For Residents

Practice Gap

Dermatology residents can struggle with surgical closure early in their training years. Although experienced dermatologic surgeons may intuitively be able to align edges for maximal cosmesis, doing so can prove challenging in the context of learning basic surgical techniques for early residents.

Furthermore, local anesthesia can distort cutaneous anatomy and surgical landmarks, requiring the surgeon to reexamine their closure technique. Patients may require position changes or may make involuntary movements, both of which require dynamic thinking and planning on the part of the dermatologic surgeon to achieve optimal outcomes.

The Technique

We propose the use of sutures to intraoperatively guide placement of the dermal needle. This technique can be used for various closure types; here, we demonstrate its use in a standard elliptical excision.

To begin, a standard length to width ellipse ratio of 3:1 is drawn with appropriate margins around a neoplasm.¹ After excision and appropriate undermining of the ellipse, we typically use deep sutures to close the deep space. The first pass of the needle through tissue can be performed in a place of the surgeon’s preference but typically abides by the rule of halves or the zipper method (Figure 1A). To determine optimal placement of the second needle pass through tissue, we recommend applying gentle opposing traction forces to the wound apices to approximate the linear outcome of the wound edges. The surgeon can use a skin hook to guide placement of the needle to the contralateral wound edge in an unassisted method of this technique (Figure 1B). The surgeon’s assistant also can aid in applying cutaneous traction along the length of the excision if the surgeon wishes to free their hands (Figure 1C). Because the risk of needlestick injury at this step is small, it is prudent for the surgeon to advise the assistant to avoid needlestick injury by keeping their hands away from the needle path in the surgical site.

Although traction is being applied to the wound apices, the deep suture should extend across the wound with just enough pressure to leave a serosanguineous notched mark in the contralateral tissue edge (Figure 1D). After releasing traction on the wound edges, the surgeon can effortlessly visualize the target for needle placement and make a throw through the tissue accordingly.

This process can be continued until wound closure is complete (Figure 2). Top sutures or adhesive strips can be placed afterward for completing approximation of the wound edges superficially.

Practice Implications

By using this technique to align wound edges intraoperatively, the surgeon can have a functional guide for needle placement. The technique allows improvement of function and cosmesis of surgical wounds, while also accounting for topographical variations in the patient’s surgical site. Approximation of the wound edges is particularly important at the beginning of closure, as the wound edges align and approximate more with each subsequent stitch, with decreasing tension.²

In addition, when operating on a curvilinear or challenging topographical surface of the body, this technique can provide a clear template for guiding suture placement for approximating wound edges. Furthermore, local biodynamic anatomy might become distorted after excision of the tissue specimen due to release of centripetal tangential forces that were present in the pre-excised skin.¹ Local change in biodynamic forces may be difficult to plan for preoperatively using other techniques.³

Although this technique can be utilized for all suture placements in closure, it is of greatest value when placing the first few sutures and when operating on nonplanar surfaces that might become distorted after excision. To ensure the best outcome, it is important to be certain that the area has been properly cleaned prior to surgery and a sterile technique is used.

Practice Gap

Dermatology residents can struggle with surgical closure early in their training years. Although experienced dermatologic surgeons may intuitively be able to align edges for maximal cosmesis, doing so can prove challenging in the context of learning basic surgical techniques for early residents.

Furthermore, local anesthesia can distort cutaneous anatomy and surgical landmarks, requiring the surgeon to reexamine their closure technique. Patients may require position changes or may make involuntary movements, both of which require dynamic thinking and planning on the part of the dermatologic surgeon to achieve optimal outcomes.

The Technique

We propose the use of sutures to intraoperatively guide placement of the dermal needle. This technique can be used for various closure types; here, we demonstrate its use in a standard elliptical excision.

To begin, a standard length to width ellipse ratio of 3:1 is drawn with appropriate margins around a neoplasm.¹ After excision and appropriate undermining of the ellipse, we typically use deep sutures to close the deep space. The first pass of the needle through tissue can be performed in a place of the surgeon’s preference but typically abides by the rule of halves or the zipper method (Figure 1A). To determine optimal placement of the second needle pass through tissue, we recommend applying gentle opposing traction forces to the wound apices to approximate the linear outcome of the wound edges. The surgeon can use a skin hook to guide placement of the needle to the contralateral wound edge in an unassisted method of this technique (Figure 1B). The surgeon’s assistant also can aid in applying cutaneous traction along the length of the excision if the surgeon wishes to free their hands (Figure 1C). Because the risk of needlestick injury at this step is small, it is prudent for the surgeon to advise the assistant to avoid needlestick injury by keeping their hands away from the needle path in the surgical site.

Although traction is being applied to the wound apices, the deep suture should extend across the wound with just enough pressure to leave a serosanguineous notched mark in the contralateral tissue edge (Figure 1D). After releasing traction on the wound edges, the surgeon can effortlessly visualize the target for needle placement and make a throw through the tissue accordingly.

This process can be continued until wound closure is complete (Figure 2). Top sutures or adhesive strips can be placed afterward for completing approximation of the wound edges superficially.

Practice Implications

By using this technique to align wound edges intraoperatively, the surgeon can have a functional guide for needle placement. The technique allows improvement of function and cosmesis of surgical wounds, while also accounting for topographical variations in the patient’s surgical site. Approximation of the wound edges is particularly important at the beginning of closure, as the wound edges align and approximate more with each subsequent stitch, with decreasing tension.²

In addition, when operating on a curvilinear or challenging topographical surface of the body, this technique can provide a clear template for guiding suture placement for approximating wound edges. Furthermore, local biodynamic anatomy might become distorted after excision of the tissue specimen due to release of centripetal tangential forces that were present in the pre-excised skin.¹ Local change in biodynamic forces may be difficult to plan for preoperatively using other techniques.³

Although this technique can be utilized for all suture placements in closure, it is of greatest value when placing the first few sutures and when operating on nonplanar surfaces that might become distorted after excision. To ensure the best outcome, it is important to be certain that the area has been properly cleaned prior to surgery and a sterile technique is used.

Practice Gap

Dermatology residents can struggle with surgical closure early in their training years. Although experienced dermatologic surgeons may intuitively be able to align edges for maximal cosmesis, doing so can prove challenging in the context of learning basic surgical techniques for early residents.

Furthermore, local anesthesia can distort cutaneous anatomy and surgical landmarks, requiring the surgeon to reexamine their closure technique. Patients may require position changes or may make involuntary movements, both of which require dynamic thinking and planning on the part of the dermatologic surgeon to achieve optimal outcomes.

The Technique

We propose the use of sutures to intraoperatively guide placement of the dermal needle. This technique can be used for various closure types; here, we demonstrate its use in a standard elliptical excision.

To begin, a standard length to width ellipse ratio of 3:1 is drawn with appropriate margins around a neoplasm.¹ After excision and appropriate undermining of the ellipse, we typically use deep sutures to close the deep space. The first pass of the needle through tissue can be performed in a place of the surgeon’s preference but typically abides by the rule of halves or the zipper method (Figure 1A). To determine optimal placement of the second needle pass through tissue, we recommend applying gentle opposing traction forces to the wound apices to approximate the linear outcome of the wound edges. The surgeon can use a skin hook to guide placement of the needle to the contralateral wound edge in an unassisted method of this technique (Figure 1B). The surgeon’s assistant also can aid in applying cutaneous traction along the length of the excision if the surgeon wishes to free their hands (Figure 1C). Because the risk of needlestick injury at this step is small, it is prudent for the surgeon to advise the assistant to avoid needlestick injury by keeping their hands away from the needle path in the surgical site.

Although traction is being applied to the wound apices, the deep suture should extend across the wound with just enough pressure to leave a serosanguineous notched mark in the contralateral tissue edge (Figure 1D). After releasing traction on the wound edges, the surgeon can effortlessly visualize the target for needle placement and make a throw through the tissue accordingly.

This process can be continued until wound closure is complete (Figure 2). Top sutures or adhesive strips can be placed afterward for completing approximation of the wound edges superficially.

Practice Implications

By using this technique to align wound edges intraoperatively, the surgeon can have a functional guide for needle placement. The technique allows improvement of function and cosmesis of surgical wounds, while also accounting for topographical variations in the patient’s surgical site. Approximation of the wound edges is particularly important at the beginning of closure, as the wound edges align and approximate more with each subsequent stitch, with decreasing tension.²

In addition, when operating on a curvilinear or challenging topographical surface of the body, this technique can provide a clear template for guiding suture placement for approximating wound edges. Furthermore, local biodynamic anatomy might become distorted after excision of the tissue specimen due to release of centripetal tangential forces that were present in the pre-excised skin.¹ Local change in biodynamic forces may be difficult to plan for preoperatively using other techniques.³

Although this technique can be utilized for all suture placements in closure, it is of greatest value when placing the first few sutures and when operating on nonplanar surfaces that might become distorted after excision. To ensure the best outcome, it is important to be certain that the area has been properly cleaned prior to surgery and a sterile technique is used.

In patients with attention-deficit/hyperactivity disorder (ADHD), stimulants reduce impulsivity and improve attention and focus. In individuals who do not have this disorder, stimulants are believed to enhance cognition, attention, and physical performance. In this article, I describe how a patient whose intermittent use of stimulants for motivation and cognitive enhancement shaped my approach to the diagnosis of ADHD.

Instant gratification and quick solutions

When I joined my psychiatry residency program, I expected to primarily treat patients who had depression, bipolar disorder, or psychosis. However, as I transitioned to my second year of residency, most patients I was assigned to had been diagnosed with ADHD. One of them was a 30-year-old in his fourth year of dental school. On his first visit, he requested a refill of dextroamphetamine and amphetamine 10 mg twice a day. He had been diagnosed with ADHD 5 years ago. He explained that he only needed this medication when preparing for his board examinations to motivate him and boost his focus and retention before studying. His study schedule included the exact doses and times he planned to take his stimulant.

I asked him questions to confirm the diagnosis, but he rushed to reassure me that he had already been diagnosed with ADHD and had been doing well on dextroamphetamine and amphetamine for many years. I was inclined to question his diagnosis of ADHD after learning of his “as-needed” use of stimulants as brain enhancers. His medical record reflecting the diagnosis of ADHD dated back to when he was a first-year dental student. The diagnosis was based on the patient’s report of procrastination for as long as he could remember. It also hinged on difficulties learning a second language and math being a challenging subject for him. Despite this, he managed to do well in school and earn an undergraduate degree, well enough to later pursue dentistry at a reputable university.

I thought, “Isn’t it normal to lose motivation and have doubts when preparing for a high-stakes exam like the boards? Aren’t these negative thoughts distracting enough to render sustained focus impossible? Doesn’t everyone struggle with procrastination, especially when they need to study? If learning a new language requires devotion, consistency, and sacrifice, isn’t it inherently challenging? Doesn’t good performance in math depend on multiple factors (ie, a strong foundation, cumulative learning, frequent practice), and thus leaves many students struggling?”

This interaction and many similar ones made me scrutinize the diagnosis of ADHD in patients I encounter in clinical settings. We live in a society where instant gratification is cherished, and quick fixes are pursued with little contemplation of pitfalls. Students use stimulants to cram for exams, high-functioning professionals use them to meet deadlines, and athletes use them to enhance performance and improve reaction times. Psychiatry seems to be drawn into the demands of society and may be fueling the “quick-fix” mentality by prescribing stimulants to healthy individuals who want to improve their focus, and then diagnosing them with ADHD to align the prescription with an appropriate diagnosis. Research on the adverse effects of stimulant use in adults is not convincing nor conclusive enough to sway prescribers from denying the average adult patient a stimulant to enhance cognitive function before a high-stakes exam or a critical, career-shaping project if they present with some ADHD traits, which the patient might even hyperbolize to secure the desired prescription. All of this may contribute to the perceived rising prevalence of ADHD among adults.

As for my 30-year-old dental student, I reasoned that continuing his medication, for now, would help me establish rapport and trust. This would allow me to counsel him on the long-term adverse effects of stimulants, and develop a plan to optimize his sleep, focus, and time management skills, eventually improving his cognition and attention naturally. Unfortunately, he did not show up to future appointments after I sent him the refill.

In patients with attention-deficit/hyperactivity disorder (ADHD), stimulants reduce impulsivity and improve attention and focus. In individuals who do not have this disorder, stimulants are believed to enhance cognition, attention, and physical performance. In this article, I describe how a patient whose intermittent use of stimulants for motivation and cognitive enhancement shaped my approach to the diagnosis of ADHD.

Instant gratification and quick solutions

When I joined my psychiatry residency program, I expected to primarily treat patients who had depression, bipolar disorder, or psychosis. However, as I transitioned to my second year of residency, most patients I was assigned to had been diagnosed with ADHD. One of them was a 30-year-old in his fourth year of dental school. On his first visit, he requested a refill of dextroamphetamine and amphetamine 10 mg twice a day. He had been diagnosed with ADHD 5 years ago. He explained that he only needed this medication when preparing for his board examinations to motivate him and boost his focus and retention before studying. His study schedule included the exact doses and times he planned to take his stimulant.

I asked him questions to confirm the diagnosis, but he rushed to reassure me that he had already been diagnosed with ADHD and had been doing well on dextroamphetamine and amphetamine for many years. I was inclined to question his diagnosis of ADHD after learning of his “as-needed” use of stimulants as brain enhancers. His medical record reflecting the diagnosis of ADHD dated back to when he was a first-year dental student. The diagnosis was based on the patient’s report of procrastination for as long as he could remember. It also hinged on difficulties learning a second language and math being a challenging subject for him. Despite this, he managed to do well in school and earn an undergraduate degree, well enough to later pursue dentistry at a reputable university.

I thought, “Isn’t it normal to lose motivation and have doubts when preparing for a high-stakes exam like the boards? Aren’t these negative thoughts distracting enough to render sustained focus impossible? Doesn’t everyone struggle with procrastination, especially when they need to study? If learning a new language requires devotion, consistency, and sacrifice, isn’t it inherently challenging? Doesn’t good performance in math depend on multiple factors (ie, a strong foundation, cumulative learning, frequent practice), and thus leaves many students struggling?”

This interaction and many similar ones made me scrutinize the diagnosis of ADHD in patients I encounter in clinical settings. We live in a society where instant gratification is cherished, and quick fixes are pursued with little contemplation of pitfalls. Students use stimulants to cram for exams, high-functioning professionals use them to meet deadlines, and athletes use them to enhance performance and improve reaction times. Psychiatry seems to be drawn into the demands of society and may be fueling the “quick-fix” mentality by prescribing stimulants to healthy individuals who want to improve their focus, and then diagnosing them with ADHD to align the prescription with an appropriate diagnosis. Research on the adverse effects of stimulant use in adults is not convincing nor conclusive enough to sway prescribers from denying the average adult patient a stimulant to enhance cognitive function before a high-stakes exam or a critical, career-shaping project if they present with some ADHD traits, which the patient might even hyperbolize to secure the desired prescription. All of this may contribute to the perceived rising prevalence of ADHD among adults.

As for my 30-year-old dental student, I reasoned that continuing his medication, for now, would help me establish rapport and trust. This would allow me to counsel him on the long-term adverse effects of stimulants, and develop a plan to optimize his sleep, focus, and time management skills, eventually improving his cognition and attention naturally. Unfortunately, he did not show up to future appointments after I sent him the refill.

In patients with attention-deficit/hyperactivity disorder (ADHD), stimulants reduce impulsivity and improve attention and focus. In individuals who do not have this disorder, stimulants are believed to enhance cognition, attention, and physical performance. In this article, I describe how a patient whose intermittent use of stimulants for motivation and cognitive enhancement shaped my approach to the diagnosis of ADHD.

Instant gratification and quick solutions

When I joined my psychiatry residency program, I expected to primarily treat patients who had depression, bipolar disorder, or psychosis. However, as I transitioned to my second year of residency, most patients I was assigned to had been diagnosed with ADHD. One of them was a 30-year-old in his fourth year of dental school. On his first visit, he requested a refill of dextroamphetamine and amphetamine 10 mg twice a day. He had been diagnosed with ADHD 5 years ago. He explained that he only needed this medication when preparing for his board examinations to motivate him and boost his focus and retention before studying. His study schedule included the exact doses and times he planned to take his stimulant.

I asked him questions to confirm the diagnosis, but he rushed to reassure me that he had already been diagnosed with ADHD and had been doing well on dextroamphetamine and amphetamine for many years. I was inclined to question his diagnosis of ADHD after learning of his “as-needed” use of stimulants as brain enhancers. His medical record reflecting the diagnosis of ADHD dated back to when he was a first-year dental student. The diagnosis was based on the patient’s report of procrastination for as long as he could remember. It also hinged on difficulties learning a second language and math being a challenging subject for him. Despite this, he managed to do well in school and earn an undergraduate degree, well enough to later pursue dentistry at a reputable university.

I thought, “Isn’t it normal to lose motivation and have doubts when preparing for a high-stakes exam like the boards? Aren’t these negative thoughts distracting enough to render sustained focus impossible? Doesn’t everyone struggle with procrastination, especially when they need to study? If learning a new language requires devotion, consistency, and sacrifice, isn’t it inherently challenging? Doesn’t good performance in math depend on multiple factors (ie, a strong foundation, cumulative learning, frequent practice), and thus leaves many students struggling?”

This interaction and many similar ones made me scrutinize the diagnosis of ADHD in patients I encounter in clinical settings. We live in a society where instant gratification is cherished, and quick fixes are pursued with little contemplation of pitfalls. Students use stimulants to cram for exams, high-functioning professionals use them to meet deadlines, and athletes use them to enhance performance and improve reaction times. Psychiatry seems to be drawn into the demands of society and may be fueling the “quick-fix” mentality by prescribing stimulants to healthy individuals who want to improve their focus, and then diagnosing them with ADHD to align the prescription with an appropriate diagnosis. Research on the adverse effects of stimulant use in adults is not convincing nor conclusive enough to sway prescribers from denying the average adult patient a stimulant to enhance cognitive function before a high-stakes exam or a critical, career-shaping project if they present with some ADHD traits, which the patient might even hyperbolize to secure the desired prescription. All of this may contribute to the perceived rising prevalence of ADHD among adults.

As for my 30-year-old dental student, I reasoned that continuing his medication, for now, would help me establish rapport and trust. This would allow me to counsel him on the long-term adverse effects of stimulants, and develop a plan to optimize his sleep, focus, and time management skills, eventually improving his cognition and attention naturally. Unfortunately, he did not show up to future appointments after I sent him the refill.

The World Health Organization declared COVID-19 a pandemic on March 11, 2020, just 4 months before the start of a new residency cycle. Referred to as “COVID interns,” PGY-1 residents transitioning out of medical school in 2020 faced an unprecedented challenge of doctoring within a confused and ill-prepared health care system, while senior residents scrambled to adjust to their rapidly changing training programs. Each subsequent week brought more sobering news of increasing hospitalizations, intensive care unit admissions, and deaths; hospitals across the country resorted to the redeployment of residents across all specialties to buffer the growing need within their internal medicine and critical care units.¹ And while the news and social media blurred into a collage of ventilator shortages, politicization of science, and “#healthcareheroes,” one study showed53.7% of medical interns (N=108) were struggling with mild to extremely severe depression, while 63.9% reported mild to severe anxiety.²

Many shortcomings of our health care system—ill preparedness, racial disparity, health illiteracy—were highlighted during the COVID-19 pandemic, and providers’ mental health was no exception.³ Classic psychosocial risk factors, such as high demands, lack of control, lack of institutional support, and absence of reward defined the workplace, leading Theorell⁴ to call it “a randomized trial for maximal worsening of the work environment.” Stress and burnout during residency are not novel concepts. A 2002 survey including 415 medical residency programs with a response from more than 4000 residents found depressive symptoms in 35% of respondents, paired with feelings of increased cynicism and decreased humanism despite major curricular reforms and duty hour limitations.⁵ Unfortunately, the statistics in the coming years hardly budged and, in the wake of the pandemic, culminated to more than 50% to 76% of physicians worldwide reporting burnout in 2020.^6-8

As a COVID intern at Brigham and Women’s Hospital (Boston, Massachusetts), I also experienced the demanding workload and witnessed the struggle of my colleagues firsthand. Brigham and Women’s Hospital, similar to many of its peer institutions, implemented frequent mental health check-ins within its curriculum. Known as the Intern Humanistic Curriculum, these check-ins essentially were an echo chamber to unload the psychological burdens of our workdays, and we eagerly shared what made us angry, sad, hopeful, and hopeless. During one such session, I learned about moral injury, a term originating in the military defined as the psychological stress resulting from actions—or the lack of actions—that violates one’s moral or ethical code.⁹ With the onslaught of patient deaths for which most of us felt unprepared, we had all endured varying degrees of moral injury. Greenberg et al⁹ described 2 potential outcomes after moral injury: (1) the development of mental health disorders such as depression and posttraumatic stress disorder, or (2) posttraumatic growth, which is the bolstering of psychological resilience. Notably, the outcome is based on the way someone is supported before, during, and after the challenging incident.⁹

With the aim of psychological growth and developing resilience, residents should prioritize mental health throughout their training. To this end, several resources are readily available, many of which I actively use or frequently revisit, which are reviewed here.

Mindfulness Meditation App

Calm (https://www.calm.com/) is one of several popular mobile applications (apps) that delivers mindfulness mediation—the practice of attending to experiences, thoughts, and emotions without bias or judgment. With more than 100 million downloads, Calm includes meditation tutorials, breathing exercises, nature scenes and sounds, and audio programs taught by mindfulness experts for $69.99 a year or $14.99 a month. Systemic reviews have demonstrated reduced sleep disturbance, decreased ruminative thoughts and emotional reactivity, and increased awareness and acceptance in those practicing mindfulness meditation. Calm users have reported these benefits, with many able to forego the time- and cost-intensive cognitive behavioral therapy that requires highly trained therapists.^10-12

Exercise to Relieve Stress

Both aerobic and anaerobic exercises are antidepressive and anxiolytic and also lower one’s overall sensitivity to stress. Whether it is governed by neurotransmitters such as the activation of the opioid systems or the release of endogenous endorphins or time spent focusing on a different task at hand, the benefits of exercise against mental stressors have been extensively studied and established.¹³ Consider obtaining a new gym membership at the start of residency or joining an intramural team. Both have the added benefit of expanding your social circle.

Socialize With Others

Social isolation and perceived loneliness are key stressors linked to neuroendocrine disturbances that underlie depression, anxiety, and even schizophrenia.^14,15 Throughout residency there will be several social events and opportunities to gather with colleagues—inside or outside of the work environment—and residents should attend as time allows. Even virtual social interactions were found to reduce stress and help in the treatment of social anxiety disorder.¹⁴

Open up to your co-residents, friends, and family about any struggles that may be invisible on the outside. Even attendings can empathize with the struggles of residency, and the mentors in place are actively trained to prioritize resident wellness. If verbal communication is not your strength, try journaling. Writing helps to untangle and better define underlying stressors and is itself meditative.^16,17 However, ensure that your journaling is focused on positive emotional responses and aims to determine the positive benefits within any stressful event; those solely expressing negative emotions were found to have higher levels of stress and anxiety afterward than they had before.¹⁷

Seek a Mental Health Specialist

As with all other human ailments, severe mental health disorders require specialists and proper medication. Unfortunately, substantial stigma accompanying mental health continues to permeate medicine, creating considerable barriers for residents in need of care.¹⁸ A 2016 survey of more than 2000 physicians found that those with mental illnesses did not seek treatment due to limited time, fear of being reported to a medical licensing board, concern over obtaining licensure, and shame or embarrassment at the diagnosis.¹⁹ Besides urging residents to seek care, more effort should be invested in addressing the stigma and ensuring confidentiality. In 2021, the internal medicine and medicine-pediatrics residency at the University of Colorado Anschutz Medical Campus (Aurora, Colorado) developed a confidential opt-out, rather than opt-in, mental health program, and appointments were made for all 80 interns in advance. In doing so, they found increased participation and self-reported wellness at a relatively low cost and simple implementation.²⁰ For trainees without such access, online or mobile therapy platforms offering electronic mental health treatment or telepsychiatry also have been employed.^21,22 The onus ultimately is still on the individual to seek the care they need. Although only an anecdotal piece of evidence, I have found the prevalence of physicians taking selective serotonin reuptake inhibitors such as escitalopram, sertraline, or fluoxetine to be strikingly common and quite beneficial.

Final Thoughts

Residency remains rife with financial, emotional, and physical stressors; even as the dust settles on the COVID-19 pandemic, the light shed on the importance of trainee mental health must remain illuminated. For the aforementioned resources to have an impact, residents need to be empowered to openly discuss mental health issues and to seek help if necessary. Finally, in 2018, the Journal of Graduate Medical Education published a 10-year prospective cohort study that found that emotional distress during residency persists in professional practice even 10 years after residency and is associated with future burnout.²³ Trainees should consider prioritizing their mental health to not only improve their quality of life in the present but also as an investment for their future.

The World Health Organization declared COVID-19 a pandemic on March 11, 2020, just 4 months before the start of a new residency cycle. Referred to as “COVID interns,” PGY-1 residents transitioning out of medical school in 2020 faced an unprecedented challenge of doctoring within a confused and ill-prepared health care system, while senior residents scrambled to adjust to their rapidly changing training programs. Each subsequent week brought more sobering news of increasing hospitalizations, intensive care unit admissions, and deaths; hospitals across the country resorted to the redeployment of residents across all specialties to buffer the growing need within their internal medicine and critical care units.¹ And while the news and social media blurred into a collage of ventilator shortages, politicization of science, and “#healthcareheroes,” one study showed53.7% of medical interns (N=108) were struggling with mild to extremely severe depression, while 63.9% reported mild to severe anxiety.²

Many shortcomings of our health care system—ill preparedness, racial disparity, health illiteracy—were highlighted during the COVID-19 pandemic, and providers’ mental health was no exception.³ Classic psychosocial risk factors, such as high demands, lack of control, lack of institutional support, and absence of reward defined the workplace, leading Theorell⁴ to call it “a randomized trial for maximal worsening of the work environment.” Stress and burnout during residency are not novel concepts. A 2002 survey including 415 medical residency programs with a response from more than 4000 residents found depressive symptoms in 35% of respondents, paired with feelings of increased cynicism and decreased humanism despite major curricular reforms and duty hour limitations.⁵ Unfortunately, the statistics in the coming years hardly budged and, in the wake of the pandemic, culminated to more than 50% to 76% of physicians worldwide reporting burnout in 2020.^6-8

As a COVID intern at Brigham and Women’s Hospital (Boston, Massachusetts), I also experienced the demanding workload and witnessed the struggle of my colleagues firsthand. Brigham and Women’s Hospital, similar to many of its peer institutions, implemented frequent mental health check-ins within its curriculum. Known as the Intern Humanistic Curriculum, these check-ins essentially were an echo chamber to unload the psychological burdens of our workdays, and we eagerly shared what made us angry, sad, hopeful, and hopeless. During one such session, I learned about moral injury, a term originating in the military defined as the psychological stress resulting from actions—or the lack of actions—that violates one’s moral or ethical code.⁹ With the onslaught of patient deaths for which most of us felt unprepared, we had all endured varying degrees of moral injury. Greenberg et al⁹ described 2 potential outcomes after moral injury: (1) the development of mental health disorders such as depression and posttraumatic stress disorder, or (2) posttraumatic growth, which is the bolstering of psychological resilience. Notably, the outcome is based on the way someone is supported before, during, and after the challenging incident.⁹

With the aim of psychological growth and developing resilience, residents should prioritize mental health throughout their training. To this end, several resources are readily available, many of which I actively use or frequently revisit, which are reviewed here.

Mindfulness Meditation App

Calm (https://www.calm.com/) is one of several popular mobile applications (apps) that delivers mindfulness mediation—the practice of attending to experiences, thoughts, and emotions without bias or judgment. With more than 100 million downloads, Calm includes meditation tutorials, breathing exercises, nature scenes and sounds, and audio programs taught by mindfulness experts for $69.99 a year or $14.99 a month. Systemic reviews have demonstrated reduced sleep disturbance, decreased ruminative thoughts and emotional reactivity, and increased awareness and acceptance in those practicing mindfulness meditation. Calm users have reported these benefits, with many able to forego the time- and cost-intensive cognitive behavioral therapy that requires highly trained therapists.^10-12

Exercise to Relieve Stress

Both aerobic and anaerobic exercises are antidepressive and anxiolytic and also lower one’s overall sensitivity to stress. Whether it is governed by neurotransmitters such as the activation of the opioid systems or the release of endogenous endorphins or time spent focusing on a different task at hand, the benefits of exercise against mental stressors have been extensively studied and established.¹³ Consider obtaining a new gym membership at the start of residency or joining an intramural team. Both have the added benefit of expanding your social circle.

Socialize With Others

Social isolation and perceived loneliness are key stressors linked to neuroendocrine disturbances that underlie depression, anxiety, and even schizophrenia.^14,15 Throughout residency there will be several social events and opportunities to gather with colleagues—inside or outside of the work environment—and residents should attend as time allows. Even virtual social interactions were found to reduce stress and help in the treatment of social anxiety disorder.¹⁴

Open up to your co-residents, friends, and family about any struggles that may be invisible on the outside. Even attendings can empathize with the struggles of residency, and the mentors in place are actively trained to prioritize resident wellness. If verbal communication is not your strength, try journaling. Writing helps to untangle and better define underlying stressors and is itself meditative.^16,17 However, ensure that your journaling is focused on positive emotional responses and aims to determine the positive benefits within any stressful event; those solely expressing negative emotions were found to have higher levels of stress and anxiety afterward than they had before.¹⁷

Seek a Mental Health Specialist

As with all other human ailments, severe mental health disorders require specialists and proper medication. Unfortunately, substantial stigma accompanying mental health continues to permeate medicine, creating considerable barriers for residents in need of care.¹⁸ A 2016 survey of more than 2000 physicians found that those with mental illnesses did not seek treatment due to limited time, fear of being reported to a medical licensing board, concern over obtaining licensure, and shame or embarrassment at the diagnosis.¹⁹ Besides urging residents to seek care, more effort should be invested in addressing the stigma and ensuring confidentiality. In 2021, the internal medicine and medicine-pediatrics residency at the University of Colorado Anschutz Medical Campus (Aurora, Colorado) developed a confidential opt-out, rather than opt-in, mental health program, and appointments were made for all 80 interns in advance. In doing so, they found increased participation and self-reported wellness at a relatively low cost and simple implementation.²⁰ For trainees without such access, online or mobile therapy platforms offering electronic mental health treatment or telepsychiatry also have been employed.^21,22 The onus ultimately is still on the individual to seek the care they need. Although only an anecdotal piece of evidence, I have found the prevalence of physicians taking selective serotonin reuptake inhibitors such as escitalopram, sertraline, or fluoxetine to be strikingly common and quite beneficial.

Final Thoughts

Residency remains rife with financial, emotional, and physical stressors; even as the dust settles on the COVID-19 pandemic, the light shed on the importance of trainee mental health must remain illuminated. For the aforementioned resources to have an impact, residents need to be empowered to openly discuss mental health issues and to seek help if necessary. Finally, in 2018, the Journal of Graduate Medical Education published a 10-year prospective cohort study that found that emotional distress during residency persists in professional practice even 10 years after residency and is associated with future burnout.²³ Trainees should consider prioritizing their mental health to not only improve their quality of life in the present but also as an investment for their future.

The World Health Organization declared COVID-19 a pandemic on March 11, 2020, just 4 months before the start of a new residency cycle. Referred to as “COVID interns,” PGY-1 residents transitioning out of medical school in 2020 faced an unprecedented challenge of doctoring within a confused and ill-prepared health care system, while senior residents scrambled to adjust to their rapidly changing training programs. Each subsequent week brought more sobering news of increasing hospitalizations, intensive care unit admissions, and deaths; hospitals across the country resorted to the redeployment of residents across all specialties to buffer the growing need within their internal medicine and critical care units.¹ And while the news and social media blurred into a collage of ventilator shortages, politicization of science, and “#healthcareheroes,” one study showed53.7% of medical interns (N=108) were struggling with mild to extremely severe depression, while 63.9% reported mild to severe anxiety.²

Many shortcomings of our health care system—ill preparedness, racial disparity, health illiteracy—were highlighted during the COVID-19 pandemic, and providers’ mental health was no exception.³ Classic psychosocial risk factors, such as high demands, lack of control, lack of institutional support, and absence of reward defined the workplace, leading Theorell⁴ to call it “a randomized trial for maximal worsening of the work environment.” Stress and burnout during residency are not novel concepts. A 2002 survey including 415 medical residency programs with a response from more than 4000 residents found depressive symptoms in 35% of respondents, paired with feelings of increased cynicism and decreased humanism despite major curricular reforms and duty hour limitations.⁵ Unfortunately, the statistics in the coming years hardly budged and, in the wake of the pandemic, culminated to more than 50% to 76% of physicians worldwide reporting burnout in 2020.^6-8

As a COVID intern at Brigham and Women’s Hospital (Boston, Massachusetts), I also experienced the demanding workload and witnessed the struggle of my colleagues firsthand. Brigham and Women’s Hospital, similar to many of its peer institutions, implemented frequent mental health check-ins within its curriculum. Known as the Intern Humanistic Curriculum, these check-ins essentially were an echo chamber to unload the psychological burdens of our workdays, and we eagerly shared what made us angry, sad, hopeful, and hopeless. During one such session, I learned about moral injury, a term originating in the military defined as the psychological stress resulting from actions—or the lack of actions—that violates one’s moral or ethical code.⁹ With the onslaught of patient deaths for which most of us felt unprepared, we had all endured varying degrees of moral injury. Greenberg et al⁹ described 2 potential outcomes after moral injury: (1) the development of mental health disorders such as depression and posttraumatic stress disorder, or (2) posttraumatic growth, which is the bolstering of psychological resilience. Notably, the outcome is based on the way someone is supported before, during, and after the challenging incident.⁹

With the aim of psychological growth and developing resilience, residents should prioritize mental health throughout their training. To this end, several resources are readily available, many of which I actively use or frequently revisit, which are reviewed here.

Mindfulness Meditation App

Calm (https://www.calm.com/) is one of several popular mobile applications (apps) that delivers mindfulness mediation—the practice of attending to experiences, thoughts, and emotions without bias or judgment. With more than 100 million downloads, Calm includes meditation tutorials, breathing exercises, nature scenes and sounds, and audio programs taught by mindfulness experts for $69.99 a year or $14.99 a month. Systemic reviews have demonstrated reduced sleep disturbance, decreased ruminative thoughts and emotional reactivity, and increased awareness and acceptance in those practicing mindfulness meditation. Calm users have reported these benefits, with many able to forego the time- and cost-intensive cognitive behavioral therapy that requires highly trained therapists.^10-12

Exercise to Relieve Stress

Both aerobic and anaerobic exercises are antidepressive and anxiolytic and also lower one’s overall sensitivity to stress. Whether it is governed by neurotransmitters such as the activation of the opioid systems or the release of endogenous endorphins or time spent focusing on a different task at hand, the benefits of exercise against mental stressors have been extensively studied and established.¹³ Consider obtaining a new gym membership at the start of residency or joining an intramural team. Both have the added benefit of expanding your social circle.

Socialize With Others

Social isolation and perceived loneliness are key stressors linked to neuroendocrine disturbances that underlie depression, anxiety, and even schizophrenia.^14,15 Throughout residency there will be several social events and opportunities to gather with colleagues—inside or outside of the work environment—and residents should attend as time allows. Even virtual social interactions were found to reduce stress and help in the treatment of social anxiety disorder.¹⁴

Open up to your co-residents, friends, and family about any struggles that may be invisible on the outside. Even attendings can empathize with the struggles of residency, and the mentors in place are actively trained to prioritize resident wellness. If verbal communication is not your strength, try journaling. Writing helps to untangle and better define underlying stressors and is itself meditative.^16,17 However, ensure that your journaling is focused on positive emotional responses and aims to determine the positive benefits within any stressful event; those solely expressing negative emotions were found to have higher levels of stress and anxiety afterward than they had before.¹⁷

Seek a Mental Health Specialist

As with all other human ailments, severe mental health disorders require specialists and proper medication. Unfortunately, substantial stigma accompanying mental health continues to permeate medicine, creating considerable barriers for residents in need of care.¹⁸ A 2016 survey of more than 2000 physicians found that those with mental illnesses did not seek treatment due to limited time, fear of being reported to a medical licensing board, concern over obtaining licensure, and shame or embarrassment at the diagnosis.¹⁹ Besides urging residents to seek care, more effort should be invested in addressing the stigma and ensuring confidentiality. In 2021, the internal medicine and medicine-pediatrics residency at the University of Colorado Anschutz Medical Campus (Aurora, Colorado) developed a confidential opt-out, rather than opt-in, mental health program, and appointments were made for all 80 interns in advance. In doing so, they found increased participation and self-reported wellness at a relatively low cost and simple implementation.²⁰ For trainees without such access, online or mobile therapy platforms offering electronic mental health treatment or telepsychiatry also have been employed.^21,22 The onus ultimately is still on the individual to seek the care they need. Although only an anecdotal piece of evidence, I have found the prevalence of physicians taking selective serotonin reuptake inhibitors such as escitalopram, sertraline, or fluoxetine to be strikingly common and quite beneficial.

Final Thoughts

Residency remains rife with financial, emotional, and physical stressors; even as the dust settles on the COVID-19 pandemic, the light shed on the importance of trainee mental health must remain illuminated. For the aforementioned resources to have an impact, residents need to be empowered to openly discuss mental health issues and to seek help if necessary. Finally, in 2018, the Journal of Graduate Medical Education published a 10-year prospective cohort study that found that emotional distress during residency persists in professional practice even 10 years after residency and is associated with future burnout.²³ Trainees should consider prioritizing their mental health to not only improve their quality of life in the present but also as an investment for their future.

In the 2021-2022 residency application cycle, the Association of American Medical Colleges (AAMC) piloted a supplemental application to accompany the standard residency application submitted via the AAMC’s Electronic Residency Application Service (ERAS).¹ Dermatology was 1 of 3 specialties to participate in the pilot alongside internal medicine and general surgery. The goal was to develop a tool that could align applicants with programs that best matched their career goals as well as program and geographic preferences. The Association of Professors of Dermatology Residency Program Directors Section was an early advocate for the supplemental application, and members of our leadership were involved in the design, implementation, and evaluation of the pilot supplemental application.

Participating in the supplemental application was optional for both applicants and programs. The supplemental application included a Past Experiences section, which allowed applicants to highlight their 5 most meaningful research, work, and/or volunteer experiences and to describe a challenging life event that might not otherwise be included with their application. The geographic preferences section permitted applicants to select up to 3 regions of interest as well as to indicate an urban vs rural preference. Lastly, a preference-signaling section allowed dermatology applicants to send signals to up to 3 programs of particular interest.

With the close of another application cycle, applicants and programs will begin preparing for the 2022-2023 recruitment season. In this column, we present dermatology-specific data regarding the supplemental application, highlight tentative changes for the upcoming application cycle, and offer tips for applicants and programs as we approach year 2 of the supplemental application.

Results of Supplemental Application Evaluation Surveys

During the 2021-2022 recruitment season, 93% (950/1019) of dermatology applicants submitted the supplemental application, and 87% (117/135) of dermatology residency programs participated in the pilot.² Surveys conducted by the AAMC between October 2021 and January 2022 showed that a large majority of dermatology programs used supplemental application data during initial application review when deciding who to interview. Eighty-three percent (40/48) of program directors felt that preference signals in particular helped them identify applicants they would have otherwise overlooked. Fifty-seven percent (4288/7516) of applicants across all specialties that participated in the pilot felt that preference signals would help them be noticed by their preferred programs.² Preference signals were not evenly distributed among dermatology programs. Programs received an average of 23 signals, with a range of 2 to 87 (AAMC, unpublished data, February 2022).

Additional questions remain to be answered: How does the number of signals received affect application review? How often do geographic and program signals convert to interview offers and matches? Regardless, enthusiasm among dermatology programs for the supplemental application remains. In a recent survey of Association of Professors of Dermatology program directors, all 43 respondents planned to participate in the supplemental application again in the upcoming year (Ilana Rosman, MD; unpublished data; February 2022). The pilot will be expanded to include at least 12 other specialties.¹As many who reviewed residency applications in 2021-2022 will attest, there was difficulty accessing the supplemental application data because it was not integrated into the Program Directors’ Work Station, the ERAS platform for programs to access applications, which will be remedied for the 2022-2023 iteration. Other tentative changes include modifications to the past experiences sections and timeline of the application.²

Utilizing the Supplemental Application: Recommendations to Applicants

Format of the Application—Applicants should familiarize themselves with the format of the supplemental application in advance and give themselves sufficient time to complete the application. In general, 3 to 4 hours of focused work should be enough time. Applicants should proofread for grammar and spelling before submitting.

Past Experiences—The past experiences section is intended to provide a focused snapshot of an applicant’s most meaningful activities and unique path to residency. Applicants should answer honestly based on their interests. If a student’s focus has been on volunteerism, the bulk of their 5 experiences listed may be related to service. Similarly, a student who has focused on research may preferentially highlight those experiences. In place of the long list of research, volunteer, and work experiences in the traditional ERAS application, applicants can highlight those activities in which they have been most invested. Applicants are encouraged to reflect on all genres of activities at any stage of their careers, even those not medical in nature, including work experience, military service, college athletics, or sustained musical or artistic achievement. Applicants should explain why each experience is meaningful rather than simply describing the activity.

Applicants also have the option to share a notable challenge they have overcome. It is not expected that each applicant will complete this question; in general, applicants who have not faced notable personal or professional obstacles should avoid answering. Additionally, if these challenges have been discussed in other areas of the application—for example, in the personal statement or medical student performance evaluation—it is not necessary to restate them here, though applicants can choose to do so. Examples of topics a student might discuss include being a first-generation college or medical student, growing up in poverty, facing notable personal or family health challenges, or having limited educational opportunities. It is important to share how this experience impacted an applicant’s journey to dermatology residency.

Geographic Preferences—The geographic preferences section can be difficult for applicants to navigate, as it may involve balancing a desire to attend a residency program in a particular region vs a greater desire to simply match in dermatology. In the past, programs may have made assumptions about geographic preferences based on an applicant’s birthplace, hometown, or medical school. In the supplemental application, applicants have the opportunity to directly reveal their preferences. We encourage applicants to be candid. Selecting a geographic region will not necessarily exclude applicants from consideration at other programs. For some applicants, program qualities may be more important than geography, or there may be no regional preferences. Those applicants can choose “no geographic preference.” There is considerable variability in how programs use geographic preferences. For this reason, it is in the best interest of applicants to simply respond honestly.

Preference Signaling—Preference signaling allows applicants to signal up to 3 preferred programs. Dermatology program directors agree that applicants should not signal their home program or programs at which they did in-person away rotations, as those programs would already be aware of the applicant’s interest. Although a signal increases the chances that the application will be reviewed holistically, it does not guarantee an interview offer. Programs may differentially utilize signals depending on multiple factors, including the number of signals received. We encourage applicants to discuss preference signaling strategies with advisors and focus on signaling programs in which they have genuine interest.

Recommendations to Selection Committees and Program Directors

The intent of the supplemental application is to provide a more meaningful picture of applicants and their experiences and preferences, with the goal of optimizing applicant-program fit. Programs should explicitly define for themselves the applicant characteristics and experiences they prioritize as well as their program goals. The supplemental application offers the potential to streamline holistic application review based on these elements. The short essay answers in the past experiences section permit reviewers to quickly scan for important experiences that align with the program’s recruitment goals. Importantly, reviewers should not penalize applicants who have not completed the question regarding other impactful life experiences, as not all applicants will have relevant information to share.

Some programs may find the geographic preferences section more valuable than others. Multiple factors affect how much weight will be given to geographic preferences, including program location and other characteristics that affect the desirability of the program to applicants. The competitiveness of the field, relatively low match rate, and limited number of programs may lead to less emphasis on geographic preferences in dermatology compared to other specialties. The purpose of this section is not to exclude applicants but to give programs more information that may help with alignment.

Anecdotally, many dermatology program directors were most interested in the preference signaling section of the supplemental application. Programs should consider signals to be evidence of strong preliminary interest. Programs may utilize signals differently depending on many factors such as the overall competitiveness of the program, program location, and the total number of signals the program receives. We recommend that programs holistically review all applications accompanied by a signal. Programs that utilize a points system may choose to award a certain number of points for a signal to their program. A signal might have a higher value at a program that receives only a few signals; conversely, a program that receives a large number of signals might not place tremendous value on the signal but may use it as a tiebreaker between similarly qualified applicants. Preference signaling is solely a tool for application review; because applicants’ preferences may change after the interview process, signals should not be utilized during ranking.

Next Steps

For program directors who have excitedly awaited residency application reform, the supplemental ERAS application is an important first step. Ultimately, we hope the supplemental application supplants much of the current residency application, serving as an efficient high-yield tool for holistically evaluating applicants’ academic and service records, accomplishments, and training preferences. Arriving at a new application will undoubtedly take time and discussion among the various stakeholders. Please continue to complete surveys from the AAMC, as feedback is the best method for refining the tool to serve its intended purpose.

Optimization of the application content is only one component of the reforms needed to improve the application process. Even with a revamped application tool, holistic review is challenging when programs are inundated with an ever-increasing number of applications. As such, we encourage stakeholders to simultaneously consider other potential reforms, such as caps on the number of applications, to allow programs and applicants the best opportunity for a mutually successful match.

In the 2021-2022 residency application cycle, the Association of American Medical Colleges (AAMC) piloted a supplemental application to accompany the standard residency application submitted via the AAMC’s Electronic Residency Application Service (ERAS).¹ Dermatology was 1 of 3 specialties to participate in the pilot alongside internal medicine and general surgery. The goal was to develop a tool that could align applicants with programs that best matched their career goals as well as program and geographic preferences. The Association of Professors of Dermatology Residency Program Directors Section was an early advocate for the supplemental application, and members of our leadership were involved in the design, implementation, and evaluation of the pilot supplemental application.

Participating in the supplemental application was optional for both applicants and programs. The supplemental application included a Past Experiences section, which allowed applicants to highlight their 5 most meaningful research, work, and/or volunteer experiences and to describe a challenging life event that might not otherwise be included with their application. The geographic preferences section permitted applicants to select up to 3 regions of interest as well as to indicate an urban vs rural preference. Lastly, a preference-signaling section allowed dermatology applicants to send signals to up to 3 programs of particular interest.

With the close of another application cycle, applicants and programs will begin preparing for the 2022-2023 recruitment season. In this column, we present dermatology-specific data regarding the supplemental application, highlight tentative changes for the upcoming application cycle, and offer tips for applicants and programs as we approach year 2 of the supplemental application.

Results of Supplemental Application Evaluation Surveys

During the 2021-2022 recruitment season, 93% (950/1019) of dermatology applicants submitted the supplemental application, and 87% (117/135) of dermatology residency programs participated in the pilot.² Surveys conducted by the AAMC between October 2021 and January 2022 showed that a large majority of dermatology programs used supplemental application data during initial application review when deciding who to interview. Eighty-three percent (40/48) of program directors felt that preference signals in particular helped them identify applicants they would have otherwise overlooked. Fifty-seven percent (4288/7516) of applicants across all specialties that participated in the pilot felt that preference signals would help them be noticed by their preferred programs.² Preference signals were not evenly distributed among dermatology programs. Programs received an average of 23 signals, with a range of 2 to 87 (AAMC, unpublished data, February 2022).

Additional questions remain to be answered: How does the number of signals received affect application review? How often do geographic and program signals convert to interview offers and matches? Regardless, enthusiasm among dermatology programs for the supplemental application remains. In a recent survey of Association of Professors of Dermatology program directors, all 43 respondents planned to participate in the supplemental application again in the upcoming year (Ilana Rosman, MD; unpublished data; February 2022). The pilot will be expanded to include at least 12 other specialties.¹As many who reviewed residency applications in 2021-2022 will attest, there was difficulty accessing the supplemental application data because it was not integrated into the Program Directors’ Work Station, the ERAS platform for programs to access applications, which will be remedied for the 2022-2023 iteration. Other tentative changes include modifications to the past experiences sections and timeline of the application.²

Utilizing the Supplemental Application: Recommendations to Applicants

Format of the Application—Applicants should familiarize themselves with the format of the supplemental application in advance and give themselves sufficient time to complete the application. In general, 3 to 4 hours of focused work should be enough time. Applicants should proofread for grammar and spelling before submitting.

Past Experiences—The past experiences section is intended to provide a focused snapshot of an applicant’s most meaningful activities and unique path to residency. Applicants should answer honestly based on their interests. If a student’s focus has been on volunteerism, the bulk of their 5 experiences listed may be related to service. Similarly, a student who has focused on research may preferentially highlight those experiences. In place of the long list of research, volunteer, and work experiences in the traditional ERAS application, applicants can highlight those activities in which they have been most invested. Applicants are encouraged to reflect on all genres of activities at any stage of their careers, even those not medical in nature, including work experience, military service, college athletics, or sustained musical or artistic achievement. Applicants should explain why each experience is meaningful rather than simply describing the activity.

Applicants also have the option to share a notable challenge they have overcome. It is not expected that each applicant will complete this question; in general, applicants who have not faced notable personal or professional obstacles should avoid answering. Additionally, if these challenges have been discussed in other areas of the application—for example, in the personal statement or medical student performance evaluation—it is not necessary to restate them here, though applicants can choose to do so. Examples of topics a student might discuss include being a first-generation college or medical student, growing up in poverty, facing notable personal or family health challenges, or having limited educational opportunities. It is important to share how this experience impacted an applicant’s journey to dermatology residency.

Geographic Preferences—The geographic preferences section can be difficult for applicants to navigate, as it may involve balancing a desire to attend a residency program in a particular region vs a greater desire to simply match in dermatology. In the past, programs may have made assumptions about geographic preferences based on an applicant’s birthplace, hometown, or medical school. In the supplemental application, applicants have the opportunity to directly reveal their preferences. We encourage applicants to be candid. Selecting a geographic region will not necessarily exclude applicants from consideration at other programs. For some applicants, program qualities may be more important than geography, or there may be no regional preferences. Those applicants can choose “no geographic preference.” There is considerable variability in how programs use geographic preferences. For this reason, it is in the best interest of applicants to simply respond honestly.

Preference Signaling—Preference signaling allows applicants to signal up to 3 preferred programs. Dermatology program directors agree that applicants should not signal their home program or programs at which they did in-person away rotations, as those programs would already be aware of the applicant’s interest. Although a signal increases the chances that the application will be reviewed holistically, it does not guarantee an interview offer. Programs may differentially utilize signals depending on multiple factors, including the number of signals received. We encourage applicants to discuss preference signaling strategies with advisors and focus on signaling programs in which they have genuine interest.

Recommendations to Selection Committees and Program Directors

The intent of the supplemental application is to provide a more meaningful picture of applicants and their experiences and preferences, with the goal of optimizing applicant-program fit. Programs should explicitly define for themselves the applicant characteristics and experiences they prioritize as well as their program goals. The supplemental application offers the potential to streamline holistic application review based on these elements. The short essay answers in the past experiences section permit reviewers to quickly scan for important experiences that align with the program’s recruitment goals. Importantly, reviewers should not penalize applicants who have not completed the question regarding other impactful life experiences, as not all applicants will have relevant information to share.

Some programs may find the geographic preferences section more valuable than others. Multiple factors affect how much weight will be given to geographic preferences, including program location and other characteristics that affect the desirability of the program to applicants. The competitiveness of the field, relatively low match rate, and limited number of programs may lead to less emphasis on geographic preferences in dermatology compared to other specialties. The purpose of this section is not to exclude applicants but to give programs more information that may help with alignment.

Anecdotally, many dermatology program directors were most interested in the preference signaling section of the supplemental application. Programs should consider signals to be evidence of strong preliminary interest. Programs may utilize signals differently depending on many factors such as the overall competitiveness of the program, program location, and the total number of signals the program receives. We recommend that programs holistically review all applications accompanied by a signal. Programs that utilize a points system may choose to award a certain number of points for a signal to their program. A signal might have a higher value at a program that receives only a few signals; conversely, a program that receives a large number of signals might not place tremendous value on the signal but may use it as a tiebreaker between similarly qualified applicants. Preference signaling is solely a tool for application review; because applicants’ preferences may change after the interview process, signals should not be utilized during ranking.

Next Steps

For program directors who have excitedly awaited residency application reform, the supplemental ERAS application is an important first step. Ultimately, we hope the supplemental application supplants much of the current residency application, serving as an efficient high-yield tool for holistically evaluating applicants’ academic and service records, accomplishments, and training preferences. Arriving at a new application will undoubtedly take time and discussion among the various stakeholders. Please continue to complete surveys from the AAMC, as feedback is the best method for refining the tool to serve its intended purpose.

Optimization of the application content is only one component of the reforms needed to improve the application process. Even with a revamped application tool, holistic review is challenging when programs are inundated with an ever-increasing number of applications. As such, we encourage stakeholders to simultaneously consider other potential reforms, such as caps on the number of applications, to allow programs and applicants the best opportunity for a mutually successful match.

In the 2021-2022 residency application cycle, the Association of American Medical Colleges (AAMC) piloted a supplemental application to accompany the standard residency application submitted via the AAMC’s Electronic Residency Application Service (ERAS).¹ Dermatology was 1 of 3 specialties to participate in the pilot alongside internal medicine and general surgery. The goal was to develop a tool that could align applicants with programs that best matched their career goals as well as program and geographic preferences. The Association of Professors of Dermatology Residency Program Directors Section was an early advocate for the supplemental application, and members of our leadership were involved in the design, implementation, and evaluation of the pilot supplemental application.

Participating in the supplemental application was optional for both applicants and programs. The supplemental application included a Past Experiences section, which allowed applicants to highlight their 5 most meaningful research, work, and/or volunteer experiences and to describe a challenging life event that might not otherwise be included with their application. The geographic preferences section permitted applicants to select up to 3 regions of interest as well as to indicate an urban vs rural preference. Lastly, a preference-signaling section allowed dermatology applicants to send signals to up to 3 programs of particular interest.

With the close of another application cycle, applicants and programs will begin preparing for the 2022-2023 recruitment season. In this column, we present dermatology-specific data regarding the supplemental application, highlight tentative changes for the upcoming application cycle, and offer tips for applicants and programs as we approach year 2 of the supplemental application.

Results of Supplemental Application Evaluation Surveys

During the 2021-2022 recruitment season, 93% (950/1019) of dermatology applicants submitted the supplemental application, and 87% (117/135) of dermatology residency programs participated in the pilot.² Surveys conducted by the AAMC between October 2021 and January 2022 showed that a large majority of dermatology programs used supplemental application data during initial application review when deciding who to interview. Eighty-three percent (40/48) of program directors felt that preference signals in particular helped them identify applicants they would have otherwise overlooked. Fifty-seven percent (4288/7516) of applicants across all specialties that participated in the pilot felt that preference signals would help them be noticed by their preferred programs.² Preference signals were not evenly distributed among dermatology programs. Programs received an average of 23 signals, with a range of 2 to 87 (AAMC, unpublished data, February 2022).

Additional questions remain to be answered: How does the number of signals received affect application review? How often do geographic and program signals convert to interview offers and matches? Regardless, enthusiasm among dermatology programs for the supplemental application remains. In a recent survey of Association of Professors of Dermatology program directors, all 43 respondents planned to participate in the supplemental application again in the upcoming year (Ilana Rosman, MD; unpublished data; February 2022). The pilot will be expanded to include at least 12 other specialties.¹As many who reviewed residency applications in 2021-2022 will attest, there was difficulty accessing the supplemental application data because it was not integrated into the Program Directors’ Work Station, the ERAS platform for programs to access applications, which will be remedied for the 2022-2023 iteration. Other tentative changes include modifications to the past experiences sections and timeline of the application.²

Utilizing the Supplemental Application: Recommendations to Applicants

Format of the Application—Applicants should familiarize themselves with the format of the supplemental application in advance and give themselves sufficient time to complete the application. In general, 3 to 4 hours of focused work should be enough time. Applicants should proofread for grammar and spelling before submitting.

Past Experiences—The past experiences section is intended to provide a focused snapshot of an applicant’s most meaningful activities and unique path to residency. Applicants should answer honestly based on their interests. If a student’s focus has been on volunteerism, the bulk of their 5 experiences listed may be related to service. Similarly, a student who has focused on research may preferentially highlight those experiences. In place of the long list of research, volunteer, and work experiences in the traditional ERAS application, applicants can highlight those activities in which they have been most invested. Applicants are encouraged to reflect on all genres of activities at any stage of their careers, even those not medical in nature, including work experience, military service, college athletics, or sustained musical or artistic achievement. Applicants should explain why each experience is meaningful rather than simply describing the activity.

Applicants also have the option to share a notable challenge they have overcome. It is not expected that each applicant will complete this question; in general, applicants who have not faced notable personal or professional obstacles should avoid answering. Additionally, if these challenges have been discussed in other areas of the application—for example, in the personal statement or medical student performance evaluation—it is not necessary to restate them here, though applicants can choose to do so. Examples of topics a student might discuss include being a first-generation college or medical student, growing up in poverty, facing notable personal or family health challenges, or having limited educational opportunities. It is important to share how this experience impacted an applicant’s journey to dermatology residency.

Geographic Preferences—The geographic preferences section can be difficult for applicants to navigate, as it may involve balancing a desire to attend a residency program in a particular region vs a greater desire to simply match in dermatology. In the past, programs may have made assumptions about geographic preferences based on an applicant’s birthplace, hometown, or medical school. In the supplemental application, applicants have the opportunity to directly reveal their preferences. We encourage applicants to be candid. Selecting a geographic region will not necessarily exclude applicants from consideration at other programs. For some applicants, program qualities may be more important than geography, or there may be no regional preferences. Those applicants can choose “no geographic preference.” There is considerable variability in how programs use geographic preferences. For this reason, it is in the best interest of applicants to simply respond honestly.

Preference Signaling—Preference signaling allows applicants to signal up to 3 preferred programs. Dermatology program directors agree that applicants should not signal their home program or programs at which they did in-person away rotations, as those programs would already be aware of the applicant’s interest. Although a signal increases the chances that the application will be reviewed holistically, it does not guarantee an interview offer. Programs may differentially utilize signals depending on multiple factors, including the number of signals received. We encourage applicants to discuss preference signaling strategies with advisors and focus on signaling programs in which they have genuine interest.

Recommendations to Selection Committees and Program Directors

The intent of the supplemental application is to provide a more meaningful picture of applicants and their experiences and preferences, with the goal of optimizing applicant-program fit. Programs should explicitly define for themselves the applicant characteristics and experiences they prioritize as well as their program goals. The supplemental application offers the potential to streamline holistic application review based on these elements. The short essay answers in the past experiences section permit reviewers to quickly scan for important experiences that align with the program’s recruitment goals. Importantly, reviewers should not penalize applicants who have not completed the question regarding other impactful life experiences, as not all applicants will have relevant information to share.

Some programs may find the geographic preferences section more valuable than others. Multiple factors affect how much weight will be given to geographic preferences, including program location and other characteristics that affect the desirability of the program to applicants. The competitiveness of the field, relatively low match rate, and limited number of programs may lead to less emphasis on geographic preferences in dermatology compared to other specialties. The purpose of this section is not to exclude applicants but to give programs more information that may help with alignment.

Anecdotally, many dermatology program directors were most interested in the preference signaling section of the supplemental application. Programs should consider signals to be evidence of strong preliminary interest. Programs may utilize signals differently depending on many factors such as the overall competitiveness of the program, program location, and the total number of signals the program receives. We recommend that programs holistically review all applications accompanied by a signal. Programs that utilize a points system may choose to award a certain number of points for a signal to their program. A signal might have a higher value at a program that receives only a few signals; conversely, a program that receives a large number of signals might not place tremendous value on the signal but may use it as a tiebreaker between similarly qualified applicants. Preference signaling is solely a tool for application review; because applicants’ preferences may change after the interview process, signals should not be utilized during ranking.

Next Steps

For program directors who have excitedly awaited residency application reform, the supplemental ERAS application is an important first step. Ultimately, we hope the supplemental application supplants much of the current residency application, serving as an efficient high-yield tool for holistically evaluating applicants’ academic and service records, accomplishments, and training preferences. Arriving at a new application will undoubtedly take time and discussion among the various stakeholders. Please continue to complete surveys from the AAMC, as feedback is the best method for refining the tool to serve its intended purpose.

Optimization of the application content is only one component of the reforms needed to improve the application process. Even with a revamped application tool, holistic review is challenging when programs are inundated with an ever-increasing number of applications. As such, we encourage stakeholders to simultaneously consider other potential reforms, such as caps on the number of applications, to allow programs and applicants the best opportunity for a mutually successful match.

Ramadan is one of the obligatory pillars in Islam during which healthy Muslims are required to fast from dawn until sunset every day for 1 month. There are an estimated 3.45 million Muslims in the United States, and this population will continue to grow by 100,000 per year.¹ With the increased growth of the Muslim population, it is important for clinicians to be aware of how patients of Muslim faith are affected during Ramadan. In this article, we explore the potential risks, as well as the benefits, the month of Ramadan brings to patients. We will also explain how being religiously aware is necessary to provide optimal care for these individuals.

For some patients, fasting may pose risks

Similar to other communities in the United States, individuals who are Muslim experience mood disorders, anxiety disorders, posttraumatic stress disorder, obsessive-compulsive disorder, schizophrenia, substance use disorders, and other psychiatric illnesses.² During the month of Ramadan, Muslims are to abstain completely from eating and drinking from dawn until sunset. This includes medications as well as food and drink.

Due to these circumstances, patients will often change the timing, frequency, and dosing of their medications to allow them to fast. One study found 60% of Muslims made medication adjustments during Ramadan without seeking medical advice.³ It is possible that such alterations may be detrimental. During Ramadan, some Muslims wake up early in the morning to eat a pre-dawn meal, and often go back to sleep. This has been reported to cause a delay in sleep-wake times and to reduce rapid eye movement sleep.⁴ These circadian rhythm changes can be detrimental to patients with bipolar disorder. One study found higher rates of relapse to depression and mania in patients with bipolar disorder who were fasting during Ramadan.⁵ Circadian rhythm disturbances also may worsen depression.⁶ Another point of concern is patients with eating disorders. One small case series (N = 6) found that fasting during Ramadan exacerbated symptoms in patients with eating disorders.⁷

Another concern is that dehydration while fasting can lead to lithium toxicity. However, one study found lithium levels remained stable while fasting for 10 to 12 hours.⁵ Another showed that changing lithium dosing from twice a day to once a day allowed for easier administration without causing a subtherapeutic change in blood lithium levels.⁸

The practice also may have benefits for mental health

For many Muslims, Ramadan is the best time of the year, where they reconnect with their religion and experience the utmost spiritual growth. Studies have shown that the incidence of suicide is lowest during Ramadan compared to other months.⁹ A study of older men found that intermittent fasting and calorie restriction (not during Ramadan) resulted in decreases in tension, confusion, anger, and mood disturbance.¹⁰ Another study found that fasting during Ramadan had a positive impact on depression, anxiety, stress, and cognitive function.¹¹

Clinical considerations

To provide the best care for Muslim patients during Ramadan, clinicians should take a holistic approach and take all factors into consideration. It is common for circadian rhythm disruptions to exacerbate mood disorders, so encourage patients to maintain healthy sleep hygiene to their best ability during this month. Another important consideration is medication timing and dosing.¹² For patients prescribed a medication that typically is taken twice a day, determine if this dosing can be changed to once a day, or if both doses can be taken when it is permissible to eat (sunset to dawn). For medications that are absorbed with food, consider how these medications might be adjusted and maintained while a patient is fasting. Some medications may be sedating or activating, so the timing of administration may need to be adjusted to meet the patient’s needs. Lastly, keep in mind that certain medications can have withdrawal effects, and the likelihood of this occurring while a patient is fasting.

One vital point is that if a patient is at high risk of clinically decompensating due to fasting or medication adjustments or discontinuation, advise them to not fast. Muslims with physical or mental illnesses are excused from fasting. Bear in mind that because Ramadan is meant to be a month of heightened spirituality, many Muslims will prefer to fast.

Ramadan is one of the obligatory pillars in Islam during which healthy Muslims are required to fast from dawn until sunset every day for 1 month. There are an estimated 3.45 million Muslims in the United States, and this population will continue to grow by 100,000 per year.¹ With the increased growth of the Muslim population, it is important for clinicians to be aware of how patients of Muslim faith are affected during Ramadan. In this article, we explore the potential risks, as well as the benefits, the month of Ramadan brings to patients. We will also explain how being religiously aware is necessary to provide optimal care for these individuals.

For some patients, fasting may pose risks

Similar to other communities in the United States, individuals who are Muslim experience mood disorders, anxiety disorders, posttraumatic stress disorder, obsessive-compulsive disorder, schizophrenia, substance use disorders, and other psychiatric illnesses.² During the month of Ramadan, Muslims are to abstain completely from eating and drinking from dawn until sunset. This includes medications as well as food and drink.

Due to these circumstances, patients will often change the timing, frequency, and dosing of their medications to allow them to fast. One study found 60% of Muslims made medication adjustments during Ramadan without seeking medical advice.³ It is possible that such alterations may be detrimental. During Ramadan, some Muslims wake up early in the morning to eat a pre-dawn meal, and often go back to sleep. This has been reported to cause a delay in sleep-wake times and to reduce rapid eye movement sleep.⁴ These circadian rhythm changes can be detrimental to patients with bipolar disorder. One study found higher rates of relapse to depression and mania in patients with bipolar disorder who were fasting during Ramadan.⁵ Circadian rhythm disturbances also may worsen depression.⁶ Another point of concern is patients with eating disorders. One small case series (N = 6) found that fasting during Ramadan exacerbated symptoms in patients with eating disorders.⁷

Another concern is that dehydration while fasting can lead to lithium toxicity. However, one study found lithium levels remained stable while fasting for 10 to 12 hours.⁵ Another showed that changing lithium dosing from twice a day to once a day allowed for easier administration without causing a subtherapeutic change in blood lithium levels.⁸

The practice also may have benefits for mental health

For many Muslims, Ramadan is the best time of the year, where they reconnect with their religion and experience the utmost spiritual growth. Studies have shown that the incidence of suicide is lowest during Ramadan compared to other months.⁹ A study of older men found that intermittent fasting and calorie restriction (not during Ramadan) resulted in decreases in tension, confusion, anger, and mood disturbance.¹⁰ Another study found that fasting during Ramadan had a positive impact on depression, anxiety, stress, and cognitive function.¹¹

Clinical considerations

To provide the best care for Muslim patients during Ramadan, clinicians should take a holistic approach and take all factors into consideration. It is common for circadian rhythm disruptions to exacerbate mood disorders, so encourage patients to maintain healthy sleep hygiene to their best ability during this month. Another important consideration is medication timing and dosing.¹² For patients prescribed a medication that typically is taken twice a day, determine if this dosing can be changed to once a day, or if both doses can be taken when it is permissible to eat (sunset to dawn). For medications that are absorbed with food, consider how these medications might be adjusted and maintained while a patient is fasting. Some medications may be sedating or activating, so the timing of administration may need to be adjusted to meet the patient’s needs. Lastly, keep in mind that certain medications can have withdrawal effects, and the likelihood of this occurring while a patient is fasting.

One vital point is that if a patient is at high risk of clinically decompensating due to fasting or medication adjustments or discontinuation, advise them to not fast. Muslims with physical or mental illnesses are excused from fasting. Bear in mind that because Ramadan is meant to be a month of heightened spirituality, many Muslims will prefer to fast.

Ramadan is one of the obligatory pillars in Islam during which healthy Muslims are required to fast from dawn until sunset every day for 1 month. There are an estimated 3.45 million Muslims in the United States, and this population will continue to grow by 100,000 per year.¹ With the increased growth of the Muslim population, it is important for clinicians to be aware of how patients of Muslim faith are affected during Ramadan. In this article, we explore the potential risks, as well as the benefits, the month of Ramadan brings to patients. We will also explain how being religiously aware is necessary to provide optimal care for these individuals.

For some patients, fasting may pose risks

Similar to other communities in the United States, individuals who are Muslim experience mood disorders, anxiety disorders, posttraumatic stress disorder, obsessive-compulsive disorder, schizophrenia, substance use disorders, and other psychiatric illnesses.² During the month of Ramadan, Muslims are to abstain completely from eating and drinking from dawn until sunset. This includes medications as well as food and drink.

Due to these circumstances, patients will often change the timing, frequency, and dosing of their medications to allow them to fast. One study found 60% of Muslims made medication adjustments during Ramadan without seeking medical advice.³ It is possible that such alterations may be detrimental. During Ramadan, some Muslims wake up early in the morning to eat a pre-dawn meal, and often go back to sleep. This has been reported to cause a delay in sleep-wake times and to reduce rapid eye movement sleep.⁴ These circadian rhythm changes can be detrimental to patients with bipolar disorder. One study found higher rates of relapse to depression and mania in patients with bipolar disorder who were fasting during Ramadan.⁵ Circadian rhythm disturbances also may worsen depression.⁶ Another point of concern is patients with eating disorders. One small case series (N = 6) found that fasting during Ramadan exacerbated symptoms in patients with eating disorders.⁷

Another concern is that dehydration while fasting can lead to lithium toxicity. However, one study found lithium levels remained stable while fasting for 10 to 12 hours.⁵ Another showed that changing lithium dosing from twice a day to once a day allowed for easier administration without causing a subtherapeutic change in blood lithium levels.⁸

The practice also may have benefits for mental health

For many Muslims, Ramadan is the best time of the year, where they reconnect with their religion and experience the utmost spiritual growth. Studies have shown that the incidence of suicide is lowest during Ramadan compared to other months.⁹ A study of older men found that intermittent fasting and calorie restriction (not during Ramadan) resulted in decreases in tension, confusion, anger, and mood disturbance.¹⁰ Another study found that fasting during Ramadan had a positive impact on depression, anxiety, stress, and cognitive function.¹¹

Clinical considerations

To provide the best care for Muslim patients during Ramadan, clinicians should take a holistic approach and take all factors into consideration. It is common for circadian rhythm disruptions to exacerbate mood disorders, so encourage patients to maintain healthy sleep hygiene to their best ability during this month. Another important consideration is medication timing and dosing.¹² For patients prescribed a medication that typically is taken twice a day, determine if this dosing can be changed to once a day, or if both doses can be taken when it is permissible to eat (sunset to dawn). For medications that are absorbed with food, consider how these medications might be adjusted and maintained while a patient is fasting. Some medications may be sedating or activating, so the timing of administration may need to be adjusted to meet the patient’s needs. Lastly, keep in mind that certain medications can have withdrawal effects, and the likelihood of this occurring while a patient is fasting.

One vital point is that if a patient is at high risk of clinically decompensating due to fasting or medication adjustments or discontinuation, advise them to not fast. Muslims with physical or mental illnesses are excused from fasting. Bear in mind that because Ramadan is meant to be a month of heightened spirituality, many Muslims will prefer to fast.

Motherhood and dermatology residency are both full-time jobs. The thought that a woman must either be superhuman to succeed at both or that success at one must come at the expense of the other is antiquated. With careful navigation and sufficient support, these two roles can complement and heighten one another. The most recent Accreditation Council for Graduate Medical Education (ACGME) report showed that nearly 60% of dermatology residents are women,¹ with most women in training being of childbearing age. One study showed that female dermatologists were most likely to have children during residency (51% of those surveyed), despite residents reporting more barriers to childbearing at this career stage.² Trainees thinking of starting a family have many considerations to navigate: timing of pregnancy, maternity leave scheduling, breastfeeding while working, and planning for childcare. For the first time in the history of the specialty, most active dermatologists in practice are women.³ Thus, the future of dermatology requires supportive policies and resources for the successful navigation of these issues by today’s trainees.

Timing of Pregnancy

Timing of pregnancy can be a source of stress to the female dermatology resident. Barriers to childbearing during residency include the perception that women who have children during residency training are less committed to their jobs; concerns of overburdening fellow residents; and fear that residency may need to be extended, thereby delaying the ability to sit for the board examination.² However, the potential increased risk for infertility in delaying pregnancy adds to the stress of pregnancy planning. A 2016 survey of female physicians (N=327) showed that 24.1% of respondents who had attempted conception were diagnosed with infertility, with an average age at diagnosis of 33.7 years.⁴ This is higher than the national average, with the Centers for Disease Control and Prevention reporting that approximately 19% of women aged 15 to 49 years with no prior births experience infertility.⁵ In a 1992 survey of female physician residents (N=373) who gave birth during residency, 32% indicated that they would not recommend the experience to others; of the 68% who would recommend the experience, one-third encouraged timing delivery to occur in the last 2 months of residency due to benefits of continued insurance coverage, a decrease in clinic responsibilities, and the potential for extended maternity leave during hiatus between jobs.⁶ Although this may be a good strategy, studying and sitting for board examinations while caring for a newborn right after graduation may be overly difficult for some. The first year of residency was perceived as the most stressful time to be pregnant, with each subsequent year being less problematic.⁶ Planning pregnancy for delivery near the end of the second year and beginning of the third year of dermatology residency may be a reasonable choice.

Maternity Leave

The Family and Medical Leave Act entitles eligible employees of covered employers to take unpaid, job-protected leave, with 12 workweeks of leave in a 12-month period for the birth of a child and to care for the newborn child within 1 year of birth.⁷ The actual length of maternity leave taken by most surveyed female dermatologists (n=96) is shorter: 25% (24/96) took less than 4 weeks, 42.7% (41/96) took 4 to 8 weeks, 25% (24/96) took 9 to 12 weeks, and 7.3% (7/96) were able to take more than 12 weeks of maternity leave.²

The American Board of Dermatology implemented a new Resident Leave policy that went into effect July 1, 2021, stipulating that, within certain parameters, time spent away from training for family and parental leave would not exhaust vacation time or require an extension in training. Under this policy, absence from training exceeding 8 weeks (6 weeks leave, plus 2 weeks of vacation) in a given year should be approved only under exceptional circumstances and may necessitate additional training time to ensure that competency requirements are met.⁸ Although this policy is a step in the right direction, institutional policies still may vary. Dermatology residents planning to start a family during training should consider their plans for fellowship, as taking an extended maternity leave beyond 8 weeks may jeopardize a July fellowship start date.

Lactation and Residency

The American Academy of Pediatrics recommends exclusive breastfeeding for approximately 6 months, with continuation of breastfeeding for 1 year or longer as mutually desired by the mother and infant.⁹ Successful lactation and achieving breastfeeding goals can be difficult during medical training. A national cross-sectional survey of female residents (N=312) showed that the median total time of breastfeeding and pumping was 9 months, with 74% continuing after 6 months and 13% continuing past 12 months. Of those surveyed, 73% reported residency limited their ability to lactate, and 37% stopped prior to their desired goal.¹⁰ As of July 1, 2020, the ACGME requires that residency programs and sponsoring institutions provide clean and private facilities for lactation that have refrigeration capabilities, with proximity appropriate for safe patient care.¹¹ There has been a call to dermatology program leadership to support breastfeeding residents by providing sufficient time and space to pump; a breastfeeding resident will need a 20- to 30-minute break to express milk approximately every 3 hours during the work day.¹² One innovative initiative to meet the ACGME lactation requirement reported by the Kansas University Medical Center Graduate Medical Education program (Kansas City, Kansas) was the purchase of wearable breast pumps to loan to residents. The benefits of wearable breast pumps are that they are discreet and can allow mothers to express milk inconspicuously while working, can increase milk supply, require less set up and expression time than traditional pumps, and can allow the mother to manage time more efficiently.¹³ Breastfeeding plans and goals should be discussed with program leadership before return from leave to strategize and anticipate gaps in clinic scheduling to accommodate the lactating resident.

Planning for Childcare

Resident hours can be long and erratic, making choices for childcare difficult. In one survey of female residents, 61% of married or partnered respondents (n=447) were delaying childbearing, and 46% cited lack of access to childcare as a reason.¹⁴ Not all dermatology residents are fortunate enough to match to a program near family, but close family support can be an undeniable asset during childrearing and should be weighed heavily when ranking programs. Options for childcare include relying on a stay-at-home spouse or other family member, a live-in or live-out nanny, part-time babysitters, and daycare. It is crucial to have multiple layers and back-up options for childcare available at any given time when working as a resident. Even with a child enrolled in a full-time daycare and a live-in nanny, a daycare closure due to a COVID-19 exposure or sudden medical emergency in the nanny can still leave unpredicted holes in your childcare plan, leaving the resident to potentially miss work to fill the gap. A survey of residents at one institution showed that the most common backup childcare plan for situations in which either the child or the regular caregiver is ill is for the nontrainee parent or spouse to stay home (45%; n=101), with 25% of respondents staying home to care for a sick child themselves, which clearly has an impact on the hospital. The article proposed implementation of on-site or near-site childcare for residents with extended hours or a 24-hour emergency drop-in availability.¹⁵ One institution reported success with the development of a departmentally funded childcare supplementation stipend offered to residents to support daycare costs during the first 6 months of a baby’s life.¹⁶

Final Thoughts

Due to the competitiveness of the field, dermatology residents are by nature high performing and academically successful. For a high achiever, the idea of potentially disappointing faculty and colleagues by starting a family during residency can be guilt inducing. Concerns about one’s ability to adequately study the breadth of dermatology while simultaneously raising a child can be distressing; however, there are many ways in which motherhood can hone skills to become a better dermatology resident. Through motherhood one can enhance time management skills, increase efficiency, and improve rapport with pediatric patients and trust with their parents/guardians. A dermatology resident may be her own harshest critic, but it is time that the future generation of dermatologists become their own greatest advocates for establishing supportive policies and resources for the successful navigation of motherhood and dermatology residency.

Motherhood and dermatology residency are both full-time jobs. The thought that a woman must either be superhuman to succeed at both or that success at one must come at the expense of the other is antiquated. With careful navigation and sufficient support, these two roles can complement and heighten one another. The most recent Accreditation Council for Graduate Medical Education (ACGME) report showed that nearly 60% of dermatology residents are women,¹ with most women in training being of childbearing age. One study showed that female dermatologists were most likely to have children during residency (51% of those surveyed), despite residents reporting more barriers to childbearing at this career stage.² Trainees thinking of starting a family have many considerations to navigate: timing of pregnancy, maternity leave scheduling, breastfeeding while working, and planning for childcare. For the first time in the history of the specialty, most active dermatologists in practice are women.³ Thus, the future of dermatology requires supportive policies and resources for the successful navigation of these issues by today’s trainees.

Timing of Pregnancy

Timing of pregnancy can be a source of stress to the female dermatology resident. Barriers to childbearing during residency include the perception that women who have children during residency training are less committed to their jobs; concerns of overburdening fellow residents; and fear that residency may need to be extended, thereby delaying the ability to sit for the board examination.² However, the potential increased risk for infertility in delaying pregnancy adds to the stress of pregnancy planning. A 2016 survey of female physicians (N=327) showed that 24.1% of respondents who had attempted conception were diagnosed with infertility, with an average age at diagnosis of 33.7 years.⁴ This is higher than the national average, with the Centers for Disease Control and Prevention reporting that approximately 19% of women aged 15 to 49 years with no prior births experience infertility.⁵ In a 1992 survey of female physician residents (N=373) who gave birth during residency, 32% indicated that they would not recommend the experience to others; of the 68% who would recommend the experience, one-third encouraged timing delivery to occur in the last 2 months of residency due to benefits of continued insurance coverage, a decrease in clinic responsibilities, and the potential for extended maternity leave during hiatus between jobs.⁶ Although this may be a good strategy, studying and sitting for board examinations while caring for a newborn right after graduation may be overly difficult for some. The first year of residency was perceived as the most stressful time to be pregnant, with each subsequent year being less problematic.⁶ Planning pregnancy for delivery near the end of the second year and beginning of the third year of dermatology residency may be a reasonable choice.

Maternity Leave

The Family and Medical Leave Act entitles eligible employees of covered employers to take unpaid, job-protected leave, with 12 workweeks of leave in a 12-month period for the birth of a child and to care for the newborn child within 1 year of birth.⁷ The actual length of maternity leave taken by most surveyed female dermatologists (n=96) is shorter: 25% (24/96) took less than 4 weeks, 42.7% (41/96) took 4 to 8 weeks, 25% (24/96) took 9 to 12 weeks, and 7.3% (7/96) were able to take more than 12 weeks of maternity leave.²

The American Board of Dermatology implemented a new Resident Leave policy that went into effect July 1, 2021, stipulating that, within certain parameters, time spent away from training for family and parental leave would not exhaust vacation time or require an extension in training. Under this policy, absence from training exceeding 8 weeks (6 weeks leave, plus 2 weeks of vacation) in a given year should be approved only under exceptional circumstances and may necessitate additional training time to ensure that competency requirements are met.⁸ Although this policy is a step in the right direction, institutional policies still may vary. Dermatology residents planning to start a family during training should consider their plans for fellowship, as taking an extended maternity leave beyond 8 weeks may jeopardize a July fellowship start date.

Lactation and Residency

The American Academy of Pediatrics recommends exclusive breastfeeding for approximately 6 months, with continuation of breastfeeding for 1 year or longer as mutually desired by the mother and infant.⁹ Successful lactation and achieving breastfeeding goals can be difficult during medical training. A national cross-sectional survey of female residents (N=312) showed that the median total time of breastfeeding and pumping was 9 months, with 74% continuing after 6 months and 13% continuing past 12 months. Of those surveyed, 73% reported residency limited their ability to lactate, and 37% stopped prior to their desired goal.¹⁰ As of July 1, 2020, the ACGME requires that residency programs and sponsoring institutions provide clean and private facilities for lactation that have refrigeration capabilities, with proximity appropriate for safe patient care.¹¹ There has been a call to dermatology program leadership to support breastfeeding residents by providing sufficient time and space to pump; a breastfeeding resident will need a 20- to 30-minute break to express milk approximately every 3 hours during the work day.¹² One innovative initiative to meet the ACGME lactation requirement reported by the Kansas University Medical Center Graduate Medical Education program (Kansas City, Kansas) was the purchase of wearable breast pumps to loan to residents. The benefits of wearable breast pumps are that they are discreet and can allow mothers to express milk inconspicuously while working, can increase milk supply, require less set up and expression time than traditional pumps, and can allow the mother to manage time more efficiently.¹³ Breastfeeding plans and goals should be discussed with program leadership before return from leave to strategize and anticipate gaps in clinic scheduling to accommodate the lactating resident.

Planning for Childcare

Resident hours can be long and erratic, making choices for childcare difficult. In one survey of female residents, 61% of married or partnered respondents (n=447) were delaying childbearing, and 46% cited lack of access to childcare as a reason.¹⁴ Not all dermatology residents are fortunate enough to match to a program near family, but close family support can be an undeniable asset during childrearing and should be weighed heavily when ranking programs. Options for childcare include relying on a stay-at-home spouse or other family member, a live-in or live-out nanny, part-time babysitters, and daycare. It is crucial to have multiple layers and back-up options for childcare available at any given time when working as a resident. Even with a child enrolled in a full-time daycare and a live-in nanny, a daycare closure due to a COVID-19 exposure or sudden medical emergency in the nanny can still leave unpredicted holes in your childcare plan, leaving the resident to potentially miss work to fill the gap. A survey of residents at one institution showed that the most common backup childcare plan for situations in which either the child or the regular caregiver is ill is for the nontrainee parent or spouse to stay home (45%; n=101), with 25% of respondents staying home to care for a sick child themselves, which clearly has an impact on the hospital. The article proposed implementation of on-site or near-site childcare for residents with extended hours or a 24-hour emergency drop-in availability.¹⁵ One institution reported success with the development of a departmentally funded childcare supplementation stipend offered to residents to support daycare costs during the first 6 months of a baby’s life.¹⁶

Final Thoughts

Due to the competitiveness of the field, dermatology residents are by nature high performing and academically successful. For a high achiever, the idea of potentially disappointing faculty and colleagues by starting a family during residency can be guilt inducing. Concerns about one’s ability to adequately study the breadth of dermatology while simultaneously raising a child can be distressing; however, there are many ways in which motherhood can hone skills to become a better dermatology resident. Through motherhood one can enhance time management skills, increase efficiency, and improve rapport with pediatric patients and trust with their parents/guardians. A dermatology resident may be her own harshest critic, but it is time that the future generation of dermatologists become their own greatest advocates for establishing supportive policies and resources for the successful navigation of motherhood and dermatology residency.

Motherhood and dermatology residency are both full-time jobs. The thought that a woman must either be superhuman to succeed at both or that success at one must come at the expense of the other is antiquated. With careful navigation and sufficient support, these two roles can complement and heighten one another. The most recent Accreditation Council for Graduate Medical Education (ACGME) report showed that nearly 60% of dermatology residents are women,¹ with most women in training being of childbearing age. One study showed that female dermatologists were most likely to have children during residency (51% of those surveyed), despite residents reporting more barriers to childbearing at this career stage.² Trainees thinking of starting a family have many considerations to navigate: timing of pregnancy, maternity leave scheduling, breastfeeding while working, and planning for childcare. For the first time in the history of the specialty, most active dermatologists in practice are women.³ Thus, the future of dermatology requires supportive policies and resources for the successful navigation of these issues by today’s trainees.

Timing of Pregnancy

Timing of pregnancy can be a source of stress to the female dermatology resident. Barriers to childbearing during residency include the perception that women who have children during residency training are less committed to their jobs; concerns of overburdening fellow residents; and fear that residency may need to be extended, thereby delaying the ability to sit for the board examination.² However, the potential increased risk for infertility in delaying pregnancy adds to the stress of pregnancy planning. A 2016 survey of female physicians (N=327) showed that 24.1% of respondents who had attempted conception were diagnosed with infertility, with an average age at diagnosis of 33.7 years.⁴ This is higher than the national average, with the Centers for Disease Control and Prevention reporting that approximately 19% of women aged 15 to 49 years with no prior births experience infertility.⁵ In a 1992 survey of female physician residents (N=373) who gave birth during residency, 32% indicated that they would not recommend the experience to others; of the 68% who would recommend the experience, one-third encouraged timing delivery to occur in the last 2 months of residency due to benefits of continued insurance coverage, a decrease in clinic responsibilities, and the potential for extended maternity leave during hiatus between jobs.⁶ Although this may be a good strategy, studying and sitting for board examinations while caring for a newborn right after graduation may be overly difficult for some. The first year of residency was perceived as the most stressful time to be pregnant, with each subsequent year being less problematic.⁶ Planning pregnancy for delivery near the end of the second year and beginning of the third year of dermatology residency may be a reasonable choice.

Maternity Leave

The Family and Medical Leave Act entitles eligible employees of covered employers to take unpaid, job-protected leave, with 12 workweeks of leave in a 12-month period for the birth of a child and to care for the newborn child within 1 year of birth.⁷ The actual length of maternity leave taken by most surveyed female dermatologists (n=96) is shorter: 25% (24/96) took less than 4 weeks, 42.7% (41/96) took 4 to 8 weeks, 25% (24/96) took 9 to 12 weeks, and 7.3% (7/96) were able to take more than 12 weeks of maternity leave.²

The American Board of Dermatology implemented a new Resident Leave policy that went into effect July 1, 2021, stipulating that, within certain parameters, time spent away from training for family and parental leave would not exhaust vacation time or require an extension in training. Under this policy, absence from training exceeding 8 weeks (6 weeks leave, plus 2 weeks of vacation) in a given year should be approved only under exceptional circumstances and may necessitate additional training time to ensure that competency requirements are met.⁸ Although this policy is a step in the right direction, institutional policies still may vary. Dermatology residents planning to start a family during training should consider their plans for fellowship, as taking an extended maternity leave beyond 8 weeks may jeopardize a July fellowship start date.

Lactation and Residency

The American Academy of Pediatrics recommends exclusive breastfeeding for approximately 6 months, with continuation of breastfeeding for 1 year or longer as mutually desired by the mother and infant.⁹ Successful lactation and achieving breastfeeding goals can be difficult during medical training. A national cross-sectional survey of female residents (N=312) showed that the median total time of breastfeeding and pumping was 9 months, with 74% continuing after 6 months and 13% continuing past 12 months. Of those surveyed, 73% reported residency limited their ability to lactate, and 37% stopped prior to their desired goal.¹⁰ As of July 1, 2020, the ACGME requires that residency programs and sponsoring institutions provide clean and private facilities for lactation that have refrigeration capabilities, with proximity appropriate for safe patient care.¹¹ There has been a call to dermatology program leadership to support breastfeeding residents by providing sufficient time and space to pump; a breastfeeding resident will need a 20- to 30-minute break to express milk approximately every 3 hours during the work day.¹² One innovative initiative to meet the ACGME lactation requirement reported by the Kansas University Medical Center Graduate Medical Education program (Kansas City, Kansas) was the purchase of wearable breast pumps to loan to residents. The benefits of wearable breast pumps are that they are discreet and can allow mothers to express milk inconspicuously while working, can increase milk supply, require less set up and expression time than traditional pumps, and can allow the mother to manage time more efficiently.¹³ Breastfeeding plans and goals should be discussed with program leadership before return from leave to strategize and anticipate gaps in clinic scheduling to accommodate the lactating resident.

Planning for Childcare

Resident hours can be long and erratic, making choices for childcare difficult. In one survey of female residents, 61% of married or partnered respondents (n=447) were delaying childbearing, and 46% cited lack of access to childcare as a reason.¹⁴ Not all dermatology residents are fortunate enough to match to a program near family, but close family support can be an undeniable asset during childrearing and should be weighed heavily when ranking programs. Options for childcare include relying on a stay-at-home spouse or other family member, a live-in or live-out nanny, part-time babysitters, and daycare. It is crucial to have multiple layers and back-up options for childcare available at any given time when working as a resident. Even with a child enrolled in a full-time daycare and a live-in nanny, a daycare closure due to a COVID-19 exposure or sudden medical emergency in the nanny can still leave unpredicted holes in your childcare plan, leaving the resident to potentially miss work to fill the gap. A survey of residents at one institution showed that the most common backup childcare plan for situations in which either the child or the regular caregiver is ill is for the nontrainee parent or spouse to stay home (45%; n=101), with 25% of respondents staying home to care for a sick child themselves, which clearly has an impact on the hospital. The article proposed implementation of on-site or near-site childcare for residents with extended hours or a 24-hour emergency drop-in availability.¹⁵ One institution reported success with the development of a departmentally funded childcare supplementation stipend offered to residents to support daycare costs during the first 6 months of a baby’s life.¹⁶

Final Thoughts

Due to the competitiveness of the field, dermatology residents are by nature high performing and academically successful. For a high achiever, the idea of potentially disappointing faculty and colleagues by starting a family during residency can be guilt inducing. Concerns about one’s ability to adequately study the breadth of dermatology while simultaneously raising a child can be distressing; however, there are many ways in which motherhood can hone skills to become a better dermatology resident. Through motherhood one can enhance time management skills, increase efficiency, and improve rapport with pediatric patients and trust with their parents/guardians. A dermatology resident may be her own harshest critic, but it is time that the future generation of dermatologists become their own greatest advocates for establishing supportive policies and resources for the successful navigation of motherhood and dermatology residency.

The chances are good that at least one patient you saw today could have been provided a better environment to foster your patient-physician relationship. A 2020 Gallup poll revealed that an estimated 5.6% of US adults identified as lesbian, gay, bisexual, and transgender (LGBT).¹ Based on the estimated US population of 331.7 million individuals on December 3, 2020, this means that approximately 18.6 million identified as LGBT and could potentially require health care services.² These numbers highlight the increasing need within the medical community to provide quality and accessible care to the LGBT community, and dermatologists have a role to play. They treat conditions that are apparent to the patient and others around them, attracting those that may not be motivated to see different physicians. They can not only help with skin diseases that affect all patients but also can train other physicians to screen for some dermatologic diseases that may have a higher prevalence within the LGBT community. Dermatologists have a unique opportunity to help patients better reflect themselves through both surgical and nonsurgical modalities.

Demographics and Definitions

To discuss this topic effectively, it is important to define LGBT terms (Table).³ As a disclaimer, language is fluid. Despite a word or term currently being used and accepted, it quickly can become obsolete. A clinician can always do research, follow the lead of the patient, and respectfully ask questions if there is ever confusion surrounding terminology. Patients do not expect every physician they encounter to be an expert in this subject. What is most important is that patients are approached with an open mind and humility with the goal of providing optimal care.

Although the federal government now uses the term sexual and gender minorities (SGM), the more specific terms lesbian, gay, bisexual, and transgender usually are preferred.^3,4 Other letters are at times added to the acronym LGBT, including Q for questioning or queer, I for intersex, and A for asexual; all of these letters are under the larger SGM umbrella. Because LGBT is the most commonly used acronym in the daily vernacular, it will be the default for this article.

A term describing sexual orientation does not necessarily describe sexual practices. A woman who identifies as straight may have sex with both men and women, and a gay man may not have sex at all. To be more descriptive regarding sexual practices, one may use the terms men who have sex with men or women who have sex with women.³ Because of this nuance, it is important to elicit a sexual history when speaking to all patients in a forward nonjudgmental manner.

The term transgender is used to describe people whose gender identity differs from the sex they were assigned at birth. Two examples of transgender individuals would be transgender women who were assigned male at birth and transgender men who were assigned female at birth. The term transgender is used in opposition to the term cisgender, which is applied to a person whose gender and sex assigned at birth align.³ When a transgender patient presents to a physician, they may want to discuss methods of gender affirmation or transitioning. These terms encompass any action a person may take to align their body or gender expression with that of the gender they identify with. This could be in the form of gender-affirming hormone therapy (ie, estrogen or testosterone treatment) or gender-affirming surgery (ie, “top” and “bottom” surgeries, in which someone surgically treats their chest or genitals, respectively).³

Creating a Safe Space

The physician is responsible for providing a safe space for patients to disclose medically pertinent information. It is then the job of the dermatologist to be cognizant of health concerns that directly affect the LGBT population and to be prepared if one of these concerns should arise. A safe space consists of both the physical location in which the patient encounter will occur and the people that will be conducting and assisting in the patient encounter. Safe spaces provide a patient with reassurance that they will receive care in a judgement-free location. To create a safe space, both the physical and interpersonal aspects must be addressed to provide an environment that strengthens the patient-physician alliance.

Dermatology residents often spend more time with patients than their attending physicians, providing them the opportunity to foster robust relationships with those served. Although they may not be able to change the physical environment, residents can advocate for patients in their departments and show solidarity in subtle ways. One way to show support for the LGBT community is to publicly display a symbol of solidarity, which could be done by wearing a symbol of support on a white coat lapel. Although there are many designs and styles to choose from, one example is the American Medical Student Association pins that combine the caduceus (a common symbol for medicine) with a rainbow design.⁵ Whichever symbol is chosen, this small gesture allows patients to immediately know that their physician is an ally. Residents also can encourage their department to add a rainbow flag, a pink triangle, or another symbol somewhere prominent in the check-in area that conveys a message of support.⁶ Many institutions require residents to perform quality improvement projects. The resident can make a substantial difference in their patients’ experiences by revising their office’s intake forms as a quality improvement project, which can be done by including a section on assigned sex at birth separate from gender.⁷ When inquiring about gender, in addition to “male” and “female,” a space can be left for people that do not identify with the traditional binary. When asking about sexual orientation, inclusive language options can be provided with additional space for self-identification. Finally, residents can incorporate pronouns below their name in their email signature to normalize this disclosure of information.⁸ These small changes can have a substantial impact on the health care experience of SGM patients.

The previously described changes can be implemented by residents to provide better care to SGM patients, a group usually considered to be more burdened by physical and psychological diseases.⁹ Furthermore, dermatologists can provide care for these patients in ways that other physicians cannot. There are special considerations for LGBT patients, as some dermatologic conditions may be more common in this patient population.

Prior studies have shown that men who have sex with men have a higher rate of HIV and other sexually transmitted infections, methicillin-resistant Staphylococcus aureus skin infections, and potentially nonmelanoma skin cancer.^10-14 Transgender women also have been found to have higher rates of HIV, in addition to a higher incidence of anal human papillomavirus.^15,16 Women who have sex with women have been shown to see physicians less frequently and to be less up to date on their pertinent cancer-related screenings.^10,17 Although these associations should not dictate the patient encounter, awareness of them will lead to better patient care. Such awareness also can provide further motivation for dermatologists to discuss safe sexual practices, potential initiation of pre-exposure prophylactic antiretroviral therapy, sun-protective practices, and the importance of following up with a primary physician for examinations and age-specific cancer screening.

Transgender patients may present with unique dermatologic concerns. For transgender male patients, testosterone therapy can cause acne breakouts and androgenetic alopecia. Usually considered worse during the start of treatment, hormone-related acne can be managed with topical retinoids, topical and oral antibiotics, and isotretinoin (if severe).^18,19 The iPLEDGE system necessary for prescribing isotretinoin to patients in the United States recently has changed its language to “patients who can get pregnant” and “patients who cannot get pregnant,” following urging by the medical community for inclusivity and progress.^20,21 This change creates an inclusive space where registration is no longer centered around gender and instead focuses on the presence of anatomy. Although androgenetic alopecia is a side effect of hormone therapy, it may not be unwanted.¹⁸ Discussion about patient desires is important. If the alopecia is unwanted, the Endocrine Society recommends treating cisgender and transgender patients the same in terms of treatment modalities.²²

Transgender female patients also can experience dermatologic manifestations of gender-affirming hormone therapy. Melasma may develop secondary to estrogen replacement and can be treated with topical bleaching creams, lasers, and phototherapy.²³ Hair removal may be pursued for patients with refractory unwanted body hair, with laser hair removal being the most commonly pursued treatment. Patients also may desire cosmetic procedures, such as botulinum toxin or fillers, to augment their physical appearance.²⁴ Providing these services to patients may allow them to better express themselves and live authentically.

Final Thoughts

There is no way to summarize the experience of everyone within a community. Each person has different thoughts, values, and goals. It also is impossible to encompass every topic that is important for SGM patients. The goal of this article is to empower clinicians to be comfortable discussing issues related to sexuality and gender while also offering resources to learn more, allowing optimal care to be provided to this population. Thus, this article is not comprehensive. There are articles to provide further resources and education, such as the continuing medical education series by Yeung et al^10,25 in the Journal of the American Academy of Dermatology, as well as organizations within medicine, such as the GLMA: Health Professionals Advancing LGBTQ Equality (https://www.glma.org/), and in dermatology, such as GALDA, the Gay and Lesbian Dermatology Association (https://www.glderm.org/). By providing a safe space for our patients and learning about specific health-related risk factors, dermatologists can provide the best possible care to the LGBT community.

Acknowledgments—I thank Warren R. Heymann, MD (Camden, New Jersey), and Howa Yeung, MD, MSc (Atlanta, Georgia), for their guidance and mentorship in the creation of this article.

The chances are good that at least one patient you saw today could have been provided a better environment to foster your patient-physician relationship. A 2020 Gallup poll revealed that an estimated 5.6% of US adults identified as lesbian, gay, bisexual, and transgender (LGBT).¹ Based on the estimated US population of 331.7 million individuals on December 3, 2020, this means that approximately 18.6 million identified as LGBT and could potentially require health care services.² These numbers highlight the increasing need within the medical community to provide quality and accessible care to the LGBT community, and dermatologists have a role to play. They treat conditions that are apparent to the patient and others around them, attracting those that may not be motivated to see different physicians. They can not only help with skin diseases that affect all patients but also can train other physicians to screen for some dermatologic diseases that may have a higher prevalence within the LGBT community. Dermatologists have a unique opportunity to help patients better reflect themselves through both surgical and nonsurgical modalities.

Demographics and Definitions

To discuss this topic effectively, it is important to define LGBT terms (Table).³ As a disclaimer, language is fluid. Despite a word or term currently being used and accepted, it quickly can become obsolete. A clinician can always do research, follow the lead of the patient, and respectfully ask questions if there is ever confusion surrounding terminology. Patients do not expect every physician they encounter to be an expert in this subject. What is most important is that patients are approached with an open mind and humility with the goal of providing optimal care.

Although the federal government now uses the term sexual and gender minorities (SGM), the more specific terms lesbian, gay, bisexual, and transgender usually are preferred.^3,4 Other letters are at times added to the acronym LGBT, including Q for questioning or queer, I for intersex, and A for asexual; all of these letters are under the larger SGM umbrella. Because LGBT is the most commonly used acronym in the daily vernacular, it will be the default for this article.

A term describing sexual orientation does not necessarily describe sexual practices. A woman who identifies as straight may have sex with both men and women, and a gay man may not have sex at all. To be more descriptive regarding sexual practices, one may use the terms men who have sex with men or women who have sex with women.³ Because of this nuance, it is important to elicit a sexual history when speaking to all patients in a forward nonjudgmental manner.

The term transgender is used to describe people whose gender identity differs from the sex they were assigned at birth. Two examples of transgender individuals would be transgender women who were assigned male at birth and transgender men who were assigned female at birth. The term transgender is used in opposition to the term cisgender, which is applied to a person whose gender and sex assigned at birth align.³ When a transgender patient presents to a physician, they may want to discuss methods of gender affirmation or transitioning. These terms encompass any action a person may take to align their body or gender expression with that of the gender they identify with. This could be in the form of gender-affirming hormone therapy (ie, estrogen or testosterone treatment) or gender-affirming surgery (ie, “top” and “bottom” surgeries, in which someone surgically treats their chest or genitals, respectively).³

Creating a Safe Space

The physician is responsible for providing a safe space for patients to disclose medically pertinent information. It is then the job of the dermatologist to be cognizant of health concerns that directly affect the LGBT population and to be prepared if one of these concerns should arise. A safe space consists of both the physical location in which the patient encounter will occur and the people that will be conducting and assisting in the patient encounter. Safe spaces provide a patient with reassurance that they will receive care in a judgement-free location. To create a safe space, both the physical and interpersonal aspects must be addressed to provide an environment that strengthens the patient-physician alliance.

Dermatology residents often spend more time with patients than their attending physicians, providing them the opportunity to foster robust relationships with those served. Although they may not be able to change the physical environment, residents can advocate for patients in their departments and show solidarity in subtle ways. One way to show support for the LGBT community is to publicly display a symbol of solidarity, which could be done by wearing a symbol of support on a white coat lapel. Although there are many designs and styles to choose from, one example is the American Medical Student Association pins that combine the caduceus (a common symbol for medicine) with a rainbow design.⁵ Whichever symbol is chosen, this small gesture allows patients to immediately know that their physician is an ally. Residents also can encourage their department to add a rainbow flag, a pink triangle, or another symbol somewhere prominent in the check-in area that conveys a message of support.⁶ Many institutions require residents to perform quality improvement projects. The resident can make a substantial difference in their patients’ experiences by revising their office’s intake forms as a quality improvement project, which can be done by including a section on assigned sex at birth separate from gender.⁷ When inquiring about gender, in addition to “male” and “female,” a space can be left for people that do not identify with the traditional binary. When asking about sexual orientation, inclusive language options can be provided with additional space for self-identification. Finally, residents can incorporate pronouns below their name in their email signature to normalize this disclosure of information.⁸ These small changes can have a substantial impact on the health care experience of SGM patients.

The previously described changes can be implemented by residents to provide better care to SGM patients, a group usually considered to be more burdened by physical and psychological diseases.⁹ Furthermore, dermatologists can provide care for these patients in ways that other physicians cannot. There are special considerations for LGBT patients, as some dermatologic conditions may be more common in this patient population.

Prior studies have shown that men who have sex with men have a higher rate of HIV and other sexually transmitted infections, methicillin-resistant Staphylococcus aureus skin infections, and potentially nonmelanoma skin cancer.^10-14 Transgender women also have been found to have higher rates of HIV, in addition to a higher incidence of anal human papillomavirus.^15,16 Women who have sex with women have been shown to see physicians less frequently and to be less up to date on their pertinent cancer-related screenings.^10,17 Although these associations should not dictate the patient encounter, awareness of them will lead to better patient care. Such awareness also can provide further motivation for dermatologists to discuss safe sexual practices, potential initiation of pre-exposure prophylactic antiretroviral therapy, sun-protective practices, and the importance of following up with a primary physician for examinations and age-specific cancer screening.

Transgender patients may present with unique dermatologic concerns. For transgender male patients, testosterone therapy can cause acne breakouts and androgenetic alopecia. Usually considered worse during the start of treatment, hormone-related acne can be managed with topical retinoids, topical and oral antibiotics, and isotretinoin (if severe).^18,19 The iPLEDGE system necessary for prescribing isotretinoin to patients in the United States recently has changed its language to “patients who can get pregnant” and “patients who cannot get pregnant,” following urging by the medical community for inclusivity and progress.^20,21 This change creates an inclusive space where registration is no longer centered around gender and instead focuses on the presence of anatomy. Although androgenetic alopecia is a side effect of hormone therapy, it may not be unwanted.¹⁸ Discussion about patient desires is important. If the alopecia is unwanted, the Endocrine Society recommends treating cisgender and transgender patients the same in terms of treatment modalities.²²

Transgender female patients also can experience dermatologic manifestations of gender-affirming hormone therapy. Melasma may develop secondary to estrogen replacement and can be treated with topical bleaching creams, lasers, and phototherapy.²³ Hair removal may be pursued for patients with refractory unwanted body hair, with laser hair removal being the most commonly pursued treatment. Patients also may desire cosmetic procedures, such as botulinum toxin or fillers, to augment their physical appearance.²⁴ Providing these services to patients may allow them to better express themselves and live authentically.

Final Thoughts

There is no way to summarize the experience of everyone within a community. Each person has different thoughts, values, and goals. It also is impossible to encompass every topic that is important for SGM patients. The goal of this article is to empower clinicians to be comfortable discussing issues related to sexuality and gender while also offering resources to learn more, allowing optimal care to be provided to this population. Thus, this article is not comprehensive. There are articles to provide further resources and education, such as the continuing medical education series by Yeung et al^10,25 in the Journal of the American Academy of Dermatology, as well as organizations within medicine, such as the GLMA: Health Professionals Advancing LGBTQ Equality (https://www.glma.org/), and in dermatology, such as GALDA, the Gay and Lesbian Dermatology Association (https://www.glderm.org/). By providing a safe space for our patients and learning about specific health-related risk factors, dermatologists can provide the best possible care to the LGBT community.

Acknowledgments—I thank Warren R. Heymann, MD (Camden, New Jersey), and Howa Yeung, MD, MSc (Atlanta, Georgia), for their guidance and mentorship in the creation of this article.

The chances are good that at least one patient you saw today could have been provided a better environment to foster your patient-physician relationship. A 2020 Gallup poll revealed that an estimated 5.6% of US adults identified as lesbian, gay, bisexual, and transgender (LGBT).¹ Based on the estimated US population of 331.7 million individuals on December 3, 2020, this means that approximately 18.6 million identified as LGBT and could potentially require health care services.² These numbers highlight the increasing need within the medical community to provide quality and accessible care to the LGBT community, and dermatologists have a role to play. They treat conditions that are apparent to the patient and others around them, attracting those that may not be motivated to see different physicians. They can not only help with skin diseases that affect all patients but also can train other physicians to screen for some dermatologic diseases that may have a higher prevalence within the LGBT community. Dermatologists have a unique opportunity to help patients better reflect themselves through both surgical and nonsurgical modalities.

Demographics and Definitions

To discuss this topic effectively, it is important to define LGBT terms (Table).³ As a disclaimer, language is fluid. Despite a word or term currently being used and accepted, it quickly can become obsolete. A clinician can always do research, follow the lead of the patient, and respectfully ask questions if there is ever confusion surrounding terminology. Patients do not expect every physician they encounter to be an expert in this subject. What is most important is that patients are approached with an open mind and humility with the goal of providing optimal care.

Although the federal government now uses the term sexual and gender minorities (SGM), the more specific terms lesbian, gay, bisexual, and transgender usually are preferred.^3,4 Other letters are at times added to the acronym LGBT, including Q for questioning or queer, I for intersex, and A for asexual; all of these letters are under the larger SGM umbrella. Because LGBT is the most commonly used acronym in the daily vernacular, it will be the default for this article.

A term describing sexual orientation does not necessarily describe sexual practices. A woman who identifies as straight may have sex with both men and women, and a gay man may not have sex at all. To be more descriptive regarding sexual practices, one may use the terms men who have sex with men or women who have sex with women.³ Because of this nuance, it is important to elicit a sexual history when speaking to all patients in a forward nonjudgmental manner.

The term transgender is used to describe people whose gender identity differs from the sex they were assigned at birth. Two examples of transgender individuals would be transgender women who were assigned male at birth and transgender men who were assigned female at birth. The term transgender is used in opposition to the term cisgender, which is applied to a person whose gender and sex assigned at birth align.³ When a transgender patient presents to a physician, they may want to discuss methods of gender affirmation or transitioning. These terms encompass any action a person may take to align their body or gender expression with that of the gender they identify with. This could be in the form of gender-affirming hormone therapy (ie, estrogen or testosterone treatment) or gender-affirming surgery (ie, “top” and “bottom” surgeries, in which someone surgically treats their chest or genitals, respectively).³

Creating a Safe Space

The physician is responsible for providing a safe space for patients to disclose medically pertinent information. It is then the job of the dermatologist to be cognizant of health concerns that directly affect the LGBT population and to be prepared if one of these concerns should arise. A safe space consists of both the physical location in which the patient encounter will occur and the people that will be conducting and assisting in the patient encounter. Safe spaces provide a patient with reassurance that they will receive care in a judgement-free location. To create a safe space, both the physical and interpersonal aspects must be addressed to provide an environment that strengthens the patient-physician alliance.

Dermatology residents often spend more time with patients than their attending physicians, providing them the opportunity to foster robust relationships with those served. Although they may not be able to change the physical environment, residents can advocate for patients in their departments and show solidarity in subtle ways. One way to show support for the LGBT community is to publicly display a symbol of solidarity, which could be done by wearing a symbol of support on a white coat lapel. Although there are many designs and styles to choose from, one example is the American Medical Student Association pins that combine the caduceus (a common symbol for medicine) with a rainbow design.⁵ Whichever symbol is chosen, this small gesture allows patients to immediately know that their physician is an ally. Residents also can encourage their department to add a rainbow flag, a pink triangle, or another symbol somewhere prominent in the check-in area that conveys a message of support.⁶ Many institutions require residents to perform quality improvement projects. The resident can make a substantial difference in their patients’ experiences by revising their office’s intake forms as a quality improvement project, which can be done by including a section on assigned sex at birth separate from gender.⁷ When inquiring about gender, in addition to “male” and “female,” a space can be left for people that do not identify with the traditional binary. When asking about sexual orientation, inclusive language options can be provided with additional space for self-identification. Finally, residents can incorporate pronouns below their name in their email signature to normalize this disclosure of information.⁸ These small changes can have a substantial impact on the health care experience of SGM patients.

The previously described changes can be implemented by residents to provide better care to SGM patients, a group usually considered to be more burdened by physical and psychological diseases.⁹ Furthermore, dermatologists can provide care for these patients in ways that other physicians cannot. There are special considerations for LGBT patients, as some dermatologic conditions may be more common in this patient population.

Prior studies have shown that men who have sex with men have a higher rate of HIV and other sexually transmitted infections, methicillin-resistant Staphylococcus aureus skin infections, and potentially nonmelanoma skin cancer.^10-14 Transgender women also have been found to have higher rates of HIV, in addition to a higher incidence of anal human papillomavirus.^15,16 Women who have sex with women have been shown to see physicians less frequently and to be less up to date on their pertinent cancer-related screenings.^10,17 Although these associations should not dictate the patient encounter, awareness of them will lead to better patient care. Such awareness also can provide further motivation for dermatologists to discuss safe sexual practices, potential initiation of pre-exposure prophylactic antiretroviral therapy, sun-protective practices, and the importance of following up with a primary physician for examinations and age-specific cancer screening.

Transgender patients may present with unique dermatologic concerns. For transgender male patients, testosterone therapy can cause acne breakouts and androgenetic alopecia. Usually considered worse during the start of treatment, hormone-related acne can be managed with topical retinoids, topical and oral antibiotics, and isotretinoin (if severe).^18,19 The iPLEDGE system necessary for prescribing isotretinoin to patients in the United States recently has changed its language to “patients who can get pregnant” and “patients who cannot get pregnant,” following urging by the medical community for inclusivity and progress.^20,21 This change creates an inclusive space where registration is no longer centered around gender and instead focuses on the presence of anatomy. Although androgenetic alopecia is a side effect of hormone therapy, it may not be unwanted.¹⁸ Discussion about patient desires is important. If the alopecia is unwanted, the Endocrine Society recommends treating cisgender and transgender patients the same in terms of treatment modalities.²²

Transgender female patients also can experience dermatologic manifestations of gender-affirming hormone therapy. Melasma may develop secondary to estrogen replacement and can be treated with topical bleaching creams, lasers, and phototherapy.²³ Hair removal may be pursued for patients with refractory unwanted body hair, with laser hair removal being the most commonly pursued treatment. Patients also may desire cosmetic procedures, such as botulinum toxin or fillers, to augment their physical appearance.²⁴ Providing these services to patients may allow them to better express themselves and live authentically.

Final Thoughts

There is no way to summarize the experience of everyone within a community. Each person has different thoughts, values, and goals. It also is impossible to encompass every topic that is important for SGM patients. The goal of this article is to empower clinicians to be comfortable discussing issues related to sexuality and gender while also offering resources to learn more, allowing optimal care to be provided to this population. Thus, this article is not comprehensive. There are articles to provide further resources and education, such as the continuing medical education series by Yeung et al^10,25 in the Journal of the American Academy of Dermatology, as well as organizations within medicine, such as the GLMA: Health Professionals Advancing LGBTQ Equality (https://www.glma.org/), and in dermatology, such as GALDA, the Gay and Lesbian Dermatology Association (https://www.glderm.org/). By providing a safe space for our patients and learning about specific health-related risk factors, dermatologists can provide the best possible care to the LGBT community.

Acknowledgments—I thank Warren R. Heymann, MD (Camden, New Jersey), and Howa Yeung, MD, MSc (Atlanta, Georgia), for their guidance and mentorship in the creation of this article.

Oh, great!” a senior resident sardonically remarked with a smirk as they read up on the next patient in the clinic. “A borderline patient. Get ready for a rough one ... Ugh.”

Before ever stepping foot into the patient’s room, this resident had prematurely established and demonstrated an unfortunate dynamic for any student or trainee within earshot. This is an all-too-familiar occurrence when caring for individuals with borderline personality disorder (BPD), or any other patients deemed to be “difficult.” The patient, however, likely walked into the room with a traumatic past that they continue to suffer from, in addition to any other issues for which they were seeking care.

Consider what these patients have experienced

A typical profile of these resilient patients with BPD: They were born emotionally sensitive. They grew up in homes with caretakers who knowingly or unknowingly invalidated their complaints about having their feelings hurt, about being abused emotionally, sexually, or otherwise, or about their worries concerning their interactions with peers at school. These caretakers may have been frightening and unpredictable, randomly showing affection or arbitrarily punishing for any perceived misstep, which led these patients to develop (for their own safety’s sake) a hypersensitivity to the affect of others. Their wariness and distrust of their social surroundings may have led to a skeptical view of kindness from others. Over time, without any guidance from prior demonstrations of healthy coping skills or interpersonal outlets from their caregivers, the emotional pressure builds. This pressure finally erupts in the form of impulsivity, self-harm, desperation, and defensiveness—in other words, survival. This is often followed by these patients’ first experience with receiving some degree of appropriate response to their complaints—their first experience with feeling seen and heard by their caretakers. They learn that their needs are met only when they cry out in desperation.^1-3

These patients typically bring these maladaptive coping skills with them into adulthood, which often leads to a series of intense, unhealthy, and short-lived interpersonal and professional connections. They desire healthy, lasting connections with others, but through no fault of their own are unable to appropriately manage the normal stressors therein.¹ Often, these patients do not know of their eventual BPD diagnosis, or even reject it due to its ever-negative valence. For other patients, receiving a personality disorder diagnosis is incredibly validating because they are no longer alone regarding this type of suffering, and a doctor—a caretaker—is finally making sense of this tumultuous world.

The countertransference of frustration, anxiety, doubt, and annoyance we may feel when caring for patients with BPD pales in comparison to living in their shoes and carrying the weight of what they have had to endure before presenting to our care. As these resilient patients wait in the exam room for the chance to be heard, let this be a reminder to greet them with the patience, understanding, empathy, and compassion that physicians are known to embody.

Suggestions for working with ‘difficult’ patients

The following tips may be helpful for building rapport with patients with BPD or other “difficult” patients:

• validate their complaints, and the difficulties they cause
• be genuine and honest when discussing their complaints
• acknowledge your own mistakes and misunderstandings in their care
• don’t be defensive—accept criticism with an open mind
• practice listening with intent, and reflective listening
• set ground rules and stick to them (eg, time limits, prescribing expectations, patient-physician relationship boundaries)
• educate and support the patient and their loved ones.

Oh, great!” a senior resident sardonically remarked with a smirk as they read up on the next patient in the clinic. “A borderline patient. Get ready for a rough one ... Ugh.”

Before ever stepping foot into the patient’s room, this resident had prematurely established and demonstrated an unfortunate dynamic for any student or trainee within earshot. This is an all-too-familiar occurrence when caring for individuals with borderline personality disorder (BPD), or any other patients deemed to be “difficult.” The patient, however, likely walked into the room with a traumatic past that they continue to suffer from, in addition to any other issues for which they were seeking care.

Consider what these patients have experienced

A typical profile of these resilient patients with BPD: They were born emotionally sensitive. They grew up in homes with caretakers who knowingly or unknowingly invalidated their complaints about having their feelings hurt, about being abused emotionally, sexually, or otherwise, or about their worries concerning their interactions with peers at school. These caretakers may have been frightening and unpredictable, randomly showing affection or arbitrarily punishing for any perceived misstep, which led these patients to develop (for their own safety’s sake) a hypersensitivity to the affect of others. Their wariness and distrust of their social surroundings may have led to a skeptical view of kindness from others. Over time, without any guidance from prior demonstrations of healthy coping skills or interpersonal outlets from their caregivers, the emotional pressure builds. This pressure finally erupts in the form of impulsivity, self-harm, desperation, and defensiveness—in other words, survival. This is often followed by these patients’ first experience with receiving some degree of appropriate response to their complaints—their first experience with feeling seen and heard by their caretakers. They learn that their needs are met only when they cry out in desperation.^1-3

These patients typically bring these maladaptive coping skills with them into adulthood, which often leads to a series of intense, unhealthy, and short-lived interpersonal and professional connections. They desire healthy, lasting connections with others, but through no fault of their own are unable to appropriately manage the normal stressors therein.¹ Often, these patients do not know of their eventual BPD diagnosis, or even reject it due to its ever-negative valence. For other patients, receiving a personality disorder diagnosis is incredibly validating because they are no longer alone regarding this type of suffering, and a doctor—a caretaker—is finally making sense of this tumultuous world.

The countertransference of frustration, anxiety, doubt, and annoyance we may feel when caring for patients with BPD pales in comparison to living in their shoes and carrying the weight of what they have had to endure before presenting to our care. As these resilient patients wait in the exam room for the chance to be heard, let this be a reminder to greet them with the patience, understanding, empathy, and compassion that physicians are known to embody.

Suggestions for working with ‘difficult’ patients

The following tips may be helpful for building rapport with patients with BPD or other “difficult” patients:

• validate their complaints, and the difficulties they cause
• be genuine and honest when discussing their complaints
• acknowledge your own mistakes and misunderstandings in their care
• don’t be defensive—accept criticism with an open mind
• practice listening with intent, and reflective listening
• set ground rules and stick to them (eg, time limits, prescribing expectations, patient-physician relationship boundaries)
• educate and support the patient and their loved ones.

Oh, great!” a senior resident sardonically remarked with a smirk as they read up on the next patient in the clinic. “A borderline patient. Get ready for a rough one ... Ugh.”

Before ever stepping foot into the patient’s room, this resident had prematurely established and demonstrated an unfortunate dynamic for any student or trainee within earshot. This is an all-too-familiar occurrence when caring for individuals with borderline personality disorder (BPD), or any other patients deemed to be “difficult.” The patient, however, likely walked into the room with a traumatic past that they continue to suffer from, in addition to any other issues for which they were seeking care.

Consider what these patients have experienced

A typical profile of these resilient patients with BPD: They were born emotionally sensitive. They grew up in homes with caretakers who knowingly or unknowingly invalidated their complaints about having their feelings hurt, about being abused emotionally, sexually, or otherwise, or about their worries concerning their interactions with peers at school. These caretakers may have been frightening and unpredictable, randomly showing affection or arbitrarily punishing for any perceived misstep, which led these patients to develop (for their own safety’s sake) a hypersensitivity to the affect of others. Their wariness and distrust of their social surroundings may have led to a skeptical view of kindness from others. Over time, without any guidance from prior demonstrations of healthy coping skills or interpersonal outlets from their caregivers, the emotional pressure builds. This pressure finally erupts in the form of impulsivity, self-harm, desperation, and defensiveness—in other words, survival. This is often followed by these patients’ first experience with receiving some degree of appropriate response to their complaints—their first experience with feeling seen and heard by their caretakers. They learn that their needs are met only when they cry out in desperation.^1-3

These patients typically bring these maladaptive coping skills with them into adulthood, which often leads to a series of intense, unhealthy, and short-lived interpersonal and professional connections. They desire healthy, lasting connections with others, but through no fault of their own are unable to appropriately manage the normal stressors therein.¹ Often, these patients do not know of their eventual BPD diagnosis, or even reject it due to its ever-negative valence. For other patients, receiving a personality disorder diagnosis is incredibly validating because they are no longer alone regarding this type of suffering, and a doctor—a caretaker—is finally making sense of this tumultuous world.

The countertransference of frustration, anxiety, doubt, and annoyance we may feel when caring for patients with BPD pales in comparison to living in their shoes and carrying the weight of what they have had to endure before presenting to our care. As these resilient patients wait in the exam room for the chance to be heard, let this be a reminder to greet them with the patience, understanding, empathy, and compassion that physicians are known to embody.

Suggestions for working with ‘difficult’ patients

The following tips may be helpful for building rapport with patients with BPD or other “difficult” patients:

• validate their complaints, and the difficulties they cause
• be genuine and honest when discussing their complaints
• acknowledge your own mistakes and misunderstandings in their care
• don’t be defensive—accept criticism with an open mind
• practice listening with intent, and reflective listening
• set ground rules and stick to them (eg, time limits, prescribing expectations, patient-physician relationship boundaries)
• educate and support the patient and their loved ones.

We are excited to announce a new partnership between Cutis and the Association of Professors of Dermatology Residency Program Directors Section (APD-RPDS). The new APD-RPDS column Residency Roundup will contain quarterly communications and submissions that we hope will facilitate greater dissemination of information that is useful to the dermatology teaching community.

The APD is a group of academic dermatologists whose membership comprises chairs, chiefs, residency and fellowship program directors, and teaching faculty. Each fall, the group convenes in Chicago, Illinois, for a 2-day meeting centered around departmental and program leadership with a focus on education. The APD-RPDS was formed in 2020 and is led by a steering committee of 9 members, including our current Chair, Ilana S. Rosman, MD (Washington University School of Medicine, St. Louis, Missouri), and Vice Chair, Jo-Ann M. Latkowski, MD (New York University, New York). Committee members are elected from and by the APD membership and must serve in program leadership at their home programs. The APD-RPDS helps plan and coordinate breakout sessions and lectures at the annual APD meeting, which typically relate to program director duties, changing policies within the American Board of Dermatology or Accreditation Council for Graduate Medical Education, ideas for future growth, and changes in our specialty and in resident education. Members of the APD-RPDS have access to the APD listserv, a valuable resource for discussing issues affecting residency training. We also have work groups led by our members, which include diversity, equity, and inclusion; resource development; communications; and the annual survey. To join the APD, the RPDS, and/or any of our workgroups, please reach out to us or visit the APD website (https://www.dermatologyprofessors.org).

We look forward to welcoming and expediently reviewing members’ submissions to the new Residency Roundup column falling into 2 principal categories within the scope of dermatologic recruitment, didactic education, and clinical training. The first category will feature novel tools, programs, and platforms to improve dermatology training through collaboration. This could entail a description of a new platform designed for sharing resources among programs and specialties to enhance learning for trainees and faculty alike. For example, if a database is created that contains prerecorded lectures pertaining to alopecia, a potential article submission might introduce the database and provide information on what topics are covered and how to access these lectures for readers worldwide. Likewise, if a new technology emerges that allows for easier collaboration among programs, a possible submission would introduce the technology and discuss its potential benefits to trainees, faculty, and practicing dermatologists.

Secondly and more commonly, we anticipate the Residency Roundup column will feature articles that delve into the critical issues and challenges currently impacting recruitment, training, and administration in dermatology residency programs. Specific topics may include but are not limited to recruitment of underrepresented in medicine applicants to dermatology, technological advances to improve teaching methods within training programs, surveys delving into the dermatology match process, and educational gaps or future directions in the specialty. The column occasionally may be used to disseminate information from our section of the APD, including consensus statements or editorials related to changes implemented in the dermatology residency application process. A prospective editorial on this subject could explore varying viewpoints of implemented and proposed changes as well as the reasons behind the changes.

Our group is collaborative, and our aim is to improve education, equity, management of program director responsibilities, and the dermatology application process for programs and applicants alike. With your input, experience, and varied perspectives, we look forward to moving the field of dermatology to a better future by working together. 

We are excited to announce a new partnership between Cutis and the Association of Professors of Dermatology Residency Program Directors Section (APD-RPDS). The new APD-RPDS column Residency Roundup will contain quarterly communications and submissions that we hope will facilitate greater dissemination of information that is useful to the dermatology teaching community.

The APD is a group of academic dermatologists whose membership comprises chairs, chiefs, residency and fellowship program directors, and teaching faculty. Each fall, the group convenes in Chicago, Illinois, for a 2-day meeting centered around departmental and program leadership with a focus on education. The APD-RPDS was formed in 2020 and is led by a steering committee of 9 members, including our current Chair, Ilana S. Rosman, MD (Washington University School of Medicine, St. Louis, Missouri), and Vice Chair, Jo-Ann M. Latkowski, MD (New York University, New York). Committee members are elected from and by the APD membership and must serve in program leadership at their home programs. The APD-RPDS helps plan and coordinate breakout sessions and lectures at the annual APD meeting, which typically relate to program director duties, changing policies within the American Board of Dermatology or Accreditation Council for Graduate Medical Education, ideas for future growth, and changes in our specialty and in resident education. Members of the APD-RPDS have access to the APD listserv, a valuable resource for discussing issues affecting residency training. We also have work groups led by our members, which include diversity, equity, and inclusion; resource development; communications; and the annual survey. To join the APD, the RPDS, and/or any of our workgroups, please reach out to us or visit the APD website (https://www.dermatologyprofessors.org).

We look forward to welcoming and expediently reviewing members’ submissions to the new Residency Roundup column falling into 2 principal categories within the scope of dermatologic recruitment, didactic education, and clinical training. The first category will feature novel tools, programs, and platforms to improve dermatology training through collaboration. This could entail a description of a new platform designed for sharing resources among programs and specialties to enhance learning for trainees and faculty alike. For example, if a database is created that contains prerecorded lectures pertaining to alopecia, a potential article submission might introduce the database and provide information on what topics are covered and how to access these lectures for readers worldwide. Likewise, if a new technology emerges that allows for easier collaboration among programs, a possible submission would introduce the technology and discuss its potential benefits to trainees, faculty, and practicing dermatologists.

Secondly and more commonly, we anticipate the Residency Roundup column will feature articles that delve into the critical issues and challenges currently impacting recruitment, training, and administration in dermatology residency programs. Specific topics may include but are not limited to recruitment of underrepresented in medicine applicants to dermatology, technological advances to improve teaching methods within training programs, surveys delving into the dermatology match process, and educational gaps or future directions in the specialty. The column occasionally may be used to disseminate information from our section of the APD, including consensus statements or editorials related to changes implemented in the dermatology residency application process. A prospective editorial on this subject could explore varying viewpoints of implemented and proposed changes as well as the reasons behind the changes.

Our group is collaborative, and our aim is to improve education, equity, management of program director responsibilities, and the dermatology application process for programs and applicants alike. With your input, experience, and varied perspectives, we look forward to moving the field of dermatology to a better future by working together. 

We are excited to announce a new partnership between Cutis and the Association of Professors of Dermatology Residency Program Directors Section (APD-RPDS). The new APD-RPDS column Residency Roundup will contain quarterly communications and submissions that we hope will facilitate greater dissemination of information that is useful to the dermatology teaching community.

The APD is a group of academic dermatologists whose membership comprises chairs, chiefs, residency and fellowship program directors, and teaching faculty. Each fall, the group convenes in Chicago, Illinois, for a 2-day meeting centered around departmental and program leadership with a focus on education. The APD-RPDS was formed in 2020 and is led by a steering committee of 9 members, including our current Chair, Ilana S. Rosman, MD (Washington University School of Medicine, St. Louis, Missouri), and Vice Chair, Jo-Ann M. Latkowski, MD (New York University, New York). Committee members are elected from and by the APD membership and must serve in program leadership at their home programs. The APD-RPDS helps plan and coordinate breakout sessions and lectures at the annual APD meeting, which typically relate to program director duties, changing policies within the American Board of Dermatology or Accreditation Council for Graduate Medical Education, ideas for future growth, and changes in our specialty and in resident education. Members of the APD-RPDS have access to the APD listserv, a valuable resource for discussing issues affecting residency training. We also have work groups led by our members, which include diversity, equity, and inclusion; resource development; communications; and the annual survey. To join the APD, the RPDS, and/or any of our workgroups, please reach out to us or visit the APD website (https://www.dermatologyprofessors.org).

We look forward to welcoming and expediently reviewing members’ submissions to the new Residency Roundup column falling into 2 principal categories within the scope of dermatologic recruitment, didactic education, and clinical training. The first category will feature novel tools, programs, and platforms to improve dermatology training through collaboration. This could entail a description of a new platform designed for sharing resources among programs and specialties to enhance learning for trainees and faculty alike. For example, if a database is created that contains prerecorded lectures pertaining to alopecia, a potential article submission might introduce the database and provide information on what topics are covered and how to access these lectures for readers worldwide. Likewise, if a new technology emerges that allows for easier collaboration among programs, a possible submission would introduce the technology and discuss its potential benefits to trainees, faculty, and practicing dermatologists.

Secondly and more commonly, we anticipate the Residency Roundup column will feature articles that delve into the critical issues and challenges currently impacting recruitment, training, and administration in dermatology residency programs. Specific topics may include but are not limited to recruitment of underrepresented in medicine applicants to dermatology, technological advances to improve teaching methods within training programs, surveys delving into the dermatology match process, and educational gaps or future directions in the specialty. The column occasionally may be used to disseminate information from our section of the APD, including consensus statements or editorials related to changes implemented in the dermatology residency application process. A prospective editorial on this subject could explore varying viewpoints of implemented and proposed changes as well as the reasons behind the changes.

Our group is collaborative, and our aim is to improve education, equity, management of program director responsibilities, and the dermatology application process for programs and applicants alike. With your input, experience, and varied perspectives, we look forward to moving the field of dermatology to a better future by working together. 

With the COVID-19 pandemic turning the world on its head, we have seen more first-episode psychotic breaks and quick deterioration in previously stable patients. Early in the pandemic, care was particularly complicated for psychiatric patients who had been infected with the virus. Many of these patients required immediate psychiatric hospitalization. At that time, many community hospital psychiatric inpatient units did not have the capacity, staffing, or infrastructure to safely admit such patients, so they needed to be managed on a medical unit. Here, I discuss the case of a COVID-19–positive woman with psychiatric illness who we managed while she was in quarantine on a medical unit.

Case report

Early in the COVID-19 pandemic, Ms. B, a 35-year-old teacher with a history of depression, was evaluated in the emergency department for bizarre behavior and paranoid delusions regarding her family. Initial laboratory and imaging testing was negative for any potential medical causes of her psychiatric symptoms. Psychiatric hospitalization was recommended, but before Ms. B could be transferred to the psychiatric unit, she tested positive for COVID-19. At that time, our community hospital did not have a designated wing on our psychiatric unit for patients infected with COVID-19. Thus, Ms. B was admitted to the medical floor, where she was quarantined in her room. She would need to remain asymptomatic and test negative for COVID-19 before she could be transferred to the psychiatric unit.

Upon arriving at the medical unit, Ms. B was hostile and uncooperative. She frequently attempted to leave her room and required restraints throughout the day. Our consultation-liaison (CL) team was consulted to assist in managing her. During the initial interview, we noticed that she had covered all 4 walls of her room with papers filled with handwritten notes. Ms. B had cut her gown to expose her stomach and legs. She had pressured speech, tangential thinking, and was religiously preoccupied. She denied any visual and auditory hallucinations, but her persecutory delusions involving her family persisted. We believed that her signs and symptoms were consistent with a manic episode from underlying, and likely undiagnosed, bipolar I disorder that was precipitated by her COVID-19 infection.

We first addressed Ms. B’s and the staff’s safety by transferring her to a larger room with a vestibule at the end of the hallway so she had more room to walk and minimal exposure to the stimuli of the medical unit. We initiated one-on-one observation to redirect her and prevent elopement. We incentivized her cooperation with staff by providing her with paper, pencils, reading material, and phone privileges. We started oral risperidone 2 mg twice daily and lorazepam 2 mg 3 times daily for short-term behavioral control and acute treatment of her symptoms, with the goal of deferring additional treatment decisions to the inpatient psychiatry team after she was transferred to the psychiatric unit. Ms. B’s agitation and impulsivity improved. She began participating with the medical team and was eventually transferred out of our medical unit to a psychiatric unit at a different facility.

COVID-19 and psychiatric illness: Clinical concerns

While infection from COVID-19 and widespread social distancing of the general population have been linked to depression and anxiety, manic and psychotic symptoms secondary to the COVID-19 pandemic have not been well described. The association between influenza infection and psychosis has been reported since the Spanish Flu pandemic,¹ but there is limited data on the association between COVID-19 and psychosis. A review of 14 studies found that 0.9% to 4% of people exposed to a virus during an epidemic or pandemic develop psychosis or psychotic symptoms.¹ Psychosis was associated with viral exposure, treatments used to manage the infection (steroid therapy), and psychosocial stress. This study also found that treatment with low doses of antipsychotic medication—notably aripiprazole—seemed to have been effective.¹

Nonetheless, it is important to keep in mind a thorough differential diagnosis and rule out any potential organic etiologies in a COVID-19–positive patient who presents with psychiatric symptoms.² For Ms. B, we began by ruling out drug-induced psychosis and electrolyte imbalance, and obtained brain imaging to rule out malignancy. We considered an interictal behavior syndrome of temporal lobe epilepsy, a neuropsychiatric disorder characterized by alterations in sexual behavior, religiosity, and extensive and compulsive writing and drawing.³ Neurology was consulted to evaluate the patient and possibly use EEG to detect interictal spikes, a tall task given the patient’s restlessness and paranoia. Ultimately, we determined the patient was most likely exhibiting symptoms of previously undetected bipolar disorder.

Managing patients with psychiatric illness on a medical floor during a pandemic such as COVID-19 requires the psychiatrist to truly serve as a consultant and liaison between the patient and the treatment team.⁴ Clinical management should address both infection control and psychiatric symptoms.⁵ We visited with Ms. B frequently, provided psychoeducation, engaged her in treatment, and updated her on the treatment plan.

As the medical world continues to adjust to treating patients during the pandemic, CL psychiatrists may be tasked with managing patients with acute psychiatric illness on the medical unit while they await transfer to a psychiatric unit. A creative, multifaceted, and team-based approach is key to ensure effective care and safety for all involved.

With the COVID-19 pandemic turning the world on its head, we have seen more first-episode psychotic breaks and quick deterioration in previously stable patients. Early in the pandemic, care was particularly complicated for psychiatric patients who had been infected with the virus. Many of these patients required immediate psychiatric hospitalization. At that time, many community hospital psychiatric inpatient units did not have the capacity, staffing, or infrastructure to safely admit such patients, so they needed to be managed on a medical unit. Here, I discuss the case of a COVID-19–positive woman with psychiatric illness who we managed while she was in quarantine on a medical unit.

Case report

Early in the COVID-19 pandemic, Ms. B, a 35-year-old teacher with a history of depression, was evaluated in the emergency department for bizarre behavior and paranoid delusions regarding her family. Initial laboratory and imaging testing was negative for any potential medical causes of her psychiatric symptoms. Psychiatric hospitalization was recommended, but before Ms. B could be transferred to the psychiatric unit, she tested positive for COVID-19. At that time, our community hospital did not have a designated wing on our psychiatric unit for patients infected with COVID-19. Thus, Ms. B was admitted to the medical floor, where she was quarantined in her room. She would need to remain asymptomatic and test negative for COVID-19 before she could be transferred to the psychiatric unit.

Upon arriving at the medical unit, Ms. B was hostile and uncooperative. She frequently attempted to leave her room and required restraints throughout the day. Our consultation-liaison (CL) team was consulted to assist in managing her. During the initial interview, we noticed that she had covered all 4 walls of her room with papers filled with handwritten notes. Ms. B had cut her gown to expose her stomach and legs. She had pressured speech, tangential thinking, and was religiously preoccupied. She denied any visual and auditory hallucinations, but her persecutory delusions involving her family persisted. We believed that her signs and symptoms were consistent with a manic episode from underlying, and likely undiagnosed, bipolar I disorder that was precipitated by her COVID-19 infection.

We first addressed Ms. B’s and the staff’s safety by transferring her to a larger room with a vestibule at the end of the hallway so she had more room to walk and minimal exposure to the stimuli of the medical unit. We initiated one-on-one observation to redirect her and prevent elopement. We incentivized her cooperation with staff by providing her with paper, pencils, reading material, and phone privileges. We started oral risperidone 2 mg twice daily and lorazepam 2 mg 3 times daily for short-term behavioral control and acute treatment of her symptoms, with the goal of deferring additional treatment decisions to the inpatient psychiatry team after she was transferred to the psychiatric unit. Ms. B’s agitation and impulsivity improved. She began participating with the medical team and was eventually transferred out of our medical unit to a psychiatric unit at a different facility.

COVID-19 and psychiatric illness: Clinical concerns

While infection from COVID-19 and widespread social distancing of the general population have been linked to depression and anxiety, manic and psychotic symptoms secondary to the COVID-19 pandemic have not been well described. The association between influenza infection and psychosis has been reported since the Spanish Flu pandemic,¹ but there is limited data on the association between COVID-19 and psychosis. A review of 14 studies found that 0.9% to 4% of people exposed to a virus during an epidemic or pandemic develop psychosis or psychotic symptoms.¹ Psychosis was associated with viral exposure, treatments used to manage the infection (steroid therapy), and psychosocial stress. This study also found that treatment with low doses of antipsychotic medication—notably aripiprazole—seemed to have been effective.¹

Nonetheless, it is important to keep in mind a thorough differential diagnosis and rule out any potential organic etiologies in a COVID-19–positive patient who presents with psychiatric symptoms.² For Ms. B, we began by ruling out drug-induced psychosis and electrolyte imbalance, and obtained brain imaging to rule out malignancy. We considered an interictal behavior syndrome of temporal lobe epilepsy, a neuropsychiatric disorder characterized by alterations in sexual behavior, religiosity, and extensive and compulsive writing and drawing.³ Neurology was consulted to evaluate the patient and possibly use EEG to detect interictal spikes, a tall task given the patient’s restlessness and paranoia. Ultimately, we determined the patient was most likely exhibiting symptoms of previously undetected bipolar disorder.

Managing patients with psychiatric illness on a medical floor during a pandemic such as COVID-19 requires the psychiatrist to truly serve as a consultant and liaison between the patient and the treatment team.⁴ Clinical management should address both infection control and psychiatric symptoms.⁵ We visited with Ms. B frequently, provided psychoeducation, engaged her in treatment, and updated her on the treatment plan.

As the medical world continues to adjust to treating patients during the pandemic, CL psychiatrists may be tasked with managing patients with acute psychiatric illness on the medical unit while they await transfer to a psychiatric unit. A creative, multifaceted, and team-based approach is key to ensure effective care and safety for all involved.

With the COVID-19 pandemic turning the world on its head, we have seen more first-episode psychotic breaks and quick deterioration in previously stable patients. Early in the pandemic, care was particularly complicated for psychiatric patients who had been infected with the virus. Many of these patients required immediate psychiatric hospitalization. At that time, many community hospital psychiatric inpatient units did not have the capacity, staffing, or infrastructure to safely admit such patients, so they needed to be managed on a medical unit. Here, I discuss the case of a COVID-19–positive woman with psychiatric illness who we managed while she was in quarantine on a medical unit.

Case report

Early in the COVID-19 pandemic, Ms. B, a 35-year-old teacher with a history of depression, was evaluated in the emergency department for bizarre behavior and paranoid delusions regarding her family. Initial laboratory and imaging testing was negative for any potential medical causes of her psychiatric symptoms. Psychiatric hospitalization was recommended, but before Ms. B could be transferred to the psychiatric unit, she tested positive for COVID-19. At that time, our community hospital did not have a designated wing on our psychiatric unit for patients infected with COVID-19. Thus, Ms. B was admitted to the medical floor, where she was quarantined in her room. She would need to remain asymptomatic and test negative for COVID-19 before she could be transferred to the psychiatric unit.

Upon arriving at the medical unit, Ms. B was hostile and uncooperative. She frequently attempted to leave her room and required restraints throughout the day. Our consultation-liaison (CL) team was consulted to assist in managing her. During the initial interview, we noticed that she had covered all 4 walls of her room with papers filled with handwritten notes. Ms. B had cut her gown to expose her stomach and legs. She had pressured speech, tangential thinking, and was religiously preoccupied. She denied any visual and auditory hallucinations, but her persecutory delusions involving her family persisted. We believed that her signs and symptoms were consistent with a manic episode from underlying, and likely undiagnosed, bipolar I disorder that was precipitated by her COVID-19 infection.

We first addressed Ms. B’s and the staff’s safety by transferring her to a larger room with a vestibule at the end of the hallway so she had more room to walk and minimal exposure to the stimuli of the medical unit. We initiated one-on-one observation to redirect her and prevent elopement. We incentivized her cooperation with staff by providing her with paper, pencils, reading material, and phone privileges. We started oral risperidone 2 mg twice daily and lorazepam 2 mg 3 times daily for short-term behavioral control and acute treatment of her symptoms, with the goal of deferring additional treatment decisions to the inpatient psychiatry team after she was transferred to the psychiatric unit. Ms. B’s agitation and impulsivity improved. She began participating with the medical team and was eventually transferred out of our medical unit to a psychiatric unit at a different facility.

COVID-19 and psychiatric illness: Clinical concerns

While infection from COVID-19 and widespread social distancing of the general population have been linked to depression and anxiety, manic and psychotic symptoms secondary to the COVID-19 pandemic have not been well described. The association between influenza infection and psychosis has been reported since the Spanish Flu pandemic,¹ but there is limited data on the association between COVID-19 and psychosis. A review of 14 studies found that 0.9% to 4% of people exposed to a virus during an epidemic or pandemic develop psychosis or psychotic symptoms.¹ Psychosis was associated with viral exposure, treatments used to manage the infection (steroid therapy), and psychosocial stress. This study also found that treatment with low doses of antipsychotic medication—notably aripiprazole—seemed to have been effective.¹

Nonetheless, it is important to keep in mind a thorough differential diagnosis and rule out any potential organic etiologies in a COVID-19–positive patient who presents with psychiatric symptoms.² For Ms. B, we began by ruling out drug-induced psychosis and electrolyte imbalance, and obtained brain imaging to rule out malignancy. We considered an interictal behavior syndrome of temporal lobe epilepsy, a neuropsychiatric disorder characterized by alterations in sexual behavior, religiosity, and extensive and compulsive writing and drawing.³ Neurology was consulted to evaluate the patient and possibly use EEG to detect interictal spikes, a tall task given the patient’s restlessness and paranoia. Ultimately, we determined the patient was most likely exhibiting symptoms of previously undetected bipolar disorder.

Managing patients with psychiatric illness on a medical floor during a pandemic such as COVID-19 requires the psychiatrist to truly serve as a consultant and liaison between the patient and the treatment team.⁴ Clinical management should address both infection control and psychiatric symptoms.⁵ We visited with Ms. B frequently, provided psychoeducation, engaged her in treatment, and updated her on the treatment plan.

As the medical world continues to adjust to treating patients during the pandemic, CL psychiatrists may be tasked with managing patients with acute psychiatric illness on the medical unit while they await transfer to a psychiatric unit. A creative, multifaceted, and team-based approach is key to ensure effective care and safety for all involved.