For Residents

“Hi Dr. Burke, thanks for coming in today. My daughter struggles with depression and I feel like every time I try to reach out, I hit a dead end with her. How do I connect with someone, who by the nature of their disease, is hard to reach?”

The answer? I’m not quite sure. I stood in front of a classroom of parents, siblings, and persons struggling with mental health issues, lecturing about depression. I can tell you about the complex interplay of biologic, psychological, and social factors that can lead one to become depressed. I can tell you the prevalence of depression in today’s society, and how it is rising among all age groups. I can tell you a myriad of different treatments, from pharmacologic to therapeutic to procedural, for depression. But how, from a parent’s perspective, can you connect with your child struggling with depression when they do not want your help? That I cannot tell you, at least not yet, anyways.

I had connected with the National Alliance on Mental Illness (NAMI) in the Fall of 2018, when a patient of mine was discharged from hospitalization and told by a faith-based substance use treatment program that he would not be allowed to use any “mind-altering” medications when he returned to their program. Concerned about my patient, whom I had just stabilized with the use of medications, I did my best to work through that organization’s resistance to psychotropic medications. When that failed, I reached out to NAMI for help in advocating for persons with mental illness. My involvement escalated to giving a lecture on “Living with Depression” to our local chapter of approximately 25 individuals that night. I had expected to lecture to an engaged crowd about what I thought was my immense knowledge of depression, from diagnosis to development to treatment. What I had not expected, however, was to have a learning experience of my own.

I stood at the front of the room, listening to story after story of persons with depression and their family members discussing their experiences. Throughout the 90-minute lecture, my emotions ranged from being impressed to shocked, scared, and, ultimately, proud. For the past year and 7 months, I had been spending time with persons with mental illness on what was likely the worst days of their lives. I had seen a variety of severe presentations, from grossly psychotic to acutely manic to majorly depressed to highly agitated. With that wealth of experience, I had thought I was becoming an expert; however, at the front of that classroom that night, I realized how little I actually knew. Yes, I had contemplated before how much severe mental illness and hospitalization could affect a person and their loved ones. However, it was a different level of understanding to hear first-hand accounts of the loss of relationships, the struggle to connect, and the fall-out from intensive inpatient treatment.

In residency, we spend what seems like an immeasurable amount of time on inpatient psychiatric units, in outpatient clinics, and everywhere in between. We see so many patients on a daily, weekly, monthly, and yearly basis that it becomes easy to lose the individuality of each patient. We start associating patients with their disorder, rather than with who they are. However, if we take a step back and allow a larger perspective—one that considers not only the patient but their families and communities—we likely would be able to provide greater and more comprehensive care.

My experience at NAMI was one that I will treasure forever. It opened my eyes to struggles that had I failed to even notice, and for that, and many other connections I made, I am grateful to have been blessed with this experience. My greatest recommendation to my fellow residents would be to engage with your local community organizations in the hope that you, too, can have an eye-opening experience that will strengthen your practice.

“Hi Dr. Burke, thanks for coming in today. My daughter struggles with depression and I feel like every time I try to reach out, I hit a dead end with her. How do I connect with someone, who by the nature of their disease, is hard to reach?”

The answer? I’m not quite sure. I stood in front of a classroom of parents, siblings, and persons struggling with mental health issues, lecturing about depression. I can tell you about the complex interplay of biologic, psychological, and social factors that can lead one to become depressed. I can tell you the prevalence of depression in today’s society, and how it is rising among all age groups. I can tell you a myriad of different treatments, from pharmacologic to therapeutic to procedural, for depression. But how, from a parent’s perspective, can you connect with your child struggling with depression when they do not want your help? That I cannot tell you, at least not yet, anyways.

I had connected with the National Alliance on Mental Illness (NAMI) in the Fall of 2018, when a patient of mine was discharged from hospitalization and told by a faith-based substance use treatment program that he would not be allowed to use any “mind-altering” medications when he returned to their program. Concerned about my patient, whom I had just stabilized with the use of medications, I did my best to work through that organization’s resistance to psychotropic medications. When that failed, I reached out to NAMI for help in advocating for persons with mental illness. My involvement escalated to giving a lecture on “Living with Depression” to our local chapter of approximately 25 individuals that night. I had expected to lecture to an engaged crowd about what I thought was my immense knowledge of depression, from diagnosis to development to treatment. What I had not expected, however, was to have a learning experience of my own.

I stood at the front of the room, listening to story after story of persons with depression and their family members discussing their experiences. Throughout the 90-minute lecture, my emotions ranged from being impressed to shocked, scared, and, ultimately, proud. For the past year and 7 months, I had been spending time with persons with mental illness on what was likely the worst days of their lives. I had seen a variety of severe presentations, from grossly psychotic to acutely manic to majorly depressed to highly agitated. With that wealth of experience, I had thought I was becoming an expert; however, at the front of that classroom that night, I realized how little I actually knew. Yes, I had contemplated before how much severe mental illness and hospitalization could affect a person and their loved ones. However, it was a different level of understanding to hear first-hand accounts of the loss of relationships, the struggle to connect, and the fall-out from intensive inpatient treatment.

In residency, we spend what seems like an immeasurable amount of time on inpatient psychiatric units, in outpatient clinics, and everywhere in between. We see so many patients on a daily, weekly, monthly, and yearly basis that it becomes easy to lose the individuality of each patient. We start associating patients with their disorder, rather than with who they are. However, if we take a step back and allow a larger perspective—one that considers not only the patient but their families and communities—we likely would be able to provide greater and more comprehensive care.

My experience at NAMI was one that I will treasure forever. It opened my eyes to struggles that had I failed to even notice, and for that, and many other connections I made, I am grateful to have been blessed with this experience. My greatest recommendation to my fellow residents would be to engage with your local community organizations in the hope that you, too, can have an eye-opening experience that will strengthen your practice.

“Hi Dr. Burke, thanks for coming in today. My daughter struggles with depression and I feel like every time I try to reach out, I hit a dead end with her. How do I connect with someone, who by the nature of their disease, is hard to reach?”

The answer? I’m not quite sure. I stood in front of a classroom of parents, siblings, and persons struggling with mental health issues, lecturing about depression. I can tell you about the complex interplay of biologic, psychological, and social factors that can lead one to become depressed. I can tell you the prevalence of depression in today’s society, and how it is rising among all age groups. I can tell you a myriad of different treatments, from pharmacologic to therapeutic to procedural, for depression. But how, from a parent’s perspective, can you connect with your child struggling with depression when they do not want your help? That I cannot tell you, at least not yet, anyways.

I had connected with the National Alliance on Mental Illness (NAMI) in the Fall of 2018, when a patient of mine was discharged from hospitalization and told by a faith-based substance use treatment program that he would not be allowed to use any “mind-altering” medications when he returned to their program. Concerned about my patient, whom I had just stabilized with the use of medications, I did my best to work through that organization’s resistance to psychotropic medications. When that failed, I reached out to NAMI for help in advocating for persons with mental illness. My involvement escalated to giving a lecture on “Living with Depression” to our local chapter of approximately 25 individuals that night. I had expected to lecture to an engaged crowd about what I thought was my immense knowledge of depression, from diagnosis to development to treatment. What I had not expected, however, was to have a learning experience of my own.

I stood at the front of the room, listening to story after story of persons with depression and their family members discussing their experiences. Throughout the 90-minute lecture, my emotions ranged from being impressed to shocked, scared, and, ultimately, proud. For the past year and 7 months, I had been spending time with persons with mental illness on what was likely the worst days of their lives. I had seen a variety of severe presentations, from grossly psychotic to acutely manic to majorly depressed to highly agitated. With that wealth of experience, I had thought I was becoming an expert; however, at the front of that classroom that night, I realized how little I actually knew. Yes, I had contemplated before how much severe mental illness and hospitalization could affect a person and their loved ones. However, it was a different level of understanding to hear first-hand accounts of the loss of relationships, the struggle to connect, and the fall-out from intensive inpatient treatment.

In residency, we spend what seems like an immeasurable amount of time on inpatient psychiatric units, in outpatient clinics, and everywhere in between. We see so many patients on a daily, weekly, monthly, and yearly basis that it becomes easy to lose the individuality of each patient. We start associating patients with their disorder, rather than with who they are. However, if we take a step back and allow a larger perspective—one that considers not only the patient but their families and communities—we likely would be able to provide greater and more comprehensive care.

My experience at NAMI was one that I will treasure forever. It opened my eyes to struggles that had I failed to even notice, and for that, and many other connections I made, I am grateful to have been blessed with this experience. My greatest recommendation to my fellow residents would be to engage with your local community organizations in the hope that you, too, can have an eye-opening experience that will strengthen your practice.

Two patients were admitted to our unit at the same time: Mr. P, age 27, an architect with unspecified personality disorder, and Mr. D, age 62, a bank manager who has had bipolar disorder for 40 years and was experiencing a moderate depressive episode. Mr. P’s discomfort with the treatment team informing him of his treatment plan was evident, and he discussed at length his terms and stipulations for management. Mr. D, on the other hand, was loath to shoulder the burden of any decision-making, even in minor matters such as what time he should take his daily walk.

Patient autonomy is a central factor in the present-day doctor–patient equation. In psychiatry, this is sometimes further complicated by a patient’s impaired judgment and lowered decision-making capacity (DMC). In our clinical practice, we often notice that younger patients (ie, millennials) prefer to have autonomy rather than being given instructions, which they may find patronizing, whereas the older generation relies more on the doctor for decision-making.

What the decision-making process entails

The decision-making process involves 3 steps:

• information gathering
• deliberation
• implementation.

Decision-making preferences fall on a spectrum that ranges from paternalism at one end to autonomy on the other, with many intervening components, characterized by varying amounts of responsibility shared between doctor and patient.¹ This typically comes into play when there is more than one treatment option with similar outcomes.² Paternalism is defined as an action performed with the intent of promoting another’s good but occurring against the other’s will, or without consent.³ Here, the patient is not privy to the deliberation process, and no explanations are provided.¹Hard paternalism focuses on doing good for the patient rather than respecting his or her decision-making, whereas soft paternalism implies trying to raise one final red flag, but ultimately not standing in the way of the patient’s choice.⁴

Two other decision-making constructs are shared decision-making (SDM) and informed decision-making (IDM). In SDM, the deliberation process involves participation of both patient and doctor, with active discussion and a final decision after both parties reach an agreement. In IDM, the deliberation is conducted solely by the patient, after he or she receives all information. Shared decision-making and IDM are frequently used interchangeably, but in the latter, the doctor has no role other than to provide information.^1,5

Before choosing SDM or IDM, it is necessary to assess the patient’s DMC—the ability to understand information about choices, make a judgment that respects personal values, understand potential outcomes, and freely communicate his or her wishes.⁶

Benefits and risks

The progression from paternalism to autonomy began in the mid-20th century as a consequence of the Nuremberg Trials, from which the concept of “informed consent” first came into existence.⁷ The Indian value system has always regarded the medical profession and its practitioners with high esteem, as evidenced by the Sanskrit quote “Vaidyo Narayano Harihi,” which translates to “The doctor is God.” A significant chunk of the Indian population still considers the doctor’s word to be law, and they hand over health-related decisions to medical professionals. Here, the expectation of a paternalistic attitude is decidedly unequivocal.

Continue to: Of course...

Of course, there are pros and cons to every approach. Making patients’ independence a priority is the highest virtue of autonomy, but in such cases a patient may have difficulty comprehending medical consequences, and therefore may miss out on the benefits of a sound professional perspective. Paternalism may be superior medically, but the doctor may not be aware of all patient-specific factors, and it would not be prudent to make a decision for a patient without being privy to the entire picture.

The 21st century has witnessed a change in attitudes regarding medical care. With an increasing interest in patient autonomy, it is time for us to adopt these changes and move towards the patient-centred end of the spectrum. However, this should occur only after the patient improves enough symptomatically to regain DMC; autonomy is unlikely to be appropriate for patients with serious mental illness. Ideally, SDM includes the best of both worlds, and results in optimal outcomes. However, when SDM breaks down, a selective, soft paternalistic attitude would be most beneficial, without impinging on the patient’s basic personal rights.

Two patients were admitted to our unit at the same time: Mr. P, age 27, an architect with unspecified personality disorder, and Mr. D, age 62, a bank manager who has had bipolar disorder for 40 years and was experiencing a moderate depressive episode. Mr. P’s discomfort with the treatment team informing him of his treatment plan was evident, and he discussed at length his terms and stipulations for management. Mr. D, on the other hand, was loath to shoulder the burden of any decision-making, even in minor matters such as what time he should take his daily walk.

Patient autonomy is a central factor in the present-day doctor–patient equation. In psychiatry, this is sometimes further complicated by a patient’s impaired judgment and lowered decision-making capacity (DMC). In our clinical practice, we often notice that younger patients (ie, millennials) prefer to have autonomy rather than being given instructions, which they may find patronizing, whereas the older generation relies more on the doctor for decision-making.

What the decision-making process entails

The decision-making process involves 3 steps:

• information gathering
• deliberation
• implementation.

Decision-making preferences fall on a spectrum that ranges from paternalism at one end to autonomy on the other, with many intervening components, characterized by varying amounts of responsibility shared between doctor and patient.¹ This typically comes into play when there is more than one treatment option with similar outcomes.² Paternalism is defined as an action performed with the intent of promoting another’s good but occurring against the other’s will, or without consent.³ Here, the patient is not privy to the deliberation process, and no explanations are provided.¹Hard paternalism focuses on doing good for the patient rather than respecting his or her decision-making, whereas soft paternalism implies trying to raise one final red flag, but ultimately not standing in the way of the patient’s choice.⁴

Two other decision-making constructs are shared decision-making (SDM) and informed decision-making (IDM). In SDM, the deliberation process involves participation of both patient and doctor, with active discussion and a final decision after both parties reach an agreement. In IDM, the deliberation is conducted solely by the patient, after he or she receives all information. Shared decision-making and IDM are frequently used interchangeably, but in the latter, the doctor has no role other than to provide information.^1,5

Before choosing SDM or IDM, it is necessary to assess the patient’s DMC—the ability to understand information about choices, make a judgment that respects personal values, understand potential outcomes, and freely communicate his or her wishes.⁶

Benefits and risks

The progression from paternalism to autonomy began in the mid-20th century as a consequence of the Nuremberg Trials, from which the concept of “informed consent” first came into existence.⁷ The Indian value system has always regarded the medical profession and its practitioners with high esteem, as evidenced by the Sanskrit quote “Vaidyo Narayano Harihi,” which translates to “The doctor is God.” A significant chunk of the Indian population still considers the doctor’s word to be law, and they hand over health-related decisions to medical professionals. Here, the expectation of a paternalistic attitude is decidedly unequivocal.

Continue to: Of course...

Of course, there are pros and cons to every approach. Making patients’ independence a priority is the highest virtue of autonomy, but in such cases a patient may have difficulty comprehending medical consequences, and therefore may miss out on the benefits of a sound professional perspective. Paternalism may be superior medically, but the doctor may not be aware of all patient-specific factors, and it would not be prudent to make a decision for a patient without being privy to the entire picture.

The 21st century has witnessed a change in attitudes regarding medical care. With an increasing interest in patient autonomy, it is time for us to adopt these changes and move towards the patient-centred end of the spectrum. However, this should occur only after the patient improves enough symptomatically to regain DMC; autonomy is unlikely to be appropriate for patients with serious mental illness. Ideally, SDM includes the best of both worlds, and results in optimal outcomes. However, when SDM breaks down, a selective, soft paternalistic attitude would be most beneficial, without impinging on the patient’s basic personal rights.

Two patients were admitted to our unit at the same time: Mr. P, age 27, an architect with unspecified personality disorder, and Mr. D, age 62, a bank manager who has had bipolar disorder for 40 years and was experiencing a moderate depressive episode. Mr. P’s discomfort with the treatment team informing him of his treatment plan was evident, and he discussed at length his terms and stipulations for management. Mr. D, on the other hand, was loath to shoulder the burden of any decision-making, even in minor matters such as what time he should take his daily walk.

Patient autonomy is a central factor in the present-day doctor–patient equation. In psychiatry, this is sometimes further complicated by a patient’s impaired judgment and lowered decision-making capacity (DMC). In our clinical practice, we often notice that younger patients (ie, millennials) prefer to have autonomy rather than being given instructions, which they may find patronizing, whereas the older generation relies more on the doctor for decision-making.

What the decision-making process entails

The decision-making process involves 3 steps:

• information gathering
• deliberation
• implementation.

Decision-making preferences fall on a spectrum that ranges from paternalism at one end to autonomy on the other, with many intervening components, characterized by varying amounts of responsibility shared between doctor and patient.¹ This typically comes into play when there is more than one treatment option with similar outcomes.² Paternalism is defined as an action performed with the intent of promoting another’s good but occurring against the other’s will, or without consent.³ Here, the patient is not privy to the deliberation process, and no explanations are provided.¹Hard paternalism focuses on doing good for the patient rather than respecting his or her decision-making, whereas soft paternalism implies trying to raise one final red flag, but ultimately not standing in the way of the patient’s choice.⁴

Two other decision-making constructs are shared decision-making (SDM) and informed decision-making (IDM). In SDM, the deliberation process involves participation of both patient and doctor, with active discussion and a final decision after both parties reach an agreement. In IDM, the deliberation is conducted solely by the patient, after he or she receives all information. Shared decision-making and IDM are frequently used interchangeably, but in the latter, the doctor has no role other than to provide information.^1,5

Before choosing SDM or IDM, it is necessary to assess the patient’s DMC—the ability to understand information about choices, make a judgment that respects personal values, understand potential outcomes, and freely communicate his or her wishes.⁶

Benefits and risks

The progression from paternalism to autonomy began in the mid-20th century as a consequence of the Nuremberg Trials, from which the concept of “informed consent” first came into existence.⁷ The Indian value system has always regarded the medical profession and its practitioners with high esteem, as evidenced by the Sanskrit quote “Vaidyo Narayano Harihi,” which translates to “The doctor is God.” A significant chunk of the Indian population still considers the doctor’s word to be law, and they hand over health-related decisions to medical professionals. Here, the expectation of a paternalistic attitude is decidedly unequivocal.

Continue to: Of course...

Of course, there are pros and cons to every approach. Making patients’ independence a priority is the highest virtue of autonomy, but in such cases a patient may have difficulty comprehending medical consequences, and therefore may miss out on the benefits of a sound professional perspective. Paternalism may be superior medically, but the doctor may not be aware of all patient-specific factors, and it would not be prudent to make a decision for a patient without being privy to the entire picture.

The 21st century has witnessed a change in attitudes regarding medical care. With an increasing interest in patient autonomy, it is time for us to adopt these changes and move towards the patient-centred end of the spectrum. However, this should occur only after the patient improves enough symptomatically to regain DMC; autonomy is unlikely to be appropriate for patients with serious mental illness. Ideally, SDM includes the best of both worlds, and results in optimal outcomes. However, when SDM breaks down, a selective, soft paternalistic attitude would be most beneficial, without impinging on the patient’s basic personal rights.

A yoga-based wellness program was associated with reductions in blood pressure and measures of depersonalization in a pilot study of ob.gyn. trainees, according to Shilpa Babbar, MD, of Saint Louis University, and associates.

The wellness program consisted of weekly 1-hour yoga classes over an 8-week period as well as weekly physical and nutritional challenges. The 29 people recruited to participate had their blood pressures, heart rates, and weights measured at baseline; they also took the abbreviated Maslach Burnout Inventory, the Depression Anxiety Stress Scale, and the Five Facet Mindfulness Questionnaire. These tests were repeated after the 8-week study period.

Of the 29 people who were recruited, 25 completed the study and 26 attended at least one class. Those who completed the program attended a mean of 3.8 classes, and 68% of participants attended at least half of the classes; no participant attended all classes. Participation in the weekly challenges was slightly less common, with 80% of participants engaging in at least one nutrition challenge and 60% of participants engaging in at least one physical challenge.

After the program had ended, participants had a significant decrease in the depersonalization component of burnout (P = .04), anxiety (P = .02), and systolic (P = .01) and diastolic (P = .01) blood pressures. In addition, those who attended more than 50% of classes had significantly lower systolic and diastolic blood pressures, compared with those who attended less frequently (P = .02 and P = .04, respectively). Participants also expressed increased camaraderie, appreciation, motivation, and overall training experience in a postprogram survey.

“Future studies providing evidence-based, multidisciplinary solutions are needed to improve not only the well-being of the caregiver, but also patient care and overall health care system performance,” the investigators concluded.

One coauthor reported consulting with Health Insights Collaborative; no other conflicts of interest were reported.

[email protected]

SOURCE: Babbar S et al. Obstet Gynecol. 2019 May;133(5):994-1001.

A yoga-based wellness program was associated with reductions in blood pressure and measures of depersonalization in a pilot study of ob.gyn. trainees, according to Shilpa Babbar, MD, of Saint Louis University, and associates.

The wellness program consisted of weekly 1-hour yoga classes over an 8-week period as well as weekly physical and nutritional challenges. The 29 people recruited to participate had their blood pressures, heart rates, and weights measured at baseline; they also took the abbreviated Maslach Burnout Inventory, the Depression Anxiety Stress Scale, and the Five Facet Mindfulness Questionnaire. These tests were repeated after the 8-week study period.

Of the 29 people who were recruited, 25 completed the study and 26 attended at least one class. Those who completed the program attended a mean of 3.8 classes, and 68% of participants attended at least half of the classes; no participant attended all classes. Participation in the weekly challenges was slightly less common, with 80% of participants engaging in at least one nutrition challenge and 60% of participants engaging in at least one physical challenge.

After the program had ended, participants had a significant decrease in the depersonalization component of burnout (P = .04), anxiety (P = .02), and systolic (P = .01) and diastolic (P = .01) blood pressures. In addition, those who attended more than 50% of classes had significantly lower systolic and diastolic blood pressures, compared with those who attended less frequently (P = .02 and P = .04, respectively). Participants also expressed increased camaraderie, appreciation, motivation, and overall training experience in a postprogram survey.

“Future studies providing evidence-based, multidisciplinary solutions are needed to improve not only the well-being of the caregiver, but also patient care and overall health care system performance,” the investigators concluded.

One coauthor reported consulting with Health Insights Collaborative; no other conflicts of interest were reported.

[email protected]

SOURCE: Babbar S et al. Obstet Gynecol. 2019 May;133(5):994-1001.

A yoga-based wellness program was associated with reductions in blood pressure and measures of depersonalization in a pilot study of ob.gyn. trainees, according to Shilpa Babbar, MD, of Saint Louis University, and associates.

The wellness program consisted of weekly 1-hour yoga classes over an 8-week period as well as weekly physical and nutritional challenges. The 29 people recruited to participate had their blood pressures, heart rates, and weights measured at baseline; they also took the abbreviated Maslach Burnout Inventory, the Depression Anxiety Stress Scale, and the Five Facet Mindfulness Questionnaire. These tests were repeated after the 8-week study period.

Of the 29 people who were recruited, 25 completed the study and 26 attended at least one class. Those who completed the program attended a mean of 3.8 classes, and 68% of participants attended at least half of the classes; no participant attended all classes. Participation in the weekly challenges was slightly less common, with 80% of participants engaging in at least one nutrition challenge and 60% of participants engaging in at least one physical challenge.

After the program had ended, participants had a significant decrease in the depersonalization component of burnout (P = .04), anxiety (P = .02), and systolic (P = .01) and diastolic (P = .01) blood pressures. In addition, those who attended more than 50% of classes had significantly lower systolic and diastolic blood pressures, compared with those who attended less frequently (P = .02 and P = .04, respectively). Participants also expressed increased camaraderie, appreciation, motivation, and overall training experience in a postprogram survey.

“Future studies providing evidence-based, multidisciplinary solutions are needed to improve not only the well-being of the caregiver, but also patient care and overall health care system performance,” the investigators concluded.

One coauthor reported consulting with Health Insights Collaborative; no other conflicts of interest were reported.

[email protected]

SOURCE: Babbar S et al. Obstet Gynecol. 2019 May;133(5):994-1001.

Originating in 1968, the dermatologic surgery fellowship is as young as many dermatologists in practice today. Not surprisingly, the blossoming fellowship has undergone its fair share of both growth and growing pains over the last 5 decades. 

A Brief History

The first dermatologic surgery fellowship was born in 1968 when Dr. Perry Robins established a program at the New York University Medical Center for training in chemosurgery.¹ The fellowship quickly underwent notable change with the rising popularity of the fresh tissue technique, which was first performed by Dr. Fred Mohs in 1953 and made popular following publication of a series of landmark articles on the technique by Drs. Sam Stegman and Theodore Tromovitch in the late 1960s and early 1970s. The fellowship correspondingly saw a rise in fresh tissue technique training, accompanied by a decline in chemosurgery training. In 1974, Dr. Daniel Jones coined the term micrographic surgery to describe the favored technique, and at the 1985 annual meeting of the American College of Chemosurgery, the name of the technique was changed to Mohs micrographic surgery.¹

By 1995, the fellowship was officially named Procedural Dermatology, and programs were exclusively accredited by the American College of Mohs Surgery (ACMS). A 1-year Procedural Dermatology fellowship gained accreditation by the Accreditation Council for Graduate Medical Education (ACGME) in 2003.² Beginning in July 2013, all fellowship programs in the United States fell under the governance of the ACGME; however, the ACMS has remained the sponsor of the matching process.³ In 2014, the ACGME changed the name of the fellowship to Micrographic Surgery and Dermatologic Oncology (MSDO).² Fellowship training today is centered on the core elements of cutaneous oncologic surgery, cutaneous reconstructive surgery, and dermatologic oncology; however, the scope of training in technologies and techniques offered has continued to broaden.⁴ Many programs now offer additional training in cosmetic and other procedural dermatology. To date, there are 76 accredited MSDO fellowship training programs in the United States and more than 1500 fellowship-trained micrographic surgeons.^2,4

Trends in Program and Match Statistics

As the role of dermatologic surgery within the field of dermatology continues to expand, the MSDO fellowship has become increasingly popular over the last decade. From 2005 to 2018, applicants participating in the fellowship match increased by 34%.³ Despite the fellowship’s growing popularity, programs participating in the match have remained largely stable from 2005 to 2018, with 50 positions offered in 2005 and 58 in 2018. The match rate has correspondingly decreased from 66.2% in 2005 to 61.1% in 2018.³ 

Changes in the Match Process

The fellowship match is processed by the SF Match and sponsored by the ACMS. Over the last decade, programs have increasingly opted for exemptions from participation in the SF Match. In 2005, there were 8 match exemptions. In 2018, there were 20.⁴ Despite the increasing popularity of match exemptions, in October 2018 the ACMS Board of Directors approved a new policy that eliminated match exemptions, with the exception of applicants on active military duty and international (non-Canadian) applicants. All other applicants applying for a fellowship position for the 2020-2021 academic year must participate in the match.⁴ This new policy attempts to ensure a fair match process, especially for applicants who have trained at a program without an affiliated MSDO fellowship. 

The Road to Board Certification

Further growth during the fellowship’s mid-adult years centered on the long-contested debate on subspecialty board certification. In 2009, an American Society for Dermatologic Surgery membership survey demonstrated an overwhelming majority in opposition. In 2014, the debate resurfaced. At the 2016 American Society for Dermatologic Surgery annual meeting, former American Academy of Dermatology presidents Brett Coldiron, MD, and Darrell S. Rigel, MD, MS, conveyed opposing positions, after which an audience survey demonstrated a 69% opposition rate. Proponents continued to argue that board certification would decrease divisiveness in the specialty, create a better brand, help to obtain a Medicare specialty designation that could help prevent exclusion of Mohs surgeons from insurance networks, give allopathic dermatologists the same opportunity for certification as osteopathic counterparts, and demonstrate competence to the public. Those in opposition argued that the term dermatologic oncology erroneously suggests general dermatologists are not experts in the treatment of skin cancers, practices may be restricted by carriers misusing the new credential, and subspecialty certification would actually create division among practicing dermatologists.⁵

Following years of debate, the American Board of Dermatology’s proposal to offer subspecialty certification in Micrographic Dermatologic Surgery was submitted to the American Board of Medical Specialties and approved on October 26, 2018. The name of the new subspecialty (Micrographic Dermatologic Surgery) is different than that of the fellowship (Micrographic Surgery and Dermatologic Oncology), a decision reached in response to diplomats indicating discomfort with the term oncology potentially misleading the public that general dermatologists do not treat skin cancer. Per the American Board of Dermatology official website, the first certification examination likely will take place in about 2 years. A maintenance of certification examination for the subspecialty will be required every 10 years.⁶

Final Thoughts 

During its short history, the MSDO fellowship has undergone a notable evolution in recognition, popularity among residents, match process, and board certification, which attests to its adaptability over time and growing prominence.

Originating in 1968, the dermatologic surgery fellowship is as young as many dermatologists in practice today. Not surprisingly, the blossoming fellowship has undergone its fair share of both growth and growing pains over the last 5 decades. 

A Brief History

The first dermatologic surgery fellowship was born in 1968 when Dr. Perry Robins established a program at the New York University Medical Center for training in chemosurgery.¹ The fellowship quickly underwent notable change with the rising popularity of the fresh tissue technique, which was first performed by Dr. Fred Mohs in 1953 and made popular following publication of a series of landmark articles on the technique by Drs. Sam Stegman and Theodore Tromovitch in the late 1960s and early 1970s. The fellowship correspondingly saw a rise in fresh tissue technique training, accompanied by a decline in chemosurgery training. In 1974, Dr. Daniel Jones coined the term micrographic surgery to describe the favored technique, and at the 1985 annual meeting of the American College of Chemosurgery, the name of the technique was changed to Mohs micrographic surgery.¹

By 1995, the fellowship was officially named Procedural Dermatology, and programs were exclusively accredited by the American College of Mohs Surgery (ACMS). A 1-year Procedural Dermatology fellowship gained accreditation by the Accreditation Council for Graduate Medical Education (ACGME) in 2003.² Beginning in July 2013, all fellowship programs in the United States fell under the governance of the ACGME; however, the ACMS has remained the sponsor of the matching process.³ In 2014, the ACGME changed the name of the fellowship to Micrographic Surgery and Dermatologic Oncology (MSDO).² Fellowship training today is centered on the core elements of cutaneous oncologic surgery, cutaneous reconstructive surgery, and dermatologic oncology; however, the scope of training in technologies and techniques offered has continued to broaden.⁴ Many programs now offer additional training in cosmetic and other procedural dermatology. To date, there are 76 accredited MSDO fellowship training programs in the United States and more than 1500 fellowship-trained micrographic surgeons.^2,4

Trends in Program and Match Statistics

As the role of dermatologic surgery within the field of dermatology continues to expand, the MSDO fellowship has become increasingly popular over the last decade. From 2005 to 2018, applicants participating in the fellowship match increased by 34%.³ Despite the fellowship’s growing popularity, programs participating in the match have remained largely stable from 2005 to 2018, with 50 positions offered in 2005 and 58 in 2018. The match rate has correspondingly decreased from 66.2% in 2005 to 61.1% in 2018.³ 

Changes in the Match Process

The fellowship match is processed by the SF Match and sponsored by the ACMS. Over the last decade, programs have increasingly opted for exemptions from participation in the SF Match. In 2005, there were 8 match exemptions. In 2018, there were 20.⁴ Despite the increasing popularity of match exemptions, in October 2018 the ACMS Board of Directors approved a new policy that eliminated match exemptions, with the exception of applicants on active military duty and international (non-Canadian) applicants. All other applicants applying for a fellowship position for the 2020-2021 academic year must participate in the match.⁴ This new policy attempts to ensure a fair match process, especially for applicants who have trained at a program without an affiliated MSDO fellowship. 

The Road to Board Certification

Further growth during the fellowship’s mid-adult years centered on the long-contested debate on subspecialty board certification. In 2009, an American Society for Dermatologic Surgery membership survey demonstrated an overwhelming majority in opposition. In 2014, the debate resurfaced. At the 2016 American Society for Dermatologic Surgery annual meeting, former American Academy of Dermatology presidents Brett Coldiron, MD, and Darrell S. Rigel, MD, MS, conveyed opposing positions, after which an audience survey demonstrated a 69% opposition rate. Proponents continued to argue that board certification would decrease divisiveness in the specialty, create a better brand, help to obtain a Medicare specialty designation that could help prevent exclusion of Mohs surgeons from insurance networks, give allopathic dermatologists the same opportunity for certification as osteopathic counterparts, and demonstrate competence to the public. Those in opposition argued that the term dermatologic oncology erroneously suggests general dermatologists are not experts in the treatment of skin cancers, practices may be restricted by carriers misusing the new credential, and subspecialty certification would actually create division among practicing dermatologists.⁵

Following years of debate, the American Board of Dermatology’s proposal to offer subspecialty certification in Micrographic Dermatologic Surgery was submitted to the American Board of Medical Specialties and approved on October 26, 2018. The name of the new subspecialty (Micrographic Dermatologic Surgery) is different than that of the fellowship (Micrographic Surgery and Dermatologic Oncology), a decision reached in response to diplomats indicating discomfort with the term oncology potentially misleading the public that general dermatologists do not treat skin cancer. Per the American Board of Dermatology official website, the first certification examination likely will take place in about 2 years. A maintenance of certification examination for the subspecialty will be required every 10 years.⁶

Final Thoughts 

During its short history, the MSDO fellowship has undergone a notable evolution in recognition, popularity among residents, match process, and board certification, which attests to its adaptability over time and growing prominence.

Originating in 1968, the dermatologic surgery fellowship is as young as many dermatologists in practice today. Not surprisingly, the blossoming fellowship has undergone its fair share of both growth and growing pains over the last 5 decades. 

A Brief History

The first dermatologic surgery fellowship was born in 1968 when Dr. Perry Robins established a program at the New York University Medical Center for training in chemosurgery.¹ The fellowship quickly underwent notable change with the rising popularity of the fresh tissue technique, which was first performed by Dr. Fred Mohs in 1953 and made popular following publication of a series of landmark articles on the technique by Drs. Sam Stegman and Theodore Tromovitch in the late 1960s and early 1970s. The fellowship correspondingly saw a rise in fresh tissue technique training, accompanied by a decline in chemosurgery training. In 1974, Dr. Daniel Jones coined the term micrographic surgery to describe the favored technique, and at the 1985 annual meeting of the American College of Chemosurgery, the name of the technique was changed to Mohs micrographic surgery.¹

By 1995, the fellowship was officially named Procedural Dermatology, and programs were exclusively accredited by the American College of Mohs Surgery (ACMS). A 1-year Procedural Dermatology fellowship gained accreditation by the Accreditation Council for Graduate Medical Education (ACGME) in 2003.² Beginning in July 2013, all fellowship programs in the United States fell under the governance of the ACGME; however, the ACMS has remained the sponsor of the matching process.³ In 2014, the ACGME changed the name of the fellowship to Micrographic Surgery and Dermatologic Oncology (MSDO).² Fellowship training today is centered on the core elements of cutaneous oncologic surgery, cutaneous reconstructive surgery, and dermatologic oncology; however, the scope of training in technologies and techniques offered has continued to broaden.⁴ Many programs now offer additional training in cosmetic and other procedural dermatology. To date, there are 76 accredited MSDO fellowship training programs in the United States and more than 1500 fellowship-trained micrographic surgeons.^2,4

Trends in Program and Match Statistics

As the role of dermatologic surgery within the field of dermatology continues to expand, the MSDO fellowship has become increasingly popular over the last decade. From 2005 to 2018, applicants participating in the fellowship match increased by 34%.³ Despite the fellowship’s growing popularity, programs participating in the match have remained largely stable from 2005 to 2018, with 50 positions offered in 2005 and 58 in 2018. The match rate has correspondingly decreased from 66.2% in 2005 to 61.1% in 2018.³ 

Changes in the Match Process

The fellowship match is processed by the SF Match and sponsored by the ACMS. Over the last decade, programs have increasingly opted for exemptions from participation in the SF Match. In 2005, there were 8 match exemptions. In 2018, there were 20.⁴ Despite the increasing popularity of match exemptions, in October 2018 the ACMS Board of Directors approved a new policy that eliminated match exemptions, with the exception of applicants on active military duty and international (non-Canadian) applicants. All other applicants applying for a fellowship position for the 2020-2021 academic year must participate in the match.⁴ This new policy attempts to ensure a fair match process, especially for applicants who have trained at a program without an affiliated MSDO fellowship. 

The Road to Board Certification

Further growth during the fellowship’s mid-adult years centered on the long-contested debate on subspecialty board certification. In 2009, an American Society for Dermatologic Surgery membership survey demonstrated an overwhelming majority in opposition. In 2014, the debate resurfaced. At the 2016 American Society for Dermatologic Surgery annual meeting, former American Academy of Dermatology presidents Brett Coldiron, MD, and Darrell S. Rigel, MD, MS, conveyed opposing positions, after which an audience survey demonstrated a 69% opposition rate. Proponents continued to argue that board certification would decrease divisiveness in the specialty, create a better brand, help to obtain a Medicare specialty designation that could help prevent exclusion of Mohs surgeons from insurance networks, give allopathic dermatologists the same opportunity for certification as osteopathic counterparts, and demonstrate competence to the public. Those in opposition argued that the term dermatologic oncology erroneously suggests general dermatologists are not experts in the treatment of skin cancers, practices may be restricted by carriers misusing the new credential, and subspecialty certification would actually create division among practicing dermatologists.⁵

Following years of debate, the American Board of Dermatology’s proposal to offer subspecialty certification in Micrographic Dermatologic Surgery was submitted to the American Board of Medical Specialties and approved on October 26, 2018. The name of the new subspecialty (Micrographic Dermatologic Surgery) is different than that of the fellowship (Micrographic Surgery and Dermatologic Oncology), a decision reached in response to diplomats indicating discomfort with the term oncology potentially misleading the public that general dermatologists do not treat skin cancer. Per the American Board of Dermatology official website, the first certification examination likely will take place in about 2 years. A maintenance of certification examination for the subspecialty will be required every 10 years.⁶

Final Thoughts 

During its short history, the MSDO fellowship has undergone a notable evolution in recognition, popularity among residents, match process, and board certification, which attests to its adaptability over time and growing prominence.

I had the unique opportunity to attend a civilian medical school followed by residency and fellowship training along civilian providers, and I often was asked about my military experience. The more time I spent with civilian providers, the more I realized how unaware they are about the intricacies of military lifestyle and culture.

Of course, this makes sense. During the draft era, almost every family had a member who served, and more people were exposed to the uniqueness of military culture.¹ However, with the shift to an all-volunteer military came a decrease in the number of both active duty members and veterans.² Consequently, today’s society is generally less aware of the realities of the military lifestyle. This is especially true among people born after the Vietnam War, whose knowledge about military life is frequently limited to movies and video games. These movies and games are as accurate a reflection of military life as watching TV series such as ER or The Resident are for learning what it’s like to be a physician. To add to the problem, most medical schools and residency training curricula include little information about military culture.³ As a result, psychiatrists, like many other physicians, often feel unequipped to provide care for veterans, current military personnel, and their loved ones.⁴ At the very least, most psychiatrists are unaware of the differences between military and civilian cultures.

Veterans, current military members, and their families who seek mental health services outside the Veterans Affairs (VA) and military treatment facilities are more likely to encounter a clinician who does not feel comfortable with the nuances of the military lifestyle and its challenges.³ Facing a physician with limited familiarity with their experiences, and out of fear of being misunderstood, patients may not feel comfortable disclosing pertinent details.

The US military has its own culture, lingo, customs, rules, and regulations. Its structure is hierarchical and mission-oriented. The moment a person joins the military, he or she falls under a set of legal guidelines of the Uniform Code of Military Justice (UCMJ).⁵ For example, extra-marital sexual conduct, fistfighting (not in combat), disrespecting superior officers, and insubordination are all punishable under UCMJ.^5,6 Active duty military members are also prohibited from suing the federal government for injuries.⁷ The Health Insurance Portability and Accountability Act (HIPAA) permits protected health information of Armed Forces personnel to be disclosed under special circumstances. These include fitness for duty determinations, fitness to perform a particular assignment, or other activities necessary for the military mission.⁸ A mental health provider’s understanding of the unique aspects of military culture can positively influence the patient-provider relationship whether the patient is still serving, has left the military, or is a family member of a current or former military member.

Not all military veterans qualify for VA health care. For example, those who didn’t serve the required time on active duty, those whose injury existed prior to joining the military and was not worsened by their military service, and those discharged under other-than-honorable, bad conduct, or dishonorable conditions are unlikely to qualify.⁹ Other veterans simply prefer to be privately treated outside the VA. However, despite where a veteran receives treatment, the clinician’s knowledge of important military concepts can facilitate rapport-building and providing a safe space for disclosure of pertinent history. Obtaining a military history that includes (for example) years of service, number and location of deployments, combat experience, and number of transfers can help with understanding the biopsychosocial factors contributing to the diagnosis and important treatment needs.

While military dependents (spouses and children) don’t wear uniforms, they are also affected by the service and sacrifices of the military member. Spouses have to deal with adjusting to the military lifestyle, searching for new housing and jobs, finding schools for children, and separation and reconnection with a military member. Military children are not spared, either. They, too, have to leave their friends and find new ones, and adjust to new places, routines, and schools, knowing that in 2 to 3 years they likely will have to move again.

As a military member, mother, and spouse of a former military member, I know how life-changing military service can be for the entire family. I encourage all physicians to start routinely asking if their patient or his or her loved ones have ever been in the military, because a positive answer could help you to better understand the patient and provide the most appropriate, person-centered, culturally-informed treatment.

I had the unique opportunity to attend a civilian medical school followed by residency and fellowship training along civilian providers, and I often was asked about my military experience. The more time I spent with civilian providers, the more I realized how unaware they are about the intricacies of military lifestyle and culture.

Of course, this makes sense. During the draft era, almost every family had a member who served, and more people were exposed to the uniqueness of military culture.¹ However, with the shift to an all-volunteer military came a decrease in the number of both active duty members and veterans.² Consequently, today’s society is generally less aware of the realities of the military lifestyle. This is especially true among people born after the Vietnam War, whose knowledge about military life is frequently limited to movies and video games. These movies and games are as accurate a reflection of military life as watching TV series such as ER or The Resident are for learning what it’s like to be a physician. To add to the problem, most medical schools and residency training curricula include little information about military culture.³ As a result, psychiatrists, like many other physicians, often feel unequipped to provide care for veterans, current military personnel, and their loved ones.⁴ At the very least, most psychiatrists are unaware of the differences between military and civilian cultures.

Veterans, current military members, and their families who seek mental health services outside the Veterans Affairs (VA) and military treatment facilities are more likely to encounter a clinician who does not feel comfortable with the nuances of the military lifestyle and its challenges.³ Facing a physician with limited familiarity with their experiences, and out of fear of being misunderstood, patients may not feel comfortable disclosing pertinent details.

The US military has its own culture, lingo, customs, rules, and regulations. Its structure is hierarchical and mission-oriented. The moment a person joins the military, he or she falls under a set of legal guidelines of the Uniform Code of Military Justice (UCMJ).⁵ For example, extra-marital sexual conduct, fistfighting (not in combat), disrespecting superior officers, and insubordination are all punishable under UCMJ.^5,6 Active duty military members are also prohibited from suing the federal government for injuries.⁷ The Health Insurance Portability and Accountability Act (HIPAA) permits protected health information of Armed Forces personnel to be disclosed under special circumstances. These include fitness for duty determinations, fitness to perform a particular assignment, or other activities necessary for the military mission.⁸ A mental health provider’s understanding of the unique aspects of military culture can positively influence the patient-provider relationship whether the patient is still serving, has left the military, or is a family member of a current or former military member.

Not all military veterans qualify for VA health care. For example, those who didn’t serve the required time on active duty, those whose injury existed prior to joining the military and was not worsened by their military service, and those discharged under other-than-honorable, bad conduct, or dishonorable conditions are unlikely to qualify.⁹ Other veterans simply prefer to be privately treated outside the VA. However, despite where a veteran receives treatment, the clinician’s knowledge of important military concepts can facilitate rapport-building and providing a safe space for disclosure of pertinent history. Obtaining a military history that includes (for example) years of service, number and location of deployments, combat experience, and number of transfers can help with understanding the biopsychosocial factors contributing to the diagnosis and important treatment needs.

While military dependents (spouses and children) don’t wear uniforms, they are also affected by the service and sacrifices of the military member. Spouses have to deal with adjusting to the military lifestyle, searching for new housing and jobs, finding schools for children, and separation and reconnection with a military member. Military children are not spared, either. They, too, have to leave their friends and find new ones, and adjust to new places, routines, and schools, knowing that in 2 to 3 years they likely will have to move again.

As a military member, mother, and spouse of a former military member, I know how life-changing military service can be for the entire family. I encourage all physicians to start routinely asking if their patient or his or her loved ones have ever been in the military, because a positive answer could help you to better understand the patient and provide the most appropriate, person-centered, culturally-informed treatment.

I had the unique opportunity to attend a civilian medical school followed by residency and fellowship training along civilian providers, and I often was asked about my military experience. The more time I spent with civilian providers, the more I realized how unaware they are about the intricacies of military lifestyle and culture.

Of course, this makes sense. During the draft era, almost every family had a member who served, and more people were exposed to the uniqueness of military culture.¹ However, with the shift to an all-volunteer military came a decrease in the number of both active duty members and veterans.² Consequently, today’s society is generally less aware of the realities of the military lifestyle. This is especially true among people born after the Vietnam War, whose knowledge about military life is frequently limited to movies and video games. These movies and games are as accurate a reflection of military life as watching TV series such as ER or The Resident are for learning what it’s like to be a physician. To add to the problem, most medical schools and residency training curricula include little information about military culture.³ As a result, psychiatrists, like many other physicians, often feel unequipped to provide care for veterans, current military personnel, and their loved ones.⁴ At the very least, most psychiatrists are unaware of the differences between military and civilian cultures.

Veterans, current military members, and their families who seek mental health services outside the Veterans Affairs (VA) and military treatment facilities are more likely to encounter a clinician who does not feel comfortable with the nuances of the military lifestyle and its challenges.³ Facing a physician with limited familiarity with their experiences, and out of fear of being misunderstood, patients may not feel comfortable disclosing pertinent details.

The US military has its own culture, lingo, customs, rules, and regulations. Its structure is hierarchical and mission-oriented. The moment a person joins the military, he or she falls under a set of legal guidelines of the Uniform Code of Military Justice (UCMJ).⁵ For example, extra-marital sexual conduct, fistfighting (not in combat), disrespecting superior officers, and insubordination are all punishable under UCMJ.^5,6 Active duty military members are also prohibited from suing the federal government for injuries.⁷ The Health Insurance Portability and Accountability Act (HIPAA) permits protected health information of Armed Forces personnel to be disclosed under special circumstances. These include fitness for duty determinations, fitness to perform a particular assignment, or other activities necessary for the military mission.⁸ A mental health provider’s understanding of the unique aspects of military culture can positively influence the patient-provider relationship whether the patient is still serving, has left the military, or is a family member of a current or former military member.

Not all military veterans qualify for VA health care. For example, those who didn’t serve the required time on active duty, those whose injury existed prior to joining the military and was not worsened by their military service, and those discharged under other-than-honorable, bad conduct, or dishonorable conditions are unlikely to qualify.⁹ Other veterans simply prefer to be privately treated outside the VA. However, despite where a veteran receives treatment, the clinician’s knowledge of important military concepts can facilitate rapport-building and providing a safe space for disclosure of pertinent history. Obtaining a military history that includes (for example) years of service, number and location of deployments, combat experience, and number of transfers can help with understanding the biopsychosocial factors contributing to the diagnosis and important treatment needs.

While military dependents (spouses and children) don’t wear uniforms, they are also affected by the service and sacrifices of the military member. Spouses have to deal with adjusting to the military lifestyle, searching for new housing and jobs, finding schools for children, and separation and reconnection with a military member. Military children are not spared, either. They, too, have to leave their friends and find new ones, and adjust to new places, routines, and schools, knowing that in 2 to 3 years they likely will have to move again.

As a military member, mother, and spouse of a former military member, I know how life-changing military service can be for the entire family. I encourage all physicians to start routinely asking if their patient or his or her loved ones have ever been in the military, because a positive answer could help you to better understand the patient and provide the most appropriate, person-centered, culturally-informed treatment.

For neurology, the 2019 Match marked the fourth consecutive year of double-digit increases in the number of first-year residency positions, according to the National Resident Matching Program (NRMP).

This year, 617 first-year (PGY-1) neurology slots were offered, an increase of 11.8% over the 552 offered in 2018 and well above the 6.5% gain recorded for the Match as whole. The 114 neurology programs participating this year filled 96.3% of those PGY-1 positions, compared with 94.7% for the 52 programs that offered PGY-2 positions, the NRMP reported.

“The results of the Match are closely watched because they can be predictors of future physician workforce supply. There also is significant interest in the competitiveness of specialties, as measured by the percentage of positions filled overall and the percentage filled by senior students in U.S. allopathic medical schools,” the NRMP said.


The proportion of PGY-1 neurology positions filled by U.S. seniors dropped to 46.0% from 50.7% last year, although the number of U.S. seniors filling spots actually went up from 280 in 2018 to 284. The PGY-2 positions saw declines in both cases: The 175 U.S. seniors represented 62.3% of the 2019 spots, compared with the 190 U.S. seniors who filled 66.2% of slots in 2018, the NRMP data show.

The total numbers of applicants (38,376) and positions offered (35,185) were both record highs for the Match, although they were affected, in part, by “increased numbers of osteopathic programs that joined the Main Residency Match as a result of the ongoing transition to a single accreditation system for graduate medical education programs,” the NRMP noted.

[email protected]

For neurology, the 2019 Match marked the fourth consecutive year of double-digit increases in the number of first-year residency positions, according to the National Resident Matching Program (NRMP).

This year, 617 first-year (PGY-1) neurology slots were offered, an increase of 11.8% over the 552 offered in 2018 and well above the 6.5% gain recorded for the Match as whole. The 114 neurology programs participating this year filled 96.3% of those PGY-1 positions, compared with 94.7% for the 52 programs that offered PGY-2 positions, the NRMP reported.

“The results of the Match are closely watched because they can be predictors of future physician workforce supply. There also is significant interest in the competitiveness of specialties, as measured by the percentage of positions filled overall and the percentage filled by senior students in U.S. allopathic medical schools,” the NRMP said.


The proportion of PGY-1 neurology positions filled by U.S. seniors dropped to 46.0% from 50.7% last year, although the number of U.S. seniors filling spots actually went up from 280 in 2018 to 284. The PGY-2 positions saw declines in both cases: The 175 U.S. seniors represented 62.3% of the 2019 spots, compared with the 190 U.S. seniors who filled 66.2% of slots in 2018, the NRMP data show.

The total numbers of applicants (38,376) and positions offered (35,185) were both record highs for the Match, although they were affected, in part, by “increased numbers of osteopathic programs that joined the Main Residency Match as a result of the ongoing transition to a single accreditation system for graduate medical education programs,” the NRMP noted.

[email protected]

For neurology, the 2019 Match marked the fourth consecutive year of double-digit increases in the number of first-year residency positions, according to the National Resident Matching Program (NRMP).

This year, 617 first-year (PGY-1) neurology slots were offered, an increase of 11.8% over the 552 offered in 2018 and well above the 6.5% gain recorded for the Match as whole. The 114 neurology programs participating this year filled 96.3% of those PGY-1 positions, compared with 94.7% for the 52 programs that offered PGY-2 positions, the NRMP reported.

“The results of the Match are closely watched because they can be predictors of future physician workforce supply. There also is significant interest in the competitiveness of specialties, as measured by the percentage of positions filled overall and the percentage filled by senior students in U.S. allopathic medical schools,” the NRMP said.


The proportion of PGY-1 neurology positions filled by U.S. seniors dropped to 46.0% from 50.7% last year, although the number of U.S. seniors filling spots actually went up from 280 in 2018 to 284. The PGY-2 positions saw declines in both cases: The 175 U.S. seniors represented 62.3% of the 2019 spots, compared with the 190 U.S. seniors who filled 66.2% of slots in 2018, the NRMP data show.

The total numbers of applicants (38,376) and positions offered (35,185) were both record highs for the Match, although they were affected, in part, by “increased numbers of osteopathic programs that joined the Main Residency Match as a result of the ongoing transition to a single accreditation system for graduate medical education programs,” the NRMP noted.

[email protected]

Dermatology had its second-largest gain in residency slots and matches since 2015 on what is now the largest Match Day on record, according to the National Resident Matching Program (NRMP).

Available dermatology PGY-2 slots rose by 4.9% from 426 in 2018 to 447 in 2019, while slots filled grew by 5.5% from 420 to 443, for an overall fill rate of 99.3%. In addition, the fill rate for U.S. graduates grew for the first time since 2015, rising from 81.7% to 82.8%.

An overall total of 2,756 PGY-2 slots were offered, 97.2% of which were filled; 67.5% were filled by U.S. graduates, the NRMP said in its 2019 Main Residency Match report.

The 2019 Match set a record for most positions offered (35,185; up 6.1%), most positions filled (up 4.8%), most PGY-1 positions offered (32,194; up 6.5%), and total applicants (38,376; up 3.4%).

“The results of the Match are closely watched because they can be predictors of future physician workforce supply. There also is significant interest in the competitiveness of specialties, as measured by the percentage of positions filled overall and the percentage filled by senior students in U.S. allopathic medical schools,” NRMP officials said in a statement.

[email protected]

Dermatology had its second-largest gain in residency slots and matches since 2015 on what is now the largest Match Day on record, according to the National Resident Matching Program (NRMP).

Available dermatology PGY-2 slots rose by 4.9% from 426 in 2018 to 447 in 2019, while slots filled grew by 5.5% from 420 to 443, for an overall fill rate of 99.3%. In addition, the fill rate for U.S. graduates grew for the first time since 2015, rising from 81.7% to 82.8%.

An overall total of 2,756 PGY-2 slots were offered, 97.2% of which were filled; 67.5% were filled by U.S. graduates, the NRMP said in its 2019 Main Residency Match report.

The 2019 Match set a record for most positions offered (35,185; up 6.1%), most positions filled (up 4.8%), most PGY-1 positions offered (32,194; up 6.5%), and total applicants (38,376; up 3.4%).

“The results of the Match are closely watched because they can be predictors of future physician workforce supply. There also is significant interest in the competitiveness of specialties, as measured by the percentage of positions filled overall and the percentage filled by senior students in U.S. allopathic medical schools,” NRMP officials said in a statement.

[email protected]

Dermatology had its second-largest gain in residency slots and matches since 2015 on what is now the largest Match Day on record, according to the National Resident Matching Program (NRMP).

Available dermatology PGY-2 slots rose by 4.9% from 426 in 2018 to 447 in 2019, while slots filled grew by 5.5% from 420 to 443, for an overall fill rate of 99.3%. In addition, the fill rate for U.S. graduates grew for the first time since 2015, rising from 81.7% to 82.8%.

An overall total of 2,756 PGY-2 slots were offered, 97.2% of which were filled; 67.5% were filled by U.S. graduates, the NRMP said in its 2019 Main Residency Match report.

The 2019 Match set a record for most positions offered (35,185; up 6.1%), most positions filled (up 4.8%), most PGY-1 positions offered (32,194; up 6.5%), and total applicants (38,376; up 3.4%).

“The results of the Match are closely watched because they can be predictors of future physician workforce supply. There also is significant interest in the competitiveness of specialties, as measured by the percentage of positions filled overall and the percentage filled by senior students in U.S. allopathic medical schools,” NRMP officials said in a statement.

[email protected]

In 1973, the Supreme Court of the United States recognized a constitutional right to abortion in the landmark case of Roe v Wade. The Court held that states may regulate, but not ban, abortion after the first trimester, for the purpose of protecting the woman’s health. The Court further indicated that states’ interest in “potential life” could be the basis for abortion regulations only after the point of viability, at which point states may ban abortion except when necessary to preserve the life or health of the woman.¹ In 1992, the Court decided Planned Parenthood v Casey and eliminated the trimester framework while upholding women’s right to abortion.² As with Roe v Wade, the Casey decision held that there must be an exception for the woman’s health and life.

Fast forward to 2019

New York passed a law in 2019,³ and Virginia had a proposed law that was recently tabled by the House of Delegates,⁴ both related to abortions performed past the first trimester.

New York. The New York law supports legal abortion by a licensed practitioner within 24 weeks of pregnancy commencement. After 24 weeks’ gestation, if there is “an absence of fetal viability, or the abortion is necessary to protect the patient’s life or health” then termination is permissible.³

Virginia. Previously, Virginia had abortion laws that required significant measures to approve a third-trimester abortion, including certification by 3 physicians that the procedure is necessary to “save mother’s life or [prevent] substantial and irremediable impairment of mental or physical health of the mother.”⁵ Violation included potential for jail time and a significant monetary fine.

The proposed bill, now tabled, was introduced by delegate Kathy Tran (House Bill 2491) and would have rolled back many requirements of the old law, including the 24-hour waiting period and mandate for second-trimester abortions to occur in a hospital.

The controversy centered on a provision concerning third-trimester abortions. Specifically, the proposed bill would only have required 1 doctor to deem the abortion necessary and would have removed the “substantially and irremediably” qualifier. Thus, abortions would be allowed in cases in which the woman’s mental or physical health was threatened, even in cases in which the potential damage may be reversible.⁵
 

The facts

Misconceptions about abortion care can be dangerous and work to further stigmatize our patients who may need an abortion or who have had an abortion in the past. The American College of Obstetricians and Gynecologists (ACOG) recently published a document discussing facts regarding abortion care later in pregnancy. The document (aptly named “Facts are Important”) enforces that policy be based on medical science and facts, and not simply driven by political beliefs.⁶

Fact. The majority of abortions occur prior to 21 weeks, before viability:

• 91.1% of abortions occur at or before 13 weeks’ gestation⁷
• only 1.3% of abortions occur at or after 21 weeks’ gestation⁷
• abortions occurring later in the second trimester or in the third trimester are very uncommon.

Fact. The language “late-term abortion” has no medical definition, is not used in a clinical setting or to describe the delivery of abortion care later in pregnancy in any medical institution.⁶

Fact. Many of the abortions occurring later in pregnancy are due to fetal anomalies incompatible with life. Anomalies can include lack of a major portion of the brain (anencephaly), bilateral renal agenesis, some skeletal dysplasias, and other chromosomal abnormalities. These are cases in which death is likely before or shortly after birth, with great potential for suffering of both the fetus and the family.

Fact. The need for abortion also may be due to serious complications that will likely cause significant morbidity or mortality to the woman. These complications, in turn, reduce the likelihood of survival of the fetus.

It is thus vital for women to have the freedom to evaluate their medical circumstance with their provider and, using evidence, make informed health care decisions—which may include abortion, induction of labor, or cesarean delivery in some circumstances. Access to accurate, complete information and care is a right bestowed amongst all women and “must never be constrained by politicians.”⁶ We must focus on medically appropriate and compassionate care for both the family and the fetus.

Use your voice

As clinicians, we are trusted members of our communities. The New York law and the prior proposed Virginia law emphasize important access to care for women and their families. Abortions at a later gestational age are a rare event but are most often performed when the health or life of the mother is at risk or the fetus has an anomaly incompatible with life.

We urge you to use your voice to correct misconceptions, whether in your office with your patients or colleagues or in your communities, locally and nationally. Email your friends and colleagues about ACOG’s “Facts are Important” document, organize a grand rounds on the topic, and utilize social media to share facts about abortion care. These actions support our patients and can make an impact by spreading factual information.

For more facts and figures about abortion laws, visit the website of the Guttmacher Institute.

In 1973, the Supreme Court of the United States recognized a constitutional right to abortion in the landmark case of Roe v Wade. The Court held that states may regulate, but not ban, abortion after the first trimester, for the purpose of protecting the woman’s health. The Court further indicated that states’ interest in “potential life” could be the basis for abortion regulations only after the point of viability, at which point states may ban abortion except when necessary to preserve the life or health of the woman.¹ In 1992, the Court decided Planned Parenthood v Casey and eliminated the trimester framework while upholding women’s right to abortion.² As with Roe v Wade, the Casey decision held that there must be an exception for the woman’s health and life.

Fast forward to 2019

New York passed a law in 2019,³ and Virginia had a proposed law that was recently tabled by the House of Delegates,⁴ both related to abortions performed past the first trimester.

New York. The New York law supports legal abortion by a licensed practitioner within 24 weeks of pregnancy commencement. After 24 weeks’ gestation, if there is “an absence of fetal viability, or the abortion is necessary to protect the patient’s life or health” then termination is permissible.³

Virginia. Previously, Virginia had abortion laws that required significant measures to approve a third-trimester abortion, including certification by 3 physicians that the procedure is necessary to “save mother’s life or [prevent] substantial and irremediable impairment of mental or physical health of the mother.”⁵ Violation included potential for jail time and a significant monetary fine.

The proposed bill, now tabled, was introduced by delegate Kathy Tran (House Bill 2491) and would have rolled back many requirements of the old law, including the 24-hour waiting period and mandate for second-trimester abortions to occur in a hospital.

The controversy centered on a provision concerning third-trimester abortions. Specifically, the proposed bill would only have required 1 doctor to deem the abortion necessary and would have removed the “substantially and irremediably” qualifier. Thus, abortions would be allowed in cases in which the woman’s mental or physical health was threatened, even in cases in which the potential damage may be reversible.⁵
 

The facts

Misconceptions about abortion care can be dangerous and work to further stigmatize our patients who may need an abortion or who have had an abortion in the past. The American College of Obstetricians and Gynecologists (ACOG) recently published a document discussing facts regarding abortion care later in pregnancy. The document (aptly named “Facts are Important”) enforces that policy be based on medical science and facts, and not simply driven by political beliefs.⁶

Fact. The majority of abortions occur prior to 21 weeks, before viability:

• 91.1% of abortions occur at or before 13 weeks’ gestation⁷
• only 1.3% of abortions occur at or after 21 weeks’ gestation⁷
• abortions occurring later in the second trimester or in the third trimester are very uncommon.

Fact. The language “late-term abortion” has no medical definition, is not used in a clinical setting or to describe the delivery of abortion care later in pregnancy in any medical institution.⁶

Fact. Many of the abortions occurring later in pregnancy are due to fetal anomalies incompatible with life. Anomalies can include lack of a major portion of the brain (anencephaly), bilateral renal agenesis, some skeletal dysplasias, and other chromosomal abnormalities. These are cases in which death is likely before or shortly after birth, with great potential for suffering of both the fetus and the family.

Fact. The need for abortion also may be due to serious complications that will likely cause significant morbidity or mortality to the woman. These complications, in turn, reduce the likelihood of survival of the fetus.

It is thus vital for women to have the freedom to evaluate their medical circumstance with their provider and, using evidence, make informed health care decisions—which may include abortion, induction of labor, or cesarean delivery in some circumstances. Access to accurate, complete information and care is a right bestowed amongst all women and “must never be constrained by politicians.”⁶ We must focus on medically appropriate and compassionate care for both the family and the fetus.

Use your voice

As clinicians, we are trusted members of our communities. The New York law and the prior proposed Virginia law emphasize important access to care for women and their families. Abortions at a later gestational age are a rare event but are most often performed when the health or life of the mother is at risk or the fetus has an anomaly incompatible with life.

We urge you to use your voice to correct misconceptions, whether in your office with your patients or colleagues or in your communities, locally and nationally. Email your friends and colleagues about ACOG’s “Facts are Important” document, organize a grand rounds on the topic, and utilize social media to share facts about abortion care. These actions support our patients and can make an impact by spreading factual information.

For more facts and figures about abortion laws, visit the website of the Guttmacher Institute.

In 1973, the Supreme Court of the United States recognized a constitutional right to abortion in the landmark case of Roe v Wade. The Court held that states may regulate, but not ban, abortion after the first trimester, for the purpose of protecting the woman’s health. The Court further indicated that states’ interest in “potential life” could be the basis for abortion regulations only after the point of viability, at which point states may ban abortion except when necessary to preserve the life or health of the woman.¹ In 1992, the Court decided Planned Parenthood v Casey and eliminated the trimester framework while upholding women’s right to abortion.² As with Roe v Wade, the Casey decision held that there must be an exception for the woman’s health and life.

Fast forward to 2019

New York passed a law in 2019,³ and Virginia had a proposed law that was recently tabled by the House of Delegates,⁴ both related to abortions performed past the first trimester.

New York. The New York law supports legal abortion by a licensed practitioner within 24 weeks of pregnancy commencement. After 24 weeks’ gestation, if there is “an absence of fetal viability, or the abortion is necessary to protect the patient’s life or health” then termination is permissible.³

Virginia. Previously, Virginia had abortion laws that required significant measures to approve a third-trimester abortion, including certification by 3 physicians that the procedure is necessary to “save mother’s life or [prevent] substantial and irremediable impairment of mental or physical health of the mother.”⁵ Violation included potential for jail time and a significant monetary fine.

The proposed bill, now tabled, was introduced by delegate Kathy Tran (House Bill 2491) and would have rolled back many requirements of the old law, including the 24-hour waiting period and mandate for second-trimester abortions to occur in a hospital.

The controversy centered on a provision concerning third-trimester abortions. Specifically, the proposed bill would only have required 1 doctor to deem the abortion necessary and would have removed the “substantially and irremediably” qualifier. Thus, abortions would be allowed in cases in which the woman’s mental or physical health was threatened, even in cases in which the potential damage may be reversible.⁵
 

The facts

Misconceptions about abortion care can be dangerous and work to further stigmatize our patients who may need an abortion or who have had an abortion in the past. The American College of Obstetricians and Gynecologists (ACOG) recently published a document discussing facts regarding abortion care later in pregnancy. The document (aptly named “Facts are Important”) enforces that policy be based on medical science and facts, and not simply driven by political beliefs.⁶

Fact. The majority of abortions occur prior to 21 weeks, before viability:

• 91.1% of abortions occur at or before 13 weeks’ gestation⁷
• only 1.3% of abortions occur at or after 21 weeks’ gestation⁷
• abortions occurring later in the second trimester or in the third trimester are very uncommon.

Fact. The language “late-term abortion” has no medical definition, is not used in a clinical setting or to describe the delivery of abortion care later in pregnancy in any medical institution.⁶

Fact. Many of the abortions occurring later in pregnancy are due to fetal anomalies incompatible with life. Anomalies can include lack of a major portion of the brain (anencephaly), bilateral renal agenesis, some skeletal dysplasias, and other chromosomal abnormalities. These are cases in which death is likely before or shortly after birth, with great potential for suffering of both the fetus and the family.

Fact. The need for abortion also may be due to serious complications that will likely cause significant morbidity or mortality to the woman. These complications, in turn, reduce the likelihood of survival of the fetus.

It is thus vital for women to have the freedom to evaluate their medical circumstance with their provider and, using evidence, make informed health care decisions—which may include abortion, induction of labor, or cesarean delivery in some circumstances. Access to accurate, complete information and care is a right bestowed amongst all women and “must never be constrained by politicians.”⁶ We must focus on medically appropriate and compassionate care for both the family and the fetus.

Use your voice

As clinicians, we are trusted members of our communities. The New York law and the prior proposed Virginia law emphasize important access to care for women and their families. Abortions at a later gestational age are a rare event but are most often performed when the health or life of the mother is at risk or the fetus has an anomaly incompatible with life.

We urge you to use your voice to correct misconceptions, whether in your office with your patients or colleagues or in your communities, locally and nationally. Email your friends and colleagues about ACOG’s “Facts are Important” document, organize a grand rounds on the topic, and utilize social media to share facts about abortion care. These actions support our patients and can make an impact by spreading factual information.

For more facts and figures about abortion laws, visit the website of the Guttmacher Institute.

It is no secret that a well-stocked on-call bag is one of the keys to providing inpatient care as a dermatology resident. Beyond the basic items that should never be left at home, there are some lesser-known tools that I have learned about from my book- and street-smart attendings and co-residents in the Department of Dermatology at the State University of New York Downstate Medical Center (referred to here as Downstate). Here are our top 4 items to pack the next time you are on call. (Bonus: you will find them helpful in clinic, too.)

Item 1: WoundSeal Powder

The most valuable player in my on-call bag, WoundSeal Powder (Biolife) is an over-the-counter hemostatic agent that I learned about from Daniel M. Siegel, MD, MS, a Mohs surgeon at Downstate and former president of the American Academy of Dermatology. The powder consists of a hydrophilic polymer and potassium ferrate.¹ When poured over a bleeding wound and pressed in place (eg, with a sterile cotton-tipped swab), the hydrophilic polymer absorbs plasma while the iron in potassium ferrate agglomerates blood solids. The result is a scablike seal that is safe to leave in place until the wound has healed.¹

Since Dr. Siegel introduced WoundSeal to Downstate about a decade ago, it has become our department’s go-to hemostatic agent for most punch biopsies performed in the inpatient setting. In our experience, achieving hemostasis in the hospital usually is easier, safer, and faster with WoundSeal than suture. Furthermore, using WoundSeal eliminates the need for patients to follow up for suture removal. From a practical perspective, WoundSeal works best when the biopsy defect is positioned parallel to the ground so the powder can be poured directly over and into the defect. From a cosmetic perspective, we have found that WoundSeal and suture have similar outcomes when used for punch biopsies up to 4 mm in size on the trunk and extremities in both adult and pediatric patients. Working with other dermatology attendings such as Sharon A. Glick, MD; Eve Lowenstein, MD, PhD; and Jeannette Jakus, MD, MBA, I also have found WoundSeal helpful when taking care of suture-phobic children or patients with lesions that are less amenable to suture, such as an ulcer or indurated plaque.

Item 2: Purple Surgical Marker

Another tip I have learned from Drs. Siegel and Jakus: If you are ever in a bind for a topical antibacterial or antifungal agent, look no further than a sterile purple surgical marker. These markers are a surprising source of gentian violet, the same purple dye that is the basis of Gram staining and sold as an over-the-counter antiseptic in 1% to 2% concentrations. Purple surgical markers, on the other hand, are 2.5% to 10% gentian violet.²

Gentian violet has been shown to have antibacterial, antifungal, antiviral, antihelminthic, and antitrypanosomal properties, but its efficacy has been mostly demonstrated against Streptococcus, methicillin-sensitive and methicillin-resistant Staphylococcus aureus, and Candida.³ Given the dermatologic relevance of these organisms, gentian violet is a favorite among attendings at my residency program; it is not uncommon to remove a patient’s dressing and uncover an iatrogenically purple wound. Best of all, pediatric patients are invariably amused when they see someone drawing on their skin with a purple marker.

When using a sterile surgical marker to apply gentian violet to the skin, we use either the marker tip or the ink core, which Dr. Siegel taught me can be easily accessed by snapping most plastic markers in half.

Item 3: Handheld Blacklight

The Wood lamp is a useful tool in the diagnosis of various infectious diseases and pigmentary disorders,⁴ but it is not always practical to use when on call, as standard ones are relatively large and corded, so they must be plugged into an electric outlet to work. You can therefore imagine the gratitude I have for my co-residents Miriam Lieberman, MD; Jaime Alexander, MD; Nicole Weiler, MD; and Alessandra Haskin, MD, for introducing me to the most convenient Wood lamp: the handheld blacklight. For less than $10, this gadget combines the diagnostic power of UV light with the portability of a pocket-sized, battery-powered flashlight. You will never want to use another Wood lamp again.

Item 4: Normal Saline Flush

Normal saline can be used for more than storing specimens for frozen section or tissue culture; it also can substitute for Michel solution when storing specimens for direct immunofluorescence (DIF) studies. I learned this tip from Edward Heilman, MD, a dermatopathologist at Downstate. For the last 20 years, Dr. Heilman has been successfully storing DIF specimens in refrigerated normal saline for up to 24 hours when Michel solution is unavailable, after which the specimen is processed or transferred to Michel solution for further storage while being transported to an immunofluorescence laboratory.

In 2004, Vodegel et al⁵ formally studied this technique in 25 patients with autoimmune skin diseases such as pemphigus and pemphigoid. (Thanks to Dr. Lieberman for telling me about this study.) The experiment involved taking 4 punch biopsies from each patient and placing them in either normal saline at −80°C for 24 or 48 hours, room temperature Michel solution for 48 hours, or liquid nitrogen for up to 2 weeks before being processed for DIF and analyzed by a blinded interpreter. Interestingly, specimens stored in normal saline for 24 hours were the most diagnostic, with a conclusive diagnosis reached in 21 of 25 specimens (84%). This result was attributed to the statistically significant reduction (P<.01) in background fluorescence with normal saline compared to Michel solution and liquid nitrogen, which in turn allowed for easier detection of diagnostic immunoreactants. Similar to Dr. Heilman, the authors cautioned against placing DIF specimens in normal saline for more than 24 hours; in their experience, the risk for an artefactual split developing at the dermoepidermal junction increases with this practice.⁵

It is no secret that a well-stocked on-call bag is one of the keys to providing inpatient care as a dermatology resident. Beyond the basic items that should never be left at home, there are some lesser-known tools that I have learned about from my book- and street-smart attendings and co-residents in the Department of Dermatology at the State University of New York Downstate Medical Center (referred to here as Downstate). Here are our top 4 items to pack the next time you are on call. (Bonus: you will find them helpful in clinic, too.)

Item 1: WoundSeal Powder

The most valuable player in my on-call bag, WoundSeal Powder (Biolife) is an over-the-counter hemostatic agent that I learned about from Daniel M. Siegel, MD, MS, a Mohs surgeon at Downstate and former president of the American Academy of Dermatology. The powder consists of a hydrophilic polymer and potassium ferrate.¹ When poured over a bleeding wound and pressed in place (eg, with a sterile cotton-tipped swab), the hydrophilic polymer absorbs plasma while the iron in potassium ferrate agglomerates blood solids. The result is a scablike seal that is safe to leave in place until the wound has healed.¹

Since Dr. Siegel introduced WoundSeal to Downstate about a decade ago, it has become our department’s go-to hemostatic agent for most punch biopsies performed in the inpatient setting. In our experience, achieving hemostasis in the hospital usually is easier, safer, and faster with WoundSeal than suture. Furthermore, using WoundSeal eliminates the need for patients to follow up for suture removal. From a practical perspective, WoundSeal works best when the biopsy defect is positioned parallel to the ground so the powder can be poured directly over and into the defect. From a cosmetic perspective, we have found that WoundSeal and suture have similar outcomes when used for punch biopsies up to 4 mm in size on the trunk and extremities in both adult and pediatric patients. Working with other dermatology attendings such as Sharon A. Glick, MD; Eve Lowenstein, MD, PhD; and Jeannette Jakus, MD, MBA, I also have found WoundSeal helpful when taking care of suture-phobic children or patients with lesions that are less amenable to suture, such as an ulcer or indurated plaque.

Item 2: Purple Surgical Marker

Another tip I have learned from Drs. Siegel and Jakus: If you are ever in a bind for a topical antibacterial or antifungal agent, look no further than a sterile purple surgical marker. These markers are a surprising source of gentian violet, the same purple dye that is the basis of Gram staining and sold as an over-the-counter antiseptic in 1% to 2% concentrations. Purple surgical markers, on the other hand, are 2.5% to 10% gentian violet.²

Gentian violet has been shown to have antibacterial, antifungal, antiviral, antihelminthic, and antitrypanosomal properties, but its efficacy has been mostly demonstrated against Streptococcus, methicillin-sensitive and methicillin-resistant Staphylococcus aureus, and Candida.³ Given the dermatologic relevance of these organisms, gentian violet is a favorite among attendings at my residency program; it is not uncommon to remove a patient’s dressing and uncover an iatrogenically purple wound. Best of all, pediatric patients are invariably amused when they see someone drawing on their skin with a purple marker.

When using a sterile surgical marker to apply gentian violet to the skin, we use either the marker tip or the ink core, which Dr. Siegel taught me can be easily accessed by snapping most plastic markers in half.

Item 3: Handheld Blacklight

The Wood lamp is a useful tool in the diagnosis of various infectious diseases and pigmentary disorders,⁴ but it is not always practical to use when on call, as standard ones are relatively large and corded, so they must be plugged into an electric outlet to work. You can therefore imagine the gratitude I have for my co-residents Miriam Lieberman, MD; Jaime Alexander, MD; Nicole Weiler, MD; and Alessandra Haskin, MD, for introducing me to the most convenient Wood lamp: the handheld blacklight. For less than $10, this gadget combines the diagnostic power of UV light with the portability of a pocket-sized, battery-powered flashlight. You will never want to use another Wood lamp again.

Item 4: Normal Saline Flush

Normal saline can be used for more than storing specimens for frozen section or tissue culture; it also can substitute for Michel solution when storing specimens for direct immunofluorescence (DIF) studies. I learned this tip from Edward Heilman, MD, a dermatopathologist at Downstate. For the last 20 years, Dr. Heilman has been successfully storing DIF specimens in refrigerated normal saline for up to 24 hours when Michel solution is unavailable, after which the specimen is processed or transferred to Michel solution for further storage while being transported to an immunofluorescence laboratory.

In 2004, Vodegel et al⁵ formally studied this technique in 25 patients with autoimmune skin diseases such as pemphigus and pemphigoid. (Thanks to Dr. Lieberman for telling me about this study.) The experiment involved taking 4 punch biopsies from each patient and placing them in either normal saline at −80°C for 24 or 48 hours, room temperature Michel solution for 48 hours, or liquid nitrogen for up to 2 weeks before being processed for DIF and analyzed by a blinded interpreter. Interestingly, specimens stored in normal saline for 24 hours were the most diagnostic, with a conclusive diagnosis reached in 21 of 25 specimens (84%). This result was attributed to the statistically significant reduction (P<.01) in background fluorescence with normal saline compared to Michel solution and liquid nitrogen, which in turn allowed for easier detection of diagnostic immunoreactants. Similar to Dr. Heilman, the authors cautioned against placing DIF specimens in normal saline for more than 24 hours; in their experience, the risk for an artefactual split developing at the dermoepidermal junction increases with this practice.⁵

It is no secret that a well-stocked on-call bag is one of the keys to providing inpatient care as a dermatology resident. Beyond the basic items that should never be left at home, there are some lesser-known tools that I have learned about from my book- and street-smart attendings and co-residents in the Department of Dermatology at the State University of New York Downstate Medical Center (referred to here as Downstate). Here are our top 4 items to pack the next time you are on call. (Bonus: you will find them helpful in clinic, too.)

Item 1: WoundSeal Powder

The most valuable player in my on-call bag, WoundSeal Powder (Biolife) is an over-the-counter hemostatic agent that I learned about from Daniel M. Siegel, MD, MS, a Mohs surgeon at Downstate and former president of the American Academy of Dermatology. The powder consists of a hydrophilic polymer and potassium ferrate.¹ When poured over a bleeding wound and pressed in place (eg, with a sterile cotton-tipped swab), the hydrophilic polymer absorbs plasma while the iron in potassium ferrate agglomerates blood solids. The result is a scablike seal that is safe to leave in place until the wound has healed.¹

Since Dr. Siegel introduced WoundSeal to Downstate about a decade ago, it has become our department’s go-to hemostatic agent for most punch biopsies performed in the inpatient setting. In our experience, achieving hemostasis in the hospital usually is easier, safer, and faster with WoundSeal than suture. Furthermore, using WoundSeal eliminates the need for patients to follow up for suture removal. From a practical perspective, WoundSeal works best when the biopsy defect is positioned parallel to the ground so the powder can be poured directly over and into the defect. From a cosmetic perspective, we have found that WoundSeal and suture have similar outcomes when used for punch biopsies up to 4 mm in size on the trunk and extremities in both adult and pediatric patients. Working with other dermatology attendings such as Sharon A. Glick, MD; Eve Lowenstein, MD, PhD; and Jeannette Jakus, MD, MBA, I also have found WoundSeal helpful when taking care of suture-phobic children or patients with lesions that are less amenable to suture, such as an ulcer or indurated plaque.

Item 2: Purple Surgical Marker

Another tip I have learned from Drs. Siegel and Jakus: If you are ever in a bind for a topical antibacterial or antifungal agent, look no further than a sterile purple surgical marker. These markers are a surprising source of gentian violet, the same purple dye that is the basis of Gram staining and sold as an over-the-counter antiseptic in 1% to 2% concentrations. Purple surgical markers, on the other hand, are 2.5% to 10% gentian violet.²

Gentian violet has been shown to have antibacterial, antifungal, antiviral, antihelminthic, and antitrypanosomal properties, but its efficacy has been mostly demonstrated against Streptococcus, methicillin-sensitive and methicillin-resistant Staphylococcus aureus, and Candida.³ Given the dermatologic relevance of these organisms, gentian violet is a favorite among attendings at my residency program; it is not uncommon to remove a patient’s dressing and uncover an iatrogenically purple wound. Best of all, pediatric patients are invariably amused when they see someone drawing on their skin with a purple marker.

When using a sterile surgical marker to apply gentian violet to the skin, we use either the marker tip or the ink core, which Dr. Siegel taught me can be easily accessed by snapping most plastic markers in half.

Item 3: Handheld Blacklight

The Wood lamp is a useful tool in the diagnosis of various infectious diseases and pigmentary disorders,⁴ but it is not always practical to use when on call, as standard ones are relatively large and corded, so they must be plugged into an electric outlet to work. You can therefore imagine the gratitude I have for my co-residents Miriam Lieberman, MD; Jaime Alexander, MD; Nicole Weiler, MD; and Alessandra Haskin, MD, for introducing me to the most convenient Wood lamp: the handheld blacklight. For less than $10, this gadget combines the diagnostic power of UV light with the portability of a pocket-sized, battery-powered flashlight. You will never want to use another Wood lamp again.

Item 4: Normal Saline Flush

Normal saline can be used for more than storing specimens for frozen section or tissue culture; it also can substitute for Michel solution when storing specimens for direct immunofluorescence (DIF) studies. I learned this tip from Edward Heilman, MD, a dermatopathologist at Downstate. For the last 20 years, Dr. Heilman has been successfully storing DIF specimens in refrigerated normal saline for up to 24 hours when Michel solution is unavailable, after which the specimen is processed or transferred to Michel solution for further storage while being transported to an immunofluorescence laboratory.

In 2004, Vodegel et al⁵ formally studied this technique in 25 patients with autoimmune skin diseases such as pemphigus and pemphigoid. (Thanks to Dr. Lieberman for telling me about this study.) The experiment involved taking 4 punch biopsies from each patient and placing them in either normal saline at −80°C for 24 or 48 hours, room temperature Michel solution for 48 hours, or liquid nitrogen for up to 2 weeks before being processed for DIF and analyzed by a blinded interpreter. Interestingly, specimens stored in normal saline for 24 hours were the most diagnostic, with a conclusive diagnosis reached in 21 of 25 specimens (84%). This result was attributed to the statistically significant reduction (P<.01) in background fluorescence with normal saline compared to Michel solution and liquid nitrogen, which in turn allowed for easier detection of diagnostic immunoreactants. Similar to Dr. Heilman, the authors cautioned against placing DIF specimens in normal saline for more than 24 hours; in their experience, the risk for an artefactual split developing at the dermoepidermal junction increases with this practice.⁵

Editor’s note: Career Choices features a psychiatry resident/fellow interviewing a psychiatrist about why he or she has chosen a specific career path. The goal is to inform trainees about the various psychiatric career options, and to give them a feel for the pros and cons of the various paths.

In this Career Choices, Saeed Ahmed, MD, talked with Cornel Stanciu, MD. Dr. Stanciu is an addiction psychiatrist at Dartmouth’s Geisel School of Medicine, where he is an Assistant Professor, and serves as the Director of Addiction Services at New Hampshire Hospital. He provides support to clinicians managing patients with addictive disorders in a multitude of settings, and also assists with policy making and delivery of addiction care at the state level. He is also the author of Deciphering the Addicted Brain, a guide to help families and the general public better understand addictive disorders.

Dr. Ahmed: What attracted you to pursue subspecialty training in addictive disorders?

Dr. Stanciu: In the early stages of my training, I frequently encountered individuals with medical and mental health disorders whose treatment was impacted by underlying substance use. I soon came to realize any attempts at (for example) managing hypertension in someone with cocaine use disorder, or managing schizophrenia in someone with ongoing cannabis use, were futile. Almost all of my patients receiving treatment for mental health disorders were dependent on tobacco or other substances, and most were interested in cessation. Through mentorship from addiction-trained residency faculty members, I was able to get a taste of the neurobiologic complexities of the disease, something that left me with a desire to develop a deeper understanding of the disease process. Witnessing strikingly positive outcomes with implementation of evidence-based treatment modalities further solidified my path to subspecialty training. Even during that early phase, because I expressed interest in managing these conditions, I was immediately put in a position to share and disseminate any newly acquired knowledge to other specialties as well as the public.

Dr. Ahmed: Could one manage addictive disorders with just general psychiatry training, and what are the differences between the different paths to certification that a resident could undertake?

Dr. Stanciu: Addictive disorders fall under the general umbrella of psychiatric care. Most individuals with these disorders exhibit some degree of mental illness. Medical school curriculum offers on average 2 hours of addiction-related didactics during 4 years. General psychiatry training programs vary significantly in the type of exposure to addiction—some residencies have an affiliated addiction fellowship, others have addiction-trained psychiatrists on staff, but most have none. Ultimately, there is great variability in the degree of comfort in working with individuals with addictive disorders post-residency. Being able to prescribe medications for the treatment of addictive disorders is very different from being familiar with the latest evidence-based recommendations and guidelines; the latter is unlikely to be gleaned simply though residency training. There are 2 routes to specialization after residency: addiction psychiatry, and addiction medicine. The American Board of Psychiatry and Neurology (ABPN) recognized addiction psychiatry as a subspecialty in 1993. Since 1998, completion of a fellowship recognized through the Accreditation Council for Graduate Medical Education has been required for board certification. There are almost 50 programs nationwide with approximately 150 spots. There is no match process for admissions; acceptance is based on a review of application documents and a personal interview. Upon completion of this 1 year of training, candidates sit for the certification exam, which is offered every other year.

Addiction medicine is a fairly new route initially intended to allow non-psychiatric specialties access to addictive disorders training and certification. This is offered through the American Board of Preventive Medicine. There are currently 2 routes to sitting for the exam: through completion of a 1-year addiction medicine fellowship, or through the “practice pathway” still available until 2020. To be eligible for the latter, individuals must provide documentation of clinical experience post-residency, which is quantified as number of hours spent treating patients with addictions, plus any additional courses or training, and must be endorsed by a certified addictionologist.

Continue to: What was your fellowship experience link...

Dr. Ahmed: What was your fellowship experience like, and what should one consider when choosing a program?

Dr. Stanciu: I completed my fellowship training through Dartmouth’s Geisel School of Medicine, and the experience was tremendously valuable. In evaluating programs, one of the starting points is whether you have interest in a formal research track, because several programs include an optional year for that. Most programs tend to provide exposure to the Veterans Affairs system. The 1 year should provide you with broad exposure to all possible settings, all addictive disorders and patient populations, and all treatment modalities, in addition to rigorous didactic sessions. The ideal program should include rotations through methadone treatment centers, intensive outpatient programs, pain and interdisciplinary clinics, detoxification units, and centers for treatment of adolescent and young adults, as well as general medical settings and infectious disease clinics. There should also be close collaboration with psychologists who can provide training in evidence-based therapeutic modalities. During this year, it is vital to expand your knowledge of the ethical and legal regulations of treatment programs, state and federal requirements, insurance complexities, and requirements for privacy and protection of health information. The size of these programs can vary significantly, which may limit the one-on-one time devoted to your training, which is something I personally valued. My faculty was very supportive of academic endeavors, providing guidance, funding, and encouragement for attending and presenting at conferences, publishing papers, and other academic pursuits. Additionally, faculty should be current with emerging literature and willing to develop or implement new protocols and evaluate new pharmacologic therapies.

Dr. Ahmed: What are some of the career options and work settings for addiction psychiatrists?

Dr. Stanciu: Addiction psychiatrists work in numerous settings and various capacities. They can provide subspecialty care directly by seeing patients in outpatient clinics or inpatient addiction treatment centers for detoxification or rehabilitation, or they can work with dual-diagnosis populations in inpatient units. The expansion of telemedicine also holds promise for a role through virtual services. Indirectly, they can serve as a resource for expertise in the field through consultations in medical and psychiatric settings, or through policy making by working with the legislature and public health departments. Additionally, they can help create and integrate new knowledge into practice and educate future generations of physicians and the public.

Dr. Ahmed: What are some of the prevalent disorders and reasons for consultation that you encounter in your daily practice?

Continue to: Dr. Stanciu's response...

Dr. Stanciu: This can vary significantly depending on the setting, geographical region, and demographics of the population. My main non-administrative responsibilities are primarily consultative assisting clinicians at a 200-bed psychiatric hospital to address co-occurring addictive disorders. In short-term units, I am primarily asked to provide input on issues related to various toxidromes and withdrawals and the use of relapse prevention medications for alcohol use disorders as well as the use of buprenorphine or other forms of medication-assisted treatment. I work closely with licensed drug and alcohol counselors in implementing brief interventions as well as facilitating outpatient treatment referrals. Clinicians in longer term units may consult on issues related to pain management in individuals who have addictive disorders, the use of evidence-based pharmacologic agents to address cravings, or the use of relapse prevention medications for someone close to discharge. In terms of specific drugs of abuse, although opioids have recently received a tremendous amount of attention due to the visible costs through overdose deaths, the magnitude of individuals who are losing years of quality life through the use of alcohol and tobacco is significant, and hence this is a large portion of the conditions I encounter. I have also seen an abundance of marijuana use due to decreased perception of harm and increased access.

Dr. Ahmed: What are some of the challenges in working in this field?

Dr. Stanciu: Historically, funding for services has been an issue for clinicians working primarily with addictive disorders from the standpoint of reimbursement, patient access to evidence-based pharmacotherapy, and ability to collaborate with existing levels of care. In recent years, federal funding and policies have changed this, and after numerous studies have found increased cost savings, commercial insurances are providing coverage. A significant challenge also has been public stigma and dealing with a condition that is relapsing-remitting, poorly understood by other specialties and the general public, and sometimes labeled as a defect of character. Several efforts in education have lessened this; however, the impact still takes a toll on patients, who may feel ashamed of their disorder and sometimes are hesitant to take medications because they may believe that they are not “clean” if they depend on a medication for remission. Lastly, recent changes in marijuana policies make conversations about this drug quite difficult because patients often view it as harmless, and the laws governing legality and indications for therapeutic use are slightly ahead of the evidence.

Dr. Ahmed: In what direction do you believe the subspecialty is headed?

Dr. Stanciu: Currently, there are approximately 1,000 certified addiction psychiatrists for the 45 million Americans who have addictive disorders. Smoking and other forms of tobacco use pose significant threats to the 2020 Healthy People Tobacco Use objectives. There is a significant demand for addictionologists in both public and private sectors. As with mental health, demand exceeds supply, and efforts are underway to expand downstream education and increase access to specialists. Several federal laws have been put in place to remove barriers and expand access to care and have paved the way to a brighter future. One is the Affordable Care Act, which requires all insurances including Medicaid to cover the cost of treatment. Second is the Mental Health Parity and Addiction Equity Act, which ensures that the duration and dollar amount of coverage for substance use disorders is comparable to that of medical and surgical care.

Continue to: Another exciting possibility...

Another exciting possibility comes from the world of pharmaceuticals. Some medications have modest efficacy for addressing addictive disorders; however, historically these have been poorly utilized. Enhanced understanding of the neurobiology combined with increased insurance reimbursement should prompt research and new drug development. Some promising agents are already in the pipeline. Research into molecular and gene therapy as a way to better individualize care is also underway.

Going forward, I think we will also encounter a different landscape of drugs. Synthetic agents are emerging and increasing in popularity. Alarmingly, public perception of harm is decreasing. When it comes to cannabis use, I see a rise in pathologic use and the ramifications of this will have a drastic impact, particularly on patients with mental health conditions. We will need to undertake better efforts in monitoring, staying updated, and providing public education campaigns.

Dr. Ahmed: What advice do you have for trainees contemplating subspecialty training in addiction psychiatry?

Dr. Stanciu: I cannot emphasize enough the importance of mentorship. The American Academy of Addiction Psychiatry has a robust system for connecting mentees with mentors at all stages in their careers. This can be extremely helpful, especially in situations where the residency program does not have addiction-trained faculty or rotations through treatment centers. Joining such an organization also grants you access to resources that can help further your enthusiasm. Those interested should also familiarize themselves with currently available pharmacotherapeutic treatments that have evidence supporting efficacy for various addictive disorders, and begin to incorporate these medications into general mental health practice, along with attempts at motivational interviewing. For example, begin discussing naltrexone with patients who have comorbid alcohol use disorders and are interested in reducing their drinking; and varenicline with patients who smoke and are interested in quitting. The outcomes should automatically elicit an interest in pursuing further training in the field!

Editor’s note: Career Choices features a psychiatry resident/fellow interviewing a psychiatrist about why he or she has chosen a specific career path. The goal is to inform trainees about the various psychiatric career options, and to give them a feel for the pros and cons of the various paths.

In this Career Choices, Saeed Ahmed, MD, talked with Cornel Stanciu, MD. Dr. Stanciu is an addiction psychiatrist at Dartmouth’s Geisel School of Medicine, where he is an Assistant Professor, and serves as the Director of Addiction Services at New Hampshire Hospital. He provides support to clinicians managing patients with addictive disorders in a multitude of settings, and also assists with policy making and delivery of addiction care at the state level. He is also the author of Deciphering the Addicted Brain, a guide to help families and the general public better understand addictive disorders.

Dr. Ahmed: What attracted you to pursue subspecialty training in addictive disorders?

Dr. Stanciu: In the early stages of my training, I frequently encountered individuals with medical and mental health disorders whose treatment was impacted by underlying substance use. I soon came to realize any attempts at (for example) managing hypertension in someone with cocaine use disorder, or managing schizophrenia in someone with ongoing cannabis use, were futile. Almost all of my patients receiving treatment for mental health disorders were dependent on tobacco or other substances, and most were interested in cessation. Through mentorship from addiction-trained residency faculty members, I was able to get a taste of the neurobiologic complexities of the disease, something that left me with a desire to develop a deeper understanding of the disease process. Witnessing strikingly positive outcomes with implementation of evidence-based treatment modalities further solidified my path to subspecialty training. Even during that early phase, because I expressed interest in managing these conditions, I was immediately put in a position to share and disseminate any newly acquired knowledge to other specialties as well as the public.

Dr. Ahmed: Could one manage addictive disorders with just general psychiatry training, and what are the differences between the different paths to certification that a resident could undertake?

Dr. Stanciu: Addictive disorders fall under the general umbrella of psychiatric care. Most individuals with these disorders exhibit some degree of mental illness. Medical school curriculum offers on average 2 hours of addiction-related didactics during 4 years. General psychiatry training programs vary significantly in the type of exposure to addiction—some residencies have an affiliated addiction fellowship, others have addiction-trained psychiatrists on staff, but most have none. Ultimately, there is great variability in the degree of comfort in working with individuals with addictive disorders post-residency. Being able to prescribe medications for the treatment of addictive disorders is very different from being familiar with the latest evidence-based recommendations and guidelines; the latter is unlikely to be gleaned simply though residency training. There are 2 routes to specialization after residency: addiction psychiatry, and addiction medicine. The American Board of Psychiatry and Neurology (ABPN) recognized addiction psychiatry as a subspecialty in 1993. Since 1998, completion of a fellowship recognized through the Accreditation Council for Graduate Medical Education has been required for board certification. There are almost 50 programs nationwide with approximately 150 spots. There is no match process for admissions; acceptance is based on a review of application documents and a personal interview. Upon completion of this 1 year of training, candidates sit for the certification exam, which is offered every other year.

Addiction medicine is a fairly new route initially intended to allow non-psychiatric specialties access to addictive disorders training and certification. This is offered through the American Board of Preventive Medicine. There are currently 2 routes to sitting for the exam: through completion of a 1-year addiction medicine fellowship, or through the “practice pathway” still available until 2020. To be eligible for the latter, individuals must provide documentation of clinical experience post-residency, which is quantified as number of hours spent treating patients with addictions, plus any additional courses or training, and must be endorsed by a certified addictionologist.

Continue to: What was your fellowship experience link...

Dr. Ahmed: What was your fellowship experience like, and what should one consider when choosing a program?

Dr. Stanciu: I completed my fellowship training through Dartmouth’s Geisel School of Medicine, and the experience was tremendously valuable. In evaluating programs, one of the starting points is whether you have interest in a formal research track, because several programs include an optional year for that. Most programs tend to provide exposure to the Veterans Affairs system. The 1 year should provide you with broad exposure to all possible settings, all addictive disorders and patient populations, and all treatment modalities, in addition to rigorous didactic sessions. The ideal program should include rotations through methadone treatment centers, intensive outpatient programs, pain and interdisciplinary clinics, detoxification units, and centers for treatment of adolescent and young adults, as well as general medical settings and infectious disease clinics. There should also be close collaboration with psychologists who can provide training in evidence-based therapeutic modalities. During this year, it is vital to expand your knowledge of the ethical and legal regulations of treatment programs, state and federal requirements, insurance complexities, and requirements for privacy and protection of health information. The size of these programs can vary significantly, which may limit the one-on-one time devoted to your training, which is something I personally valued. My faculty was very supportive of academic endeavors, providing guidance, funding, and encouragement for attending and presenting at conferences, publishing papers, and other academic pursuits. Additionally, faculty should be current with emerging literature and willing to develop or implement new protocols and evaluate new pharmacologic therapies.

Dr. Ahmed: What are some of the career options and work settings for addiction psychiatrists?

Dr. Stanciu: Addiction psychiatrists work in numerous settings and various capacities. They can provide subspecialty care directly by seeing patients in outpatient clinics or inpatient addiction treatment centers for detoxification or rehabilitation, or they can work with dual-diagnosis populations in inpatient units. The expansion of telemedicine also holds promise for a role through virtual services. Indirectly, they can serve as a resource for expertise in the field through consultations in medical and psychiatric settings, or through policy making by working with the legislature and public health departments. Additionally, they can help create and integrate new knowledge into practice and educate future generations of physicians and the public.

Dr. Ahmed: What are some of the prevalent disorders and reasons for consultation that you encounter in your daily practice?

Continue to: Dr. Stanciu's response...

Dr. Stanciu: This can vary significantly depending on the setting, geographical region, and demographics of the population. My main non-administrative responsibilities are primarily consultative assisting clinicians at a 200-bed psychiatric hospital to address co-occurring addictive disorders. In short-term units, I am primarily asked to provide input on issues related to various toxidromes and withdrawals and the use of relapse prevention medications for alcohol use disorders as well as the use of buprenorphine or other forms of medication-assisted treatment. I work closely with licensed drug and alcohol counselors in implementing brief interventions as well as facilitating outpatient treatment referrals. Clinicians in longer term units may consult on issues related to pain management in individuals who have addictive disorders, the use of evidence-based pharmacologic agents to address cravings, or the use of relapse prevention medications for someone close to discharge. In terms of specific drugs of abuse, although opioids have recently received a tremendous amount of attention due to the visible costs through overdose deaths, the magnitude of individuals who are losing years of quality life through the use of alcohol and tobacco is significant, and hence this is a large portion of the conditions I encounter. I have also seen an abundance of marijuana use due to decreased perception of harm and increased access.

Dr. Ahmed: What are some of the challenges in working in this field?

Dr. Stanciu: Historically, funding for services has been an issue for clinicians working primarily with addictive disorders from the standpoint of reimbursement, patient access to evidence-based pharmacotherapy, and ability to collaborate with existing levels of care. In recent years, federal funding and policies have changed this, and after numerous studies have found increased cost savings, commercial insurances are providing coverage. A significant challenge also has been public stigma and dealing with a condition that is relapsing-remitting, poorly understood by other specialties and the general public, and sometimes labeled as a defect of character. Several efforts in education have lessened this; however, the impact still takes a toll on patients, who may feel ashamed of their disorder and sometimes are hesitant to take medications because they may believe that they are not “clean” if they depend on a medication for remission. Lastly, recent changes in marijuana policies make conversations about this drug quite difficult because patients often view it as harmless, and the laws governing legality and indications for therapeutic use are slightly ahead of the evidence.

Dr. Ahmed: In what direction do you believe the subspecialty is headed?

Dr. Stanciu: Currently, there are approximately 1,000 certified addiction psychiatrists for the 45 million Americans who have addictive disorders. Smoking and other forms of tobacco use pose significant threats to the 2020 Healthy People Tobacco Use objectives. There is a significant demand for addictionologists in both public and private sectors. As with mental health, demand exceeds supply, and efforts are underway to expand downstream education and increase access to specialists. Several federal laws have been put in place to remove barriers and expand access to care and have paved the way to a brighter future. One is the Affordable Care Act, which requires all insurances including Medicaid to cover the cost of treatment. Second is the Mental Health Parity and Addiction Equity Act, which ensures that the duration and dollar amount of coverage for substance use disorders is comparable to that of medical and surgical care.

Continue to: Another exciting possibility...

Another exciting possibility comes from the world of pharmaceuticals. Some medications have modest efficacy for addressing addictive disorders; however, historically these have been poorly utilized. Enhanced understanding of the neurobiology combined with increased insurance reimbursement should prompt research and new drug development. Some promising agents are already in the pipeline. Research into molecular and gene therapy as a way to better individualize care is also underway.

Going forward, I think we will also encounter a different landscape of drugs. Synthetic agents are emerging and increasing in popularity. Alarmingly, public perception of harm is decreasing. When it comes to cannabis use, I see a rise in pathologic use and the ramifications of this will have a drastic impact, particularly on patients with mental health conditions. We will need to undertake better efforts in monitoring, staying updated, and providing public education campaigns.

Dr. Ahmed: What advice do you have for trainees contemplating subspecialty training in addiction psychiatry?

Dr. Stanciu: I cannot emphasize enough the importance of mentorship. The American Academy of Addiction Psychiatry has a robust system for connecting mentees with mentors at all stages in their careers. This can be extremely helpful, especially in situations where the residency program does not have addiction-trained faculty or rotations through treatment centers. Joining such an organization also grants you access to resources that can help further your enthusiasm. Those interested should also familiarize themselves with currently available pharmacotherapeutic treatments that have evidence supporting efficacy for various addictive disorders, and begin to incorporate these medications into general mental health practice, along with attempts at motivational interviewing. For example, begin discussing naltrexone with patients who have comorbid alcohol use disorders and are interested in reducing their drinking; and varenicline with patients who smoke and are interested in quitting. The outcomes should automatically elicit an interest in pursuing further training in the field!

Editor’s note: Career Choices features a psychiatry resident/fellow interviewing a psychiatrist about why he or she has chosen a specific career path. The goal is to inform trainees about the various psychiatric career options, and to give them a feel for the pros and cons of the various paths.

In this Career Choices, Saeed Ahmed, MD, talked with Cornel Stanciu, MD. Dr. Stanciu is an addiction psychiatrist at Dartmouth’s Geisel School of Medicine, where he is an Assistant Professor, and serves as the Director of Addiction Services at New Hampshire Hospital. He provides support to clinicians managing patients with addictive disorders in a multitude of settings, and also assists with policy making and delivery of addiction care at the state level. He is also the author of Deciphering the Addicted Brain, a guide to help families and the general public better understand addictive disorders.

Dr. Ahmed: What attracted you to pursue subspecialty training in addictive disorders?

Dr. Stanciu: In the early stages of my training, I frequently encountered individuals with medical and mental health disorders whose treatment was impacted by underlying substance use. I soon came to realize any attempts at (for example) managing hypertension in someone with cocaine use disorder, or managing schizophrenia in someone with ongoing cannabis use, were futile. Almost all of my patients receiving treatment for mental health disorders were dependent on tobacco or other substances, and most were interested in cessation. Through mentorship from addiction-trained residency faculty members, I was able to get a taste of the neurobiologic complexities of the disease, something that left me with a desire to develop a deeper understanding of the disease process. Witnessing strikingly positive outcomes with implementation of evidence-based treatment modalities further solidified my path to subspecialty training. Even during that early phase, because I expressed interest in managing these conditions, I was immediately put in a position to share and disseminate any newly acquired knowledge to other specialties as well as the public.

Dr. Ahmed: Could one manage addictive disorders with just general psychiatry training, and what are the differences between the different paths to certification that a resident could undertake?

Dr. Stanciu: Addictive disorders fall under the general umbrella of psychiatric care. Most individuals with these disorders exhibit some degree of mental illness. Medical school curriculum offers on average 2 hours of addiction-related didactics during 4 years. General psychiatry training programs vary significantly in the type of exposure to addiction—some residencies have an affiliated addiction fellowship, others have addiction-trained psychiatrists on staff, but most have none. Ultimately, there is great variability in the degree of comfort in working with individuals with addictive disorders post-residency. Being able to prescribe medications for the treatment of addictive disorders is very different from being familiar with the latest evidence-based recommendations and guidelines; the latter is unlikely to be gleaned simply though residency training. There are 2 routes to specialization after residency: addiction psychiatry, and addiction medicine. The American Board of Psychiatry and Neurology (ABPN) recognized addiction psychiatry as a subspecialty in 1993. Since 1998, completion of a fellowship recognized through the Accreditation Council for Graduate Medical Education has been required for board certification. There are almost 50 programs nationwide with approximately 150 spots. There is no match process for admissions; acceptance is based on a review of application documents and a personal interview. Upon completion of this 1 year of training, candidates sit for the certification exam, which is offered every other year.

Addiction medicine is a fairly new route initially intended to allow non-psychiatric specialties access to addictive disorders training and certification. This is offered through the American Board of Preventive Medicine. There are currently 2 routes to sitting for the exam: through completion of a 1-year addiction medicine fellowship, or through the “practice pathway” still available until 2020. To be eligible for the latter, individuals must provide documentation of clinical experience post-residency, which is quantified as number of hours spent treating patients with addictions, plus any additional courses or training, and must be endorsed by a certified addictionologist.

Continue to: What was your fellowship experience link...

Dr. Ahmed: What was your fellowship experience like, and what should one consider when choosing a program?

Dr. Stanciu: I completed my fellowship training through Dartmouth’s Geisel School of Medicine, and the experience was tremendously valuable. In evaluating programs, one of the starting points is whether you have interest in a formal research track, because several programs include an optional year for that. Most programs tend to provide exposure to the Veterans Affairs system. The 1 year should provide you with broad exposure to all possible settings, all addictive disorders and patient populations, and all treatment modalities, in addition to rigorous didactic sessions. The ideal program should include rotations through methadone treatment centers, intensive outpatient programs, pain and interdisciplinary clinics, detoxification units, and centers for treatment of adolescent and young adults, as well as general medical settings and infectious disease clinics. There should also be close collaboration with psychologists who can provide training in evidence-based therapeutic modalities. During this year, it is vital to expand your knowledge of the ethical and legal regulations of treatment programs, state and federal requirements, insurance complexities, and requirements for privacy and protection of health information. The size of these programs can vary significantly, which may limit the one-on-one time devoted to your training, which is something I personally valued. My faculty was very supportive of academic endeavors, providing guidance, funding, and encouragement for attending and presenting at conferences, publishing papers, and other academic pursuits. Additionally, faculty should be current with emerging literature and willing to develop or implement new protocols and evaluate new pharmacologic therapies.

Dr. Ahmed: What are some of the career options and work settings for addiction psychiatrists?

Dr. Stanciu: Addiction psychiatrists work in numerous settings and various capacities. They can provide subspecialty care directly by seeing patients in outpatient clinics or inpatient addiction treatment centers for detoxification or rehabilitation, or they can work with dual-diagnosis populations in inpatient units. The expansion of telemedicine also holds promise for a role through virtual services. Indirectly, they can serve as a resource for expertise in the field through consultations in medical and psychiatric settings, or through policy making by working with the legislature and public health departments. Additionally, they can help create and integrate new knowledge into practice and educate future generations of physicians and the public.

Dr. Ahmed: What are some of the prevalent disorders and reasons for consultation that you encounter in your daily practice?

Continue to: Dr. Stanciu's response...

Dr. Stanciu: This can vary significantly depending on the setting, geographical region, and demographics of the population. My main non-administrative responsibilities are primarily consultative assisting clinicians at a 200-bed psychiatric hospital to address co-occurring addictive disorders. In short-term units, I am primarily asked to provide input on issues related to various toxidromes and withdrawals and the use of relapse prevention medications for alcohol use disorders as well as the use of buprenorphine or other forms of medication-assisted treatment. I work closely with licensed drug and alcohol counselors in implementing brief interventions as well as facilitating outpatient treatment referrals. Clinicians in longer term units may consult on issues related to pain management in individuals who have addictive disorders, the use of evidence-based pharmacologic agents to address cravings, or the use of relapse prevention medications for someone close to discharge. In terms of specific drugs of abuse, although opioids have recently received a tremendous amount of attention due to the visible costs through overdose deaths, the magnitude of individuals who are losing years of quality life through the use of alcohol and tobacco is significant, and hence this is a large portion of the conditions I encounter. I have also seen an abundance of marijuana use due to decreased perception of harm and increased access.

Dr. Ahmed: What are some of the challenges in working in this field?

Dr. Stanciu: Historically, funding for services has been an issue for clinicians working primarily with addictive disorders from the standpoint of reimbursement, patient access to evidence-based pharmacotherapy, and ability to collaborate with existing levels of care. In recent years, federal funding and policies have changed this, and after numerous studies have found increased cost savings, commercial insurances are providing coverage. A significant challenge also has been public stigma and dealing with a condition that is relapsing-remitting, poorly understood by other specialties and the general public, and sometimes labeled as a defect of character. Several efforts in education have lessened this; however, the impact still takes a toll on patients, who may feel ashamed of their disorder and sometimes are hesitant to take medications because they may believe that they are not “clean” if they depend on a medication for remission. Lastly, recent changes in marijuana policies make conversations about this drug quite difficult because patients often view it as harmless, and the laws governing legality and indications for therapeutic use are slightly ahead of the evidence.

Dr. Ahmed: In what direction do you believe the subspecialty is headed?

Dr. Stanciu: Currently, there are approximately 1,000 certified addiction psychiatrists for the 45 million Americans who have addictive disorders. Smoking and other forms of tobacco use pose significant threats to the 2020 Healthy People Tobacco Use objectives. There is a significant demand for addictionologists in both public and private sectors. As with mental health, demand exceeds supply, and efforts are underway to expand downstream education and increase access to specialists. Several federal laws have been put in place to remove barriers and expand access to care and have paved the way to a brighter future. One is the Affordable Care Act, which requires all insurances including Medicaid to cover the cost of treatment. Second is the Mental Health Parity and Addiction Equity Act, which ensures that the duration and dollar amount of coverage for substance use disorders is comparable to that of medical and surgical care.

Continue to: Another exciting possibility...

Another exciting possibility comes from the world of pharmaceuticals. Some medications have modest efficacy for addressing addictive disorders; however, historically these have been poorly utilized. Enhanced understanding of the neurobiology combined with increased insurance reimbursement should prompt research and new drug development. Some promising agents are already in the pipeline. Research into molecular and gene therapy as a way to better individualize care is also underway.

Going forward, I think we will also encounter a different landscape of drugs. Synthetic agents are emerging and increasing in popularity. Alarmingly, public perception of harm is decreasing. When it comes to cannabis use, I see a rise in pathologic use and the ramifications of this will have a drastic impact, particularly on patients with mental health conditions. We will need to undertake better efforts in monitoring, staying updated, and providing public education campaigns.

Dr. Ahmed: What advice do you have for trainees contemplating subspecialty training in addiction psychiatry?

Dr. Stanciu: I cannot emphasize enough the importance of mentorship. The American Academy of Addiction Psychiatry has a robust system for connecting mentees with mentors at all stages in their careers. This can be extremely helpful, especially in situations where the residency program does not have addiction-trained faculty or rotations through treatment centers. Joining such an organization also grants you access to resources that can help further your enthusiasm. Those interested should also familiarize themselves with currently available pharmacotherapeutic treatments that have evidence supporting efficacy for various addictive disorders, and begin to incorporate these medications into general mental health practice, along with attempts at motivational interviewing. For example, begin discussing naltrexone with patients who have comorbid alcohol use disorders and are interested in reducing their drinking; and varenicline with patients who smoke and are interested in quitting. The outcomes should automatically elicit an interest in pursuing further training in the field!