dermatology ranked the lowest, that is still nearly a whopping 1 in 3 dermatology residents with burnout symptoms. The absolute prevalence should not be obscured by the ranking among other specialties.

Preventing Burnout

Several burnout prevention and coping strategies across specialties have been suggested.

Mindfulness and Self-awareness
A study by Chaukos et al⁵ found that mindfulness and self-awareness are resilience factors associated with resident burnout. Counseling is one strategy demonstrated to increase self-awareness. Mindfulness may be practiced through meditation or yoga. Regular meditation has been shown to improve mood and emotional stress.⁶ Similarly, yoga has been shown to yield physical, emotional, and psychological benefits to resdients.⁷

Work Factors
A supportive clinical faculty and receiving constructive monthly performance feedback have been negatively correlated with dermatology resident burnout.³ Other workplace interventions demonstrating utility in decreasing resident burnout include increasing staff awareness about burnout, increasing support for health professionals treating challenging populations, and ensuring a reasonable workload.⁶

Sleep
It has been demonstrated that sleeping less than 7 hours per night also is associated with resident burnout,⁷ yet it has been reported that 72% of dermatology residents fall into this category.³ Poor sleep quality has been shown to be a predictor of lower academic performance. It has been proposed that to minimize sleep deprivation and poor sleep quality, institutions should focus on programs that promote regular exercise, sleep hygiene, mindfulness, and time-out activities such as meditation.⁷

Social Support
Focusing on peers may foster the inner strength to endure suffering.¹ Venting, laughing, and discussing care with colleagues has been demonstrated to decrease anxiety.⁶ Work-related social networks may be strengthened through attendance at conferences, lectures, and professional organizations.⁷ Additionally, social supports and spending quality time with family have been demonstrated as negative predictors of dermatology resident burnout.³

Physical Exercise
Exercise has been demonstrated to improve mood, anxiety, and depression, thereby decreasing resident burnout.⁶

Final Thoughts

Burnout among dermatology residents warrants awareness, as it does in other medical specialties. Awareness may facilitate identification and prevention, the latter of which is perhaps best summarized by the words of psychologist Dr. Christina Maslach: “If all of the knowledge and advice about how to beat burnout could be summed up in 1 word, that word would be balance—balance between giving and getting, balance between stress and calm, balance between work and home.”⁸

Dermatologist Dr. Jeffrey Benabio quipped, “The phrase ‘dermatologist burnout’ may seem as oxymoronic as jumbo shrimp, yet both are real.”¹ Indeed, dermatologists often self-report as among the happiest specialists both at work and home, according to the annual Medscape Physician Lifestyle and Happiness Report.² Similarly, others in the medical field may perceive dermatologists as low-stress providers—well-groomed, well-rested rays of sunshine, getting out of work every day at 5:00 pm to catch happy hour and live the #dermlife. However, the reality is that the syndrome of burnout does not spare our specialty. In fact, the low-stress perception of dermatologists may instead make recognizing burnout within others and ourselves challenging. Awareness of the notable prevalence of burnout within dermatology may facilitate identification and modification of associated predictors.

Burnout in Dermatology Residents

Burnout is a syndrome of emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment that affects residents of all specialties³; however, there is a paucity of literature on burnout as it relates to dermatology. Although long work hours and schedule volatility have captured the focus of resident burnout conversations, a less discussed set of factors may contribute to dermatology resident burnout, such as increasing patient load, intensifying regulations, and an unrelenting pace of clinic. A recent survey study by Shoimer et al³ found that 61% of 116 participating Canadian dermatology residents cited examinations (including the board certifying examination) as their top stressor, followed by work (27%). Other stressors included family, relationships, finances, pressure from staff, research, and moving. More than 50% of dermatology residents surveyed experienced high levels of emotional exhaustion and depersonalization, while 40% demonstrated a low sense of personal accomplishment, all of which are determinants of the burnout syndrome.³

Comparison to Residents in Other Specialties

Although dermatology residents experience lower burnout rates than colleagues in other specialties, the absolute prevalence warrants attention. A recent study published in the Journal of the American Medical Association of 3588 second-year medical residents in the United States found that rates of burnout symptoms across clinical specialties ranged from 29.6% to 63.8%. The highest rates of burnout were found in urology (63.8%), neurology (61.6%), and ophthalmology (55.8%), but the lowest reported rate of burnout was demonstrated in dermatology (29.6%).⁴ Although dermatology ranked the lowest, that is still nearly a whopping 1 in 3 dermatology residents with burnout symptoms. The absolute prevalence should not be obscured by the ranking among other specialties.

Preventing Burnout

Several burnout prevention and coping strategies across specialties have been suggested.

Mindfulness and Self-awareness
A study by Chaukos et al⁵ found that mindfulness and self-awareness are resilience factors associated with resident burnout. Counseling is one strategy demonstrated to increase self-awareness. Mindfulness may be practiced through meditation or yoga. Regular meditation has been shown to improve mood and emotional stress.⁶ Similarly, yoga has been shown to yield physical, emotional, and psychological benefits to resdients.⁷

Work Factors
A supportive clinical faculty and receiving constructive monthly performance feedback have been negatively correlated with dermatology resident burnout.³ Other workplace interventions demonstrating utility in decreasing resident burnout include increasing staff awareness about burnout, increasing support for health professionals treating challenging populations, and ensuring a reasonable workload.⁶

Sleep
It has been demonstrated that sleeping less than 7 hours per night also is associated with resident burnout,⁷ yet it has been reported that 72% of dermatology residents fall into this category.³ Poor sleep quality has been shown to be a predictor of lower academic performance. It has been proposed that to minimize sleep deprivation and poor sleep quality, institutions should focus on programs that promote regular exercise, sleep hygiene, mindfulness, and time-out activities such as meditation.⁷

Social Support
Focusing on peers may foster the inner strength to endure suffering.¹ Venting, laughing, and discussing care with colleagues has been demonstrated to decrease anxiety.⁶ Work-related social networks may be strengthened through attendance at conferences, lectures, and professional organizations.⁷ Additionally, social supports and spending quality time with family have been demonstrated as negative predictors of dermatology resident burnout.³

Physical Exercise
Exercise has been demonstrated to improve mood, anxiety, and depression, thereby decreasing resident burnout.⁶

Final Thoughts

Burnout among dermatology residents warrants awareness, as it does in other medical specialties. Awareness may facilitate identification and prevention, the latter of which is perhaps best summarized by the words of psychologist Dr. Christina Maslach: “If all of the knowledge and advice about how to beat burnout could be summed up in 1 word, that word would be balance—balance between giving and getting, balance between stress and calm, balance between work and home.”⁸

The Federal Bureau of Labor Statistics projects 37% job growth for physician assistants (PAs) from 2016 to 2026, much greater than the average for all other occupations as well as for other medical professions.¹ This growth has been accompanied by increased enrollment in medical (doctor of medicine [MD], doctor of osteopathic medicine) and nurse practitioner (NP) schools.² Clinical teaching sites serve a crucial function in the training of all clinical disciplines. These sites provide hands-on and experiential learning in medical settings, necessary components for learners practicing to become clinicians. Significant PA program expansion has led to increased demand for clinical training, creating competition for sites and a shortage of willing and well-trained preceptors.³

This challenge has been recognized by PA program directors. In the Joint Report of the 2013 Multi-Discipline Clerkship/Clinical Training Site Survey, PA program directors expressed concern about the adequacy of clinical opportunities for students, increased difficulty developing new core sites, and preserving existing core sites. In addition, they noted that a shortage of clinical sites was one of the greatest barriers to the PA programs’ sustained growth and success.⁴

Program directors also indicated difficulty securing clinical training sites in internal medicine (IM) and high rates of attrition of medicine clinical preceptors for their students.⁵ The reasons are multifold: increasing clinical demands, time, teaching competence, lack of experience, academic affiliation, lack of reimbursement, or compensation. Moreover, there is a declining number of PAs who work in primary care compared with specialty and subspecialty care, limiting the availability of clinical training preceptors in medicine and primary care.^6-8 According to the American Academy of PAs (AAPA) census and salary survey data, the percentage of PAs working in the primary care specialties (ie, family medicine, IM, and general pediatrics) has decreased from > 47% in 1995 to 24% in 2017.⁹ As such, there is a need to broaden the educational landscape to provide more high-quality training sites in IM.

The postacute health care setting may address this training need. It offers a unique clinical opportunity to expose learners to a broad range of disease complexity and clinical acuity, as the percentage of patients discharged from hospitals to postacute care (PAC) has increased and care shifts from the hospital to the PAC setting.^10,11 The longer PAC length of stay also enables learners to follow patients longitudinally over several weeks and experience interprofessional team-based care. In addition, the PAC setting offers learners the ability to acquire the necessary skills for smooth and effective transitions of care. This setting has been extensively used for trainees of nursing, pharmacy, physical therapy (PT) and occupational therapy (OT), speech-language pathology, psychology, and social work (SW), but few programs have used the PAC setting as clerkship sites for IM rotations for PA students. To address this need for IM sites, the VA Boston Healthcare System (VABHS), in conjunction with the Boston University School of Medicine Physician Assistant Program, developed a novel medicine clinical clerkship site for physician assistants in the PAC unit of the community living center (CLC) at VABHS. This report describes the program structure, curriculum, and participant evaluation results.

Clinical Clerkship Program

VABHS CLC is a 110-bed facility comprising 3 units: a 65-bed PAC unit, a 15-bed closed hospice/palliative care unit, and a 30-bed long-term care unit. The service is staffed continuously with physicians, PAs, and NPs. A majority of patients are admitted from the acute care hospital of VABHS (West Roxbury campus) and other regional VA facilities. The CLC offers dynamic services, including phlebotomy, general radiology, IV diuretics and antibiotics, wound care, and subacute PT, OT, and speech-language pathology rehabilitation. The CLC serves as a venue for transitioning patients from acute inpatient care to home. The patient population is often elderly, with multiple active comorbidities and variable medical literacy, adherence, and follow-up.

The CLC provides a diverse interprofessional learning environment, offering core IM rotations for first-year psychiatry residents, oral and maxillofacial surgery residents, and PA students. The CLC also has expanded as a clinical site both for transitions-in-care IM resident curricula and electives as well as a geriatrics fellowship. In addition, the site offers rotations for NPs, nursing, pharmacy, physical and occupational therapies, speech-language pathology, psychology, and SW.

The Boston University School of Medicine Physician Assistant Program was founded in 2015 as a master’s degree program completed over 28 months. The first 12 months are didactic, and the following 16 months are clinical training with 14 months of rotations (2 IM, family medicine, pediatrics, emergency medicine, general surgery, obstetrics and gynecology, psychiatry, neurology, and 5 elective rotations), and 2 months for a thesis. The program has about 30 students per year and 4 clerkship sites for IM.

Program Description

The VABHS medicine clerkship hosts 1 to 2 PA students for 4-week blocks in the PAC unit of the CLC. Each student rotates on both PA and MD teams. Students follow 3 to 4 patients and participate fully in their care from admission to discharge; they prepare daily presentations and participate in medical management, family meetings, chart documentation, and care coordination with the interprofessional team. Students are provided a physical examination checklist and feedback form, and they are expected to track findings and record feedback and goals with their supervising preceptor weekly. They also make formal case presentations and participate in monthly medicine didactic rounds available to all VABHS IM students and trainees via videoconference.

In addition, beginning in July 2017, all PA students in the CLC began to participate in a 4-week Interprofessional Curriculum in Transitional Care. The curriculum includes 14 didactic lectures taught by 16 interprofessional faculty, including medicine, geriatric, and palliative care physicians; PAs; social workers; physical and occupational therapists; pharmacists; and a geriatric psychologist. The didactics include topics on the interprofessional team, the care continuum, teams and teamwork, interdisciplinary coordination of care, components of effective transitions in care, medication reconciliation, approaching difficult conversations, advance care planning, and quality improvement. The goal of the curriculum is to provide learners the knowledge, skills, and dispositions necessary for high-quality transitional care and interprofessional practice as well as specific training for effective and safe transfers of care between clinical settings. Although PA students are the main participants in this curriculum, all other learners in the PAC unit are also invited to attend the lectures.

The unique attributes of this training site include direct interaction with supervising PAs and physicians, rather than experiencing the traditional teaching hierarchy (with interns, residents, fellows); observation of the natural progression of disease of both acute care and primary care issues due to the longer length of stay (2 to 6 weeks, where the typical student will see the same patient 7 to 10 times during their rotation); exposure to a host of medically complex patients offering a multitude of clinical scenarios and abnormal physical exam findings; exposure to a hospice/palliative care ward and end-of-life care; and interaction within an interprofessional training environment of nursing, pharmacy, PT, OT, speech-language pathology, psychology, and SW trainees.

Program Evaluation

At the end of rotations continuously through the year, PA students electronically complete a site evaluation from the Boston University School of Medicine Physician Assistant Program. The evaluation consists of 14 questions: 6 about site quality and 8 about instruction quality. The questions are answered on a 5-point Likert scale. Also included are 2 open-ended response questions that ask what they liked about the rotation and what they felt could be improved. Results are anonymous, de-identified and blinded both to the program as well as the clerkship site. Results are aggregated and provided to program sites annually. Responses are converted to a dichotomous variable, where any good or excellent response (4 or 5) is considered positive and any neutral or below (3, 2, 1) is considered a nonpositive response.

Results

The clerkship site has been operational since June 22, 2015. There have been 59 students who participated in the rotation. A different scale in these evaluations was used between June 22, 2015, and September 13, 2015. Therefore, 7 responses were excluded from the analysis, leaving 52 usable evaluations. The responses were analyzed both in total (for the CLC as well as other IM rotation sites) and by individual clerkship year to look for any trends over time: September 14, 2015, through April 24, 2016; April 25, 2016, through April 28, 2017; and May 1, 2017, through March 1, 2018 (Table).

Site evaluations showed high satisfaction regarding the quality of the physical environment as well as the learning environment. Students endorsed the PAC unit having resources and physical space for them, such as a desk and computer, opportunity for participation in patient care, and parking (100%; n = 52). Site evaluations revealed high satisfaction with the quality of teaching and faculty encouragement and support of their learning (100%; n = 52). The evaluations revealed that bedside teaching was strong (94%; n = 49). The students reported high satisfaction with the volume of patients provided (92%; n = 48) as well as the diversity of diagnoses (92%; n = 48).

There were fewer positive responses in the first 2 years of the rotation with regard to formal lectures (50% and 67%; 7/14 and 16/24, respectively). In the third year of the rotation, students had a much higher satisfaction rate (93%; 13/14). This increased satisfaction was associated with the development and incorporation of the Interprofessional Curriculum in Transitional Care in 2017.

Discussion

Access to high-quality PA student clerkship sites has become a pressing issue in recent years because of increased competition for sites and a shortage of willing and well-trained preceptors. There has been marked growth in schools and enrollment across all medical professions. The Accreditation Review Commission on Education for the PA (ARC-PA) reported that the total number of accredited entry-level PA programs in 2018 was 246, with 58 new accredited programs projected by 2022.¹² The Joint Report of the 2013 Multi-Discipline Clerkship/Clinical Training Site Survey reported a 66% increase in first-year enrollment in PA programs from 2002 to 2012.⁵ Programs must implement alternative strategies to attract clinical sites (eg, academic appointments, increased clinical resources to training sites) or face continued challenges with recruiting training sites for their students. Postacute care may be a natural extension to expand the footprint for clinical sites for these programs, augmenting acute inpatient and outpatient rotations. This implementation would increase the pool of clinical training sites and preceptors.

The experience with this novel training site, based on PA student feedback and evaluations, has been positive, and the postacute setting can provide students with high-quality IM clinical experiences. Students report adequate patient volume and diversity. In addition, evaluations are comparable with that of other IM site rotations the students experience. Qualitative feedback has emphasized the value of following patients over longer periods; eg, weeks vs days (as in acute care) enabling students to build relationships with patients as well as observe a richer clinical spectrum of disease over a less compressed period. “Patients have complex issues, so from a medical standpoint it challenges you to think of new ways to manage their care,” commented a representative student. “It is really beneficial that you can follow them over time.”

Furthermore, in response to student feedback on didactics, an interprofessional curriculum was developed to add formal structure as well as to create a curriculum in care transitions. This curriculum provided a unique opportunity for PA students to receive formal instruction on areas of particular relevance for transitional care (eg, care continuum, end of life issues, and care transitions). The curriculum also allows the interprofessional faculty a unique and enjoyable opportunity for interprofessional collaboration.

The 1 month PAC rotation is augmented with inpatient IM and outpatient family medicine rotations, consequently giving exposure to the full continuum of care. The PAC setting provides learners multifaceted benefits: the opportunity to strengthen and develop the knowledge, attitudes, and skills necessary for IM; increased understanding of other professions by observing and interacting as a team caring for a patient over a longer period as opposed to the acute care setting; the ability to perform effective, efficient, and safe transfer between clinical settings; and broad exposure to transitional care. As a result, the PAC rotation enhances but does not replace the necessary and essential rotations of inpatient and outpatient medicine.

Moreover, this rotation provides unique and core IM training for PA students. Our site focuses on interprofessional collaboration, emphasizing the importance of team-based care, an essential concept in modern day medicine. Formal exposure to other care specialties, such as PT and OT, SW, and mental health, is essential for students to appreciate clinical medicine and a patient’s physical and mental experience over the course of a disease and clinical state. In addition, the physical exam checklist ensures that students are exposed to the full spectrum of IM examination findings during their rotation. Finally, weekly feedback forms require students to ask and receive concrete feedback from their supervising providers.

Limitations

The generalizability of this model requires careful consideration. VABHS is a tertiary care integrated health care system, enabling students to learn from patients moving through multiple care transitions in a single health care system. In addition, other settings may not have the staffing or clinical volume to sustain such a model. All PAC clinical faculty teach voluntarily, and local leadership has set expectations for all clinicians to participate in teaching of trainees and PA students. Evaluations also note less diversity in the patient population, a challenge that some VA facilities face. This issue could be addressed by ensuring that students also have IM rotations at other inpatient medical facilities. A more balanced experience, where students reap the positive benefits of PAC but do not lose exposure to a diverse patient pool, could result. Furthermore, some of the perceived positive impacts also may be related to professional and personal attributes of the teaching clinicians rather than to the PAC setting.

Conclusion

PAC settings can be effective training sites for medicine clerkships for PA students and can provide high-quality training in IM as PA programs continue to expand. This setting offers students exposure to interprofessional, team-based care and the opportunity to care for patients with a broad range of disease complexity. Learning is further enhanced by the ability to follow patients longitudinally over their disease course as well as to work directly with teaching faculty and other interprofessional health care professionals. Evaluations of this novel clerkship experience have shown high levels of student satisfaction in knowledge growth, clinical skills, bedside teaching, and mentorship.

Acknowledgments
We thank Juman Hijab for her critical role in establishing and maintaining the clerkship. We thank Steven Simon, Matt Russell, and Thomas Parrino for their leadership and guidance in establishing and maintaining the clerkship. We thank the Boston University School of Medicine Physician Assistant Program Director Mary Warner for her support and guidance in creating and supporting the clerkship. In addition, we thank the interprofessional education faculty for their dedicated involvement in teaching, including Stephanie Saunders, Lindsay Lefers, Jessica Rawlins, Lindsay Brennan, Angela Viani, Eric Charette, Nicole O’Neil, Susan Nathan, Jordana Meyerson, Shivani Jindal, Wei Shen, Amy Hanson, Gilda Cain, and Kate Hinrichs.

The Federal Bureau of Labor Statistics projects 37% job growth for physician assistants (PAs) from 2016 to 2026, much greater than the average for all other occupations as well as for other medical professions.¹ This growth has been accompanied by increased enrollment in medical (doctor of medicine [MD], doctor of osteopathic medicine) and nurse practitioner (NP) schools.² Clinical teaching sites serve a crucial function in the training of all clinical disciplines. These sites provide hands-on and experiential learning in medical settings, necessary components for learners practicing to become clinicians. Significant PA program expansion has led to increased demand for clinical training, creating competition for sites and a shortage of willing and well-trained preceptors.³

This challenge has been recognized by PA program directors. In the Joint Report of the 2013 Multi-Discipline Clerkship/Clinical Training Site Survey, PA program directors expressed concern about the adequacy of clinical opportunities for students, increased difficulty developing new core sites, and preserving existing core sites. In addition, they noted that a shortage of clinical sites was one of the greatest barriers to the PA programs’ sustained growth and success.⁴

Program directors also indicated difficulty securing clinical training sites in internal medicine (IM) and high rates of attrition of medicine clinical preceptors for their students.⁵ The reasons are multifold: increasing clinical demands, time, teaching competence, lack of experience, academic affiliation, lack of reimbursement, or compensation. Moreover, there is a declining number of PAs who work in primary care compared with specialty and subspecialty care, limiting the availability of clinical training preceptors in medicine and primary care.^6-8 According to the American Academy of PAs (AAPA) census and salary survey data, the percentage of PAs working in the primary care specialties (ie, family medicine, IM, and general pediatrics) has decreased from > 47% in 1995 to 24% in 2017.⁹ As such, there is a need to broaden the educational landscape to provide more high-quality training sites in IM.

The postacute health care setting may address this training need. It offers a unique clinical opportunity to expose learners to a broad range of disease complexity and clinical acuity, as the percentage of patients discharged from hospitals to postacute care (PAC) has increased and care shifts from the hospital to the PAC setting.^10,11 The longer PAC length of stay also enables learners to follow patients longitudinally over several weeks and experience interprofessional team-based care. In addition, the PAC setting offers learners the ability to acquire the necessary skills for smooth and effective transitions of care. This setting has been extensively used for trainees of nursing, pharmacy, physical therapy (PT) and occupational therapy (OT), speech-language pathology, psychology, and social work (SW), but few programs have used the PAC setting as clerkship sites for IM rotations for PA students. To address this need for IM sites, the VA Boston Healthcare System (VABHS), in conjunction with the Boston University School of Medicine Physician Assistant Program, developed a novel medicine clinical clerkship site for physician assistants in the PAC unit of the community living center (CLC) at VABHS. This report describes the program structure, curriculum, and participant evaluation results.

Clinical Clerkship Program

VABHS CLC is a 110-bed facility comprising 3 units: a 65-bed PAC unit, a 15-bed closed hospice/palliative care unit, and a 30-bed long-term care unit. The service is staffed continuously with physicians, PAs, and NPs. A majority of patients are admitted from the acute care hospital of VABHS (West Roxbury campus) and other regional VA facilities. The CLC offers dynamic services, including phlebotomy, general radiology, IV diuretics and antibiotics, wound care, and subacute PT, OT, and speech-language pathology rehabilitation. The CLC serves as a venue for transitioning patients from acute inpatient care to home. The patient population is often elderly, with multiple active comorbidities and variable medical literacy, adherence, and follow-up.

The CLC provides a diverse interprofessional learning environment, offering core IM rotations for first-year psychiatry residents, oral and maxillofacial surgery residents, and PA students. The CLC also has expanded as a clinical site both for transitions-in-care IM resident curricula and electives as well as a geriatrics fellowship. In addition, the site offers rotations for NPs, nursing, pharmacy, physical and occupational therapies, speech-language pathology, psychology, and SW.

The Boston University School of Medicine Physician Assistant Program was founded in 2015 as a master’s degree program completed over 28 months. The first 12 months are didactic, and the following 16 months are clinical training with 14 months of rotations (2 IM, family medicine, pediatrics, emergency medicine, general surgery, obstetrics and gynecology, psychiatry, neurology, and 5 elective rotations), and 2 months for a thesis. The program has about 30 students per year and 4 clerkship sites for IM.

Program Description

The VABHS medicine clerkship hosts 1 to 2 PA students for 4-week blocks in the PAC unit of the CLC. Each student rotates on both PA and MD teams. Students follow 3 to 4 patients and participate fully in their care from admission to discharge; they prepare daily presentations and participate in medical management, family meetings, chart documentation, and care coordination with the interprofessional team. Students are provided a physical examination checklist and feedback form, and they are expected to track findings and record feedback and goals with their supervising preceptor weekly. They also make formal case presentations and participate in monthly medicine didactic rounds available to all VABHS IM students and trainees via videoconference.

In addition, beginning in July 2017, all PA students in the CLC began to participate in a 4-week Interprofessional Curriculum in Transitional Care. The curriculum includes 14 didactic lectures taught by 16 interprofessional faculty, including medicine, geriatric, and palliative care physicians; PAs; social workers; physical and occupational therapists; pharmacists; and a geriatric psychologist. The didactics include topics on the interprofessional team, the care continuum, teams and teamwork, interdisciplinary coordination of care, components of effective transitions in care, medication reconciliation, approaching difficult conversations, advance care planning, and quality improvement. The goal of the curriculum is to provide learners the knowledge, skills, and dispositions necessary for high-quality transitional care and interprofessional practice as well as specific training for effective and safe transfers of care between clinical settings. Although PA students are the main participants in this curriculum, all other learners in the PAC unit are also invited to attend the lectures.

The unique attributes of this training site include direct interaction with supervising PAs and physicians, rather than experiencing the traditional teaching hierarchy (with interns, residents, fellows); observation of the natural progression of disease of both acute care and primary care issues due to the longer length of stay (2 to 6 weeks, where the typical student will see the same patient 7 to 10 times during their rotation); exposure to a host of medically complex patients offering a multitude of clinical scenarios and abnormal physical exam findings; exposure to a hospice/palliative care ward and end-of-life care; and interaction within an interprofessional training environment of nursing, pharmacy, PT, OT, speech-language pathology, psychology, and SW trainees.

Program Evaluation

At the end of rotations continuously through the year, PA students electronically complete a site evaluation from the Boston University School of Medicine Physician Assistant Program. The evaluation consists of 14 questions: 6 about site quality and 8 about instruction quality. The questions are answered on a 5-point Likert scale. Also included are 2 open-ended response questions that ask what they liked about the rotation and what they felt could be improved. Results are anonymous, de-identified and blinded both to the program as well as the clerkship site. Results are aggregated and provided to program sites annually. Responses are converted to a dichotomous variable, where any good or excellent response (4 or 5) is considered positive and any neutral or below (3, 2, 1) is considered a nonpositive response.

Results

The clerkship site has been operational since June 22, 2015. There have been 59 students who participated in the rotation. A different scale in these evaluations was used between June 22, 2015, and September 13, 2015. Therefore, 7 responses were excluded from the analysis, leaving 52 usable evaluations. The responses were analyzed both in total (for the CLC as well as other IM rotation sites) and by individual clerkship year to look for any trends over time: September 14, 2015, through April 24, 2016; April 25, 2016, through April 28, 2017; and May 1, 2017, through March 1, 2018 (Table).

Site evaluations showed high satisfaction regarding the quality of the physical environment as well as the learning environment. Students endorsed the PAC unit having resources and physical space for them, such as a desk and computer, opportunity for participation in patient care, and parking (100%; n = 52). Site evaluations revealed high satisfaction with the quality of teaching and faculty encouragement and support of their learning (100%; n = 52). The evaluations revealed that bedside teaching was strong (94%; n = 49). The students reported high satisfaction with the volume of patients provided (92%; n = 48) as well as the diversity of diagnoses (92%; n = 48).

There were fewer positive responses in the first 2 years of the rotation with regard to formal lectures (50% and 67%; 7/14 and 16/24, respectively). In the third year of the rotation, students had a much higher satisfaction rate (93%; 13/14). This increased satisfaction was associated with the development and incorporation of the Interprofessional Curriculum in Transitional Care in 2017.

Discussion

Access to high-quality PA student clerkship sites has become a pressing issue in recent years because of increased competition for sites and a shortage of willing and well-trained preceptors. There has been marked growth in schools and enrollment across all medical professions. The Accreditation Review Commission on Education for the PA (ARC-PA) reported that the total number of accredited entry-level PA programs in 2018 was 246, with 58 new accredited programs projected by 2022.¹² The Joint Report of the 2013 Multi-Discipline Clerkship/Clinical Training Site Survey reported a 66% increase in first-year enrollment in PA programs from 2002 to 2012.⁵ Programs must implement alternative strategies to attract clinical sites (eg, academic appointments, increased clinical resources to training sites) or face continued challenges with recruiting training sites for their students. Postacute care may be a natural extension to expand the footprint for clinical sites for these programs, augmenting acute inpatient and outpatient rotations. This implementation would increase the pool of clinical training sites and preceptors.

The experience with this novel training site, based on PA student feedback and evaluations, has been positive, and the postacute setting can provide students with high-quality IM clinical experiences. Students report adequate patient volume and diversity. In addition, evaluations are comparable with that of other IM site rotations the students experience. Qualitative feedback has emphasized the value of following patients over longer periods; eg, weeks vs days (as in acute care) enabling students to build relationships with patients as well as observe a richer clinical spectrum of disease over a less compressed period. “Patients have complex issues, so from a medical standpoint it challenges you to think of new ways to manage their care,” commented a representative student. “It is really beneficial that you can follow them over time.”

Furthermore, in response to student feedback on didactics, an interprofessional curriculum was developed to add formal structure as well as to create a curriculum in care transitions. This curriculum provided a unique opportunity for PA students to receive formal instruction on areas of particular relevance for transitional care (eg, care continuum, end of life issues, and care transitions). The curriculum also allows the interprofessional faculty a unique and enjoyable opportunity for interprofessional collaboration.

The 1 month PAC rotation is augmented with inpatient IM and outpatient family medicine rotations, consequently giving exposure to the full continuum of care. The PAC setting provides learners multifaceted benefits: the opportunity to strengthen and develop the knowledge, attitudes, and skills necessary for IM; increased understanding of other professions by observing and interacting as a team caring for a patient over a longer period as opposed to the acute care setting; the ability to perform effective, efficient, and safe transfer between clinical settings; and broad exposure to transitional care. As a result, the PAC rotation enhances but does not replace the necessary and essential rotations of inpatient and outpatient medicine.

Moreover, this rotation provides unique and core IM training for PA students. Our site focuses on interprofessional collaboration, emphasizing the importance of team-based care, an essential concept in modern day medicine. Formal exposure to other care specialties, such as PT and OT, SW, and mental health, is essential for students to appreciate clinical medicine and a patient’s physical and mental experience over the course of a disease and clinical state. In addition, the physical exam checklist ensures that students are exposed to the full spectrum of IM examination findings during their rotation. Finally, weekly feedback forms require students to ask and receive concrete feedback from their supervising providers.

Limitations

The generalizability of this model requires careful consideration. VABHS is a tertiary care integrated health care system, enabling students to learn from patients moving through multiple care transitions in a single health care system. In addition, other settings may not have the staffing or clinical volume to sustain such a model. All PAC clinical faculty teach voluntarily, and local leadership has set expectations for all clinicians to participate in teaching of trainees and PA students. Evaluations also note less diversity in the patient population, a challenge that some VA facilities face. This issue could be addressed by ensuring that students also have IM rotations at other inpatient medical facilities. A more balanced experience, where students reap the positive benefits of PAC but do not lose exposure to a diverse patient pool, could result. Furthermore, some of the perceived positive impacts also may be related to professional and personal attributes of the teaching clinicians rather than to the PAC setting.

Conclusion

PAC settings can be effective training sites for medicine clerkships for PA students and can provide high-quality training in IM as PA programs continue to expand. This setting offers students exposure to interprofessional, team-based care and the opportunity to care for patients with a broad range of disease complexity. Learning is further enhanced by the ability to follow patients longitudinally over their disease course as well as to work directly with teaching faculty and other interprofessional health care professionals. Evaluations of this novel clerkship experience have shown high levels of student satisfaction in knowledge growth, clinical skills, bedside teaching, and mentorship.

Acknowledgments
We thank Juman Hijab for her critical role in establishing and maintaining the clerkship. We thank Steven Simon, Matt Russell, and Thomas Parrino for their leadership and guidance in establishing and maintaining the clerkship. We thank the Boston University School of Medicine Physician Assistant Program Director Mary Warner for her support and guidance in creating and supporting the clerkship. In addition, we thank the interprofessional education faculty for their dedicated involvement in teaching, including Stephanie Saunders, Lindsay Lefers, Jessica Rawlins, Lindsay Brennan, Angela Viani, Eric Charette, Nicole O’Neil, Susan Nathan, Jordana Meyerson, Shivani Jindal, Wei Shen, Amy Hanson, Gilda Cain, and Kate Hinrichs.

The Federal Bureau of Labor Statistics projects 37% job growth for physician assistants (PAs) from 2016 to 2026, much greater than the average for all other occupations as well as for other medical professions.¹ This growth has been accompanied by increased enrollment in medical (doctor of medicine [MD], doctor of osteopathic medicine) and nurse practitioner (NP) schools.² Clinical teaching sites serve a crucial function in the training of all clinical disciplines. These sites provide hands-on and experiential learning in medical settings, necessary components for learners practicing to become clinicians. Significant PA program expansion has led to increased demand for clinical training, creating competition for sites and a shortage of willing and well-trained preceptors.³

This challenge has been recognized by PA program directors. In the Joint Report of the 2013 Multi-Discipline Clerkship/Clinical Training Site Survey, PA program directors expressed concern about the adequacy of clinical opportunities for students, increased difficulty developing new core sites, and preserving existing core sites. In addition, they noted that a shortage of clinical sites was one of the greatest barriers to the PA programs’ sustained growth and success.⁴

Program directors also indicated difficulty securing clinical training sites in internal medicine (IM) and high rates of attrition of medicine clinical preceptors for their students.⁵ The reasons are multifold: increasing clinical demands, time, teaching competence, lack of experience, academic affiliation, lack of reimbursement, or compensation. Moreover, there is a declining number of PAs who work in primary care compared with specialty and subspecialty care, limiting the availability of clinical training preceptors in medicine and primary care.^6-8 According to the American Academy of PAs (AAPA) census and salary survey data, the percentage of PAs working in the primary care specialties (ie, family medicine, IM, and general pediatrics) has decreased from > 47% in 1995 to 24% in 2017.⁹ As such, there is a need to broaden the educational landscape to provide more high-quality training sites in IM.

The postacute health care setting may address this training need. It offers a unique clinical opportunity to expose learners to a broad range of disease complexity and clinical acuity, as the percentage of patients discharged from hospitals to postacute care (PAC) has increased and care shifts from the hospital to the PAC setting.^10,11 The longer PAC length of stay also enables learners to follow patients longitudinally over several weeks and experience interprofessional team-based care. In addition, the PAC setting offers learners the ability to acquire the necessary skills for smooth and effective transitions of care. This setting has been extensively used for trainees of nursing, pharmacy, physical therapy (PT) and occupational therapy (OT), speech-language pathology, psychology, and social work (SW), but few programs have used the PAC setting as clerkship sites for IM rotations for PA students. To address this need for IM sites, the VA Boston Healthcare System (VABHS), in conjunction with the Boston University School of Medicine Physician Assistant Program, developed a novel medicine clinical clerkship site for physician assistants in the PAC unit of the community living center (CLC) at VABHS. This report describes the program structure, curriculum, and participant evaluation results.

Clinical Clerkship Program

VABHS CLC is a 110-bed facility comprising 3 units: a 65-bed PAC unit, a 15-bed closed hospice/palliative care unit, and a 30-bed long-term care unit. The service is staffed continuously with physicians, PAs, and NPs. A majority of patients are admitted from the acute care hospital of VABHS (West Roxbury campus) and other regional VA facilities. The CLC offers dynamic services, including phlebotomy, general radiology, IV diuretics and antibiotics, wound care, and subacute PT, OT, and speech-language pathology rehabilitation. The CLC serves as a venue for transitioning patients from acute inpatient care to home. The patient population is often elderly, with multiple active comorbidities and variable medical literacy, adherence, and follow-up.

The CLC provides a diverse interprofessional learning environment, offering core IM rotations for first-year psychiatry residents, oral and maxillofacial surgery residents, and PA students. The CLC also has expanded as a clinical site both for transitions-in-care IM resident curricula and electives as well as a geriatrics fellowship. In addition, the site offers rotations for NPs, nursing, pharmacy, physical and occupational therapies, speech-language pathology, psychology, and SW.

The Boston University School of Medicine Physician Assistant Program was founded in 2015 as a master’s degree program completed over 28 months. The first 12 months are didactic, and the following 16 months are clinical training with 14 months of rotations (2 IM, family medicine, pediatrics, emergency medicine, general surgery, obstetrics and gynecology, psychiatry, neurology, and 5 elective rotations), and 2 months for a thesis. The program has about 30 students per year and 4 clerkship sites for IM.

Program Description

The VABHS medicine clerkship hosts 1 to 2 PA students for 4-week blocks in the PAC unit of the CLC. Each student rotates on both PA and MD teams. Students follow 3 to 4 patients and participate fully in their care from admission to discharge; they prepare daily presentations and participate in medical management, family meetings, chart documentation, and care coordination with the interprofessional team. Students are provided a physical examination checklist and feedback form, and they are expected to track findings and record feedback and goals with their supervising preceptor weekly. They also make formal case presentations and participate in monthly medicine didactic rounds available to all VABHS IM students and trainees via videoconference.

In addition, beginning in July 2017, all PA students in the CLC began to participate in a 4-week Interprofessional Curriculum in Transitional Care. The curriculum includes 14 didactic lectures taught by 16 interprofessional faculty, including medicine, geriatric, and palliative care physicians; PAs; social workers; physical and occupational therapists; pharmacists; and a geriatric psychologist. The didactics include topics on the interprofessional team, the care continuum, teams and teamwork, interdisciplinary coordination of care, components of effective transitions in care, medication reconciliation, approaching difficult conversations, advance care planning, and quality improvement. The goal of the curriculum is to provide learners the knowledge, skills, and dispositions necessary for high-quality transitional care and interprofessional practice as well as specific training for effective and safe transfers of care between clinical settings. Although PA students are the main participants in this curriculum, all other learners in the PAC unit are also invited to attend the lectures.

The unique attributes of this training site include direct interaction with supervising PAs and physicians, rather than experiencing the traditional teaching hierarchy (with interns, residents, fellows); observation of the natural progression of disease of both acute care and primary care issues due to the longer length of stay (2 to 6 weeks, where the typical student will see the same patient 7 to 10 times during their rotation); exposure to a host of medically complex patients offering a multitude of clinical scenarios and abnormal physical exam findings; exposure to a hospice/palliative care ward and end-of-life care; and interaction within an interprofessional training environment of nursing, pharmacy, PT, OT, speech-language pathology, psychology, and SW trainees.

Program Evaluation

At the end of rotations continuously through the year, PA students electronically complete a site evaluation from the Boston University School of Medicine Physician Assistant Program. The evaluation consists of 14 questions: 6 about site quality and 8 about instruction quality. The questions are answered on a 5-point Likert scale. Also included are 2 open-ended response questions that ask what they liked about the rotation and what they felt could be improved. Results are anonymous, de-identified and blinded both to the program as well as the clerkship site. Results are aggregated and provided to program sites annually. Responses are converted to a dichotomous variable, where any good or excellent response (4 or 5) is considered positive and any neutral or below (3, 2, 1) is considered a nonpositive response.

Results

The clerkship site has been operational since June 22, 2015. There have been 59 students who participated in the rotation. A different scale in these evaluations was used between June 22, 2015, and September 13, 2015. Therefore, 7 responses were excluded from the analysis, leaving 52 usable evaluations. The responses were analyzed both in total (for the CLC as well as other IM rotation sites) and by individual clerkship year to look for any trends over time: September 14, 2015, through April 24, 2016; April 25, 2016, through April 28, 2017; and May 1, 2017, through March 1, 2018 (Table).

Site evaluations showed high satisfaction regarding the quality of the physical environment as well as the learning environment. Students endorsed the PAC unit having resources and physical space for them, such as a desk and computer, opportunity for participation in patient care, and parking (100%; n = 52). Site evaluations revealed high satisfaction with the quality of teaching and faculty encouragement and support of their learning (100%; n = 52). The evaluations revealed that bedside teaching was strong (94%; n = 49). The students reported high satisfaction with the volume of patients provided (92%; n = 48) as well as the diversity of diagnoses (92%; n = 48).

There were fewer positive responses in the first 2 years of the rotation with regard to formal lectures (50% and 67%; 7/14 and 16/24, respectively). In the third year of the rotation, students had a much higher satisfaction rate (93%; 13/14). This increased satisfaction was associated with the development and incorporation of the Interprofessional Curriculum in Transitional Care in 2017.

Discussion

Access to high-quality PA student clerkship sites has become a pressing issue in recent years because of increased competition for sites and a shortage of willing and well-trained preceptors. There has been marked growth in schools and enrollment across all medical professions. The Accreditation Review Commission on Education for the PA (ARC-PA) reported that the total number of accredited entry-level PA programs in 2018 was 246, with 58 new accredited programs projected by 2022.¹² The Joint Report of the 2013 Multi-Discipline Clerkship/Clinical Training Site Survey reported a 66% increase in first-year enrollment in PA programs from 2002 to 2012.⁵ Programs must implement alternative strategies to attract clinical sites (eg, academic appointments, increased clinical resources to training sites) or face continued challenges with recruiting training sites for their students. Postacute care may be a natural extension to expand the footprint for clinical sites for these programs, augmenting acute inpatient and outpatient rotations. This implementation would increase the pool of clinical training sites and preceptors.

The experience with this novel training site, based on PA student feedback and evaluations, has been positive, and the postacute setting can provide students with high-quality IM clinical experiences. Students report adequate patient volume and diversity. In addition, evaluations are comparable with that of other IM site rotations the students experience. Qualitative feedback has emphasized the value of following patients over longer periods; eg, weeks vs days (as in acute care) enabling students to build relationships with patients as well as observe a richer clinical spectrum of disease over a less compressed period. “Patients have complex issues, so from a medical standpoint it challenges you to think of new ways to manage their care,” commented a representative student. “It is really beneficial that you can follow them over time.”

Furthermore, in response to student feedback on didactics, an interprofessional curriculum was developed to add formal structure as well as to create a curriculum in care transitions. This curriculum provided a unique opportunity for PA students to receive formal instruction on areas of particular relevance for transitional care (eg, care continuum, end of life issues, and care transitions). The curriculum also allows the interprofessional faculty a unique and enjoyable opportunity for interprofessional collaboration.

The 1 month PAC rotation is augmented with inpatient IM and outpatient family medicine rotations, consequently giving exposure to the full continuum of care. The PAC setting provides learners multifaceted benefits: the opportunity to strengthen and develop the knowledge, attitudes, and skills necessary for IM; increased understanding of other professions by observing and interacting as a team caring for a patient over a longer period as opposed to the acute care setting; the ability to perform effective, efficient, and safe transfer between clinical settings; and broad exposure to transitional care. As a result, the PAC rotation enhances but does not replace the necessary and essential rotations of inpatient and outpatient medicine.

Moreover, this rotation provides unique and core IM training for PA students. Our site focuses on interprofessional collaboration, emphasizing the importance of team-based care, an essential concept in modern day medicine. Formal exposure to other care specialties, such as PT and OT, SW, and mental health, is essential for students to appreciate clinical medicine and a patient’s physical and mental experience over the course of a disease and clinical state. In addition, the physical exam checklist ensures that students are exposed to the full spectrum of IM examination findings during their rotation. Finally, weekly feedback forms require students to ask and receive concrete feedback from their supervising providers.

Limitations

The generalizability of this model requires careful consideration. VABHS is a tertiary care integrated health care system, enabling students to learn from patients moving through multiple care transitions in a single health care system. In addition, other settings may not have the staffing or clinical volume to sustain such a model. All PAC clinical faculty teach voluntarily, and local leadership has set expectations for all clinicians to participate in teaching of trainees and PA students. Evaluations also note less diversity in the patient population, a challenge that some VA facilities face. This issue could be addressed by ensuring that students also have IM rotations at other inpatient medical facilities. A more balanced experience, where students reap the positive benefits of PAC but do not lose exposure to a diverse patient pool, could result. Furthermore, some of the perceived positive impacts also may be related to professional and personal attributes of the teaching clinicians rather than to the PAC setting.

Conclusion

PAC settings can be effective training sites for medicine clerkships for PA students and can provide high-quality training in IM as PA programs continue to expand. This setting offers students exposure to interprofessional, team-based care and the opportunity to care for patients with a broad range of disease complexity. Learning is further enhanced by the ability to follow patients longitudinally over their disease course as well as to work directly with teaching faculty and other interprofessional health care professionals. Evaluations of this novel clerkship experience have shown high levels of student satisfaction in knowledge growth, clinical skills, bedside teaching, and mentorship.

Acknowledgments
We thank Juman Hijab for her critical role in establishing and maintaining the clerkship. We thank Steven Simon, Matt Russell, and Thomas Parrino for their leadership and guidance in establishing and maintaining the clerkship. We thank the Boston University School of Medicine Physician Assistant Program Director Mary Warner for her support and guidance in creating and supporting the clerkship. In addition, we thank the interprofessional education faculty for their dedicated involvement in teaching, including Stephanie Saunders, Lindsay Lefers, Jessica Rawlins, Lindsay Brennan, Angela Viani, Eric Charette, Nicole O’Neil, Susan Nathan, Jordana Meyerson, Shivani Jindal, Wei Shen, Amy Hanson, Gilda Cain, and Kate Hinrichs.